Mothering: What is Quality time?

Time and again, I have had patients who have forgotten the meaning of parenting so much so that they will continue to provide sustenance but hold back love and attention in their child on an ongoing basis. Mothers who are so worried that their figure will spoil if they breastfeed their infant, fathers who claim that they love their child but will stay at their place of work from dawn to midnight (thereby ensuring that they never meet their child awake), parents who give expensive mobiles to their child, or X-boxes, or PS3, but will not be able to spend half an hour each day just talking to their daughter ... these are the sure prescriptions for disaster.

Quality time means devoting 1-2 hours every day for simply "being" with the child/children, with the T.V. switched off, the mobiles put away, no guests or visitors, no chiming door-bells to disturb the bonding and then, listening to your child. Listen. Don't unburden your problems when you meet with your child. Remain silent and attentive, and listen. Play, sing, dance, jump, or just ... listen. You will be surprised at the amount of information that really trickles in ... even a small toddler with a vocabulary of less than 100 words will tell you things you could not have even imagined.

Bonding begins at birth, but the process continues throughout the child's childhood, teenhood, and occasionally into adulthood too.

What are the pros and cons of seeing a specialist vs. a general practitioner for day-to-day illnesses of children?

The title looks forbidding, does it not? It must be first made clear that what I am about to write is most applicable for the kind of practice in India. You see, and this is for readers from places other than India, we have a two tiered private practice system in India, which is in addition to the practice that is available from municipal and government hospitals, which is collectively referred to as the "public" system. 

Going back to the private practice, we have general practitioners, or family doctors, who have the basic practice of seeing all ages of patients from a newborn baby to a nonagenerian (that is someone who is over 90); he/she not only sees the patient, he/she may refer the patient to a specialist or to a lab or a diagnostic centre, and finally, if no referrals are done, he/she may, in the patient's best interest, even dispense a medicinal mixture of syrups and tablets. This is charged quite nominally.

On the second tier, of course, are the various specialists, and they include, not just the basic specialists like pediatricians, but also super-specialists like cardiac surgeons, neuro-surgeons and the like. These doctors, some of whom have their own hospitals or nursing homes to manage in-patients, are those who have studied further and specialised in a particular area. They are generally known to see the patients and write down medicines which have to be purchased from the pharmacy. Their practice is more in the nature of a consultation, and hence, their charges are also higher.

The question that many parents do NOT ask is: should I go to the G.P. and get the medicines or should I seek an appointment with a specialist? Now, this post is not meant to denigrade G.P.s or shower enconiums on specialists, since I have known G.P.s who are really good at diagnosing and treating illnesses on a day-to-day basis; conversely, I have seen specialists who are bad ... bad enough to jeopardise the life of their own patients because of errors of omission or commission. 

Generally, however, the benefits of going to a specialist increase as the age of the pediatric patient comes down ... in the youngest of the young, it is always better to visit a specialist. This is not only because G.P.s have less knowledge about how to manage the baby-patient, but also because babies cannot speak, and the index of suspicion of a major illness has to be very high so that no problem is missed out. Action must also be that much more prompt; for example, a child of 10 years with a mild cough can be managed by the G.P., but the same complaint in a small 1-month old baby may be associated with a potentially bigger problem like a pneumonia and may need even hospitalisation. 

In addition to this age-related difference, there are a few more advantages of going to a specialist: as the medicines are prescribed, there is no secrecy of the prescribed medicines, and this allows the patient to cross check the treatment with any other doctor of his own choice (something like a second opinion, but without the formality of a request sent by the first doctor - a thing that is very normal in India). Also, the complete course of therapy is written down, so that the patient does not have to go to the doctor every day. Whereas, with the G.P., only 1-2 days' treatment is usually dispensed,  and often, as there is some relief, the patient is then NOT taken back to the doctor.

This is not to say that G.P.s are not at all advantageous! They are! Sometimes, they are the only doctors available, for example, late in the evenings when the consultants have already left. At times, they are better able to understand the dynamics of a disease as they know the entire family, they have visited the patients' homes, and so on. This helps them to easily decipher environmental or epidemiological clues to a possible infectious illness. Also, they probably have known 2-3 previous generations of the child and know which illnesses prevail in a particular family, what kind of thinking (howsoever much abstruse or crazy it might be) prevails among the senior members of a family and so on. Finally, as they have seen the treatments of many different specialists in their years of practice, they are often able to pinpoint the better specialists from among the many who are practising in that area.

Does this make the decision making easier or more difficult? I don't know, but it is for you, dear reader, to understand what I am saying.

What is the Injectable Polio vaccine?

Several of my patients have been asking me about the recently made available vaccines in the Indian market, and one of them is the Injectable Polio vaccine or the I.P.V. So what is it, really?

Well, in India, the government is currently struggling with the final stages of eradicating poliomyelitis, a crippling disease that now occurs in less than ten countries all over the world. Although the incidence is falling every year, we are still having to conduct special rounds of pulse polio immunisation and mop-ups to take care of the cases of poliomyelitis that are still being diagnosed - mostly from the state of U.P.

Having said that, today, we give 2 drops of the Oral Polio Vaccine or the OPV to all the children. However, this is the case only with the few countries where cases of polio are still being diagnosed. In all the other countries of the world, whether from the Western world or the third world, the vaccine that is administered is the more effective and less problematic IPV.

It is more effective because giving three shots of this vaccine to all children below the age of one year and a booster each at 18 months and 5 years will probably wipe out poliomyelitis sooner than the oral vaccine will (or can!)

I currently give IPV only after a one-to-one consultation with the relatives of the patient. In such cases, the routine doses of OPV can be avoided.

When should one worry about an illness?

I have often wondered about what makes a parent who is nursing a sick child decide that it is time to take her to a specialist. In India, we often have people who cannot afford the specialist's fees: but then, I believe the same is the case even in developed countries when the family does not have insurance. So there.

Imagine, for a few minutes, if you may, that your child has started having a runny nose. I don't think you are going to run to a specialist with just THAT, are you? Now think what you will do if she has a slight cough AND a little temperature. At this point, if you have seen such a thing before, or if your child is a little older than being a baby in arms, you are probably going to do one of the following (in increasing order of anxiety):

1. Ignore the problem and say - it is no big deal, she will soon be all right
2. Make a concoction of home-based stuff like ginger tea, honey and ginger drops, an inhalation of an aromatic substance like Vicks VapoRub or roasted seeds of "ajwain"
3. Give her one of the previously prescribed cough and cold mixtures that your child's specialist had given on a previous visit
4. Go to the local chemist and ask him to give you a suitable cough and cold medicine
5. Call up your local family doctor and ask him if the medicine you have in your medicine cupboard is all right to be used
6. Go to the local family doctor and ask him to "give" you some medicine for cough and cold for your child, or at least prescribe it
7. Go to the local family doctor with the child and seek a proper check-up and prescription
8. Call up the specialist and ask him to either suggest some medicine for cough and cold or ask him if the medicine he had given to your child previously will be all right this time too
9. Go to the specialist with the child for a professional consultation

Now, based on the list above, where are you likely to be? And what has made you decide that position? In my opinion, people do an action after a lot of confounding variables are taken care of:

• Is the child really sick?
• Does she really need a professional consultation or is a phone call going to be enough?
• Can I afford a pediatrician's fees or should I make do with a local doctor?
• How old is the child?
  
• Can I afford to take a risk with this child after already having lost one to pneumonia?
• Did I lose that child with pneumonia because I neglected it or because my wife did not take her to the doctor in time ....

and so on.

Thus, as you can see, parents do not often think alike in these matters.

So, here is a guide: take the child to a specialist if:

1. She has been ill for more than two days and the medicines that you have been giving her (whether herbal, home, local doctor or specialist's previously prescribed medicine) does not seem to be working
2. She has very severe symptoms - lot of loose motions or vomiting, dry hacking cough with chest pain, severe headache or stomach pain that makes the child cry, she is unable to breathe because of a blocked nose, etc
3. She has dangerous symptoms such as bleeding from any orifice, dark coloured urine, blood in stools, a fit, a difficulty in using any part of the body - muscles and bones, I mean, a loss of consciousness however brief, a change in voice or speech, a swelling that is very painful, a very high fever more than 39 C or 101 F, change in vision or hearing, and so on.
4. She has recurrence of symptoms within a few days of stopping the medicines for the same problems
   
5. She develops fresh symptoms like a rash, high fever, visual disturbances, headaches, bodyaches, bloody vomiting, difficulty in breathing or blood in the urine etc. soon after taking a certain medicine
6. She has acute vomiting or loose motions or both within hours of consuming food - esp. in a restaurant or at a community dinner
7. She is not the only one with a particular set of symptoms: many of her school mates have the same problem, or many others in the family

Of course, this list is not conclusive, but I am sure it will be a help to parents who often get stuck about what to do next.