Children subjected to cardiac surgery for congenital heart disease. Part 1 - emotional and psychological outcomes

Potential role of salivary cortisol levels to reflect stress response in children undergoing congenital heart surgery

AIM

This study aimed to provide baseline information on the potential role of salivary cortisol in reflecting the stress response in children undergoing congenital heart surgery.

PATIENTS AND METHODS

Children underwent congenital cardiac surgery, aged between one and seventeen years were included. Saliva samples were collected pre- and postoperatively by the health caregiver immediately after the children woke up (07:00-09:00 am) and at 06:00 pm in the evening. Salivary cortisol levels were compared with the reference index values from a large database.

RESULTS

Median baseline preoperative morning salivary cortisol levels were significantly lower than the reference values in both < 5-year-old females (p = 0.01) and males (p = 0.04) and in males between 11 and 20 years of age (p = 0.01). Median baseline preoperative evening salivary cortisol levels were significantly higher than the reference value in < 5-year-old females (p = 0.01) and between 5 and 10 years of age (p = 0.04) and in between 11- and20-year-old males (p = 0.01). Median postoperative morning salivary cortisol levels were significantly lower than the reference value in both < 5-year-old females (p = 0.01) and males (p = 0.04) and females between 5 and 10 year of age (p = 0.04). Median postoperative evening salivary cortisol levels were significantly higher than the reference value in < 5-year-old females (p = 0.01) and between 5- and 10-year-old females (p = 0.04).

CONCLUSION

Diurnal variability of salivary cortisol levels in children undergoing congenital heart surgery may be different from normal reference values both in preoperative and postoperative periods that can be a predictive indicator of anxiety on pre- and postoperative period for children that undergoing cardiac surgery.

Psychosocial Impact of Congenital Heart Diseases on Patients and Their Families: A Parent's Perspective

BACKGROUND

Currently, over 90% of children with congenital heart disease (CHD) survive into adulthood. As a consequence the psychosocial impact on children and their families has become an important outcome measure. Therefore, the goal of this study was to assess the psychosocial impact from a parent's perspective and to identify possible predictors.

METHODS

We included all parents of children who underwent open-heart surgery in the years 2010 and 2011 at the Department of Cardiothoracic Surgery at University Hospital Heidelberg and invited them to complete standardized questionnaires. Psychosocial outcome was measured via parent self- and proxy reporting of family burden (Family Burden Questionnaire, FaBel), health-related quality of life (KidScreen-10), developmental problems (Five-to-Fifteen, FTF), and mental health problems (Strength and Difficulties Questionnaire, SDQ).

RESULTS

In total, 113 families returned the questionnaires completely (71.5%). The Aristotle Basic Complexity score and the STAT 2020 Score overall did not predict the psychosocial impact, whereas the number of surgical operations did significantly predict psychosocial impact across all domains in this study cohort.

CONCLUSIONS

These data suggest that the number of surgical operations might be a relevant predictor for the long-term psychosocial impact on families suffering from CHD and a potential connecting factor for specialized psychological support. When setting up screening instruments or support programs the entire family must be considered.

ADHD symptomatology of children with congenital heart disease 10 years after cardiac surgery: the role of age at operation

BACKGROUND

The aim of the present study was to investigate the differences in ADHD symptomatology between healthy controls and children who underwent cardiac surgery at different ages.

METHODS

Altogether, 133 children (54 patients with congenital heart disease undergoing first cardiac surgery under 3 years of age, 26 operated at the age of 3 or later, and 53 healthy controls) were examined. Patients completed the Youth Self Report (YSR), while their parents completed the Child Behaviour Checklist (CBCL) and the ADHD Rating Scale-IV.

RESULTS

Children receiving surgery for the first time under the age of 3 years were more likely diagnosed with cyanotic type malformation and have undergone to a greater number of operations. However, ADHD symptoms of those treated surgically at or above 3 years of age were more severe than that of the control group or those who were treated surgically at a younger age. The control group and those treated surgically below the age of three did not differ across any of the ADHD symptom severity indicators.

CONCLUSIONS

The age at the time of cardiac surgery might be associated with later ADHD symptom severity - with lower age at operation associated with better outcomes. Further, adequately powered studies are needed to confirm these exploratory findings and investigate the moderators of this relationship.

The Experiences of Parents of Children Undergoing Surgery for Congenital Heart Defects: A Holistic Model of Care

The present article is based on a qualitative study focusing on parents of children born with congenital heart defects (CHDs) and hospitalized in the children's intensive care unit post-surgery. Our aim was to explore parents' subjective experiences as primary caregivers. Ten semi-structured interviews were conducted and analyzed using interpretative phenomenological analysis according to the instructions of Smith and Osborn. Our analysis yielded eight categories which were grouped into four themes and two main superordinate themes: (1) dialectical tension between positive and negative experiences; and (2) fluctuations between the inner and the outer world. The two superordinate themes intersect such that parents report positive as well as negative experiences within both their inner and outer worlds. Based on our analysis, we found that the experience of having a child undergo surgery for a CHD can be regarded as a chaotic period characterized by uncertainty, confusion, and helplessness. It is therefore no surprise that many parents display negative psychological outcomes which extend beyond the period of hospitalization and may also affect their future parenting and coping. However, within this chaotic and stressful situation, parents had occasional supportive experiences which decreased their emotional distress and isolation and helped them throughout this difficult period. We thus conclude that the support offered to parents during the hospitalization period should be increased by trying to minimize their negative experiences and strengthen their inner coping abilities. These changes cannot be implemented without also addressing the needs of the medical staff in their role as caregivers. Therefore, we propose a holistic model of care which supports both parents as caregivers of children undergoing surgery for CHD and the medical staff involved in their care.

Resilience in children and their parents enduring pediatric medical traumatic stress

Due to the general lack of familiarity with the concept in the medical field, resilience is rarely considered in pediatric medical traumas. Resilience is an ability that enables recovery after adversities such as traumas, surgeries, serious health problems, or social issues. Stress from medical traumas encompasses both the psychological and physical responses of children and their families. Lack of resilience in children with medical traumatic stress may contribute to poor adjustment, slow recovery, disruptive behaviors, and psychiatric disorders. Furthermore, persistent parental distress increases the child's risk of low resilience. Consequently, these patients and their parents require early identification. This is achievable using a common stress measure such as the Perceived Stress Scale. Moreover, health care providers can screen patients' risks for low resilience, which include few social contacts, poor family functioning, and low cohesion among family members. Findings from the stress scale and screened risks could indicate the need for additional psychosocial support at the time of diagnosis of a serious illness, soon after injuries, and before and after operations. Such interventions can include decreasing distress, counseling children and their parents, and enabling strong connections to health care providers. Health care providers can help parents to minimize distress and adjust to their child's illness, thereby supporting the child's resilience, adjustment, and recovery.

Maternal Distress and Infant Social Withdrawal (ADBB) Following Infant Cardiac Surgery for Congenital Heart Disease

Background:

Mothers and infants are exposed to multiple stresses when cardiac surgery is required for the infant. This study reviewed infant responsiveness using a standardized objective observational measure of social withdrawal and explored its association with measures of maternal distress.

Methods:

Mother–infant pairs involving infants surviving early cardiac surgery were assessed when the infant was aged two months. Infant social withdrawal was measured using the Alarm Distress Baby Scale. Maternal distress was assessed using self-report measures for maternal depression (Edinburgh Postnatal Depression Scale), anxiety (Spielberger State-Trait Anxiety Scale), and parenting stress (Parenting Stress Index–Short Form). Potential associations between infant social withdrawal and maternal distress were evaluated.

Results:

High levels of maternal distress and infant social withdrawal were identified relative to community norms with a positive association. Such an association was not found between infant social withdrawal and the cardiac abnormality and surgery performed.

Conclusion:

The vulnerability of infants requiring cardiac surgery may be better understood when factors beyond their medical condition are considered. The findings suggested an association between maternal distress and infant social withdrawal, which may be consistent with mothers’ distress placing infants subjected to cardiac surgery at substantially increased risk of social withdrawal. However, it is unclear to what extent infant withdrawal may trigger maternal distress and what the interactive effects are. Further research is warranted. Trialing a mother–infant support program may be helpful in alleviating distress and improving the well-being and outcomes for these families.

The CHIP-Family study to improve the psychosocial wellbeing of young children with congenital heart disease and their families: design of a randomized controlled trial

BACKGROUND

Children with congenital heart disease (CHD) are at increased risk for behavioral, emotional, and cognitive problems. They often have reduced exercise capacity and participate less in sports, which is associated with a lower quality of life. Starting school may present more challenges for children with CHD and their families than for families with healthy children. Moreover, parents of children with CHD are at risk for psychosocial problems. Therefore, a family-centered psychosocial intervention for children with CHD when starting school is needed. Until now, the 'Congenital Heart Disease Intervention Program (CHIP) - School' is the only evidence-based intervention in this field. However, CHIP-School targeted parents only and resulted in non-significant, though positive, effects as to child psychosocial wellbeing. Hence, we expanded CHIP by adding a specific child module and including siblings, creating the CHIP-Family intervention. The CHIP-Family study aims to (1) test the effects of CHIP-Family on parental mental health and psychosocial wellbeing of CHD-children and to (2) identify baseline psychosocial and medical predictors for the effectiveness of CHIP-Family.

METHODS

We will conduct a single-blinded randomized controlled trial comparing the effects of CHIP-Family with care as usual (no psychosocial intervention). Children with CHD (4-7 years old) who are starting or attending kindergarten or primary school (first or second year) at the time of first assessment and their families are eligible. CHIP-Family consists of a separate one-day workshop for parents and children. The child workshop consists of psychological exercises based on the evidence-based cognitive behavioral therapy Fun FRIENDS protocol and sports exercises. The parent workshop focuses on problem prevention therapy, psychoeducation, general parenting skills, skills specific to parenting a child with CHD, and medical issues. Approximately 4 weeks after the workshop, parents receive an individual follow-up session. The baseline (T1) and follow-up assessment (T2 = 6 months after T1) consist of online questionnaires filled out by the child, parents, and teacher (T2 only). Primary outcome measures are the CBCL for children and the SCL-90-R for parents.

DISCUSSION

This trial aims to test the effects of an early family-centered psychosocial intervention to meet the compelling need of young children with CHD and their families to prevent (further) problems. If CHIP-Family proves to be effective, it should be structurally implemented in standard care.

TRIAL REGISTRATION

Dutch Trial Registry; NTR6063 on 23 August, 2016.

Predictors of health-related quality of life in children with chronic heart disease

OBJECTIVE

Chronic paediatric heart disease is often associated with residual symptoms, persisting functional restrictions, and late sequelae for psychosocial development. It is, therefore, increasingly important to evaluate the health-related quality of life of children and adolescents with chronic heart disease. The aim of this study was to determine medical and socio-demographic variables affecting health-related quality of life in school-aged children and adolescents with chronic heart disease. Patients and methods The Pediatric Cardiac Quality of Life Inventory was administered to 375 children and adolescents and 386 parental caregivers. Medical information was obtained from the charts. The socio-demographic information was provided by the patients and caregivers.

RESULTS

Greater disease severity, low school attendance, current cardiac medication, current parental employment, uncertain or limited prognosis, history of connection to a heart-lung machine, number of nights spent in a hospital, and need for treatment in a paediatric aftercare clinic independently contributed to lower health-related quality of life (self-report: R2=0.41; proxy-report: R2=0.46). High correlations between self-reports and parent-proxy reports indicated concordance regarding the evaluation of a child's health-related quality of life.

CONCLUSIONS

Beyond medical treatment, integration into school is important to increase health-related quality of life in children and adolescents surviving with chronic heart disease. Regular screening of health-related quality of life is recommended to identify patients with special needs.

Psychosocial needs of children undergoing an invasive procedure for a CHD and their parents

OBJECTIVE

The aim of this study was to investigate the psychosocial needs of both parents of children with CHD (aged 0-18 years) and patients themselves (aged 8-18 years) in the week before cardiac surgery or a catheter intervention. Patients Eligible participants included all consecutive patients (0-18 years) scheduled to undergo cardiac surgery or a catheter intervention in our hospital between March, 2012 and July, 2013. Psychosocial needs were assessed using a disease-specific questionnaire designed for this study, consisting of a 83-item parent version and a 59-item child version (for children ⩾8 years), each covering five domains: physical/medical, emotional, social, educational/occupational, and health behaviour; two items assessed from whom and in what format psychosocial care was preferred. Quality of life was also assessed. Interventions If parents/patients reported a need for psychosocial care, referral to adequate mental health-care professionals was arranged.

RESULTS

More than 40% of participating parents and >50% of participating children reported a need for psychosocial care on each of the five domains. Needs for psychosocial care for parents themselves were highest for those with children aged 0-12 years. Parents and patients report clear preferences when asked from whom and in what format they would like to receive psychosocial care. Quality of life was relatively high for both parents and patients. Psychosocial care interventions in our hospital increased significantly after the implementation of this study.

CONCLUSIONS

Results show that psychosocial care is rated as (very) important by both parents and children during an extremely stressful period of their life.

Prediction of preschool functional abilities after early complex cardiac surgery

BACKGROUND

It is important to identify early predictors of functional limitations in children after congenital heart surgery to optimise their independence as they prepare for school. The purpose of this study is to determine potentially modifiable predictor variables of functional abilities in pre-school children who underwent complex cardiac surgery at 6 weeks of age or earlier.

METHODS

This prospective inception cohort study comprised a sample of 165 survivors (63% boys) who had complex cardiac surgery (75% biventricular repairs) at Stollery Children's Hospital, Edmonton, Alberta. We excluded children with chromosomal abnormalities. When children were 4-5 years of age, the parents completed the Adaptive Behavioral Assessment System II. Regression analysis was used to assess the association between multiple risk factors and each of the four continuous composite scores.

RESULTS

The mean scores for the practical domain and general adaptive composite score of the Adaptive Behavioural Assessment System were lower than the conceptual and social domains, with 13.3% of the children having a delay in the practical domain. There was a significant association between the general adaptive (p=0.003; 0.012), conceptual (p=0.0004; 0.042), social (p=0.0007; 0.028), and the practical (p=0.046; 0.003) domain composite scores with the mother's education and preoperative plasma lactate, respectively.

CONCLUSION

Maternal education may be a marker for the social context of children, and warrants societal attention to improve functional outcomes. Preoperative lactate as a potentially modifiable variable may warrant increased attention to early diagnosis and aggressive resuscitation of young infants with congenital heart disease.

Self-representation of children suffering from congenital heart disease and maternal competence

Child development may be subject to forms of motor, physical, cognitive and self-representation impairments when complex congenital heart disease (CHD) occurs. In some cases, inadequacy of both self-representation as well as the family system are displayed. It seems to be important to search the likely internal and external resources of the CHD child, and the possible connections among such resources, which may help him/her to manage his/her own risk condition. The research project inquires the possible resources related to the self-representation and self-esteem levels of the CHD child, and those related to maternal self-perception as competent mothers. A group of 25 children (mean age = 10.2; SD=1.8) suffering from specific forms of CHD, and a group made up of their relative mothers (mean age = 38.2; SD=5) were studied. The tools used were the Human Figure Drawing, to investigate child body-related self-representation; the TMA scale (Self-esteem Multidimensional Test), to investigate the child's self-esteem; and the Q-sort questionnaire, to assess how mothers perceived their maternal competence. Data concerning the likely correlations between the child's self-representation and the maternal role competence show [that] positive correlations between some indicators of maternal competence, specific aspects of CHD children's self-representation (mothers' emotional coping and children's self-image adequacy) and self-esteem (mothers' emotional scaffolding and children's self-esteem at an emotional level). By detecting the occurrence of specific correlations among resources of both child and mother, the study provides cardiologists with information that is useful for building a relationship with the families concerned, which would seem to enhance the quality of the process of the cure itself.

Does the severity of congenital heart defects affect disease-specific health-related quality of life in children in Bosnia and Herzegovina?

The aim of this study was to assess whether the severity of congenital heart defects (CHD) affects disease-specific health-related quality of life (HRQOL) in children after open heart surgery. One hundred and fourteen children with CHD and one of their parents participated in the study. HRQOL was evaluated by the PedsQL 3.0 Cardiac Module. The children were assigned to one of three groups according to severity of CHD. Children with cyanotic CHD (Group 3) reported that their HRQOL on several domains was lower than that of children with anomalies with the left-right shunt and children with obstructive anomalies. Also, by parent proxy-report, patients with anomalies with the left-right shunt had statistically significant, better HRQOL scores for the heart problems and treatment scales, perceived physical appearance, treatment anxiety, cognitive problems, and communication scales in comparison to the children with cyanotic CHD. By self-report, children of Group 1 reported that they had statistically significant, better HRQOL in the heart problems and treatment scales compared with Group 2.

CONCLUSIONS

The results of the assessment by the PedsQL 3.0 Cardiac Module, a cardiac disease-specific instrument for children with CHD, indicate that HRQOL is poorest in children with complex CHD. Therefore, it is necessary to take the appropriate preventive measures for these patients, which include early (timely) cardiosurgical intervention and active psychological support to limit the negative impact of serious forms of CHD on the quality of life of these children.