 Everybody, I am Dr. Nareesh, Consultant Pediatrics and Manipal Hospital, Malaysia. I am here today to discuss a very significant topic that matters to all of us. We refer to all of them as our bundles of joy, are probably the best gifts of our life, obviously our children. But somehow during this pandemic in the last one year, I have felt that most of the parents are not giving them the importance that has to be given. So just a few suggestions, a few learning tips for the parents and how you can spend time with your children at home. Why this topic has come up today is because we are going to face this COVID pandemic mostly for another one year and definitely the primary school and the early preschool, the KG is not going to be there for at least next six months, let us say June to December. So to solve the doubt that the parents have, first while spending time with your children, what you need to know or what are the cues you need to pick up from them, talking about the development of your child if the parents have to observe. See when the child is very small, let us say two to three months, most important thing is good eye contact will develop by two to three months, especially with the mother and the child will have a good social smile, we look at the mother and have a comforting smile, the mother will be able to recognize this. This has to develop by three months, the parents need to recognize this. Next, between six to nine months, the child starts making good observations about the world around them. Basically, the people close to the child, the grandparents, the parents, siblings and the house in which they live. The observation part is important between six to nine months. The child will start knowing familiar faces and when the child looks at somebody unfamiliar with the child will cry, it is called a stranger anxiety. This should come between six to nine months. Also, the child will start expressing with words like a, who, so monosidibles will be expressed. Next, the child is very curious about the surroundings. I will give you a very small example. Let us say the child has turned around and is lying on a carpet in the hall, the door bell rings. So, the mother comes out of the kitchen, walks to the door, opens the door. So, the child is observing all this. This kind of observation has to develop by six to nine months. Next, between one year and one and a half year, basically between 12 months and 15 months. This is the time when the child starts involving the parents into their small world. Let us say the child sees a parrot or child sees some animal on the road. They will point out to the animal. They will look at the parent and point out. So, they are involving you in their world. That is very important. By one year, maximum by 15 months, your child has to involve you in their small world by calling out to you mama, tata, ajji, vice-illubils. Four to five words are enough. But they should involve you for at least some time in the day in things that they see. That involvement of the parents by the child is important. They should not be completely to self. Then they should start waving their hands well. This starts as early as nine months. They should shake their hand when somebody gives their hand to them. And they should follow simple instructions. Let us say, go and pick up that toy. They should be able to do it. All this will develop with the preceding milestones. Only when the child has a good eye contact, all these developments will follow. So, to summarize, by two to three months, you need to observe that the child has a good eye contact, social smile. By six to nine months, they are making good observations about the surroundings. They have developed mono syllables of expressions like ah, he, who. And by one year or maximum by 15 months, the child should start pointing out objects and involve you in their world, show you things, should start referring to you like mama, tata, ajji. These are the things you need to observe at home. So, all these can be done only when you spend some quality time with your children. Next, turn understanding the small part of the development. I am mainly concentrating on the communication part and the social development of the child, not the motor development. The most important question which or the most important problem that all of them are facing, screen time to be very specific, mobile time and tablet time. See, there are certain recommendations which have been made by the WHO after lots of studies, zero to two years of age. These recommendations are important. Zero to two years of age, there is nothing called as mobile time for kids. You need not give them the mobile at all. Maximum for 30 minutes, the child can do a video call. Let us say the father is out of station or the grandparents want to see the child. So, by a video call, you can show them. Other than this, there is nothing called a screen time. You should not give them any mobile or any tablet till they are two years old. And between two to five years, it is one to one and a half hour per day that is the screen time that to preferably TV. It is controlled screen time or monitored screen time. Let us say the child will see some channel on animals. Weekly two days, it is discovery or national geography. Another two days, they can see some cartoons. It is fine. Two more days some channel on some craft or some artwork, but it is completely monitored. They should not be having the free will to scroll. Let us say YouTube videos or any game not to be given till five years of age. So, to summarize, zero to two years, it is just 30 minutes per day of video calling only. Other than this, no screen time is recommended, no mobile and no laptops, no tablets to children. And two to five years, it is one hour, preferably TV. Now, why have they stressed on this zero to two years and two to five years is to just make you realize nobody has ever taught us how to open the door when the bell rings or how to latch the door, unlock the door. When we need water, we go to the filter, hold the glass and turn on the filter, turn on the tap. So, such things are learned by observation from an early age. Let us say by one year itself, the child is observing all this, some of them as early as six months. For this, you need to understand a little bit of physiology. The human brain develops maximally before two years of age. 80% of your child's brain is developed by two to two and half years. And by four to five years, 90% is developed. Growth of the brain occurs, that means the synapses are formed between the neurons and some kind of memory is stored. So, at this age, before two years especially, your child has to receive certain stimulus from the external environment. And that should not be from the screen, I mean from the mobile and laptop and tablets. It should be stimulus from things, parents, animals on the road, the sky, the birds that fly, stimulus from people who come home, mainly stimulus from the parents and grandparents. Please follow the recommendations given. No mobile less than two years except for video calling for 30 minutes per day if required. And two to five years, it's just one hour of monitored screen time. Now, what are the disadvantages of giving mobile to your child? All this external stimulus that the child is going to receive from the parents, from the grandparents, everything is gone once the child sees the mobile. Because it's very unfortunate, it's just a one-way traffic from the mobile. You keep seeing the screen, the child gets addicted to it. And it is just a one-way information that keeps coming. There is no component of expression for the child. The child slowly becomes a kind of introvert, gets addicted to the mobile and eventually stops expressing herself for himself. It's very difficult to pick this up because parents think the child is happy with the mobile. But that is not what we need. Before your child's brain has developed 90% or 80%, you need to give the appropriate stimulus to the child, let us say love or anger, a hug once in a way, the physical stimulus that has to be given, involving them in things like watering the plants or feeding the pets at home. These are the stimuli that the child misses out on once you start showing the mobile. So, please follow the screen time recommendations. And now coming to the most important topic, what is the scenario that I have seen in the OPD during the COVID times? COVID has affected the whole world and all of them have been directly or indirectly going through the COVID problem. One year of COVID is done and most probably we have another six months to one year to go. This is looking at the pandemic of the Spanish flu that happened in 1919. It lasted for two and a half years. So, we'll always plan for the worst. I'm not frightening anybody, but if it shortens before that, we are all very lucky. Maximum advantage is to kids who have to go to school. They have missed out on school last year. They have missed out on school most probably even this year they'll be missing out on school. I classify the children into three scenarios when I see them in the OPD, especially during this COVID wave, the COVID era, what I call the best scenario, the moderate scenario, and the worst scenario for the children. See, the best scenario will be, this is for the kids, for the children I'm talking, their perspective. The best scenario will be grandparents being present at home, mother and father at home with the child and either mother or the father spends at least four hours with the kid in the evening. Anything more than this is obviously best, but the child, the parents, the grandparents, either of the parents are able to spend at least four hours with your child in the evening time. It can be feeding, it can be taking them out for a walk. This is like the best scenario. These children usually don't have a delay in their milestones. Next, coming to the moderate scenario, the mom and dad at home with the baby, presents of a caretaker. See, they have substituted the affection of the mom and dad with the caretaker, but she should be a good caretaker who's able to give the appropriate stimulus for the growing kid. This is also acceptable, but still I would call it the moderate scenario for the child because the child is not exposed to grandparents, neither exposed to the parents, most of the time with the caretaker. But still it's fine, better than mobile usage. Now coming to the worst scenario, which I'm a little worried about. Since I have seen few children in the last one year who have faced problems, that's why I'm stressing on this. The worst scenario will be the mother and father at home with the child, both of them mother and father working full-time. What will the child do? There is no doubt the child will be with the mobile, two hours in the morning, three hours of TV in the afternoon, two hours of mobile in the evening. That eight hours of the day is gone with screen time, which is almost 20 times of the recommended normal for a single day. So why I'm stressing on this is, just to make you understand from one of the examples, one of my OBD patients, one year old, came last year, 2020, February before the COVID era started. One year kid, as I explained the milestones, kid was perfectly happy, looking around at everything in the room. I have put on some stickers of some animals, so the child would point out to the parents, ah, ah, that's for an ahane, then they would point out, amma, ahane. So the child was perfectly all right, would respond to the call. When I called the child's name, the child would look at me. This was at one year, in February 2020, a perfectly normal kid. Then they could not come at 15 months and 18 months for the vaccination because the COVID spike was going on. They turned up in November, when the child was 21 months old. Once I saw the child, immediately observe, the child had completely withdrawn into self. Once they entered the room, no expression at all, completely stuck to the mother, looking down. Worst part was, there was no eye contact, no response to call. What the child had before, we documented in our OBD sheet, good eye contact, response to name. So it was written in my previous note in February, when the child was one year old. Now in November, nothing is there. So then I asked them, is the child unwell? Is there any fever or anything? Nothing, perfectly normal, right? Has come for the 15th month vaccination at 21 months. They have missed the vaccination. I felt very sad when I looked at the child, because there was a regression of the milestones. And then we had to refer them to a developmental doctor. And then the diagnosis, which most of us fear the most. It was not complete autism. The child was diagnosed as high risk of developing autistic spectrum disorder. Child was at high risk, so the mother comes back to the OBD. And obviously she started crying. We developed her app further with her and I asked her, what have you been doing for the past nine months? The child was perfectly all right. Then she tells me that she has joined her job online from March. This is the worst scenario. Both parents are at home. Both are working full-time. The kid used to use mobile from six to eight hours a day. Only half an hour of video calling is recommended. The child can scroll on YouTube. The child can open the mobile with the password. Imagine a one, one and a half year kid knows the password. I am not exaggerating. This is from my personal experience. And the child was so much involved in the mobile, no external stimulus at all. Luckily, they came at least 21 months. Two and a half years were not over. So the brain is yet not completely developed. So she came and questioned what has to be done. I personally gave my opinion. Once your parents, first most important, children and family, then comes job and money. So I told her, you earn a lot of money and then you need to spend it on the treatment of your kid. So she quit her job in December and now it's been four months. She came back with the child last week. I am not exaggerating. She came back with the same kid last week. And the kid is almost perfectly normal. The mother spends time with the kids. No mobile time at all. Taking the kid out for a walk and sitting and playing games with the kid daily. So the child was perfectly alright, responding to call. So it was like developmental delay, which has been reversed by the presence of the mother at home, spending quality time with the kid. So that is the importance of giving your time to the kid. What are the problems that parents face in the COVID? First of all, there is no school. So that part of social interaction, which should develop, let us say after two years, if the child is not developing. And they are avoiding regular visits to the pediatrician. They are not even taking online consultations. So what happens is usually if there is a developmental delay, which is present in around five to six percent of children, that is 100 children, five to six will have some amount of developmental delay. If they come to the doctor like before for the vaccinations regularly, it might be picked up. And after two years, if they go to school, the teacher will usually pick it up. Because the teacher will see 30 kids, so they can easily make out the difference if one or two kids are not in tune with others. So both are not there last year and most probably even next year it is not going to be there. So early developmental delay, mild autism, it is being missed. And unfortunately, if they present after three years, when the brain wiring is almost complete to 85 to 90 percent, the prognosis is not as good as it could have been with the earlier treatment. What is expected as parents? How do you spend time with your child? First, you make all the observations that have to be made, no mobile. The most important thing is the rule for the day, don't substitute the child being with people. Don't substitute the people with mobile or with screen time. That has to go in everybody's head. Don't substitute people with mobile and screen time. People have to be substituted with people. If parents can't be with the kid, arrange for grandparents. Grandparents cannot be with the kid, arrange for a caretaker, but not mobile or laptop, anything, screen. You need to fix a schedule for the child, wake up time, brushing time, potty time, bathing time, let's say get up by 6.30, rest for around half an hour, do some yoga, involve the kid, seven to eight, get ready, freshen up, eight to nine, breakfast time with the kid. There should be a fixed schedule, the play time, the afternoon lunch time, nap time. Everyday try to maintain the schedule and stick on to the schedule. Don't change it. Over a period of one week, the child will look forward to it. And the schedule should be related to activities, activity based. If the parents can't do it, either with the grandparents or with the caretaker, nanny. Next, your presents and your gifts are not that matter to the child. It is your presents or your time that you give. And quality time given to the child is never a waste. Remember, at least 30 minutes of face to face talking or spending time with your kid morning ones and night ones. This is the minimum required. 24 hours, you need to spend at least 30 minutes of face to face time with the kid in the morning and in the evening. Both parents put together. It doesn't include feeding time, napping time, walking out in the road. It's face to face, looking at them, keeping an eye contact, playing a game with them. 30 minutes in the morning, 30 minutes in the evening. And also in the next one year to get rid of the COVID boredom at home, you try to give them one game per day. Let us say you play with blocks on Monday. On Tuesday, it can be a jigsaw puzzle. On Wednesday, it can be painting time. On Thursday, it can be watering the plants or cleaning the house. You can do it with them. So each day, one activity at a fixed time according to the schedule will keep them engaged with you. And again, I repeat, don't substitute people with screen time with mobiles. Now just briefing upon my take home message. Important is, parents need to observe a few things if they are avoiding the pediatrician. The child should start observing things around by six months for which the child should have a good eye contact before the age of three months. Ideally, at two to three months, the child should have a good eye contact. Should observe the surroundings by six months. And should respond to call by six months. Should involve you in their surroundings. Should point out to things by one year. These are the things you need to observe at home. Anything is delayed by beyond two months. If there is no eye contact by two to two and a half months, it is like an emergency. The rest of the milestones, if the child is not, let us say using monosyllables by six months, you can wait till eight months and then consult the doctor. But make sure you are addressing at least final points in the development, good eye contact, respond to call, all these have to be there at appropriate ages. At least once in four months, in the next one year, try to visit the pediatrician or take an online consult at least so that they are able to check the child and see what the child is doing. Till the child is two years old, spend quality time with your kids at least 30 minutes in the morning and 30 minutes in the evening, face to face quality time, not sitting next to the kid and looking at the mobile. That's not what is expected of the father and mother. If you are finding that the child is having a regression of the milestone, no good eye contact, if there is any doubt, please consult the doctor, your nearest pediatrician as soon as possible, so that the problem can be rectified before it's too late, before the brain is completely synapsed, two and a half to three months before that. So best wishes to all of us, so that we can cross over this COVID data successfully and we all hope for the best. Thank you. Some of them have asked question. Sunita Vaadwa has asked, is it safe to come to the hospital for vaccination? My daughter is six months old. Yes, definitely you can visit the hospital, undergo the screening. You will have a COVID and a non-COVID section, so they will screen your child's temperature, ask you a few questions. And if you are worried about the crowd, midweek time is the best, Tuesday, Wednesday, Thursday would be the best time to bring the child. So you can finish the vaccination. Six months vaccination ideally should not be delayed more than one month, I mean before seven months you need to finish it. And what's the impact on a child using mobile to a large extent? That's what I told, I gave an example also. The child was using, I saw, was using mobile for eight hours in a day, eight hours in a day, screen time. So there was a regression of the milestones, lack of communication, lack of eye contact, but the child had become into a shell completely drawn into itself. So please follow the recommendations of screen time, less than two years, no mobile at all except for video calling if parents are far away or grandparents want to see them once in a week or twice in a week, it's fine. Mobile means it's for video calling, they should not know how to unlock the mobile before two years. I mean they know mobile at all before two years. And two to five years it's just one to one and a half hour of screen time, preferably TV. Most of them ask me some silly questions like how to avoid the mobile, they will come and take it. See, we have all grown up and we all never face this problem. You have your wallet, so nobody gives your wallet to the kid, never it happens. So when that can be avoided lock your mobile, keep it at a high point in the house where the child cannot reach it. And it is something that the child should not touch, that's it. No showing videos to the child, no showing what's up funny videos, nothing at all. Keep them away from the mobile, you will be doing good to the kid, otherwise you'll be pushing them into developmental delay. Yeah, they have asked, is it safe to visit the hospital for vaccination? Yeah, that's okay. Visiting the hospital for vaccination is fine because they have a COVID and a non-COVID section in most hospitals, most pediatric hospitals. So if you're worried about the crowd, you come between Tuesday, Wednesday or Thursday, fix an appointment, they'll screen you, finish the vaccination and get back. It should be safe, otherwise the COVID is not going to end for another one year, we cannot give delaying vaccinations, most probably under six months it may not end. So we should learn to live with it. I'm sorry, just with restrictions on leaving home, how do I ensure that child participates in physical activities? Nitin H. Malesh Gouda has asked how with restrictions on leaving home, there are no restrictions on leaving home now. I don't think there are restrictions on leaving home. You can take the child out for a walk in the morning for 20 minutes, evening for 20 minutes. They will be very happy knowing to go to the park. We are not talking about the previous lockdown. There are restrictions only in the night after 10 to morning six. You can take the child to the terrace, show them some birds, show them some plants. Well, there is a way, there is a way. 20 minutes morning when outing, 20 minutes evening when outing in the road close by is not a restriction, they have not restricted as of now. What are some activities to keep the children engaged? I'll just explain. See, I will just repeat it for her again. Most important is you need to maintain a fixed schedule. You need to wake up at a fixed time, brushing, potty time, bathing time, breakfast time, then activity time. Every day you keep on activity. Let us say on first day you play with blocks. So, second day you are able to, first day you are going to play with blocks. The next day you are able to play a jigsaw puzzle or something. The third day you are going to do some painting or drawing with the child. The fourth day you clean the house. Fifth day you water the plants, clean out the garden. Show the child some old album. Each day you keep on activity. The games to play big blocks can be done on a day. Jigsaw puzzle can be done on a day. And don't repeat the same thing every day. In a week one day, Monday is for blocks. Tuesday is for another activity like coloring or painting. So that's how it goes on. And the parents have to stay with the child. Or you keep grandparents or you keep a caretaker. Please don't substitute people with mobile. Yeah. Okay. Thank you everybody.