Over the past week, at least three infants a day have been brought to the emergency ward of Sir Ganga Ram Hospital (SGRH) with persistent cough and breathlessness. Roughly 10% require admission; almost all of them are sent home with a nebuliser. At the moment, the hospital’s paediatric ICU has four kids on inhalation therapy.
The youngest is a 10-month-old boy.
“Infants and children suffer more than adults. There has been a consistent rise in the use of inhalation therapies like nebulisers, metered dose inhalation and dry powder inhalation in the last five years. More and more children are prescribed inhalation therapy due to recurrent cough and respiratory symptoms,” said Dr Anil Sachdev, director of the paediatric intensive care at SGRH.
As Delhi’s air quality has plummeted since Diwali — with a mix of firecrackers, stubble burning, wind and weather factors taking it to the ‘severe’ level — the city’s children have been worst hit. On Friday, as a public health emergency was declared and schools were shut until November 5, Chief Minister Arvind Kejriwal spent his morning distributing pollution masks to children.
Across the capital, doctors and public health specialists told The Indian Express, children are dealing with illnesses that could have long-term effects.
An alarming number of them are on nebulisers, used to administer medication in the form of a mist inhaled into the lungs. The most common symptoms of respiratory trouble, doctors said, are inflammation of the nose and lungs, red and sore eyes, sleeplessness and prolonged nasal discharge. “People are now aware that doctors will advise them to buy nebulisers, so many keep the device at home as a preventive measure. The sale of such devices has more than doubled this season,” said Dr Arvind Kumar, founder of the Lung Care Foundation and chairperson, Centre for Chest Surgery, SGRH.
According to doctors, exposure to high levels of pollution can also impact a child’s neuro-development and cognitive ability. Children also become prone to cancer as well as cardiovascular diseases later in life if exposed to pollution for a longer period of time, doctors said.
“Pollution can have an acute and, sometimes, long-term effect on youngsters… Exposure starts from when a baby is in the womb… whatever gets into the mother, some amount of it enters the blood and placenta. If exposure to pollutants is there for a period of time, it is going to affect the growth and function of the lungs,” said Prof Rakesh Lodha, department of paediatrics, AIIMS.
Those with a history of asthma are especially vulnerable. “For such children, nebulisers and inhalers are part of maintenance therapy. This controls inflammation for some time so that the child doesn’t get flares of acute attacks… Increase in pollution also increases risk of pneumonia. A fair proportion of children are diagnosed with pneumonia these days, and air pollution increases the risk of contracting the disease,” added Prof Lodha.
Experts said the finer PM 2.5 — atmospheric particulate matter with a diameter of less than 2.5 micrometres — can go much deeper and reach lower airways, causing more damage. Moreover, pollutants such as sulphur oxide and nitrate can further exacerbate the condition.
“PM 2.5 goes into the lungs and has a long-term effect. Many children who are exposed to this have a greater chance of getting asthma and bronchitis. The damage has a lasting effect. More cases of asthma are coming up year after year,” said Dr Rohit Sarin, director, National Institute of Tuberculosis and Respiratory Diseases (NITRD).
The institute, in collaboration with IIT-Delhi, also conducted a six-year follow-up study, in which they found that the proportion of patients visiting the emergency department and OPD increased manifold during peak pollution season.
“The study also found that air quality in Delhi has deteriorated over the years,” added Dr Sarin.
Given the gravity of the situation, a multi-centre study in collaboration with UK researchers has been kicked off in the city. The study, called DAPHNE (Delhi air pollution: Health & Effects), has been divided into two parts — one is to assess the effect of pollution on children, and the second to see its impact on pregnant women.
Both studies kicked off last year. While AIIMS is responsible for the first part of the study, the Delhi government-run GTB Hospital is taking care of the second part.
“The actual assessment will begin this year. We had given children a wearable belt to monitor their exposure to pollution; this has now been replaced with a small sensor. This is the first season we are going to observe the children and analyse data. The study will also help us identify how a child’s health is worsening with changing levels of pollution,” said Dr Karan Madaan, associate professor, department of pulmonology, AIIMS.
For pregnant women, the hospital is tracking foetus growth. IIT-Delhi is monitoring mothers’ exposure to air pollution and GTB is tracking foetus growth by performing ultrasounds, collecting samples. Personal sensors have been given to pregnant women and doctors visit their houses once in three months to assess levels of air pollution.
“We are using extra parameters like foetal biometry to get an idea of foetal growth,” said Dr Kiran Guleria, principal investigator of the study from GTB Hospital.
As per an analysis in the Global Burden of Disease 2017, reported last month, every three minutes, a child dies in India because of inhaling toxic pollutants. As per the report, 1,95,546 children lost their lives due to air pollution-related diseases.
“Children are the biggest risk group and more prone to having reactive airway disease. The younger the child, the less developed the airways. The diameter of the airway is not adequate and a little mucus and swelling in the airway reduces it further,” explained Dr Sachdev.
Lower respiratory tract infection caused by exposure to air pollutants was recorded as the second biggest reason for child mortality, after neonatal disorder, data from 1990-2017 suggests. Data stated that LRI claimed the lives of 1,85,422 children aged between 0 and 5, and 10,124 children aged between 5 and 10.
Meanwhile, as custodians of children for a significant portion of the day, schools in Delhi-NCR have, over the last few years, started working in the post-Diwali season to adapt to the environmental changes as well as the increasing alarm over deteriorating air quality.
“Three years ago, when we saw that the situation was poor, we started taking a number of steps. At that time, we didn’t have air purifiers — it wasn’t a very known thing. We got those as well as more plants. We use sprinklers on the approach-way and along corridors, which go a long way in making it better. We have re-aligned our annual calendar so that sports days and other functions, usually conducted in October-November, are done with earlier,” said Shashi Banerjee, principal of Shiv Nadar School, Noida.
Schools in the capital were shaken into making sure their medical rooms are stocked with resources to deal with respiratory illnesses after a tragic incident 10 years ago in which a class XII student of Modern School, Vasant Vihar, died after an asthma attack in school.
“If we find that a child is wheezing, the first step is to stabilise them through these means. But the immediate next step is to contact their parents so they can decide what medical measures they want to take. We have medical records of all students, so teachers know which children to look out for. When pollution levels rise, we communicate to parents of children with asthma and bronchial disorders that they may choose to keep them at home for a few days,” said Nikita Tomar Mann, principal, Tagore International School, Vasant Vihar.
However, most principals also felt that shutting schools is not only a limited, but also a counter-productive step. “We are talking about a diverse milieu of students here. There are those who live in slum clusters, students of government schools… For parents who do not have help, who will ensure the children do not go outside? Many parents are more comfortable with children being in school where they will be engaged indoors. In any case, there are so many children out on the street,” said Ameeta Wattal, principal of Springdales School, Pusa Road, arguing that an alarming situation should not be created, and a more holistic government approach is required.
“The effects on children are going to show in the long term. For now, those who require immediate attention are those who needed it anyway because they already had asthma, bronchitis. But for the rest, the air quality has to be addressed by the government; these conversations on nebulisers and purifiers are limited,” she said.
Health experts, however, warned that given the high levels of pollution, the air indoors isn’t significantly better. Leading pulmonologist and director of AIIMS, Dr Randeep Guleria, also said most people are still unaware about using an N-95 mask: “Those with severe asthma can opt for a three-layered surgical or an N-95 mask. But it has to be worn tightly around the nose and mouth. If it is worn loosely, it will be of no use. At best, masks and air purifiers give you a false sense of security.”