Sociodemographics and the impact of a colostomy to indigent families and children with colorectal disorders in Honduras

The relationship between the caregiver burden and quality of life in parents of Turkish children with anorectal malformation or Hirschsprung's disease

BACKGROUND

Anorectal malformation (ARM) or Hirschsprung's disease (HD) in children impact on parents' burden of care and quality of life (QoL). The aim of this study was to investigate the relationship between caregiver burden and QoL in parents of children with ARM or HD.

DESIGN AND METHODS

This cross-sectional study was conducted with 51 parents who completed the Zarit Burden Inventory (ZBI) and World Health Organization Quality of Life Scale-Short Form Turkish Version (WHOQOL-BREF-TR).

RESULTS

The mean (±SD) ZBI score was 33.6 (±12.7), and 47.1% of parents (n = 24) perceived their caregiver burden as mild, 31.4% (n = 16) as moderate, and 3.9% (n = 2) as severe. According to the multivariate linear regression, associated anomalies (β1 = 5.912), family income (β1 = -6.007), stoma care (β1 = 8.287), and diagnosis were identified to be significant determinants of caregiver burden. A negative, moderate, and significant relationship was identified between the ZBI scores and the physical domain (r = -0.417, p < .01), psychological domain (r = -0.421, p < .01), social relations domain (r = -0.398, p < .01), and environmental domain (r = -0.495, p < .01) scores of the WHOQOL-BREF-TR.

CONCLUSIONS

The mothers perceived their caregiver burden as mild. However, a significant number of parents suffer from moderate to heavy caregiver burden. An increase in the caregiver burden of parents reduces their quality of life.

PRACTICE IMPLICATIONS

Heightened awareness of the potential for caregiver burden and its association with quality of life among parents of children with ARM and HD may contribute to improved.

"The People Criticized Me and Insulted Me Due to Having a Child with Defect": Experiences of Somali Parents of Children with Anorectal Malformation

Background

Treatment of anorectal malformations (ARM) and the management of clinical outcomes are challenging for families. While most studies focus on mothers suffering from care burden, high stress, and low quality of life, there is limited knowledge of what fathers of children with ARM experience; therefore, this study aimed to examine how both mothers and fathers have experience caring for children with ARM and how beliefs and cultural issues affect the perception of congenital anomalies.

Methods

A qualitative design. Consolidated criteria for reporting the qualitative research guidelines were used in this study. The guidelines for thematic analysis were followed for data analysis.

Results

Ten mothers and six fathers were interviewed, and their mean age was 32.5 ± 4.2 years. Of the 75% (n = 12) illiterate and 93.7% (n = 15) had an expanded family type, all their religious affiliations were Muslim. The four main themes were (1) ambiguity, (2) challenges, (3) stigma, and (4) coping, which were determined in line with the results of the data analysis of parents' views on having and caring for children with ARM.

Conclusion

In this study, many Somali parents reported that they lacked disease and treatment knowledge, physical exhaustion, and some difficulties related to a lack of access to the hospital because of living in rural areas, caring for the child, and dealing with long-term complications, colostomy, anal dilatation, and enema before or after anoplasty. While all parents mentioned that having a child with ARM was a fate, it was seen as punishment by their close social environment. Consequently, this study could serve as a foundation for planning comprehensive healthcare and physical and psychosocial support for multidisciplinary health professionals.

A scoping review of the post-discharge care needs of babies requiring surgery in the first year of life

Congenital anomalies are among the leading causes of under-5 mortality, predominantly impacting low- and middle-income countries (LMICs). A particularly vulnerable group are babies with congenital disorders requiring surgery in their first year. Addressing this is crucial to meet SDG-3, necessitating targeted efforts. Post-discharge, these infants have various care needs provided by caregivers, yet literature on these needs is scant. Our scoping review aimed to identify the complex care needs of babies post-surgery for critical congenital cardiac conditions and non-cardiac conditions. Employing the Joanna Briggs Institute's methodological framework for scoping reviews we searched Pubmed, EMBASE, CINAHL, PsychINFO, and Web of Science databases. Search terms included i) specific congenital conditions (informed by the literature and surgeons in the field), ii) post-discharge care, and iii) newborns/infants. English papers published between 2002-2022 were included. Findings were summarised using a narrative synthesis. Searches yielded a total of 10,278 papers, with 40 meeting inclusion criteria. 80% of studies were conducted in High-Income Countries (HICs). Complex care needs were shared between cardiac and non-cardiac congenital conditions. Major themes identified included 1. Monitoring, 2. Feeding, and 3. Specific care needs. Sub-themes included monitoring (oxygen, weight, oral intake), additional supervision, general feeding, assistive feeding, condition-specific practices e.g., stoma care, and general care. The post-discharge period poses a challenge for caregivers of babies requiring surgery within the first year of life. This is particularly the case for caregivers in LMICs where access to surgical care is challenging and imposes a financial burden. Parents need to be prepared to manage feeding, monitoring, and specific care needs for their infants before hospital discharge and require subsequent support in the community. Despite the burden of congenital anomalies occurring in LMICs, most of the literature is HIC-based. More research of this nature is essential to guide families caring for their infants post-surgical care.

State of the Art Bowel Management for Pediatric Colorectal Problems: Hirschsprung Disease

After an initial pull-though, patients with Hirschsprung disease (HD) can present with obstructive symptoms, Hirschsprung-associated enterocolitis (HAEC), failure to thrive, or fecal soiling. This current review focuses on algorithms for evaluation and treatment in children with HD as a part of a manuscript series on updates in bowel management. In constipated patients, anatomic causes of obstruction should be excluded. Once anatomy is confirmed to be normal, laxatives, fiber, osmotic laxatives, or mechanical management can be utilized. Botulinum toxin injections are performed in all patients with HD before age five because of the nonrelaxing sphincters that they learn to overcome with increased age. Children with a patulous anus due to iatrogenic damage of the anal sphincters are offered sphincter reconstruction. Hypermotility is managed with antidiarrheals and small-volume enemas. Family education is crucial for the early detection of HAEC and for performing at-home rectal irrigations.

Social injustice symposium: Urban, rural, and global disparities in access to care

BACKGROUND

Barriers in access to pediatric surgical care are common in low- and middle-income countries (LMICs), but also exist in high-income countries, particularly in urban and rural areas.

METHODS

This article describes "Disparities in Access to Care"-held within the Social Injustice Symposium at the 2020 American Pediatric Surgical Association (APSA) Annual Meeting.

RESULTS

This symposium outlined disparities in access to care, illustrated by examples from pediatric trauma and neonatal surgery in U.S. urban, U.S. rural, and non-U.S. global locations (LMICs). Geographic and financial challenges were common to families from the rural U.S. and LMICs. In contrast, families in U.S. urban settings generally do not face geographic barriers, but are often economically and racially diverse and many face complex societal factors leading to poor outcomes. Systemic processes must be changed to improve pediatric surgical health outcomes.

CONCLUSION

A comprehensive health system with an equal emphasis on supportive care and surgery is required in all settings. Global collaboration and partnerships can provide an avenue for advocacy and strategic innovation to improve quality of care.

LEVEL OF EVIDENCE

Ⅴ.

Distress and post-traumatic stress in parents of patients with congenital gastrointestinal malformations: a cross-sectional cohort study

Background

Congenital gastrointestinal malformation (CGIM) require neonatal surgical treatment and may lead to disease-specific sequelae, which have a potential psychological impact on parents. The aim of this study is to assess distress and symptoms of post-traumatic stress disorder (PTSD) in parents of patients with CGIM. In this cross-sectional study, seventy-nine parents (47 mothers and 32 fathers) of 53 patients with CGIM completed the Distress Thermometer for Parents (DT-P) and the Self Rating Scale for Posttraumatic Stress Disorders (SRS-PTSD) as part of the multidisciplinary follow-up of their children (aged 5–35 months). Group differences were tested between parents and representative Dutch reference groups with regard to rates of (clinical) distress and PTSD, and severity of overall distress and PTSD, for mothers and fathers separately. Mixed model regression models were used to study factors associated with the risk of (clinical) distress, PTSD and with severity of symptoms of PTSD (intrusion, avoidance and hyperarousal).

Results

Prevalence of clinical distress was comparable to reference groups for mothers (46%) and fathers (34%). There was no difference in severity of overall distress between both mothers as well as fathers and reference groups. Prevalence of PTSD was significantly higher in mothers (23%) compared to the reference group (5.3%) (OR = 5.51, p < 0.001), not in fathers (6.3% vs 2.2.%). Symptoms of intrusion were commonly reported by all the parents (75%). Longer total length of child’s hospital stay was associated with more severe symptoms of intrusion, avoidance and hyperarousal. Child’s length of follow-up was negatively associated with severity of intrusion.

Conclusions

Having a child with CGIM has a huge impact on parents, demonstrated by a higher prevalence of PTSD in mothers, but not fathers, compared to parents in the general population. Monitoring of symptoms of PTSD of parents in follow-up is necessary.

Hirschsprung disease outcomes

Hirschsprung disease (HD) is a complex surgical and medical problem that appears to have varied health and social outcomes with the age and neurodevelopmental state of patients. In general, long-term outcomes are thought to be good for the majority of patients despite recognized problems with constipation and/or fecal incontinence. However, there are no universally accepted pathways regarding post-operative bowel management programs nor clearly defined follow-up pathways making the current outcome measures difficult to interpret. Further, other factors that may influence outcome including age at the time of procedure and procedure type continue to lack consensus. Improved support of children in resource limited environments and during periods of transition into the adult medical care environment are needed to improve outcome.  Recent proliferation of multidisciplinary care teams and consortia may help to better understand outcomes and address current knowledge gaps. Continuing these collaborations will be imperative to continuing improvements in care which may ultimately impact outcome.

Hirschsprung disease managed with one-stage transanal endorectal pullthrough in a low-resource setting without frozen section

BACKGROUND

Over the past few decades, surgery for Hirschsprung's disease (HD) has evolved into a minimally invasive, single-stage procedure with excellent outcomes. Intraoperative frozen section biopsy is critical for this procedure to avoid the potential risk of leaving a retained aganglionic segment. However, this facility is not available in most low-income countries. Therefore, a two-stage procedure with an initial colostomy is still practiced in the developing world. We aimed to evaluate the outcome of single-stage transanal pullthrough performed in a facility without frozen section biopsy.

METHODS

A retrospective review of all patients who underwent transanal pullthrough in two teaching hospitals over a 6-year period (2015-2020).

RESULTS

Forty-seven children underwent transanal endorectal pullthrough (TERPT). Age at surgery ranged from 2 months to 6 years and mean weight was 8.7 kg. Barium enema did not show transition zone in 6 patients (12.8%) while others demonstrated short segment HD. Intraoperatively, the transition zone was visualized in 40 patients (85%). TERPT alone was performed in 35 (74.5%), TERPT with laparotomy to visualize transition zone in 9 (26.7%) and TERPT with transabdominal mobilization was required in 3 (6.4%). Definitive histopathologic examination revealed aganglionic segment pullthrough in 4 (8.5%) and transitional zone pullthrough in another 4 (8.5%). However, with long term follow up all eight children remained asymptomatic and no intervention was required.

CONCLUSIONS

Transanal pullthrough offers reduced number of surgeries and faster recovery. We have also observed a good functional outcome despite a discrepancy with pathology results. Overall, our data suggests it is a safe and viable option for the treatment of short segment HD in facilities where frozen section is not available.

Psychosocial factors affecting quality of life in patients with anorectal malformation and Hirschsprung disease-a qualitative systematic review

INTRODUCTION

Little is known about psychosocial and behavioral factors that impact the quality of life of patient's with anorectal malformations (ARM) and Hirschsprung disease (HSCR). We aimed to highlight the psychosocial, emotional, and behavioral themes that affect these patients.

METHODS

A qualitative literature review of articles published between 1980 and 2019 was performed. Articles that reported quality of life (QoL) measures not directly related to bowel function and incorporated data on patients aged 0-21 years old were included. Data were separated based on distinct developmental time points.

RESULTS

In the neonatal period, parents relayed uncertainty about the future and feeling overwhelmed by lack of social support. Difficulties with anxiety, peer rejection, and behavioral problems were noted in primary grades, while adolescents experienced low self-confidence, poor body image, and depression. Young adults expressed hesitancy to engage in romantic relationships or sexual activity. Lack of long-term follow-up, an incomplete transition to adult healthcare, and lack of psychology services leave young adults without guidance to manage a chronic condition.

CONCLUSION

Multiple psychosocial stressors are present in the lives of ARM and HSCR patients. Provision of developmentally matched medical, psychological, and community-based supports for ARM and HSCR patients and their families can lead to improved QoL.

Follow-up Plan as a Necessity for Nursing Care: A Decrease of Stress in Mothers with their Children in Pediatric Surgical Units

Introduction: Children are vulnerable to damage. Health problems in children, especially if necessitate hospitalization, can cause stress in their parents that may persist even long after discharge. This study aimed to investigate the effect of implementing follow-up care plans on stress in mothers of children discharged from pediatric surgical units.

Methods: A quasi-experimental study was conducted on 64 mothers whose children were hospitalized in the surgical wards of two educational hospitals affiliated to Isfahan University of Medical Sciences, Iran. The participants were randomly assigned into two groups of control and experimental. The data collection tools included a demographic data questionnaire and stress response inventory (SRI). The interventions were performed using a four-stage follow-up care plan. The data were analyzed using SPSS software version 13 and descriptive statistics, independent t-test, repeated measures analysis of variance (ANOVA), and least significant difference (LSD) test.

Results: The mean (SD) stress scores of the experimental group were 64.1 (28.8), 20.4 (12.4), and 11.6 (7.5) before, one week, and one month after the intervention, respectively. In the control group, these scores were 61.2 (29.2), 59.9 (25.5), and 46.7 (19.1), respectively. The results showed the mean score was significantly lower than that of the control group at one week and one month after the intervention in the experimental group.

Conclusion: Our results demonstrated that a follow-up care plan can decrease the stress levels of mothers as a continuity of patient care even after discharge.

Quality outcomes for pediatric colorectal surgery treated during short-term international medical service trips at a dedicated site in Honduras

INTRODUCTION

Short-term international medical service trips (MSTs) provide specialized care in resource-constrained countries. There are limited data on immediate and long-term reported outcomes following specialty MST. We hypothesized that dedicated collaborative MST team and host institution produce outcomes and results comparable to those of high-income settings. Our primary aim was to analyze the long-term surgical and functional outcomes of our specialty-specific MSTs following five years of annual MST in Honduras.

METHODS

We performed a single-institution retrospective analysis of 56 children who underwent colorectal and pelvic reconstructive operations between 2014 and 2018. Demographics, diagnosis, comorbidities, type of repair, long-term complications, and functional bowel and bladder results were recorded.

RESULTS

We included a total of 56 children, 47 with ARM and 9 with HD, with a median age of 43.5 months (17-355) at the time of surgery. 25% (22) of the patients were lost to follow-up. Fecal continence was achieved by 23 (60%) patients <5 years who reported toilet training (n = 39) and by 5 (45%) patients >5 years (n = 11). Complications included constipation in 18 (42.9%) children with ARM and in 1 (12.5%) with HD. Eleven (19.6%) patients required revisional surgery for skin level anal stricture. Seventy-five percent of the patients with pediatric colorectal disorders attending the MST were compliant with continued long-term follow-up.

CONCLUSION

We were able to demonstrate that with organized, dedicated site and surgeon, results achieved can be comparable to those in the high-income countries (HICs). We conclude that this type of specialized care is feasible and beneficial for affected pediatric colorectal patients in resource-limited settings, when a strong partnership with a system of preoperative assessments and peri- and postoperative care can be established.

LEVEL OF EVIDENCE

Level IV (retrospective cohort study).

An Evaluative Study to Assess the Effectiveness of a Video-Assisted Teaching Module on Knowledge and Practice Regarding Home-Based Colostomy Care of Children Among Primary Caregivers in Selected Hospital Lucknow, Uttar Pradesh

INTRODUCTION

The aim of the study is to assess the knowledge and practice skills of home-based colostomy caregivers of children with a colostomy. The objective of the study was to assess the effectiveness of video teaching module on colostomy care among home-based colostomy caregivers.

METHOD

A quasi-experimental study design and 30 samples were adopted. The samples selected by the purposive sampling technique those were fulfilled the sample criteria. Demographic and structured knowledge questionnaires were used for the data collection.

RESULT

Descriptive and inferential statistics were used for data analysis by using SPSS software version 16.0. Out of 30 samples, demographic variables, 23 (76.6%) of the participants are of age between 21 and 30 years, 21 (70%) were housewives, 23 (76.6%) were mothers, 16 (53.4%) completed higher secondary, and 23 (76.6%) have monthly family income of INR 5001-10000. The majority of the children with a colostomy were toddler 22 (73.3%), gender ratio was equal, 27 (90%) are of Hindu religion, and 29 (96.7%) undergone colostomy. Knowledge score was divided based on percentage. Good knowledge scores in pre- and posttest are 0 and 29 (96.5%); moderate knowledge in pre- and posttest, 9 (30.5%) and 1 (3.3%); and poor knowledge in pre- vs posttest, 21(70%) and 0, respectively. Inferential statistics evaluated colostomy care video intervention. Knowledge was assessed by paired t test, - 19.607 (p < 0.05); similarly, practice skill assessed by Wilcoxon signed-rank was (z) - 4.716 (p < 0.01).

CONCLUSION

Colostomy care video was a powerful tool to enhance primary caregivers' confidence, colostomy care skills, and attitude.

The socioeconomic impact of a pediatric ostomy in Uganda: a pilot study

INTRODUCTION

Multiple pediatric surgical conditions require ostomies in low-middle-income countries. Delayed presentations increase the numbers of ostomies. Patients may live with an ostomy for a prolonged time due to the high backlog of cases with insufficient surgical capacity. In caring for these patients in Uganda, we frequently witnessed substantial socioeconomic impact of their surgical conditions.

METHODS

The operative log at the only pediatric surgery referral center in Uganda was reviewed to assess the numbers of children receiving ostomies over a 3-year period. Charts for patients with anorectal malformations (ARM) and Hirschsprung's disease (HD) were reviewed to assess delays in accessing care. Focus group discussions (FGD) were held with family members of children with ostomies based on themes from discussions with the surgical and nursing teams. A pilot survey was developed based on these themes and administered to a sample of patients in the outpatient clinic.

RESULTS

During the period of January 2012-December 2014, there was one specialty-certified pediatric surgeon in the country. There were 493 ostomies placed for ARM (n = 234), HD (N = 114), gangrenous ileocolic intussusception (n = 95) and typhoid-induced intestinal perforation (n = 50). Primary themes covered in the FGD were: stoma care, impact on caregiver income, community integration of the child, impact on family unit, and resources to assist families. Many patients with HD and ARM did not present for colostomy until after 1 year of life. None had access to formal ostomy bags. 15 caregivers completed the survey. 13 (86%) were mothers and 2 (13%) were fathers. Almost half of the caregivers (n = 7, 47%) stated that their spouse had left the family. 14 (93%) caregivers had to leave jobs to care for the stoma. 14 respondents (93%) reported that receiving advice from other caregivers was beneficial.

CONCLUSION

The burden of pediatric surgical disease in sub-Saharan Africa is substantial with significant disparities compared to high-income countries. Significant socioeconomic complexity surrounds these conditions. While some solutions are being implemented, we are seeking resources to implement others. This data will inform the design of a more expansive survey of this patient population to better measure the socioeconomic impact of pediatric ostomies and guide more comprehensive advocacy and program development.