Kerala’s ‘Hridyam’ beats for children born with congenial heart defects, offers free treatment

This is an exclusive interview of Dr Krishnakumar R, Head of Department ,Professor, Department of Paediatric Cardiology, School of Medicine, Amrita Institute of Medical Science, Kochi given to Navjeevan Express Executive Editor R Arivanantham

R ARIVANANTHAM
CHENNAI, NOV 30

In a free-wheel chat with navjeevanexpress.com on the sidelines of Paediatric Cardiac Society of India (PCSI) held in Chennai recently, Dr Krishnakumar said that 0.8 per cent of children die due to CHD every year due to lack of awareness.

• Kids born with congenial heart defects are curable; early detection & treatment are need of the hour: Dr Krishnakumar R
• AMMA established Amrita Hospital to serve the children
• 0.8 per cent of children born with CHD every year due to lack of awareness
• Today, India has progressed a lot and southern states have progressed much more than other parts of the country because of the better education, better health care, and better awareness
• If the mother takes folic acid containing multivitamins in adequate quantity three months before conception, then one can avoid certain categories of heart defects
• We have done screening camps in Kashmir, in Jharkhand, in Uttar Pradesh and certain parts of Tamil Nadu like we have done in Virudhunagar

“When there was not enough number of trained paediatric cardiologists in early 2000, hardly two in 100 children used to get correct treatment. Keeping this in mind, immediately after my return from USA as a trained paediatric cardiologist, I started to train doctors in this specialization and that was followed by establishing the Paediatric Cardiac Society of India (PCSI) with 6 to 7 cardiologists, the number has now grown to 700,’’ he said.

He further said, “I built a training program. My first training program was established in the year 2003, and then I probably must have trained about 40 or 50 doctors in the country. We had to train them so that the speciality could grow and develop. So things have improved today. Earlier in the 1998, if there were 100 children born with heart disease, only two use to get correct treatment in India. That is the condition of congenital heart disease or even other forms of heart disease.’’

Today, India has progressed a lot and southern states have progressed much more than other parts of the country because of the better education, better health care, and better awareness. So we have been able to deliver much better quality healthcare services in southern India, particularly in Kerala, where it is now very good. It’s at par with the West. But even in Tamil Nadu there has been some progress. The main reasons for this, that ten more diseases know the disease has not changed, Dr Krishnakumar said.

How to identify the new born with CHD?

First of all symptoms is breathing difficulty, fast breathing room especially asthma, fast breathing ribs, excessive sweating during feeds in a poor feeding because of which weight gain is poor. Symptoms of the common defects in the heart called holes in the heart.

One of the common reasons for heart defects is they can become blue number, blue color of fingers, a pink color. That is because the blood oxygen content. The child with heart problems which are associated with cyanosis, that means blueness, the fingers will become blue, oxygen content will come down fingernail beds and lips and tongue. Your conclusion is that they are not doing well in terms of their oxygenation, and because of that, a lot of damage is done not only to the heart, but to the brain as well. Developing brain needs a lot of oxygen in the blood. If it is not provided, then the brain doesn’t develop normally. So a lot of complications develop because of that.

Kerala mandates every new born to be screened with Pulse Oximeter

Kerala has mandated that every newborn child should undergo screening with Pulse Oximeter within 24 hours of birth. So if there is a serious heart problem it gets picked up identified in time. Other thing that can be done is number mother.

Fetal Echocardiography

CHD of the baby can be screened before 12 weeks of delivery with the help of Fetal Echocardiography. If the defect is found, necessary medication could be given to save the child in womb and advise the concerned mother to get admitted at the hospital where Paediatric Cardiology facility is available for treating child born with CHD to go for cardiac surgery immediately after the birth i.e. between 16 to 20 weeks, Dr Krishnakumar said.

Heart disease detection training is inadequate

Dr Krishnakumar said, “The challenges that we are faced to identify the congenial heart disease were at multiple levels from lack of awareness among paediatricians. Heart disease detection training is not adequate because our central medical colleges lack cardiac treatment, so they are not aware. Awareness amongst paediatricians was not good, and awareness amongst general public was also not good. Second, you need trained people, you need good institutions, you need good facilities and you need lot of resources because these conditions are resource intensive conditions. Once you are able to put it all together, you can deliver good care.’’

Survival rate after CHD surgery is 98% to 99% in Amrita

After the correction of CHD through surgery, the survival rate in Amrita is 98% to 99%. Amrita can be able to give feel good result. So that is modern quality of care. That much is possible.

When can the CHD be corrected?

Some defects need to be corrected soon after birth. But some defects, doctors choose to correct a little later after six months, eight months. Some others can be corrected even much later, but they are relatively less common. Most defects that are serious need treatment early.

Is there a technology to correct the disease inside the womb?

There is no technology to correct the disease inside the womb. There are 1 or 2 conditions that may get treatment in the womb, but even then it is not corrected. It will allow the child to develop a little better. But that is mostly, I would say for all practical purposes we don’t have anything. Only after birth we have.

What is the reason for children born with CHD?

There are multiple reasons. Sometimes it is very much related to chromosome and genetic problems. Even when the heart defects chances are very high 50%. Sometimes it is because of mother’s exposure to some medicines and some environmental toxins. Very small proportion, but most of the times we can’t exactly pinpoint it.. In some cases we can identify, in some there is hereditary tendency. So mother has a tendency for the heart defect. The child can also have about 5% of her heart defects. Mother could have inherited from parents 5% some diseases. It’s a little more, but on an average 5% can be inherited from the parents. So multiple reasons exist from the mother or the family. The family has a genetic tendency for a certain disease. It may not manifest fully in the parents either, either the girl or boy. It doesn’t matter mother or father, it doesn’t matter some genetic conditions. That is, for example a common heart defect ASD – atrial septal defect  — sometimes called a hole in the heart — is a type of congenital heart defect.

Mother or a small percent chance child will also have if that gene is present. So there is a small proportion. Often mothers get very guilty heart problem. Is it because of me? I reassure them by saying that no 99%, 95% of the times it’s not you, but small percentage. So if that particular child’s defect cannot be attributed to genetics, it’s not your fault. So it’s only a small proportion then others. It’s a matter of research. We are working on it. We are trying to find out some other associations. For example, we recently found rapid climate change, high temperatures. They may have an association with higher likelihood of a critical time heart problem develop. If there is an exposure to high environmental temperature, we are finding a weak association with the likelihood of congenital heart disease.

What are the precautions the pregnant woman should take?

So one of the things we have found that they call it preconception period at a time when the conception happens. If the mother takes folic acid containing multivitamins in adequate quantity three months before conception, then one can avoid certain categories of heart defects. Another thing is there is one infection in the mother called rubella or German measles and rubella infection. Still in India, we are having a lot of children who are suffering because they are having heart defects, because the mother had rubella. If mother has rubella in the first few months of pregnancy, there is a high chance that the child will be born with heart defects. Now this is very simple. It can be prevented by rubella vaccine and unfortunately in India that still there are many mothers who are not getting rubella vaccines, and folic acid in the preconception period.

Avoid consanguineous marriage

Then another very important thing is marriage within close blood relatives or consanguineous marriage. Overall, the south Indian states display higher occurrence of consanguineous marriages than other regions of India which is still very prevalent. Now if you have consanguinity, the chances of heart defects, birth defects of all kinds are higher.

Rashtriya Bal Swasthya Karyakram

There is a national scheme called Rashtriya Bal Swasthya Karyakram (RBSK) lunched under under the National Health Mission, which involves screening of children from birth to 18 years of age for 4 Ds- Defects at birth, Diseases, Deficiencies and Development delays.

It is basically a programme that was introduced to take care of the preschool children, pre-school.. They were given extra attention. This programme was a very beautiful programme because it took care of the children in the most vulnerable period, and heart defect is a part of that.

There is a scheme which is for and each state will have to adopt according to their local requirements, regional requirements in some way or the other. But in Kerala it took a little better shape in the form of a programme called ‘Hridyam.’ As per the current program your baby may be registered in the web portal – https://hridyam.kerala.gov.in/chd – so that the child is referred, followed up and tracked based on the guidelines and protocol.

Whether CHD treatment is covered under central, state health insurance schemes?

Treatment for CHD is covered under the state as well as central insurance schemes. Most private insurance schemes are not adequately compensating for congenital heart defects in this case.

What is the main goal of Amrita hospital?

Amrita Hospital has been a care provider. We are having a simple philosophy which is that we want to provide high quality healthcare at affordable costs. So our goal has not been to profit from this, but to try and make ourselves accessible, affordable without compromising quality. So that has been our motto throughout. So until recently we have been serving the region, but more recently we are now reaching out to the populations that are underprivileged across the country. So we have done screening camps in Kashmir, in Jharkhand, in Uttar Pradesh and certain parts of Tamil land like we have done in Virudhunagar. And of course now we are going to do in Ramanathapuram. So wherever there is a shortfall of services or difficulty in reaching out, we have a mandate that we have to go there.

How Amrita screening camps are organized?

We basically send out notices that anybody who is aware that their child has a heart problem, it may not be clearly identified but has not received treatment then they can attend our screening camps. We diagnose these patients, do the tests, and once we do the tests, we provide the advice and if we can correct the defect, we do it free of cost. We usually pair these events with the funder and ourselves. Also, our hospital also does a lot of funding of these surgeries. This is a mandate because this has been our kind of mission from the day we established our hospital. I think this as one of the big reasons why AMMA established Amrita Hospital. This was because one of the parents of a child with a heart problem came to her, and that was one of the reasons why she really felt it’s important. And she has said this in many occasions.

How many medical colleges have CHD training facilities?

Egmore Children Hospital, part of a medical college has paediatric cardiology division. CMC Vellore has some paediatric cardiology, but other than that they don’t have cardiac care in the public sector. In the private sector, in Kerala it’s a little better.