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Abell BR, Eagleson K, Auld B, Bora S, Justo R, Parsonage W, Sharma P, Kularatna S, McPhail SM. Implementing neurodevelopmental follow-up care for children with congenital heart disease: A scoping review with evidence mapping. Dev Med Child Neurol 2024; 66:161-175. [PMID: 37421232 PMCID: PMC10953404 DOI: 10.1111/dmcn.15698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 05/04/2023] [Accepted: 06/07/2023] [Indexed: 07/10/2023]
Abstract
AIM To identify and map evidence describing components of neurodevelopmental follow-up care for children with congenital heart disease (CHD). METHOD This was a scoping review of studies reporting components of neurodevelopmental follow-up programmes/pathways for children with CHD. Eligible publications were identified through database searches, citation tracking, and expert recommendations. Two independent reviewers screened studies and extracted data. An evidence matrix was developed to visualize common characteristics of care pathways. Qualitative content analysis identified implementation barriers and enablers. RESULTS The review included 33 studies. Twenty-one described individual care pathways across the USA (n = 14), Canada (n = 4), Australia (n = 2), and France (n = 1). The remainder reported surveys of clinical practice across multiple geographical regions. While heterogeneity in care existed across studies, common attributes included enrolment of children at high-risk of neurodevelopmental delay; centralized clinics in children's hospitals; referral before discharge; periodic follow-up at fixed ages; standardized developmental assessment; and involvement of multidisciplinary teams. Implementation barriers included service cost/resourcing, patient burden, and lack of knowledge/awareness. Multi-level stakeholder engagement and integration with other services were key drivers of success. INTERPRETATION Defining components of effective neurodevelopmental follow-up programmes and care pathways, along with enhancing and expanding guideline-based care across regions and into new contexts, should continue to be priorities. WHAT THIS PAPER ADDS Twenty-two different neurodevelopmental follow-up care pathways/programmes were published, originating from four countries. Twelve additional publications described broad practices for neurodevelopmental follow-up across regions Common attributes across eligibility, service structure, assessment processes, and care providers were noted. Studies reported programme acceptability, uptake, cost, and effectiveness. Implementation barriers included service cost/resourcing, patient burden, and lack of knowledge/awareness.
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Affiliation(s)
- Bridget R. Abell
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of HealthQueensland University of TechnologyBrisbaneQLDAustralia
| | - Karen Eagleson
- Queensland Paediatric Cardiac ServiceQueensland Children's HospitalBrisbaneQLDAustralia
- Faculty of MedicineThe University of QueenslandBrisbaneQLDAustralia
| | - Benjamin Auld
- Queensland Paediatric Cardiac ServiceQueensland Children's HospitalBrisbaneQLDAustralia
| | - Samudragupta Bora
- Faculty of MedicineThe University of QueenslandBrisbaneQLDAustralia
- University Hospitals Rainbow Babies & Children's HospitalCase Western Reserve University School of MedicineClevelandOHUSA
| | - Robert Justo
- Queensland Paediatric Cardiac ServiceQueensland Children's HospitalBrisbaneQLDAustralia
- Faculty of MedicineThe University of QueenslandBrisbaneQLDAustralia
| | - William Parsonage
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of HealthQueensland University of TechnologyBrisbaneQLDAustralia
- Royal Brisbane and Women's HospitalMetro North HealthBrisbaneQLDAustralia
| | - Pakhi Sharma
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of HealthQueensland University of TechnologyBrisbaneQLDAustralia
| | - Sanjeewa Kularatna
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of HealthQueensland University of TechnologyBrisbaneQLDAustralia
| | - Steven M. McPhail
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of HealthQueensland University of TechnologyBrisbaneQLDAustralia
- Digital Health and Informatics Directorate, Metro South HealthBrisbaneQLDAustralia
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Neurodevelopmental Outcomes in Children with Congenital Heart Disease: Ten Years After the American Heart Association Statement. Clin Perinatol 2023; 50:53-66. [PMID: 36868713 DOI: 10.1016/j.clp.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
Even before birth, children with congenital heart disease (CHD) are at risk for neurodevelopmental concerns, with additional insults occurring as part of their treatment course and from subsequent exposures to socioeconomic stressors. With multiple affected neurodevelopmental domains, individuals with CHD face lifelong cognitive, academic, psychological, and quality-of-life difficulties. Early and repeated neurodevelopmental evaluation is key to receiving appropriate services. However, obstacles at the level of the environment, provider, patient, and family can make the completion of these evaluations difficult. Future neurodevelopmental endeavors should aim to evaluate CHD-specific programs, their effectiveness, and barriers to access.
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Read JS, Brown K, Wray J. The Feasibility and Acceptability of Remote Videoconference Use of the Brief Developmental Assessment Tool for Young Children with Congenital Heart Disease. Telemed J E Health 2023; 29:146-151. [PMID: 35649232 DOI: 10.1089/tmj.2021.0609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Background: Young children with congenital heart disease (CHD) are at heightened risk of developmental delay. The outbreak of COVID-19 and the ensuing lockdowns presented an opportunity to test the feasibility of using a short neurodevelopmental assessment tool-the Brief Developmental Assessment (BDA)-remotely via new technologies. Methods: We tested the feasibility and acceptability of remote testing of the tool's 6 domains of development with 30 children younger than 5 years with CHD and 10 healthy controls. Results: Despite some technical issues, parents largely responded positively to the use of the remote assessment as opposed to traditional face-to-face appointments, citing the beneficial saving of time, money, and childcare. Conclusions: The acceptability of the remote use of the BDA for the developmental screening of children with CHD will allow for the possibility of increased screening for more children and earlier identification of developmental problems, both during and after COVID-19 restrictions.
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Affiliation(s)
- Julie S Read
- Centre for Outcomes and Experience Research in Children's Health, Illness and Disability, Great Ormond Street Hospital for Children National Health Service Foundation Trust, London, United Kingdom
| | - Katherine Brown
- Heart and Lung Division, Zayed Centre for Rare Diseases Research, Great Ormond Street Hospital for Children National Health Service Foundation Trust, London, United Kingdom
| | - Jo Wray
- Centre for Outcomes and Experience Research in Children's Health, Illness and Disability, Great Ormond Street Hospital for Children National Health Service Foundation Trust, London, United Kingdom
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Hoskote A, Ridout D, Banks V, Kakat S, Lakhanpaul M, Pagel C, Franklin RC, Witter T, Lakhani R, Tibby SM, Anderson D, Tsang V, Wray J, Brown K. Neurodevelopmental status and follow-up in preschool children with heart disease in London, UK. Arch Dis Child 2021; 106:263-271. [PMID: 32907808 DOI: 10.1136/archdischild-2019-317824] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 06/15/2020] [Accepted: 08/05/2020] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To describe neurodevelopment and follow-up services in preschool children with heart disease (HD). DESIGN Secondary analysis of a prospectively collected multicentre dataset. SETTING Three London tertiary cardiac centres. PATIENTS Preschool children<5 years of age: both inpatients and outpatients. METHODS We analysed results of Mullen Scales of Early Learning (MSEL) and parental report of follow-up services in a representative convenience sample evaluated between January 2014 and July 2015 within a previous study. RESULTS Of 971 preschool children: 577 (59.4%) had ≥1 heart operation, 236 (24.3%) had a known diagnosis linked to developmental delay (DD) ('known group') and 130 (13.4%) had history of clinical event linked to DD. On MSEL assessment, 643 (66.2%) had normal development, 181 (18.6%) had borderline scores and 147 (15.1%) had scores indicative of DD. Of 971 children, 609 (62.7%) were not receiving follow-up linked to child development and were more likely to be under these services with a known group diagnosis, history of clinical event linked to DD and DD (defined by MSEL). Of 236 in known group, parents of 77 (32.6%) and of 48 children not in a known group but with DD 29 (60.4%), reported no child development related follow-up. DD defined by MSEL assessment was more likely with a known group and older age at assessment. CONCLUSIONS Our findings indicate that a 'structured neurodevelopmental follow-up pathway' in preschool children with HD should be considered for development and evaluation as children get older, with particular focus on those at higher risk.
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Affiliation(s)
- Aparna Hoskote
- Heart and Lung Directorate, Great Ormond Street Hospital For Children NHS Foundation Trust, London, UK .,NIHR Great Ormond Street Hospital Biomedical Research Centre, Great Ormond Street Hospital For Children NHS Foundation Trust, London, UK
| | - Deborah Ridout
- NIHR Great Ormond Street Hospital Biomedical Research Centre, Great Ormond Street Hospital For Children NHS Foundation Trust, London, UK.,Population Policy and Practice Department, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Victoria Banks
- Information Office, Great Ormond Street Hospital For Children NHS Foundation Trust, London, UK
| | - Suzan Kakat
- Heart and Lung Directorate, Great Ormond Street Hospital For Children NHS Foundation Trust, London, UK.,NIHR Great Ormond Street Hospital Biomedical Research Centre, Great Ormond Street Hospital For Children NHS Foundation Trust, London, UK
| | - Monica Lakhanpaul
- Population Policy and Practice Department, UCL Great Ormond Street Institute of Child Health, London, UK.,Whittington Health NHS Trust, London, UK
| | - Christina Pagel
- Clinical Operational Research Unit, University College of London, London, UK
| | - Rodney Cg Franklin
- Paediatric Cardiology, Royal Brompton and Harefield NHS Trust, London, UK
| | - Thomas Witter
- Paediatric Cardiology and Cardiac Surgery, Evelina London Children's Hospital, London, UK
| | - Rhian Lakhani
- Paediatric Cardiology and Cardiac Surgery, Evelina London Children's Hospital, London, UK
| | - Shane M Tibby
- Paediatric Intensive Care Unit, Evelina London Children's Hospital, London, UK
| | - David Anderson
- Cardiothoracic Surgery, Evelina London Children's Hospital, London, UK
| | - Victor Tsang
- Heart and Lung Directorate, Great Ormond Street Hospital For Children NHS Foundation Trust, London, UK.,NIHR Great Ormond Street Hospital Biomedical Research Centre, Great Ormond Street Hospital For Children NHS Foundation Trust, London, UK
| | - Jo Wray
- Heart and Lung Directorate, Great Ormond Street Hospital For Children NHS Foundation Trust, London, UK.,NIHR Great Ormond Street Hospital Biomedical Research Centre, Great Ormond Street Hospital For Children NHS Foundation Trust, London, UK
| | - Katherine Brown
- Heart and Lung Directorate, Great Ormond Street Hospital For Children NHS Foundation Trust, London, UK.,NIHR Great Ormond Street Hospital Biomedical Research Centre, Great Ormond Street Hospital For Children NHS Foundation Trust, London, UK
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Brown KL, Pagel C, Ridout D, Wray J, Tsang VT, Anderson D, Banks V, Barron DJ, Cassidy J, Chigaru L, Davis P, Franklin R, Grieco L, Hoskote A, Hudson E, Jones A, Kakat S, Lakhani R, Lakhanpaul M, McLean A, Morris S, Rajagopal V, Rodrigues W, Sheehan K, Stoica S, Tibby S, Utley M, Witter T. Early morbidities following paediatric cardiac surgery: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08300] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Background
Over 5000 paediatric cardiac surgeries are performed in the UK each year and early survival has improved to > 98%.
Objectives
We aimed to identify the surgical morbidities that present the greatest burden for patients and health services and to develop and pilot routine monitoring and feedback.
Design and setting
Our multidisciplinary mixed-methods study took place over 52 months across five UK paediatric cardiac surgery centres.
Participants
The participants were children aged < 17 years.
Methods
We reviewed existing literature, ran three focus groups and undertook a family online discussion forum moderated by the Children’s Heart Federation. A multidisciplinary group, with patient and carer involvement, then ranked and selected nine key morbidities informed by clinical views on definitions and feasibility of routine monitoring. We validated a new, nurse-administered early warning tool for assessing preoperative and postoperative child development, called the brief developmental assessment, by testing this among 1200 children. We measured morbidity incidence in 3090 consecutive surgical admissions over 21 months and explored risk factors for morbidity. We measured the impact of morbidities on quality of life, clinical burden and costs to the NHS and families over 6 months in 666 children, 340 (51%) of whom had at least one morbidity. We developed and piloted methods suitable for routine monitoring of morbidity by centres and co-developed new patient information about morbidities with parents and user groups.
Results
Families and clinicians prioritised overlapping but also different morbidities, leading to a final list of acute neurological event, unplanned reoperation, feeding problems, renal replacement therapy, major adverse events, extracorporeal life support, necrotising enterocolitis, surgical infection and prolonged pleural effusion. The brief developmental assessment was valid in children aged between 4 months and 5 years, but not in the youngest babies or 5- to 17-year-olds. A total of 2415 (78.2%) procedures had no measured morbidity. There was a higher risk of morbidity in neonates, complex congenital heart disease, increased preoperative severity of illness and with prolonged bypass. Patients with any morbidity had a 6-month survival of 81.5% compared with 99.1% with no morbidity. Patients with any morbidity scored 5.2 points lower on their total quality of life score at 6 weeks, but this difference had narrowed by 6 months. Morbidity led to fewer days at home by 6 months and higher costs. Extracorporeal life support patients had the lowest days at home (median: 43 days out of 183 days) and highest costs (£71,051 higher than no morbidity).
Limitations
Monitoring of morbidity is more complex than mortality, and hence this requires resources and clinician buy-in.
Conclusions
Evaluation of postoperative morbidity provides important information over and above 30-day survival and should become the focus of audit and quality improvement.
Future work
National audit of morbidities has been initiated. Further research is needed to understand the implications of feeding problems and renal failure and to evaluate the brief developmental assessment.
Funding
This project was funded by the NIHR Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 30. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Katherine L Brown
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Christina Pagel
- Clinical Operational Research Unit, University College London, London, UK
| | - Deborah Ridout
- Population, Policy and Practice Programme, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Jo Wray
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Victor T Tsang
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - David Anderson
- Departments of Paediatric Intensive Care, Cardiology and Cardiac Surgery, Evelina London Children’s Hospital, London, UK
| | - Victoria Banks
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - David J Barron
- Departments of Intensive Care and Paediatric Cardiac Surgery, Birmingham Children’s Hospital, Birmingham, UK
| | - Jane Cassidy
- Departments of Intensive Care and Paediatric Cardiac Surgery, Birmingham Children’s Hospital, Birmingham, UK
| | - Linda Chigaru
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Peter Davis
- Departments of Intensive Care and Paediatric Cardiac Surgery, Bristol Royal Hospital for Children, Bristol, UK
| | - Rodney Franklin
- Paediatric Cardiology Department, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Luca Grieco
- Clinical Operational Research Unit, University College London, London, UK
| | - Aparna Hoskote
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Emma Hudson
- Department of Applied Health Research, University College London, London, UK
| | - Alison Jones
- Departments of Intensive Care and Paediatric Cardiac Surgery, Birmingham Children’s Hospital, Birmingham, UK
| | - Suzan Kakat
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Rhian Lakhani
- Departments of Paediatric Intensive Care, Cardiology and Cardiac Surgery, Evelina London Children’s Hospital, London, UK
| | - Monica Lakhanpaul
- Population, Policy and Practice Programme, UCL Great Ormond Street Institute of Child Health, London, UK
- Community Child Health, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Andrew McLean
- Department of Intensive care, Royal Hospital for Children, Glasgow, UK
| | - Steve Morris
- Department of Applied Health Research, University College London, London, UK
| | - Veena Rajagopal
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Warren Rodrigues
- Department of Intensive care, Royal Hospital for Children, Glasgow, UK
| | - Karen Sheehan
- Departments of Intensive Care and Paediatric Cardiac Surgery, Bristol Royal Hospital for Children, Bristol, UK
| | - Serban Stoica
- Departments of Intensive Care and Paediatric Cardiac Surgery, Bristol Royal Hospital for Children, Bristol, UK
| | - Shane Tibby
- Departments of Paediatric Intensive Care, Cardiology and Cardiac Surgery, Evelina London Children’s Hospital, London, UK
| | - Martin Utley
- Clinical Operational Research Unit, University College London, London, UK
| | - Thomas Witter
- Departments of Paediatric Intensive Care, Cardiology and Cardiac Surgery, Evelina London Children’s Hospital, London, UK
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Hoskote A, Wray J, Banks V, Brown K, Lakhanpaul M. A referral pathway for potentially abnormal neurodevelopment in children with heart disease in the United Kingdom: a Delphi consensus. BMJ Paediatr Open 2020; 4:e000587. [PMID: 32399503 PMCID: PMC7204815 DOI: 10.1136/bmjpo-2019-000587] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 01/22/2020] [Accepted: 01/30/2020] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Children with congenital heart disease have complex medical and neurodevelopmental needs. We aimed to develop a multi-professional consensus-based referral pathway applicable to action the results of the brief developmental assessment (BDA), a validated early recognition tool, that categorises the neurodevelopmental status as green (appropriate for age), amber (equivocal) or red (delayed) in children aged between 4 months and 5 years. METHODS A Delphi consensus survey detailing two scenarios-a child categorised as delayed (red) and another as equivocal (amber) on administration of the BDA at the time of discharge from the tertiary centre-was sent to 80 expert professionals from primary, secondary and tertiary care seeking agreement on next steps and referral pathways. An iterative process was proposed with a pre-defined rule of 75% for consensus. RESULTS The survey was completed by 77 Delphi panel experts in Round 1, 73 in Round 2 and 70 in Round 3. Consensus was achieved (1) for the child with amber or red BDA, the child should be under the care of a paediatrician with expertise in cardiology (PEC) (or general paediatrician if no PEC) based at their local hospital, (2) for the child with red BDA, the PEC should initiate referral to community services at first assessment, (3) for child with amber BDA, a re-assessment by the health visitor should occur within 1-2 months, with referral to community services and notification to the PEC if on-going concerns. CONCLUSIONS The Delphi process enabled a consensus to be reached between health professionals on referral pathways for specialist neurodevelopmental assessment/treatment for children with heart disease, in response to amber or red BDA results. The agreed referral pathway, if implemented, could underpin a national guideline to address and intervene on the neurodevelopmental difficulties in children with heart disease.
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Affiliation(s)
- Aparna Hoskote
- Heart and Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | - Jo Wray
- Heart and Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | - Victoria Banks
- Heart and Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | - Katherine Brown
- Heart and Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
- NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | - Monica Lakhanpaul
- NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
- Population, Policy and Practice Department, UCL Great Ormond Street Institute of Child Health, London, UK
- Whittington Health NHS Trust, London, UK
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Abstract
UNLABELLED Introduction The objective of this study was to prospectively validate the "Brief Developmental Assessment", which is a new early recognition tool for neurodevelopmental abnormalities in children with heart disease that was developed for use by cardiac teams. METHODS This was a prospective validation study among a representative sample of 960 pre-school children with heart disease from three United Kingdom tertiary cardiac centres who were analysed grouped into five separate age bands. RESULTS The "Brief Developmental Assessment" was successfully validated in the older four age bands, but not in the youngest representing infants under the age of 4 months, as pre-set validation thresholds were met - lower 95% confidence limit for the correlation coefficient above 0.75 - in terms of agreement of scores between two raters and with an external measure the "Mullen Scales of Early Learning". On the basis of American Association of Pediatrics Guidelines, which state that the sensitivity and specificity of a developmental screening tool should fall between 70 and 80%, "Brief Developmental Assessment" outcome of Red meets this threshold for detection of Mullen scores >2 standard deviations below the mean. CONCLUSION The "Brief Developmental Assessment" may be used to improve the quality of assessment of children with heart disease. This will require a training package for users and a guide to action for abnormal results. Further research is needed to determine how best to deploy the "Brief Developmental Assessment" at different time points in children with heart disease and to determine the management strategy in infants younger than 4 months old.
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