Prevalence of traumatic psychological stress reactions in children and parents following paediatric surgery: a systematic review and meta-analysis

MEDIC: Development and validation of a new instrument to assess emotional reactivity to medical stimuli in a representative community sample of adults

To support investigation of the etiology and psychophysiology of medical traumatic stress, we developed a standardized set of emotionally-salient medical images, called the 'MEDical Image Collection' (MEDIC), for use in neuroimaging or psychological research. This study aimed to establish internal consistency, test re-test reliability, and congruent validity of the image set. A representative sample of 300 adults in the United States were recruited via research recruitment platform, Prolific. Participants rated 124 images depicting medical stimuli on one of two dimensions: emotional arousal (i.e., how strongly an evoked emotion is felt) or affective valence (i.e., how positive or negative the evoked emotion is). Sociodemographic and health-related characteristics, including experiences during the COVID-19 pandemic, were also assessed. To assess test re-test reliability, a subset (n = 200) rated the images on the same dimension a second time, 3 months later. The MEDIC image set was found to: (a) elicit a range of emotional arousal and valence ratings, (b) have excellent inter-rater reliability, (c) moderate test-retest reliability, and (d) good face validity. Results indicate the new MEDIC 124-image set is a reliable and valid instrument, enabling researchers to provide context-specific and emotionally-salient stimuli to individuals when studying affective responses in relation to health and medicine.

Coping With COVID-19: Perspectives of Caregivers of Children and Young People With Chronic Kidney Disease

BACKGROUND

Caregivers of children and young people with chronic kidney disease (CKD) face challenging circumstances on a daily basis; however, the difficulties they experienced during the COVID-19 pandemic, as well as potentially positive experiences, are not yet fully understood. The aim of this study was to explore the pandemic-related experiences of these caregivers.

METHODS

Twelve caregivers were recruited from a hospital-based pediatric renal program; eight families were posttransplant. Caregivers participated in virtual semistructured interviews conducted between March 2021 and November 2022. They provided responses to open-ended questions concerning how the pandemic affected their child with CKD, their family, and themselves. Interviews were transcribed and coded using thematic analysis.

RESULTS

Four main themes were identified: (1) Family Life, which included disruptions in routine, reduced social supports, and changes in the quality of family relationships; (2) Mental Health and Coping, which included increased anxiety and positive coping strategies; (3) Work and School Life, which included changes to work and school; and (4) Health and Health Care Systems, which included virtual health care and public health restrictions.

CONCLUSIONS

Despite facing profound challenges, caregivers identified both positive and negative aspects of their pandemic experiences. Their coping strategies highlighted individual and family resilience characteristics. Implications for health care providers, including future pandemic planning, support for the transition from in-person to virtual care, and strategies to better address barriers to resources for families of children with chronic kidney disease were discussed.

Perioperative Staff's Experiences of Premedication for Children

PURPOSE

Providing perioperative care for children who express anxiety or react with negative anxiety-associated consequences can be a challenge. The use of premedication is established as an important intervention for young children before surgery, yet research into care providers' experiences of premedication is limited. The aim of this study was to explore perioperative staff's experiences of premedication for preschool-age children.

DESIGN

A descriptive inductive qualitative study was performed based on focus group discussions.

METHODS

A purposive sample of a team from the operating department with experience in anesthetizing and caring for children in the perioperative period was interviewed in small focus groups: five preoperative and postoperative care nurses, five nurse anesthetists, and five anesthesiologists. The transcribed text was categorized using qualitative content analysis.

FINDINGS

The content analysis revealed three themes: a matter of time, do not wake the sleeping bear, and on responsive tiptoes.

CONCLUSIONS

Care providers must adapt their work to the child's emotional state of mind and needs, allowing time for the child to trust and accept the premedication and for the premedication to reach its peak effect. Premedication provides light sleep preoperatively, which requires careful treatment of the child to avoid emotional reactions, and the postoperative path is most peaceful when the premedication supports a long duration of sedation. Our findings highlight the need for safety precautions and a permissive and flexible organization with the goal of achieving a smooth and safe journey for the child in the perioperative path.

Impact of the Age at Distal Hypospadias Surgery on Behavioral Problems, Somatic Symptoms and Irritability Levels in Children

BACKGROUND

To assess the effect of age at hypospadias surgery on emotional and behavioural problems, somatic symptoms, irritability, and penile perception.

METHODS

We retrospectively identified the patients who underwent single distal hypospadias surgery and age-matched healthy controls were included. There were two further subgroups according to the age at the time of hypospadias repair (<2 vs. >2 years). The Strengths and Difficulties Questionnaire (SDQ), Revised Children's Anxiety and Depression Scale (RCADS), Affective Reactivity Index (ARI), Level 2 Somatic Symptom Scale, and Penile Perception Score (PPS) scale were used. The groups were compared using multivariate variance analysis (MANOVA).

RESULTS

Both groups consisted of 70 patients (mean age 14.0 ± 0.2 years, for both), while there were 34 patients in the hypospadias groups who underwent surgery at <2 years of age. Depressive, panic, separation anxiety, social phobia, and somatic complaint symptom scores of the hypospadias group were lower than those of the control group. Obsessive-compulsive symptom levels were significantly higher in patients who underwent hypospadias surgery at >2 vs. <2 years of age. Additionally, PPSs rated by the surgeon were significantly higher in the former. A multivariate linear regression model indicated that panic disorder symptom scores predicted child PPS in the hypospadias group. Limitations include retrospective design.

CONCLUSIONS

Single hypospadias surgery seems not to have a negative impact on emotional and behavioural status. Children who underwent distal hypospadias surgery after 2 years of age had higher levels of obsessive-compulsive symptoms. Following emotional status may help the early diagnosis of future psychopathologies.

TYPE OF STUDY

Retrospective comparative study.

LEVEL OF EVIDENCE

III.

Pediatric urothelial cancer: a cross-sectional descriptive analysis of the National Cancer Database

Background

Urothelial cancer is a rare pediatric malignancy; previous analyses suggest lower rates of recurrence and death as compared to adults. We analyzed pediatric bladder cancer information in a national database, hypothesizing that survival would be better in children than adults.

Methods

We analyzed the 2004-2016 National Cancer Database (NCDB) for children and adolescents (0-18 years) with urothelial bladder cancer. Rhabdomyosarcoma patients were excluded. Assessed variables included TNM staging, pathology, tumor size, surgical procedures, and post-operative re-admissions. Overall survival was defined as months since diagnosis as of last follow-up.

Results

Of 140 urothelial tumors reported to NCDB between 2004-2016, 75.7% (N=106) were stage 0 at diagnosis, 6.4% (N=9) were stage I, 2.9% (N=4) were stage II and 3.6% (N=5) were stage IV, while 11.4% cases (N=16) were unknown. From available mortality data (121 patients), no patients died after definitive surgical resection. Only 1 mortality was reported at 90 days, although cause of death was reportedly unknown. Three (2.5%) patients were lost to follow-up, and most (96.7%) were alive at 90 days.

Conclusions

Short-term survival outcomes among children and adolescents with urothelial bladder tumors captured in NCDB are reassuring. Future investigations focused on long-term outcomes and appropriate surveillance in this rare patient cohort are imperative to better guide management options.

Prevalence of Mental Health Disorders in Individuals With Gastrointestinal Congenital Surgical Anomalies: A Systematic Review and Meta-analysis

PURPOSE

Studies examining functional outcomes and health-related quality of life for patients with congenital surgical anomalies (CSA) are increasingly common. However, the prevalence of mental health disorders in this population has not been determined. The purpose of this review is to summarize the reported prevalence of mental health disorders in children born with gastrointestinal CSA.

METHODS

A systematic review of the literature was conducted on Medline (OVID), EMBASE (OVID), CINAHL (EbscoHost), and Scopus to identify studies reporting mental health diagnoses in children with a gastrointestinal CSA. A meta-analysis of the prevalence of anxiety disorders and depressive disorders was completed.

RESULTS

Of 2546 manuscripts, seven met the inclusion criteria. All included manuscripts looked at patients with anorectal malformation (ARM) and/or Hirschsprung disease (HD). No studies assessed other gastrointestinal CSAs. A total of 183 psychiatric diagnoses were reported in 1167 patients. A pooled analysis of ARM patients revealed a 14.0% prevalence of anxiety disorders (N = 208; CI95 = 4.4-23.4%) and an 18.75% prevalence of depressive disorders (N = 48; CI95 = 7.7-29.8%). A pooled analysis of HD patients revealed a 15.8% prevalence of anxiety disorders (N = 19; CI95 = 0.6-32.2%) and a 4.75% prevalence of depressive disorders (N = 758; CI95 = 3.23-6.26%).

CONCLUSIONS

There is a paucity of evidence on mental health outcomes of individuals born with gastrointestinal CSA. However, the available evidence suggested a high prevalence of mental health diagnoses in individuals born with ARM or HD with 1 in 7 having an anxiety disorder. Additionally, 1 in 5 ARM patients and 1 in 20 HD patients were diagnosed with a depressive disorder.

TYPE OF STUDY

Systematic review and meta-analysis.

LEVEL OF EVIDENCE

IV.

Nature-based mindfulness programs using virtual reality to reduce pediatric perioperative anxiety: a narrative review

Over 75% of pediatric surgery patients experience preoperative anxiety, which can lead to complicated recoveries. Current interventions are less effective for children over 12 years old. New interventions, like mindfulness-based ones (MBIs), are needed to address this issue. MBIs work well for reducing mental health symptoms in youth, but they can be challenging for beginners. Virtual reality (VR) nature settings can help bridge this gap, providing an engaging 3-D practice environment that minimizes distractions and enhances presence. However, no study has investigated the combined effects of mindfulness training in natural VR settings for pediatric surgery patients, creating a significant gap for a novel intervention. This paper aims to fill that gap by presenting a narrative review exploring the potential of a nature-based mindfulness program using VR to reduce pediatric preoperative anxiety. It begins by addressing the risks of anxiety in children undergoing surgery, emphasizing its impact on physical recovery, and supporting the use of VR for anxiety reduction in hospitals. The review then delves into VR's role in nature and mindfulness, discussing theoretical concepts, clinical applications, and effectiveness. It also examines how the combination of mindfulness, nature, and VR can create an effective intervention, supported by relevant literature. Finally, it synthesizes the existing literature's limitations, findings, gaps, and contradictions, concluding with research and clinical implications.

A systematic review of differences in outcome between one and two stage palate repair in cleft lip and palate

The aim of this systematic review was to determine whether one-stage palatoplasty for children born with cleft lip and palate shows overall advantages in outcome compared with two-stage palatoplasty. The included studies were controlled studies of syndromic and non-syndromic children born with unilateral cleft lip and palate, bilateral cleft lip and palate, or isolated cleft palate. The interventions studied were one-stage palatoplasty and two-stage palatoplasty starting with the soft palate. The outcomes were facial growth, speech, hearing, presence of fistulae, other complications related to surgery, health-related quality of life, and health economics. In total, 14 original studies were included. Results were dichotomized into showing advantage for one- or two-stage palatoplasty for the respective outcome and compared with the results from six included systematic reviews. No overall advantage for either surgical strategy was found for any of the outcome measures. The certainty of evidence was highest for the presence of fistulae, followed by facial growth and speech. For several outcomes, the quality of the existing evidence was too low to allow for any conclusions to be drawn. Neither one- nor two-stage palatoplasty showed significant advantages in clinical outcomes compared with the other. Other aspects such as ethics, economics, or surgeon's preference might hence be of more importance. Homogenous choices of outcome measures and defined minimal clinically important differences would facilitate further research.

Addressing health equity in pediatric surgical care in the United States- Progress and challenges

There are notable inequities in health outcomes for children based on their social determinants of health (SDOH), including where they are born and live, their primary language, their race and ethnicity, socioeconomic status, and more. These health inequities are not restricted to resource limited settings; here we highlight three broad topics that are relevant to pediatric surgeons in the United States (US): access to care and disparities, and examples of inequities in firearm-related injuries and appendicitis. Most of our patients will at some point require operative interventions, yet there can be significant challenges in accessing this care and navigating our health systems, particularly around complex perioperative care. There are significant opportunities to improve equitable care by helping patients navigate our health systems and connecting them with additional resources, including screening for primary care services. Firearm-related injuries are now the leading cause of death in children in the US, with significant associated morbidity for non-fatal injuries. There are notable inequities in the risk of injury and types of injuries experienced by children based on their SDOH. Appendicitis is one of the most common pathologies managed by pediatric surgeons, with similar inequities in the rates of perforated appendicitis based on a child's SDOH. For both issues, addressing the inequities our patients experience requires moving upstream and working towards prevention. Key opportunities include better research and data to understand the drivers for observed inequities, multidisciplinary collaboration, community engagement, and public health advocacy among others. As a profession, we have a responsibility to work to address the health inequities our patients experience.

Prevalence and associated factors of post-traumatic stress disorder in parents whose infants have single ventricle heart disease

INTRODUCTION

Post-traumatic stress disorder occurs in parents of infants with CHD, contributing to psychological distress with detrimental effects on family functioning and well-being. We sought to determine the prevalence and factors associated with post-traumatic stress disorder symptoms in parents whose infants underwent staged palliation for single ventricle heart disease.

MATERIALS AND METHODS

A large longitudinal multi-centre cohort study evaluated 215 mothers and fathers for symptoms of post-traumatic stress disorder at three timepoints, including post-Norwood, post-Stage II, and a final study timepoint when the child reached approximately 16 months of age, using the self-report questionnaire Impact of Event Scale - Revised.

RESULTS

The prevalence of probable post-traumatic stress disorder post-Norwood surgery was 50% of mothers and 39% of fathers, decreasing to 27% of mothers and 24% of fathers by final follow-up. Intrusive symptoms such as flashbacks and nightmares and hyperarousal symptoms such as poor concentration, irritability, and sudden physical symptoms of racing heart and difficulty breathing were particularly elevated in parents. Higher levels of anxiety, reduced coping, and decreased satisfaction with parenting were significantly associated with symptoms of post-traumatic stress disorder in parents. Demographic and clinical variables such as parent education, pre-natal diagnosis, medical complications, and length of hospital stay(s) were not significantly associated with symptoms of post-traumatic stress disorder.

DISCUSSION

Parents whose infants underwent staged palliation for single ventricle heart disease often reported symptoms of post-traumatic stress disorder. Symptoms persisted over time and routine screening might help identify parents at-risk and prompt referral to appropriate supports.

Exploring the Prevalence of PTSD in Hand Trauma: A Comprehensive Study

Hand trauma is a common and debilitating condition that can have significant physical, functional, and psychological effects on individuals. This study used a case-control design to investigate the frequency and factors associated with symptoms of post-traumatic stress disorder (PTSD) in a sample of individuals with complex hand and forearm injuries. Our hypothesis suggests that demographic data, among other factors, influences the intensity of PTSD symptoms measured by the PCL-5 scale three months post-surgery. This study included 166 individuals, 142 males and 24 females, with an average age of 42.14 years (SD = 12.71). Our study found significant associations between symptoms of PTSD and various demographic and clinical factors. PTSD symptoms were observed in females, individuals from specific regions, and certain socio-professional groups. Furthermore, educational attainment and personal background have been identified as significant factors in the development of PTSD. The role of trauma type was crucial, amputees and fractures were more prone to developing PTSD. A strong link was found between increased symptoms of PTSD and negative postoperative outcomes, including amputation of necessity and the need for additional surgery. The absence of family support exacerbates the psychological distress of trauma survivors. The findings highlight the intricate nature of PTSD development and underscore the significance of a comprehensive postoperative treatment strategy encompassing psychological assessment and support.

Perioperative stress and anxiety in parents of children operated on for congenital heart disease

INTRODUCTION

Levels of stress and anxiety suffered by parents of children with congenital heart disease (PCUCS) during their children's admission for cardiac surgery may be higher than those suffered by other parents who go through the same experience.

OBJECTIVE

General objective of this study was to measure the stress and anxiety suffered by PCUCS and parents of children undergoing renal surgery (PCURS) in relation to the intervention of their children. The specific objective of the quantitative study was to compare global stress and anxiety according to sex, time of the perioperative period, and cohort. The general objective of the qualitative section is to explore the experience that PCUCS and PCURS have during their hospital stay and to identify the specific factors that influence the genesis of stress and anxiety.

METHOD

A cohort study was carried out in which PCURS and PCUCS were included. The quantitative part was performed by comparing the scores of three questionnaires that measure stress levels (PSS-14), state anxiety (STAIE) and trait anxiety (STAIR) throughout three perioperative moments. At the same time, a qualitative study was carried out with semi-structured interviews and collection of diaries on which a descriptive phenomenological analysis was carried out, according to Munhall. The analysis of the text was carried out according to Colaizzi.

RESULTS

Stress and anxiety levels were significantly higher in PCUCS compared to PCURS. Mothers in the cardiac cohort were those with the highest scores on all scales. In the qualitative study, four themes emerged: "stress and anxiety from the moment of diagnosis", "surgical intervention as a critical moment", "harshness of the postoperative period in the Intensive Care Unit" and "joy and gratitude versus dependence and fear for the future".

CONCLUSIONS

PCUCS suffer higher levels of stress and anxiety than PCURS, being the mothers of the cardiac cohort those who suffer these disorders with greater intensity. This study can constitute a starting point to develop strategies that cover these parental needs.

Empowering Parents of Pediatric Surgical Oncology Patients Through Collaborative Engagement with Surgeons

BACKGROUND

Ninety percent of parents of pediatric oncology patients report distressing, emotionally burdensome healthcare interactions. Assuring supportive, informative treatment discussions may limit parental distress. Here, we interview parents of pediatric surgical oncology patients to better understand parental preferences for surgical counseling.

METHODS

We interviewed 10 parents of children who underwent solid tumor resection at a university-based, tertiary children's hospital regarding their preferences for surgical discussions. Thematic content analysis of interview transcripts was performed using deductive and inductive methods.

RESULTS

Three main themes were identified: (1) the emotional burden of a pediatric cancer diagnosis; (2) complexities of treatment discussions; (3) collaborative engagement between parents and surgeons. Within the collaborative engagement theme, there were four sub-themes: (1) variable informational needs; (2) parents as advocates; (3) parents as gatekeepers of information delivery to their children, family, friends, and community; (4) parental receptivity to structured guidance to support treatment discussions. Two cross-cutting themes were identified: (1) perception that no treatment decision needed to be made regarding surgery and (2) reliance on diverse support resources.

CONCLUSIONS

Parents feel discussions with surgeons promote informed involvement in their child's care, but they recognize that there may be few decisions to make regarding surgery. Even when parents perceive that there are there are no decisions to make, they prioritize asking questions to advocate for their children. The emotional burden of a cancer diagnosis often prevents parents from knowing what questions to ask. Merging this data with our prior pediatric surgeon interviews will facilitate development of a novel decision support tool that can empower parents to ask meaningful questions.

LEVEL OF EVIDENCE

III.

Psychiatric Disorder in a Patient With Beckwith-Wiedemann Syndrome: A Case Report

Patients with Beckwith-Wiedemann syndrome (BWS) often suffer from pheochromocytoma and hypoglycaemia and are vulnerable to disorders associated with the hypothalamic-pituitary-adrenal axis (HPA), such as major depressive disorder, generalised anxiety disorder, borderline personality disorder, etc. Features of pheochromocytoma even overlap with features of anxiety disorders, panic disorders, etc. These patients undergo multiple major surgeries under general anaesthesia at a very young age due to recurrent tumours that can affect their behavioural and emotional development. Depriving them of much-needed medical and emotional support negatively impacts their physical and psychological well-being. In this case report, we present the case of a 23-year-old woman with Beckwith-Wiedemann syndrome (BWS) who underwent major surgeries such as partial pancreatectomy, adrenalectomy, osteotomy, and paraganglioma resection at an early age. She was neglected by her parents and spent her childhood in an abusive environment. All these factors could have increased her vulnerability to mental health problems. She was diagnosed with borderline personality disorder, major depressive disorder, unspecified trauma, stressor-related disorders, cannabis use disorder, and cannabis-induced psychotic symptoms. This report emphasises the role of medical comorbidity in a patient presenting with borderline personality disorder.

European study showed that children with congenital anomalies often underwent multiple surgical procedures at different ages across Europe

AIM

Children with congenital anomalies often require surgery but data on the burden of surgery for these children are limited.

METHODS

A population-based record-linkage study in Finland, Wales and regions of Denmark, England, Italy and Spain. A total of 91 504 children with congenital anomalies born in 1995-2014 were followed to their tenth birthday or the end of 2015. Electronic linkage to hospital databases provided data on inpatient surgical procedures and meta-analyses of surgical procedures were performed by age groups.

RESULTS

The percentage of children having surgery in the first year was 38% with some differences across regions and 14% also underwent surgery at age 1-4 years. Regional differences in age at the time of their first surgical procedure were observed for children with cleft palate, hydronephrosis, hypospadias, clubfoot and craniosynostosis. The children had a median of 2.0 (95% CI 1.98, 2.02) surgical procedures before age 5 years with children with oesophageal atresia having the highest median number of procedures (4.5; 95% CI 3.3, 5.8).

CONCLUSION

A third of children with congenital anomalies required surgery during infancy and often more than one procedure was needed before age 5 years. There was no European consensus on the preferred age for surgery for some anomalies.

A Cross Sectional Study to Identify Traumatic Stress, Medical Phobia and Non-Adherence to Medical Care among Very Young Pediatric Patients

After a traumatic medical event, such as surgery or hospitalization, a child may develop a phobia of medical care, sometimes preventing future medical adherence and impairing recovery. This study examined the correlation of Pediatric Medical Traumatic Stress (PMTS) on the development of Medical Phobia (MP) and subsequent treatment adherence. We enrolled 152 parents of children aged 1-6 hospitalized in a surgical ward. During hospitalization, parents completed questionnaires that identified post-traumatic stress symptoms. Four months post hospitalization, parents completed questionnaires on post-traumatic stress, medical phobia, psychosocial variables and medical adherence. We found a positive correlation between PMTS and MP and low adherence to medical treatment. In addition, MP mediated the relationship between PMTS severity and adherence, indicating that PMTS severity is associated with stronger medical phobia, and lower pediatric adherence to medical treatment. Our findings suggest that medical phobia serves as an essential component of PMTS. It is important to add medical phobia to medical stress syndrome definition. In addition, as MP and PMTS are involved in the rehabilitation and recovery process and subsequent success, it is an important aspect of treatment adherence.