Parental understanding of neonatal congenital heart disease

Risk Factors and Outcomes Associated with Gaps in Care in Children with Congenital Heart Disease

Adults with congenital heart disease (CHD) benefit from cardiology follow-up at recommended intervals of ≤ 2 years. However, benefit for children is less clear given limited studies and unclear current guidelines. We hypothesize there are identifiable risks for gaps in cardiology follow-up in children with CHD and that gaps in follow-up are associated with differences in healthcare utilization. Our cohort included children < 10 years old with CHD and a healthcare encounter from 2008 to 2013 at one of four North Carolina (NC) hospitals. We assessed associations between cardiology follow-up and demographics, lesion severity, healthcare access, and educational isolation (EI). We compared healthcare utilization based on follow-up. Overall, 60.4% of 6,969 children received cardiology follow-up within 2 years of initial encounter, including 53.1%, 58.1%, and 79.0% of those with valve, shunt, and severe lesions, respectively. Factors associated with gaps in care included increased drive time to a cardiology clinic (Hazard Ratio (HR) 0.92/15-min increase), EI (HR 0.94/0.2-unit increase), lesion severity (HR 0.48 for shunt/valve vs severe), and older age (HR 0.95/month if < 1 year old and 0.94/year if > 1 year old; p < 0.05). Children with a care gap subsequently had more emergency department (ED) visits (Rate Ratio (RR) 1.59) and fewer inpatient encounters and procedures (RR 0.51, 0.35; p < 0.05). We found novel factors associated with gaps in care for cardiology follow-up in children with CHD and altered health care utilization with a gap. Our findings demonstrate a need to mitigate healthcare barriers and generate clear cardiology follow-up guidelines for children with CHD.

Mapping parents' journey following prenatal diagnosis of CHD: a qualitative study

OBJECTIVE

To better understand parents' accounts of their prenatal and postnatal experience after prenatal diagnosis of CHD - particularly emotional processing and coping mechanisms - to identify strategies to improve support.

METHODS

This single-centre, longitudinal qualitative study included pregnant mothers and their support persons seen in Fetal Cardiology Clinic at Vanderbilt Children's Hospital from May through August 2019 for probable complex CHD. Twenty-seven individuals from 17 families participated in 62 phone interviews during pregnancy and postpartum: 27 conducted after the initial prenatal cardiology consultation, 15 after a follow-up prenatal visit, and 20 after birth. Applied thematic analysis approach was used to code and analyse transcribed interviews. Coding and codebook revisions occurred iteratively; intercoder reliability was >80%.

RESULTS

Patients included mothers (16 [59%]), fathers (8 [30%]), and other support persons (3 [11%]). Initial fetal diagnoses included a range of moderate to severe CHD. Prenatally, parents sought to maintain hope while understanding the diagnosis; planning for the future rather than focusing on day-to-day was more common if prognoses were better. Postnatally, with confirmation of prenatal diagnoses, parents' sense of control expanded, and they desired more active engagement in clinical decision making.

CONCLUSIONS

To enhance effective communication and support, understanding how parents conceptualise hope in relation to diagnosis and how that may evolve over time is critical. Expectant parents whose child has a significant risk of mortality may demonstrate hope by focusing on positivity. As prognostic uncertainty diminishes postpartum, the parental role on the team may shift, requiring clinicians to provide different support.

Maternal Reaction and Psychological Coping After Diagnosis of Congenital Heart Disease

OBJECTIVES

A diagnosis of congenital heart disease (CHD) during fetal life or infancy can be devastating for parents, resulting in significant psychological stressors. The goals of this study were to (1) assess maternal resolution and adaptation to a new diagnosis of CHD, (2) explore how maternal resolution and adaptation relates to psychological well-being and (3) evaluate whether specific illness parameters impact resolution status.

METHODS

This cross-sectional study evaluated resolution to diagnosis in the first 6 months of life for mothers of children with CHD. Mothers completed a Reaction to Diagnosis Interview (RDI) and psychological surveys assessing stress, depression, and coping skills. The RDI invites parents to discuss the diagnosis, changes in their thoughts and feelings since the diagnosis, and reflections on why they think they have a child with a medical condition. A chart review of the child recording illness parameters was also performed.

RESULTS

Thirty-six mothers participated in this study. Twelve of their children had a prenatal diagnosis of CHD (33.3%). Seventeen mothers (47.2%) were unresolved to the diagnosis of CHD in their child, regardless of the timing or severity of the diagnosis. Twenty-four participants (68.6%) had significant or highly significant life stress and 9 participants (25.7%) had clinical concerns or met criteria for Post-Traumatic Stress Disorder. Nineteen mothers (55.9%) were at risk for clinical depression. Mothers unresolved to the diagnosis had higher rates of post-traumatic stress than those resolved to the diagnosis (47.1% vs. 10.5%, p = 0.03). Mothers of infants with a prenatal diagnosis of CHD reported significantly lower rates of life stress despite higher severity of heart defects (p = 0.02).

CONCLUSIONS FOR PRACTICE

Mothers of infants with CHD have similar proportions of resolution to diagnosis compared to mothers of children with other chronic diseases. They experience a high rate of symptoms of life stress, post-traumatic stress and clinical depression. Symptoms of post-traumatic stress are higher in mothers unresolved to the diagnosis. Identification of those at highest risk for poor adaptation to the diagnosis may allow for targeted psychological support services for those most vulnerable.

Care of the Fetus With Congenital Cardiovascular Disease: From Diagnosis to Delivery

BACKGROUND

The majority of congenital cardiovascular disease including structural cardiac defects, abnormalities in cardiac function, and rhythm disturbances can be identified prenatally using screening obstetrical ultrasound with referral for fetal echocardiogram when indicated.

METHODS

Diagnosis of congenital heart disease in the fetus should prompt assessment for extracardiac abnormalities and associated genetic abnormalities once maternal consent is obtained. Pediatric cardiologists, in conjunction with maternal-fetal medicine, neonatology, and cardiothoracic surgery subspecialists, should counsel families about the details of the congenital heart defect as well as prenatal and postnatal management.

RESULTS

Prenatal diagnosis often leads to increased maternal depression and anxiety; however, it decreases morbidity and mortality for many congenital heart defects by allowing clinicians the opportunity to optimize prenatal care and plan delivery based on the specific lesion. Changes in prenatal care can include more frequent assessments through the remainder of the pregnancy, maternal medication administration, or, in selected cases, in utero cardiac catheter intervention or surgical procedures to optimize postnatal outcomes. Delivery planning may include changing the location, timing or mode of delivery to ensure that the neonate is delivered in the most appropriate hospital setting with the required level of hospital staff for immediate postnatal stabilization.

CONCLUSIONS

Based on the specific congenital heart defect, prenatal echocardiogram assessment in late gestation can often aid in predicting the severity of postnatal instability and guide the medical or interventional level of care needed for immediate postnatal intervention to optimize the transition to postnatal circulation.

Maternal knowledge of the child's heart defect over a 1-year time span, its development and associated factors

BACKGROUND

Mothers are the link between patients, physicians, and other caregivers. Therefore, they should be well informed about the child's heart defect and accompanying issues. This study aimed to assess the mothers' understanding of their child's heart defect at hospitalisation and one year later and to analyse the individual development and associated factors.

MATERIAL AND METHODS

Mothers of children with CHD (aged ≤2 years) were interviewed at time of hospitalisation and after one year. Development was calculated using the Wilcoxon signed-rank test. Knowledge was assessed using the Hannover Inventory of Parental Knowledge of Congenital Heart Disease that consists of eight subscales. Associated factors were self-assessed knowledge at hospitalisation, educational level, cardiac diagnosis, self-assessed severity of CHD, and source of information at follow-up.

RESULTS

Mothers showed mixed understanding at hospitalisation, but their knowledge improved over a 1-year time span. This was especially true for the subscales "management of CHD" and "surveillance of deterioration", which resulted in an overall good knowledge at follow-up, whereas knowledge on infective endocarditis was still poor. Mothers with lowest and highest education had the most notable improvements. The same holds for caregivers with children with more severe CHD and who rated their knowledge as less than good.

CONCLUSION

Overall, mothers showed significant improvement especially for topics that are important to provide adequate care, but still revealed knowledge gaps one year after hospitalisation. Consequently, clinicians should evaluate the individual knowledge level at all times and inform mothers accordingly.

Fetal counseling for congenital heart disease: is communication effective?

PURPOSE

To assess the accuracy of maternal understanding of fetal cardiac defects following initial fetal counseling.

METHODS

Pregnant women with a fetal diagnosis of congenital heart disease (CHD) were surveyed regarding understanding of their fetus's heart defect. The survey asked: (1) for a description of the heart condition; (2) how confident they were in the diagnosis; (3) whether their fetus would require heart surgery. Two fetal cardiologists evaluated the maternal qualitative description. Partners were excluded from the study.

RESULTS

Fifty-one participants consented and 39 completed the survey. Mean age was 31 years, 60% had some college level or post-graduate education, 48% had Medicaid insurance, and 81% were Caucasian. More than three-quarters of participants, stated they had either "quite a bit" or "very much" understanding of their fetus's diagnosis. Maternal assessment matched the physician's assessment of accuracy with 77% (N = 30) demonstrating either "quite a bit" or a "very accurate" description of the diagnosis. All women correctly understood if their fetus would require heart surgery. Highest level of maternal education positively correlated with the accuracy of diagnosis (regression coefficient 0.48, p < .002). However, confidence in the diagnosis was independent of both education (0.30, p = .167) and maternal age (-0.03, p = .234).

CONCLUSIONS

Fetal counseling is effective in conveying anatomy and the need for surgery; however, accuracy amongst women with lower levels of education and maternal confidence in understanding can be improved.

Post-operative discharge education for parent caregivers of children with congenital heart disease: a needs assessment

OBJECTIVE

Children with congenital heart disease (CHD) have complex unique post-operative care needs. Limited data assess parents' hospital discharge preparedness and education quality following cardiac surgery. The goals were to identify knowledge gaps in discharge preparedness after congenital heart surgery and to assess the acceptability of an educational mobile application to improve discharge preparedness.

METHODS

Telephonic interviews with parents of children with two-ventricle physiology who underwent cardiac surgery 5-7 days post-discharge and in-person interviews with clinicians were conducted. We collected parent and clinician demographics, parent health literacy information and patient clinical data. We analysed interview transcripts using summative content analysis.

RESULTS

We interviewed 26 parents and 6 clinicians. Twenty-two of the 26 (85%) parents felt ready for discharge; 4 of the 6 (67%) clinicians did not feel most parents were ready for discharge. Fifteen of the 26 parents (58%) reported receiving the majority of discharge teaching on the day of discharge. Eight parents did not feel like all of their questions were answered. Most parents (14/26, 54%) preferred visual educational learning aids and could accurately describe important aspects of care. Most parents (23/26, 88%) and all 6 clinicians felt a mobile application for post-operative care education would be helpful.

CONCLUSIONS

Most parents received education on the day of discharge and could describe the information they received prior to discharge, although there were some preparedness gaps identified after discharge. Clinicians and parents varied in their perceptions of the readiness for discharge. Most responses suggest that a mobile application for discharge education may be helpful for transition to home.

Parental Understanding of Surgical Care in the Neonatal Intensive Care Unit

BACKGROUND

Pediatric surgeons are routinely required to discuss complex diagnoses and treatment plans with the parents of their patients. Yet, how well this information is understood by its target audience is unknown. To explore this issue, we asked parents of postoperative neonatal intensive care unit patients to describe their children's care in a variety of domains. Our goal was to assess the degree of parental understanding and to identify factors that influenced comprehension.

MATERIALS AND METHODS

Parents of neonatal intensive care unit patients who underwent a general surgical procedure were asked to complete a survey of their children's care in six domains of comprehension: name of the primary diagnosis, description of the primary diagnosis, description of the purpose of surgery, identification of surgical risks, identification of surgical benefits, and identification of concerning signs or symptoms to look for after discharge. Parental demographic factors such as age, level of education, and socioeconomic status were recorded, as was the presence of a prenatal diagnosis.

RESULTS

Overall, 66% of participants described their child's primary surgical condition. Even fewer were able to describe a benefit or risk of the procedure. Parental use of outside resources to gain information was found to significantly relate to parental understanding in all domains. Parental level of education also improved comprehension.

CONCLUSIONS

Parental understanding of surgical procedures, including the events leading up to and after an operation, is an important component of overall patient care. However, we were able to demonstrate that this understanding may be limited in spite of the best efforts of medical professionals. Further investigations should focus on ways in which information can be delivered more effectively to parents.

Uncertainty of Prenatally Diagnosed Congenital Heart Disease: A Qualitative Study

IMPORTANCE

Parents who receive a prenatal diagnosis of congenital heart disease may experience more short- and long-term stress than those who receive a postnatal diagnosis. To identify potential interventions to ameliorate that stress, the longitudinal emotional experience of parents must first be understood.

OBJECTIVE

To better understand parents' accounts of their own prenatal experience, particularly aspects they found to be stressful or challenging, and to identify strategies to improve support.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study included analysis of transcripts of audio recorded telephone interviews with pregnant mothers and their support persons, as applicable, who were referred to and seen at the Fetal Cardiology Clinic at Vanderbilt Children's Hospital from May 2019 to August 2019 with an initial likely diagnosis of complex congenital heart disease at any gestational age. Data analysis was conducted from August 2019 to November 2019.

MAIN OUTCOMES AND MEASURES

An applied thematic analysis approach was used to code and analyze professionally transcribed interviews. Coding and codebook revisions occurred iteratively; intercoder reliability was assessed and confirmed routinely. One author coded all transcripts; a second author independently reviewed one-fifth of the transcripts at fixed intervals to ensure that interrater reliability remained greater than 80%.

RESULTS

Twenty-seven individuals from 17 families participated in 42 phone interviews during pregnancy, 27 conducted at the first time point after the initial prenatal cardiology consultation and 15 at the second time point after a follow-up prenatal cardiology visit. Most interviewees were mothers (16 interviewees [59%]; median [interquartile range] age, 30.0 [27.3-34.8] years) or fathers (8 interviewees [30%)], with a few support individuals (3 interviewees [11%]) (median [interquartile range] age of family member or support individual, 30.0 [26.0-42.0] years). Initial fetal diagnoses included a range of severe congenital heart disease. Uncertainty was identified as a pervasive central theme and was related both to concrete questions on scheduling, logistics, or next steps, and long-term unknown variables concerning the definitiveness of the diagnosis or overall prognosis. Practitioners helped families through their framing of uncertainty at various time points including before, during, and after the clinic visit.

CONCLUSIONS AND RELEVANCE

Families walk an uncertain path following a fetal diagnosis of severe congenital heart disease. The challenges faced by the cardiologists caring for them overlap in many ways with those experienced by pediatric palliative care practitioners. Potential future interventions to improve parental support were identified in the areas of expectation setting before the referral visit, communication in clinic, and identity formation after the new diagnosis.

Parental understanding of intoeing gait - A preliminary study

OBJECTIVE

Evaluation of a child's intoeing gait is one of the most common referrals made to a pediatric orthopedist. Families may have difficulty understanding the often transient and usually benign nature of intoeing. The purpose of this study was to investigate parental perceptions of an intoeing gait both before and after consultation with an orthopedic practitioner.

METHODS

48 parents of children referred to pediatric orthopedic surgeons for evaluation of intoeing gait completed a 22-item questionnaire that assessed demographics, anxiety, and parental perceptions of intoeing. Questionnaires were administered before and after visits. Statistical analysis was performed using Wilcoxon signed-rank tests and Fisher exact tests.

RESULTS

Before their visits, parents reported similar levels of anxiety and understanding regarding intoeing, independent of their age or education. After the visits, anxiety decreased (P < 0.001), and understanding increased (P < 0.001) although younger parents (18-25 years) reported higher post-visit anxiety compared to parents older than 25 (P = 0.014). Similarly, parents with a high school degree or less reported higher post-visit anxiety compared to parents who attended college (P = 0.009). Post-visit understanding was inversely correlated with post-visit anxiety (r = -0.717; P < 0.001). Additionally, parents who reported high anxiety post-visit stated they were more likely to seek additional care (P < 0.001).

CONCLUSIONS

Younger parents with lower education levels were more likely to leave visits with high anxiety and poor understanding. These parents were more likely to consider seeking further treatment for their child's intoeing, placing additional stress on their child, themselves and an overburdened healthcare system.

Resource Utilization for Prenatally Diagnosed Single-Ventricle Cardiac Defects: A Philadelphia Fetus-to-Fontan Cohort Study

Background

Healthcare resource utilization is substantial for single‐ventricle cardiac defects (SVCD), with effort commencing at time of fetal diagnosis through staged surgical palliation. We sought to characterize and identify variables that influence resource utilization for SVCD from fetal diagnosis through death, completed staged palliation, or cardiac transplant.

Methods and Results

Patients with a prenatal diagnosis of SVCD at our institution from 2004 to 2011 were screened. Patients delivered with intent to treat who received cardiac care exclusively at our institution were included. Primary end points included the total days hospitalized and the numbers of echocardiograms and cardiac catheterizations. Subanalysis was performed on survivors of completed staged palliation on the basis of Norwood operation, dominant ventricular morphology, and additional risk factors. Of 202 patients born with intent to treat, 136 patients survived to 6 months after completed staged palliation. The median number of days hospitalized per patient‐year was 25.1 days, and the median numbers of echocardiograms and catheterizations per patient‐year were 7.2 and 0.7, respectively. Mortality is associated with increased resource utilization. Survivors had a cumulative length of stay of 57 days and underwent a median of 21 echocardiograms and 2 catheterizations through staged palliation. Right‐ventricle–dominant lesions requiring Norwood operation are associated with increased resource utilization among survivors of staged palliation.

Conclusions

For fetuses with SVCD, those with dominant right‐ventricular morphology requiring Norwood operation demand increased resource utilization regardless of mortality. Our findings provide insight into care for SVCD, facilitate precise prenatal counseling, and provide information about the resources utilized to successfully manage SVCD.

Parents' Experiences of Caring for Their Child at the Time of Discharge After Cardiac Surgery and During the Postdischarge Period: Qualitative Study Using an Online Forum

Background

Congenital heart disease (CHD) is the most common class of birth defects, which encompasses a broad spectrum of severity ranging from relatively minor to extremely complex. Improvements in surgery and intensive care have resulted in an increasing number of infants with the most complex lesions surviving after surgery until the time of discharge from the hospital, but there remain concerns about out-of-hospital mortality, variability in how services are provided at the time of discharge and beyond, and difficulties experienced by some families in accessing care.

Objective

As part of a mixed-methods program of research, this study aimed to elicit parental experiences of caring for a child with CHD after hospital discharge following a cardiac surgery and collect information to inform interviews for a subsequent stage of the project.

Methods

A closed online discussion group was set up via the main Facebook page of the Children’s Heart Federation (CHF), a national charity offering support to children with heart disease and their families. The discussion group was advertised through the charity’s webpage, and interested participants were directed to the charity’s Facebook page from where they could access the closed Facebook group and respond to questions posted. The CHF moderated the forum, and the research team provided questions to be posted on the forum. Responses were collated into a single transcript and subjected to thematic analysis.

Results

The forum was open for 4 months, and 91 participants (mean age 35 years, range 23-58 years, 89 females, 89 parents, and 2 grandparents) submitted demographic information and were given access to the closed forum group. A common experience of isolation emerged from the data, with descriptions of how that isolation was experienced (physical, social, knowledge) and its psychological impact, together with the factors that made it worse or better. Woven through this theme was the notion that parents developed expertise over time.

Conclusions

The use of an online forum provided a means for eliciting data from a large number of parents regarding their experiences of caring for their child after hospital discharge following cardiac surgery. Parents engaged with the forum and were able to articulate what went well and what went less well, together with sharing their stories and supporting each other through doing so. Some parents clearly found participating in the forum a positive experience in itself, demonstrating the potential of social media as a mechanism for providing support and reducing isolation. Information gained from the forum was used to shape questions for interviews with parents in a subsequent phase of the study. Furthermore, the themes identified in the online forum have contributed to identifying ways of improving the provision of care and support for parents of high-risk babies following discharge after cardiac surgery.

Maternal factors and preoperative nutrition in children with mild cases of congenital heart disease

AIM

The preoperative poor nutrition of children with congenital heart disease (CHD) impacts the postoperative rehabilitation process of pediatric CHD cases. The factors of these children's preoperative poor nutrition, excluding the disease, have been underreported. The aim was to investigate the preoperative nutritional status of children with CHD who required a simple surgical repair and to analyze the maternal characteristics that are associated with poor nutrition in these sick children.

METHODS

This was a cross-sectional survey. The weight and height of the children were measured, maternal data were collected via a questionnaire and a univariate analysis and multivariate logistic regression were used to analyze the association between maternal factors and the preoperative poor nutrition of the children with CHD.

RESULTS

A total of 119 children with simple CHD were recruited to the study. The prevalence of poor nutrition was higher in the children with CHD ("cases") than in the healthy children ("controls"). An increased risk of poor nutrition was associated with lower mothers' perception, education level, understanding of the disease, and higher anxiety.

CONCLUSIONS

Paying attention to maternal anxiety, depression, and knowledge and providing interventions for the mothers of children with CHD are important in order to promote the nutritional status of these children.

Determinants of successful medical education of caregivers of children with congenital heart diseases

Objective

To assess the implementation and efficiency of medical education among the caregivers of children with congenital heart disease (CHD) and to investigate its success factors.

Material and method

A cross-sectional study was conducted from February 2014 to March 2014 in a tertiary healthcare center. Study included 120 caregivers of children with CHD visiting the Paediatric Cardiology Clinic that included 93% mothers, aged 31.72 ± 6.67 years, 38.3% Saudi citizens and 45.0% had a high educational level. Caregivers were interviewed through a semi-structured questionnaire that included socio-demographic data of participants and demographic and clinical data of patients; awareness about the diagnosis and self-assessed understanding of thedisease; disease dimensions explained, educational material used andefficacy of whole medical education received in alleviating caregivers' anxiety.

Results

Of children who had CHD, around 42.5% were males aged 5.65 ± 3.99 years and 37.3% had ventral septal defect, 14.4% had atrial septal defectand 19.5% had a complex CHD. Study results showed that 83.3% of caregivers were aware of the correct diagnosis and 64.2% had good understanding of the nature and effect of the disease. Frequently explained disease dimensions were impact on child's growth (65.8%), complications (57.5%), and outcomes (55.0%). Least frequently explained dimensions were those related to infective endocarditis (IEC) including risk factors (15.8%), prophylaxis (17.5%), complications (19.2%) and symptoms (22.5%). The whole medical education received was efficient to enable good understanding of the disease and alleviate anxiety in 70.8% and 62.5% of the cases, respectively. Time dedicated to educate, use of illustrating educational materials, explaining various disease dimensions (aetiology, complications, prognosis, long-term management, etc.) and the number of dimensions explained were all significant predictors for both good understanding of the child's disease and anxiety relief among caregivers.

Psychosocial impact on families with an infant with a hypoplastic left heart syndrome during and after the interstage monitoring period - a prospective mixed-method study

AIMS AND OBJECTIVES

To investigate parents' experiences, coping ability and quality of life while monitoring their sick child with hypoplastic left heart syndrome at home.

BACKGROUND

Interstage home monitoring for children with hypoplastic left heart syndrome reduces interstage mortality between Norwood stages I and II. Little is known about the psychosocial impact of interstage home monitoring.

DESIGN

Prospective mixed-method study.

METHODS

This study assessed the psychosocial impact on parents during interstage home monitoring. This contains for quantitative assessment the Short Form Health Survey questionnaire and the Impact of Family Scale administered one and five weeks following discharge before and after stage II. For qualitative assessment, semi-structured interviews focussing on the postdischarge coping strategies were conducted twice, five weeks after hospital discharge before and after stage II.

RESULTS

Ten infants (eight males) with hypoplastic left heart syndrome (n = 7) or other types of univentricular heart malformations (n = 3), and their parents (nine mother/father two-parent households, one single mother) were included. There were no interstage deaths. Mental Health Composite Summary scores were low in both parents (mothers: 40·45 ± 9·07; fathers: 40·58 ± 9·69) and lowest for the item 'vitality' (mothers: 37·0 ± 19·46; fathers: 43·12 ± 25·9) before and after stage II. Impact of Family Scale values showed higher daily and social burdens for mothers. 'Becoming a family' was the most important task as coping strategy to equilibrate the fragile emotional balance. The parents judged interstage home monitoring as a protective intervention.

CONCLUSIONS

Although psychosocial burden before and after stage II remains high, becoming a family is an essential experience for parents and confirms their parenthood.

RELEVANCE TO CLINICAL PRACTICE

Healthcare professionals must be aware of parents' needs during this vulnerable interstage period and to provide psychosocial and nursing support.

Important knowledge for parents of children with heart disease: parent, nurse, and physician views

OBJECTIVES

Parental understanding of their children's heart disease is inadequate, which may contribute to poor health outcomes. The purpose of this study was to determine what parental knowledge is important in the care of children with heart disease from the perspective of parents, nurses, and physicians.

METHODS

Focus groups were formed with parents of children with single ventricle congenital heart disease (CHD), biventricular CHD, and heart transplantation, and with nurses and physicians who provide care for these children. A nominal group technique was used to identify and prioritise important parental knowledge items and themes. The voting data for each theme were reported by participant type--parent, nurse, and physician--and patient diagnosis--single ventricle CHD, biventricular CHD, and heart transplantation.

RESULTS

The following three themes were identified as important by all groups: recognition of and response to clinical deterioration, medications, and prognosis and plan. Additional themes that were unique to specific groups included the following: medical team members and interactions (parents), tests and labs (parents), neurodevelopmental outcomes and interventions (physicians), lifelong disease requiring lifelong follow-up (physicians and nurses), and diagnosis, physiology, and interventions (single ventricle and biventricular CHD).

CONCLUSIONS

Parents, nurses, and physicians have both common and unique views regarding what parents should know to effectively care for their children with single ventricle CHD, biventricular CHD, or heart transplantation. Specific targeted parental education that incorporates these findings should be provided to each group. Further development of questionnaires regarding parental knowledge with appropriate content validity is warranted.

Prenatal Counseling and Care for Single-Ventricle Heart Disease: One Center’s Model for Care

Advances in prenatal imaging allow early detection of single-ventricle congenital heart disease, which may enhance prenatal care and maximize care options and decision making. Boston Children’s Hospital’s Advanced Fetal Care Center and fetal cardiology program provide prenatal counseling and care for single-ventricle congenital heart disease. Key points for optimal prenatal counseling and education include explanation of the diagnosis, delivery, the first surgery, cardiac neurodevelopmental issues, feeding and growth issues, quality of life and long-term care, family stressors, and fetal cardiac intervention. Such counseling and education help families make the difficult decisions required in this situation.

Prenatal diagnosis of congenital heart disease and birth outcomes

This study was undertaken to examine the impact that prenatal diagnosis of congenital heart disease (CHD) has on birth and early neonatal outcomes. The prevalence of prenatally diagnosed CHD has risen over the past decade, but the effect that prenatal diagnosis of CHD has on peripartum decisions remains unclear. No consensus exists on the effect of prenatal diagnosis on neonatal outcomes. Between January 2004 and July 2009, a retrospective chart review of all neonates with CHD admitted to our institution's neonatal intensive care unit was conducted. Obstetric and postnatal variables were collected. Among the 993 subjects, 678 (68.3%) had a prenatal diagnosis. A prenatal diagnosis increased the odds of a scheduled delivery [odds ratio (OR) 4.1, 95% confidence interval (CI) 3.0-5.6] and induction of labor (OR 11.5, 95% CI 6.6-20.1). Prenatal diagnosis was not significantly associated with cesarean delivery when control was used for maternal age, multiple gestation, and presence of extracardiac anomaly. Mean gestational age had no impact on prenatal diagnosis, but prenatal diagnosis was associated with increased odds of delivery before a gestational age of 39 weeks (OR 1.5, 95% CI 1.1-1.9) and decreased odds of preoperative intubation (OR 0.5, 95% CI 0.3-0.6). Prenatal diagnosis did not have an impact on preoperative or predischarge mortality. Prenatal diagnosis was associated with increased odds of a scheduled delivery, birth before a gestational age of 39 weeks, and a decreased need for invasive respiratory support. Prenatal diagnosis of CHD was not associated with preoperative or predischarge mortality.

Parents of children with congenital heart disease prefer more information than cardiologists provide

OBJECTIVES

To determine whether pediatric cardiologists and parents of older children with congenital heart disease (CHD) share similar expectations regarding the education and counseling that should be provided to parents of children with CHD in both the prenatal and neonatal period.

DESIGN

Consenting parents of older children with CHD (age >3 years) and cardiologists ranked the importance of education topics on a scale of 1 (unimportant) to 10 (very important). The rankings of parents and cardiologists were compared using Student's t-test.

RESULTS

We had 38 cardiologists and 41 parents complete the questionnaire. There was a statistically significant difference in rankings between cardiologist and parents of children with CHD (P<0.03). Parents consistently ranked topics as more important than cardiologists with a mean difference in rank score of 0.85 ±0.3. In the prenatal period, the most significant differences between parents and cardiologists were noted for information related to the child's quality of life. For neonatal counseling, the most significant differences were noted for information regarding follow-up care and the parent's ability to describe the child's CHD to medical personnel.

CONCLUSION

Parents of older children with CHD would prefer to receive more counseling and education in the prenatal and newborn period than cardiologists perceive is wanted.

Fetal cardiac screening and variation in prenatal detection rates of congenital heart disease: why bother with screening at all?

Antenatal screening for fetal cardiac abnormalities was introduced over 25 years ago, yet detection of congenital heart disease before birth remains a challenge. While experienced tertiary centers report a high level of diagnostic accuracy, with most major forms of congenital heart disease being detectable before birth, the overall detection rate remains low. Pregnancies at increased risk of having an affected baby are referred to tertiary centers for fetal ECG, but most cases of congenital heart disease will occur in low-risk pregnancies. These cases will only be detected by screening the low-risk population at the time of routine obstetric scanning. Many obstetric ultrasound units have learnt to successfully obtain, and correctly interpret, views of the heart, including the four-chamber view and outflow tract views. However, standards for doing this are not uniform, nationally or internationally, so there is a significant variation in detection rates across individual countries and between different countries. Early diagnosis of babies with lesions that can result in cardiovascular collapse and death, could improve their survival as well as reducing morbidity. In addition, detection of a cardiac abnormality during pregnancy allows time to prepare parents for the likely course of events after birth. It also facilitates detection of other abnormalities in the baby and gives parents a choice, even if the choice is difficult and unwelcome. As well as providing parents with accurate and up-to-date information regarding the their baby’s abnormality, it is vital to provide continuing support to help them deal with the problem, regardless of what decisions they make. Much work remains to establish a uniform standard for antenatal detection of cardiac abnormalities. More recent national guidelines for examining the fetal heart along with formalized auditing processes should help to achieve this, although considerable time and effort will be required, particularly with regard to the teaching and training required.

Referral for fetal echocardiography is associated with increased maternal anxiety

BACKGROUND

Referral for fetal echocardiography (fECHO) is an acute stressor that may induce significant maternal anxiety. To promote good clinical management of expectant mothers in this situation, including adequate screening for possible psychiatric interventions, data are needed regarding the psychosocial functioning of women scheduled for fECHO procedures.

OBJECTIVE

To investigate the association between fECHO and maternal anxiety.

METHODS

Pregnant women answered two questionnaires before first fECHO. The Spielberger State-Trait Anxiety Inventory (STAI) assessed how subjects feel "now" (state) versus how they "usually feel" (trait). Separate state and trait anxiety scores were calculated; scores were compared between the study cohort and a gestational age-matched historical cohort of 31 pregnant women who did not undergo fECHO. A second questionnaire developed by the investigators ascertained pregnancy specific concerns and characteristics.

RESULTS

Forty subjects were enrolled. The mean state score of the fECHO cohort (42.1 +/- 15.1) differed from the historical cohort (32.8 +/- 11.3; p = 0.006); however there was no difference between trait scores (34.7 +/- 10.8 vs. 35.4 +/- 12.8; p = 0.8). A multivariate linear regression model controlling for race and maternal age demonstrated that fECHO was a strong independent predictor of maternal state anxiety score (p = 0.004, beta = 10.4).

CONCLUSIONS

Pregnant women presenting for fECHO report high anxiety levels compared with women not presenting for fECHO. Clinician awareness and sensitivity are recommended and further investigation of modifiers of anxiety in this high risk group should be explored.