Parental anxiety related to referral of childhood heart murmur; an observational/interventional study

Anxiety levels in parents of asymptomatic neonates and young infants referred for echocardiography

INTRODUCTION

Previous studies in children with innocent murmurs have shown that parental concern is common.

METHODS

We assessed the anxiety levels among parents of asymptomatic neonates or infants up-to 6 weeks referred for cardiologic consultation because of a heart murmur. A six-item short-form of the state scale of the Spielberger State-Trait Anxiety Inventory (STAI) was completed by the parents before and after consultation.

RESULTS

The average STAI score decreased from 14.42 ± 4.54 on arrival to 9.69 ± 4.26 after the consultation (p < 0.001). Overall, the parents felt more calm, less tense, less upset, more relaxed, more content and less worried after the consultation (p < 0.001). Multivariable linear regression analysis showed that the STAI score prior to consultation was related to infants age (coefficient β = - 0.172; P = 0.046) and STAI score post consultation was related to the final diagnosis (β = 0.312; P < 0.001).

CONCLUSION

In conclusion, parents of asymptomatic neonates and young infants with a murmur exhibit moderate levels of anxiety which can be ameliorated after consultation. Parental education in the field is of paramount importance and the role of both paediatric cardiologists as well as primary care physicians is crucial and decisive.

Parental anxiety and misperceptions in children with innocent murmurs

BACKGROUND

Previous studies in children with innocent murmurs have shown that parental concern is common. Our aim was to assess the level of anxiety among parents of children referred for cardiology evaluation because of an innocent heart murmur and investigate their perceptions about innocent murmurs.

METHODS

A questionnaire was completed by parents before and after consultation. The questionnaire included a six-item short form of the state scale of the Spielberger State-Trait Anxiety Inventory. After the echocardiogram, a detailed consultation was offered including a thorough explanation that the results were normal, as well as a written report.

RESULTS

A total of 417 questionnaires were completed by parents of 340 children. Almost half of the parents believed that a heart murmur signifies heart disease or may interfere with child's ability to exercise; 21% of them stated that the siblings should also be investigated irrespective of the presence of a murmur. The mean Spielberger State-Trait Anxiety Inventory questionnaire score before pediatric cardiology consultation was 17.1 ± 4.3 and increased to 22.6 ± 2.8 after the consultation (Wilcoxon P < 0.001).

CONCLUSIONS

Parents of infants and children with innocent murmurs exhibit moderate levels of anxiety and this condition can be ameliorated significantly after pediatric cardiology consultation. Focused parental education is of paramount importance and the role of pediatric cardiologists is crucial and decisive.

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.

Parent-directed intervention versus controls whilst their child waits for diagnostic assessment: a systematic review protocol

BACKGROUND

Waiting lists are an ongoing issue for publicly funded community and hospital-based health services. Parents and caregivers are instrumental supports in the health and well-being of young and school-aged children, yet little is known about the way they can be supported during waiting periods. Given mounting evidence about the value of early intervention in physical and mental health literature, and waits for some public health services extending past 12 months, it is both timely and warranted to explore interim interventions that may be applied in this period.

METHODS

Intervention studies that have applied an educational programme, information, group-based support or individualised therapy to primary caregivers of children (heron referred to as parent-directed interventions), waiting for diagnostic assessment at any inpatient or outpatient health service and aged between 1 and 12 years of age, will be reviewed. These will include intervention studies of any type that have included more than 5 participants or participant groups and where a control or comparison group has been included. Abstract screening, full-text review, data extraction and risk of bias will be conducted by two reviewers. Relevant databases in health and education will be systematically searched using key words and Medical Subject Headings (MeSH) and grey literature will be explored. Databases will include PubMed, Ovid for MEDLINE and PsycINFO, EBSCO for the Cumulative Index of Nursing and Allied Health Literature (CINAHL), and the Education Resources Information Center (ERIC). Covidence© will be used to support abstract and full text screening, which will be completed by two main reviewers. Results will be tabulated, summarised and meta-analysed using a random-effects model, in any instance where concordant outcome measures have been applied. Results will be published and reported in line with PRISMA reporting guidelines.

DISCUSSION

Given little is known about effective support for families when children are awaiting diagnostic assessment for any medical, developmental or behavioural condition, the authors will synthesise existing evidence about parent-directed interventions in this period. It is hoped that by understanding the existing evidence interventions that are proven to be effective will be adopted and intervention innovation can occur.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2020 CRD42020159360.

Parents of Very Young Children with Congenital Heart Defects Report Good Quality of Life for Their Children and Families Regardless of Defect Severity

The purpose of this study was to investigate parent reports of quality of life for their very young children with congenital heart defects (CHD) and to compare their scores to previously published data. Parents of children 1-3 years old with CHD or innocent heart murmurs completed the Pediatric Quality of Life Inventory (PedsQL) core, cardiac, and family impact modules. Multivariable regression analyses assessed the impact of age, sex, family income, and CHD treatment history (study group) on PedsQL scores. Correlations between family impact and core/cardiac modules were examined. PedsQL scores were compared to healthy norms. 140 parents of young children participated within four study groups: CHD no treatment (n = 44), CHD treatment without bypass (n = 26), CHD treatment with bypass (n = 42) ,and innocent heart murmurs (n = 28). Male sex was associated with higher core (F = 4.16, p = 0.04, σ² = .03) and cardiac quality of life (F = 4.41, p = .04, σ² = 0.04). Higher family income was associated with higher family quality of life (F = 8.89, p < .01, σ² = 0.13). Parents of children with innocent heart murmurs and children with CHD not requiring treatment had higher core quality of life compared to young healthy children. Cardiac-related quality of life scores were associated with family impact (r = 0.68) and core module (r = 0.63) quality of life scores. Parents of very young children with CHD report good quality of life for their children and families. Quality of life exceeds in children with innocent murmurs or CHD not requiring repair. Parents report a lower quality of life among girls, and lower family quality of life is associated with lower family income.

Cardiac Murmurs in Children: A Challenge For The Primary Care Physician

Congenital heart disease is present in almost 1% of live births and despite current progress in prenatal screening a significant percentage has delayed diagnosis or remain undiagnosed. A cardiac murmur may be the first or unique clinical sign of congenital heart disease in childhood, however, less than 1% of auscultated murmurs are of an organic cause. Distinguishing between an innocent and a pathologic murmur can be challenging and the experience of the examiner is crucial for identifying the distinctive properties of an innocent murmur. Timely diagnosis of underlying cardiovascular pathology is of great significance so that prompt management is provided and morbidity or mortality are restricted. Of similar importance is the avoidance of unnecessary anxiety for the parents and unreasonable referrals to Paediatric Cardiologists. Indications for referral include a medical history suggestive of a cardiac abnormality, such as the presence of relevant symptoms, the identification of abnormal findings on clinical examination, auscultatory findings suggestive of an organic murmur, and very young patient age. ECG and a chest X-ray are not usually part of the diagnostic approach of a child with a cardiac murmur, as they do not increase the success rate of diagnosing heart disease, as compared to a detailed medical history accompanied by a thorough physical examination. In conclusion, the recognition of suspicious distinctive features of cardiac murmurs is crucial and requires skills based on sufficient training and experience.

Innocent Heart Murmur

Heart murmur is the most common reason for a referral to a pediatric cardiologist. Virtually all children have a heart murmur during their childhood. Less than 1% of murmurs are pathological in children. Innocent/functional heart murmur is the most common type of heart murmur. There are multiple theories proposed to identify etiology of innocent heart murmur with varying consensus, but everybody agrees that innocent heart murmur does not carry any morbidity or mortality risk. Even today, heart murmur is associated with high physician uncertainty and parental anxiety. Extensive cardiac evaluation for such a benign finding is also associated with high health care utilization and cost. This article attempts to review this long-known finding which continues to remain a diagnostic challenge.

Heightened anxiety state among parents of sick children attending emergency department using State-Trait Anxiety Inventory

Background:

The anxiety and stress level of both parent and child seeking treatment at the emergency department is assumed to be high. However, it is rarely quantified as to ascertain any need for intervention.

Objective:

The study seeks to quantify anxiety of parents accompanying sick children presenting acutely to the emergency department and to explore possible pre-visit factors that may contribute to anxiety.

Methods:

A 12-month cross-sectional study was conducted at the Emergency Department, Universiti Kebangsaan Malaysia Medical Centre. All parents accompanying a child presenting to the study location, fitting the inclusion and exclusion criteria, were invited to participate. Parents required to fill a self-administered questionnaire on anxiety, State-Trait Anxiety Inventory and any related factors that can influence anxiety.

Results:

A total of 233 subjects were recruited. The mean state anxiety score was 53.48 ± 11.36, compared to the mean score for trait anxiety of 39.85 ± 7.66, suggesting a heightened state of anxiety. Majority of subjects (65.7%) had reported clinically detected anxiety as defined by state anxiety score above 49. There was no significant association between parental anxiety level with pre-visit factors: children’s age, duration of illness, the presence of co-morbidities, time of presentation, prior medical contact and primary care referral. The child’s state of illness was the dominant psychosocial factor associated with parental anxiety reported by the subjects.

Conclusion:

Parental anxiety upon arrival appeared to be significantly higher than expected, suggesting intervention may be needed.

[Heart murmur in children less than 2 years-old: looking for a safe and effective referral strategy]

INTRODUCTION

Current guidelines in Spain recommend performing transthoracic echocardiography (TTE) in all children under 2 years of age with a heart murmur. In 2014, the American Paediatric Association published the first appropriate use criteria (AUC) for outpatient paediatric transthoracic echocardiography (TTE) to promote its cost-efficient use. The aim of this article is to analyse the AUC and other clinical factors as predictors of congenital heart disease (CHD) in children less than 2 years of age with a heart murmur, and to develop a safe and efficient referral strategy.

PATIENTS AND METHOD

Case-control study conducted with children less than 2 years of age, referred from Paediatric Primary Care to Paediatric Cardiology during a 4-year study. A predictive model for CHD was determined using multivariate analysis.

RESULTS

A total of 688 patients were included, with 129 (19%) cases of CHD. An age less than 3 months (adjusted odds ratio [ORa] 3.8 [1.5-8.4], p=.030) and fulfilling AUC (ORa 16.3 [9.4-28.3], p<.001) were predictors of CHD. Concurrent infection (ORa 0.6 [0.2-0.8], p<.001) and a negative neonatal screening with pulse oximetry (ORa 0.1 [0.05-0.4], p=.001) decreased the risk of CHD. The referral strategy that included these criteria had a 98% sensitivity, 39% specificity, and positive and negative predictive values of 27% and 99%, respectively. It could not diagnose 2% of CHD (all mild), and showed a 32% TTE reduction rate compared to our current strategy.

CONCLUSION

To refer children less than 3 months old, fulfilling AUC, without a concurrent infection, or without negative neonatal pulse oximetry screening, is a safe and efficient strategy for the management of heart murmur in children under 2 years of age.

Auscultation While Standing: A Basic and Reliable Method to Rule Out a Pathologic Heart Murmur in Children

PURPOSE

The distinction between physiologic (innocent) and pathologic (organic) heart murmurs is not always easy in routine practice, leading too often to unnecessary cardiology referrals and expensive investigations. We aimed to test the hypothesis that the complete disappearance of murmur on standing can exclude cardiac disease in children.

METHODS

From January 2014 to January 2015, we prospectively included 194 consecutive children aged 2 to 18 years who were referred for heart murmur evaluation to pediatric cardiologists at 2 French medical centers. Heart murmur characteristics while supine and then while standing were recorded, and an echo-cardiogram was performed.

RESULTS

Overall, 30 (15%) of the 194 children had a pathologic heart murmur as determined by an abnormal echocardiogram. Among the 100 children (51%) who had a murmur that was present while they were supine but completely disappeared when they stood up, only 2 had a pathologic murmur, and just 1 of them needed further evaluation. Complete disappearance of the heart murmur on standing therefore excluded a pathologic murmur with a high positive predictive value of 98% and specificity of 93%, albeit with a lower sensitivity of 60%.

CONCLUSIONS

Disappearance of a heart murmur on standing is a reliable clinical tool for ruling out pathologic heart murmurs in children aged 2 years and older. This basic clinical assessment would avoid many unnecessary referrals to cardiologists.