The Care of Children With Congenital Heart Disease in Their Primary Medical Home

Case Management Implications for Pediatric Patients With Congenital Heart Disease in China: A Randomized Controlled Trial

Objectives. Case management, which is defined as a fully collaborative process that includes evaluation, planning, execution, coordination and supervision, has been widely used in the field of chronic diseases. However, the clinical effect of case management in pediatric patients with congenital heart disease (CHD) is unclear. This study was to explore the effects of case management model in pediatric patients with CHD. Methods. A total of 110 pediatric CHD patients referred to our center from January 2018 to January 2020 were enrolled for analysis. Patients were randomly assigned to a case management (experimental) group or a conventional nursing (control) group. Patient satisfaction, quality of life, and clinical outcomes were compared between the 2 groups. Results. Compared with that in the control group, patient satisfaction rate was significantly greater in the experimental group. Furthermore, the experimental group showed more significant improvement in quality of life than the control group did (73.8 ± 12.3 vs 66.5 ± 14.2, P < .001). In addition, the readmission rate in the experimental group was significantly lower than that in the control group (5% vs 20%, P = .022). Conclusions. Case management mode can be effectively applied in pediatric patients with CHD, which can improve patient satisfaction rate, health-related quality of life and lower the readmission rate.

Quality Improvement Identifies Healthcare Transition Disparities in Adolescents with Congenital Heart Disease and Disabilities

Introduction

We aim to implement healthcare transition (HCT) education for youth with congenital heart disease (CHD) and assess HCT preparedness for cardiac self-care.

Methods

An HCT clinic was implemented at an academic pediatric cardiology clinic for CHD youth 17 years of age and older. An educator used transition readiness assessment questionnaires and discussed HCT material. The percentage of eligible youth who received HCT education and the cause for missed occurrences were tracked. Plan-do-study-act cycles began in August 2020 to improve the number of youths reached. Secondary analyses assessed improvement differences among those without cardiac procedures or disabilities.

Results

HCT education provision improved from a mean of 38% to 73% in the 17-year and older age group by December 2022. Communication failure was the leading cause of missed visits in 2021 (30%), reduced to 0 by 2022 following plan-do-study-act cycles. Other missed HCT visits included clinic add-ons after screening, limited staff availability, and unidentified eligibility. Readiness assessments were similar for youth with and without prior cardiac procedures, for example, confidence in taking charge of their health care (P = 0.47) and moving to adult care (P = 0.22). Adolescents with disabilities were significantly less confident than those without disabilities in taking charge of their heart health care (6.3 versus 7.5, P = 0.04) and moving to adult care (4.9 versus 7.4, P < 0.001).

Conclusions

Implementation of a CHD HCT clinic improved successful education delivery. Provider engagement and clinic staffing are important for sustainability. HCT knowledge gaps exist for all adolescents, yet those with disabilities had the greatest deficits.

Assessment of Disaster Preparedness at the Household Level in a Pediatric Cardiology Clinic Population

Natural and human-provoked disasters pose serious health risks to children, particularly children and youth with special healthcare needs, including many cardiology patients. The American Academy of Pediatrics (AAP) provides preparedness recommendations for families, but little is known about recommendation adherence. Caregivers of children seen in a pediatric cardiology clinic network were recruited to complete an electronic survey. Participants self-reported child medical history and their household's implementation of AAP recommended disaster preparedness items. Families received a link to AAP resources and a child ID card. Data were analyzed using descriptive statistics with Fisher's exact and Wilcoxon rank sum tests. 320 caregivers participated in the study, of whom 124 (38.8%) indicated that their child has a diagnosed cardiac condition, and 150 (46.9%) indicated that their child had special healthcare needs. The average preparedness item completion rate was 70.7% for household preparedness, 40.1% for reunification preparedness, and 26.3% for community preparedness. Households of children with medical needs had similar rates of preparedness compared to overall rates. Of all respondents, 27.8% previously received disaster preparedness resources, 67.7% would like resources on discussing disaster preparedness, and 93.0% intend to talk with their household about disaster preparedness after completing the survey. These results demonstrate a gap between AAP recommendations and household-level disaster preparedness, including patients with cardiac conditions and those with special healthcare needs. Families expressed that they were interested in getting resources for disaster preparedness. Pediatric cardiologists may consider asking about disaster preparedness and providing disaster preparedness resources tailored to the needs of their patients.

Congenital Heart Disease

More people are living with congenital heart disease (CHD) because many children now survive to adulthood with advances in medical and surgical treatments. Patients with CHD have ongoing complex health-care needs in the various life stages of infancy, childhood, adolescence, and adulthood. Primary care providers should collaborate with pediatric specialists to provide ongoing care for people living with CHD and to create smooth transitions of care.

SSSH: Responsive soothing bassinet feasibility study for infants with congenital heart disease after cardiac surgery

PURPOSE

For infants with congenital heart disease (CHD) requiring surgery, prolonged hospital stays, intermittent caregiver visitation, and constrained unit staffing ratios present barriers to adequately address post-operative stressors and associated need to retain cognitive and physiological reserves. Similar patients requiring high-engagement interventions, such as hospitalized infants with neonatal abstinence syndrome, have found success in utilizing responsive bassinets to soothe infants and save floor nurses' time. However, it remains unclear if such technology can be leveraged in the CHD population given their complex hemodynamics, feeding intolerance, and monitoring requirements.

METHODS

This multidisciplinary feasibility study evaluated responsive bassinet use in a cohort of infants with CHD <6 months of age in a medical-surgical unit at a midwestern children's hospital. Specifically assessing 1) implementation requirements, challenges, and potential of utilizing the device, together with 2) ability to perform bedside monitoring (monitoring) and 3) measuring physiologic trends during use.

RESULTS

Between 11/2020-1/2022, nine infants utilized a responsive bassinet over 599 h (mean 13, range 4-26 days per infant). No increase in monitoring alarms and accurate vital signs monitoring during bassinet activity were noted with appropriate physiologic responses for infants with single ventricle and biventricular surgeries.

CONCLUSIONS

Feasibility of introducing new technology into care, and successful use of its functionality for soothing was found to be plausible for infants with CHD.

PRACTICE IMPLICATIONS

After cardiac surgery, infants with CHD have need for interventions to reduce stress. Use of a soothing bassinet has the potential to aid in doing so without interference with monitoring requirements.

Psychosocial, neurodevelopmental, and transition of care practices provided to children with CHD across North American cardiac clinics

Children with CHD are at risk for psychosocial and neurodevelopmental difficulties, as well as lapses in care during their transition from paediatric to adult CHD providers. The American Heart Association and American Academy of Pediatrics released guidelines for best practices in the neurodevelopmental and transitional care for children with CHD in 2012 and 2011, respectively. CHD providers from 48 (42.1% response rate) geographically diverse cardiac clinics completed a 31-item electronic survey designed to assess the cardiac teams' consistency with neurodevelopmental evaluation and management recommendations, consultation/liaison patterns for psychosocial services, and procedures regarding transitional services for emerging adults. Responses suggest most cardiac teams refer patients to psychosocial services as needed, and 39.6% of teams screen for psychosocial distress. CHD providers at 66.7% of cardiac clinics reported a formal neurodevelopmental programme/clinic. Nearly half of cardiac teams conduct routine neurodevelopmental evaluations, most frequently occurring at 9 months of age. Less than 10% of cardiac clinics have resources to meet the American Heart Association and American Academy of Pediatrics 2012 neurodevelopmental evaluation and management guidelines. Formal paediatric to adult CHD transition programmes were reported at 70.8% of cardiac clinics and were associated with younger ages of transition to adult CHD care. Care practices varied across the 48 represented cardiac clinics, indicating inconsistent practices for patients with CHD. Barriers and facilitators to the provision of care for children in these areas were reported and are presented. More support is needed for cardiac clinics to continue improvements in psychosocial, neurodevelopmental, and transitional care services.

Medical Home Outcomes for School-Aged Children With Chronic Health Care Needs: A Mokken Analysis

BACKGROUND AND OBJECTIVES

We examined the structure of the medical home construct as well as the association of having a medical home with school outcomes among children with chronic health conditions.

METHODS

The current study utilized a combination of structural equation modeling, item response theory, and Mokken scaling techniques to determine how components of a medical home may be prioritized. The components of an operationally defined medical home were the main measures along with number of missed school days and the degree of interference with a child's school.

RESULTS

Results of the current study provide a clear structure for the components of a medical home using Mokken scaling analyses. These components of a medical home are important as they were associated with fewer missed school days and a lower likelihood of a child's condition interfering with school as reported by parents.

CONCLUSION

With the results of the current study, providers working with schools can quickly discriminate (1) whether a child has a medical home and (2) understand how to guide parents toward a comprehensive medical home by understanding the hierarchy of medical home components.

Evaluation and Management of Noncardiac Comorbidities in Children With Congenital Heart Disease

Outcomes for patients with neonatal heart disease are affected by numerous noncardiac and genetic factors. These can include neonatal concerns, such as prematurity and low birth weight, and congenital anomalies, such as airway, pulmonary, gastrointestinal, and genitourinary anomalies, and genetic syndromes. This section will serve as a summary of these issues and how they may affect the evaluation and management of a neonate with heart disease. These noncardiac factors are heavily influenced by conditions common to neonatologists, making a strong argument for multidisciplinary care with neonatologists, cardiologists, surgeons, anesthesiologists, and cardiovascular intensivists. Through this section and this project, we aim to facilitate a comprehensive approach to the care of neonates with congenital heart disease.

A multi-disciplinary, comprehensive approach to management of children with heterotaxy

Heterotaxy (HTX) is a rare condition of abnormal thoraco-abdominal organ arrangement across the left-right axis of the body. The pathogenesis of HTX includes a derangement of the complex signaling at the left-right organizer early in embryogenesis involving motile and non-motile cilia. It can be inherited as a single-gene disorder, a phenotypic feature of a known genetic syndrome or without any clear genetic etiology. Most patients with HTX have complex cardiovascular malformations requiring surgical intervention. Surgical risks are relatively high due to several serious comorbidities often seen in patients with HTX. Asplenia or functional hyposplenism significantly increase the risk for sepsis and therefore require antimicrobial prophylaxis and immediate medical attention with fever. Intestinal rotation abnormalities are common among patients with HTX, although volvulus is rare and surgical correction carries substantial risk. While routine screening for intestinal malrotation is not recommended, providers and families should promptly address symptoms concerning for volvulus and biliary atresia, another serious morbidity more common among patients with HTX. Many patients with HTX have chronic lung disease and should be screened for primary ciliary dyskinesia, a condition of respiratory cilia impairment leading to bronchiectasis. Mental health and neurodevelopmental conditions need to be carefully considered among this population of patients living with a substantial medical burden. Optimal care of children with HTX requires a cohesive team of primary care providers and experienced subspecialists collaborating to provide compassionate, standardized and evidence-based care. In this statement, subspecialty experts experienced in HTX care and research collaborated to provide expert- and evidence-based suggestions addressing the numerous medical issues affecting children living with HTX.

Do children with congenital heart defects meet the vaccination recommendations? Immunisation in children with congenital heart defects

INTRODUCTION

Congenital heart defects (CHDs) are the most common congenital malformations. Patients with CHD have a higher morbidity and mortality rate and are at greater risk for infectious diseases. The risk might even be higher if complex CHD occurs and if CHD is associated with additional co-morbidities. Therefore, immunisations in these children are essential.

MATERIALS AND METHODS

Individuals were recruited at the outpatient centre of the Department of Congenital Heart Defects and Pediatric Cardiology at the German Heart Center Munich in the time between February 2016 and February 2017. Included were children between 23 months and 17 years and a diagnosis of CHD. The vaccination certificate aimed to assess the immunization status.

RESULTS

In total, 657 children with CHD were included and analysed. Regarding primary immunisation, only 34 % (n = 221) of the children reached the complete vaccination status within the allowed catch-up time. Among these primary immunisation rates, vaccinations against Hepatitis B, Meningococci, Varicella and Pneumococci were found to have the lowest coverage with all being below 80%. The vaccination rate was partly influenced by the previously performed number of surgeries but not by the diagnosis of specific genetic diseases. At the age of school entry, the immunisation rate in children with CHD was also lower than in the comparable healthy population.

CONCLUSION

The vaccination coverage rate in children with CHD is lower than in comparable healthy children, although this is a vulnerable patient group. Further education of parents and treating physicians of children with CHD regarding vaccination is still needed.

A Survey of Immunization Practices in Patients With Congenital Heart Disease

Background

Congenital heart disease, the most common congenital anomaly, often presents in neonates. Because of perceived risks, health care providers may consider deferring immunizations in this population. We sought to understand the perceived risk of immunizations in those providing health care to children with particular heart conditions.

Methods

A survey, which included 6 hypothetical scenarios assessing immunization recommendations, was distributed internationally to relevant health care providers, and responses were compared between the different scenarios.

Results

Majority of responses (n = 142) were from paediatric cardiologists (n = 98; 69%) and nurse practitioners (n = 27; 19%) located in the United States (n = 77; 54%) or Canada (n = 53; 37%) working in academic teaching hospitals (n = 133; 93.7%). Most favoured vaccinations (n = 107; 75.4%) and less likely to proceed with the first immunization in infants with structural heart disease compared with channelopathy (risk ratio: 0.80, confidence interval: 0.73-0.87; P < 0.001). Only 40% would proceed with immunization as normal in an infant with manifest Brugada type I electrocardiogram. Special precautions after the immunization included longer duration of observation (19%) and administering prophylactic antipyretic medication (92%).

Conclusions

Respondents were 20% more likely to defer immunizations in the presence of treatable structural heart disease as compared with channelopathy despite the lack of evidence supporting deferring immunizations in children with structural heart disease. Most were cautious in their response to the scenario involving Brugada syndrome, indicating awareness of the risk of haemodynamic instability in the event of a fever. The majority of respondents still strongly recommend immunizations in this population as the benefits outweigh the potential for adverse events.

Making every contact count: recognising obesity in paediatric and young adult cardiology

INTRODUCTION

With increased survival, children with CHD are reaching adulthood, however, obesity amongst this cohort is an emerging problem. Making every contact count encourages clinicians to utilise contact to elicit behaviour change. The aim of this work was to identify whether the body habitus of children classified as obese was addressed during a clinical review.

METHODS

A retrospective observational cohort study was completed using a cardiology outpatient dataset from 2010 to 2019. Inclusion criteria are all children with a body mass index z score classified as obese (≥ 2 z scores). Individual electronic patient records were reviewed to identify long-term anthropometric measures including (i) recognition of body habitus, (ii) prescription of physical activity or dietary intervention, and (iii) referral to a weight management programme or dietitian.

RESULTS

From the cohort of 95 patients, 285 "obese clinical encounters" were identified, at the time of a cardiology clinic attendance. Of those, obesity was acknowledged in 25 clinic letters (8.65%), but only 8 used the correct terms "obese" or "obesity" (2.77%). Action to tackle obesity was recorded in 9.3% of cases with a direct referral to a dietitian being made on 3 occasions (1.04%).

CONCLUSIONS

Body habitus is not being routinely addressed by cardiologists caring for paediatric and young adult cardiac patients. This study has recognised an alarmingly high incidence of missed opportunities to make every contact count, to manage those with obesity and associated risk factors.

Congenital heart disease: Saving lives and securing liveliness with early primary care and expert family care

Pertinent perspectives for practical applications is advantageous professionalism. Congenital heart diseases (CHDs) are of varied types, severity, and complexity. Simple scientific approach along with sophistication is required for successful management at all levels. We gleaned important information from published evidence and authoritative resources and have put things in practical perspective. These include current prevention, care, correction, cure, and rehabilitation strategies for robust practices. Prospective prevention is with preconception counseling and addressing environmental factors. Fetal echocardiography and nondirective genetic counseling are important. Early detection and expert diligence is desirable. The suspicion is clinical. A number of clinical and investigative diagnostic modalities are available and should be utilized as guided by the clinical cues. Medical management includes general health maintenance, immunizations, monitoring, and complications treatment. Pediatric interventional cardiology is making rapid strides and treating many types of lesions. Understanding of procedure done is a prerequisite of follow-up care. Surgery is of curative, reparative, or palliative types. After surgical correction in early childhood long-term sequelae are rare. After reparative surgery some have life-long sequelae and some have significant late impairment. The number of postintervention/surgery survivors into adulthood is increasing. Microsurgical techniques are leading the way for precision and fewer complications. Follow-up care with "Ten Points Information and Action Plan (TP-IAP)" is suggested. The Armed Forces scenario involves frequent movements to difficult and harsh conditions. Special precautions for affected children needed. Cardiovascular health is enhanced by avoiding a sedentary lifestyle and obesity. Various intrinsic and extrinsic factors limiting functioning need to be suitably addressed.

Congenital Heart Disease

Most children with congenital heart disease (CHD) survive to adulthood, owing largely to significant advances in the diagnosis and management of CHD over the past few decades. Primary care providers are essential partners in the recognition and management of these patients in our current medical environment. This article reviews the role of the primary care physician in detecting fetuses, infants, and children with possible CHD. Furthermore, this article discusses common primary care issues arising for patients with CHD, including growth and development, mental illness, dental care, and the transition to adult primary care.

Development of an international standard set of clinical and patient-reported outcomes for children and adults with congenital heart disease: a report from the International Consortium for Health Outcomes Measurement Congenital Heart Disease Working Group

AIMS

Congenital heart disease (CHD) is the most common congenital malformation. Despite the worldwide burden to patient wellbeing and health system resource utilization, tracking of long-term outcomes is lacking, limiting the delivery and measurement of high-value care. To begin transitioning to value-based healthcare in CHD, the International Consortium for Health Outcomes Measurement aligned an international collaborative of CHD experts, patient representatives, and other stakeholders to construct a standard set of outcomes and risk-adjustment variables that are meaningful to patients.

METHODS AND RESULTS

The primary aim was to identify a minimum standard set of outcomes to be used by health systems worldwide. The methodological process included four key steps: (i) develop a working group representative of all CHD stakeholders; (ii) conduct extensive literature reviews to identify scope, outcomes of interest, tools used to measure outcomes, and case-mix adjustment variables; (iii) create the outcome set using a series of multi-round Delphi processes; and (iv) disseminate set worldwide. The Working Group established a 15-item outcome set, incorporating physical, mental, social, and overall health outcomes accompanied by tools for measurement and case-mix adjustment variables. Patients with any CHD diagnoses of all ages are included. Following an open review process, over 80% of patients and providers surveyed agreed with the set in its final form.

CONCLUSION

This is the first international development of a stakeholder-informed standard set of outcomes for CHD. It can serve as a first step for a lifespan outcomes measurement approach to guide benchmarking and improvement among health systems.

How do caregivers of children with congenital heart diseases access and navigate the healthcare system in Ethiopia?

BACKGROUND

Surgery can correct congenital heart defects, but disease management in low- and middle-income countries can be challenging and complex due to a lack of referral system, financial resources, human resources, and infrastructure for surgical and post-operative care. This study investigates the experiences of caregivers of children with CHD accessing the health care system and pediatric cardiac surgery.

METHODS

A qualitative study was conducted at a teaching hospital in Ethiopia. We conducted semi-structured interviews with 13 caregivers of 10 patients with CHD who underwent cardiac surgery. We additionally conducted chart reviews for triangulation and verification. Interviews were conducted in Amharic and then translated into English. Data were analyzed according to the principles of interpretive thematic analysis, informed by the candidacy framework.

RESULTS

The following four observations emerged from the interviews: (a) most patients were diagnosed with CHD at birth if they were born at a health care facility, but for those born at home, CHD was discovered much later (b) many patients experienced misdiagnoses before seeking care at a large hospital, (c) after diagnosis, patients were waiting for the surgery for more than a year, (d) caregivers felt anxious and optimistic once they were able to schedule the surgical date. During the care-seeking journey, caregivers encountered financial constraints, struggled in a fragmented delivery system, and experienced poor service quality.

CONCLUSIONS

Delayed access to care was largely due to the lack of early CHD recognition and financial hardships, related to the inefficient and disorganized health care system. Fee waivers were available to assist low-income children in gaining access to health services or medications, but application information was not readily available. Indirect costs like long-distance travel contributed to this challenge. Overall, improvements must be made for district-level screening and the health care workforce.

Preventive care and medical homes among US children with heart conditions

Within a medical home, primary care providers can identify needs, provide services, and coordinate care for children with heart conditions. Using parent-reported data from the 2016-2017 National Survey of Children's Health, we examined receipt of preventive care in the last 12 months and having a medical home (care that is accessible, continuous, comprehensive, family-centred, coordinated, compassionate, and culturally effective) among US children aged 0-17 years with and without heart conditions. Using the marginal predictions approach to multivariable logistic regression, we examined associations between presence of a heart condition and receipt of preventive care and having a medical home. Among children with heart conditions, we evaluated associations between sociodemographic and health characteristics and receipt of preventive care and having a medical home. Of the 66,971 children included, 2.2% had heart conditions. Receipt of preventive care was reported for more children with heart conditions (91.0%) than without (82.7%) (adjusted prevalence ratio = 1.09, 95% confidence interval: 1.05-1.13). Less than half of children with heart conditions (48.2%) and without (49.5%) had a medical home (adjusted prevalence ratio = 1.02, 95% confidence interval: 0.91-1.14). For children with heart conditions, preventive care was slightly more common among younger children and less common among those with family incomes 200-399% of the federal poverty level. Having a medical home was less common among younger children, non-Hispanic "other" race, and those with ≥2 other health conditions. Most children with heart conditions received preventive care, but less than half had a medical home, with disparities by age, socioeconomic status, race, and concurrent health conditions. These findings highlight opportunities to improve care for children with heart conditions.

Post-operative discharge education for parent caregivers of children with congenital heart disease: a needs assessment

OBJECTIVE

Children with congenital heart disease (CHD) have complex unique post-operative care needs. Limited data assess parents' hospital discharge preparedness and education quality following cardiac surgery. The goals were to identify knowledge gaps in discharge preparedness after congenital heart surgery and to assess the acceptability of an educational mobile application to improve discharge preparedness.

METHODS

Telephonic interviews with parents of children with two-ventricle physiology who underwent cardiac surgery 5-7 days post-discharge and in-person interviews with clinicians were conducted. We collected parent and clinician demographics, parent health literacy information and patient clinical data. We analysed interview transcripts using summative content analysis.

RESULTS

We interviewed 26 parents and 6 clinicians. Twenty-two of the 26 (85%) parents felt ready for discharge; 4 of the 6 (67%) clinicians did not feel most parents were ready for discharge. Fifteen of the 26 parents (58%) reported receiving the majority of discharge teaching on the day of discharge. Eight parents did not feel like all of their questions were answered. Most parents (14/26, 54%) preferred visual educational learning aids and could accurately describe important aspects of care. Most parents (23/26, 88%) and all 6 clinicians felt a mobile application for post-operative care education would be helpful.

CONCLUSIONS

Most parents received education on the day of discharge and could describe the information they received prior to discharge, although there were some preparedness gaps identified after discharge. Clinicians and parents varied in their perceptions of the readiness for discharge. Most responses suggest that a mobile application for discharge education may be helpful for transition to home.

Associations Between Postoperative Management in the Critical Care Unit and Adolescent Developmental Outcomes Following Cardiac Surgery in Infancy: An Exploratory Study

OBJECTIVES

Children with congenital heart disease are at high risk for developmental sequelae. Most studies focus on preoperative and intraoperative predictors of developmental impairment, with less attention to the postoperative period. The relationship between patient-related factors specific to the postoperative course in the PICU following cardiac surgery with long-term neurodevelopmental outcomes in adolescence was examined.

DESIGN

Retrospective chart review of patients previously recruited to a study describing their developmental outcomes in adolescence.

SETTING

Single tertiary care pediatric hospital in Canada.

PATIENTS

Eighty adolescents, born between 1991 and 1999, with congenital heart disease who required open-heart surgery before 2 years old.

MEASUREMENTS AND MAIN RESULTS

Several variables related to acuity of illness and complexity of postoperative course in the PICU were collected. Outcome measures included the Movement-Assessment Battery for Children-2 (motor), Leiter Brief Intelligence Quotient (cognition), and Strength and Difficulties Questionnaire (behavior). Analyses examined associations between PICU variables and long-term outcomes. Longer mechanical ventilation (β = -0.49; p = 0.013) and dopamine use (β = -14.41; p = 0.012) were associated with lower motor scores. Dopamine use was associated with lower cognitive scores (β = -14.02; p = 0.027). Longer PICU stay (β = 0.18; p = 0.002), having an open chest postoperatively (β = 3.83; p = 0.017), longer mechanical ventilation (β = 0.20; p = 0.001), longer inotrope support (β = 0.27; p = 0.002), hours on dopamine (β = 0.01; p = 0.007), days to enteral feeding (β = 0.22; p = 0.012), lower hemoglobin (β = -0.11; p = 0.004), and higher creatinine (β = 0.05; p = 0.014) were all associated with behavioral difficulties.

CONCLUSIONS

Several important developmental outcomes in adolescents were associated with factors related to their postoperative course in the PICU as infants. Findings may highlight those children at highest risk for neurodevelopmental sequelae and suggest new approaches to critical care management following open-heart surgery, with the aim of mitigating or preventing adverse long-term outcomes.

Health-related quality of life in adult CHD surgical patients in a low middle-income country: a mixed-methods study

BACKGROUND AND OBJECTIVES

This mixed-methods study aimed to assess health-related quality of life in young adults with CHD following surgery in a low middle-income country, Pakistan. Despite the knowledge that geographic, cultural and socio-economic factors may shape the way health and illness is experienced and managed and consequently determine a person's health-related quality of life, few health-related quality of life studies are conducted in low middle-income countries. This deficit is pronounced in CHD, so there is little guidance for patient care.

METHODS

The study utilised concurrent, mixed methods. Adults with CHD (n = 59) completed health-related quality of life surveys (PedsQLTM 4.0 Generic Core Scale, PedsQLTM Cognitive Functioning Scale and PedsQLTM 3.0 Cardiac Module). Semi-structured interview data were collected from a nested sub-sample of 17 participants and analysed using qualitative content analysis, guided by the revised Wilson-Cleary model of health-related quality of life.

RESULTS

The lowest health-related quality of life domain was emotional with the mean score (71.61 ± 20.6), followed by physical (78.81 ± 21.18) and heart problem (79.41 ± 18.05). There was no statistical difference in general or cardiac-specific health-related quality of life between mild, moderate or complex CHD. Qualitative findings suggested low health-related quality of life arose from a reduced capacity to contribute to family life including family income and gender. A sense of reduced marriageability and fear of dependency were important socio-cultural considerations.

CONCLUSIONS

CHD surgical patients in this low-income country experience poor health-related quality of life, and contributing factors differ to those reported for high-income countries. Socio-cultural understandings should underpin assessment, management and care-partnering with young adults with CHD following surgical correction.

Perception of general pediatricians in Riyadh towards vaccination of patients with congenital heart diseases

Background:

Congenital heart defected (CHD) children are often predisposed to numerous conditions ranging from arrythmias, infections, to heart failure. Proper implementation of vaccination plan and multidisciplinary acts are mandatory for maintaining such cases to reduce the mortality and morbidity. Furthermore, CHD are also at risk of vaccine adverse reaction and several blooddisseminated pathogens infections, and at risk of death if such events where to occur. Perception and Interpretation of the knowledge and experience of general pediatricians towards vaccination of patients with congenital heart diseases is a crucial element to understand, and to improve healthcare practice in Riyadh, Saudi Arabia.

Aims:

To clarify, our aim is to investigate views of different pediatricians in vaccination plans, to perceive junior and senior pediatricians, and to identify extra vaccines given to children with a congenital heart defect.

Settings and Design:

This study is a cross-sectional study that includes the distribution of 246 questionnaires through personal interview focusing on pediatric cardiologists and general pediatricians with varying years of practice and degrees. Study was conducted by six medical interns: Mohammed O. Alfakhri, Meshal F. Alhajji, Abdulrahman M. Alyani, Yahya Z. Murad, Abdulrahman E. Alghannam, Alwaleed H. Algahtani, in six different teritiary hospitals, King Abdulaziz Medical City (KAMC), King Fahad Medical City (KFMC), King Faisal Specialist Hospital (KFSH), King Salman Hospital, and Alyamamah Hospital, in Riyadh, Saudi Arabia.

Methods and Material:

Data was collected through a convenient sampling technique and was analyzed using SPSS (version 20) and rearranged to observe the most frequent information obtained from the questionnaire.

Statistical Analysis Used:

Categorical study was described in frequencies and bar charts. Chi-Square test of significance was used after the data entry to assess the significance of the values obtained.

Results and Conclusions:

There was no significant difference between the six hospitals. In the following study, 81.7% of the participants believe that patients with congenital heart diseases are combined immunodeficient, and 84.6% agreed on giving special\extra vaccine with no preference over live and\or killed vaccine. On top of that, participants believe that the extra vaccines given to congenital heart disease patients with combined immunodeficiency are meningococcal and pneumococcal vaccines, and the special vaccine given to them are respiratory syncytial virus (RSV) and influenza vaccine. To conclude, congenitally heart defected children are widespread worldwide. Children suffering from the disease are having a serious problem that affects their lives from its earliest. For that, our research mainly focuses on improving their lives by trying to reduce the effect of several other preventable diseases using vaccines as and when they need. Several other studies believed in giving extra/special vaccines that vary depending on the location of the study. However, in Riyadh, we found that most pediatricians agree on giving extra vaccines as meningococcal and pneumococcal, and RSV and influenza as special vaccines to children with congenital heart defects.

Physical Activity Assessment and Counseling in Pediatric Clinical Settings

Physical activity plays an important role in children's cardiovascular health, musculoskeletal health, mental and behavioral health, and physical, social, and cognitive development. Despite the importance in children's lives, pediatricians are unfamiliar with assessment and guidance regarding physical activity in children. With the release of the 2018 Physical Activity Guidelines by the US Department of Health and Human Services, pediatricians play a critical role in encouraging physical activity in children through assessing physical activity and physical literacy; providing guidance toward meeting recommendations by children and their families; advocating for opportunities for physical activity for all children in schools, communities, and hospitals; setting an example and remaining physically active personally; advocating for the use of assessment tools and insurance coverage of physical activity and physical literacy screening; and incorporating physical activity assessment and prescription in medical school curricula.

Call to Action: Rural Health: A Presidential Advisory From the American Heart Association and American Stroke Association

Understanding and addressing the unique health needs of people residing in rural America is critical to the American Heart Association's pursuit of a world with longer, healthier lives. Improving the health of rural populations is consistent with the American Heart Association's commitment to health equity and its focus on social determinants of health to reduce and ideally to eliminate health disparities. This presidential advisory serves as a call to action for the American Heart Association and other stakeholders to make rural populations a priority in programming, research, and policy. This advisory first summarizes existing data on rural populations, communities, and health outcomes; explores 3 major groups of factors underlying urban-rural disparities in health outcomes, including individual factors, social determinants of health, and health delivery system factors; and then proposes a set of solutions spanning health system innovation, policy, and research aimed at improving rural health.

ACOG Committee Opinion No. 778: Newborn Screening and the Role of the Obstetrician-Gynecologist

Newborn screening is the largest genetic screening program in the United States, with approximately 4 million infants screened annually. Newborn screening is a mandatory state-based public health program that provides all newborns in the United States with testing and necessary follow-up health care for a variety of medical conditions. The goal of this public health program is to decrease morbidity and mortality by screening for disorders in which early intervention will improve neonatal and long-term health outcomes. The program's functions include the initial screening of all newborns, identifying screen-positive newborns, diagnosing conditions, communicating with families, ensuring that affected children are referred to treatment centers, following up with long-term outcomes, and educating physicians and the public according to individual state or jurisdictional guidelines. All states and the District of Columbia have newborn screening programs with varying screening panels, policies, statutes, and regulations. Most programs have adopted the guidelines suggested by the Discretionary Advisory Committee on Heritable Disorders in Newborns and Children. Obstetrician-gynecologists and other obstetric care providers should make resources about newborn screening available to patients during pregnancy. Providing newborn screening information during prenatal care visits can be accomplished in several ways and should be adapted to individual practice style. Integrating education about newborn screening into prenatal care allows parents to be prepared for having their child undergo screening as well as for receiving newborn screening test results. This document includes updated information on the Recommended Uniform Screening Panel (RUSP) and recommendations for incorporating newborn screening into obstetric practice.

Financial burdens and mental health needs in families of children with congenital heart disease

OBJECTIVE

To examine the financial burdens and mental health needs of families of children with special healthcare needs (CSHCN) with congenital heart disease (CHD).

METHODS

Data from the 2009-2010 National Survey of Children with Special Health Care Needs (NS-CSHCN) were used to examine parent-reported financial burdens (out-of-pocket expenses, financial problems, employment impact, caregiving hours) and family members' need for mental health services in families of CSHCN with CHD. Multivariable logistic regression was used to compare financial burdens and family members' need for mental health services among CSHCN with and without CHD. Among CSHCN with CHD, multivariable logistic regression, stratified by age (0-5 and 6-17 years), was used to assess characteristics associated with the outcomes.

RESULTS

Overall, families of 89.1% of CSHCN with CHD experienced at least one financial burden and 14.9% needed mental health services due to the child's condition. Compared with CSHCN without CHD, those with CHD had families with a higher prevalence of all financial burdens (adjusted prevalence ratio [aPR] range: 1.4-1.8) and similar family member need for mental health services (aPR = 1.3, 95% CI [1.0, 1.6]). Across both age groups, insurance type, activity limitations, and comorbidities were significantly associated with financial burdens and/or family members' need for mental health services.

CONCLUSIONS

CSHCN with CHD, compared with those without CHD, lived in families with more financial burdens. Interventions that reduce financial burdens and improve mental health of family members are needed, especially among CSHCN with CHD who are uninsured and have comorbidities or activity limitations.