Conversations On Coping with Corona

 Dr.S.Subramanian, Director,Smrthi Healthcare, Chennai 

in conversation with

Mrs. Chitra, Health Communicator.

Here is a free transcript of the conversation.

Mrs C: 

Hello Dr, your patients to are eager to hear your views on the pandemic situation and this the context of our conversation.

Let me begin by asking  as to how you are  doing as a medical professional also as a member of the society?

Dr S:

Just like anybody else in the society, we are also taken aback by the kind of changes we need to adapt to, as  result of the pandemic. It has thrown all our plans and comfort zones out of the place and we are really adapting to situations every day. It is very tiring. With medical profession being on the forefront of the struggle of COVID, we must bear the brunt. Our elders, our senior members of our society have faced such problems earlier too and if we look back and take from their experiences, we will be able to come through this very well.

Mrs C: 

How has Smrthi Healthcare adapted as a healthcare system?

Dr S:

Unlike many other entities, we were not able to completely shut down our work during COVID. Instead we continued to provide our services in the best possible manner. So, given the fact that we have a medical background and we had a responsibility towards the community, right through the lockdown,  we decided to provide our best possible services, whatever it takes, in the best possible manner. Through God’s grace and lot of support from community we were functional.  Manu parents and lot of children and pregnant women came to us through the pandemic. I would not call it an achievement. But I feel that we have been able to live up to the commitment given at the beginning. 

Mrs C: 

We are evolving in our response. Do you think the changes are here to stay?

Dr S:

The changes are here to stay yes and we have learnt certain things and we have adapted to them. Because we are forced to learn, we learnt it very quickly and having learnt that we can have the comfort of certain services at the comfort of home, we would not want to go back on certain aspects of care back to olden methods. For example, certain review visits may not happen at all because we will be able to provide near adequate care online. Through this, we  will be able to cut short lot of effort, time and money for the patient and the healthcare.  These changes are removing lot of pressure on the healthcare system. These changes are here to stay. But this will also evolve over a period.

Mrs C: 

In this context, how do we access healthcare system, like do we restrict it to sickness visits or do we consult even  if we see  challenges like red flags?

Dr S:

When you look at access to healthcare system, during the time immediately following the outbreak, it was relevant to say that it was better to stay back at home and to avoid unnecessary visits. Restrict to immediate care needs only. But with prolonged lockdown, what was emergency care has now been extended to care which cannot be postponed any further. For example, we did postpone vaccinations for the first 10 -15 days of lockdown. IAP and other associations recommended that postponing vaccines would mean return of vaccine preventable diseases. Especially the initial ones like DTP, MMR etc if skipped would create an outbreak of these diseases over and above COVID which would be a catastrophe. Given that fact, now many pediatricians have started with it. So, what was not considered emergency earlier, has now become essential. So, we have transitioned from emergency to essential care services.

Mrs C: 

For children undergoing therapies, what does this break, or shift mean?

Dr S:

For children undergoing therapy  due to issues with developmental progress not being age appropriate, we need to look at it not just from medical but also social context. When we look at the child, the parents, family, siblings, and people around the child have to put that much effort on the child than the previous state of the child prior to break of therapy. The longer they do not have care they are going to slip back as far their progress is concerned. Their goals are not going to be reached. It is going to be more and more difficult to provide care for these kids. Breakage of continuity of care is a major issue in rehab. In rehab you do not see immediate effect, you do not administer therapy and see change the next day. In therapy many a times you need to put in sustained effort, faith in therapy over a period  of time to see the results coming out. When you are not able to provide that care for more than  two three months, this is definitely  going to be a big problem for these kids.

Mrs C: 

Do you mean to say that we need to move forward and get in tandem with therapy schedule?

Dr S:

Definitely. It is not just about therapy it is about everything in life. We know that COVID is here to stay we have many authorities stating that it is going to be a pandemic and slowly it is going to be an endemic like Swine flu or other illness. We are going to live with it. Whether we have vaccines or not, this is not going to go away from the community. Given that fact ,we must look forward as to how we are going to handle this. We cannot expect the pre-pandemic situation to return. We need to start looking at other options.

Mrs C: 

Do you mean to say that ultimately, we need to come onsite as the situation is not going to go away?

Dr S:

Our response must be according to local community spread. It cannot be same for every state, community, or city. We must provide care based on the situation in the society. Depending on this we  have to provide onsite or a distant or online therapy where the parent becomes the provider  and the therapist/specialist  trains the parent to deliver it. The therapist here provides therapy through the parental mode. In fact, I would go a step further and we should probably think of providing a hybrid mode, ready to shift from one mode to another depending on the situation in community. We need to continue to provide care. It may not be the optimal mode of providing care, but it is better than not providing care at all.

Mrs C: 

How safe is the onsite therapy?

Dr S:

Being a medical system which was running through the pandemic, our adaption has been according to the recommendations and to  to the needs of the challenges, Whatever needs to be done in the form of screening patients  who come to the system or in the form of providing only one to one therapy, stopping group therapy, ensuring  safety of provider to ensure continuity of therapy is being done. We are ensuring that the place is sanitized. We make sure the rooms are sanitized before therapy, just before therapy starts, all materials are sanitized, then therapy is administered. Once the therapy ends, the entire place is again sanitized, and the items are sanitized too. Though the recent evidence does say that fomite borne infections is low, we still ensure that kids are safe. We are also ensuring that the parents are there with the child and most of the handling of the child is done by the parents so that physical touch by others is avoided as far as possible. Enough amount of social distancing is ensured between the child and the therapist.

Mrs C: 

The escalated costs, time, and stress on the system as a result of this. How have you coped up with that?

Dr S:

It is all part of the game and if we are to ensure sustained therapy, we need to sustain in every other aspect as well. It is not the time to look at cost now. The other point is about time. Yes, it is taking away lot of our time. You can imagine, literally mopping down the entire space and cleansing every material  after every therapy is taking a lot of time. But I feel that this is going to be essential . With time, as we get better evidence on maintenance, we may probably scale down this amount of precautionary measures. As of now we are taking all precautions as we still cannot take such evidence as final word.

Mrs C: 

Doctor, in this context, I would like to know as to how you have managed with cost? Have you transferred it to patients?
Dr S:
Cost has escalated. But it has not been transferred to the patients. We are bearing it. As of now, we are able to manage. In fact we have packaged our costs for therapies at 10% lower than the pre-pandemic costs.

Mrs C: 

How would you assess/ elaborate your online interventions ?

Dr S:

As I mentioned earlier, to measure any outcome of an intervention, you should allow sufficient time for the intervention to act. There is a time lag between  providing therapy and outcome being manifest. In rehab we know it is going to take a long time  before we can  have a definitive outcome. This is where we stand as far as evidence is concerned. We only started in April and with the kind of numbers we have, I do not think that I can clam that I have evidence for or against the online therapy. There have been  previous papers about online settings and those are in different community settings, time etc. We cannot extrapolate those data in our system. We will be able to gauge this only with time. But what I can say is that by not providing therapy, these children are going to  slip. But I can say that by providing online or hybrid therapy and by studies in other organizations where parent directed therapy have been effective, I am confident that this will be a good mode to provide therapy during these Corona times.

Mrs C: 

Thank you, as we carry forward this confidence that you have,  I  would want you to give this a finishing touch with a two liner for every parent.

Dr S:

We are challenged by the present situation and we need to look forward and start adapting. We cannot continue to say that the previous setting would come back,  and we would only work around such setting. We should start looking for options, other modalities of providing care, education, and stimulation for children. In this setting we can spend the time to communicate appropriately with children and we should realize that we are the role models in showing strength, resilience, and patience. I am sure that children will grow up  watching this and as they grow up, they will realize that they have learnt a very important lesson in life when they face adverse situations.

Thank you!

INTERNATIONAL DAY OF THE DISABLED

Mrs Chitra, Health Communicator, Nishta Team

Today Dec 3, is the International Day of the Disabled. The theme this year is : Empowering persons with disabilities and ensuring inclusiveness and equality.    There are scores of programs, schemes  etc. towards this goal  but then why haven’t we still not been able to empower the disabled adequately? Empowerment has a deeper connotation than enabling in the context of the disabled. There needs to be a change in the mindset of the society at large as well as the disabled themselves.

Serving the underprivileged should be more than a mere lip service. Supporting a disabled person adequately means designing our plans be it for a party or work or an event considering the challenged in our plans. Given the rate of disabilities that we see in our society, we need to be more sensitive about this issue. In the race to be the best we even forget our own self, but it is time to reflect on issues of social concern with a genuity. 

There are numerous stories of heroes with disabilities and one common streak in them is their will to get out of their self-pity. Heroes are inspiring and the most inspiring aspects of the heroes with disability is their will to win over their weaknesses and barriers.

Tamilnadu has inspiring stories of Shri.H.Ramakrishnan, Ms.Preethi Srinivasan,Shri Ramakrishnan, Shri.Sankarraman and many more. Let us take a leaf out of their notes.  In the state of Jallikattu revolution and Gaja relief work this should not be a problem. The society including the disabled should make a move. Let’s do it.

 A thought is the seed that transforms into a tree called action, so let us think about this today and work with a goal to empower the disabled and ensure inclusiveness and equality in the society

Let the action begin!!*

Dr.S.Subramanian

Autism has been recognized as a neurological condition characterized by difficulty in social skills of those afflicted. Autistic people do have emotions and empathy. They are not a class to be condemned. Many have good intelligence. 

Autism as a condition has gained global attention in the recent past. With evolving research and ideologies focusing on causes, prevention and therapies the need of the hour is for us the general society to understand the context and concepts behind it. As with any evolving field, there are going to be new theories postulated and certain old thoughts thwarted. We have to be mature and dynamic enough to accept the ones with solid scientific base and reject the flawed ones. 

More than lack of understanding, a major dissuader in autism awareness is the set of myths associated with it. It takes a very short time span for the myths to spread while it takes a painstaking effort to remove those. One of the popular misconceptions was linking childhood vaccines to be a trigger. This notion is still in the minds of many while it has been scientificallyproved and accepted by the medical fraternity that vaccinations do not contribute to autism.Another misconception was that parenting style is a contributor to autism, with autistic kids lacking the maternal warmth in their upbringing. 

“Vasudaiva kutumbakam”, is a popular quote by many. It means the world is a family. Is it not time we extend this into action? If one among the family is different, we do our best toaccommodate their interests, we try to understand them. Same goes to our autistic brethren. While they take their strides towards progress, we the more mature and supposedly better endowed with social skills need to be accommodating them as part of our society.  We need to facilitate the social life of autistic people. Try to be empathetic, teach young ones to accommodate such people in peer groups. Be it school or workplace or a public forum, let us welcome them. Please remember they do not need our sympathy, we need to understand and accommodate them.  

While science strives to help the cause of autism, I strongly believe the society is the biggest contributor in empowering the autistic. 

As a pediatrician, it is heartwarming to see many children cruise out of illness. But I do not want to stop at that. I want to see what we can do as a society to help the not too lucky among us. Chennaiites are known for their activism for a cause. Be it flood relief or jallikattu protest. I want the youth to use their power of viral uprising to understand, facilitate and fight for the cause of a dignified life for the autistic. Are you with me?

*This article is reproduced from the Autism awareness booklet by Nishta Neurodevelopment Centre 

FLAT FEET

Here are a few facts about FLAT FEET, shared by our physiotherapist Mr.Lokesh Kumar.

What are flat feet?

 Most adult feet have an arch along the inside edge of the foot. Flat foot is when this arch is apparently absent or reduced in standing. The arches may ‘appear’ when your child is sitting, when the big toe is bent backwards or if your child stands on tiptoe. Before the age of 3 all children have flat feet, as the arch on the inside of the foot does not begin to develop until after this age.

What causes flat feet?

 The many bones in the feet are held together by stretchy bands called ligaments. Flat feet are usually due to loose or soft ligaments and baby fat between the foot bones. This causes the arch to fall when your child stands up which is why flat feet are sometimes called “fallen arches”. The typical flat foot is flexible and most children have no symptoms. Flat feet can occasionally be caused by tight muscles, which is more likely to cause pain. There are different terms that are used to describe flat feet but essentially they all mean the same thing.

 They are: · Pes planus · Pes valgus · Pronated feet · Fallen arches

Will my child need treatment?

 If your child does not have any associated problems with their flat feet then they are unlikely to need treating. Many people have a long -standing belief that flat feet are abnormal and require treatment with special shoes, insoles or even splints or braces. We now know that the majority of children between 1-5 years of age have flat feet. This is part of normal development of their feet and over 95 percent of children grow out of their flat feet and develop a normal arch. The other 5 percent continue to have flat feet, but only a small number will ever have a problem. Most children with a persistent flat foot participate in physical activities, including competitive sports, and experience no pain or other symptoms. It is less important how your foot looks as to how it functions. However, if your child complains of foot, ankle or knee pain, or has poor balance, or poor stamina in walking, then a referral to see a physiotherapist may be necessary. They can then assess the problem and treat appropriately if required.

 What would be the treatment?

 Treatment for a more severe or painful flat foot can consist of exercises and/or stretches for your child to do. It can also include your physiotherapist referring your child to an orthotist or podiatrist who specialise in providing corrective devices such as arch supports (insoles) to put in your child’s shoes. Most children with painless flexible flat feet do not need any treatment. Insoles will not change the shape of the foot and are therefore not a ‘cure’; they simply hold the foot in a better position so that it can work more effectively and may help reduce some of the symptoms.

 Will anything make it worse?

 No, you do not need to restrict your child’s activities. Walking barefoot, running, doing foot exercises or jumping will not make flat feet better or worse. Supportive footwear is always recommended for your child’s feet.

 

MATHLOGIC OR MATHEMAGIC?

Is Math Magic or Logic?

Too often, we are puzzled with the topic in question – Is math a magic or logic? Let’s unfold the logic behind the magic.

Math is based on pattern, language, symbol, and visuo-spatial aspects.  If we can appreciate the importance of these aspects, math can be a cakewalk. The first step toward decoding the logic is to understand the various operators, symbols and remember them. Then the logic behind each one of them can be revealed and as it unfolds, one can work magic with it.

Based on language and symbol math is a logic. For example let’s take the word “Volume”. Volume of a cone is different from volume of a radio or voluminous meaning volume of a book.

When we take a symbol at the elementary level, the four main operations are plus, minus, multiply and division. When we take the operation of division the symbols that are introduced for the same concept are first L  then ) followed by) ---- (   and of course /.  

In the above concept, the visuo spatial aspect is concerned and the visuo spatial is connected to pictures with magic and the space it occupies is logic.

Let’s see the magic. For example 4.1.2018 can be written as 2 ².1 ². 4² + 4 4 ²+2. Isn’t this pattern a magic?

So from 0 to 9 the numbers with their vibrant patterns, language, symbol and visuospatial profile make Math Magic and Logic too!! You can work magic if you can first understand the logic. It is indeed fun!!

Mrs.Sujatha Sriram

Department Head of Special Education

Nistha Center

 

                                                                

 The role of routine in your child's life!!

Routines help children do better with everyday tasks, boosts confidence to handle life and can be used to help the child meet developmental milestones through early intervention.

Three types of routines are vital

Transition routines
They help your child switch from one task to other with ease.  For instance if it is lunch time after a reading session, plan a reading activity on food at the end which would remind the child of food and what to expect next. Plan transitions for every activity right from therapy sessions to fun time. This will help the kid internalize changes in activity.

Intervention routines

You might be taking your kid for therapy sessions where they will be taught new skills as part of interventions. Combining those interventions with the child's daily routine can make it far more effective compared to therapies that occur only during the therapy sessions. For instance, for a child with delayed language development, you  could say the same phrase every time the child takes a bath so that the child learns to associate those words with the activity.

Play routines

Routines can be especially effective during playtime because the child is more likely to be fully engaged in the activity. For instance, a child being taught to button a shirt can be engaged in a dressing up game for a toy and this can be repeated every day so that the child picks up the ability. Later the game could be modified by playing the game with self- buttoning.

The above are few instances where routines help a child have a grip over daily activities.

MULTIPLE INTELLIGENCE

Multiple Intelligence- a Pediatrician's perspective

 

Dr.S.Subramanian

 

 The variety and dynamism that I see in the children that come to me, enthuses me.  Alas! I find that most of the time, their potential is not brought out.  I keep pondering if there could be a means to tap the apt means to bring out the best in every child.  Multiple Intelligence could be one way to do so.

 

Dr Howard Gardner, Prof of education in Harvard University developed this theory of Multiple Intelligence. This has helped educators, psychologist and parenting experts understand how children process and learn information.

This is a theory that directly challenged the traditional understanding of intelligence and its evaluation.

According to this theory every child has seven different intelligence. Once we understand this, it becomes easy to present a given information in a pattern that may best suit a given child.

The domains are (as seen in the picture)

Linguistic, logical- mathematical, spatial, bodily-kinaesthetic, musical, interpersonal, intrapersonal, natural and existential.

How are we to use this theory best? Though there are multiple ways in which this theory an be successfully applied in a daily life or class room setting, like any other idea, there has been an array of offshoots and methodologies that claim to have originated from MI theory. Dr Gardner, himself has suggested three possible ways in which this theory can be applied in day to day setting.

1.       Multiple approaches to a concept, subject matter or discipline- creating variety of ways in which a single item can learnt. The more the number of approaches more likely that more children are understanding the concept better. This can be especially be done to make children understand and explore and get hands- on with respect to certain important concepts.

2.       Personalisation of education: understanding a child's strength and understanding that essentially all of us are different in the way we approach a learning. MI theory takes this concept seriously. As a corollary, when the aim is to help a child understand a key concept or help a child understand a specific field of learning it needs to be individualised to the child's strength based on MI.

3.       Cultivation of desired capabilities: schools should plan to cultivate skills and capabilities that are highly valued in a given society. For eg if in a community performance of musical instrument is considered important, then it is important and of high value for schools to cultivate intelligence related to that domain.

Yes, multiple Intelligence does explain to us why a given child takes to a specific domain like music or public relation easily. But it also gives us approach or pathways to reach, teach and inculcate concepts that are considered important for a child to be part of the community as a whole.