Five-year-old Simon is reluctantly brought to see me by his mother at the request of his teacher. He becomes wheezy with exercise and seems generally tired at school. His mother has also noticed that he often wakes during the night as a result of coughing. I explain to her that this is likely to be due to asthma, but despite spending some time addressing her concerns, she wants to try homoeopathic treatment and will not consent to using inhalers.
A GP'S VIEW - LOUISE WARBURTON, A GP IN IRONBRIDGE, SHROPSHIRE
I often see mothers who either will not accept that their child has asthma, or refuse to take advice about the type of inhalers used.
Simon obviously has quite bad asthma as it is affecting his sleep and he is tired at school. I would point this out to his mother and explain the fact that uncontrolled asthma can affect a child's development and lead to weight gain.
I would also explain the mechanism of wheezing and sleep loss and the possible harm this could do to Simon.
It would be worth exploring with his mother why she has so much faith in homoeopathic remedies and so little in orthodox medicine - she may have had a bad experience in the past with doctors.
It might be worth measuring Simon's peak flow and asking him to check his peak flow throughout the day and get his mother to record the results on a chart.
Hopefully this would provide black-and-white evidence of asthma and its severity. I would also check his height and weight because he may be of small stature if he is chronically tired.
However, I cannot insist that she uses conventional methods. I would agree to a trial period of a month or two with the homoeopathic treatment, and a regular measurement of his peak flow (assuming that she does not falsify the readings).
After review, if he was still failing to thrive, I would become more insistent that he used orthodox treatment.
A referral to the local paediatrician might be helpful to 'diagnose' the asthma, while steering her towards treating her son correctly. A quick phone call to the consultant would put him in the picture.
It is important to remember that not allowing her son to be treated correctly and preventing him from thriving is a type of child abuse.
I doubt if the situation would deteriorate to this level, but it should always be at the back of the doctor's mind. I would hope the problem could be sorted out before social services were involved.
A PATIENT'S VIEW - TREVOR SEEMANN, A MEMBER OF THE PATIENT PARTNERSHIP GROUP
It is only natural that your prime concern is for the health and welfare of this child.
You are entitled to your own views and beliefs on homoeopathic treatments but you must accept that his mother also has very strong beliefs, and is vehemently opposed to the use of steroids.
While you might be doubtful over the benefits of homoeopathy, it must be remembered that there are NHS homoeopathic hospitals and centres, and that many people are convinced of real effective results.
If you have serious clinical objections, advise the mother to refer her child to another GP. Alternatively, you could refer him to a homoeopathic specialist GP or consultant.
Perhaps though, if you are wary of homoeopathy, your first course of action could be to refer Simon to a consultant who is experienced in paediatric asthma.
A MEDICO-LEGAL OPINION - DR PETER MACKENZIE, MEDICO-LEGAL ADVISER, MEDICAL PROTECTION SOCIETY
This is a difficult situation in which a mother is refusing conventional treatment for her son's asthma, thereby possibly putting his health at risk.
While the child's welfare is paramount, you should also try to build a relationship of trust with his mother for the future. Assuming that the child is not capable of giving consent himself it will be important to explore the validity of the mother's refusal.
Is she competent? This involves assessing her ability to understand, retain and assess the information and advice which you give her. You should make all reasonable efforts to enable her to understand; sometimes the use of pictures, photographs or diagrams might be helpful.
You should be satisfied that the mother is properly informed about the treatment and investigations which you propose, with some reassurance about what is known of the safety and efficacy of conventional treatment.
It might also be necessary to explain the potential consequences for her and her son of refusing conventional treatment, but this would depend on your assessment of the seriousness of his condition. It might be helpful to explore the mother's reasons for refusing conventional treatment; is she under pressure from a third party?
If the mother continues to refuse consent for conventional treatment and you are satisfied that this is a valid refusal, your next steps will depend on your assessment of the immediate risk to the child. It would certainly be important to ensure follow-up, close liaison with health visitors and to consider further opinion through referral to hospital.
It might be helpful to see whether you can engage with another family member.
If, however, your assessment is that Simon is at great risk of more immediate threat to his health it might be necessary to involve social services or consider hospital admission for further assessment.
When faced with a difficult decision about which you might be challenged in future, a second opinion from a colleague can be invaluable.