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Indian Pediatr 2015;52: 563-565 |
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Pediatric Cardiology in India: Onset of a New
Era
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Dinesh Kumar and *Narendra Bagri
From Departments of Pediatrics; PGIMER and Dr Ram
Manohar Lohia Hospital, New Delhi, and *Institute of Medical Sciences,
Banaras Hindu University, Varanasi, UP; India.
Correspondence to: Dr Dinesh Kumar, Assistant
Professor, Department of Pediatrics, Dr Ram Manohar Lohia Hospital, New
Delhi, India.
Email:
[email protected]
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Pediatric cardiology is
outgrowing from the shadows of adult cardiology and cardiac surgery
departments in India. It promises to be an attractive and
sought-after subspeciality of Pediatrics, dealing with not only
congenital cardiac diseases but also metabolic, rheumatic and host
of other cardiac diseases. The new government policy shall provide
more training avenues for the budding pediatric cardiologists,
pediatric cardiac surgeons, pediatric anesthetists, pediatric
cardiac intensivists, neonatologists and a host of supportive
workforce. The proactive role of Indian Academy of Pediatrics and
Pediatric Cardiac Society of India, towards creating a political
will at the highest level for framing policies towards building
infrastructure, training of workforce and subsidies for pediatric
cardiac surgeries and procedures shall fuel the development of
multiple tertiary cardiac centers in the country, making pediatric
cardiology services accessible to the needy population.
Keywords: Congenital heart disease, Health
policy, National programs, Training.
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I
n India, Pediatric cardiology has only recently
been identified as a separate subspecialty of pediatrics. It evolved as
an offshoot of the adult cardiology services, as they had the necessary
infrastructure (echocardiography, Cardiac catheterization laboratory)
[1]. Creating a wholesome pediatric cardiology care program was usually
considered economically unviable because of the need of a lot of
infrastructural investment.
Congenital heart diseases (CHDs) account for 6-10 %
of all the infant deaths [2,4]. However, with recent advances in
diagnostic and treatment modalities, over 75% of these patients can
survive and lead normal lives [4]. Approximately 180,000 to 200,000
children are born with CHD every year in India, of which one-third to
half are critical CHD requiring early intervention [4]. Only about 2500
are operated, whereas the rest either perish or are added to the ever
increasing total pool of cases with CHD in the country [1]. This is not
only because of non-affordability; even if we use our existing
infrastructure to its optimum, we may be able to handle only around 10%
of the patient load [5]. In the absence of an organised program and an
acute shortage of pediatric cardiologists, pediatric cardiac surgeons,
pediatric anesthetists and other trained workforce in the country; along
with an absence of a well-oiled referral and tertiary-care
infrastructure network; and no fund allocation, these children and their
families are left to themselves [6].
There were several reasons for poor evolution of this
subspecialty of pediatrics in our country. In the early era of its
development, pediatric cardiologist was entirely dependent on the adult
surgical units. Unlike in the West, there was no dedicated hospitals in
our country where structured training in pediatric cardiology could
evolve due to lack of optimum surgical facility, pediatric cardiac
catheterization services, pediatric intensive care and echocardiography.
Even today, these facilities are insufficient and non-existent in vast
swathes of Northern and Eastern parts of India. Pediatric fraternity did
not identify the need to prioritize and take up the issue of pediatric
cardiology with the erstwhile establishments. Pediatricians not only
found it extremely difficult to enter the ‘cardiology’ training program,
as the entrance examination was more oriented towards students with MD
in Internal Medicine, but also the overall cardiology program were
mainly oriented towards ‘coronary care’, which was of little use to
them. Quality pediatric cardiology training and care programs were only
available in a couple of centers. Overseas training, on the other hand,
required huge investments. This largely restricted pediatricians from
venturing in this field. Cardiologists from internal medicine background
were more interested in looking after adults, and were hesitant in
taking up pediatric cardiology since they do not have the background
training in neonatology and pediatrics.
In contrast, by the late 1950s, pediatric cardiology
centers had developed all over the USA. Pediatric cardiology became the
first sub-board of pediatrics and by the end of 2002, the total number
of certified pediatric cardiologists was 1740, with every medical school
having a pediatric cardiologist [3]. Financial support for training of
pediatricians was provided by the National Institutes of Health.
In keeping with the requirements, the Government of
India, Ministry of Health and Family Welfare endorsed Pediatric
cardiology as a subspecialty of pediatrics in 2012. It, for the first
time, underlined the need of an MD in Pediatrics, with two years of
training in pediatric cardiology as one of the basic qualifications
needed, as recommended by the Medical Council of India; DM cardiology
was no longer considered an essential requirement for this post. This
shall go in a long way to promote the growth of pediatric cardiology in
India by handing over pediatric cardiology services to pediatricians.
The grim scenario of pediatric cardiology in India
cannot be changed overnight. Certain drastic steps need to be undertaken
as follows:
1. Improving institutional deliveries:
Most of the births are not attended by trained personnal, and most
of the critical CHDs are missed at birth. ‘National Health Mission’
will go a long way to address this.
2. Improving skills of pediatricians:
Usually pediatricians are unaware of the diagnosis, prognosis,
treatment options and the appropriate time of referral of congenital
heart diseases to the tertiary hospitals. Structured program of
pediatric cardiology during postgraduate training in pediatrics
coupled with compulsory update courses are needed.
3. Creating divisions of pediatric cardiology:
Throughout the globe, pediatric cardiology is a subspecialty evolved
and practised within the ambit of pediatrics, in close conjunction
with the surgical and anesthesia team [7]. Neonatologists and the
pediatricians are best trained in the normal physiology as well as
critical care of sick babies. They are already using cranial and
abdominal ultrasound and placing arterial and venous sheaths and
long lines, skills which could be of great help in managing babies
with congenital cardiac defects. DM courses and/or fellowships in
other pediatric sub-specialities are being run in the pediatric
departments in several government medical colleges and private
corporate hospitals. It is high time that pediatricians should
develop Division of pediatric cardiology with the entire necessary
infrastructure, especially where adult cardiology and cardiac
surgical back-up is present. In the presence of all the pediatric
subspecialties under one umbrella, the infant with congenital
cardiac lesion with other common co-morbidities can be best managed.
4. Increasing the number of pediatric
cardiologists: Indian Academy of Pediatrics (IAP) should impress
upon the urgent need of getting at least one faculty trained and
certified as ‘pediatric cardiologist’ at the cost of the government
exchequer from every medical college through the existing centers of
excellence within the country. The fellowship programs in Pediatric
cardiology as initiated by the National Board of Examination and the
DM (Pediatric Cardiology) will take too long to correct the current
scenario. There are no formal training programs for pediatric
cardiac surgeons and anaesthetists, which will become a major
bottleneck as new centres are established.
5. Increasing awareness about cardiac diseases:
IAP along with Pediatric Cardiac Society of India (PCSI) should make
efforts towards educating the masses for early detection of cardiac
diseases. They should create political will at the highest level for
framing policies towards creation of infrastructure, training of
work force and subsidies for pediatric cardiac surgeries and
procedures.
6. Creation of a proper referral system:
Community health centers and district hospitals should have a state
of the art referral system supported by telemedicine and proper
triage.
The future of Pediatric cardiology in India looks
bright. With better education, rising per-capita income, sustenance of
nuclear family model and shrinking family size, emphasis on management
of congenital diseass is increasing. With increasing awareness among
masses and pediatricians, more and more infants are diagnosed with
cardiac defects leading to an increase in procedures and surgeries.
Moreover, the recent changes in the recruitment rules for the post of
pediatric cardiologist by Government of India have increased the job
opportunities for pediatricians with fellowship in pediatric cardiology.
Contributors: DK; conceptualised, revised the
manuscript for important intellectual content, NB: carried out the data
collection, and drafted the manuscript. Both authors approved the final
version.
Funding: None; Competing interests: None
stated.
References
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2. Fyler DC, Buckly LP, Hellenbrand WE, Cohn HE.
Report of the New England Regional Infant Care Programme. Pediatrics.
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3. Saxena A. Congenital heart disease in India: A
status report. Indian J Pediatr. 2005;72:595-8
4. Wren C, Reinhardt Z, Khwaja K. Twenty year trends
in diagnosis of life threatening neonatal cardiovascular malformations.
Arch Dis Child Fetal Neonatal Ed. 2008;93:F33-7
5. Kothari SS. Pediatric cardiac care for the
economically disadvantaged in India: Problems and prospects. Ann Pediatr
Cardiol. 2009;2:95-8.
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