Physical Activity and Sedentary Behavior in Children With Congenital Heart Disease

Early hybrid cardiac rehabilitation in congenital heart disease: the QUALIREHAB trial

BACKGROUND AND AIMS

Cardiopulmonary fitness in congenital heart disease (CHD) decreases faster than in the general population resulting in impaired health-related quality of life (HRQoL). As the standard of care seems insufficient to encourage and maintain fitness, an early hybrid cardiac rehabilitation programme could improve HRQoL in CHD.

METHODS

The QUALIREHAB multicentre, randomized, controlled trial evaluated and implemented a 12-week centre- and home-based hybrid cardiac rehabilitation programme, including multidisciplinary care and physical activity sessions. Adolescent and young adult CHD patients with impaired cardiopulmonary fitness were randomly assigned to either the intervention (i.e. cardiac rehabilitation) or the standard of care. The primary outcome was the change in HRQoL from baseline to 12-month follow-up in an intention-to-treat analysis. The secondary outcomes were the change in cardiovascular parameters, cardiopulmonary fitness, and mental health.

RESULTS

The expected number of 142 patients was enroled in the study (mean age 17.4 ± 3.4 years, 52% female). Patients assigned to the intervention had a significant positive change in HRQoL total score [mean difference 3.8; 95% confidence interval (CI) 0.2; 7.3; P = .038; effect size 0.34], body mass index [mean difference -0.7 kg/m2 (95% CI -1.3; -0.1); P = .022; effect size 0.41], level of physical activity [mean difference 2.5 (95% CI 0.1; 5); P = .044; effect size 0.39], and disease knowledge [mean difference 2.7 (95% CI 0.8; 4.6); P = .007; effect size 0.51]. The per-protocol analysis confirmed these results with a higher magnitude of differences. Acceptability, safety, and short-time effect of the intervention were good to excellent.

CONCLUSIONS

This early hybrid cardiac rehabilitation programme improved HRQoL, body mass index, physical activity, and disease knowledge, in youth with CHD, opening up the possibility for the QUALIREHAB programme to be rolled out to the adult population of CHD and non-congenital cardiac disease.

Exploring the Promise of Telemedicine Exercise Interventions in Children and Adolescents With Congenital Heart Disease

Youth with congenital heart disease (CHD) have reduced exercise capacity via various physical and psychosocial mechanisms. In addition to limited physiologic exercise capacity, these patients experience lower levels of physical activity, physical activity self-efficacy, health-related quality of life, and endothelial function. The study of exercise interventions and cardiac rehabilitation programs in pediatric CHD populations remains limited, particularly home-based interventions that incorporate real-time physiologic monitoring. Home-based interventions provide improved access and convenience to patients. This is principally important for patients from geographically disperse regions who receive their care at centralized subspecialty centres, as is the case for Canadian pediatric cardiac care. These programs, however, have traditionally not permitted the supervision of safety, technique, and adherence that are afforded by hospital/facility-based programs. As such, telemedicine is an important evolving area that combines the benefits of traditional home and facility-based cardiac rehabilitation. An additional key area lacking study surrounds the types of exercise interventions in youth with CHD. To date, interventions have often centred around moderate-intensity continuous exercise. High-intensity interval training might offer superior cardiorespiratory advantages but remains understudied in the CHD population. In this review, we highlight the existing evidence basis for exercise interventions in youth with CHD, explore the promise of incorporating telemedicine home-based solutions, and highlight key knowledge gaps. To address identified knowledge gaps, we are undertaking a 12-week randomized crossover trial of a home-based telemedicine high-intensity interval training intervention in youth with repaired moderate-severe CHD using a video game-linked cycle ergometer (known as the MedBIKE; https://spaces.facsci.ualberta.ca/ahci/projects/medical-projects/remote-rehab-bike-projects).

Physical activity in relation to motor performance, exercise capacity, sports participation, parental perceptions, and overprotection in school aged children with a critical congenital heart defect

OBJECTIVE

To depict objectively measured moderate-to-vigorous physical activity (MVPA), motor performance (MP), cardiorespiratory fitness (CRF), organized sports participation, parental perceptions of vulnerability and parenting style in children with a Critical Congenital Heart Disease (CCHD), and to explore whether these factors are associated with MVPA.

STUDY DESIGN

A prospective observational cohort study in 62 7-10 years old children with a CCHD.

RESULTS

On average, children with CCHD spent 64 min on MVPA per day (accelerometry), 61 % met the international WHO physical activity guideline. Only 12 % had >60 min of MVPA daily. Eighteen percent had a motor delay (movement-assessment-battery-for children-II) and 38 % showed a below average CRF (cardiopulmonary exercise test using the Godfrey ramp protocol). Seventy-seven percent participated in organized sports activities at least once a week. Twenty-one percent of the parents are classified as overprotective (parent protection scale) and 7.3 % consider their child as being vulnerable (child vulnerability scale). A significant positive association was found between MVPA and MP (rs = 0.359), CRF(V̇O2peak/ml/kg: rs = 0.472 and Wpeak/kg: rs = 0.396) and sports participation (rs = 0.286). Children who were perceived as vulnerable by their parents showed a significantly lower MVPA (rs = -0.302). No significant associations were found between mean MVPA and parental overprotection.

CONCLUSION

Even though the majority of school aged children with a CCHD is sufficiently active, counseling parents regarding the importance of sufficient MVPA and sports participation, especially in parents who consider their child being vulnerable, could be useful. Since motor delays can be detected at an early age, motor development could be an important target to improve exercise capacity and sports participation to prevent inactivity in children with a CCHD.

Facilitators and barriers of physical activity participation in children with a single ventricle physiology: a mixed-methods study

BACKGROUND

The present study focuses on assessing the physical activity level of children with Fontan circulation for Hypoplastic Left Heart Syndrome and identifying potential barriers and facilitators toward their participation in physical activity.

PATIENTS AND METHODS

Seven children aged 5-16 years (mean (SD) 8.8 (3.7) years) with a Fontan procedure for hypoplastic left heart syndrome, their parents (n = 7), and siblings (n = 1) were recruited. Data were collected using a mixed-methods approach: (i) children wore an activity monitor for 7 days to record physical activity, with sedentary time and level of activity calculated from accelerometer data; (ii) children completed a bespoke questionnaire recording limitations in physical activity; (iii) parents completed a semi-structured interview discussing perceptions about their child's physical activity participation. Qualitative data were analysed using thematic analysis.

RESULTS

Activity monitors data recorded highly active children with a mean (SD) of 153(36) minutes/day spent in moderate-to-vigorous physical activity. Time spent in sedentary behaviour was also high (57.5% of total accelerometer wearing-time). Four key themes relating to parental perceptions of physical activity were identified: (i) A new lease of life -post-Fontan; (ii) Setting limits - managing limitations; (iii) The wider world - how others set limits; and (iv) "I fear the future" - parental concerns.

CONCLUSION

Following completion of the Fontan circulation, children engaged in higher levels of physical activity in comparison to the national average. However, more than half their time was spent in sedentary behaviour. Fears and anxiety from parents and teachers may act as a barrier toward physical activity participation.

Activities of Daily Living, Physical Activity, Physical Fitness and Quality of Life in Children with Congenital Heart Disease: A Case-Control Study

BACKGROUND

Despite reports of reduced physical fitness in children with congenital heart disease (CHD), no specific performance evaluations for activities of daily living have been conducted.

OBJECTIVES

The aim was to compare the activities of daily living, quality of life, posture, physical fitness and physical activity levels of children with CHD with healthy controls (HC).

METHODS

The study included 30 children aged 6-14 diagnosed with moderate or severe CHD and 30 age-sex-matched HC. The sociodemographic and clinical data of the participants were recorded. All participants went through several tests, namely the TGlittre-P test for activities of daily living, the 6-minute walk test (6MWT) for functional capacity, the Fitnessgram test battery for physical fitness, the hand dynamometer for measuring grip strength, the pedometer for measuring physical activity, and both the child and parents reported the Pediatric Quality of Life Inventory (PedsQL) for evaluating the quality of life, in addition to posture analyses. Values of p < 0.05 were considered statistically significant.

RESULTS

Individuals with CHD had a longer TGlittre-P test completion time and a shorter 6MWT distance than HC (TGlittre-P: CHD 3.45 [3.24-4.02]min vs. HC 3.10 [2.57-3.23]min, 6MWT: CHD 514.00 [412.50-566.00]m vs. HC 591.50 [533.00-631.00]m). For the CHD group, sit-ups, push-ups, trunk lift, and sit-and-reach test scores within the Fitnessgram battery, grip strength, posture, and quality of life scores were lower than those for the HC group. Physical activity levels were similar in the groups.

CONCLUSIONS

The performance of activities of daily living, functional capacity, physical fitness, posture, and quality of life of children with moderate and severe CHD were affected compared to healthy peers.

Preventing sedentary lifestyles among young children born with congenital heart defects: A feasibility study of physical activity rehabilitation after surgical or catheterization intervention

BACKGROUND

Children with congenital heart disease (CHD) often have inactive lifestyles and motor skill deficits beginning in infancy. The least active infants continue to be the least active children at school age. Enhancing physical activity and motor development in infancy, at the time of CHD treatment, may prevent inactive lifestyle habits.

METHODS

All children being treated, through surgery or catheterization, for congenital heart disease are eligible if they are 3 to 72 months of age at enrollment. The Peabody Motor Development Scales (Version 2) and 7-day accelerometry (Actigraph GT9X Link) assess motor skills and physical activity prior to treatment and 7 weeks, 6 months and 12 months post-treatment. Participants are randomized 3:1 to intervention:control. Until 7 weeks post-treatment, intervention activities focus on regaining pre-treatment mobility and midline crossing. From 7 weeks to 6 months post-treatment, the intervention is individualized to each child's assessment results and is parent-led, delivered at home and play-based.

CONCLUSION

This feasibility study will provide essential data for a randomized controlled trial to evaluate play-based, parent-delivered interventions optimized to support age-appropriate physical activity and motor skills among young children with CHD. Preliminary intervention efficacy data will inform an evidence-based sample size calculation, optimize intervention timing, and identify hypotheses on the motor skill-physical activity connection and the impact of play-based, parent-led interventions during recovery from CHD treatment. Long-term, the goal is to optimize motor skill and active lifestyles among young children with CHD, enabling their healthy growth and development and enhancing childhood quality of life.

TRIAL REGISTRATION

Clinical trials registration: NCT04619745.

Positive mindset and exercise capacity in school-aged children and adolescents with congenital heart disease

Introduction

Patients with congenital heart disease (CHD) have variable degrees of peak oxygen consumption (VO₂) that can be improved with supervised fitness training. The ability to exercise is affected by anatomy, hemodynamics, and motivation. Motivation is in part related to mindset, or personal attitudes and beliefs, and a more positive mindset around exercise has been associated with better outcomes. It is unknown whether variations in measured peak VO₂ in patients with CHD are related to having a positive mindset.

Methods

Patient's ages 8-17 years with CHD were administered quality of life and physical activity questionnaires at the time of their routine cardiopulmonary exercise test. Those with severe hemodynamic burden were excluded. Patients were grouped based on disease classification. Mindset was evaluated via validated questionnaires including a PROMIS Meaning and Purpose (MaP) survey and an Anxiety survey. Pearson correlation coefficients were calculated to estimate the magnitude of the association between percent predicted peak oxygen consumption (pppVO₂) and questionnaire scores overall and within CHD subgroups.

Results

Eighty-five patients participated; median age was 14.7 years, 53% were female, 66% had complex CHD, 20% had simple CHD, and 14% had single ventricle heart disease. Mean MaP scores were significantly lower in all CHD groups compared to population norms (p < 0.001). As a group, MaP scores were positively associated with the amount of reported physical activity (p = 0.017). In patients with simple CHD, MaP scores were positively associated with pppVO₂ (p = 0.015). The association was even stronger for MaP:Anxiety, with worse ratios associated with lower pppVO₂ (p = 0.005). Patients with complex and single ventricle CHD did not show a similar association.

Conclusions

Patients with CHD, regardless of severity, had lower meaning and purpose scores than the general population, and these scores were associated with amount of reported physical activity. In the simple CHD subset, having a more positive mindset was associated with higher peak VO₂ and a more negative mindset with lower peak VO₂. This relationship was not seen with more significant CHD. While underlying CHD diagnoses are not modifiable, mindset and peak VO₂ are, and consideration should be given to measuring both as each may be a target for intervention.

ehealth technology in cardiac exercise therapeutics for pediatric patients with congenital and acquired heart conditions: a summary of evidence and future directions

Many children and adolescents with congenital and acquired heart disease (CHD) are physically inactive and participate in an insufficient amount of moderate-to-vigorous intensity exercise. Although physical activity (PA) and exercise interventions are effective at improving short- and long-term physiological and psychosocial outcomes in youth with CHD, several barriers including resource limitations, financial costs, and knowledge inhibit widespread implementation and dissemination of these beneficial programs. New and developing eHealth, mHealth, and remote monitoring technologies offer a potentially transformative and cost-effective solution to increase access to PA and exercise programs for youth with CHD, yet little has been written on this topic. In this review, a cardiac exercise therapeutics (CET) model is presented as a systematic approach to PA and exercise, with assessment and testing guiding three sequential PA and exercise intervention approaches of progressive intensity and resource requirements: (1) PA and exercise promotion within a clinical setting; (2) unsupervised exercise prescription; and (3) medically supervised fitness training intervention (i.e., cardiac rehabilitation). Using the CET model, the goal of this review is to summarize the current evidence describing the application of novel technologies within CET in populations of children and adolescents with CHD and introduce potential future applications of these technologies with an emphasis on improving equity and access to patients in low-resource settings and underserved communities.

Nationwide Survey Reveals High Prevalence of Non-Swimmers among Children with Congenital Heart Defects

BACKGROUND

Physical activity is important for children with congenital heart defects (CHD), not only for somatic health, but also for neurologic, emotional, and psychosocial development. Swimming is a popular endurance sport which is in general suitable for most children with CHD. Since we have previously shown that children with CHD are less frequently physically active than their healthy peers, we hypothesized that the prevalence of non-swimmers is higher in CHD patients than in healthy children.

METHODS

To obtain representative data, we performed a nationwide survey in collaboration with the German National Register of Congenital Heart Defects (NRCHD) and the Institute for Sport Sciences of the Karlsruhe Institute for Technology (KIT). The questionnaire included questions capturing the prevalence of swimming skills and the timing of swim learning and was part of the "Motorik-Modul" (MoMo) from the German Health Interview and Examination Survey for Children and Adolescents (KiGGS). A representative age-matched subset of 4569 participants of the MoMo wave two study served as a healthy control group.

RESULTS

From 894 CHD-patients (mean age of 12.5 ± 3.1 years), the proportion of non-swimmers in children with CHD was significantly higher (16% versus 4.3%; p < 0.001) compared to healthy children and was dependent on CHD severity: Children with complex CHD had an almost five-fold increased risk (20.4%) of being unable to swim, whereas in children with simple CHD, the ability to swim did not differ significantly from their healthy reference group (5.6% vs. 4.3% non-swimmers (p = not significant).

CONCLUSIONS

According to our results, one in five patients with complex CHD are non-swimmers, a situation that is concerning in regard of motoric development, inclusion and integration, as well as prevention of drowning accidents. Implementation of swim learning interventions for children with CHD would be a reasonable approach.

Digital Health Nudging to increase physical activity in pediatric patients with congenital heart disease: A randomized controlled trial

BACKGROUND

Digital nudging is a modern e-health approach to increase physical activity (PA) in younger age groups. As activity promotion is particularly important in adolescents with congenital heart disease (CHD) this randomized-controlled trail examines if Digital Health Nudging via daily smartphone messages increases PA, activity-related self-efficacy (ArSE) and health-related quality of life (HrQoL) in adolescents with CHD.

METHODS

From May 2021 to April 2022, 97 patients (15.1 ± 2.0 years, 50% girls) with moderate or severe CHD were randomly allocated 1:1 to intervention (IG) or control group (CG). Daily PA was objectively assessed in minutes of moderate-to-vigorous PA (MVPA) by the wearable "Garmin Vivofit jr. 2" over the entire study period. The IG received daily smartphone messages based on Bandura's social cognitive theory on the subject of PA over a period of 12-weeks.

RESULTS

According to the linear mixed model, the change of MVPA over the study period did not significantly differ between IG and CG when taking baseline MVPA into account (b = 0.136, 95%-CI [-0.355; 0.627], P = .587). Activity level was comparably high and showed only minor variability in both groups with 73.7 [62.3; 78.8] min/day in IG and 78.4 [66.6; 93.9] min/d in CG throughout the whole 12-weeks. Emotional well-being significantly increased over the study period in the IG (IG: Δ1.60 [-0.2; 6.3] vs CG: Δ0.0 [-12.5; 6.3], P = .043), but not total HrQoL (P = .518) and ArSE (P = .305).

CONCLUSIONS

12-weeks, of Digital Health Nudging did not increase PA, but improved feelings of emotional well-being in adolescents with CHD.

TRIAL REGISTRATION

Clinical Trials Identifier NCT04933786.

Participation of children with long-term health conditions compared to that of healthy peers: A cross-sectional comparative study

BACKGROUND

Knowledge is limited on attendance and involvement of perceived participation of children with long-term health conditions.

AIMS

To evaluate the perceived participation of children with long-term health conditions and to compare their participation with that of healthy peers.

MATERIAL AND METHODS

A cross-sectional comparative study was designed using self-reported data from 65 children with long-term health conditions and from 65 healthy peers, utilising the simplified Chinese version of Picture My Participation (PMP-C; Simplified).

RESULTS

The frequency scores of children with long-term health conditions were significantly lower than those of healthy peers in terms of attendance for the total domain and for 13 activity items. The involvement scores of children with long-term health conditions were significantly lower than those of healthy children in 3 items. There was a strong correlation between rank orders of the most important activities for the two groups (r = 0.83).

CONCLUSIONS

Children with long-term health conditions participated less in activities compared to healthy children. Further studies are required to investigate factors of the participation of children.

SIGNIFICANCE

The PMP-C (Simplified) offered an opportunity for children to express their own perspectives of participation based on their individual experience of the activity.

Wearable Biosensors in Congenital Heart Disease: Needs to Advance the Field

Traditional measures of clinical status and physiology have generally been based in health care settings, episodic, short in duration, and performed at rest. Wearable biosensors provide an opportunity to obtain continuous non-invasive physiologic data from patients with congenital heart disease (CHD) in the real-world setting, over longer durations, and across varying levels of activity. However, there are significant technical limitations to the use of wearable biosensors in CHD. Here, we review current applications of wearable biosensors in CHD; how clinical and research uses of wearable biosensors must consider various CHD physiologies; the technical challenges in developing wearable biosensors for CHD; and special considerations for digital biomarkers in CHD.

Participation in physical activity of adolescents with congenital heart disease

BACKGROUND

Participation in physical activity improves health in individuals with congenital heart disease. However, most do not sufficiently engage in physical activity. The aim of this study was to collect information regarding the experiences of adolescents with congenital heart disease who practiced physical activities.

METHODS

French adolescents aged 13-18 years, diagnosed with congenital heart disease, class I or II dyspnoea on the NYHA scale and authorized physical activity were interviewed individually about their physical activity experiences using a semi-structured format. The qualitative interview transcript data were analysed using a phenomenological approach; data analysis was performed independently by three researchers and merged at each step until saturation.

RESULTS

Eleven adolescents with congenital heart disease participated. Three main themes emerged: 'own representation', 'physical activity (PA) set-up' and 'environment'. Adolescents had a generally positive view of physical activity, which was associated with positive experiences. However, they reported that their physical condition limited PA, and they wished for adapted activities. The results revealed the importance of environmental factors, for example, within the social and school environments. The participants indicated that they appreciated the social interactions that PA afforded, but that integration into a group could be difficult, especially in school, with some participants describing feelings such as anxiety, frustration or guilt when they could not participate fully. PA facilitators included familial support. However, participants noted a lack of clear medical guidance to help them choose suitable activities based on their circumstances and personal preferences. They wished for the public to be better informed about congenital heart disease to reduce stigmatism.

CONCLUSIONS

This study provides valuable information for clinicians, physical educators and policy makers to help them promote physical activity and support adolescents and their families in understanding their own condition, maximizing their potential and in their choice of activities.

Clusters of lifestyle behaviors associated with atherosclerosis risk factors in children and adolescents with congenital heart disease: Floripa CHild Study

Secondary cardiovascular disease is the main cause of mortality in congenital heart disease (CHD) patients. The cardiovascular risk could be widely prevented with adherence to a healthy lifestyle; however, clusters of lifestyle behaviors related to atherosclerosis risk factors in children and adolescents with CHD remain unclear. We aimed to describe the clusters of lifestyle behaviors of children and adolescents with CHD and to evaluate their association with atherosclerosis risk factors. We conducted a cross-sectional study on 227 children and adolescents with CHD (median age:10.02 [IQR:7.08-13.02] years). Dietary intake, physical activity (PA), and sedentary behavior (SB) were evaluated. Clusters of lifestyle behaviors were determined using a two-step cluster analysis. Atherosclerosis risk factors evaluated include body fat mass, central obesity, blood pressure, lipid parameters, glucose, C-reactive protein, and carotid intima-media thickness (cIMT). Multiple logistic regressions were used. The "unhealthy: high SB + low PA" cluster was associated with elevated body fat mass, central obesity, and elevated cIMT. Furthermore, the "unhealthy: low PA + unhealthy eating habits" cluster was associated with elevated body fat mass, central obesity, and elevated glucose. The unhealthier lifestyle behavior clusters were associated with atherosclerosis risk factors in children and adolescents with CHD. Multidisciplinary strategies to promote healthy behaviors are needed to prevent cardiovascular disease in later life.

Cardiorespiratory fitness, muscle fitness, and physical activity in children with long QT syndrome: A prospective controlled study

Background

In children with congenital long QT syndrome (LQTS), the risk of arrhythmic events during exercise commonly makes it difficult to balance exercise restrictions versus promotion of physical activity. Nevertheless, in children with LQTS, cardiorespiratory fitness, muscle fitness, and physical activity, have been scarcely explored.

Materials and methods

In this prospective, controlled, cross-sectional study, 20 children with LQTS (12.7 ± 3.7 years old) and 20 healthy controls (11.9 ± 2.4 years old) were enrolled. All participants underwent a cardiopulmonary exercise test, a muscular architecture ultrasound assessment, (cross-sectional area on right rectus femoris and pennation angle), a handgrip muscular strength evaluation, and a standing long broad jump test. The level of physical activity was determined using with a waist-worn tri-axial accelerometer (Actigraph GT3X).

Results

Peak oxygen uptake (VO_2peak) and ventilatory anaerobic threshold (VAT) were lower in children with LQTS than in healthy controls (33.9 ± 6.2 mL/Kg/min vs. 40.1 ± 6.6 mL/Kg/min, P = 0.010; 23.8 ± 5.1 mL/Kg/min vs. 28.8 ± 5.5 mL/Kg/min, P = 0.007, respectively). Children with LQTS had lower standing long broad jump distance (119.5 ± 33.2 cm vs. 147.3 ± 36.1 cm, P = 0.02) and pennation angle (12.2 ± 2.4° vs. 14.3 ± 2.8°, P = 0.02). No differences in terms of moderate-to-vigorous physical activity were observed (36.9 ± 12.9 min/day vs. 41.5 ± 18.7 min/day, P = 0.66), but nearly all children were below the WHO guidelines.

Conclusion

Despite similar physical activity level, cardiorespiratory fitness and muscle fitness in children with LQTS were lower than in healthy controls. The origin of this limitation seemed to be multifactorial, involving beta-blocker induced chronotropic limitation, physical and muscle deconditioning. Cardiovascular rehabilitation could be of interest in children with LQTS with significant physical limitation.

Cardiopulmonary Fitness of Preschoolers with Congenital Heart Disease: An Observational Study

With advancements in cardiopulmonary rehabilitation over the past few decades, the survival rate of patients with congenital heart disease (CHD) has increased. However, the Cardiopulmonary fitness (CPF) of these patients is poor. Here, we aimed to investigate CPF in preschoolers with CHD (aged 4 to 6 years) using cardiopulmonary exercise testing. We retrospectively compared 102 healthy preschoolers with 80 preschoolers with CHD. The latter had lower peak oxygen consumption, oxygen consumption at anaerobic threshold and metabolic equivalent at anaerobic threshold. The same result was observed in boys with CHD, but not in girls, when sex was sub-analyzed. Considering the body composition, children with CHD had a lower fat-free mass index (FFMI) than their healthy peers. Healthy preschoolers with a normal body mass index (BMI) had higher anaerobic threshold and peak metabolic equivalent values than overweight or underweight children. This was categorized under the BMI reference of the Ministry of Health and Welfare in Taiwan. In conclusion, the CPF difference between the CHD and healthy groups was identified as early as in preschool age, and better CPF in healthy preschoolers within the normal BMI range suggests the importance of weight control in young children.

Fearless in Physical Activity: The Implications of Community-Based Physical Activity Interventions on Children, Adolescents, and Adults with Congenital Heart Disease

People living with CHD do less moderate-to-vigorous activity than their peers. This study sought to examine the impact of a community-based physical activity intervention for individuals with CHD. Individuals with CHD and family members participated in a 3 h, one-day Fearless event consisting of a variety of physical activity and education sessions. Consenting participants completed self-administered questionnaires pre-/post-event and completed a post-event feedback form. Descriptive statistics and paired t-tests were calculated across subgroups for each outcome/questionnaire. Written feedback was analyzed using a six-phase framework of reflexive thematic analysis. A total of 32 participants (six children, six adolescents, five youth, five all ages, and ten adults) with CHD completed this study. Following Fearless, youth with CHD reported spending less time being 'inactive' and more time being 'somewhat active'. Adults with CHD reported spending more time walking and partaking in moderate activity and less time partaking in vigorous activity. Fearless successfully engaged individuals with CHD who were more sedentary, less active, and older. Fearless is a fun, family-friendly, physical activity intervention for individuals with CHD. Attending a Fearless event helped children, adolescents, and adults with CHD make incremental improvements to their physical activity levels and provided a framework for sport and recreation leaders who aim to promote physical activity amongst individuals with CHD.

Impact of exercise training in patients after CHD surgery: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

The goal of this meta-analysis is to evaluate the effects of exercise training on long-term health and cardiorespiratory fitness in participants with CHD after surgery and to investigate the optimal type of exercise training for post-operative patients and how to improve adherence to it.

METHODS

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, and Web of Science from the date of the inception of the database through August 2021.

RESULTS

Altogether, 1424 records were identified in the literature search. Studies evaluating outcomes between exercise training and usual care among post-operative patients with CHD were included. The assessed outcomes were quality of life and cardiorespiratory fitness. We analysed heterogeneity by using the I² statistic and evaluated the evidence quality according to the recommendation by the Cochrane Collaboration. Nine randomised controlled trials were included. The evidence showed that exercise interventions increased peak oxygen consumption (mean difference = 2.29 [95% CI 0.43, 4.15]; p = 0.02, I² = 0%). However, no differences in scores of health-related quality of life and pulmonary function were observed between the experimental and control groups.

CONCLUSIONS

In conclusion, participation in a physical exercise training programme was safe and improved fitness in patients after surgery for CHD. We recommend that post-operative patients with CHD participate in physical exercise training. Additional research is needed to study the various forms of exercise training and their impact on quality of life.

Exercise training in paediatric congenital heart disease: fit for purpose?

Exercise and physical activity (PA) have been shown to be effective, safe and feasible in both healthy children and children with congenital heart disease (CHD). However, implementing exercise training as an intervention is still not routine in children with CHD despite considerable evidence of health benefits and well-being. Understanding how children with CHD can safely participate in exercise can boost participation in PA and subsequently reduce inactivity-related diseases. Home-based exercise intervention, with the use of personal wearable activity trackers, and high-intensity interval training have been beneficial in adults' cardiac rehabilitation programmes. However, these remain underutilised in paediatric care. Therefore, the aims of this narrative review were to synthesise prescribed exercise interventions in children with CHD, identify possible limitation to exercise training prescription and provide an overview on how to best integrate exercise intervention effectively for this population into daily practice.

Children with Cardiomyopathy have Active Lifestyles Despite Reporting Disease-Specific Barriers to Physical Activity: A Mixed-Methods Study

Objectives: This exploratory mixed-methods study explored the barriers to physical activity, daily physical activity and submaximal exercise capacity among children with and at risk for cardiomyopathy and children with atrial septal defects.Methods: The study followed a convergent parallel mixed methodology design. Semi-structured interviews explored physical activity barriers. Seven-day accelerometry assessed moderate-to-vigorous physical activity, and an intermittent cardiopulmonary exercise test measured submaximal exercise capacity.Results: Twenty children, including 5 with cardiomyopathy (n=2 females, 14.2 ± 2.7 years old), 7 who were genotype-positive phenotype-negative for cardiomyopathy (n=5 females, 10.6 ± 3.3 years old) and 8 with atrial septal defects (n=4 females, 9.4 ± 3.8 years old) were recruited. Children with cardiomyopathy reported disease-specific physical activity barriers, while children who were genotype-positive phenotype-negative perceived barriers related to lack of time, parent support or activity motivation. The average daily moderate-to-vigorous physical activity was less than the recommended 60-minutes/day (n=20, mean 48.1 ± 18.0 minutes). Children with cardiomyopathy participated a median of 141.2 [interquartile range (IQR): 98.8) minutes of light-intensity physical activity and a median of 55.6 (IQR: 34.6) minutes of moderate-to-vigorous physical activity. The average submaximal exercise capacity was low (n=16, 25.2 ± 5.7 mL/kg/min). Estimated submaximal exercise capacity, including metabolic equivalent (4.5 ± 3.1 METs), respiratory exchange ratio (median = 1.0, IQR: 0.09) and ratings of perceived exertion (median = 7, IQR: 5) at peak exercise suggest that children with cardiomyopathy appear to have the exercise capacity to participate in low-to-moderate intensity activities.Conclusions: These novel data suggest that a diagnosis of cardiomyopathy may not preclude children from participating in a healthy, active lifestyle. However, they perceive disease-specific physical activity barriers and may require support to optimize their level of participation for optimal health.

The Impact of Physical Activity Restrictions on Health-Related Fitness in Children with Congenital Heart Disease

Children with congenital heart disease (CHD) are often restricted from some types of physical activity (PA) despite the lack of evidence regarding the need to restrict recreational PA, apart from those with rhythm disorders. This study retrospectively investigated the associations between parent-reported activity restrictions (on-going need to restrict exertion, body contact or competition) and measures of health-related fitness among 236 children (8.2 ± 2.1 years, range 4−12 years) treated for single ventricle (n = 104), tetralogy of Fallot (n = 48), transposition of the great arteries (n = 47) or atrial septal defect (n = 37). Body mass index (BMI), moderate-to-vigorous physical activity (MVPA; 7 day accelerometry), strength, flexibility, and movement skill assessment results were collected from the baseline assessment research records for two studies completed in Ontario, Canada. A subset of 62 children also had physician-reported activity restrictions. Regression models empirically tested the goodness of fit between the dependent and independent variables. Participants with body contact restrictions from both parents and physicians had significantly higher BMI z-scores (0.23 ± 1.19 vs. −0.32 ± 0.85; t = 2.55; p = 0.04 and 0.66 ± 1.33 vs. −0.02 ± 0.98; t = 2.25; p = 0.02 for CDC and WHO scores, respectively). Otherwise, BMI z-score was not associated with patient variables (p > 0.36; sex, cardiac diagnosis, age, or activity restriction). Children with any type of parent-reported restriction (0.98 ± 2.06 vs. −0.08 ± 1.99; t = 3.77; p = 0.0002) were less flexible. Movement skill (TGMD-2) scores were 50% lower (25.1 ± 31.2 vs. 52.6 ± 28.6; F = 6.93; p = 0.009) among children with parent-reported competitive sport restrictions. Weekly MVPA (p > 0.18) and strength (p > 0.05) were not associated with activity restriction. Children whose parents reported PA restrictions were less flexible, and had decreased movement skill and increased BMI z-scores if the restrictions impacted competitive sport or body contact, respectively. Future research is recommended to confirm these results among larger samples of children who have both parent- and physician-specified PA restrictions.

Diminished Endothelial Function but Normal Vascular Structure in Adults with Tetralogy of Fallot

The life expectancy of patients with Tetralogy of Fallot (ToF) has increased in recent years. As a result, other risk factors with later onset in life are in the focus of patient care. Endothelial function is an early indicator of cardiovascular risk and was investigated along further structural vessel properties. A total of 17 patients (41.7 ± 7.1 years, 8 women) with Tetralogy of Fallot were 1:2 matched for sex with 34 (38.9 ± 8.1 years, 16 women) healthy volunteers. Participants received an assessment of their endothelial function and a structural assessment of the aorta. Patients with ToF showed a reduced endothelial function determined by reactive hyperaemia index after adjusting for age, weight and height (ToF: 1.55 ± 0.31 vs. controls: 1.84 ± 0.47; p = 0.023). No differences in carotid intima-media thickness (cIMT) between the ToF and healthy controls (ToF: 0.542 ± 0.063 mm vs. controls: 0.521 ± 0.164 mm; p = 0.319) were found. Patients with ToF had reduced vascular function compared to healthy subjects. As the structural component is not affected, endothelial dysfunction seems not to have yet manifested itself as a morphological change. Nevertheless, long-term management of these patients should include vascular parameters.

Exercise Training for People Living with a Fontan Circulation: An Underutilized Intervention

Surgical repair for children born with single ventricle congenital heart disease, culminating in the Fontan operation, has resulted in dramatic improvements in survival; children born with these lesions are now typically expected to survive well into adulthood. Most, but not all, individuals with a Fontan circulation have reduced exercise capacity compared with the general population that in turn is associated with increased cardiovascular morbidity and mortality. The cause of reduced exercise capacity is multifactorial. A significant contributor is the absence of a subpulmonary ventricular pump, which limits preload and appropriate cardiac output augmentation to meet the increased metabolic demands that occur with exercise. While in its infancy relative to adults with acquired heart disease, the evidence to date suggests that exercise interventions to improve exercise capacity and Fontan physiology in children and adults with Fontan circulation are safe, effective and well tolerated. However, many knowledge gaps remain, including a detailed understanding of the unique physiological adaptations that occur, the optimal approach to exercise in this population and the effectiveness of home-based interventions utilizing telemedicine and remote physiologic monitoring technologies. Furthermore, the long-term impact of such interventions on the Fontan-cardiovascular system, physical activity levels, health-related quality of life, and late cardiovascular morbidity and mortality are not well characterized. In this review, we outline the factors associated with reduced exercise capacity in individuals with Fontan circulation, review the experience to date of dedicated interventions to improve exercise capacity, and highlight the current knowledge gaps in the field and priorities for further study.

Differences in Cardiopulmonary Fitness Between Boy and Girls With Repaired Tetralogy of Fallot

OBJECTIVE

Many studies have demonstrated that patients with repaired tetralogy of Fallot (rTOF) have generally poorer cardiopulmonary fitness (CPF). However, little is known about how the disease results in different CPF in each sex. Therefore, this study aimed to investigate whether sex (and gender) differences affect CPF in children and adolescents with rTOF.

METHODS

This retrospective study recruited adolescents and children (aged 10-18) with rTOF following an acute stage of tetralogy of Fallot (TOF) who received cardiopulmonary exercise testing (CPET) in the past 10 years. CPF was determined by symptom-limited CPET with a treadmill under ramped Bruce protocol. Boys and girls were categorized into groups based on body mass index (BMI) and fat mass index (FMI). The BMI was grouped by Taiwanese obesity cutoff points. The FMI was categorized by the body fat percentage. Excess adiposity was defined as (1) "overweight" and "obese" by BMI and (2) greater than the sex- and age-specific 75th percentile of whole subjects by FMI.

RESULTS

A total of 185 participants (104 boys and 81 girls) with rTOF were recruited for the final analysis. Within the BMI category, 76 boys and 63 girls were in the normal group, whereas 28 boys and 18 girls were in the excessive adiposity group. Within the FMI category, 77 boys and 60 girls were in the normal group, whereas 27 boys and 21 girls were in the excessive adiposity group. The analysis of the body composition of rTOF subjects showed that there was no statistically significant difference between the subgroups of the two sexes, but both showed a smaller body size than normal Taiwanese children. When comparing the CPF within different BMI and FMI groups, the children in the excessive adiposity group had significantly lower values in metabolic equivalents (MET) at anaerobic threshold, peak MET, and measured peak oxygen consumption (VO₂) to predicted peak VO₂, regardless of sex. Moreover, boys (60.90%) presented poorer CPF than girls (74.22%, p < 0.001).

CONCLUSION

In Taiwan, patients with rTOF had poorer CPF than healthy peers. This study found that girls with rTOF had better CPF than boys with rTOF. The effect of gender stereotypes on sports participation and self-efficacy might be one of the contributing factors; however, further investigations are warranted to determine the causal effect.

Gender Differences in Physical Activity Engagement Among Adolescents With Congenital Heart Disease

OBJECTIVE

The current study aimed to (a) describe moderate-to-vigorous physical activity (MVPA), sedentary behavior (SB), and cardiorespiratory fitness (VO2Peak) via objective assessment among adolescents with congenital heart disease (CHD), (b) examine gender differences on MVPA, SB, VO2Peak, and the Theory of Planned Behavior elements, and (c) identify whether gender moderates the relationships between the Theory of Planned Behavior elements and MVPA, SB, and VO2Peak.

METHODS

Adolescent CHD survivors (N = 86; ages 15-18 years) wore an accelerometer to assess MVPA and SB, underwent an exercise stress test to assess VO2Peak, and completed a survey of the Theory of Planned Behavior elements as measured by perceived benefits (attitudes), family/friend support and perceived norms (social norms), and self-efficacy and barriers (perceived behavioral control) to engaging in physical activity.

RESULTS

On average, CHD survivors engaged in 22.3 min (SD = 15.3) of MVPA/day and 9 hr of SB/day (M = 565.8, SD = 102.5 min). Females engaged in less MVPA but not more SB had a lower mean VO2Peak, reported lower self-efficacy, and perceived greater barriers than males. In a regression model, barriers explained unique variance in MVPA and VO2Peak, but the relationship between barriers and MVPA/VO2Peak did not vary by gender. Self-efficacy did not explain unique variance in MVPA and VO2Peak when included in a model with gender and barriers.

CONCLUSIONS

Family/friend support for physical activity engagement may be an important consideration when developing physical activity interventions for adolescent CHD survivors. The role of gender differences in self-efficacy and perceived barriers on physical activity engagement warrants further investigation.

Move more - be happier? physical activity and health-related quality of life in children with congenital heart disease

OBJECTIVE

This cross-sectional study aimed to determine whether there is an association between objectively assessed physical activity (PA) and health-related quality of life (HRQoL) in children with CHD.

PATIENTS AND METHODS

From September 2017 to January 2021, 343 children with CHD (12.1 ± 3.3 years, 135 girls) provided valid PA data after a 7-day objective PA assessment. PA was evaluated as average daily steps and moderate-to-vigorous physical activity (MVPA) minutes assessed via wearable bracelet Garmin vivofit Jr. These children also completed the KINDL - a 24 Likert-scaled item questionnaires assessing HRQoL in the six dimensions physical well-being, emotional well-being, self-esteem, family, friends and everyday functioning.

RESULTS

Daily Steps (r = 0.166, P = .003) and daily MVPA minutes (r = 0.134, P = .017,) were both correlated to total KINDL score. Furthermore, both steps and MVPA were associated with the subscales physical well-being (steps: r = 0.165 p=.003; MVPA: r = 0.129, P = .022), friends (steps: r = 0.210, P < .001, MVPA: r = 0.179, P = .001), steps, and to everyday functioning (r = 0.142, P = .012). Logistic regression showed each MVPA minute increase conferred to a 1% increase in reporting better HRQoL (OR: 1.009 [95% CI: 1.002 - 1.017], P = .019).

CONCLUSIONS

PA was positively associated with HRQoL in children with CHD. Patients who move more are more likely to report better HRQoL. While the magnitude of this association needs to be further understood, continuous encouragement towards more PA seems to be crucial in a holistic approach to medical aftercare in children with CHD.

Inactive Lifestyles among Young Children with Innocent Murmurs or Congenital Heart Disease Regardless of Disease Severity or Treatment

BACKGROUND

Sedentary lifestyle morbidities are common among children with congenital heart disease (CHD). Understanding the physical activity trajectory from early childhood could enhance intervention timing/effectiveness.

METHODS

154 children (56% male) were recruited at 12-47 months of age for this prospective, longitudinal, observational study. Physical activity and sedentary behaviour (7-day accelerometry) and motor skill (Peabody Developmental Motor Scales-2) were assessed every 8 months until 5 years of age and then annually. Mixed effect repeated measures regression models described outcome trajectories across study assessments.

RESULTS

Children had an innocent heart murmur (n=28), CHD with insignificant hemodynamics not requiring treatment (n=47), CHD treated by catheterization or surgery without cardiopulmonary bypass (n=31), or CHD treated surgically with bypass (n=48). Motor skill was age appropriate (Peabody 49.0±8.4) but participants had lower physical activity (143±41 mins/day) and higher sedentary time (598±89 mins/day) than healthy peers, starting at 18 months of age. Movement behaviours were not related to treatment group (p>0.10), and physical activity was below the recommended 180 mins/day. Over time, physical activity, sedentary time and motor skill were primarily related to the baseline measure of each outcome (p<0.001).

CONCLUSIONS

Children with simple or complex CHD or innocent heart murmurs have an increased risk for sedentary lifestyles. Their physical activity and sedentary behaviours are established prior to 2 years of age, persist until school age, and are unrelated to motor skill. These results emphasize the need for interventions targeting the youngest children seen in a cardiac clinic, regardless of CHD diagnosis or innocent murmur.

Long-term effectiveness of an mHealth-tailored physical activity intervention in youth with congenital heart disease: A randomized controlled trial

AIMS

To evaluate the long-term effectiveness of the Care & Organize Our Lifestyle (COOL) programme, a self-regulation theory-based mHealth programme, on improving disease knowledge and physical activity in youth with congenital heart disease (CHD).

DESIGN

A three-arm parallel-group randomized controlled trial.

METHODS

A total 143 participants with simple and moderate CHD aged 15-24 years were recruited from June 2016 to February 2018. The 12-month programme compared two active intervention groups to a standard-care control group (n = 47). Participants in one active intervention group (n = 49) were provided with COOL Passport, a mobile healthcare application. Those in the other group (n = 47) were provided with access to the Health Promotion Cloud system and use of game-based interactive platforms along with COOL Passport. Outcomes were the Leuven Knowledge Questionnaire for Congenital Heart Disease and the International Physical Activity Questionnaire-Taiwan Show-Card Version.

RESULTS

After 12 months, 103 participants remained; the overall attrition rate was 28%. No significant differences were observed between the groups in any domain of disease knowledge after 6 months or 1 year. Neither active group exhibited significantly greater physical activity intensity than the standard-care control group in any month during the 1 year.

CONCLUSION

The mHealth-tailored intervention of the COOL programme did not improve disease knowledge or physical activity in young adults with CHD.

IMPACT

The application of the COOL Passport and Health Promotion Cloud system and use of game-based interactive platforms must be modified and verified in future studies and may have clinical potential.

TRIAL REGISTRATION

The registry of clinical trials was ClinicalTrials.gov: NCT04264650.

Improvement of physical activity levels in children and adolescents after surgery for congenital heart disease: preferences and use of physical therapy

PURPOSE

After surgery for congenital heart disease in children and adolescents, an active lifestyle is important to achieve and maintain good physical fitness. This study aimed to describe physical activity, as well as the use of patients' and parents' preferences for rehabilitative care after surgery for congenital heart disease.

METHODS

This cross-sectional study included patients aged 4-16 years old, who had undergone surgery for congenital heart disease 2 years prior to the study onset. Patients and/or parents were invited to complete questionnaires on physical activity, and on their preferences for, and -use of, rehabilitative care after surgery.

RESULTS

Forty-five of the 92 eligible patients and/or parents completed the questionnaires. The median age of the children was 12.2 years (IQR 7.8-16.1). Two children (4%) met the recommendations for taking part in moderate physical activity and 13 (29%) having done so for vigorous physical activity. Postoperatively 15 children (33%) had had physical therapy in primary care. More than 50% of the patients/parents would have preferred to have had more information on physical activity and to have taken part in an individual exercise program delivered during their primary care.

CONCLUSION

The majority of eligible patients do not meet public health recommendations for engaging in physical activity and do not use physical therapy after surgery for congenital heart disease. The majority of patients and parents preferred more information as well as individual physical therapy treatments.Implications for rehabilitationsTwo years after surgery for congenital heart disease children and adolescents are less active compared to typically developing peers.Patients with a congenital heart disease and their parents need more information and support regarding stimulation of physical activity and physical fitness after heart surgery.In the postoperative process, a well-structured and supportive (individual) rehabilitation program should be introduced to improve physical activity and physical fitness.

Exercise prescription improves exercise tolerance in young children with CHD: a randomised clinical trial

Objective

The main objective of this study was to ascertain if a structured intervention programme can improve the biophysical health of young children with congenital heart disease (CHD). The primary end point was an increase in measureable physical activity levels following the intervention.

Methods

Patients aged 5–10 years with CHD were identified and invited to participate. Participants completed a baseline biophysical assessment, including a formal exercise stress test and daily activity monitoring using an accelerometer. Following randomisation, the intervention group attended a 1 day education session and received an individual written exercise plan to be continued over the 4-month intervention period. The control group continued with their usual level of care. After 4 months, all participants were reassessed in the same manner as at baseline.

Results

One hundred and sixty-three participants (mean age 8.4 years) were recruited, 100 of whom were male (61.3%). At baseline, the majority of the children were active with good exercise tolerance. The cyanotic palliated subgroup participants, however, were found to have lower levels of daily activity and significantly limited peak exercise performance compared with the other subgroups. One hundred and fifty-two participants (93.2%) attended for reassessment. Following the intervention, there was a significant improvement in peak exercise capacity in the intervention group. There was also a trend towards increased daily activity levels.

Conclusion

Overall physical activity levels are well preserved in the majority of young children with CHD. A structured intervention programme significantly increased peak exercise capacity and improved attitudes towards positive lifestyle changes.

A National Comparative Investigation of Twins With Congenital Heart Defects for Neurodevelopmental Outcomes and Quality of Life (Same Same, but Different?): Protocol for a Prospective Observational Study

Background

Due to the increased survival rates of patients with congenital heart defects (CHD), associated disorders are an increasing focus of research. Existing studies figured out an association between CHD and its treatment, and neurodevelopmental outcomes including motor competence impairments. All these studies, however, compared their test results with reference values or results of healthy control groups. This comparison is influenced by socioeconomic and genetic aspects, which do have a known impact on neurodevelopmental outcomes.

Objective

This study protocol describes a setting that aims to find out the role of CHD and its treatments on neurodevelopmental outcomes, excluding socioeconomic and genetic aspects. Only a twin comparison provides the possibility to exclude these confounding factors.

Methods

In a German-wide prospective cohort study, 129 twin siblings registered in the National Register for Congenital Heart Defects will undergo testing on cognitive function (Wechsler Intelligence Tests age-dependent: Wechsler Adult Intelligence Scale, fourth edition; Wechsler Intelligence Scale for Children, fifth edition; and Wechsler Preschool and Primary Scale of Intelligence, fourth edition) and motor competence (Movement Assessment Battery for Children, second edition). Additionally, the self-reported health-related quality of life (KINDL-R for children, Short Form 36 for adults) and the parent-reported strength and difficulties of the children (Strength and Difficulties Questionnaire, German version) will be assessed by standardized questionnaires. CHD data on the specific diagnosis, surgeries, transcatheter procedures, and additional medical information will be received from patient records.

Results

The approval of the Medical Ethics Committee Charité Mitte was obtained in June 2018. After getting funded in April 2019, the first enrollment was in August 2019. The study is still ongoing until June 2022. Final results are expected in 2022.

Conclusions

This study protocol provides an overview of the study design’s technical details, offering an option to exclude confounding factors on neurodevelopmental outcomes in patients with CHD. This will enable a specific analysis focusing on CHD and clinical treatments to differentiate in terms of neurodevelopmental outcomes of patients with CHD compared to twin siblings with healthy hearts. Finally, we aim to clearly define what is important to prevent patients with CHD in terms of neurodevelopmental impairments to be able to develop targeted prevention strategies for patients with CHD.

Trial Registration

German Clinical Trials Register DRKS00021087; https://tinyurl.com/2rdw8w67

International Registered Report Identifier (IRRID)

DERR1-10.2196/26404

Interactions with Home and Health Environments Discourage Physical Activity: Reports from Children with Complex Congenital Heart Disease and Their Parents

Children with complex congenital heart disease are less active than recommended for optimal health, with social and physical environments important determinants. The purpose of this study was to examine the physical activity perceptions of children with complex congenital heart disease and their parents to identify social and physical environment intervention targets. A semi-structured discussion guide elicited physical activity perceptions from children (26 boys, 19 girls, 6.0-12.4 years) with complex congenital heart disease (single ventricle n = 42) and their parents during three child and three parent focus groups and 41 interviews. Interviews and focus groups were audio-recorded and transcribed verbatim for inductive thematic analysis. Children and parents identified home, peer and health environments as impacting on their children's physical activity participation. Peer environments, such as school or daycare, were supportive by providing physical activity facilities and enabling fun with peers and time outdoors. At home, parent and sibling interactions both encouraged and discouraged physical activity. The children's unique health environment fostered physical activity uncertainty, discouraging activity despite minimal or no physician recommendations to restrict physical activity. Children with complex congenital heart disease and their parents recognize the importance of physical activity and fun with friends. Physical activity uncertainty contributes to their inactive lifestyles despite minimal restrictions from health professionals. Positive clinical encouragement and health environment interventions that better support physical activity are required.

Physical activity modification in youth with congenital heart disease: a comprehensive narrative review

Congenital heart disease (CHD) affects nearly 1% of births. As survival rates have dramatically improved, the majority of individuals with CHD now live into adulthood. As these patients age, they become prone to a large range of complications, such as chronic heart failure and acquired cardiovascular disease. Promotion of a healthy and active lifestyle from childhood onwards has been suggested as a sustainable and effective strategy to enhance cardiovascular health, improve quality of life and reduce immediate and long-term risk in people with CHD. Well-established physical activity consensus statements for youth with CHD have now been published. In this article, we review how increasing physical activity in youth with CHD may offer immediate and long-term cardiovascular benefits, what is known about physical activity in children with CHD, describe the unique factors that contribute to achieving sufficient and insufficient physical activity levels and summarize the evidence of trials on physical activity promotion in youth with CHD. Furthermore, we discuss some of the challenges that need to be addressed by further research regarding the optimal strategy, timing and format of physical activity intervention programmes in children and adolescents with CHD. IMPACT: Congenital heart disease (CHD) affects nearly 1% of births, with the majority of individuals with CHD now living into adulthood due to improved survival. As CHD patients age, they become prone to a large range of cardiovascular complications. This article discusses how and why increasing physical activity in youth with CHD may offer immediate and long-term cardiovascular benefits, the barriers to achieving sufficient physical activity levels and the evidence from trials on physical activity promotion in youth with CHD. The optimal strategy, timing and format of physical activity intervention programmes in children and adolescents with CHD are discussed.

Physical activity in children and adolescents with CHD: review from a measurement methodological perspective

AIM

To compile a literature overview of physical activity in children with CHD and to critically evaluate the methodology used for physical activity assessment.

METHODS

A review of the literature was performed using PubMed to identify studies examining accelerometer and subjectively assessed physical activity in children and adolescents with CHD.

RESULT

A total of 15 studies were included (6 studies using subjective measures and 9 articles using accelerometers for the assessment of physical activity). The patients generally failed to meet the recommendations of physical activity. When compared to healthy controls, the results were widely divergent in the subjectively assessed measures and the accelerometer-based studies showed a tendency of no difference in physical activity. Neither subjective methods nor accelerometer-based studies reported any difference in physical activity in general, in relation to the severity of the heart disease.

CONCLUSION

Methodological variation and limitations in the assessment of physical activity largely explain the divergent results and the inability to establish differences in physical activity between children with CHD of different severity and compared to healthy controls. Methodological knowledge and guidelines are provided for improved assessment of physical activity using accelerometers in clinical research.

Children and Adolescents Treated for Valvular Aortic Stenosis Have Different Physical Activity Patterns Compared to Healthy Controls: A Methodological Study in a National Cohort

Previous research in children and adolescents with congenital heart defects presents contradictory findings concerning their physical activity (PA) level, due to methodological limitations in the PA assessment. The aim of the present cross-sectional study was to compare PA in children and adolescents treated for valvular aortic stenosis with healthy controls using an improved accelerometer method. Seven-day accelerometer data were collected from the hip in a national Swedish sample of 46 patients 6-18 years old treated for valvular aortic stenosis and 44 healthy controls matched for age, gender, geography, and measurement period. Sports participation was self-reported. Accelerometer data were processed with the new improved Frequency Extended Method and with the traditional ActiGraph method for comparison. A high-resolution PA intensity spectrum was investigated as well as traditional crude PA intensity categories. Children treated for aortic stenosis had a pattern of less PA in the highest intensity spectra and had more sedentary time, while the adolescent patients tended to be less physically active in higher intensities overall and with less sedentary time, compared to the controls. These patterns were evident using the Frequency Extended Method with the detailed PA intensity spectrum, but not to the same degree using the ActiGraph method and traditional crude PA intensity categories. Patients reported less sports participation than their controls in both age-groups. Specific differences in PA patterns were revealed using the Frequency Extended Method with the high-resolution PA intensity spectrum in Swedish children and adolescents treated for valvular aortic stenosis.

Determinants of Physical Fitness in Children with Repaired Congenital Heart Disease

The aim of this study was to determine factors associated with physical fitness (PF) in children who underwent surgery for congenital heart disease (CHD). Sixty-six children (7-14 years) who underwent surgery for ventricular septal defect (n = 19), transposition of great arteries (n = 22), coarctation of aorta (n = 10), and tetralogy of Fallot (n = 15) were included. All children performed PF tests: cardiorespiratory fitness, upper- and lower-limb muscle strength, speed, balance, and flexibility. Cardiac evaluation was done via echocardiography and cardiopulmonary exercise test. Factors related to child's characteristics, child's lifestyle, physical activity motivators/barriers, and parental factors were assessed. Linear regression analyses were conducted. The results showed no significant differences in physical activity (PA) level by CHD type. Boys had better cardiorespiratory fitness (difference = 1.86 ml/kg/min [0.51;3.22]) and were more physically active (difference = 19.40 min/day [8.14;30.66]), while girls had better flexibility (difference = - 3.60 cm [- 7.07;- 0.14]). Physical activity motivators showed an association with four out of six PF components: cardiorespiratory fitness, coefficient = 0.063 [0.01;0.11]; upper-limb muscle strength, coefficient = 0.076 [0.01;0.14]; lower-limb muscle strength, coefficient = 0.598 [0.07;1.13]; and speed, coefficient = 0.03 [0.01;0.05]. Age, sex, and motivators together reached a maximum adjusted R² = 0.707 for upper-limb strength. Adding other possible determinants did not significantly increase the explained variance. Apart from age and sex as non-modifiable determinants, the main target which might improve fitness would be the introduction of an intervention which increases the motivation to be active.

Perceptions of Healthy Lifestyles Among Children With Complex Heart Disease and Their Caregivers

Background

Children with complex heart problems may be at higher risk for sedentary lifestyle morbidities than their healthy peers. This project examined perceptions, barriers, and supports that influence healthy active lifestyles among children with complex heart problems and their caregivers, to enable effective health and quality-of-life interventions.

Methods

Inductive thematic analysis was conducted of semi-structured guided discussions from 6 focus groups (young child [n = 2]; older child [n = 4]; parents of young child [n = 4]; parents of older child [n = 4]; pediatric cardiologist [n = 5]; pediatric cardiac nurse [n = 5]) and individual interviews with 7 parents, 5 parent/child dyads, 2 adults with complex heart problems, 6 pediatric cardiologists, 3 pediatric cardiac nurses, 4 pediatric cardiology mental health professionals, and 14 recreation professionals.

Results

Four interrelated themes were identified: (i) "It takes a village"—coordinated and collaborative interdisciplinary support; (ii) clear healthy lifestyle communication among children, families, and professionals is critically important; (iii) Ccreating supportive environments by building professional expertise; (iv) inspiring healthy lifestyles in the children’s own environments. All groups identified a need to improve knowledge about childhood heart conditions among education and recreation professionals and to encourage effective communication between healthcare professionals and families. Participants indicated that these changes would support families, educators, and recreation professionals in engaging children with heart problems in healthy lifestyles in home, school, and community settings.

Conclusions

Important healthy lifestyle barriers were identified within individuals and in their interactions. There is a profound need to enhance knowledge of childhood heart conditions and improve interactions among key stakeholders—children and families, educators, and recreation and healthcare professionals.

Objective Physical Activity Assessment in Clinical Congenital Heart Disease Research: A Systematic Review on Study Quality, Methodology, and Outcomes

BACKGROUND

The shift toward a preventative approach in medical aftercare of congenital heart disease (CHD) patients has led to encouragement of regular physical activity (PA) in this patient population. Objective measures are crucial in accurately displaying PA levels and have increasingly found their way into clinical research. This review aims to give an overview about quality, methodology, and outcomes of current scientific work on accelerometers objectively assessing PA in patients with CHD.

METHODS

Systematically researched literature in all relevant databases (PubMed, Cochrane, and Scopus) over the past decade (2009-2019) with history of CHD and accelerometer-based PA assessment was evaluated by 2 independent reviewers according to the Study Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies of the National Heart, Lung, and Blood Institute.

RESULTS

Eight articles with 664 pediatric patients with CHD aged 3-18 years (range 10-162 patients), 5 studies with 574 adults with CHD aged 18-63 years (range 28-330 patients), and 3 studies with 177 pediatric patients and adults with CHD aged 8-52 years were included. Two studies were rated "good"; 9, "fair"; and 5, "poor." Methodologies and devices differed substantially across all studies.

CONCLUSIONS

Overall study quality was fair at best, and due to difficult methodological comparability of the studies, no clear answer on how active patients with CHD really are can currently be given. Larger studies carefully considering collection and processing criteria, and correct reporting standards exploring PA in patients with CHD from different angles are needed.

Mismatch between self-estimated and objectively assessed exercise capacity in patients with congenital heart disease varies in regard to complexity of cardiac defects

AIM

Regular evaluation of physical capacity takes a crucial part in long-term follow-up in patients with congenital heart disease (CHD). This study aims to examine the accuracy of self-estimated exercise capacity compared to objective assessments by cardiopulmonary exercise testing in patients with CHD of various complexity.

METHODS

We conducted a single centre, cross-sectional study with retrospective analysis on 382 patients aged 8-68 years with various CHD who completed cardiopulmonary exercise tests. Peak oxygen uptake was measured. Additionally, questionnaires covering self-estimation of exercise capacity were completed. Peak oxygen uptake was compared to patient's self-estimated exercise capacity with focus on differences between complex and non-complex defects.

RESULTS

Peak oxygen uptake was 25.5 ± 7.9 ml/minute/kg, corresponding to 75.1 ± 18.8% of age- and sex-specific reference values. Higher values of peak oxygen uptake were seen in patients with higher subjective rating of exercise capacity. However, oxygen uptake in patients rating their exercise capacity as good (mean oxygen uptake 78.5 ± 1.6%) or very good (mean oxygen uptake 84.8 ± 4.8%) was on average still reduced compared to normal. In patients with non-complex cardiac defects, we saw a significant correlation between peak oxygen uptake and self-estimated exercise capacity (spearman-rho -0.30, p < 0.001), whereas in patients with complex cardiac defects, no correlation was found (spearman-rho -0.11, p < 0.255).

CONCLUSION

The mismatch between self-estimated and objectively assessed exercise capacity is most prominent in patients with complex CHD.Registration number at Charité Universitätsmedizin Berlin Ethics Committee: EA2/106/14.

Physical activity assessments in children with congenital heart disease: A systematic review

AIM

To describe the physical activity (PA) of children with congenital heart disease (CHD) according to different assessment methods and compare their results with the World Health Organization (WHO) recommendations.

METHODS

A systematic review was conducted using five databases. We included cross-sectional, longitudinal, observational studies and clinical trials in a paediatric population with CHD. In publications with indirect measurement, the score in each dimension was considered. Similarly, moderate-to-vigorous PA (MVPA) was considered as the main outcome in articles with direct measurement.

RESULTS

A total of 1103 articles were found, and 16 primary articles were considered. Eight articles evaluated PA with indirect methods, six with direct methods and two used both methods, representing 1649 subjects evaluated. It was found that 46% of children with CHD do not exceed WHO recommendations for MVPA, with no differences depending on the severity of CHD.

CONCLUSION

There are a variety of ways to measure PA in children with CHD. In the articles that objectively evaluated PA, the most measured outcome was the MVPA, which shows that the MVPA time was shorter in about half of the children with CHD than what is recommended by WHO.

Children with congenital heart disease exhibit seasonal variation in physical activity

OBJECTIVE

We sought to identify seasonal variation in physical activity that different physical activity measurement tools can capture in children with congenital heart disease.

METHODS

Data were collected as part of a prospective cohort study at BC Children's Hospital, Vancouver, Canada. Daily step counts of children aged 9-16 years with moderate-to-severe CHD were assessed continuously for 1-year via a commercial activity tracker (Fitbit Charge 2™). Physical activity levels were also assessed conventionally at one time-point via accelerometers (ActiGraph) and physical activity questionnaires.

RESULTS

156 children (mean age 12.7±2.4 years; 42% female) participated in the study. Fitbit data (n = 96) over a 1-year period clearly illustrated seasonal peaks (late spring and autumn) and dips (winter and summer school holidays) in physical activity levels, with group mean values being below 12,000 steps per day throughout the year. According to conventional accelerometry data (n = 142), 26% met guidelines, which tended to differ according to season of measurement (spring: 39%, summer: 11%, fall: 20%, winter: 39%; p-value = 0.053). Questionnaire data (n = 134) identified that the most widely reported activities were walking (81%) and running (78%) with walking being the highest in summer and fall and running in winter and spring. Furthermore, regardless of overall activity levels the children exhibit similar seasonal variation.

CONCLUSIONS

We demonstrated that physical activity level changes across seasons in children with CHD. It is important to be aware of these fluctuations when assessing and interpreting physical activity levels. Season specific counselling for physical activity may be beneficial in a clinical setting.

Cardiac rehabilitation in the paediatric Fontan population: development of a home-based high-intensity interval training programme

INTRODUCTION

We evaluated the safety and feasibility of high-intensity interval training via a novel telemedicine ergometer (MedBIKE™) in children with Fontan physiology.

METHODS

The MedBIKE™ is a custom telemedicine ergometer, incorporating a video game platform and live feed of patient video/audio, electrocardiography, pulse oximetry, and power output, for remote medical supervision and modulation of work. There were three study phases: (I) exercise workload comparison between the MedBIKE™ and a standard cardiopulmonary exercise ergometer in 10 healthy adults. (II) In-hospital safety, feasibility, and user experience (via questionnaire) assessment of a MedBIKE™ high-intensity interval training protocol in children with Fontan physiology. (III) Eight-week home-based high-intensity interval trial programme in two participants with Fontan physiology.

RESULTS

There was good agreement in oxygen consumption during graded exercise at matched work rates between the cardiopulmonary exercise ergometer and MedBIKE™ (1.1 ± 0.5 L/minute versus 1.1 ± 0.5 L/minute, p = 0.44). Ten youth with Fontan physiology (11.5 ± 1.8 years old) completed a MedBIKE™ high-intensity interval training session with no adverse events. The participants found the MedBIKE™ to be enjoyable and easy to navigate. In two participants, the 8-week home-based protocol was tolerated well with completion of 23/24 (96%) and 24/24 (100%) of sessions, respectively, and no adverse events across the 47 sessions in total.

CONCLUSION

The MedBIKE™ resulted in similar physiological responses as compared to a cardiopulmonary exercise test ergometer and the high-intensity interval training protocol was safe, feasible, and enjoyable in youth with Fontan physiology. A randomised-controlled trial of a home-based high-intensity interval training exercise intervention using the MedBIKE™ will next be undertaken.

Physical Activity Patterns in Children and Adolescents With Heart Disease

PURPOSE

To quantify the differences in daily physical activity (PA) patterns, intensity-specific volumes, and PA bouts in youth with and without heart disease (HD).

METHODS

Seven-day PA was measured on children/adolescents with HD (n = 34; median age 12.4 y; 61.8% male; 70.6% single ventricle, 17.7% heart failure, and 11.8% pulmonary hypertension) and controls without HD (n = 22; median age 12.3 y; 59.1% male). Mean counts per minute were classified as sedentary, light, and moderate to vigorous PA (MVPA), and bouts of MVPA were calculated. PA was calculated separately for each hour of wear time from 8:00 to 22:00. Multilevel linear mixed modeling compared the outcomes, stratifying by group, time of day, and day part (presented as median percentage of valid wear time [interquartile range]).

RESULTS

Compared with the controls, the HD group had more light PA (33.9% [15%] vs 29.6% [9.5%]), less MVPA (1.7% [2.5%] vs 3.2% [3.3%]), and more sporadic bouts (97.4% [5.7%] vs 89.9% [9.2%]), but fewer short (2.0% [3.9%] vs 7.1% [5.7%]) and medium-to-long bouts (0.0% [1.9%] vs 1.6% [4.6%]) of MVPA. The HD group was less active in the late afternoon, between 15:00 and 17:00 (P < .03). There were no differences between groups in sedentary time.

CONCLUSION

Children/adolescents with HD exhibit differences in intensity-specific volumes, PA bouts, and daily PA patterns compared with controls.

Added sugar and trans fatty acid intake and sedentary behavior were associated with excess total-body and central adiposity in children and adolescents with congenital heart disease

BACKGROUND

Over the past three decades, the prevalence rate of overweight and obesity has increased in survivors with congenital heart disease, and little is known about the body composition and its association with clinical characteristics and lifestyle factors.

OBJECTIVES

To evaluate excess total-body adiposity and central adiposity and, to describe associated factors.

METHODS

Cross-sectional study with children and adolescents who underwent procedure to treat congenital heart disease, from January to July 2017. Sociodemographic and clinical characteristics, and lifestyle factors (dietary intake, physical activity, and sedentary behavior) were assessed. Adiposity was assessed using air-displacement plethysmography and waist circumference. Factors associated with excess total-body adiposity and central adiposity were analyzed using logistic regression models.

RESULTS

Of 232 patients, 22.4% were identified with excess total-body adiposity and 24.6% with central adiposity. Significant factors positively associated with excess total-body adiposity were intake of added sugar and trans fatty acids, adjusted for confounding factors. Similarly, lifestyle factors were positively associated with central adiposity: intake of added sugar and trans fatty acids, sedentary behavior, and family history of obesity.

CONCLUSIONS

Lifestyle factors were associated with excess total-body adiposity and central adiposity. Assessment of body composition and healthy-lifestyle counseling into outpatient care may be the key point to prevent obesity in children and adolescents with congenital heart disease.

A cardiovascular disease risk factor in children with congenital heart disease: unmasking elevated waist circumference - a CHAMPS* study *CHAMPS: Children's Healthy-Heart Activity Monitoring Program in Saskatchewan

BACKGROUND

Children with congenital heart disease (CHD) have an elevated risk of future cardiovascular disease but the underlying mechanisms are unclear. Abdominal obesity (measured as waist circumference) is a risk factor for adult onset of cardiovascular diseases and is correlated with low physical activity levels, commonly found in children with congenital heart disease. Elevated waist circumference may be a mechanism by which cardiovascular disease risk is elevated in children with CHD. The purpose of this study was to compare waist circumference between children with and without CHD, while considering potential confounders. We hypothesized that children with CHD would have higher measures of waist circumference when controlling for differences in birthweight, lean mass, and physical activity.

METHODS

Thirty-two children with CHD (10.9 ± 2.6 years; 12 female) from the Children's Healthy-Heart Activity Monitoring Program in Saskatchewan, and 23 healthy controls (11.7 ± 2.5 years; 10 female) were studied. Waist circumference, physical activity (physical activity questionnaire), body composition (lean mass; dual x-ray absorptiometry), and birthweight were assessed. Analysis of covariance, Mann-Whitney U, and independent sample t-tests were used to assess group differences (p < 0.05).

RESULTS

Children with CHD had greater waist circumference than controls, controlling for lean mass, physical activity, birthweight, and sex (F (1, 49) = 4.488, p = 0.039). Physical activity, lean mass, and birthweight were not significantly different between groups (p > 0.05).

CONCLUSION

Our findings generate a novel hypothesis-higher waist circumferences in children with CHD compared to age-matched controls, may contribute to an elevated risk of cardiovascular disease.

Physical Activity Among Children With Congenital Heart Defects in Germany: A Nationwide Survey

Objective: In children with congenital heart defects (CHD), a sedentary lifestyle should be avoided and usually WHO recommendations on physical activity (PA) are supposed to be followed. In order to obtain representative data of the actual amount of PA (and potential influencing factors) in children with CHD we performed a nationwide online survey. Methods: All patients aged 6-17 years registered in the German National Register for CHD were contacted by email and asked to participate in the survey using the comprehensive questionnaire of the "Motorik-Modul" from the German Health Interview and Examination Survey for Children and Adolescents (KiGGS), thus allowing the comparison with a representative age-matched subset of 3.385 participants of the KiGGS study. The questionnaire for CHD-patients was amended by specific questions regarding medical care, sports recommendations and PA restrictions. Results: Complete datasets of 1.198 patients (mean age of 11.6 ± 3.1 years) were available for evaluation. Compared to the reference group, CHD patients significantly less frequently reached the WHO recommended level of 60 min of daily PA (8.8 vs. 12%; p < 0.001). Enjoyment in sports was almost equally distributed across CHD and reference groups, and strongly correlated with the level of PA (r = 0.41; p < 0.001). Remarkably, 49.2% of children with complex CHD, 31.7% with moderate, and even 13.1% with simple CHD were advised by their physician to restrict PA. Conclusions: According to this nationwide survey, PA is markedly reduced in children with CHD. An important reason for this might be an unexpected high rate of physician-recommended restrictions on levels of PA.