With a compilation of ‘Guidelines for Parents’ of young and adolescent children, prepared by the Indian Academy of Pediatrics (IAP) all set to be released in January 2022, India becomes the world’s third country to bring out these important instructions, after the US and UK.
As of today, the IAP, which was set up in 1963 with 150 members, boasts a membership of 32,000 doctors across the country. Talking of the need for these guidelines for parents, outgoing president Dr Piyush Gupta says, “These guidelines are not being prepared because of the pandemic, it was a long-felt need to create a document which gives authentic information about the need for good health, food and clothing.”
The guidelines, divided into 12 chapters, deal with topics like “How to deal with my child”, and preventing disease by immunisation, behavioural and developmental issues (bullying, stammering, stuttering, suspecting abuse in children, autism, and so on), gastro-intestinal disorders, respiratory disorders and renal disorders. The last chapter, titled “Miscellaneous”, deals with issues like environmental pollution, drug and substance abuse, Down’s syndrome and child rights and labour laws that have become very important in recent years. In all there are 105 topics that the guidelines cover.
On whether these guidelines would be mandatory for pediatricians across the country, Dr Gupta says, “We have not defined medical treatment in these guidelines. These are instructions from subject experts about caring for the child, who is afflicted by a disease, and give the most relevant FAQs so that when the parents visit a doctor they can get their doubts cleared.”
Dr Kiran Aggarwal, former head of the Delhi Chapter of Pediatrics and a child rights activist, explains further: “The problem in India is that there is no single protocol being followed by doctors in different states and there is confusion as parents rush from one doctor to another to get a second and third opinion, unlike in developed countries where the rules and treatment are clearly spelt out. Hence these guidelines will fill that gap as all these chapters have been written by experts in their fields who have been working on these issues, diseases, etc. If a child is not getting treated by an expert the parents can ask the doctor why their child is being treated differently from what is mentioned in the guidelines.”
The problem with medical treatment for children is far more serious than is commonly realised. It is a travesty of justice that while the government is very serious in making a six-month working stint in a village compulsory for an MD, the treatment by our leaders of children remains muddled.
Even if doctors treating children cannot be called ‘quacks’ technically, according to Dr Anil Bansal, who has headed the anti-quackery cell of the Delhi Medical Association for years, practising doctors who put out signboards claiming to be child specialists or gynaecologists do not have the required degrees.
‘The problem in India is that there is no single protocol being followed by doctors in different states and there is confusion as parents rush from one doctor to another to get a second and third opinion, unlike in developed countries where the rules and treatment are clearly spelt out.’
“There are actually very few pediatricians available because it is mandatory in pediatrics to do either a three-year degree or a two-year diploma course after MBBS but most general medicine practitioners put up such boards because the maximum cases that come to them are of either children or pregnant women.”
Could they be hauled up for cheating like quacks? “Not easy,” says Dr Bansal, “unless we get a complaint. We can’t conduct raids on them because they have their MBBS degrees. Many of them say they have years of experience, and that an additional degree is not needed.”
Practising pediatricians admit that this was true earlier, but it did not really matter because most doctors joined government service then and they were asked to work in OPDs of different specialities including pediatrics. So, if a doctor had, for example, experience of 10 years or more of working with children he knew what he was doing. Today, of course, all new entrants have the mandatory degree, and they cannot be called quacks.
But the problem is not just related to a degree. The issue is that pediatrics has not been taken seriously by academia and the government. Even though the IAP was set up in 1963, until about seven to eight years ago there was no Indian textbook available for those going in for post-graduation and they were dependent on an American publication. The academy wants to change this. In its Action Plan 2020-21, the IAP plans to liaise with DNB instead of only MCI to increase subspecialty programmes in pediatrics, as there is no training in areas under the specialty.
Even if doctors treating children cannot be called ‘quacks’ technically, according to Dr Anil Bansal, who has headed the anti-quackery cell of the Delhi Medical Association for years, many practising doctors who put out signboards claiming to be child specialists or gynaecologists do not have the required degrees.
Many practising physicians admit that the lack of standard protocol has often led to violence by parents who complained that another doctor they had consulted had provided totally different treatment to their children for similar symptoms.
A Gurugram-based doctor pointed out, “Gurugram is a corporate town and there are no government hospitals, which means that those who come to these hospitals are paying two to three times more than what they do in Delhi, for instance. These parents, irrespective of what strata of society they belong to, are very demanding. They demand a cure in three to five days with the result that the practising pediatrician is forced to suggest antibiotics and other medication which are not advisable for children. In government hospitals the doctors can get away by saying that the cure will take time because they get their salary from the government, but we can’t as the customer will not come to us again. Incidentally, it is only in India that doctors are forced to commit that they will cure the child. In developed countries a doctor will say that they are doing their best and the parents have to wait patiently.”
According to Dr Kiran Aggarwal, in this fight for survival of the fittest, a crucial aspect of pediatrics that has remained neglected is developmental pediatrics that deals with issues like autism which is a lifelong condition. “It is very critical when dealing with children with autism to prepare the parents or guardians to live with the disease. They can’t be fooled by selling them dreams that this is a temporary issue and will get cured with time. Particularly if the firstborn is suffering from autism, the parents have to ensure that the other children or members of the family know how to live with the reality. It is here that the role of the doctor becomes crucial. But are we training them for it? You will be shocked to know that there is only one Child Development Centre in the country to deal with children who need support for disabilities like cerebral palsy, mental retardation, autism, spectrum disorder, attention deficit hyperactivity, specific learning disorders, neuromuscular disorders and behavioural and other psychological problems. The CDC is in the Maulana Azad Medical College in Delhi and was set up in 2001 after a court order.”
Practising physicians point out that the lack of standard protocol has often led to violence by parents, who complained that another doctor they had consulted had provided totally different treatment to their children for similar symptoms.
According to the CDC website, it caters to nearly 1,000 new patients annually (which appears a minuscule figure by any standards compared to the estimated 16·8 million cases of cerebral palsy alone in India in 2019, according to The Lancet) and around 18,000 patients are accommodated for follow-up and therapy sessions. Dr Aggarwal says it is the only hospital with designated doctors to deal with issues relating to symptoms where the interventions are very expensive.
Another issue that needs a serious relook is the abuse of boys that is swept under the carpet. Though a lot is being said and written about child abuse nowadays and many NGOs and schools are arranging sessions on “Good Touch and Bad Touch” by specialists and counsellors, it is a less-known fact that more boys are being sexually molested than girls, and this is corroborated by a well-known pediatrician. She says that parents are very reluctant to come to her and choose specific hours so that no one comes to know about their wards.
Parenting is multidimensional and begins with responding to the child,s varied needs. The responsibility goes beyond keeping children safe and healthy to understanding the role of professionals like doctors and teachers, and social systems, like institutions and laws. Now, there is a way to know what,s right for your child and how to find it.