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

Salivary Diurnal Cortisol Predicts Post-Traumatic Stress Symptoms in Parents of Infants With Congenital Heart Disease

BACKGROUND

Parents of infants born with congenital heart disease (CHD) who require open heart surgery after birth are at risk for prolonged psychological distress. Even after their infants are discharged, parents may experience anxiety, depressive, and post-traumatic stress (PTS) symptoms; yet, it is unclear which parents are at greater risk for ongoing symptoms. The purpose of this study was to explore whether measures of the biomarker cortisol in parents during their infants' postoperative period were associated with subsequent psychological distress symptoms at three-month post discharge.

METHODS

This was a prospective, longitudinal exploratory study of 40 parents of infants with CHD after open heart surgery using consecutive enrollment. Parents provided diurnal saliva samples for two consecutive days in the postoperative period. Six predictors were summarized and generated including waking cortisol, bedtime cortisol, cortisol awaking response, area under curve with respect to the ground (AUCg), cortisol index, and cortisol slope. Self-report outcome measures on anxiety, depressive, and PTS symptoms were collected three-months post-discharge. Linear mixed models examined the associations between each predictor and each outcome while accounting for within-dyad variance using an unstructured covariance matrix.

RESULTS

Cortisol AUCg was a predictor of PTS at three-months post-discharge (β = .34, p = .03, Cohen's d = 2.05). No significant relationships were found with the other cortisol measures.

CONCLUSIONS & IMPLICATIONS

Findings suggest that cortisol area under curve may help to identify parents at risk for increased PTS in the months following their infants' hospitalization for cardiac surgery, serving as a foundation for future study in this area.

Perceived family-centered care and post-traumatic stress in parents of infants cared for in the paediatric cardiac intensive care unit

BACKGROUND

Family-centred care (FCC), while a core value of paediatric hospitals, has not been well-studied in the paediatric cardiac intensive care unit (PCICU).

AIMS

To describe parents' perceptions of FCC provided by nurses in the PCICU during their infant's recovery from neonatal cardiac surgery and explore associations of perceptions of FCC on parent post-traumatic stress (PTS) 4 months post-discharge.

STUDY DESIGN

Data obtained from a previously conducted randomized clinical trial (RCT) on telehealth home monitoring after neonatal cardiac surgery at three free-standing paediatric hospitals were analysed from a subset of 164 parents who completed the FCC Scale at hospital discharge, which measures a parent's experience of nursing care that embodies core principles of FCC. The RCT intervention was provided after hospital discharge, having no influence on parent's perception of FCC. The intervention also had no effect on PTS.

RESULTS

Perceived FCC was lowest for items 'nurses helped me feel welcomed' and 'nurses helped me feel important in my child's care'. Having 12%-19% points lower perception of FCC at hospital discharge was associated with parent experience of six or more PTS symptoms, at least moderate PTS symptom severity, or PTS disorder diagnosis at 4-month follow-up. Every 10% increase in parental perceptions of FCC was associated with less PTS symptoms (β = -0.29, SE = 0.12; p = .02) and lower PTS symptom cluster scores of arousal (β = -0.18, SE = 0.08; p = .02).

CONCLUSIONS

Parents who perceived lower FCC during their infants' hospitalization were at increased risk for the development of PTS symptoms, more PTS symptom severity and PTS disorder diagnosis 4-months post-discharge.

RELEVANCE TO CLINICAL PRACTICE

Nurses have a prominent role to support the implementation of FCC for infants with cardiac defects and their parents. FCC may positively influence overall parent mental health and well-being, reducing the trauma and distress of the PCICU experience.

Advancing Wearable Biosensors for Congenital Heart Disease: Patient and Clinician Perspectives: A Science Advisory From the American Heart Association

Wearable biosensors (wearables) enable continual, noninvasive physiologic and behavioral monitoring at home for those with pediatric or congenital heart disease. Wearables allow patients to access their personal data and monitor their health. Despite substantial technologic advances in recent years, issues with hardware design, data analysis, and integration into the clinical workflow prevent wearables from reaching their potential in high-risk congenital heart disease populations. This science advisory reviews the use of wearables in patients with congenital heart disease, how to improve these technologies for clinicians and patients, and ethical and regulatory considerations. Challenges related to the use of wearables are common to every clinical setting, but specific topics for consideration in congenital heart disease are highlighted.

Development and validation of a questionnaire to measure the congenital heart disease of children's family stressor

Background

Families of children with congenital heart disease (CHD) face tremendous stressors in the process of coping with the disease, which threatens the health of families of children with CHD. Studies have shown that nursing interventions focusing on family stress management can improve parents' ability to cope with illness and promote family health. At present, there is no measuring tool for family stressors of CHD.

Methods

The items of the scale were generated through qualitative interviews and a literature review. Initial items were evaluated by seven experts to determine content validity. Factor analysis and reliability testing were conducted with a convenience sample of 670 family members. The criterion-related validity of the scale was calculated using scores on the Self-Rating Anxiety Scale (SAS).

Results

The CHD Children's Family Stressor Scale consisted of six dimensions and 41 items. In the exploratory factor analysis, the cumulative explained variance of the six factors was 61.085%. In the confirmatory factor analysis, the six factors in the EFA were well validated, indicating that the model fits well. The correlation coefficient between CHD Children's Family Stressor Scale and SAS was r = 0.504 (p < 0.001), which indicated that the criterion-related validity of the scale was good. In the reliability test, Cronbach's α coefficients of six sub-scales were 0.774-0.940, and the scale-level Cronbach's α coefficient value was 0.945.

Conclusion

The study indicates that the CHD Children's Family Stressor Scale is valid and reliable, and it is recommended for use in clinical practice to assess CHD children's family stressors.

School Readiness in Preschool-Age Children with Critical Congenital Heart Disease

This study examined the nature, variability, and predictors of school readiness difficulties in young children with critical congenital heart disease (CCHD). We hypothesized that, compared to a community control (CC) group, children with CCHD would score less well on measures of readiness and that readiness would be associated with CCHD-related risk factors. Children (60 CCHD and 60 CC) were 4 to 5 years of age and not yet attending kindergarten. Readiness measures included tests of cognition, executive function, motor ability, and pre-academic skills. Caregivers provided child behavior ratings. Analyses examined group differences in readiness, readiness profiles, and associations of readiness with CCHD-related medical risk factors. The CCHD group had lower scores than the CC group on testing and higher caregiver ratings of problems in social communication, as well as higher rates of deficits on several of the measures. Latent class analysis provided evidence for different readiness profiles, with more children with CCHD displaying profiles characterized by weaknesses in readiness. CCHD-related medical risk factors associated with readiness problems in the CCHD group included a co-morbid genetic disorder, postnatal diagnosis of CCHD, major perioperative complication, and longer periods of hospitalizations, cardiopulmonary bypass, and aortic cross-clamp placements. Findings document multiple problems in school readiness in young children with CCHD. Deficits vary across individuals and are associated with higher medical risk. Results confirm the importance of screening for school readiness in these children and suggest areas to target in designing screening measures and providing early childhood interventions.

A randomized controlled trial to assess the impact of psychoeducation on the quality of life of parents with children with congenital heart defects-Quantitative component

PURPOSE

To develop, implement and assess the results of psychoeducation to improve the QoL of parents with CHD newborns.

METHODS

Participants were parents of inpatient newborns with the diagnosis of non-syndromic CHD. We conducted a parallel RCT with an allocation ratio of 1:1 (intervention vs. control), considering the newborns, using mixed methods research. The intervention group received psychoeducation (Parental Psychoeducation in CHD [PPeCHD]) and the usual routines, and the control group received just the regular practices. The allocation concealment was assured. PI was involved in enrolling participants, developing and implementing the intervention, data collection and data analysis. We followed the Consolidated Standards of Reporting Trials (CONSORT) guidelines.

RESULTS

Parents of eight newborns were allocated to the intervention group (n = 15 parents) and eight to the control group (n = 13 parents). It was performed as an intention-to-treat (ITT) analysis. In M2 (4 weeks), the intervention group presented better QoL levels in the physical, psychological, and environmental domains of World Health Organization Quality of Life instrument (WHOQOL-Bref). In M3 (16 weeks), scores in physical and psychological domains maintained a statistically significant difference between the groups.

CONCLUSIONS

The PPeCHD, the psychoeducational intervention we developed, positively impacted parental QoL. These results support the initial hypothesis. This study is a fundamental milestone in this research field, adding new essential information to the literature.

Mental Health Symptoms in Parents of Infants 3 Months After Discharge Following Neonatal Cardiac Surgery

BACKGROUND

Parents of newborns with congenital heart disease (CHD) are at risk for anxiety, depression, and post-traumatic stress. Few studies have examined whether modifiable factors that influence parents' mental health after discharge are present during postoperative care in the pediatric cardiac intensive care unit (PCICU).

OBJECTIVE

To describe mental health symptoms of parents of infants with CHD 3 months after PCICU discharge and to determine factors during the PCICU stay that are predictors of such symptoms.

METHODS

A longitudinal cohort pilot study of 56 parents (28 mother-father dyads) of 28 infants with CHD. During the first postoperative week after cardiac surgery, parents completed questionnaires measuring factors potentially influencing mental health. Three months after discharge, 42 parents of 22 infants completed validated measures of anxiety, depression, and posttraumatic stress.

RESULTS

Three months after discharge, 26% of parents had clinically elevated levels of anxiety symptoms, 21% had clinically significant levels of depressive symptoms, and 19% had posttraumatic stress symptoms. In multi-variable analysis, parental role alteration in the PCICU was predictive of anxiety (P = .002), depressive (P = .02), and posttraumatic stress (P = .02) symptoms 3 months after discharge. Higher education level was predictive of anxiety symptoms (P = .009). Postnatal CHD diagnosis was predictive of posttraumatic stress symptoms (P = .04).

CONCLUSIONS

Parental role alteration perceived by parents during the PCICU stay is a modifiable stressor contributing to adverse mental health symptoms 3 months after discharge. Interventions targeting parental role alteration in the PCICU are critically needed.

The mediation effect of mental resilience between stress and coping style among parents of children with cochlear implants: Cross-sectional study

PURPOSE

This study aimed to examine the relationship of stress, mental resilience, and coping style, and the mediation effect of mental resilience between stress and coping style among parents of children with cochlear implants.

DESIGN AND METHODS

A cross-sectional design was used. A total of 231 parents of children with cochlear implants were recruited from May 1, 2022, to February 28, 2023 at a comprehensive tertiary hospital and a cochlear implant rehabilitation center in China. Parenting Stress Index-Short Form (PSI-SF), the Connor-Davidson Resilience Scale (CD-RISC) and the Simplified Coping Style Questionnaire(SCSQ) were used to measure stress, mental resilience, and coping style respectively.

RESULTS

The mean score observed for PSI-SF, CD-RISC, active coping, and passive coping was 87.85 ± 24.59, 55.63 ± 16.11, 21.36 ± 6.73, and 9.05 ± 4.52, respectively. Mental resilience was a significant mediator explaining the effect of stress on active coping (β = -0.294; 95% bias-corrected bootstrap CI: -0.358 to -0.164).

CONCLUSIONS

Attention should be paid to the status of stress, mental resilience and coping style in parents of children with cochlear implants. Mental resilience mediated stress and coping style.

PRACTICE IMPLICATIONS

This study provides a theoretical basis for establishing an active coping care program for parents of children with cochlear implants. There is a need to identify strategies that can help increase the level of mental resilience of parents of children with cochlear implants and more subjective and objective social support should be provided to reduce their stress and to encourage active coping style.

Families under pressure: A qualitative study of stressors in families of children with congenital heart disease

The objective of this study was to better understand the stressors in families of children with congenital heart disease (CHD) to assist with formulating targeted stress management plans for such families. A descriptive qualitative study was undertaken at a tertiary referral hospital in China. Following purposeful sampling, interviews were conducted with 21 parents of children with CHD regarding the stressors in their families. Following content analysis, 11 themes were generated from the data and categorised into six main domains: the initial stressor and associated hardships, normative transitions, prior strains, the consequences of family efforts to cope, intrafamily and social ambiguity, and sociocultural values. The 11 themes include confusion regarding the disease, hardships encountered during treatment, the heavy financial burden, the unusual growth track of the child due to the disease, normal events becoming abnormal for the family, impaired family functioning, family vulnerability, family resilience, family boundary ambiguity induced by role alteration, a lack of knowledge about community support and family stigma. Various and complex stressors exist for families of children with CHD. Medical personnel should fully evaluate the stressors and take targeted measures before implementing family stress management practices. It is also necessary to focus on the posttraumatic growth of families of children with CHD and strengthen resilience. Moreover, family boundary ambiguity and a lack of knowledge about community support should not be ignored, and further research is needed to explore these variables. Most importantly, policymakers and healthcare providers should adopt a range of strategies to address the stigma of being in a family of a child with CHD.

Developmental care pathway for hospitalised infants with CHD: on behalf of the Cardiac Newborn Neuroprotective Network, a Special Interest Group of the Cardiac Neurodevelopmental Outcome Collaborative

Infants and children born with CHD are at significant risk for neurodevelopmental delays and abnormalities. Individualised developmental care is widely recognised as best practice to support early neurodevelopment for medically fragile infants born premature or requiring surgical intervention after birth. However, wide variability in clinical practice is consistently demonstrated in units caring for infants with CHD. The Cardiac Newborn Neuroprotective Network, a Special Interest Group of the Cardiac Neurodevelopmental Outcome Collaborative, formed a working group of experts to create an evidence-based developmental care pathway to guide clinical practice in hospital settings caring for infants with CHD. The clinical pathway, "Developmental Care Pathway for Hospitalized Infants with Congenital Heart Disease," includes recommendations for standardised developmental assessment, parent mental health screening, and the implementation of a daily developmental care bundle, which incorporates individualised assessments and interventions tailored to meet the needs of this unique infant population and their families. Hospitals caring for infants with CHD are encouraged to adopt this developmental care pathway and track metrics and outcomes using a quality improvement framework.

The family burden of paediatric heart disease during the chronic phase of illness

BACKGROUND

CHD is a lifelong condition with a significant burden of disease to patients and families. With increased survival, attention has shifted to longer-term outcomes, with a focus on social determinants of health. Among children with CHD, socioeconomic status is associated with disparities in outcomes. Household material hardship is a concrete measure of poverty and may serve as an intervenable measure of socioeconomic status.

METHODS

A longitudinal survey study was conducted at multiple time points (at acute hospitalisation, then 12-24 months later in the chronic phase) to determine the prevalence of household material hardship among parents of children with advanced heart disease and quality of life during long-term follow-up.

RESULTS

The analytic cohort was 160 children with a median patient age of 1 year (IQR 1,4) with 54% of patients <2 years. During acute hospitalisation, over one-third of families reported household material hardship (37%), with significantly lower household material hardship in the chronic phase at 16% (N = 9 of 52). For parents reporting household material hardship during acute hospitalisation, 50% had resolution of household material hardship by the chronic phase. Household material hardship-exposed children were significantly more likely to be publicly insured (56% versus 20%, p = 0.03) with lower quality of life than those without household material hardship (64% versus 82%, p = 0.013).

CONCLUSION

The burden of heart disease during the chronic phase of illness is high. Household material hardship may serve as a target to ensure equity in the care and outcomes of CHD patients and their families.

Long-Term Effects of Child Early Surgical Ventricular Septal Defect Repair on Maternal Stress

The ventricular septal defect (VSD) represents the most common congenital heart defect (CHD). The diagnosis of and cardiac surgery for their child's VSD are highly stressful experiences for parents; especially mothers, who are at risk of developing long-lasting stress-related symptoms. This study examined long-term alterations in maternal stress including self-reported psychological and biophysiological stress levels in a case-control design. We investigated 24 mothers of children with an isolated, surgically corrected VSD compared to non-affected controls. Maternal self-reports on psychopathology, everyday stress, parenting stress and hair cortisol concentrations (HCC) were measured during children's primary school age (6-9 years, t1) and early adolescence (10-14 years, t2). In maternal self-reports, psychopathology and stress symptoms in the VSD-group and controls were comparable at t1, whereas at t2, mothers in the VSD-group even showed a decrease in psychopathology. Maternal HCC levels in the VSD-group were significantly lower (hypocortisolism) than HCC levels of controls at t1. This effect was no longer observed at t2 reflecting an approximation of HCC levels in the VSD-group to controls' levels. This study highlights the potential for improved stress hormone balance and psychological well-being in mothers following their child's surgical VSD repair. However, the need for parent-centered interventions is discussed, particularly during peri-operative phases and in early child developmental stages.

Impact of educational videos on maternal anxiety caused by children's heart surgery

BACKGROUND

Mothers of children undergoing surgery for congenital heart disease experience significant stress. Therefore, finding a strategy to decrease this is vital.

AIMS

To examine whether adding educational digital video discs to routine education can reduce maternal anxiety and depression when their children undergo heart surgery and when surgical or post-surgical complications occur.

STUDY DESIGN

In a teaching hospital, 120 mothers whose children underwent elective heart surgery were randomly and equally divided into two groups: mothers receiving routine education plus a digital video disc before surgery and mothers receiving only routine education. Mothers' anxiety and depression levels were compared before education, after education (before surgery), and on discharge day. The effect of watching the digital video disc on maternal anxiety and depression on discharge day was evaluated for the participants whose children had surgical or post-surgical complications.

RESULTS

Compared with only routine education, mothers' anxiety after education and on the discharge day decreased more if digital video disc was added. Depression decreased more after education, but no difference was found on the discharge day. Anxiety levels of mothers whose children had surgical or post-surgical complications on the discharge day decreased more if they watched the digital video disc, compared with those receiving only routine education (Beck anxiety inventory score 3.4 ± 1.9 and 6.1 ± 2.4 respectively; p-value .001).

CONCLUSIONS

Compared with only routine education, adding digital video disc could decrease mothers' anxiety, and until the day of discharge. Compared with only routine education, adding digital video disc could decrease mothers' anxiety on the discharge day if their child had surgical or post-surgical complications.

RELEVANCE TO CLINICAL PRACTICE

Adding educational digital video disc to routine education could decrease mothers' anxiety until the day of discharge. It could also decrease mothers' anxiety if their child had surgical or post-surgical complications.

A Parent-child yoga intervention for reducing attention deficits in children with congenital heart disease: the Yoga for Little Hearts Feasibility Study Protocol

INTRODUCTION

Preschoolers and school-aged children with congenital heart disease (CHD) are at higher risk of attention deficit hyperactivity disorder (ADHD) compared with the general population. To this day, no randomised controlled trial (RCT) aiming to improve attention has been conducted in young children with CHD. There is emerging evidence indicating that parent-child yoga interventions improve attention and reduce ADHD symptoms in both typically developing and clinical populations.

METHODS AND ANALYSIS

This is a single-blind, two-centre, two-arm trial during which 24 children with CHD and their parents will be randomly assigned to (1) a parent-child yoga intervention in addition to standard clinical care or (2) standard clinical care alone. All participants will undergo standardised assessments: (1) at baseline, (2) immediately post-treatment and (3) 6 months post-treatment. Descriptive statistics will be used to estimate the feasibility and neurodevelopmental outcomes. This feasibility study will evaluate: (1) recruitment capacity; (2) retention, drop-out and withdrawal rates during the yoga programme and at the 6-month follow-up; (3) adherence to the intervention; (4) acceptability of the randomisation process by families; (5) heterogeneity in the delivery of the intervention between instructors and use of home-based exercises between participants; (6) proportion of missing data in the neurodevelopmental assessments and (7) SD of primary outcomes of the full RCT in order to determine the future appropriate sample size.

ETHICS AND DISSEMINATION

Ethical approval has been obtained by the Research Ethics Board of the Sainte-Justine University Hospital. The findings will be disseminated in peer-reviewed journals and conferences and presented to the Canadian paediatric grand round meetings.

TRIAL REGISTRATION NUMBER

NCT05997680.

Parents' Psychological and Decision-Making Outcomes following Prenatal Diagnosis with Complex Congenital Heart Defect: An Exploratory Study

Background. Parents with a fetus diagnosed with a complex congenital heart defect (CHD) are at high risk of negative psychological outcomes. Purpose. To explore whether parents' psychological and decision-making outcomes differed based on their treatment decision and fetus/neonate survival status. Methods. We prospectively enrolled parents with a fetus diagnosed with a complex, life-threatening CHD from September 2018 to December 2020. We tested whether parents' psychological and decision-making outcomes 3 months posttreatment differed by treatment choice and survival status. Results. Our sample included 23 parents (average Age[years]: 27 ± 4, range = 21-37). Most were women (n = 18), non-Hispanic White (n = 20), and married (n = 21). Most parents chose surgery (n = 16), with 11 children surviving to the time of the survey; remaining parents (n = 7) chose comfort-directed care. Parents who chose comfort-directed care reported higher distress (x ¯  = 1.51, s = 0.75 v. x ¯  = 0.74, s = 0.55; Mdifference = 0.77, 95% confidence interval [CI], 0.05-1.48) and perinatal grief (x ¯  = 91.86, s = 22.96 v. x ¯  = 63.38, s = 20.15; Mdifference = 27.18, 95% CI, 6.20-48.16) than parents who chose surgery, regardless of survival status. Parents who chose comfort-directed care reported higher depression (x ¯  = 1.64, s = 0.95 v. x ¯  = 0.65, s = 0.49; Mdifference = 0.99, 95% CI, 0.10-1.88) than parents whose child survived following surgery. Parents choosing comfort-directed care reported higher regret (x ¯  = 26.43, s = 8.02 v. x ¯  = 5.00, s = 7.07; Mdifference = 21.43, 95% CI, 11.59-31.27) and decisional conflict (x ¯  = 20.98, s = 10.00 v. x ¯  = 3.44, s = 4.74; Mdifference = 17.54, 95% CI; 7.75-27.34) than parents whose child had not survived following surgery. Parents whose child survived following surgery reported lower grief (Mdifference = -19.71; 95% CI, -39.41 to -0.01) than parents whose child had not. Conclusions. The results highlight the potential for interventions and care tailored to parents' treatment decisions and outcomes to support parental coping and well-being.

Highlights

Question: Do the psychological and decision-making outcomes of parents differ based on their treatment decision and survival outcome following prenatal diagnosis with complex CHD?Findings: In this exploratory study, parents who decided to pursue comfort-directed care after a prenatal diagnosis reported higher levels of psychological distress and grief as well as higher decisional conflict and regret than parents who decided to pursue surgery.Meaning: The findings from this exploratory study highlight potential differences in parents' psychological and decision-making outcomes following a diagnosis of complex CHD for their fetus, which appear to relate to the treatment approach and the treatment outcome and may require tailoring of psychological and decision support.

Utilizing technology to expand home monitoring to high-risk infants with CHD

Infants born with single ventricle physiology that require an aorto-pulmonary shunt are at high risk for sudden cardiac death, particularly during the interstage period between the first-stage palliation and the second-stage palliation. Home monitoring programs have decreased interstage mortality in the hypoplastic left heart syndrome population prompting programs to expand the home monitoring program to other high-risk populations. At our mid-sized program, we implemented the Locus Health home monitoring platform first in the hypoplastic left heart syndrome population, then expanding to the single ventricle shunt population. Interstage mortality for the hypoplastic left heart syndrome population after initiation of the home monitoring program went from 18% prior to 2009 to 7% as of the end of 2020 (n = 99), with 2.8% mortality from 2013 to 2020 and 0% mortality since initiation of the Locus program in 2017. Caregiver surveys done prior to discharge and then 3 weeks later were used to document caregiver experience using the digital home monitoring program. Caregivers reported overall positive experience with the digital application, with 91.8% stating that they felt confident taking care of their baby at home. Transitioning the home monitoring program from a traditional binder to an iPad with the Locus Health application allowed us to expand the program, utilize the electronic medical record, bill for the service, and demonstrate positive experiences for caregivers. Overall engagement and adherence with the program by caregivers were 50.94 and 45.45%, with a total of 112 patient episodes. Reimbursement from private insurance providers was 22% of the billed amount for 2020.

Early growth trajectory is associated with psychological stress in parents of infants with congenital heart disease, but moderated by quality of partner relationship

PURPOSE

To explore the relationships between growth trajectory, parenting stress and parent post-traumatic stress (PTS), in infants with congenital heart disease, and the moderating role of parents' dyadic adjustment on those associations.

DESIGN AND METHODS

A secondary analysis of data from the REACH Telehalth home monitoring multi-site randomized clinical trial. Parents completed the Parenting Stress Index (PSI), Post-traumatic diagnostic scale, and the Dyadic Adjustment Scale. Multivariate logistic regression models were used to examine the associations of interest.

RESULTS

During 4-month follow-up after hospital discharge, parents of infants with 'Never recovered' and 'Partially recovered' growth trajectories had 2-5 times higher odds of experiencing higher stress on the Parent Domain (OR = 4.8, CI = 1.3-18.0; OR = 2.5, CI = 1.0-5.9, respectively) than those with stably grown infants. Parents of "Never recovered" infants had 4 times higher odds of PTS symptoms (OR = 3.9; CI = 1.6-9.9). Parental dyadic adjustment moderated the relationships. Parents of 'Partially recovered' infants and having low dyadic adjustment had 3-5 times higher odds of high stress on all PSI domains, while parents with high dyadic adjustment did not have increased stress due to poor infant growth. Parents of "Never recovered" infants had four times higher odds of PTS symptom, even with high dyadic adjustment.

CONCLUSIONS

Infant growth trajectory over the first four months is associated with parenting stress and PTS. Quality of partner relationship moderates some of these associations.

PRACTICE IMPLICATIONS

Infant growth should serve as a screening aid for identifying parents at psychological risk. Interventions targeting the quality of partner relationship may support parental coping and mitigate stress.

CLINICAL TRIAL REGISTRATION

NCT01941667.

Association of Adverse Childhood Experiences with Heart Conditions in Children: Insight from the 2019-2020 National Survey of Children's Health

Adverse Childhood Experiences (ACEs) have been associated with a higher risk of developing cardiovascular diseases and premature mortality in adults.

OBJECTIVES

We evaluated the associations between ACEs and heart diseases among children in the United States.

METHODS

Data on children ages 0 to 17 years reported by parents/guardians to have current heart conditions were analyzed. Using Stata version 17 software, descriptive statistics were generated for the demographic characteristics and the various health outcomes using the chi-square of independence. Multivariate logistic regression models were employed to determine the associations between ACEs and heart conditions, the severity of heart conditions, and overall health status.

RESULTS

There were 826 children with current heart conditions from a total of 68,753 surveyed children. This corresponded to an estimated 780,000 (1.13%) children living with heart conditions in the U.S. On multivariate logistic models, several ACEs, including household economic hardship, parental/guardian's alcohol/drug abuse, severe mental health illness of parents/guardians, racial/ethnic discrimination, exposure to neighborhood violence, and accumulation of two or more ACEs, were significantly associated with heart diseases among children. Though the accumulation of two or more ACEs did not have a significant association with the severity of heart condition, it was significantly associated with caregiver reports of undesirable overall health status.

CONCLUSIONS

ACEs are significantly associated with heart conditions among children and contribute to unfavorable overall health status among children with heart conditions in the U.S. There is a need for policies and programs that will promptly identify ACEs and mitigate their negative impact on children.

Developmental Care for Hospitalized Infants With Complex Congenital Heart Disease: A Science Advisory From the American Heart Association

Developmental disorders, disabilities, and delays are a common outcome for individuals with complex congenital heart disease, yet targeting early factors influencing these conditions after birth and during the neonatal hospitalization for cardiac surgery remains a critical need. The purpose of this science advisory is to (1) describe the burden of developmental disorders, disabilities, and delays for infants with complex congenital heart disease, (2) define the potential health and neurodevelopmental benefits of developmental care for infants with complex congenital heart disease, and (3) identify critical gaps in research aimed at evaluating developmental care interventions to improve neurodevelopmental outcomes in complex congenital heart disease. This call to action targets research scientists, clinicians, policymakers, government agencies, advocacy groups, and health care organization leadership to support funding and hospital-based infrastructure for developmental care in the complex congenital heart disease population. Prioritization of research on and implementation of developmental care interventions in this population should be a major focus in the next decade.

Parents of children with congenital heart defects during the COVID-19 pandemic: An examination of mental health variables, risk factors, and protective factors

BACKGROUND

Little is known about the mental health burden or the factors that contribute to mental health variables in parents of children with congenital heart defects (CHD) during the COVID-19 pandemic.

OBJECTIVE

The purpose of this study was to examine risk and protective factors associated with anxiety symptoms, depression symptoms, and perceived stress in parents of young children with CHD during the COVID-19 pandemic.

METHODS

A nonexperimental design was used in this study of 127 parents of children aged newborn to five years with CHD during the COVID-19 pandemic. Regression analyses were conducted to examine associations between COVID-19 stressors, CHD care-related factors, parental resilience, external support, and mental health variables.

RESULTS

Parental resilience, emotional support, and informational support were key protective factors for anxiety, depression, and stress. However, resilience was remarkably low in CHD parents. Increased levels of anxiety symptoms, depression symptoms, and perceived stress were associated with 1) Exposure to a greater number of COVID-19-related stressors, 2) Distress from family visitation restrictions during healthcare encounters, 3) Worry related to the perceived risk of their CHD child's exposure to COVID-19 during healthcare encounters, and 4) Worry about their CHD child's risk of death or serious illness from COVID-19.

CONCLUSIONS

The additive impact of the COVID-19 pandemic plus CHD care-related worries on this parent population's mental health is significant. Interventions that promote resilience, address the effect of healthcare system changes, and support the needs of parents of young children with CHD during this and future pandemics are needed.

Assessing the Impact of Nasotracheal Intubation on Postoperative Neonates With Congenital Heart Disease: A Quality Improvement Project at a Single Heart Center

OBJECTIVES

Nasotracheal intubation (NTI) is associated with fewer unplanned extubations and improved oral motor skills compared with orotracheal intubation (OTI). Our study aimed to implement a practice change from OTI to NTI for neonatal cardiac surgery and assess impact on postoperative outcomes.

DESIGN

Single-center, prospective, quality improvement study.

SETTING

Academic children's hospital.

PATIENTS

One hundred thirty neonates undergoing cardiac surgery with cardiopulmonary bypass.

INTERVENTIONS

NTI during index cardiac surgery.

MEASUREMENTS AND MAIN RESULTS

Data were collected between January 2019 and April 2021. The study was implemented in three phases: retrospective: OTI neonates ( n = 43), I: safety and feasibility of NTI ( n = 17), and II: speech language pathology (SLP) evaluation on postoperative day 1 facilitated by NTI ( n = 70). Retrospective and phase I patients were combined for analysis. Groups were compared using Kruskal-Wallis test or Wilcoxon rank-sum test.Ninety-one percent of eligible neonates were nasotracheally intubated. There were no clinically significant complications. Days to first SLP encounter decreased from a median 4.5 days (interquartile range [IQR], 3.8-6.2) to 1.1 days (IQR, 1.0-1.9; p < 0.001). Oral readiness time decreased from a median of 6.6 days (IQR, 5.4-8.9) to 4.3 days (IQR, 3.4-8.6; p < 0.001). .

CONCLUSIONS

NTI is feasible and safe in neonatal cardiac surgery. System-level engagement with stakeholders is necessary to change clinical practice. NTI facilitates early SLP evaluation and treatment and significantly affects oral readiness after neonatal cardiac surgery.

Disparities in surgical outcomes of neonates with congenital heart disease across regions, centers, and populations

OBJECTIVE

To summarize existing literature on neonatal disparities in congenital heart disease surgical outcomes and identify potential policies to address these disparities.

FINDING

Disparities in outcomes for neonatal congenital heart surgery were largely published under four domains: race/ethnicity, insurance type, neighborhood/socioeconomic status, and cardiac center characteristics. While existing research identifies associations between these domains and mortality, more nuanced analyses are emerging to understand the mediators between these domains and other non-mortality outcomes, as well as potential interventions and policies to reduce disparities. A broader look into social determinants of health (SDOH), prenatal diagnosis, proximity of birth to a cardiac surgical center, and post-surgical outpatient and neurodevelopmental follow-up may accelerate interventions to mitigate disparities in outcomes.

CONCLUSION

Understanding the mechanisms of how SDOH relate to neonatal surgical outcomes is paramount, as disparities research in neonatal congenital heart surgery continues to shift from identification and description, to intervention and policy.

The associations between resilience and socio-demographic factors in parents who care for their children with congenital heart disease

Objective

To examine the resilience of parents of children with congenital heart disease and to investigate socio-demographic factors that may influence parents’ resilience.

Methods

This is a web-based survey study using a cross-sectional design. A purposive sampling method was utilized to recruit 515 parents who care for children with congenital heart disease. Resilience was assessed using the Dispositional Resilience Scale-Ⅱ. Based on expert-interviews, a questionnaire was designed to collect socio-demographic data. Descriptive statistics, factor analysis, and linear regressions were used to analyze data.

Results

A total of 413 parents completed the survey study. The mean resilience score was 3.75 (SD = 0.61; range = 1.89–4.89) with higher scores indicating higher resilience. The linear regression models demonstrated that parents who had lower education levels and lower gross household income had lower resilience (P < 0.05).

Conclusions

Parents reported resilience that reflected their ability to cope with stressful events and mitigate stressors associated with having and caring for children with congenital heart disease. Lower education levels and lower gross household income are associated with lower resilience. To increase parents’ resilience, nursing practice and nurse-led interventions should target screening and providing support for parents at-risk for lower resilience. As lower education level and financial hardship are factors that are difficult to modify through personal efforts, charitable foundations, federal and state governments should consider programs that would provide financial and health literacy support for parents at-risk for lower resilience.

Quality of Life of Mothers of Infants Subjected to Neonatal Cardiac Surgery: The Importance of Psychosocial Factors

Background: The World Health Organization acknowledges quality of life (QOL) as subjectively perceived overall well-being by the individual and recognizes it as an essential construct for overall health and wellness. The purpose of this study was to examine the association of infant, environmental, and parental factors with the QOL of mothers of infants at four months post-hospital discharge from cardiac surgery. Methods: Secondary analysis of prospectively collected data from the REACH randomized clinical trial of telehealth home monitoring. The sample included mothers (n  =  148) of infants with congenital heart disease who provided data at four months post-discharge. Ten imputations were generated using fully conditional specification methods to address missing data and were combined. All analyses were performed on the imputed data. Mothers' QOL was the main outcome of the analysis, as measured by the Ulm Quality of Life Inventory for Parents. Predictors on QOL were identified based on the World Health Organization QOL framework which recognizes the multidimensional domains influencing QOL that include personal factors, environmental factors, and physical factors related to disease and functioning. Results: The treatment and control groups did not differ on any study variable, thus data were collapsed and analyzed together. Final multivariable model found that the combination of dyadic adjustment, social support, parenting stress, and post-traumatic stress symptoms explained approximately three-quarters of the variance in QOL scores. Conclusions: QOL for mothers of infants with congenital heart disease is largely influenced by psychosocial factors. Future research targeted toward improving maternal QOL should include psychosocial interventions that address social networks and stress.

Parental post-traumatic stress, overprotective parenting, and emotional and behavioural problems for children with critical congenital heart disease

OBJECTIVE

To examine relationships amongst parental post-traumatic stress symptoms, parental post-traumatic growth, overprotective parenting, and child emotional/behavioural problems in families of children with critical CHD.

METHOD

Sixty parents (15 fathers) of children aged 1-6 completed online questionnaires assessing parental post-traumatic stress symptoms and post-traumatic growth, overprotective parenting, and child emotional/behavioural problems. Bivariate correlations and mediational analyses were conducted to evaluate overprotective parenting as a mediator of the association between parental post-traumatic stress symptoms and child emotional/behavioural problems.

RESULTS

Parents reported significant post-traumatic stress symptoms, with over 18% meeting criteria for post-traumatic stress disorder and 70% meeting criteria in one or more clusters. Parental post-traumatic growth was positively correlated with intrusion (r = .32, p = .01) but it was not associated with other post-traumatic stress symptom clusters. Parental post-traumatic stress symptoms were positively associated with overprotective parenting (r = .37, p = .008) and total child emotional/behavioural problems (r = .29, p = .037). Overprotective parenting was positively associated with total child emotional/behavioural problems (r = .45, p = .001) and fully mediated the relationship between parental post-traumatic stress symptoms and child emotional/behavioural problems.

CONCLUSION

Overprotective parenting mediates the relationship between parental post-traumatic stress symptoms and child emotional and behavioural problems in families of children with CHD. Both parental post-traumatic stress symptoms and overprotective parenting may be modifiable risk factors for poor child outcomes. This study highlights the need for interventions to prevent or reduce parental post-traumatic stress symptoms and to promote effective parenting following a diagnosis of CHD.

Partnering With Stakeholders to Inform the Co-Design of a Psychosocial Intervention for Prenatally Diagnosed Congenital Heart Disease

Input from diverse stakeholders is critical to the process of designing healthcare interventions. This study applied a novel mixed-methods, stakeholder-engaged approach to co-design a psychosocial intervention for mothers expecting a baby with congenital heart disease (CHD) and their partners to promote family wellbeing. The research team included parents and clinicians from 8 health systems. Participants were 41 diverse parents of children with prenatally diagnosed CHD across the 8 health systems. Qualitative data were collected through online crowdsourcing and quantitative data were collected through electronic surveys to inform intervention co-design. Phases of intervention co-design were: (I) Engage stakeholders in selection of intervention goals/outcomes; (II) Engage stakeholders in selection of intervention elements; (III) Obtain stakeholder input to increase intervention uptake/utility; (IV) Obtain stakeholder input on aspects of intervention design; and (V) Obtain stakeholder input on selection of outcome measures. Parent participants anticipated the resulting intervention, HEARTPrep, would be acceptable, useful, and feasible for parents expecting a baby with CHD. This model of intervention co-design could be used for the development of healthcare interventions across chronic diseases.

Development of the ICF-CY Set for Cardiac Rehabilitation After Pediatric Congenital Heart Surgery

BACKGROUND

Most children with congenital heart disease (CHD) require surgical repair, and postoperative rehabilitation is an essential step to restore the quality of life. The present study constructs and confirms the International Classification of Functioning, Disability, and Health for Children and Youth core set for children with congenital heart disease 1 year after surgery (ICF-CY-CHDS).

METHODS

From February 2021 to August 2021, 340 children aged 3-6 years after CHD surgery were evaluated using the ICF-CY-CHDS and analyzed using the Rasch model.

RESULTS

The final ICF-CY-CHDS contained 22 categories; it exhibited a nonsignificant χ2 test result for the item-trait interaction (χ2 = 6736.37, p = 0.8660, Bonferroni-adjusted p = 0.0023). The average severity of children was less than the average difficulty of categories (-2.26 logit <0 logit). The weighted k of all the categories was 0.964 (p < 0.001), and the item separation index was 0.96. The area under the ROC curve of children with a diagnosis result of heart failure was 0.866 (95% CI: 0.801 ~0.931) with good sensitivity (0.875) and specificity (0.759).

CONCLUSION

The ICF-CY-CHDS presents a preliminary practical direction during early cardiac rehabilitation after pediatric CHD surgery, and thus provides a basis and scope for clinical evaluation and intervention program formulation.

Predictors of Post-traumatic stress symptomology in parents of infants with Congenital Heart Disease post-surgery and after four months

PURPOSE

To identify predictors of post-traumatic stress symptomology among parents of infants with complex congenital heart defects at hospital discharge and after 4 months.

DESIGN & METHODS

A secondary analysis utilizing data from a larger RCT performed in three pediatric cardiac centers in North America. Analysis included 158 parent-infant dyads. Generalized Linear Modeling was used to identify predictors of parental post-traumatic symptomology at hospital discharge, and after 4 months. Considered predictors included demographics/SES, illness, and psychosocial parameters.

RESULTS

At discharge, parenting stress, education, and infant's medication number were linked to post-traumatic stress symptomology severity; Parenting stress, education, insurance type, and medications number predicted number of symptoms; Tube-assisted feeding predicted PTSD. At 4 months, parenting stress, ethnicity, and number of ED visits predicted PTSS severity; Parenting stress, ethnicity, and cardiologist visits predicted number of symptoms; Parenting stress, single ventricle physiology, and number of children predicted PTSD.

CONCLUSIONS & PRACTICAL IMPLICATIONS

Parental psychosocial factors, additionally to illness and sociodemographic indicators, can potentially risk parents to experience PTSS/PTSD. Nursing and other healthcare professionals can participate in early screening of such factors to determine familial risk.

TRIAL REGISTRATION

NCT01941667.

The impact of socioeconomic status and race on the outcomes of congenital heart disease

PURPOSE OF REVIEW

Studying the outcomes of congenital heart disease and their associations allows paediatric cardiologists and intensivists to improve the care and health equity of their patients. This review presents the most recent literature discussing the socioeconomic and racial disparities that pervade the outcomes of patients with congenital heart disease in every facet of treatment. The outcomes of congenital heart disease discussed are prenatal detection, maintenance of care, quality of life, neurodevelopment and mortality.

RECENT FINDINGS

Historically, it has been documented that patients with congenital heart disease who are of racial and ethnic minorities disproportionately experience poor outcomes. Recently, the association between racial minorities and mortality has been traced to underlying socioeconomic disparities emphasizing that race and ethnicity are not independent determinants of health.

SUMMARY

The effect of socioeconomic status on the outcomes of congenital heart disease is profound and reaches beyond the association with racial and ethnic minorities. Changes to address these disparities in outcomes must be made at the individual, institutional, community and system levels.

Socioeconomic inequality in congenital heart diseases in Iran

INTRODUCTION

Social-economic factors have an important role in shaping inequality in congenital heart diseases. The current study aimed to assess and decompose the socio-economic inequality in Congenital Heart Diseases (CHDs) in Iran.

METHODS

This is a cross-sectional research conducted at Shahid Rajaie Cardiovascular Medical and Research Center in Tehran, Iran, as one of the largest referral heart hospitals in Asia. Data were collected primarily from 600 mothers who attended in pediatric cardiology department in 2020. The polychoric principal component analysis (PCA) and Errygers corrected CI (ECI) were used to construct household socioeconomic status and to assess inequality in CHDs, respectively. A regression-based decomposition analysis was also applied to explain socioeconomic-related inequalities. To select the explanatory social, medical/biological, and lifestyle variables, the chi-square test was first used.

RESULTS

There was a significant pro-rich inequality in CHDs (ECI = -0.65, 95% CI, - 0.72 to - 0.58). The social, medical/biological, and lifestyle variables accounted for 51.47, 43.25, and 3.92% of inequality in CHDs, respectively. Among the social variables, family SES (about 50%) and mother's occupation (21.05%) contributed the most to CHDs' inequality. Besides, in the medical/biological group, receiving pregnancy care (22.06%) and using acid folic (15.70%) had the highest contribution.

CONCLUSION

We concluded that Iran suffers from substantial socioeconomic inequality in CHDs that can be predominantly explained by social and medical/biological variables. It seems that distributional policies aim to reduce income inequality while increasing access of prenatal care and folic acid for disadvantaged mothers could address this inequality much more strongly in Iran.

Role alteration predicts anxiety and depressive symptoms in parents of infants with congenital heart disease: a pilot study

BACKGROUND

Parents of infants born with critical congenital heart disease are at risk for adverse mental health symptoms. The purpose of this study was to identify infant-, parent-, and environmental-based stressors for mothers and fathers after their infants' cardiac surgery, and to explore relationships between stressors and mental health symptoms of anxiety and depression.

METHODS

This study enrolled 28 biological mother-father dyads from families admitted to the paediatric cardiac intensive care unit for cardiac surgery at one free-standing children's hospital in the Northeast. Paired t-tests were used to examine group differences between mothers and fathers on perceived stressors and mental health symptoms, while linear mixed effects modelling was used to explore the predictive relationship between perceived stressors, personal factors, and mental health symptoms.

RESULTS

Mothers reported higher perceived stressor scores of parental role alteration (t = 4.03, p < 0.01) and infant appearance and behaviour (t = 2.61, p = 0.02), and total perceived stress (t = 2.29 p = 0.03), compared to fathers. Mothers also reported higher anxiety (t = 2.47, p = 0.02) and depressive symptoms (t = 3.25, p < 0.01) than fathers. In multivariable analysis, parental role alteration significantly predicted anxiety (t = 5.20, p < 0.01, d = 0.77) and depressive symptoms (t = 7.09, p < 0.01, d = 1.05) for mothers and fathers. The consensus subscale of the Dyadic Adjustment Scale also significantly predicted depressive symptoms (t = -2.42, p = 0.02, d = 0.04).

CONCLUSION

Parents were distressed during their infant's admission for surgical repair for critical congenital heart disease. Parental role alteration was significantly associated with parental anxiety and depressive symptoms, while poor relationship quality was associated with depressive symptoms, highlighting areas for potential nursing-led psychosocial led interventions.

Resilience and Associated Factors in Mothers of Children with Congenital Heart Disease: A Cross-Sectional Study

BACKGROUND

Congenital heart disease (CHD) in children affects the parents' mental and physical health and their caring and supportive functions. Resilience is an important factor in health. This study aimed to determine resilience and its associated factors in mothers of children with congenital heart disease.

METHODS

This descriptive cross-sectional study enrolled 136 mothers of children with CHD. Samples were selected in two hospitals of Shahid Modarres and Children's Medical Center in Tehran, Iran, via convenience sampling from May to early October 2019. Data were collected using demographics questionnaire, Multidimensional Scale of Perceived Social Support (MSPSS), Life Orientation Test (LOT), and Wagnild and Young Resilience Scale (RS). Data were analyzed in statistical software SPSS-16 using independent t-test, ANOVA, Pearson and Spearman correlation, and multiple linear regression. The significance level was set at P<0.05.

RESULTS

Mothers' total mean score of resilience was 94.08±12.81, while 14.7%, 66.2%, and 19.1% had low, moderate, and high resilience, respectively. Regression analysis showed that two variables of social support (B=2.20, P<0.001) and optimism (B=0.76, P=0.003) were associated with resilience in mothers. The duration of the child's disease was positively correlated with the mothers' resilience but did not predict it (B=-0.72, P=0.22).

CONCLUSION

The level of resilience in most mothers was moderate. Social support in the dimension of significant others and optimism were associated with mothers' resilience. Therefore, holistic care and providing educational training programs that enhance these variables could be effective in promoting resilience in mothers of children with CHD.

Neurodevelopmental and psychosocial interventions for individuals with CHD: a research agenda and recommendations from the Cardiac Neurodevelopmental Outcome Collaborative

In 2018, the Neurodevelopmental and Psychosocial Interventions Working Group of the Cardiac Neurodevelopmental Outcome Collaborative convened through support from an R13 grant from the National Heart, Lung, and Blood Institute to survey the state of neurodevelopmental and psychosocial intervention research in CHD and to propose a slate of critical questions and investigations required to improve outcomes for this growing population of survivors and their families. Prior research, although limited, suggests that individualised developmental care interventions delivered early in life are beneficial for improving a range of outcomes including feeding, motor and cognitive development, and physiological regulation. Interventions to address self-regulatory, cognitive, and social-emotional challenges have shown promise in other medical populations, yet their applicability and effectiveness for use in individuals with CHD have not been examined. To move this field of research forward, we must strive to better understand the impact of neurodevelopmental and psychosocial intervention within the CHD population including adapting existing interventions for individuals with CHD. We must examine the ways in which dedicated cardiac neurodevelopmental follow-up programmes bolster resilience and support children and families through the myriad transitions inherent to the experience of living with CHD. And, we must ensure that interventions are person-/family-centred, inclusive of individuals from diverse cultural backgrounds as well as those with genetic/medical comorbidities, and proactive in their efforts to include individuals who are at highest risk but who may be traditionally less likely to participate in intervention trials.

Parent mental health and family functioning following diagnosis of CHD: a research agenda and recommendations from the Cardiac Neurodevelopmental Outcome Collaborative

Diagnosis of CHD substantially affects parent mental health and family functioning, thereby influencing child neurodevelopmental and psychosocial outcomes. Recognition of the need to proactively support parent mental health and family functioning following cardiac diagnosis to promote psychosocial adaptation has increased substantially over recent years. However, significant gaps in knowledge remain and families continue to report critical unmet psychosocial needs. The Parent Mental Health and Family Functioning Working Group of the Cardiac Neurodevelopmental Outcome Collaborative was formed in 2018 through support from an R13 grant from the National Heart, Lung, and Blood Institute to identify significant knowledge gaps related to parent mental health and family functioning, as well as critical questions that must be answered to further knowledge, policy, care, and outcomes. Conceptually driven investigations are needed to identify parent mental health and family functioning factors with the strongest influence on child outcomes, to obtain a deeper understanding of the biomarkers associated with these factors, and to better understand how parent mental health and family functioning influence child outcomes over time. Investigations are also needed to develop, test, and implement sustainable models of mental health screening and assessment, as well as effective interventions to optimise parent mental health and family functioning to promote psychosocial adaptation. The critical questions and investigations outlined in this paper provide a roadmap for future research to close gaps in knowledge, improve care, and promote positive outcomes for families of children with CHD.

Parental role alteration strongly influences depressive symptoms in mothers of preoperative infants with congenital heart disease

BACKGROUND

Mothers of infants with congenital heart disease are at risk for depression.

OBJECTIVES

This study explored the influence on maternal depressive symptoms of several known factors for mothers in the pediatric cardiac intensive care unit, including perceived stressors, attachment, and anxiety.

METHODS

This study was a secondary analysis of 30 mothers of infants awaiting cardiac surgery. Linear regressions were calculated to determine the relationships between perceived stressors, maternal attachment, anxiety, and maternal depressive symptoms.

RESULTS

Nearly half of mothers reported depressive symptoms above the measure cut-off score, indicating they were at risk for likely clinical depression. Subscales of perceived stress explained 61.7% of the variance in depressive symptoms (F = 11.815, p<0.0001) with parental role alteration subscale as the strongest predictor (standardized beta=0.694, p = 0.03).

CONCLUSIONS

Findings underscore the importance of mental health screening and instituting nursing practices to enhance parental role for mothers of infants awaiting cardiac surgery.

Defining a new normal: A qualitative exploration of the parent experience during the single ventricle congenital heart disease interstage period

AIM

To explore parents' experience of transition in the period between the palliative cardiac surgeries (i.e., the interstage period) of an infant with single ventricle congenital heart disease.

DESIGN

We conducted an exploratory naturalistic inquiry using a qualitative descriptive approach.

METHODS

A purposive sample of 11 parents of children with single ventricle disease was selected among families that participated in an interstage-period parental home monitoring program during the past 2 years. Interviews and field observations were conducted September-October 2019, and data were analyzed for themes. Analysis of data was inductive, although study questions and the interpretation of results were informed by Meleis' transition theory.

RESULTS

Parents described the experience of transition in interstage as a striving for normality, a theme that was clustered in subthemes of home, self, and infant.

CONCLUSION

Parents' experiences of striving for normality indicated a need for more targeted efforts to address parents' psychosocial needs during the highly stressful interstage transition.

IMPACT

This research underscored the complexity of parents' psychosocial support needs on returning home after their child's first palliative surgery. The findings also suggest need for examination of the transition following the second palliative heart surgery, when the home monitoring program is withdrawn. Understanding parent needs will help guide healthcare teams in developing ways to support parents as they adjust to home, self, and child.

Mental Health Disorders in Children With Congenital Heart Disease

BACKGROUND

Data on anxiety, depression, and attention-deficit/hyperactivity disorder (ADHD) are lacking for youth with congenital heart disease (CHD), particularly those with simple CHD. This study aims to characterize these disorders in youth with CHD compared to those without CHD.

METHODS

A comparative cross-sectional study was conducted by using the electronic medical records of a large tertiary care hospital between 2011 and 2016. Inclusion criteria were youth aged 4 to 17 years with >1 hospitalization or emergency department visits. Exclusion criteria were patients with arrhythmias or treatment with clonidine and/or benzodiazepines. The primary predictor variable was CHD type: simple, complex nonsingle ventricle, and complex single ventricle. The primary outcome variable was a diagnosis and/or medication for anxiety and/or depression or ADHD. Data were analyzed by using logistic regression (Stata v15; Stata Corp, College Station, TX).

RESULTS

We identified 118 785 patients, 1164 with CHD. Overall, 18.2% (n = 212) of patients with CHD had a diagnosis or medication for anxiety or depression, compared with 5.2% (n = 6088) of those without CHD. All youth with CHD had significantly higher odds of anxiety and/or depression or ADHD. Children aged 4 to 9 years with simple CHD had ∼5 times higher odds (odds ratio: 5.23; 95% confidence interval: 3.87-7.07) and those with complex single ventricle CHD had ∼7 times higher odds (odds ratio: 7.46; 95% confidence interval: 3.70-15.07) of diagnosis or treatment for anxiety and/or depression. Minority and uninsured youth were significantly less likely to be diagnosed or treated for anxiety and/or depression or ADHD, regardless of disease severity.

CONCLUSIONS

Youth with CHD of all severities have significantly higher odds of anxiety and/or depression and ADHD compared to those without CHD. Screening for these conditions should be considered in all patients with CHD.

Skin-to-Skin Care is Associated with Reduced Stress, Anxiety, and Salivary Cortisol and Improved Attachment for Mothers of Infants With Critical Congenital Heart Disease

OBJECTIVE

To estimate the effect of skin-to-skin care (SSC) on biobehavioral measures of stress (anxiety and salivary cortisol) and attachment (attachment scores and salivary oxytocin) of mothers before and after their infants' neonatal cardiac surgery.

DESIGN

A prospective interventional, baseline response-paired pilot study.

SETTING

Cardiac center of a large, metropolitan, freestanding children's hospital.

PARTICIPANTS

Thirty women whose infants were hospitalized for neonatal cardiac surgery.

METHODS

Participants acted as their own controls before, during, and after SSC at two time points: once before and once after surgery. We measured the stress response of mothers, as indicated by self-reported scores of anxiety and maternal salivary cortisol, and maternal-infant attachment, as indicated by self-reported scores and maternal salivary oxytocin.

RESULTS

Significant reductions in self-reported scores of anxiety and salivary cortisol were found as a result of SSC at each time point, as well as increased self-reported attachment. No significant differences were found in oxytocin.

CONCLUSION

Our findings provide initial evidence of the benefits of SSC as a nurse-led intervention to support maternal attachment and reduce physiologic and psychological stress responses in mothers of infants with critical congenital heart disease before and after neonatal cardiac surgery.

Fathers of Children With Congenital Heart Disease: Sources of Stress and Opportunities for Intervention

OBJECTIVES

To examine sources of stress for fathers of children with congenital heart disease and opportunities for intervention to prevent or reduce paternal mental health problems.

DESIGN

Qualitative study using online crowdsourcing, an innovative research methodology to create an online community to serve as a research sample.

SETTING

Yammer, an online social networking site.

SUBJECTS

Geographically diverse sample of 70 parents (25 fathers and 45 mothers) of young children with congenital heart disease.

INTERVENTIONS

Participants joined a private group on Yammer and responded to 37 open-ended study questions over a 6-month period. Qualitative data were coded and analyzed using an iterative process, and themes regarding sources of stress for fathers of children with congenital heart disease and opportunities for intervention were identified.

MEASUREMENTS AND MAIN RESULTS

Four broad themes regarding sources of stress for fathers of children with congenital heart disease emerged from the qualitative data from both mothers and fathers: societal expectations for fatherhood and standards of masculinity, balancing work and family responsibilities, feeling overlooked as a partner in care, and lack of father supports. To begin to address these sources of stress, participants recommended that care teams acknowledge and normalize the impact of congenital heart disease on fathers, provide support for balancing work and family responsibilities, recognize and promote father knowledge and engagement, and provide formal and informal supports for fathers of children with congential heart disease.

CONCLUSIONS

Fathers of children with congenital heart disease experience unique sources of stress in the absence of targeted interventions to meet their needs. Care teams play an important role in acknowledging the experiences of fathers and including and engaging fathers in care.

Illness-Related Parenting Stress and Maladjustment in Congenital Heart Disease: Mindfulness as a Moderator

OBJECTIVE

Congenital heart disease (CHD) is characterized by structural defects to the heart or the coronary blood vessels and often requires surgical repair. Raising an infant or toddler with CHD can be challenging and lead to high parenting stress and maladjustment. The parenting literature suggests that mindfulness may buffer parenting stress. The purpose of this study was to examine whether mindfulness might moderate the relationship between illness-related parenting stress and maladjustment in parents of infants and toddlers with CHD.

METHODS

Parents of infants and toddlers with CHD attending an outpatient clinic provided background information and completed measures of illness-related parenting stress, mindfulness, and maladjustment.

RESULTS

Results indicated that illness-related parenting stress was associated with maladjustment, and mindfulness moderated this relationship. Specifically, illness-related parenting stress was related to maladjustment at low and average levels of mindfulness; at high mindfulness, there was no association between illness-related parenting stress and maladjustment.

CONCLUSIONS

Consistent with the broader literatures, our sample of parents of infants and toddlers with CHD reported high illness-related parenting stress and maladjustment. Building on other studies demonstrating the benefits of mindful parenting, our results suggest that engaging in mindfulness might thwart the association between illness-related parenting stress and maladjustment in parents of infants and toddlers with CHD.

Uncertainty of Prenatally Diagnosed Congenital Heart Disease: A Qualitative Study

IMPORTANCE

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

OBJECTIVE

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

DESIGN, SETTING, AND PARTICIPANTS

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

MAIN OUTCOMES AND MEASURES

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

RESULTS

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

CONCLUSIONS AND RELEVANCE

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

Collaborative caregiving of parents who have an infant with congenital heart disease

PURPOSE

Describe collaborative caregiving of the parents of an infant with congenital heart disease (CHD) with partner, health-care clinicians, and substitute caregivers (SC).

DESIGN AND METHODS

In a national online survey, 53 mothers and 12 fathers described collaborative caregiving for infants after CHD intervention with respect to facets of Bowlby's concept of the internal working model of caregiving. Parents identified concern for 24 everyday common problems or goals (i.e., issues; 10 for partner, 9 for clinician, 5 for SC), rated issue importance and difficulty, indicated an intention for seeking and using help (help use), and identified help source.

RESULTS

All survey items were a concern to at least 11 parents. Most prominently, all five of the SC items were identified by at least 44% of the parents as a concern. Everyday, common problems and goals were generally reported to be more important than difficult. Two items identified as partner issues, "Talking about life change" and "Handling stress," were a concern for about 50% of parents and identified by at least 74% as very important and 72% as moderately to greatly difficult. Help use was highest for SC items followed by items related to the partner. The partner was most frequently identified as a help source.

PRACTICE IMPLICATIONS

Nurses are in a position to assess and support parent collaboration within partner, clinician, and SC relationships for everyday problems and goals. The survey questions, with further development and testing, could be used for clinician assessment and tailoring of intervention to support parents' collaborative caregiving for infants with CHD.

From Surviving to Thriving - Parental Experiences of Hospitalised Infants with Congenital Heart Disease Undergoing Cardiac Surgery: A Qualitative Synthesis

PROBLEM

Congenital heart disease (CHD) is the most common congenital abnormality in infants and over one third of these infants will require surgical intervention in the neonatal period. This qualitative synthesis aimed to explore parental experiences of surgery and hospitalisation in the intensive care environment for the treatment of their infant's CHD in the first year of life in order to inform practice.

ELIGIBILITY CRITERIA

Qualitative primary research and qualitative elements of mixed methods studies published in English between January 2009 and February 2019 were eligible if they addressed the experiences and perspectives of parents whose infants had CHD undergoing cardiac surgery in the first year of life.

SAMPLE

Three hundred and forty-nine papers were screened. Six papers, with three of them from the same larger study, were included.

RESULTS

Five themes were developed from thematic synthesis. They are (1) intense conflicting emotions from heartbreak to joy, (2) the helplessness and uncertainty of waiting, (3) making sense of it all, (4) the power of relationships, and (5) parenting despite the challenges.

CONCLUSION

Parents experienced intense and fluctuating emotions, and found ways of coping. The integral role of healthcare professionals/nurses during this period was also evident.

IMPLICATIONS

Healthcare professionals/nurses have the potential to positively impact the care and outcomes for this growing population of infants with CHD and their families, helping them to thrive. More research is needed with longitudinal and multi-centred studies and in middle and low income counties to broaden our understanding of this topic.

Neurodevelopmental Outcomes Among Children With Congenital Heart Disease: At-Risk Populations and Modifiable Risk Factors

As survivable outcomes among patients with complex congenital heart disease (cCHD) have continued to improve over the last several decades, more attention is being dedicated to interventions that impact not just survival but quality of life among patients with cCHD. In particular, patients with cCHD are at risk for impaired neurodevelopmental outcomes. In this review summarizing select presentations given at the 14th Annual Pediatric Cardiac Intensive Care Society's Annual Meeting in 2019, we discuss the neurodevelopmental phenotype of patients with cCHD, patients at greatest risk of impaired development, and three specific modifiable risk factors impacting development.

Enhancing Parental Coping with a Child's Heart Condition: A Co-production Pilot Study

Families of children with congenital heart disease (CHD) can have difficulties coping with the stress of their child's condition and would benefit from assistance to cope better. To address the needs of these parents, the Australian Center for Heart Health/HeartKids Australia/Melbourne Graduate School of Education co-produced Family Coping Project was initiated. This project involved two systematic literature reviews, interviews with parents of children with CHD, and the development and piloting of a manualised parental coping program. The primary aims of the pilot study were to determine whether the program would: attract high needs families; enhance the coping self-efficacy of parents; and be acceptable to parents in terms of content and mode of delivery. The secondary aims were to investigate whether the program would impact on parental coping, parental stress and general stress. Parents completed pre-, post-program and 6-month follow up assessment measures, with parent stress scores being compared to stress scores reported for other chronic condition parent carer groups. Twenty-one parents participated and provided baseline data. They were found to be significantly more stressed than other parent carer groups. Eleven parents completed post-program data and 13 completed 6-month follow-up data. There was a significant increase in parents' coping self-efficacy from pre- to post-program, and from pre- to 6-months. Parents' use of productive coping styles increased significantly from pre- to post-program. The program was rated as highly acceptable in terms of content and delivery mode. The pilot provides strong evidence for upscaling the program in conjunction with individualized psychological support for parents to extend knowledge acquisition and attitude change into enhanced coping skills and demonstrated the benefits of a co-production process.