Caring for baby's heart

Paediatric cardiology has not made much progress in India when compared to the West. DR. R. PREM SEKHAR analyses the reasons.

PAEDIATRIC cardiology was formally established as a separate subspeciality in 1961. Mortality and morbidity in infants under one year was highest due to congenital heart defects (CHD) and underscored the need for paediatricians specially trained in managing children with heart lesions. Determining the most appropriate type of surgical palliation/correction for the specific defect, the timing of surgery and knowledge of the natural course of the heart defect both prior to and after different types of palliation/correction is important in improving the child's quality of life.

Progress has been made in the field of paediatric cardiology in the past 40 years resulting in a significant increase in the life-expectancy of children born with heart defects. However, paediatric cardiac care in our country has not kept up with advances in developed countries.

The reasons are many. First, the enormous proportion of children with heart defects. The incidence of congenital heart disease is believed to be three to eight per 1,000 live births. There are 16 million live births in our country annually. As there is no regular national data collection, calculations based on these figures tell us that there are between 48,000 and 1,28,000 babies born every year with heart defects. Of these, 65 per cent die before one year of age and only 15 per cent survive beyond five years. Adding to this problem is the high incidence of rheumatic heart disease in India. With at least 50,000 new cases every year, it is estimated that currently there are more than one million patients with rheumatic heart disease.

Second, limited access to medical help. The total number of trained paediatric cardiologists in the country is as low as 14 or 15. There are only seven or eight institutions in the country which have the infrastructure and manpower to facilitate surgical correction/palliation for neonates and children with heart defects. Also, there are no more than 10 dedicated paediatric cardiothoracic surgeons. The main reason for this is the specialised training and skills required for paediatric cardiac surgeries and the poor returns in term of monetary benefits. Consequently, many centres are forced to incorporate paediatric cardiac surgical services into a pre-existing adult cardiac setup. Data collected by oxygenator manufacturers shows that only 6,750 operations were done for congenital heart diseases in all the paediatric cardiothoracic centres in the country during 1999.

Third, is the high cost involved in cardiac surgeries. This is mainly because of the specialised equipment needed and the intra and post-operative care involved. The risk of developing complications is high, necessitating prolonged intensive care and a longer hospital stay. Yet another factor is most patients who require valve replacement for rheumatic heart disease cannot afford it.

Fourth, the lack of awareness among doctors and the public. Paediatricians are usually the first port of call for children with congenital heart problems. It is very important that they are aware of the natural course of heart defects in their patients and the appropriate timing of surgical intervention. Delayed referrals resulting in inoperability or increased post- operative mortality is a reality that needs to be addressed through seminars and continuing medical education programmes.

The public, on the other hand, needs to be educated to be able to recognise tell-tale signs and symptoms of possible heart disease in children. Telemedicine has now revolutionised medical practice by enabling patients access to specialised help.

The writer is consultant paediatric cardiologist, Apollo Hospital, Chennai.

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