Parental decision-making in congenital heart disease

Parents' experiences of receiving their child's diagnosis of congenital heart disease: A systematic review and meta-synthesis of the qualitative literature

PURPOSE

This systematic review aimed to synthesize qualitative research on parents' psychological experiences following their child's diagnosis of congenital heart disease (CHD).

METHODS

A systematic search of six electronic databases (CINAHL, Embase, MEDLINE, PsycINFO, PubMed and Web of Science) was completed, inclusive of all years up to May 2022. Any included articles were synthesized using thematic synthesis and appraised using the Critical Appraisal Skills Programme Qualitative Checklist.

RESULTS

Twenty-six articles were included. Four main themes, and 11 subthemes, emerged from the synthesis. Theme 1 (unpreparedness for the diagnosis) concerned parents' shock, guilt and anger regarding the diagnosis. Theme 2 (the overwhelming reality of CHD) described parental fear about decision-making and the child's prognosis, and the influence of professionals on parents' well-being. Theme 3 (mourning multiple losses) detailed parents' sadness at losing their envisioned pregnancy, birth and parenthood experiences. Theme 4 (redefining hopes to reach an acceptance of CHD) described parents' adjustment to the diagnosis.

CONCLUSIONS

Receiving a child's CHD diagnosis was a uniquely challenging situation for parents. The findings provided insight into the emotions parents experienced and how they adjusted to the diagnosis psychologically. As parents' experiences were significantly influenced by their interactions with professionals, clinicians should offer compassion, validation and clear information throughout the diagnosis process.

Meeting Parents' Needs for Education and Preparation following Congenital Heart Disease Diagnosis: Recommendations from a Crowdsourced Study

OBJECTIVE

 This article characterizes the educational needs of parents following fetal or neonatal congenital heart disease (CHD) diagnosis and generates recommendations for meeting these needs.

STUDY DESIGN

 Online crowdsourcing methods were used to collect qualitative data from 95 parents of children with CHD regarding their needs for education and preparation following fetal or neonatal diagnosis. Data were analyzed using qualitative methods and themes were organized around the substructure of met and unmet needs.

RESULTS

 Two themes represented consistently met needs, whereas 10 themes represented needs that were either inconsistently met or consistently unmet. Parents reported needing more information about social, emotional, and financial supports, preparation for long-term care, and guidance toward reputable online resources. Parents also provided recommendations for meeting these needs.

CONCLUSION

 Parents' needs for education and preparation following CHD diagnosis are much broader in scope than what they currently receive. Addressing these may support parental coping and active participation in medical decision-making.

KEY POINTS

· CHD counseling after diagnosis may provide opportunities to promote parents' mental health.. · Guidelines recommend that this counseling should include emotional and decision-making support, however, it is unclear what parents actually receive.. · This study found that parents' needs for education and preparation following CHD diagnosis are much broader in scope than what they currently receive..

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.

Evaluation of depression, anxiety, and stress status in parents of patient with congenital clubfoot treated with Ponseti method: A prospective study

Congenital diseases have been reported to increase the incidence of depression, anxiety, and stress among parents. In this study, we aimed to investigate the depression, anxiety, and stress status in parents of patients with congenital clubfoot before and after treatment with the Ponseti method. A total of 20 patients diagnosed with congenital clubfoot at our clinic and treated with the Ponseti method were included in this study. The Depression Anxiety Stress Scale-21 (DASS-21) was used to evaluate the depression, anxiety, and stress status of the parents before and after treatment. We considered the following parameters to investigate the effects of these on the parents: the educational level of the parents; economic status of the family; gender; birth order of the child in the family; time of diagnosis (prenatal or postnatal). The mean DASS and subdomain scores after treatment were significantly lower than those before treatment (P < .05). Moreover, there was a significant difference in the pre- and posttreatment mean DASS and depression scores of the participants in terms of the education level (P < .05). The pre- and posttreatment DASS and depression scores of the participants with an education level of primary school and below were lower than those of the participants with an education level of secondary and high school. Parents may be less concerned during this process if they are fully informed by the orthopedic surgeons about the treatment protocol and the near-perfect results of the Ponseti method as well as are counseled by healthcare professionals.

Vigilance in the Decision-Making Process Regarding Termination of Pregnancy Following Prenatal Diagnosis of Congenital Heart Disease-Application of the 'Conflict Decision-Making Model'

The decision-making process regarding termination of pregnancy following prenatal diagnosis of congenital heart disease is a stressful experience for future parents. Janis and Mann’s conflict decision-making model describes seven ideal stages that comprise vigilant information-gathering as an expression of the qualitative decision-making process. In our study, we attempted to determine whether parents who face the decision regarding termination of pregnancy undertake a qualitative decision-making process. Data were collected over 2-year period using structural questionnaires. The sample consisted of two hundred forty participants; sixty-nine (28.75%) declared that their decision was to terminate the pregnancy. A significant difference in the quality of the decision-making score was noted between parents who decided to continue with the pregnancy vs. parents who opted for termination (mean score of 10.15 (5.6) vs. 18.51 (3.9), respectively, p < 0.001). Sixty-two (90%) participants within the termination of pregnancy group went through all seven stages of vigilant decision-making process and utilized additional sources for information and consultation. Parents who decided to continue with the pregnancy made swift decisions, often without considering the negative and positive outcomes; this decision-making pattern is considered non-vigilant and ineffective. Identification of future parents at risk of going through an ineffective decision-making process may help health professionals to determine the best way to provide them with information and support.

Impact of prenatally diagnosed congenital heart defects on outcomes and management

Fetal echocardiogram aids in prenatal identification of neonates at high risk for congenital heart defects (CHD). Prenatal detection rates for CHD have increased with improved ultrasound technology, the use of the early fetal echocardiography, and standardization of the performance of the fetal echocardiogram. Accurate prenatal detection of CHD, particularly complex CHD, is an important contributor to improved survival rates for patients with CHD. Early detection allows for families to choose whether or not to continue with pregnancy, referral to pediatric cardiology specialists for patient education, and delivery planning. Better psychosocial supports are needed for families with CHD.

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.

Paternal Preferences, Perspectives, and Involvement in Perinatal Decision Making

IMPORTANCE

Despite increasing attention to the importance of father involvement during pregnancy, the literature on fathers' roles in perinatal decision making is scant.

OBJECTIVE

The aim of this study was to conduct a narrative review of the literature exploring fathers' preferences, perspectives, and involvement in perinatal decision making.

EVIDENCE ACQUISITION

We searched PubMed, Ovid, EMBASE, Cochrane Library, and CINAHL databases using the terms father, spouse(s), husband, and paternal separately with the combined terms of attitude, preference, involvement, influence, informed consent, decision making, pregnancy, labor induction, genetic testing, prenatal diagnosis, amniocentesis, fetal surgery, genetic abnormalities, congenital anomalies, birth defects, perinatal, and antenatal. The search was limited to English-language studies that were published anytime and conducted between July and September 2018.

RESULTS

The initial search identified 616 articles; 13 articles met criteria for inclusion. Fathers view themselves as serving distinct roles in perinatal decision making and have specific informational needs that would support their involvement in decision making. Although fathers want to support their partners and learn about fetal health, they often feel excluded from perinatal screening decisions. Mothers and fathers also have different needs, concerns, and preferences regarding key perinatal decisions that, if unresolved, can impact the couples' relationship and perinatal outcomes.

CONCLUSIONS

Findings provide import insights into the distinct experiences, roles, needs, and perspectives of fathers facing perinatal decision making.

RELEVANCE

Advancing research and policy on fathers' involvement in perinatal decision making could lead to a paradigm shift in how maternity care is structured, how obstetric services are delivered, and how perinatal interventions are designed and implemented.

Parental stress and resilience in CHD: a new frontier for health disparities research

Parental stress is a universal experience for parents who have children diagnosed with CHD and has been studied within the context of the child's illness, but not through a broader health disparity lens. This paper provides a thorough synthesis of the current literature on parental stress addressing disparities in parents of children with CHD. Several theories and models from within this literature are described and a new comprehensive framework, the Parental Stress and Resilience in CHD Model, is presented. Future research and clinical implications are discussed.

Effect of prenatal diagnosis on hospital costs in complete transposition of the great arteries

OBJECTIVE

Prenatal diagnosis of congenital heart disease (CHD) is associated with improved clinical outcomes, yet its impact on the cost of hospitalization is not well described. We hypothesized that prenatal diagnosis of complete transposition of the great arteries (d-TGA) results in lower total hospital costs compared with postnatal diagnosis.

METHODS

Retrospective analysis of infants with d-TGA repaired at our center from July 2006 to 2014. Total charges from initial hospitalization until discharge were converted to costs using the cost-to-charge ratio and then converted into 2016 dollars using the consumer price index. A direct cost comparison from the hospital perspective was performed between groups. A secondary analysis included the cost of prenatal diagnosis.

RESULTS

Thirty-three infants with d-TGA were identified; 8 with and 25 without prenatal diagnosis. There was no difference in baseline characteristics. Mean direct cost of hospitalization was higher in infants without prenatal diagnosis ($108 014 ± $51 305 vs $88 305 ± $22 896, P = .31). On secondary analysis, the cost of prenatal diagnosis was negligible compared with total hospital cost.

CONCLUSIONS

Total cost of initial hospitalization was higher for infants without prenatal diagnosis of d-TGA. Prenatal diagnosis not only improves clinical outcomes but may also be cost saving in the current era of increasing health care costs.

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.

The emotional process from diagnosis to birth following a prenatal diagnosis of fetal anomaly: A qualitative study of messages in online discussion boards

OBJECTIVE

to explore written statements found in online discussion boards where parents currently expecting, or with previous experience of expecting, a child with a prenatally diagnosed congenital anomaly communicate about their emotional process from diagnosis to birth.

DESIGN

cross-sectional qualitative study of messages in public online discussion boards.

SETTING

Swedish public discussion boards about reproductive subjects.

SAMPLE

ten pregnant women and eight parents (of children with prenatal diagnoses) who had written 852 messages in five threads in Swedish online discussion boards identified via systematic searches.

MEASUREMENTS AND FINDINGS

three phases were identified in the process of moving from the diagnosis to the birth: shock, existential crisis, and life remodeling. The people posting message ('posters') moved from initial shock to existential crisis and, lastly, a phase of remodeling life later in the pregnancy. During the pregnancy, considerable worries about both antenatal and postnatal aspects were expressed. To cope with their situation, the posters distanced themselves from the diagnoses, vented their feelings, sought control, and obtained practical support from friends and relatives.

KEY CONCLUSIONS

expectant parents faced with a prenatal diagnosis move from initial shock to a phase of life remodeling and acceptance. Burdened with considerable worries, expectant parents cope with their situation through informational, emotional, and instrumental support from health professionals, family, friends, and peers.

IMPLICATIONS FOR PRACTICE

health professionals should make sure that expectant parents feel involved in planning their children's postnatal care, that they are offered sufficient information, and that they have access to emotional and instrumental support structures.

Maternal Stress and Anxiety in the Pediatric Cardiac Intensive Care Unit

BACKGROUND

Mothers whose infants are born with complex congenital heart disease (CCHD) experience stress during their infant's hospitalization in a pediatric cardiac intensive care unit (PCICU).

OBJECTIVES

This study addressed 2 research questions: (1) What are the parental stressors for mothers whose infants with CCHD are in the PCICU? And (2) What are the relationships of trait anxiety and 3 parental stressors to the parental stress response of state anxiety in mothers whose infants with CCHD are in the PCICU?

METHODS

This descriptive correlational study included 62 biological mothers of infants admitted to a PCICU within 1 month of birth who had undergone cardiac surgery for CCHD. Maternal and infant demographics and responses to the Parental Stressor Scale: Infant Hospitalization and the State-Trait Anxiety Inventory were collected at 3 major PCICUs across the United States.

RESULTS

Mothers' scores revealed that infant appearance and behavior was the greatest stressor, followed by parental role alteration, then sights and sounds. The combination of trait anxiety and parental role alteration explained 26% of the variance in maternal state anxiety. Mothers with other children at home had significantly higher state anxiety than did mothers with only the hospitalized infant.

CONCLUSIONS

Results from this study revealed factors that contribute to the stress of mothers whose infants are born with CCHD and are hospitalized in a PCICU. Nurses are in a critical position to provide education and influence care to reduce maternal stressors in the PCICU, enhance mothers' parental role, and mitigate maternal state anxiety.

Does the visibility of a congenital anomaly affect maternal-infant attachment levels?

PURPOSE

To determine whether congenital anomaly visibility affects maternal-infant attachment levels.

DESIGN AND METHODS

The study population consisted of mothers who had infants with cleft lip/palate or congenital heart anomalies who were receiving treatment in a university hospital. The data were collected using the Structured Questionnaire Form and the Maternal Attachment Inventory.

RESULTS

Statistically significant differences in maternal-infant attachment levels were observed between infants with cleft lips/palates and healthy infants and between infants with congenital heart anomalies and healthy infants.

PRACTICE IMPLICATIONS

It is important to apply appropriate nursing interventions for these mothers during the postpartum period.

Identifying expectant parents at risk for psychological distress in response to a confirmed fetal abnormality

The aim of the study was to determine the incidence of psychological distress among expectant women carrying fetuses with prenatal diagnosed abnormalities and their partners. A 2-year retrospective medical chart review was completed of 1032 expectant mothers carrying fetuses with a confirmed anomaly, and 788 expectant fathers, who completed the CFDT Mental Health Screening Tool. Furthermore, 19.3 % of women and 13.1 % of men reported significant post-traumatic stress symptoms, and 14 % of men and 23 % of women scored positive for a major depressive disorder. Higher risk was noted among expectant parents of younger age and minority racial/ethnic status, and women with post-college level education and current or prior use of antidepressant medications. Heightened distress was noted within fetal diagnostic subgroups including neck masses, sacrococcygeal teratomas, neurological defects, and miscellaneous diagnoses. Incorporating screening tools into prenatal practice can help clinicians better identify the potential risk for psychological distress among expectant parents within high-risk fetal settings.

Management Options and Outcomes for Neonatal Hypoplastic Left Heart Syndrome in the Early Twenty-First Century

Without surgical treatment, neonatal hypoplastic left heart syndrome (HLHS) mortality in the first year of life exceeds 90 % and, in spite of improved surgical outcomes, many families still opt for non-surgical management. The purpose of this study was to investigate trends in neonatal HLHS management and to identify characteristics of patients who did not undergo surgical palliation. Neonates with HLHS were identified from a serial cross-sectional analysis using the Healthcare Cost and Utilization Project's Kids' Inpatient Database from 2000 to 2012. The primary analysis compared children undergoing surgical palliation to those discharged alive without surgery using a binary logistic regression model. Multivariate logistic regression was conducted to determine factors associated with treatment choice. A total of 1750 patients underwent analysis. Overall hospital mortality decreased from 35.3 % in 2000 to 22.9 % in 2012. The percentage of patients undergoing comfort care discharge without surgery also decreased from 21.2 to 14.8 %. After controlling for demographics and comorbidities, older patients at presentation were less likely to undergo surgery (OR 0.93, 0.91-0.96), and patients in 2012 were more likely to undergo surgery compared to those in prior years (OR 1.5, 1.1-2.1). Discharge without surgical intervention is decreasing with a 30 % reduction between 2000 and 2012. Given the improvement in surgical outcomes, further dialogue about ethical justification of non-operative comfort or palliative care is warranted. In the meantime, clinicians should present families with surgical outcome data and recommend intervention, while supporting their option to refuse.

Anti-Ro/SSA autoantibody-positive women’s experience of information given on the risk of congenital heart block

Objective

Congenital heart block (CHB) may develop in fetuses of women with anti-Ro/SSA autoantibodies, and carries substantial morbidity and mortality. The aim was to evaluate how information on CHB is imparted and identify areas of improvement.

Methods

A questionnaire was distributed to anti-Ro/SSA antibody-positive women who had either participated in a surveillance programme but whose expected child did not develop CHB ( n = 100, denoted Doppler-Assessed Pregnancies (DAP) group) or given birth to a child with CHB ( n = 88, denoted CHB-Affected Pregnancies (CAP) group).

Results

The response rate was 83% (157/188). Most women received the information on CHB when they were already pregnant (DAP group 60%, CAP group 83%). However, a majority of them would have wanted the information before pregnancy (DAP group 52%, CAP group 56%), and most stated that it would not have influenced their decision to have a child (DAP group 77%, CAP group 58%). The ability to both understand the information and to perceive the information as sufficient were significantly higher when someone trained in paediatric cardiology gave the information.

Conclusions

Our findings indicate that information on CHB should be given to women before pregnancy. The data further highlight the importance of having specific knowledge for giving relevant and understandable, yet sufficient information.

Families of children with congenital heart disease: A literature review

In 2000 and 2002, the National Heart, Lung, and Blood Institute launched two initiatives to encourage treatment innovations and research on children with heart disease and their families. Since then, no systematic reviews have examined the evidence regarding the impacts of having a child with congenital heart disease (CHD) on families. This review synthesized key findings regarding families of children with CHD, critiqued research methods, described what has been done, and provided recommendations for future inquiry. Databases searched included PubMed, CINAHL, Family & Society Studies Worldwide, Women's Studies International, and PsycINFO. The literature search followed the PRISMA guidelines. As a result, ninety-four articles were reviewed. Four major themes were derived: parents' psychological health, family life, parenting challenges, and family-focused interventions. In conclusion, while they found parents having psychological symptoms, researchers did not explore parents' appraisals of what led to their symptoms. Research is needed to explore parents' experiences and expectations.

Conscientious objection and refusal to provide reproductive healthcare: a White Paper examining prevalence, health consequences, and policy responses

BACKGROUND

Global Doctors for Choice-a transnational network of physician advocates for reproductive health and rights-began exploring the phenomenon of conscience-based refusal of reproductive healthcare as a result of increasing reports of harms worldwide. The present White Paper examines the prevalence and impact of such refusal and reviews policy efforts to balance individual conscience, autonomy in reproductive decision making, safeguards for health, and professional medical integrity.

OBJECTIVES AND SEARCH STRATEGY

The White Paper draws on medical, public health, legal, ethical, and social science literature published between 1998 and 2013 in English, French, German, Italian, Portuguese, and Spanish. Estimates of prevalence are difficult to obtain, as there is no consensus about criteria for refuser status and no standardized definition of the practice, and the studies have sampling and other methodologic limitations. The White Paper reviews these data and offers logical frameworks to represent the possible health and health system consequences of conscience-based refusal to provide abortion; assisted reproductive technologies; contraception; treatment in cases of maternal health risk and inevitable pregnancy loss; and prenatal diagnosis. It concludes by categorizing legal, regulatory, and other policy responses to the practice.

CONCLUSIONS

Empirical evidence is essential for varied political actors as they respond with policies or regulations to the competing concerns at stake. Further research and training in diverse geopolitical settings are required. With dual commitments toward their own conscience and their obligations to patients' health and rights, providers and professional medical/public health societies must lead attempts to respond to conscience-based refusal and to safeguard reproductive health, medical integrity, and women's lives.

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.

Fetal and post-natal diagnosis of major congenital heart disease: implications for medical and psychological care in the current era

AIM

The fetal or post-natal diagnosis of major congenital cardiac abnormality has important medical and psychological consequences.

METHODS

We reviewed infants who underwent cardiac surgery in the first year of life at the Heart Centre for Children, The Children's Hospital at Westmead during 2009. The aims of this study were to: (i) examine the key features of cardiac diagnosis and clinical outcome, and (ii) consider how these data can inform priorities for the delivery of clinical services.

RESULTS

Over the 12-month study period, a first cardiac surgical procedure was performed on 195 infants, with 85 infants (44%) diagnosed in the antenatal period. Of the total sample, a subset of 90 babies (46%) underwent their first procedure in the neonatal period, with 62% having had a fetal diagnosis. Major intracardiac lesions including truncus arteriosus (100%), single ventricular lesions (83%), pulmonary atresia with ventricular septal defect (78%) and transposition of the great arteries (53%) were diagnosed prior to birth. Improved haemodynamic stability at initial presentation was found in those with a fetal diagnosis. The overall mortality rate for all patients was 6.1% at 12 months, with a higher mortality in infants with single ventricle.

CONCLUSIONS

The contemporary paradigm of care for infants with major congenital heart disease requires a multidisciplinary approach to care, with improvements in clinician-clinician and clinician-family communication, and psychological support and education for families. Changes in the allocation of resources are required to meet this model of best practice.

Parental perception of time and decision-making in neonatal research

OBJECTIVE

To assess the impact of time on parental decision-making for research participation for neonates with congenital heart disease.

STUDY DESIGN

Interviews were conducted with 37 parents of 19 neonates with congenital heart disease who were eligible for three different studies: genetic etiology of congenital heart disease, heart rate variability (HRV) and structural and functional cranial magnetic resonance imaging (MRI). All parents were asked the same questions: (1) 'Did you have adequate time to make a decision about research?' and (2) 'Why?' Differences between groups (reporting adequate and inadequate time) were evaluated using Fisher's exact tests; central themes were examined using qualitative analysis.

RESULT

Of those parents who reported having adequate time to make their decision (22 of 37), the majority chose to participate when compared to those who reported inadequate time (genetics study, P<0.01; HRV, P=0.05; MRI, P<0.01). For the parents reporting inadequate time, consistent themes emerged: insufficient time to make an educated choice (n=10), consideration of study logistics (n=8), spouse not present at the time of decision (n=7) and insufficient time to discuss the studies (n=4).

CONCLUSION

Parental perception of adequate time to decide about research participation was associated with parental willingness to enroll the child in research. Despite any time limitations, parents were satisfied with the decisions they made. Optimizing the time available for the parental permission process could enhance research participation in the neonatal period.

From diagnosis to birth: parents' experience when expecting a child with congenital anomaly

Of 350,000 Canadian children born each year, 2% to 3% will have a serious congenital anomaly. Because of recent ultrasound diagnostic improvements and increased frequency of prenatal scans, many anomalies are determined prenatally, with more parents receiving disturbing, unanticipated news of an anomaly. This article highlights the experiences, concerns, and healthcare needs of parents who receive a prenatal diagnosis of congenital anomaly during routine ultrasound and choose to continue with the pregnancy. Examples from parent interviews describing their experience complement the sparse literature dealing with this phenomenon. Parents describe their experience from antenatal diagnosis and preparation for the child's birth and subsequent admission to the neonatal intensive care unit. Attention is paid to how neonatal nurses can positively influence this process by attending to parents' feelings or moods. The conclusion includes recommendations for neonatal nursing care for these vulnerable parents.

Parental understanding of neonatal congenital heart disease

BACKGROUND

This study aimed to evaluate the impact of prenatal diagnosis on parental understanding of congenital heart disease (CHD) in newborns.

METHODS

Consenting parents of newborns with CHD answered questions about the cardiac lesion, surgical repair, follow-up management, risk for CHD in future children, and maternal education before neonatal intensive care unit (NICU) discharge. A total understanding score was calculated (0-10) as the sum of five subscores: physician score, CHD score, surgery score, follow-up score, and reproduction score. Each category was scored as 0 (none correct), 1 (some correct), or 2 (all correct). The prenatal and postnatal diagnoses scores were compared.

RESULTS

From June 2006 to November 2006, 50 families completed the questionnaire. Of these 50 families, 26 reported a prenatal diagnosis. The mean infant age when the parents were approached was 17.3 +/- 13.3 days. The summary understanding score for the entire group was 6.3 +/- 2.4 of 10. Multivariate regression analysis demonstrated a difference in scores between prenatal and postnatal diagnosis groups (p = 0.02) when control was used for maternal education. Prenatal diagnosis and maternal education (p < 0.01) had independent effects on the score.

CONCLUSION

Prenatal diagnosis increases parental understanding of neonatal CHD. Nevertheless, parental understanding remains suboptimal.

Critical heart disease in the neonate: presentation and outcome at a tertiary care center

OBJECTIVE

To define the modes of presentation, incidence of major organ dysfunction, predictors of hospital mortality, and adverse outcomes in neonates with critical heart disease admitted to a tertiary care center.

DESIGN

Retrospective chart review.

SETTING

A tertiary care pediatric cardiac intensive care unit and neonatal intensive care unit.

PATIENTS

The medical records for all neonates (< or = 30 days of age) with heart disease admitted to the cardiac intensive care unit or neonatal intensive care unit between October 1, 2002, and September 30, 2003, were reviewed.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 190 neonates met inclusion criteria during this 1-yr period, of which 146 (77%) had at least one surgical procedure. Single ventricle heart disease was present in 42%. The most common mode of presentation was following a prenatal diagnosis (53%), followed by diagnosis in the newborn nursery (38%) and diagnosis after newborn hospital discharge (8%). The most common presenting findings in the newborn nursery were isolated murmur (38%) or cyanosis (32%), while circulatory collapse (38%) was the most common presentation after discharge. For the entire study cohort, 13% had a known genetic syndrome, 23% had a major noncardiac congenital anomaly, and 16% weighed < 2.5 kg. The hospital mortality for the entire cohort was 7.4%. Risk factors associated with an increased risk of hospital mortality included younger age at admission, higher number of cardiopulmonary bypass runs, and need for postoperative cardiopulmonary resuscitation. Total hospital length of stay was > 1 month in 17% of neonates.

CONCLUSIONS

In patients with complex congenital heart disease, including nearly half with single ventricle heart disease, neonatal hospital mortality was 7%. These patients have a high frequency of multiple congenital anomalies, genetic syndromes, low birth weight, and prolonged length of stay.

Hypoplastic left heart syndrome: consensus and controversies in 2007

Variability in practice can be considered to foster clinical innovation, and allow for individualized therapeutic plans and independence of practitioners. The Institute of Medicine, however, has issued a report suggesting that variability in patterns of practice are "illogical", and should be avoided whenever possible. Perhaps nowhere in the field of congenital cardiac disease is variability in practice more apparent than in the management of hypoplastic left heart syndrome. This review assesses the variability in practice at a large number of centres that manage neonates with hypoplastic left heart syndrome, with an emphasis on practice before, during, and after the first stage of the Norwood sequence of operations. We also suggest changes in future strategies for research. In March, 2007, colleagues were contacted to respond to an internet-based survey using commercially available software (www.surveymonkey.com) to collect responses about the management practices for neonates with "straight-forward" hypoplastic left heart syndrome. No attempt was made to correlate management practices with any measures of outcome, as neither the practices themselves, nor the outcomes of interest, could be externally validated. Data is reported from 52 centers thought to manage over 1000 neonates with hypoplastic left heart syndrome on an annual basis. The first stage of the Norwood sequence was "recommended" to families by approximately five-sixths (86.5%) of the centres. No centre recommended primary cardiac transplantation, a "hybrid" approach, or non-intervention. In 7 centres (14.5%), it was reported that there was discussion of some or all of the above options, but ultimately the families decided upon the appropriate strategy. Most centres preferentially used antegrade cerebral perfusion (54%) in contrast to deep hypothermia with circulatory arrest (24%), albeit that 11% of centres used a combination of these techniques and in 9% the support strategy was based on surgeon preference. The source of flow of blood for the lungs following the first stage of reconstruction was also highly variable. Of the 51 centres that responded to the question, 13 (25.5%) were participating in a multi-centric randomized clinical trial comparing the modified Blalock-Taussig shunt to the conduit placed from the right ventricle to the pulmonary arteries, the so-called "Sano" modification. Of the remaining 38 centres, 18 "usually" placed a conduit from the right ventricle to the pulmonary artery, 14 "usually" placed a modified Blalock-Taussig shunt, and at six centres, the decision was made "based upon the preference of the surgeon and/or the cardiologist". Similarly, significant variability in practice was evident in preoperative management, other surgical strategies, postoperative medical support, monitoring and discharge planning. Other than the randomized clinical trial of shunt type, no other medical or surgical management strategy was currently under investigation in a multi-centric or randomized trial in the centres who responded to the survey. The survey emphasises the extreme variability in our current practices for treatment of children with hypoplastic left heart syndrome. While there are some areas for which there is consensus in management, the majority of our practices are variable between and within centres. These results emphasize that large multicentric trials and registries are necessary to improve care, and to answer important clinical questions, emphasizing the need to shift from analysis of experiences of single centres to multi-centric and multi-disciplinary collaboration.