June 2016 1130

Paediatric Heart Care: Ensure Confluence of High-End Technology, Sophisticated Infrastructure & Appropriate Training

Nidhi-Rawal

Dr Nidhi Rawal, Head Pediatric Cardiology, Artemis Hospitals

Paediatric cardiac surgeons find it compelling to spend a few years in busy centres overseas as only a handful of centres conduct paediatric cardiac surgeries, shares Dr Nidhi Rawal, Head Pediatric Cardiology, Artemis Hospitals with Elets News Network (ENN)

Has India as such succeeded in creating comprehensive paediatric heart centres with the capability for infant and newborn heart surgery? What are the key challenges confronting Indian healthcare in this segment, as paediatric cardiology still remains a neglected arena?

Yes, to some extent, India has succeeded in creating comprehensive paediatric heart centres. Comprehensive paediatric heart care is very resource intensive and requires sophisticated infrastructure. It is challenging to develop a successful and effective programme in the government sector. We do have a handful of private institutions in India that have established good standards of paediatric heart care with rapidly increasing numbers. The total number of infant open-heart operations in India has almost doubled over the last five years.

There are limiting factors in the paediatric cardiology, which primarily include poor affordability, accessibility and acceptability. Additionally, finances are the big issues. In most parts of India, very little or no government subsidy exists for congenital cardiac care, and most insurance companies also do not cover congenital heart lesions. Therefore, families have to generate entire resources for surgery out of their pocket. Accessibility is another big problem, as paediatric cardiac care is very limited to metros. As a result, families have to travel long distances for treatment. Another factor is that cardiac surgery is not easily accepted, even if it is offered free of cost. There is a social stigma attached to post-surgery scars.

Comprehensive paediatric heart care is very resource-intensive and requires sophisticated infrastructure

India has no national policy for the treatment of coronary heart disease (CHD). In 2008, out of the Rs 63 billion for integrated child development schemes, no allocation was made for CHD. There is a huge load of congenital heart disease patients requiring intervention. We need over 200 large-volume centres that can cater to at least 1,000 surgeries every year. This high demand makes any healthcare policy very challenging. Although several new centres are opening up, the gap between the required number of centres and the number of patients who need treatment is very wide.

The key challenge is to establish more centres that are capable of providing good quality care for patients with CHD, as it is the most sustainable approach over long term. To date, India has almost 25 centres, of which 15 have been established in last 10 years. There are only three centres funded by the government and no new government-aided centre has been opened in the last 10 years. It is important to note that, most of the new centres have been set up in the metros, with little or no facilities in some of the most populous and poor states, such as Uttar Pradesh, Bihar and Odisha. There is an urgent need to establish good quality paediatric cardiac care centres in these states.

Paediatric care has been closely linked to ‘infant mortality rate’ (IMR). Please describe in detail in which all regions you have seen more concrete changes in terms of paediatric care and which regions continue to be afflicted by this menace.

Paediatric care in terms of easy availability and access to a paediatrician has made things better, and information about nutrition and access to immunisation have resulted in reduced IMR.

The advent of immunisation has resulted in the eradication of polio, and the next on target is measles. Infections, such as diarrhoea and pneumonia, account for almost 50 per cent of infant mortality. Improved sanitation practices, Swachh Bharat Abhiyan, proper washrooms and proper use of antibiotics are some of the concrete steps in paediatric care. A lot more needs to be done in the above-mentioned areas, especially in the rural belt. Additionally, government-funded accredited social health activists (ASHAs), who take care of pregnant mothers and infants up to six weeks of age, are also aiding in reducing the number of low birth weight babies.

The detection of congenital anomalies by the ultrasound scan in the antenatal period is a very important step in later neonatal care and management. Abuse of antibiotics resulting into resistance is a menace. Infection due to poor hygiene is a big menace in the rural area.

One of the critical elements of paediatric care is training paediatric heart surgeons. Despite statistics suggesting that 70,000 to 100,000 infants and newborns need surgery, the number of paediatric surgeon remains very low. Please explain the reasons and recommendations for improvement.

Currently, there are no structured training programmes for cardiac surgeons in India. The flawed training programme, long hours of work on high-risk patients, prolonged training requirements, modest remuneration (as compared to adult cardiac surgeons), late settlements and at times uncertain future are the keys factors amounting to the less number of trained paediatric cardiac surgeons.

With just a handful of centres conducting paediatric cardiac surgeries, most trainee cardiac surgeons completing their cardiac surgery programme have limited exposure to the sub-speciality. Thus, most of the paediatric cardiac surgeons find it compelling to spend a few years in busy centres overseas to improve their skills and knowledge.

We urgently need formal, structured medical training programmes within India. Considering the high volume of patients and procedures that most centres have, this should not be a difficult proposition. Medical bodies, such as the Medical Council of India (MCI) and the National Board of Examination (NBE), have to be engaged for initiating these programmes and fellowships.

What are the key technological and procedural gaps in the field of cardiology segment? Please enumerate some of the latest advancements made in paediatric cardiology.

Paediatric cardiology is a long endearing programme. It requires high-end technology. Paediatric surgeons need to be trained adequately in clinical and interventional skills. We need to have a trained paediatric cardiologist, paediatric cardiac surgeon, paediatric cardiac anaesthetist and intensivist to run a successful paediatric cardiac programme.

Key Challenges
  • No national policy for the treatment of CHD
  • No structured training programmes for cardiac surgeons
  • Wide gap between the number of centres and the number of patients
  • Only three centres funded by the government
  • No new government-aided centre opened in the last 10 years
  • New centres mostly in the metros
  • Need to establish good quality paediatric care centres in Uttar Pradesh, Bihar and Odisha

There are a lot of devices, catheters and sutures that have been not yet manufactured in India. When these medical devices are imported, we encounter increased costs. A lot of technology/techniques have not yet come into India. A new technology has a lag period from western world of about 7 to 8 years. People have to be trained in the new technology, as they need to be updated. All these measures require investment.

Establishing new equipped advanced cardiac centres is a big challenge, due to huge investments necessary for technology, infrastructure and trained manpower. The latest development in paediatric cardiology is the establishment of several new centres that provide comprehensive paediatric cardiac care. Additionally, we have seen an increase in the number of trained manpower and development of newer cost-effective strategies and innovations. Threedimensional (3D) echo is emerging as a big help in complex surgeries. A lot of indigenous innovative interventions have come into action. Holes are being closed in cath labs. Valve replacement has been started in cath labs. Neonatal palliative procedures, such as patent ductus arteriosus (PDA) stenting, are being done in cath labs, which have reduced child morbidity and mortality. Neonatal surgeries are being done at most of the advanced centres with ease.

‘Paediatric cardiology’ has been conventionally considered a less lucrative career option due to uncertainties involved in growth. How far do you agree with this statement? Please provide details.

Personally, I don’t feel like that. If you have passion to treat cardiac patients, you can break yourself away from the rat race with adult cardiologists and can get professional satisfaction early in life, paediatric cardiology is a lucrative option. In third world countries, such as ours where healthcare is self-financed, financial remuneration may not be high for all the sub-specialities of paediatric cardiac care.

I do agree with the fact that paediatric cardiology is a surgeon-dependent branch, because of which independent survival is difficult. This makes it little less lucrative.

Quite challenging to develop a successful and effective paediatric care programme in the government sector; a handful of private institutions have established good standards of paediatric heart care

What kind of workshops and communication campaigns are being conducted in both public and private space to spread awareness regarding ‘paediatric cardiology’? Are you part of any of these government-based and private activities?

The Government of India and several state governments are initiating health programmes for children. The national schemes, such as Janani Shishu Suraksha Karyakram and Rashtriya Bal Swasthya Karyakram, are designed to ensure care for the health of neonates, infants and children for multiple diseases, including congenital and rheumatic heart diseases. The government runs several programmes for poor patients, those below the poverty line (BPL), or below poverty line cards are provided, and they can avail several facilities free of cost. Several states in India have similar programmes, e.g. Andhra Pradesh and Tamil Nadu have a special programme for conducting free congenital heart surgery for all children whose families cannot afford treatment. The National Rural Health Mission (NRHM) programme in Punjab has helped a lot of children in getting operated for paediatric cardiac surgeries. Several regional charity organisations have established paediatric cardiac care facilities to help these children. The state of Karnataka has introduced a microfinance scheme for poor families.

Indigenous Innovative Interventions
  • Valve replacement
  • Neonatal palliative procedures

Similarly, Saving a Child’s Heart initiative (SACHi) is a voluntary organisation dedicated to paediatric cardiac care and child heart surgery for the underprivileged. I am associated with campaigning and conducting non-profitable paediatric cardiac camps in Bhiwadi, Rewari and Dwarka. I am also helping underprivileged children to get operated with the help of non-government organizations (NGOs).

We conduct continuing medical education (CME) programmes to spread awareness and ensure early diagnosis and timely referral. Additionally, we run school health schemes to screen the kids for cardiac problem. We, at Artemis Hospital, conduct a routine neonatal screening with the pulse oximeter in the neonatal intensive-care unit (NICU) and if needed, echocardiography is done.

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