An Overview of Telehealth and Paediatrics
With pediatric telehealth, the healthcare provider can reach a wide range of pediatric populations specifically those with barriers like physical location or limited resources. Pediatric telehealth has grown in the last 10 years.  The authors of a systematic review and meta-analysis found that telehealth by allied health and nurses in rural and remote areas can be as effective as a face-to-face session. However, there is poor uptake to telehealth among the practitioners.  Different devices are used in pediatric telehealth including desktops, laptops, tablets, and smartphones. 
Practitioners should understand that telehealth regulations are updated regularly, especially amidst the coronavirus pandemic.  “There is no clear-cut determination or one-size-fits-all solution regarding telepractice for pediatric services”.  It is the practitioner’s responsibility to know their local state or national rules regulating physiotherapy/ physical therapy relating to telehealth. The health care practitioner should use clinical reasoning, review the context/situation, and take into consideration ethical and individual preference to establish if telehealth will be appropriate for each individual case. It is also important to check any regulation related to further training and scope of practice for telehealth consultations. Ensure that you follow all laws pertaining to patient privacy for e.g. GDPR and HIPAA. Medical aids/ insurance companies have different payment structures or agreements pertaining to telehealth services, this should be taken into consideration and discussed with the family prior to the appointment. Have all your procedures in place for telehealth consultations and make sure you have a procedure for emergency situations. 
Barriers for healthcare professionals include licensure, poor interest from the providers, lack of training resources to adequately train the healthcare providers in using telehealth.  Technical problems are seen as less than a problem than provider challenges.  Poor internet connectivity, insurance problems, liability uncertainty, and a negative attitude in healthcare professionals and the clients are also barriers to telehealth. 
Telehealth is not appropriate for all clients as seen in different results from studies that either show satisfaction and acceptability or a high drop-out rate. There is also a limitation in using telehealth when an intervention using physical interaction is needed.  Therapists belief that they cannot effectively treat a patient when they are not able to do to put their hands on them or take physical measurements. This has changed in recent years where technology allows the therapist to do the measurement in real-time. 
Barriers specific to the pediatric population compared to adults exist. Depending on the child’s age the parent might be needed for interventions requiring physical contact, supervision, or guidance to facilitate learning and function on the therapist’s behalf. This barrier is overcome by educating the parent to deliver interventions. 
- Telehealth links a child to different types or more diverse healthcare services that might not be available in the area they live in.  
- Telehealth can be used instead of face-to-face sessions or as an addition to face-to-face sessions 
- It allows healthcare services to be provided at times and places that may not be easily accessible 
- Cost, resource and time effective 
- No weather conflicts or transportation costs 
- Decreases the long distances families or healthcare workers need to travel especially when the patient lives in a remote area 
- No struggles to find childcare for other children in the family 
- Children that are immunocompromised don’t have a risk of exposure to illness 
- Improves adherence to therapy especially when both parents need to work. 
- The child may feel more comfortable in their own environment, playing with their own toys. 
- Therapy can continue even if the child or parent is unwell
- Group therapy sessions with multiple children participating without the risk of cross-infection are also possible with telehealth 
- Telehealth can include gamification and social-based activities through activity trackers to increase physical activity 
- Multi-disciplinary follow-ups with patients
- Telehealth gives the therapist to observe from the outside and see the whole movement and make notes. 
Uses of Telehealth in Pediatrics
- In children with cystic fibrosis, the therapist can monitor and facilitate airway clearance as well as physical activity for the child 12
- Hybrid models - includes virtual telehealth visits as well as in-person visits. This serves as a complementary model where the therapist can have regular video calls to make sure the child is getting home therapy and that the techniques are properly performed. This improves the monitoring of patients and increases the number of sessions a patient can have. 
- Children with neurological conditions, cerebral palsy, intellectual disability, and congenital syndromes, developmental delays
- Pediatric orthopaedics including pre-surgery, post-surgery follow-up, pre-treatment evaluations 
- Monitoring and promoting physical activity for children with different conditions, for e.g. haemophilia
- Pediatric palliative care at home to provide patient management and care to the families 
Before the session
- Screening appropriate patients for telehealth is important. Telehealth should only be used when it is a viable tool to improve patient outcomes. 
- It is important to consider when a parent/caregiver/advocate should be present during a telehealth consultation with a child. 
- The therapist should have different toys to demonstrate what is needed like blocks, bubbles etc. Have music ready to get the child’s attention or to do an activity on music 
- Organize an orthotist to go to the patient’s house for AFO’s or adaptive equipment, you can even be on the video call when they are measuring the child.
- Check-in with the family a day or 2 ahead of the session. Find out first what they want to work on or what part of the day would work best for them. Sell the parent coaching idea and that the parent is with the child for the rest of the week and should participate in the session. 
- Prepare the family ahead of time for what is needed for the session for e.g. blocks, toys, blanket, or which room to use. 
- Educate parents about developmental progress and then break down activities to reach those developmental goals and explain to the parent why you are doing it 
During the session
- Empower, educate and train the parents to be independent with the therapy the rest of the week. 
- Have a blanket or yoga mat spread out on the patient’s floor so that the child has a video “safe” zone where they are within the camera range and you can see them when on the blanket. 
- Use props like a chair that the child can pull themselves up to standing or keep balance in standing 
- Use a baby doll to show techniques or handling to the parents 
- Use corner sitting on a corner couch or wall for sitting exercises. 
- When manual techniques need to be performed an assistant can be present with the patient (if allowed in your state or country) 
- Remember to coach the parent or caregiver. Communicate effectively. Empower the family to carry over the tasks into the daily routine, for e.g. weight bearing on the arms during other activities 
- If the child is running around and needs a break tell the parents that you will instruct them what to do next, so they are ready when the child is ready. 
- Ask the parents to do spontaneous play with their kid for a few minutes and use that as an assessment 
- If the child keeps moving out of the camera screen you can ask the parent to move the device, if that is difficult then just ask the parent to describe the movement. You can also invite other siblings to join in the session and participate which might sometimes help the keep the child engaged. 
- If you are nervous and starting with telehealth for the first time you can start by just observing their normal routine and play to see what it is like. This will help you and the family to get used to the telehealth idea. You can even turn your video and sound off for 10 minutes and just observe. Ask the parents opinion of what they experienced and where they need more coaching. Give positive feedback before giving constructive feedback. 
- Give the family a couple of possible activities to choose from to work on specific developmental goals. This will empower the parent and child to have a choice. Just asking what do you want to work on is helpful but might be too broad for some parents. 
After the session
- You can supplement your telehealth sessions with videos or handouts to support the parents when doing it at home. 
- Send a summary of what was covered during the session 
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