An Overview of Telehealth and Paediatrics
Original Editor - Tarina van der Stockt
With paediatric telehealth, the healthcare provider can reach a wide range of paediatric populations specifically those with barriers like physical location or limited resources. Paediatric 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 amongst practitioners.  Different devices are used in paediatric 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 paediatric 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. 
If you are new to telehealth or want to learn more about the fundamentals then please review these pages:
- Introduction to Telehealth
- Fundamentals of Telehealth Technology
- Practical Considerations in Telehealth
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 of 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 paediatric population compared to adults exist. Participants in a qualitative study from 2019 felt that children might not enjoy telehealth sessions or be able to concentrate during a session. Participants also felt that the communication via telehealth might not be as effective as in-person sessions, the quality of relationships might be decreased and that telehealth was not suitable for areas of health that rely on physical touch. 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 can be 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 Paediatrics
- In children with cystic fibrosis, the therapist can monitor and facilitate airway clearance as well as physical activity for the child
- 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
- Paediatric 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
- Paediatric 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.  You have to be able to bring the same standard of care as with an in-person session. 
- Share your intake form with the parents ahead of the time so that you have the necessary information about the child to help you plan for the session and what you and the parents will need. 
- Make sure you have alternative methods of contacting the parents/caregiver if technology fails 
- 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. 
- Plan the timing of the session depending on the goals. Do you want to avoid naps, feeding or medication times or do you specifically want to be there during those times to help with positioning etc? 
- Have a rough outline for your session handy 
- 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 
- Make use of past medical history and subjective history 
- Screen the patient for any red flags and refer on when necessary 
- In telehealth it is difficult to apply standardised tests and measurement, so make use of your clinical observation skills. 
- Ask the parents to do spontaneous play with their child for a few minutes and use that as an assessment 
- Evaluate the child through different functional movements and different positions including the transitions. 
- Functional outcome measures to consider:
During the session
- Be calm and confident 
- Don't overthink it - keep it simple 
- Rely on your skills of observation as a physiotherapist/ physical therapist 
- Be a good communicator by telling the parents what to expect and taking them through each step. This will prevent them from feeling overwhelmed. Explain the focus of the session and why exercise or movement aids in achieving that goal. 
- Allow time throughout the session for questions or concerns. 
- Educate the parents about the child's condition, function, level of performance. 
- Empower, educate and train the parents to be independent with the therapy the rest of the week. 
- Train the parents/ caregivers on body mechanics to prevent personal injury
- 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.  The parents might also need a rest break while you talk about education or summarising the session. 
- 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. 
- At the end of the session, summarise what was done and only give them 1-2 home exercises. If these exercises can be part of their daily routine they would be more compliant. 
- Create a moment of reflection at the end of the session, so that you can find out what the child and the parents/ caregiver liked or did not like or want to work with the next session. 
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 
- Do self-reflection on the session 
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