This story begins with a verruca, which belonged to my daughter, Frances, six years old and a frequenter of swimming pools. We tried to get rid of the thing with a selection of plasters that looked like woolly Polo mints, but to no avail.
Eventually, she started to hobble and complain. At our monthly wart clinic, I expected the doctor to take one look and apply the liquid nitrogen. I was amazed to hear him say: “Leave well alone. I think the thing will die, and I wouldn’t like to take credit for something that nature can sort out by itself.”Now, as the verruca obligingly fades, I reflect on the benefits of letting be especially where young, healthy children are concerned. I wonder how traumatic it would have been for Frances to have experienced the freezing off of a harmless growth that would eventually disappear on its own.
There are many examples of intervention in pediatric practice which might make us pause for thought. I talked to a friend who was waiting anxiously for her two year old daughter’s operation for a birth mark. I was astonished, as I had never noticed the offending mark myself.
“It’s best to get it over with,” said my friend, presumably quoting the consultant as he justified his decision to put her baby under anesthetic for cosmetic surgery. Yet birth marks often disappear before a child starts school.
Haste towards the operating table has also been apparent in the routine treatment of otitis media, or glue ear. About a quarter of all British children suffer from glue ear at least once before the age of five. This results in some 60,000 operations under general anesthetic for the insertion of grommets tiny tubes which help to equalize pressure in the middle ear. It has become the commonest reason for children to undergo elective surgery.
This might remind some readers of the fashion for taking out children’s tonsils, which brought thousands of children into hospital for a raw throat and the subsequent diet of ice cream. The treatment was so popular between the 1930s and 1970s that at one point a third of all British children were having their tonsils removed. Now discredited, the operation is comparatively rare.
Grommets are still at the height of their popularity, costing the UK’s National Health Service up to £200m a year. But discrepancies in the numbers of grommet insertions between health regions should alert us to the fact that there is controversy about this routine invasion. Researchers are beginning to realize the value of leaving glue ear alone. There is talk of “unwarranted surgery, with little or no lasting benefit” (The Lancet, 28 November 1992).
The grommet operation transforms some children’s lives, restoring hearing and improving behaviour, which may deteriorate if hearing loss is dealt with unsympathetically. But for many others, the operation brings no noticeable benefits. It has to be repeated in 30 per cent of cases.
Other treatments for the condition range from antibiotics to steroids, but neither claims to offer a long term benefit to the child.
Now there is talk of a glue ear vaccine. The trend seems to be towards developing vaccines for conditions merely because they are common, not because they are universally severe. Yet a report in “Effective Health Care”, a bulletin funded by the UK government’s Department of Health, says there is insufficient evidence that glue ear causes clinically important disability.
Other specialists point out that, in 90 per cent of cases, glue ear naturally clears up in three months. Only about 5 per cent of children are still suffering a year after diagnosis. The label “glue ear” does not mean that a child will have a persistent or severe hearing impairment.
Despite the call for caution and careful screening, one study showed that 36 per cent of ear, nose and throat consultants placed patients on the list for surgery at first visit (Clinical Otolaryngology, 1991; 16: 266-70).
Whether we are talking about a routine invasion or a life saving operation, we should never neglect to consider the long term effect on the child. As recently as 1987, doctors were still debating whether newborn babies felt pain, and it was revealed that infants commonly underwent heart surgery without any pain relief (Mother, July 1987).
Other parents report the devastating emotional repercussions of an operation. “Our seven year old, Tania, had to go to hospital for a tonsillectomy,” wrote Mr and Mrs V W to The Guardian (June 23-24 1990). “However, Tania went into the operating theatre one child and came out another . . . She spent weeks screaming and having nightmares . . . Her teachers say they cannot manage her anymore. She has stopped being able to concentrate and is either silent and withdrawn or screams.”
>From the first heel prick of healthy newborn babies to the prescription of steroids and antibiotics to young children, the medical profession is all too ready to intervene. Parents are often dissatisfied unless they leave the surgery with a note from the pharmacist.
It is the wise practitioner who remembers the underlying principle of the ancient Hippocratic Oath, which UK doctors have to take: “Primum non nocere.” First, do not disturb. The great eagerness towards preventative medicine may reflect society’s desire to control disease, but the younger the patient, the more complex and less understood will be the effects of our interventions.