Feeling of burden, psychological distress, and anxiety among primary caregivers of children with home enteral nutrition

Pediatric to adult transition care in neurogastroenterology and motility: A position paper from the American Neurogastroenterology and Motility Society and European Society of Neurogastroenterology and Motility

Transition services-programs that support adolescents and young adults (AYAs) as they move from a child-centered to a more autonomous, adult-orientated healthcare system-have been associated with improved short- and long-term healthcare outcomes. Unfortunately, there is a paucity of evidence exploring transition services within the neurogastroenterology and motility (NGM) field. The overall aim of this article, endorsed by the American Neurogastroenterology and Motility Society and European Society of Neurogastroenterology and Motility, is to promote a discussion about the role of transition services for patients with NGM disorders. The AYAs addressed herein are those who have: (a) a ROME positive disorder of gut-brain interaction (DGBI), (b) a primary or secondary motility disorder (including those with motility disorders that have been surgically managed), or (c) an artificial feeding requirement (parenteral or enteral tube feeding) to manage malnutrition secondary to categories (a) or (b). The issues explored in this position paper include the specific physical and psychological healthcare needs of patients with NGM disorders; key healthcare professionals who should form part of a secondary care NGM transition service; the triadic relationship between healthcare professionals, caregivers, and patients; approaches to selecting patients who may benefit most from transition care; methods to assess transition readiness; and strategies with which to facilitate transfer of care between healthcare professionals. Key areas for future research are also addressed, including the construction of NGM-specific transition readiness questionnaires, tools to assess post-transfer healthcare outcomes, and educational programs to train healthcare professionals about transition care in NGM.

Health-related quality of life and caregiver burden of pediatric patients with inborn errors of metabolism in Japan using EQ-5D-Y, PedsQL, and J-ZBI

PURPOSE

Inborn errors of metabolism (IEM) are known with poor long-term health concerns; however, the health-related quality of life (HRQoL) and the burden placed on families remain unclear. This study investigated the self- and proxy-reported HRQoL of pediatric patients with IEM with or without developmental disabilities and the burden placed on their caregivers.

METHODS

Patients with IEM aged 8-15 years and their caregivers were asked to respond to the Pediatric Quality of Life Inventory (PedsQL), EuroQoL five-dimension questionnaire for younger populations (EQ-5D-Y), and Japanese version of the Zarit Caregiver Burden Interview (J-ZBI). We compared EQ-5D-Y scores with matched EQ-5D-Y population norms. Intraclass correlation coefficients (ICC) for self and proxy HRQoL scores of those without developmental disabilities were calculated. Correlation coefficients of HRQoL proxy responses with J-ZBI score were estimated.

RESULTS

We included 66 patients with IEM (mean age, 11.5 years; males, 41.2%) in the study. The mean (± standard deviation) EQ-5D-Y scores without and with developmental disabilities were 0.957 (± 0.071) and 0.821 (± 0.175), respectively. The EQ-5D-Y scores significantly increased compared with the reference values (p < 0.01, effect size = 0.337). The ICC values were 0.331 and 0.477 for the EQ-5D-Y and PedsQL scores, respectively. HRQoL proxy scores had strong negative correlations with J-ZBI scores.

CONCLUSION

The HRQoL of patients with IEM without developmental disabilities in our study was similar to that of the general Japanese population. The HRQoL of patients with IEM with developmental disabilities was low and associated with a tendency towards an increased burden of care.

[The Need of Evidence-Based Treatment of Early-Onset Feeding Tube Dependency: A Pico- Framework Based Analytic Review of Clinical Features and Treatment of Feeding Tube Dependency]

Feeding Tube Dependency is a constant increasing perinatal mental health condition, with estimated 350 new cases per year in Germany.The early onset feeding tube dependency is the consequence of a generalized food aversion. To establish an evidence-based nationwide treatment plan, relevant research from the past twenty years were narratively reviewed. Feeding tube dependency is an international increasingmental health condition, with a high symptom persistence and a low spontaneous remission. The generalized food aversion would prevent the transition to oral feeding.The treatment protocols, supported by the German Health System, based on low-frequency individual treatment and intensive inpatient treatments are not supported by the most recent evidence. In treatment outcome research more promising and effective programs can be distinguished from ineffective programs. As a result, treatment which are designed as intensive treatment, home-based or inpatient and are psychodynamicbased are most effective. Day-clinic and behavioral modification programs are not or low in treatment effectiveness.The German Health System approach to assist families with feeding tube dependency is not evidence-based. A new structure of treatment is imperatively required.

Understanding the impact of pediatric single large-scale mtDNA deletion syndromes on caregivers: Burdens and challenges

Single large-scale mitochondrial deletion syndromes (SLSMDS) are ultra-rare, progressive multi-system diseases that make children largely dependent on their caregivers for both medical and non-medical needs. Yet, few studies have examined the burden felt among caregivers. As part of a larger research study, 42 caregivers of children with SLSMDS completed two surveys to assess caregiver burden. The Mitochondrial Care Network Patient Needs Survey (MCN-PNS) is a novel assessment that examines the logistical, time, and financial costs experienced by caregivers of children with SLSMDS. The Zarit Burden Interview (ZBI-22) is a validated assessment that examines caregivers' psychological health. Results demonstrate the unique burden experienced by caregivers of children with SLSMDS. One notable finding was the high psychological burden. Nearly 90% of caregivers experience psychological burden, with 20% of caregivers at risk for anxiety and depression. Caregivers were primarily concerned about what the future held for their child. Additional burdens included the time required to coordinate the child's healthcare visits and financial strains. Caregivers reported minimal delays in establishing care with a mitochondrial care specialist and felt confident in their understanding of their child's disease and treatment(s). Overall, there is a need for expanded logistical, financial, and psychological support from mitochondrial disease centers and advocacy groups for caregivers of children with SLSMDS.

Caregiver burden among parents of children with chronic diseases: A cross-sectional study

AIMS AND OBJECTIVES

This study aimed to assess the perceived caregiver burden among parents of chronically ill children in Jordan.

BACKGROUND

Although there are few studies on the accurate prevalence of chronic diseases among Jordanian children, there are a few on the burden of caregiving, which is important because most children with chronic illness rely on their caregivers to perform their daily tasks. In Jordan, little is known about the caregiver burden associated with caring for children with chronic diseases.

DESIGN

A cross-sectional design was reported in line with the STROBE guidelines.

METHODS

The Katz Index of Independence was used to determine the children's level of dependence, and the Burden Scale for Family Caregivers was used to measure the caregivers' level of burden.

RESULTS

Nearly, 49.3% of caregivers had a very severe burden, 31.2% of children had a severe functional impairment, 19.6% had a moderate impairment, and 49.3% had full functionality. Based on their children's dependency, caregivers' subjective burden varied greatly (p < .001). Fully functional children had a far lower disease burden than severely and moderately disabled children (p < .001). The caregiver burden score differed significantly across chronic disease categories (p < .001). Unemployed caregivers had a far higher subjective burden than working caregivers (p = .009), and single (divorced/widowed) caregivers had higher burdens than married caregivers.

CONCLUSIONS

Various factors can increase caregiver burden. Therefore, healthcare providers must plan holistic and family-centred interventions to reduce the caregiving burden.

RELEVANCE TO CLINICAL PRACTICE

There is a need to establish support programs to help reduce the level of burden among caregivers of children with chronic diseases.

Effectiveness of a Supportive Program on Caregiver Burden of Families Caring for Patients on Invasive Mechanical Ventilation at Home: An Experimental Study

The prevalence of patients on mechanical ventilation who are being supported at home is increasing. Due to these patients' complex and chronic conditions, the subjective burden on their family caregivers increases after discharge. The aim of this study was to evaluate the effectiveness of a supportive home care program on the caregiver burden of families caring for patients on invasive mechanical ventilation at home. Sixty patients hospitalized in three university-affiliated hospitals in Tehran, Iran between 7/2020 and 8/2021 were randomly assigned to one of two groups: A supportive home care program, and routine hospital education. The supportive home care program included six educational sessions delivered in the hospital before discharge, and home visits and continued education after discharge. Caregiver burden was measured using the Zarit Burden Interview. Results showed that caregiver burden increased significantly (p ≥ .001) after discharge without the supportive home care program intervention. Follow-up by nurses after discharge is essential to reduce the psychological burden of caring for patients on invasive mechanical ventilation at home.

Mothers' experiences and perceptions of their child's weaning process from tube feeding within a multidisciplinary Paediatric Feeding Program

OBJECTIVES

Previous studies have described the negative impact that tube feeding of children with complex chronic diseases has on the caregivers' emotions, relationships and daily life. It is unclear whether these negative experiences persist or change during and after the weaning process. We sought to explore mothers' experiences and perceptions of their child being weaned off tube feeding within a Paediatric Feeding Program (PFP).

METHODS

We conducted a qualitative study using semi-structured interviews with mothers whose children <4 years old had experienced feeding tube weaning within an outpatient, family-centred, telemedicine-supported PFP. The transcripts were analyzed using thematic analysis.

RESULTS

We conducted 9 interviews with mothers of children (n = 10) in the PFP at which point data saturation was achieved. Three main themes emerged: a) the initial emotional toll on mothers stemming from fear of perceived adverse consequences of decreasing tube feeds and uncertainty surrounding efficacy of weaning; b) achievement of weaning via a family-centered approach through gaining trust, close contact, and collaboration with the team; and c) attainment of mothers' expectations of family life through transformed relationships and social activities. A positive evolution of emotions was observed, attributable to the support of the PFP.

CONCLUSIONS

These experiences suggest that our outpatient weaning program had a positive impact on the stress, fear, and relational challenges that mothers reported before and during initial tube weaning. These findings highlight potential areas of discussion with families at multiple stages of the child's tube feeding experience, to help normalize emotions for families and support coping strategies.

Burden Among Caregivers of Pediatric Patients with Neurofibromatosis Type 1 (NF1) and Plexiform Neurofibroma (PN) in the United States: A Cross-Sectional Study

Introduction

Patients with neurofibromatosis type 1 (NF1) may develop plexiform neurofibromas (PNs) that can cause disfigurement, pain, and dysfunction, and may even be life-threatening. Studies have indicated NF1-PN can substantially impact the quality of life (QoL) of pediatric patients. However, research on caregiver burden is scarce.

Methods

Caregivers of pediatric patients ages 2–18 years with NF1-PN in the USA were recruited through the Children’s Tumor Foundation to participate in an online cross-sectional survey (December 2020–January 2021). Caregiver burden was measured using the Zarit Burden Interview (ZBI), and productivity loss from patientcare was measured using the Work Productivity and Activity Impairment questionnaire, adapted for caregiving (WPAI:CG).

Results

Ninety-five caregivers were recruited with a median age of 44.0 years. Most were female (88.4%), white/Caucasian (85.3%), and did not have NF1 or PN (86.3% and 89.5%, respectively). Commonly reported health conditions among caregivers include anxiety (48.4%) and depression (34.7%). On the ZBI (range 0–88; higher = greater burden), mean (SD) scores were 23.0 (13.8) and 12.7% of caregivers reported moderate–severe (scores 41–60) or severe burden (scores 61–88). Fifty-six caregivers were employed and working in the 7 days prior to completing the WPAI:CG. They reported missing an average of 6.9% of their working hours and an average reduction of 17.3% of on-the-job effectiveness, contributing to 22.3% loss in work productivity. Among all 95 caregivers, an average of 17.2% of regular daily activities were impaired.

Conclusions

The burden among caregivers of pediatric patients with NF1-PN is considerable and underscores an unmet need for better disease management.

Characterisation of hospital-produced guidelines regarding management of temporary tube feeding care in general paediatric patients

Background/Aims

There is significant variation in the implementation of temporary tube feeding management in children and a paucity of associated clinical practice guidelines covering all phases of care, from decision making regarding tube insertion through to tube weaning. Development of clinical practice guidelines should consider levels of evidence other than randomised control trials. Examining hospital-produced guidelines used by frontline health staff, for example, could distinguish areas of application of evidence-based recommendations, as well as domains of care in need of increased implementation. This article describes the content of existing hospital-produced guidelines relating to tube feeding care in a general paediatric population.

Methods

Hospital-produced guidelines were sought by mailing 200 health services worldwide and searching Queensland Health's Electronic Publishing Service in Australia and Google. A content analysis was then performed.

Results

The 13 collected hospital-produced guidelines from Australia, the UK and Canada generally comprehensively reported on processes related to the decision-making, tube placement and tube maintenance phases. However, reporting on oral feeding while tube feeding, tube feeding dependency, tube feeding exit planning, and the social and emotional aspects of tube feeding were areas within these phases that had limited coverage. Recommendations for the phase of tube weaning were also infrequently included.

Conclusions

Development of formal clinical practice guidelines covering all tube feeding phases should assist in optimising patient and health service outcomes.

Family reported outcomes, an unmet need in the management of a patient's disease: appraisal of the literature

BACKGROUND

A person's chronic health condition or disability can have a huge impact on the quality of life (QoL) of the whole family, but this important impact is often ignored. This literature review aims to understand the impact of patients' disease on family members across all medical specialities, and appraise existing generic and disease-specific family quality of life (QoL) measures.

METHODS

The databases Medline, EMBASE, CINHAL, ASSIA, PsycINFO and Scopus were searched for original articles in English measuring the impact of health conditions on patients' family members/partner using a valid instrument.

RESULTS

Of 114 articles screened, 86 met the inclusion criteria. They explored the impact of a relative's disease on 14,661 family members, mostly 'parents' or 'mothers', using 50 different instruments across 18 specialities including neurology, oncology and dermatology, in 33 countries including the USA, China and Australia. These studies revealed a huge impact of patients' illness on family members. An appraisal of family QoL instruments identified 48 instruments, 42 disease/speciality specific and six generic measures. Five of the six generics are aimed at carers of children, people with disability or restricted to chronic disease. The only generic instrument that measures the impact of any condition on family members across all specialities is the Family Reported Outcome Measure (FROM-16). Although most instruments demonstrated good reliability and validity, only 11 reported responsiveness and only one reported the minimal clinically important difference.

CONCLUSIONS

Family members' QoL is greatly impacted by a relative's condition. To support family members, there is a need for a generic tool that offers flexibility and brevity for use in clinical settings across all areas of medicine. FROM-16 could be the tool of choice, provided its robustness is demonstrated with further validation of its psychometric properties.

iCCareD: The Development of an Algorithm to Identify Factors Associated With Distress Among Caregivers of Children and Youth Referred for Mental Health Services

Caregiver well-being plays an important role in children's development and a number of factors have been found to impact distress levels among caregivers of children and youth referred for mental health services. Further, caregiver distress impacts youth psychopathology, its acuity as well as related mental health interventions. The purpose of this study was to develop and validate an algorithm for identifying caregivers who are at greatest risk of experiencing caregiver distress. This algorithm was derived from, and will be embedded in, existing comprehensive interRAI child and youth instruments. Ontario data based on the interRAI Child and Youth Mental Health assessment instruments (ChYMH and ChYMH-DD) were analyzed to identify predictors of distress among caregivers of children and youth ages 4-18 years. Starting with proactive aggression, the algorithm uses 40 assessment items to assign one of 30 nodes that are grouped into five levels of risk. The interRAI ChYMH Caregiver Distress (iCCareD) algorithm was validated using longitudinal data from mental health agencies across Ontario and was found to be a good predictor among this sample with a c-statistic of 0.71 for predicting new or ongoing caregiver distress and 65% for both sensitivity and specificity using algorithm values of 3 or greater. This algorithm provides an evidence-based decision-support tool embedded within a comprehensive assessment tool that may be used by clinicians to inform their selection of supports and services for families.

Autism Spectrum Disorder and Genetic Testing: Parents' Attitudes-Data from Turkish Sample

We aimed to examine the opinions of parents' having a child with ASD, on genetic testing, in a Turkish sample. 951 parents' attitudes towards genetic testing were included. 89.1% of the parents did not take a genetic test during pregnancy. 87.6% of the parents agreed to take a genetic test if it could explain the cause of ASDs. 93% agreed to take a genetic test, if it would help to have a better treatment in the future. 63.8% of the participants would approve the storage of their DNA samples for the future studies. 94.8% considered being informed about the purpose of taking DNA material for the early diagnosis and 84.2% considered being suggested genetic tests for early diagnosis as important.

Psychosocial support for families of children with neurodisability who have or are considering a gastrostomy: the G-PATH mixed-methods study

Background

Evidence reviews recommend consistent and structured support for children with neurodisability and their caregivers in care pathways in which professionals recommend a gastrostomy feeding tube. To date, and to our knowledge, no research has shown how these recommendations have been implemented.

Objectives

The objectives were to describe different exemplar models of psychosocial support and provide an estimate of their resources and costs.

Design

This was a mixed-methods study involving (1) a web-based survey, (2) a qualitative, collective case study of psychosocial support provision in four services and (3) an estimate of costs and preference through a willingness-to-pay study.

Setting

Four service configurations in different locations in England and Scotland.

Participants

Participants were staff who responded to a survey (n = 67) and interviewees (staff, n = 58; parents/children, n = 29).

Findings

Psychosocial support was rarely formalised or documented; it was delivered by different members of the multidisciplinary team, rather than by designated staff, and it was often integrated into appointments dominated by clinical care. Parents expressed different needs for support but reported little opportunity to discuss emotional aspects. Psychologists were not routinely involved and, in general, families were underserved by psychosocial services. Professionals constructed families’ need for psychosocial support in terms of their own roles and the management of risk. Mechanisms for integrating and delivering support were identified, including models of care that linked community and tertiary health services and integrated health and education through pooled budgets. Although generally valued by both staff and parents, peer-to-peer parent support was not consistently offered. Barriers included concerns about confidentiality and appropriately matching parents. Parents participated as members of a feeding committee at one site. Three analytical constructs described the provision of psychosocial support: ‘hidden work’, expressing emotional vulnerability and negotiations around risks and values. The cost-of-support study found that there was a mean of 2.25 appointments (n = 8 parents or carers) over the previous 12 months. The cost of health-care professionals’ time spent on providing psychosocial support ranged from £0.00 to £317.37 per child per year, with an average cost of £76.42, at 2017 prices. In the willingness-to-pay study the median rank of enhanced support, involving the opportunity to see a psychologist and parental peers, was significantly higher than that of usual care (n = 96 respondents, both carers and professionals, who completed rating of the service; p < 0.001).

Limitations

It proved difficult to disseminate a national survey, which resulted in a small number of returns, and to cost the provision of psychosocial support, which we designated as ‘hidden work’, owing to the lack of recording in clinical systems. Moreover, estimates were based on small numbers.

Conclusions

Parent interviews and the willingness-to-pay study demonstrated a preference for enhanced psychosocial support. The study suggests that there is a need for services to formally assess families’ needs for psychosocial support to ensure that provision is planned, costed and made explicit in care pathways. Personalised interventions may assist with the targeting of resources and ensuring that there is an appropriate balance in focus on both clinical care and psychosocial support needs in relation to and following treatment.

Future work

More work is needed to develop tools to assess families’ needs for psychosocial support and the effectiveness of training packages to strengthen team competency in providing support.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 38. See the NIHR Journals Library website for further project information.

Building trust and facilitating goals of care conversations: A qualitative study in people with heart failure receiving home hospice care

BACKGROUND

Despite a majority of persons receiving hospice care in their homes, there are gaps in understanding how to facilitate goals of care conversations between persons with heart failure and healthcare providers.

AIM

To identify barriers and facilitators which shape goals of care conversations for persons with heart failure in the context of home hospice.

DESIGN

A qualitative descriptive study design was used with semi-structured interviews.

SETTING/PARTICIPANTS

We conducted qualitative interviews with persons with heart failure, family caregivers, and interprofessional healthcare team members at a large not-for-profit hospice agency in New York City between March 2018 and February 2019.

RESULTS

A total of 39 qualitative interviews were conducted, including with healthcare team members (e.g. nurses, physicians, social workers, spiritual counselors), persons with heart failure, and family caregivers. Three themes emerged from the qualitative interviews regarding facilitators and barriers in goals of care conversations for better decision-making: (1) trust is key to building and maintaining goals of care conversations; (2) lack of understanding and acceptance of hospice inhibits goals of care conversations; and (3) family support and engagement promote goals of care conversations.

CONCLUSION

Findings from this study suggest that interventions designed to improve goals of care conversations in the home hospice setting should focus on promoting understanding and acceptance of hospice, family support and engagement, and building trusting relationships with interprofessional healthcare teams.

Perceived needs of patients and family caregivers regarding home-based enteral nutritional therapy in South Africa: A qualitative study

INTRODUCTION

The need for specialized care, particularly enteral nutritional therapy in community settings is now increasing with implications for both patients and primary care providers. More research is needed to identify the needs of patients and primary caregivers. The study aimed to explore the perceived support needs regarding the provision of home-based enteral nutritional therapy among critically ill adult patients and family caregivers in the KwaZulu-Natal Province of South Africa.

METHODS

A qualitative study of purposely selected adult patients on homebased enteral nutritional therapy and family caregivers was conducted in a district hospital, a community health centre, two primary health care clinics and selected households in the KwaZulu-Natal Province, South Africa. Semi-structured individual interviews were conducted between June and September 2018 and the content analysis approach was used to analyse data.

RESULTS

Two major themes and five subthemes emerged from the results of the interviews. The major themes concerned socioeconomic and psychosocial support needs related to the provision of home-based enteral nutritional therapy. Subthemes included the need for financial assistance, need for enteral nutrition products and supplementary supplies, need for infrastructure for continuity of care, and psychological support needs.

CONCLUSION

Results of this study confirm the need for developing strategies adapted to a South African context and yonder to meet patients' and family caregivers' needs with regard to nutritional services. More research on the identification of needs through monitoring and evaluation of the implementation of nutritional guidelines is needed, particularly in the district hospital and primary health care (PHC) setting.

Predictors of Burden of Care Among Caregivers of Drug-Naive Children and Adolescents With ADHD: A Cross-Sectional Correlative Study From Muscat, Oman

OBJECTIVE

the study assessed the prevalence of burden of care among caregivers of children with ADHD in Oman. A related aim is to explore the predictors of the burden of care, subtypes of ADHD, and socio-demographic factors.

METHOD

Arabic version of the Zarit Burden Interview (ZBI) was administered to 117 caregivers of drug-naive children with ADHD. Sociodemographic background and clinical data were gathered from medical records and from the attending caregivers themselves. The ADHD symptoms were grouped under three categories : hyperactive, inattentive, or mixed.

RESULTS

the prevalence of the burden of care was estimated to be 34%. Income levels and the child's ADHD diagnosis being of "mixed" type have significant impact on the burden of care.

CONCLUSION

the results of this study indicate that the prevalence of the burden of care among the caregivers of ADHD children in Oman is comparable with that in the other regions of the world.

Factors associated with anxiety in family caregivers of children with chronic diseases

BACKGROUND

Currently, information on factors associated with anxiety in family caregivers of children with chronic diseases is unavailable, indicating a significant gap in the literature. Therefore, this study aims to identify the psychosocial and sociodemographic variables associated with anxiety in family caregivers of children with chronic diseases.

METHODS

In 2018, a nonprobability sample of 446 family caregivers was recruited at the National Institute of Health in Mexico City. The participants completed a sociodemographic variable questionnaire, clinical questions, and 18 psychosocial assessment scales, including a scale to assess family caregiver anxiety.

RESULTS

Family caregiver anxiety was correlated with almost all psychosocial variables and one out of three clinical variables but with none of the sociodemographic variables. Furthermore, a multiple linear regression model with five psychosocial variables was established to predict family caregiver anxiety.

CONCLUSIONS

Some psychosocial variables have effects on caregiver anxiety that are relevant for interventions. Clinical interventions should be implemented based on the psychosocial variables associated with family caregiver anxiety.

Parenting a Child with Phenylketonuria (PKU): an Interpretative Phenomenological Analysis (IPA) of the Experience of Parents

Phenylketonuria (PKU) is a rare inherited metabolic disorder which can cause neurological damage if left untreated. PKU is identified through newborn screening in developed countries, and treatment begins immediately to prevent these severe consequences. When a child is diagnosed, parents must assume immediate responsibility for the management of PKU and prevention of neurological damage. Quantitative studies have identified significant psychosocial stressors for parents, but little is known about how the parents experience this process. This study aimed to explore the experiences of parents of children with PKU under the age of two. It is the first study to examine these experiences in this way. Seven parents were interviewed about their experiences, and interpretative phenomenological analysis was used to analyse the data. Three main themes were identified: control, striving for normality and acceptance of PKU as a continuum. Links between the themes and processes underpinning the results were explored with relation to existing literature and theories from a clinical psychology perspective. The role of acceptance of PKU was central to the parent's experiences. Clinical implications and suggestions for further research are discussed.

Paediatric palliative care improves patient outcomes and reduces healthcare costs: evaluation of a home-based program

Background

Around the world, different models of paediatric palliative care have responded to the unique needs of children with life shortening conditions. However, research confirming their utility and impact is still lacking. This study compared patient-related outcomes and healthcare expenditures between those who received home-based paediatric palliative care and standard care. The quality of life and caregiver burden for patients receiving home-based paediatric palliative care were also tracked over the first year of enrolment to evaluate the service’s longitudinal impact.

Method

A structured impact and cost evaluation of Singapore-based HCA Hospice Care’s Star PALS (Paediatric Advance Life Support) programme was conducted over a three-year period, employing both retrospective and prospective designs with two patient groups.

Results

Compared to the control group (n = 67), patients receiving home-based paediatric palliative care (n = 71) spent more time at home than in hospital in the last year of life by 52 days (OR = 52.30, 95% CI: 25.44–79.17) with at least two fewer hospital admissions (OR = 2.46, 95% CI: 0.43–4.48); and were five times more likely to have an advance care plan formulated (OR = 5.51, 95% CI: 1.55–19.67). Medical costs incurred by this group were also considerably lower (by up to 87%). Moreover, both patients’ quality of life (in terms of pain and emotion), and caregiver burden showed improvement within the first year of enrolment into the programme.

Discussion

Our findings suggest that home-based paediatric palliative care brings improved resource utilization and cost-savings for both patients and healthcare providers. More importantly, the lives of patients and their caregivers have improved, with terminally ill children and their caregivers being able to spend more quality time at home at the final stretch of the disease.

Conclusions

The benefits of a community paediatric palliative care programme have been validated. Study findings can become key drivers when engaging service commissioners or even policy makers in appropriate settings.

Predictors of Caregiver Burden among Mothers of Children with Chronic Conditions

Objective: The complex medical regimens of children and adolescents with chronic conditions can have a significant impact on families and households. Caregivers may experience burden, which can lead to negative health consequences and poor quality of life. The objective of this study was to determine child-related predictors and risk factors for caregiver burden among parents of children with chronic conditions. Methods: We distributed an institutional review board (IRB)-approved, online cross-sectional survey to parents of children who attended the Victory Junction therapeutic camp. Parents provided information on child demographics, disease characteristics, and healthcare utilization. Parents also answered the adapted Zarit Burden Interview, which measured caregiver burden. Children completed scales about self-management and self-efficacy. Linear regression analyses determined how children’s disease characteristics, health utilization, and self-management skills were associated with caregiver burden. Results: We enrolled 150 mother-child dyads. The mean age of child participants was 12.23 years (±2.5), with an age range of 6 to 16 years. It was determined that children’s number of medicines and injections (β = 0.161, p = 0.047), a diagnosis of attention-deficit/hyperactivity disorder (ADHD) in addition to the primary medical condition (β = 0.216, p = 0.008), frequent visits with a primary care provider (PCP) (β = 0.209, p = 0.026) and emergency room (ER) visits (β = 0.197, p = 0.038), and lower child self-efficacy (β = −0.241, p = 0.041) were predictors of increased caregiver burden. Conclusions: We identified risk factors for caregiver burden among mothers. Future studies should explore additional child-related characteristics as they relate to caregiver burden, and should determine if interventions for mothers of children with chronic conditions can lead to positive outcomes.

Family Experiences With Feeding Tubes in Neurologic Impairment: A Systematic Review

BACKGROUND AND OBJECTIVE

Gastrostomy tubes (G-tubes) are frequently used to provide enteral nutrition for children who have neurologic impairment. Understanding the impact of G-tubes from the family's perspective will inform decision-making and improve support from health care providers. This study explored the experiences of families after G-tube placement in children with neurologic impairment.

METHODS

We conducted a systematic review of English-language qualitative primary research studies describing family experiences after G-tube placement. Six electronic databases were searched from inception to June 2014. Two authors independently screened and identified relevant studies, evaluated quality of reporting by using the Consolidated Criteria for Reporting Qualitative Research tool, and extracted data. Overarching concepts were developed by using thematic analysis.

RESULTS

From 2674 screened abstracts, 84 texts were reviewed, and 13 studies met the inclusion criteria. G-tubes affect the lives of children, parents, and the family unit in many ways, both positive and negative. Improvements and challenges were described for children's health and happiness, for parental caregiving and stress, and for logistics and bonding within the family. G-tube feeding also changed relationships within the family, between the family and the medical system, and between the family and the outside world. Furthermore, experiences varied, with different families framing similar concepts as positive and negative.

CONCLUSIONS

G-tube placement has diverse effects on daily life for children with neurologic impairment and their families. Clinicians may use the themes identified in this study to guide conversations with families about their values, experiences, and expectations before and after G-tube placement.

Is functional dependence of Duchenne muscular dystrophy patients determinant of the quality of life and burden of their caregivers?

OBJECTIVE

The relationship between functional dependence and quality of life (QOL) in Duchenne muscular dystrophy (DMD) patients and burden and QOL in caregivers is not clear. This study investigated possible relationships between functional dependence/QOL of DMD patients and QOL/burden of caregivers.

METHOD

This study included 35 boys (6-17 years) and respective caregivers (above 21 years). Caregivers answered to World Health Organization Quality of Life and Zarit Burden Interview questionnaires. Patients were assessed with the Motor Function Measure and the Autoquestionnaire Qualité de vie Enfant Imagé. Spearman correlations and linear regressions were run to investigate relationships between the variables.

RESULTS

The occurrence of lower QOL and higher burden among the caregivers of patients with Duchenne muscular dystrophy was evidenced. The functional dependence of patients was not considered a determinant factor. Higher caregivers' burden was related to lower caregivers' QOL and to higher patients' ages.

Factors predicting distress among parents/caregivers of children with neurological disease and home enteral nutrition

BACKGROUND & AIMS

Caregivers of children with chronic diseases included in a home enteral nutrition (HEN) programme are at risk of experiencing a feeling of burden, high level of anxiety and psychological distress. The aims of this study were: first, to examine the prevalence of symptoms of anxiety-depression in caregivers of children with neurological diseases requiring HEN by gastrostomy tube (GT); second, to compare the characteristics of caregivers with high or low risk of exhibiting symptoms of anxiety-depression; and third, to investigate possible associations to child disease severity and nutrition support mode.

METHODS

A cross-sectional observational study was performed in 58 caregivers of children (31 boys, aged 0.3-18 years) with neurological diseases and GT feeding. The characteristics of caregivers with high or low risk of presenting symptoms of anxiety-depression were compared regarding the following variables: socio-demographic characteristics, the primary caregiver's intrapsychic factors, anthropometric parameters of the child, length of HEN, type of nutrients delivered by GT and infusion regime.

RESULTS

All primary caregivers were mothers. Fifty-three per cent of them showed high risk of exhibiting symptoms of anxiety-depression. Mothers with high or low risk of presenting symptoms of anxiety-depression were comparable in age and family socio-economic status. They were also similar in terms of age, anthropometric conditions and length of HEN in their children.No differences were found between the two groups of mothers according to the level of the child's motor function impairment, type of nutrients delivered by GT and infusion regime. Higher levels of psychological distress and perception of burden overload were found in mothers with high risk of exhibiting symptoms of anxiety-depression.

CONCLUSIONS

This study found a high prevalence of symptoms of anxiety-depression, perception of burden overload and psychological distress in caregivers of children with HEN. Thus, greater practical and emotional support is required for these families.

Sleep quality, stress, caregiver burden, and quality of life in maternal caregivers of young children with bronchopulmonary dysplasia

Little is known about the influence of sleep quality, stress, and caregiver burden on quality of life in maternal caregivers of young children with bronchopulmonary dysplasia (BPD). In 61 maternal caregivers (mean age 29.59 years) of young children with BPD (mean age 13.93 months), caregivers reported sleeping a mean of 5.8 hours, and significant correlations were found between sleep quality and depressive symptoms and stress, as well as an inverse correlation with quality of life. Sleep quality was found to be the most significant predictor of quality of life in maternal caregivers.

Paid carers' experiences of caring for mechanically ventilated children at home: implications for services and training

UK survival rates for long-term mechanically ventilated children have increased and paid carers are trained to care for them at home, however there is limited literature on carers' training needs and experience of sharing care. Using a qualitative abductive design, we purposively sampled experienced carers to generate data via diaries, semi-structured interviews, and researcher reflexive notes. Research ethics approval was granted from NHS and University committees. Five analytical themes emerged - Parent as expert; Role definition tensions; Training and Continuing Learning Needs; Mixed Emotions; Support Mechanisms highlighting the challenges of working in family homes for carers and their associated learning needs. Further work on preparing carers to share feelings with parents, using burnout prevention techniques, and building confidence is suggested. Carers highlight the lack of clinical supervision during their night-working hours. One solution may be to provide access to registered nurse support when working out-of-office hours.

The impact of bronchopulmonary dysplasia on caregiver health related quality of life during the first 2 years of life

OBJECTIVES

Preterm children with bronchopulmonary dysplasia (BPD) frequently require complex home medical regimens and re-hospitalization during the first 2 years of life. The burden of caring for these medically complex children may negatively affect caregiver health related quality of life (HRQoL). The objectives of this study were to measure caregiver HRQoL of children with BPD and to identify factors that impact caregiver HRQoL during the first 2 years of life.

METHODS

Children (n = 186) were recruited from the Johns Hopkins BPD Outpatient Clinic between January 2008 and July 2011. Caregiver HRQoL was measured using The PedsQL(TM) Family Impact Module. Respiratory symptoms and morbidities were assessed using questionnaires.

RESULTS

Among caregivers of BPD children, significant improvement in physical, worry, and daily domains improved longitudinally as children aged. An association was found between lower total HRQoL scores and caregivers of BPD children who reported more respiratory symptoms and acute care usage. No difference in total HRQoL scores was found between caregivers of BPD children requiring respiratory/enteral support and caregivers of children who did not. Caregiver income and educational level did not predict total HRQoL score, but Non-White race and public insurance was associated with a higher total HRQoL score at the first outpatient visit.

CONCLUSION

An association was found between lower HRQoL scores and caregivers of BPD children with frequent respiratory symptoms and acute care usage. Screening for low HRQoL in caregivers of BPD children with frequent respiratory illnesses should be considered to identify those who may benefit from additional support and intervention.

Psychometric properties of the structured Satisfaction Questionnaire with Gastrostomy Feeding (SAGA-8) for caregivers of children with gastrostomy tube nutritional support

BACKGROUND

To analyse the psychometric properties of the structured Satisfaction Questionnaire with Gastrostomy Feeding (SAGA-8) in parents/caregivers of children with home enteral nutrition (HEN) by gastrostomy tube (GT).

METHODS

Eighty-six caregivers (mothers) of paediatric patients with HEN by GT were recruited. Patients suffered from neurological disease (61.6%) and other chronic diseases. The SAGA-8 scale, a structured questionnaire to explore satisfaction with HEN by GT, and the Caregiver Burden Inventory (Zarit) were completed. The discriminating power of each of the SAGA-8 items, internal consistency and external validity were evaluated. An exploratory factor analysis and Kaiser-Meyer-Olkin (KMO) was performed as well.

RESULTS

Eighty-four percent of the families expressed high satisfaction with GT feeding. All eight items of SAGA-8 gave additional information. The exploratory factor analysis revealed that a significant part of the items' variability could be explained by two independent factors: Factor 1 (direct benefit), which compiled the variables related to the perception of children's overall improvement by GT feeding; Factor 2 (indirect benefit), which grouped the variables related to a decrease in respiratory infections, feeding time and institutional support. Results from KMO (0.628) indicated the high adequacy of the items assessed in the factorial analysis. Moreover, the questionnaire presented high internal consistency (0.76), and the external validation analysis confirmed the correlation between SAGA-8 and Zarit, thereby emphasising the approptiate use of the SAGA-8 to detect carers' satisfaction.

CONCLUSIONS

The SAGA-8 questionnaire has a high discriminatory power to assess the degree of satisfaction experienced by parents/caregivers of children with HEN by GT and, subsequently, the patients' wellbeing.

Linking caregiver strain to diabetes illness management and health outcomes in a sample of adolescents in chronically poor metabolic control

OBJECTIVE

This study examined a multivariate model of the relationship between caregiver strain and adolescent diabetes illness outcomes in a sample of caregivers of adolescents in chronically poor metabolic control (hemoglobin A1c ≥8.0% at enrollment and for previous 12 mo). Caregiver mental health symptoms were hypothesized to mediate the relationship between caregiver strain and adolescent illness management behavior and metabolic control. Caregivers' perceptions of social support and their level of responsibility for diabetes care tasks were hypothesized to be directly related to caregiver strain and indirectly to caregiver mental health symptoms.

METHODS

One hundred forty-six caregiver-adolescent dyads completed baseline measures of caregiver strain, responsibility for diabetes care, social support, mental health symptoms, and illness management behavior. Adolescent metabolic control was also assessed.

RESULTS

Findings from structural equation modeling suggested that caregiver strain was directly and positively associated with caregiver mental health symptoms which mediated the relationship to adolescent diabetes management behavior and metabolic control. Caregivers' responsibility for diabetes care tasks was directly related to caregiver strain and indirectly to caregiver mental health, but caregivers' perception of social support was not.

CONCLUSIONS

These findings suggest that caregiver strain is an important dimension of the caregiving context of diabetes. Clinicians and researchers should consider how caregiving strain, responsibility for illness management, and mental health symptoms might be impacting children's diabetes care behavior and diabetes health when working with and designing interventions for adolescents with diabetes.

Understanding the social networks of parents of children with sickle cell disease

Although there is substantial literature documenting the challenges of pediatric sickle cell disease (SCD) for children and their parents, there is limited research identifying how parents prioritize their needs and use their social networks to manage information regarding their child's SCD in terms of physical and mental health. We examined parents' perceived needs regarding child health issues as they relate to SCD; who and what sources of information are utilized by parents regarding SCD; the frequency with which they consult these resources; and the level at which they trust them. Parents in this study reported that mothers, physicians, the Internet, and books were key sources of support, guidance, and counsel regarding the health needs of children with SCD. These three sources were rated high in importance, trust, frequency of contact, and perceived supportiveness toward mental and physical health needs.