Maternal Stress and Anxiety in the Pediatric Cardiac Intensive Care Unit

Perceived family-centered care and post-traumatic stress in parents of infants cared for in the paediatric cardiac intensive care unit

BACKGROUND

Family-centred care (FCC), while a core value of paediatric hospitals, has not been well-studied in the paediatric cardiac intensive care unit (PCICU).

AIM

To describe parents' perceptions of FCC provided by nurses in the PCICU during their infant's recovery from neonatal cardiac surgery and explore associations of perceptions of FCC on parent post-traumatic stress (PTS) 4 months post-discharge.

STUDY DESIGN

Data obtained from a previously conducted randomized clinical trial (RCT) on telehealth home monitoring after neonatal cardiac surgery at three free-standing paediatric hospitals were analysed from a subset of 164 parents who completed the FCC Scale at hospital discharge, which measures a parent's experience of nursing care that embodies core principles of FCC. The RCT intervention was provided after hospital discharge, having no influence on parent's perception of FCC. The intervention also had no effect on PTS.

RESULTS

Perceived FCC was lowest for items 'nurses helped me feel welcomed' and 'nurses helped me feel important in my child's care'. Having 12%-19% points lower perception of FCC at hospital discharge was associated with parent experience of six or more PTS symptoms, at least moderate PTS symptom severity, or PTS disorder diagnosis at 4-month follow-up. Every 10% increase in parental perceptions of FCC was associated with less PTS symptoms (β = -0.29, SE = 0.12; p = .02) and lower PTS symptom cluster scores of arousal (β = -0.18, SE = 0.08; p = .02).

CONCLUSIONS

Parents who perceived lower FCC during their infants' hospitalization were at increased risk for the development of PTS symptoms, more PTS symptom severity and PTS disorder diagnosis 4-months post-discharge.

RELEVANCE TO CLINICAL PRACTICE

Nurses have a prominent role to support the implementation of FCC for infants with cardiac defects and their parents. FCC may positively influence overall parent mental health and well-being, reducing the trauma and distress of the PCICU experience.

Prenatal diagnosis of critical congenital heart disease associated with lower postpartum depressive symptoms: a case-control study

OBJECTIVE

When the expectant mother is faced with an unforeseen event during pregnancy, she may experience emotional fragility and depression. This study was carried out to test the association between the time of diagnosis of critical congenital heart disease (CCHD) and depressive symptoms in puerperal women.

METHOD

A case-control study. All mothers answered a semi-structured questionnaire and the Edinburgh Postnatal Depression Scale (EPDS). Pearson's correlation and multiple linear regression analysis were used to determine factors associated with depression.

RESULTS

50 puerperal women, 23 cases and 27 controls. The proportion of puerperal depressive symptoms was 26.1 % among mothers of infants prenatally diagnosed with CCHD and 77.8 % among mothers of infants postnatally diagnosed (p = 0.001 [OR] 9.917; 95 % CI 2.703-36.379). Multiple linear regression analysis showed that the use of psychotropic drugs and time of diagnosis were significantly associated with puerperal depressive symptoms.

CONCLUSION

Prenatal diagnosis of CCHD was associated with significantly lower levels of depressive symptoms.

"We want to include him in that journey": A qualitative descriptive study of parental experiences and considerations for sibling inclusion in the paediatric ICU

OBJECTIVES

Siblings are an important yet often forgotten part of the paediatric intensive care unit (PICU) family experience. Commonly, siblings are supported through the experience by their parents; however, very little is known about parental experiences of providing this support. This study aims to explore parental experiences of supporting sibling inclusion in PICU.

RESEARCH METHODOLOGY/DESIGN

This study utilised a qualitative descriptive approach to conduct semi-structured interviews with 6 parents of 5 children with congenital heart disease who had spent time in PICU. Data were analysed using reflexive thematic analysis.

SETTING

Australian PICUs.

FINDINGS

Parental considerations and experiences for sibling inclusion were identified across three key phases: Pre-inclusion, The PICU visit, and Post-inclusion. Prior to including siblings in PICU, parents considered various ways of sharing information with siblings, and weighed up the risks and benefits of bringing siblings into PICU. Parents also recounted a number of challenges and facilitators to a positive sibling experience in PICU, including supportive staff and fun activities. Finally, parents, identified that siblings require ongoing support after their inclusion in PICU and made suggestions for ongoing availability of information and supportive resources.

CONCLUSIONS

This study has illuminated key parental experiences when supporting sibling inclusion in PICU before, during and after their visit. By understanding these parental experiences, PICU staff can work with and support parents where needed, helping to achieve a positive sibling inclusion experience.

IMPLICATIONS FOR CLINICAL PRACTICE

Parents need ongoing support to explain the PICU to siblings of critically ill children and may benefit from specific visual resources to aid communication. In addition, PICUs should aim to ensure the physical layout is supportive of sibling needs, with dedicated spaces for siblings to play and take time out during their experience.

Salivary Diurnal Cortisol Predicts Post-Traumatic Stress Symptoms in Parents of Infants With Congenital Heart Disease

BACKGROUND

Parents of infants born with congenital heart disease (CHD) who require open heart surgery after birth are at risk for prolonged psychological distress. Even after their infants are discharged, parents may experience anxiety, depressive, and post-traumatic stress (PTS) symptoms; yet, it is unclear which parents are at greater risk for ongoing symptoms. The purpose of this study was to explore whether measures of the biomarker cortisol in parents during their infants' postoperative period were associated with subsequent psychological distress symptoms at three-month post discharge.

METHODS

This was a prospective, longitudinal exploratory study of 40 parents of infants with CHD after open heart surgery using consecutive enrollment. Parents provided diurnal saliva samples for two consecutive days in the postoperative period. Six predictors were summarized and generated including waking cortisol, bedtime cortisol, cortisol awaking response, area under curve with respect to the ground (AUCg), cortisol index, and cortisol slope. Self-report outcome measures on anxiety, depressive, and PTS symptoms were collected three-months post-discharge. Linear mixed models examined the associations between each predictor and each outcome while accounting for within-dyad variance using an unstructured covariance matrix.

RESULTS

Cortisol AUCg was a predictor of PTS at three-months post-discharge (β = .34, p = .03, Cohen's d = 2.05). No significant relationships were found with the other cortisol measures.

CONCLUSIONS & IMPLICATIONS

Findings suggest that cortisol area under curve may help to identify parents at risk for increased PTS in the months following their infants' hospitalization for cardiac surgery, serving as a foundation for future study in this area.

Parental presence, participation, and engagement in paediatric hospital care: A conceptual delineation

AIM

To delineate between the concepts of parental presence, participation, and engagement in paediatric hospital care.

DESIGN

The concepts' uses in the literature were analysed to determine attributes, influences, and relationships.

METHODS

Delineations of each concept are established and conceptual definitions are proposed following Morses' methods.

DATA SOURCES

MEDLINE (PubMed); CINAHL, PsycINFO, Sociology Source Ultimate (EBSCOhost); Embase, Scopus (Elsevier); Google Scholar. Search dates October 2021, February 2023.

RESULTS

Multinational publications dated 1991-2023 revealed these concepts represent a range of parental behaviours, beliefs, and actions, which are not always perceptible to nurses, but which are important in family-integrated care delivery. Parental presence is the state of a parent being physically and/or emotionally with their child. Parental participation reflects parents' performing caregiving activities with or without nurses. Parental engagement is a parents' state of emotional involvement in their child's health and the ways they act on their child's behalf.

CONCLUSION

These concepts' manifestations are important to parental role attainment but may be inadequately understood and considered by healthcare providers.

IMPLICATIONS

Nurses have influence over parents' parental presence, participation, and engagement in their child's care but need support from healthcare institutions to ensure equitable family-integrated care delivery.

IMPACT

Problem: Lack of clear definition among these concepts results in incomplete and at times inequitable family-integrated care delivery.

FINDINGS

Parental presence is an antecedent to parental participation, and parental presence and participation are elements of parental engagement. The concepts interact to influence one another.

IMPACT

Hospitalized children, their families, nurses, and researchers will benefit through a better understanding of the concepts' attributes, interactions, and implications for enhanced family-integrated care delivery.

Experiences in Tube Weaning Children with Congenital Heart Disease and Oral Feeding Aversion

Infants and children with congenital heart disease (CHD) often require supplemental nutrition via tube feeding before and after surgery. Tube feeding may be required due to poor weight gain, inadequate oral-motor skills, and/or reduced endurance for oral feeding. Our team has described a successful approach to weaning this population (Horsley et al. (2022) Pediatr Cardiol 43:1429-1437). A subgroup of tube-fed patients with CHD who demonstrate oral feeding aversion (OA) presents unique challenges to the tube weaning process. We discuss our team's experience with tube weaning orally averse children with CHD. Of 36 patients enrolled in the Cincinnati Children's Heart Institute Cardiology Feeding Tube Wean Clinic, 11 (31%) were determined to have oral feeding aversion (OA) by a speech-language pathologist (SLP). Descriptive data comparing the OA group to the non-averse group was gathered prior to and during the wean. Both groups had the ability to tube wean successfully, although the OA group had lower median oral intake (9 vs 24%) and higher age at start of the wean (9 vs 4 months). Those with OA also had a longer median duration of wean in days (17 vs 12 days) and higher likelihood of return to tube feeds within six-month post-wean (22 vs 0%). Additionally, the OA group had a higher percentage of genetic syndromes (36 vs 16%), although this was not found to be statistically significant in this study. Children with OA present with unique challenges for tube weaning. The results of this study show that weaning children with CHD and OA is possible with a multidisciplinary team who is knowledgeable about this population.

Development and validation of a questionnaire to measure the congenital heart disease of children's family stressor

Background

Families of children with congenital heart disease (CHD) face tremendous stressors in the process of coping with the disease, which threatens the health of families of children with CHD. Studies have shown that nursing interventions focusing on family stress management can improve parents' ability to cope with illness and promote family health. At present, there is no measuring tool for family stressors of CHD.

Methods

The items of the scale were generated through qualitative interviews and a literature review. Initial items were evaluated by seven experts to determine content validity. Factor analysis and reliability testing were conducted with a convenience sample of 670 family members. The criterion-related validity of the scale was calculated using scores on the Self-Rating Anxiety Scale (SAS).

Results

The CHD Children's Family Stressor Scale consisted of six dimensions and 41 items. In the exploratory factor analysis, the cumulative explained variance of the six factors was 61.085%. In the confirmatory factor analysis, the six factors in the EFA were well validated, indicating that the model fits well. The correlation coefficient between CHD Children's Family Stressor Scale and SAS was r = 0.504 (p < 0.001), which indicated that the criterion-related validity of the scale was good. In the reliability test, Cronbach's α coefficients of six sub-scales were 0.774-0.940, and the scale-level Cronbach's α coefficient value was 0.945.

Conclusion

The study indicates that the CHD Children's Family Stressor Scale is valid and reliable, and it is recommended for use in clinical practice to assess CHD children's family stressors.

Stress Coping Strategies in Parents of Newborns and Infants with Congenital Cyanotic Heart Disease with Regard to Stress Levels and Negative Emotions

BACKGROUND

Parents of children suffering from congenital heart disease experience high levels of stress and negative emotions. Therefore, recognition of parents' emotional states and their ways of coping with it is becoming more and more important.

METHODS

The study group consisted of 154 parents of newborns and infants with cyanotic congenital heart disease, before and after cardiac surgery (partial or full). To assess parental negative emotions, the level of stress, and strategies of coping with it, standardized questionnaires, such as HADS-M, PSS-10, and COPE, were used.

RESULTS

Stress levels in parents were high and associated with negative emotions (anxiety, depression, irritability), as well as the choice of non-constructive coping strategies, which was observed especially in younger parents.

CONCLUSIONS

Assessing parents' stress levels and ways of coping with stress can improve family functioning and provide better development conditions for the child.

"You Have to Find a Way for This Child to Be at the Center": Pediatric Cardiologists' Views on Triadic Communication in Consultations on Congenital Heart Defects

Congenital heart defects (CHDs) are present at birth and require ongoing management of personal, family, and medical aspects of care, including communication between family and medical staff. Effective communication is considered one of the main objectives of patient-centered care. Communication in pediatric medicine is especially challenging because it includes children and their parent(s), and children's cognitive and communication skills are still developing. Based on the model of behavior in pediatric communication , this study focused on pediatric cardiologists' views of the roles of children, parents, and physicians in the triadic encounter and their experiences in communicating information on pediatric CHDs in medical encounters. Semi-structured interviews were conducted with 17 experienced pediatric cardiologists and cardiac surgeons (five women and 12 men) at three medical centers in Israel. The grounded theory approach was used to identify three main categories: (1) the positioning (centrality) of the child in the setting (ideal vs. actual situation), (2) addressing parents' emotional needs, and (3) the physician's role as mediator between parent(s) and child. In each category, three elements are discussed: The physician's agenda, obstacles and challenges, and the physician's practical methods. Physicians strongly support children's involvement in triadic encounters yet face challenges in effectively integrating them into the information exchange process during cardiology consultations. Struggling to balance the principles of patient- and family-centered care, and without clear guidelines, they rely on their personal beliefs and experiences to formulate communication strategies that address parents' and children's needs.

Nurse-guided Mobile Health Care Program to Reduce Emotional Distress Experienced by Parents of Infants Prenatally Diagnosed with Critical Congenital Heart Disease: A Pilot Study

Background

Following prenatal diagnosis of critical congenital heart disease (CCHD), parents encounter emotional distress while facing caregiving challenges. Supportive psycho-educational interventions using mobile health (mHealth) can make care more accessible.

Objectives

We tested a novel nurse-guided mHealth care program, Preparing Heart and Mind™ (PHM™), with the objectives of examining feasibility and estimating the effect of the intervention on parents' emotional distress.

Methods

This pilot study design randomized participants using a 2:1 intervention to control ratio. Analysis involved description of retention, and intervention attendance and engagement, and adjusted linear mixed models to estimate group differences in depressive (CES-D), anxiety (STAI-S), and traumatic stress (IES-r) symptoms.

Results

The sample included 55 parents (n=38 PHM™ group, n=17 control). Complete retention of 37 (67%) parents included 29 (76%) in the PHM™ group and 8 (47%) control. Most attrition was due to infant death (7 parents), transplant referral (2 parents), or postnatal diagnostic ineligibility (4 parents). For the PHM™ group, ≥96% of parents attended pre- and postnatal sessions and most (65%) messaged with the nurse. mHealth engagement was highest prenatally, with handling uncertainty the most viewed topic (average 94% pages viewed). In linear mixed models analyses, the PHM™ group had on average 4.84 points lower depression (95% CI: -10.68-1.04), 6.56 points lower anxiety (-14.04-0.92), and 6.28 points lower trauma (-14.44-1.88) scores by study end.

Conclusion

Findings suggest that a nurse-guided mHealth approach is feasible and may contribute to a clinically important reduction in parents' emotional distress.

Parental communication satisfaction with the clinical team in the paediatric cardiac ICU

INTRODUCTION

Understanding parents' communication preferences and how parental and child characteristics impact satisfaction with communication is vital to mitigate communication challenges in the cardiac ICU.

METHODS

This cross-sectional survey was conducted from January 2019 to March 2020 in a paediatric cardiac ICU with parents of patients admitted for at least two weeks. Family satisfaction with communication with the medical team was measured using the Communication Assessment Tool for Team settings. Clinical characteristics were collected via Epic, Pediatric Cardiac Critical Care Consortium local entry and Society for Thoracic Surgeons Congenital Heart Surgery Databases. Associations between communication score and parental mood, stress, perceptions of clinical care, and demographic characteristics along with patient demographic and clinical characteristics were examined. Multivariable ordinal models were conducted with characteristics significant in bivariate analysis.

RESULTS

In total, 93 parents of 84 patients (86% of approached) completed surveys. Parents were 63% female and 70% White. Seventy per cent of patients were <6 months old at admission, 25% had an extracardiac abnormality, and 80% had a cardiac surgery this admission. Parents of children with higher pre-surgical risk of mortality scores (OR 2.875; 95%CI 1.076-7.678), presence of surgical complications (72 [63.0, 75.0] vs. 64 [95%CI 54.6, 73] (p = 0.0247)), and greater satisfaction with care in the ICU (r = 0.93922; p < 0.0001) had significantly higher communication scores.

CONCLUSION

These findings can prepare providers for scenarios with higher risk for communication challenges and demonstrate the need for further investigation into interventions that reduce parental anxiety and improve communication for patients with unexpected clinical trajectories.

A randomized controlled trial to assess the impact of psychoeducation on the quality of life of parents with children with congenital heart defects-Quantitative component

PURPOSE

To develop, implement and assess the results of psychoeducation to improve the QoL of parents with CHD newborns.

METHODS

Participants were parents of inpatient newborns with the diagnosis of non-syndromic CHD. We conducted a parallel RCT with an allocation ratio of 1:1 (intervention vs. control), considering the newborns, using mixed methods research. The intervention group received psychoeducation (Parental Psychoeducation in CHD [PPeCHD]) and the usual routines, and the control group received just the regular practices. The allocation concealment was assured. PI was involved in enrolling participants, developing and implementing the intervention, data collection and data analysis. We followed the Consolidated Standards of Reporting Trials (CONSORT) guidelines.

RESULTS

Parents of eight newborns were allocated to the intervention group (n = 15 parents) and eight to the control group (n = 13 parents). It was performed as an intention-to-treat (ITT) analysis. In M2 (4 weeks), the intervention group presented better QoL levels in the physical, psychological, and environmental domains of World Health Organization Quality of Life instrument (WHOQOL-Bref). In M3 (16 weeks), scores in physical and psychological domains maintained a statistically significant difference between the groups.

CONCLUSIONS

The PPeCHD, the psychoeducational intervention we developed, positively impacted parental QoL. These results support the initial hypothesis. This study is a fundamental milestone in this research field, adding new essential information to the literature.

Mental Health Symptoms in Parents of Infants 3 Months After Discharge Following Neonatal Cardiac Surgery

BACKGROUND

Parents of newborns with congenital heart disease (CHD) are at risk for anxiety, depression, and post-traumatic stress. Few studies have examined whether modifiable factors that influence parents' mental health after discharge are present during postoperative care in the pediatric cardiac intensive care unit (PCICU).

OBJECTIVE

To describe mental health symptoms of parents of infants with CHD 3 months after PCICU discharge and to determine factors during the PCICU stay that are predictors of such symptoms.

METHODS

A longitudinal cohort pilot study of 56 parents (28 mother-father dyads) of 28 infants with CHD. During the first postoperative week after cardiac surgery, parents completed questionnaires measuring factors potentially influencing mental health. Three months after discharge, 42 parents of 22 infants completed validated measures of anxiety, depression, and posttraumatic stress.

RESULTS

Three months after discharge, 26% of parents had clinically elevated levels of anxiety symptoms, 21% had clinically significant levels of depressive symptoms, and 19% had posttraumatic stress symptoms. In multi-variable analysis, parental role alteration in the PCICU was predictive of anxiety (P = .002), depressive (P = .02), and posttraumatic stress (P = .02) symptoms 3 months after discharge. Higher education level was predictive of anxiety symptoms (P = .009). Postnatal CHD diagnosis was predictive of posttraumatic stress symptoms (P = .04).

CONCLUSIONS

Parental role alteration perceived by parents during the PCICU stay is a modifiable stressor contributing to adverse mental health symptoms 3 months after discharge. Interventions targeting parental role alteration in the PCICU are critically needed.

The Impact of Morbidities Following Pediatric Cardiac Surgery on Family Functioning and Parent Quality of Life

We previously selected and defined nine important post-operative morbidities linked to paediatric cardiac surgery, and prospectively measured their incidence following 3090 consecutive operations. Our aim was to study the impact of these morbidities on family functioning and parental quality of life over 6 months in a subset of cases. As part of a prospective case matched study in five of the ten children's cardiac centers in the UK, we compared outcomes for parents of children who had a 'single morbidity', 'multiple morbidities', 'extracorporeal life support (ECLS)' or 'no morbidity'. Outcomes were evaluated using the PedsQL Family impact module (FIM) at 6 weeks and 6 months post-surgery. Outcomes were modelled using mixed effects regression, with adjustment for case mix and clustering within centers. We recruited 340 patients with morbidity (60% of eligible patients) and 326 with no morbidity over 21 months. In comparison to the reference group of 'no morbidity', after adjustment for case mix, at 6 weeks parent health-related quality of life (HRQoL) and total FIM sores were lower (worse) only for ECLS (p < 0.005), although a higher proportion of parents in both the ECLS and multi-morbidity groups had low/very low scores (p < .05). At 6 months, parent outcomes had improved for all groups but parent HRQoL and total score for ECLS remained lower than the 'no morbidity' group (p < .05) and a higher proportion of families had low or very low scores in the ECLS (70%) group (p < .01). Post-operative morbidities impact parent HRQoL and aspects of family functioning early after surgery, with this impact lessening by 6 months. Families of children who experience post-operative morbidities should be offered timely psychological support.

Follow-up care and support to parents of premature children: Multidisciplinary versus regular follow-up care

BACKGROUND

Preterm care involves clinical measures almost exclusively aimed at keeping the preterm alive and ready for discharge from hospital. Children are then enrolled in clinical follow-up care after this stressful period, but mental or specialised care for parents and child is often not embedded in the routine of a neonatal hospital ward and the family is then dependent on institutions for mental health or child health clinics, that is, regular care that is regionally scattered. This study aimed to investigate experiences of parents with regular care and compare them with parents visiting a fixed, specialised, multidisciplinary institute, outside the hospital walls, for preterm follow-up care.

METHODS

A survey was conducted among 56 parents (regular follow-up care N = 26; multidisciplinary follow-up care N = 30) of children born prematurely. The survey consisted out of items like parents' experiences with follow-up care, like the organisation of care, supportive care, environmental support and experienced stress.

RESULTS

Parents receiving multidisciplinary follow-up care reported higher levels of satisfaction with organisation of care (F = 5.45; p = 0.023) and supportive care (F = 11.69; p = 0.001) than parents receiving regular follow-up care. Also, it was found that the extent of support from the social environment alleviated stress but only in parents receiving regular follow-up care (ß = -0.47; p = 0.016).

CONCLUSIONS

The current study findings indicate that experience with follow-up care is valued higher when receiving multidisciplinary care than regular care, and the degree in environmental support alleviates stress in parents receiving regular care.

Toxic Stress as a Potential Factor Inducing Negative Emotions in Parents of Newborns and Infants with Cyanotic Congenital Heart Disease

BACKGROUND

Parents who have a newborn with a congenital heart defect experience negative emotions, which may determine the emotional state of their children.

METHODS

The study group included 154 parents of newborns and infants with cyanotic congenital heart disease, before cardiac surgery and after the procedure. HADS m and PSS-10 questionnaires were used to assess parental anxiety, depression, aggression, and the level of stress.

RESULTS

High levels of depression, anxiety, total HADS and stress were diagnosed in a large group of parents, regardless of the stage of cardiac surgery treatment. A high level of stress was associated with a higher prevalence of emotional disturbance both in the total HADS (overall) and in all its individual domains. Anxiety and depression were more common in mothers. A high level of stress was a significant predictor of anxiety and depression in parents.

CONCLUSIONS

A high level of stress was a significant predictor of anxiety and depression in parents of infants with congenital heart disease. The parents' psychological condition is one of many potential determinants over the course of their child's treatment and recovery.

Developmental care pathway for hospitalised infants with CHD: on behalf of the Cardiac Newborn Neuroprotective Network, a Special Interest Group of the Cardiac Neurodevelopmental Outcome Collaborative

Infants and children born with CHD are at significant risk for neurodevelopmental delays and abnormalities. Individualised developmental care is widely recognised as best practice to support early neurodevelopment for medically fragile infants born premature or requiring surgical intervention after birth. However, wide variability in clinical practice is consistently demonstrated in units caring for infants with CHD. The Cardiac Newborn Neuroprotective Network, a Special Interest Group of the Cardiac Neurodevelopmental Outcome Collaborative, formed a working group of experts to create an evidence-based developmental care pathway to guide clinical practice in hospital settings caring for infants with CHD. The clinical pathway, "Developmental Care Pathway for Hospitalized Infants with Congenital Heart Disease," includes recommendations for standardised developmental assessment, parent mental health screening, and the implementation of a daily developmental care bundle, which incorporates individualised assessments and interventions tailored to meet the needs of this unique infant population and their families. Hospitals caring for infants with CHD are encouraged to adopt this developmental care pathway and track metrics and outcomes using a quality improvement framework.

Families under pressure: A qualitative study of stressors in families of children with congenital heart disease

The objective of this study was to better understand the stressors in families of children with congenital heart disease (CHD) to assist with formulating targeted stress management plans for such families. A descriptive qualitative study was undertaken at a tertiary referral hospital in China. Following purposeful sampling, interviews were conducted with 21 parents of children with CHD regarding the stressors in their families. Following content analysis, 11 themes were generated from the data and categorised into six main domains: the initial stressor and associated hardships, normative transitions, prior strains, the consequences of family efforts to cope, intrafamily and social ambiguity, and sociocultural values. The 11 themes include confusion regarding the disease, hardships encountered during treatment, the heavy financial burden, the unusual growth track of the child due to the disease, normal events becoming abnormal for the family, impaired family functioning, family vulnerability, family resilience, family boundary ambiguity induced by role alteration, a lack of knowledge about community support and family stigma. Various and complex stressors exist for families of children with CHD. Medical personnel should fully evaluate the stressors and take targeted measures before implementing family stress management practices. It is also necessary to focus on the posttraumatic growth of families of children with CHD and strengthen resilience. Moreover, family boundary ambiguity and a lack of knowledge about community support should not be ignored, and further research is needed to explore these variables. Most importantly, policymakers and healthcare providers should adopt a range of strategies to address the stigma of being in a family of a child with CHD.

Parental holding of infants improves haemodynamics in the cardiac ICU

We performed a single-centre, retrospective study to assess physiologic changes of infants in the cardiac ICU while being held by their parent. Continuous data streaming of vital signs were collected for infants included in the study from January 2021 to March 2022. Demographic and clinical characteristics were collected from the electronic medical record. The physiologic streaming data were analysed using mixed-effects models to account for repeated measures and quantify the effect of parental holding. Comparison analysis was also performed controlling for intubation, pre-operative versus post-operative status, and whether the holding was skin-to-skin or not. Ninety-five patients with complete physiologic data were included in the study. There were no immediate adverse events associated with holding. Heart rate decreased during the response time compared to its baseline value (p = 0.01), and this decrease was more pronounced for the non-intubated and pre-operative patients. The near-infrared spectroscopy-based venous saturation increased overall (p = 0.02) in patients while being held. We conclude that parental holding of infants in the cardiac ICU can be safely accomplished, and the haemodynamic and oximetric profile during the holding is favourable compared to the infants' baseline prior to holding.

Supporting Disclosure of Unmet Mental Health Needs among Parents of Critically Ill Infants

OBJECTIVE

To characterize (1) the prevalence of mental health discussion and (2) facilitators of and barriers to parent disclosure of mental health needs to clinicians.

STUDY DESIGN

Parents of infants with neurologic conditions in neonatal and pediatric intensive care units participated in a longitudinal decision-making study from 2018 through 2020. Parents completed semi-structured interviews upon enrollment, within 1 week after a conference with providers, at discharge, and 6 months post-discharge. We used a conventional content analysis approach and NVIVO 12 to analyze data related to mental health.

RESULTS

We enrolled 61 parents (n = 40 mothers, n = 21 fathers) of 40 infants with neurologic conditions in the intensive care unit. In total, 123 interviews were conducted with 52 of these parents (n = 37 mothers, n = 15 fathers). Over two-thirds of parents (n = 35/52, 67%) discussed their mental health in a total of 61 interviews. We identified two key domains when approaching the data through the lens of mental health: (1) self-reported barriers to communicating mental health needs: parents shared uncertainty about the presence or benefit of support, a perceived lack of mental health resources and emotional support, and concerns about trust; (2) self-reported facilitators and benefits of communicating mental health needs: parents described the value of supportive team members, connecting to peer support, and speaking to a mental health professional or neutral third party.

CONCLUSIONS

Parents of critically ill infants are at high risk of unmet mental health needs. Our results highlight modifiable barriers and actionable facilitators to inform interventions to improve mental health support for parents of critically ill infants.

Optimising motor development in the hospitalised infant with CHD: factors contributing to early motor challenges and recommendations for assessment and intervention

BACKGROUND

Neurodevelopmental challenges are the most prevalent comorbidity associated with a diagnosis of critical CHD, and there is a high incidence of gross and fine motor delays noted in early infancy. The frequency of motor delays in hospitalised infants with critical CHD requires close monitoring from developmental therapies (physical therapists, occupational therapists, and speech-language pathologists) to optimise motor development. Currently, minimal literature defines developmental therapists' role in caring for infants with critical CHD in intensive or acute care hospital units.

PURPOSE

This article describes typical infant motor skill development, how the hospital environment and events surrounding early cardiac surgical interventions impact those skills, and how developmental therapists support motor skill acquisition in infants with critical CHD. Recommendations for healthcare professionals and those who provide medical or developmental support in promotion of optimal motor skill development in hospitalised infants with critical CHD are discussed.

CONCLUSIONS

Infants with critical CHD requiring neonatal surgical intervention experience interrupted motor skill interactions and developmental trajectories. As part of the interdisciplinary team working in intensive and acute care settings, developmental therapists assess, guide motor intervention, promote optimal motor skill acquisition, and support the infant's overall development.

Early growth trajectory is associated with psychological stress in parents of infants with congenital heart disease, but moderated by quality of partner relationship

PURPOSE

To explore the relationships between growth trajectory, parenting stress and parent post-traumatic stress (PTS), in infants with congenital heart disease, and the moderating role of parents' dyadic adjustment on those associations.

DESIGN AND METHODS

A secondary analysis of data from the REACH Telehalth home monitoring multi-site randomized clinical trial. Parents completed the Parenting Stress Index (PSI), Post-traumatic diagnostic scale, and the Dyadic Adjustment Scale. Multivariate logistic regression models were used to examine the associations of interest.

RESULTS

During 4-month follow-up after hospital discharge, parents of infants with 'Never recovered' and 'Partially recovered' growth trajectories had 2-5 times higher odds of experiencing higher stress on the Parent Domain (OR = 4.8, CI = 1.3-18.0; OR = 2.5, CI = 1.0-5.9, respectively) than those with stably grown infants. Parents of "Never recovered" infants had 4 times higher odds of PTS symptoms (OR = 3.9; CI = 1.6-9.9). Parental dyadic adjustment moderated the relationships. Parents of 'Partially recovered' infants and having low dyadic adjustment had 3-5 times higher odds of high stress on all PSI domains, while parents with high dyadic adjustment did not have increased stress due to poor infant growth. Parents of "Never recovered" infants had four times higher odds of PTS symptom, even with high dyadic adjustment.

CONCLUSIONS

Infant growth trajectory over the first four months is associated with parenting stress and PTS. Quality of partner relationship moderates some of these associations.

PRACTICE IMPLICATIONS

Infant growth should serve as a screening aid for identifying parents at psychological risk. Interventions targeting the quality of partner relationship may support parental coping and mitigate stress.

CLINICAL TRIAL REGISTRATION

NCT01941667.

Cultural care needs of Spanish speaking parents with limited English proficiency whose children are hospitalized: An ethnonursing study

PURPOSE

Parents' inability to speak English proficiently is associated with communication barriers in the care process of their children, social determinants of health, and poor child health outcomes. Research exploring perspectives of Spanish speaking parents with limited English proficiency (SSP-LEP) whose children are hospitalized in the context of culture is lacking in the literature. The purpose of this study was to explore the cultural experiences, values, and beliefs of SSP-LEP, of Mexican origin, whose children were hospitalized and to understand nurses' roles in providing culturally congruent care.

DESIGN AND METHODS

Leininger's qualitative, ethnonursing method was used for this study. The Theory of Culture Care Diversity and Universality provided a guiding framework. Eleven SSP-LEP, of Mexican origin, participated in interviews conducted in-person and via Zoom. Data was analyzed using Leininger's four phases of qualitative analysis.

RESULTS

Three themes emerged: 1. role of the mother as an ever-present manager of care for the hospitalized child and family, 2. parents' difficult, fearful, stressful, and unknowing experiences in the presence of a language barrier, and 3. expected nursing care that was kind, respectful, compassionate, and attentive.

CONCLUSIONS

Lack of knowledge creates hardships for parents who desire to be involved, informed caregivers. Communication in Spanish language is integral to parents' understanding and expected nursing care. SSP-LEP may have negative feelings; yet describe a positive care experience.

PRACTICE IMPLICATIONS

Culturally congruent care should incorporate language services for information sharing that facilitates parent participation and decision-making; be kind, respectful, compassionate, and attentive; and promote maternal role maintenance.

What is Known About Critical Congenital Heart Disease Diagnosis and Management Experiences from the Perspectives of Family and Healthcare Providers? A Systematic Integrative Literature Review

The experience of diagnosis, decision-making and management in critical congenital heart disease is layered with complexity for both families and clinicians. We synthesise the current evidence regarding the family and healthcare provider experience of critical congenital heart disease diagnosis and management. A systematic integrative literature review was conducted by keyword search of online databases, MEDLINE (Ovid), PsycINFO, Cochrane, cumulative index to nursing and allied health literature (CINAHL Plus) and two journals, the Journal of Indigenous Research and Midwifery Journal from 1990. Inclusion and exclusion criteria were applied to search results with citation mining of final included papers to ensure completeness. Two researchers assessed study quality combining three tools. A third researcher reviewed papers where no consensus was reached. Data was coded and analysed in four phases resulting in final refined themes to summarise the findings. Of 1817 unique papers, 22 met the inclusion criteria. The overall quality of the included studies was generally good, apart from three of fair quality. There is little information on the experience of the healthcare provider. Thematic analysis identified three themes relating to the family experience: (1) The diagnosis and treatment of a critical congenital heart disease child significantly impacts parental health and wellbeing. (2) The way that healthcare and information is provided influences parental response and adaptation, and (3) parental responses and adaptation can be influenced by how and when support occurs. The experience of diagnosis and management of a critical congenital heart disease child is stressful and life-changing for families. Further research is needed into the experience of minority and socially deprived families, and of the healthcare provider, to inform potential interventions at the healthcare provider and institutional levels to improve family experience and support.

Assessment and management of feeding difficulties for infants with complex CHD

Early surgical intervention in infants with complex CHD results in significant disruptions to their respiratory, gastrointestinal, and nervous systems, which are all instrumental to the development of safe and efficient oral feeding skills. Standardised assessments or treatment protocols are not currently available for this unique population, requiring the clinician to rely on knowledge based on neonatal literature. Clinicians need to be skilled at evaluating and analysing these systems to develop an appropriate treatment plan to improve oral feeding skill and safety, while considering post-operative recovery in the infant with complex CHD. Supporting the family to re-establish their parental role during the hospitalisation and upon discharge is critical to reducing parental stress and oral feeding success.

Optimizing Neurodevelopmental Outcomes in Neonates With Congenital Heart Disease

Neurodevelopmental impairment is a common and important long-term morbidity among infants with congenital heart disease (CHD). More than half of those with complex CHD will demonstrate some form of neurodevelopmental, neurocognitive, and/or psychosocial dysfunction requiring specialized care and impacting long-term quality of life. Preventing brain injury and treating long-term neurologic sequelae in this high-risk clinical population is imperative for improving neurodevelopmental and psychosocial outcomes. Thus, cardiac neurodevelopmental care is now at the forefront of clinical and research efforts. Initial research primarily focused on neurocritical care and operative strategies to mitigate brain injury. As the field has evolved, investigations have shifted to understanding the prenatal, genetic, and environmental contributions to impaired neurodevelopment. This article summarizes the recent literature detailing the brain abnormalities affecting neurodevelopment in children with CHD, the impact of genetics on neurodevelopmental outcomes, and the best practices for neonatal neurocritical care, focusing on developmental care and parental support as new areas of importance. A framework is also provided for the infrastructure and resources needed to support CHD families across the continuum of care settings.

Assessing the Impact of Nasotracheal Intubation on Postoperative Neonates With Congenital Heart Disease: A Quality Improvement Project at a Single Heart Center

OBJECTIVES

Nasotracheal intubation (NTI) is associated with fewer unplanned extubations and improved oral motor skills compared with orotracheal intubation (OTI). Our study aimed to implement a practice change from OTI to NTI for neonatal cardiac surgery and assess impact on postoperative outcomes.

DESIGN

Single-center, prospective, quality improvement study.

SETTING

Academic children's hospital.

PATIENTS

One hundred thirty neonates undergoing cardiac surgery with cardiopulmonary bypass.

INTERVENTIONS

NTI during index cardiac surgery.

MEASUREMENTS AND MAIN RESULTS

Data were collected between January 2019 and April 2021. The study was implemented in three phases: retrospective: OTI neonates ( n = 43), I: safety and feasibility of NTI ( n = 17), and II: speech language pathology (SLP) evaluation on postoperative day 1 facilitated by NTI ( n = 70). Retrospective and phase I patients were combined for analysis. Groups were compared using Kruskal-Wallis test or Wilcoxon rank-sum test.Ninety-one percent of eligible neonates were nasotracheally intubated. There were no clinically significant complications. Days to first SLP encounter decreased from a median 4.5 days (interquartile range [IQR], 3.8-6.2) to 1.1 days (IQR, 1.0-1.9; p < 0.001). Oral readiness time decreased from a median of 6.6 days (IQR, 5.4-8.9) to 4.3 days (IQR, 3.4-8.6; p < 0.001). .

CONCLUSIONS

NTI is feasible and safe in neonatal cardiac surgery. System-level engagement with stakeholders is necessary to change clinical practice. NTI facilitates early SLP evaluation and treatment and significantly affects oral readiness after neonatal cardiac surgery.

Parents' and healthcare professionals' experiences and perceptions of parental readiness for resuscitation in Iranian paediatric hospitals: a qualitative study

OBJECTIVE

The aim of this study was to examine parents' and healthcare professionals' experiences and perceptions of parental readiness for resuscitation of their child in a paediatric hospital.

DESIGN

This exploratory descriptive qualitative study used content analysis. Participants shared their experiences and perceptions about parental readiness for cardiopulmonary resuscitation through semi-structured and in-depth interviews. MAXQDA 2020 software was also used for data analysis.

SETTING

The setting was two large teaching paediatric hospitals in Iran (Este Azerbaijan and Mashhad).

PARTICIPANTS

Participants were 10 parents and 13 paediatric healthcare professionals (8 nurses and 5 physicians). Selection criteria were: (a) parents who experienced their child's resuscitation crisis at least 3 months prior and (b) nurses and physicians who were working in emergency rooms or intensive care wards with at least 2 years of experience on the resuscitation team.

RESULTS

Participants shared their experiences about parental readiness for resuscitation of their child in four categories: awareness (acceptance of resuscitation and its consequences; providing information about the child's current condition and prognosis), chaos in providing information (defect of responsibility in informing; provide selective protection of information; hardness in obtaining information), providing situational information (honest information on the border of hope and hopeless; providing information with apathy; providing information as individual; dualism in blaming; assurance to parents; presence of parents to better understand the child's situation) and psychological and spiritual requirements (reliance on supernatural power; need for access to a psychologist; sharing emotions; collecting mementos).

CONCLUSION

The results of this study provide insight on the needs of parents and strategies to use to prepare them for their child's resuscitation crisis, which can be used to enhance family centred care practices in paediatric acute care settings.

Parental wellbeing after diagnosing a child with biliary atresia: A prospective cohort study

PURPOSE

To determine anxiety, stress, and quality of life (QoL) in parents of children who are diagnosed with biliary atresia (BA).

METHODS

Parents of BA patients (0-3 years) completed validated questionnaires at three time points: at first hospitalization (T0); 1-2 months post diagnosis (T1); and 2-3 years post diagnosis (T2). Results are presented in medians (min-max).

RESULTS

We included 52 parents (age 31 [24-51 y], 31 females) of 30 BA patients. In fathers, neither anxiety nor stress levels significantly differed from reference values. Mothers reported significantly higher anxiety levels compared to reference values (T0: 48 vs 35, p = 0.001; T1: 43 vs 35, p = 0.03; T2: 37 vs 35, p = 0.04), which significantly decreased over time (-23% between T0 and T2: p = 0.04). Stress in mothers was significantly higher at T1 than at T2 (+35%, p = 0.02), but was not significantly different from reference values at each time point (T0: 17 vs 14, p = 0.07; T1: 18 vs 14, p = 0.09; T2: 13 vs 14, p = 0.52).The overall QoL in mothers and fathers was rather unaffected.

CONCLUSIONS

Particularly mothers of infants diagnosed with BA report high anxiety levels up to three years after diagnosis. The overall QoL of parents is rather unaffected after diagnosing BA in their child.

LEVEL OF EVIDENCE

Level 2.

Feeding outcomes in post-discharge feeding clinic for infants following cardiac surgery

INTRODUCTION

The aim of this study was to describe the development and assess the usefulness of a feeding clinic to help infants with CHD tolerate the highest level of oral feeding while achieving growth velocity and supporting neurodevelopment.

MATERIALS AND METHODS

This retrospective, cohort study assessed feeding outcomes for infants who underwent cardiac surgery at <30 days of age with cardiopulmonary bypass between February 2016 and April 2020. Diagnoses, age at surgery, hospitalisation variables, and feeding outcomes were compared between two cohorts, pre- and post-implementation of a specialised feeding clinic using Exact Wilcoxon signed-rank test, chi-squared, or Fisher's exact test. The association between time to full oral feed and risk factors was assessed using univariable and multivariable Cox regression model.

RESULTS

Post-clinic infants (n = 116) surgery was performed at a median of 6 days of life (interquartile range: 4, 8) with median hospital length of stay of 19 days (interquartile range: 16, 26). Infants' median age at first clinic visit was at 30 days old (interquartile range: 24, 40) and took median 10 days (interquartile range: 7, 12) after hospital discharge to first clinic visit. In the post-clinic cohort, the median time to 100% oral feeding was 47 days (interquartile range: 27, 96) compared to the 60 days (interquartile range: 20, 84) in the pre-clinic cohort (n = 22), but the difference was not statistically significant.

DISCUSSION

The cardiac feeding clinic was utilised by our neonatal surgery population and feasible in coordination with cardiology follow-up visits. Future assessment of cardiac feeding clinic impact should include additional measures of feeding and neurodevelopmental success.

The Associations of Psychologic and Physiologic Manifestations of Parental Stress in Critical Congenital Heart Disease

Background: The primary objective of this exploratory, feasibility study was to examine the relationships of self-reported perceived stressors and psychological stress responses with measures of the biomarker cortisol in parents of infants hospitalized after neonatal cardiac surgery for critical congenital heart disease (cCHD). Methods: This was a prospective, cross-sectional study of 28 biological mother–father dyads of neonates with cCHD using consecutive enrollment. In the postoperative period after neonatal cardiac surgery, parents provided awakening and diurnal saliva samples and self-report measures on stress, anxiety, depression, dyadic adjustment, and perceived severity of illness of their neonate. Results: Evaluable data, including salivary cortisol samples, were obtained for 27 of the 28 dyads enrolled in the study. Compared to fathers, mothers exhibited significantly higher mean cortisol values at wakeup ( p = .032), 30-minute post-wakeup ( p = .024), and bedtime ( p = .010) timepoints. Anxiety and depressive symptoms were both significant predictors of awakening cortisol measures. Depressive symptoms were also a predictor of diurnal cortisol ( p < .05). Stress arising from infant appearance and behavior was found to significantly predict cortisol awakening response ( p = .0403). Conclusions: Findings suggest that cortisol may be an important biomarker in the examination of parent stress in the pediatric cardiac intensive care unit (PCICU), serving as a foundation for future study in this area. Furthermore, we have provided preliminary evidence of feasibility of including saliva collection in studies of highly stressed parents in a challenging environment.

Maternal parenting stress changes over the first year of life in infants with complex cardiac defects and in healthy infants

OBJECTIVES

Parents of infants with CHDs experience increased parenting stress compared to the general population, potentially interfering with parenting practices and bear adverse family outcomes. The changes in stress over the critical period of infancy have yet to be studied. The current study aimed to compare parenting stress changes over time between parents of infants with CHDs and parents of healthy infants during the first year of infants' life.

METHODS

Data from a larger prospective cohort study were longitudinally analysed using mixed-effects multivariable regression modelling. Sample included mothers of 129 infants with complex cardiac defects and healthy infants, recruited from the cardiac ICU of a large cardiac centre and outpatient paediatric practices in Northeastern America. Outcome was measured over four visits via the Parenting Stress Index Long Form.

RESULTS

Stress in the cardiac group has significantly decreased over time on the Parent Domain (p = 0.025), and stress in the healthy group has significantly increased over time on the Child Domain (p = 0.033). Parenting stress trajectories demonstrated significant differences between groups on the Parent Domain (p = 0.026) and on the Total Stress (p = 0.039) subscales.

CONCLUSIONS

Parenting stress in the paediatric cardiac population changes over time and differs from stress experienced by parents of healthy infants. Findings highlight stressful periods that may be potentially risky for parents of infants with CHDs and introduce additional illness-related and psychosocial/familial aspects to the parenting stress concept.

Coping strategies used by mothers and fathers following diagnosis of congenital heart disease

BACKGROUND

Parents of children with congenital heart disease (CHD) exhibit high rates of mental health difficulties, which can influence child developmental and behavioural outcomes. While extensive research has focused on CHD-related stressors that contribute to parental mental health difficulties, few studies have investigated parental coping strategies that may mitigate or heighten risk. This study aimed to identify parental coping strategies following diagnosis of CHD and compare use of coping strategies among different groups (mothers vs. fathers; prenatal vs. postnatal diagnosis).

METHODS

A diverse sample of 34 parents (20 mothers and 14 fathers) of young children with CHD participated in semistructured interviews focused on their responses to CHD-related stressors. Coping strategies were identified from qualitative data and categorized according to the COPE Inventory, an instrument that assesses common adult responses to stress. Coping strategies deemed as unique to parenting a critically ill child were identified. χ² and independent sample t tests evaluated group differences.

RESULTS

Parents described using between 1 and 10 different adaptive and maladaptive strategies measured by the COPE Inventory. Most parents (82.35%) also described coping strategies that may be unique to parenting a critically ill child. Mothers were more likely than fathers to report a focus on and venting of emotions (70% vs. 21.43%) and behavioural disengagement (25% vs. 0%). Compared with parents receiving a postnatal CHD diagnosis, those receiving a prenatal diagnosis described a greater variety of coping strategies (6.23 vs. 4.52) and more often reported positive reinterpretation and growth (69.23% vs. 14.29%), behavioural disengagement (38.46% vs. 0%) and denial (38.46% vs. 0%).

CONCLUSIONS

Parents of children with CHD utilize a variety of coping strategies, some of which are maladaptive. Interventions tailored to the needs of mothers and fathers of young children with CHD, including those receiving a postnatal diagnosis, are needed to promote adaptive coping and optimize family psychosocial outcomes.

Individualized Family-Centered Developmental Care for Infants With Congenital Heart Disease in the Intensive Care Unit

BACKGROUND

Individualized family-centered developmental care (IFDC) is considered the standard of care for premature/medically fragile newborns and their families in intensive care units (ICUs). Such care for infants with congenital heart disease (CHD) varies.

OBJECTIVE

The Consortium for Congenital Cardiac Care- Measurement of Nursing Practice (C4-MNP) was surveyed to determine the state of IFDC for infants younger than 6 months with CHD in ICUs.

METHODS

An electronic survey was disseminated to 1 nurse at each participating center. The survey included questions on IFDC-related nursing practice, organized in 4 sections: demographics, nursing practice, interdisciplinary practice, and parent support. Data were summarized by using descriptive statistics. Differences in IFDC practices and IFDC-related education were assessed, and practices were compared across 3 clinical scenarios of varying infant acuity by using the χ2 test.

RESULTS

The response rate was 66% (25 centers). Most respondents (72%) did not have IFDC guidelines; 63% incorporated IFDC interventions and 67% documented IFDC practices. Only 29% reported that their ICU had a neurodevelopmental team. Significant differences were reported across the 3 clinical scenarios for 11 of 14 IFDC practices. Skin-to-skin holding was provided least often across all levels of acuity. Nurse education related to IFDC was associated with more use of IFDC (P < .05).

CONCLUSION

Practices related to IFDC vary among ICUs. Opportunities exist to develop IFDC guidelines for infants with CHD to inform clinical practice and nurse education. Next steps include convening a C4-MNP group to develop guidelines and implement IFDC initiatives for collaborative evaluation.

Role alteration predicts anxiety and depressive symptoms in parents of infants with congenital heart disease: a pilot study

BACKGROUND

Parents of infants born with critical congenital heart disease are at risk for adverse mental health symptoms. The purpose of this study was to identify infant-, parent-, and environmental-based stressors for mothers and fathers after their infants' cardiac surgery, and to explore relationships between stressors and mental health symptoms of anxiety and depression.

METHODS

This study enrolled 28 biological mother-father dyads from families admitted to the paediatric cardiac intensive care unit for cardiac surgery at one free-standing children's hospital in the Northeast. Paired t-tests were used to examine group differences between mothers and fathers on perceived stressors and mental health symptoms, while linear mixed effects modelling was used to explore the predictive relationship between perceived stressors, personal factors, and mental health symptoms.

RESULTS

Mothers reported higher perceived stressor scores of parental role alteration (t = 4.03, p < 0.01) and infant appearance and behaviour (t = 2.61, p = 0.02), and total perceived stress (t = 2.29 p = 0.03), compared to fathers. Mothers also reported higher anxiety (t = 2.47, p = 0.02) and depressive symptoms (t = 3.25, p < 0.01) than fathers. In multivariable analysis, parental role alteration significantly predicted anxiety (t = 5.20, p < 0.01, d = 0.77) and depressive symptoms (t = 7.09, p < 0.01, d = 1.05) for mothers and fathers. The consensus subscale of the Dyadic Adjustment Scale also significantly predicted depressive symptoms (t = -2.42, p = 0.02, d = 0.04).

CONCLUSION

Parents were distressed during their infant's admission for surgical repair for critical congenital heart disease. Parental role alteration was significantly associated with parental anxiety and depressive symptoms, while poor relationship quality was associated with depressive symptoms, highlighting areas for potential nursing-led psychosocial led interventions.

The Impact of Visiting Restrictions During the COVID-19 Pandemic on Pediatric Patients

Visitor restriction policies have been implemented on many hospital units as a result of the Covid-19 pandemic. These policies are integral to the strategies that hospitals are using to limit exposure risks during the pandemic. However, visitor restriction policies disproportionally affect hospitalized children. The trauma caused by lack of family at the bedside of adult patients during the Covid-19 pandemic has been studied but there is a lack of primary research on the impact of the Covid-19 visiting policy restrictions on pediatric patients. Long term studies are needed to understand the effect of this separation on children and their caregivers.

Addressing Perinatal Mental Health Risk within a Fetal Care Center

Diagnosis of a fetal anomaly in pregnancy increases the risk for perinatal mental health difficulties, including anxiety, depression, and traumatic stress among expectant parents. Common emotional challenges include uncertainty about the diagnosis/prognosis, anticipated neonatal course, fears of fetal or neonatal demise, loss of a typical, uncomplicated pregnancy and postpartum course, and disruption of family roles due to medical care-related activities and restrictions. Psychologists in multidisciplinary fetal care centers are uniquely positioned to assess mental health risks and address the needs of expectant parents. Psychologists bring additional expertise in screening and assessment, clinical interventions to promote coping and symptom reduction while preparing for birth and a complicated neonatal course, consultation and effective communication, and programmatic development. This review paper provides an overview of the challenges and behavioral health risks for expectant parents carrying a fetus with a birth defect and the unique role psychologists play to support patients and families within fetal care settings.

Going home after a child's cardiac surgery: education for safe care

OBJECTIVES

to validate the content and appearance of the booklet "Going home after a child's cardiac surgery" and assess family members' cognitive learning regarding its use.

METHODS

a methodological and quasi-experimental study of before and after type, with semi-structured interview, pre-test and reading of the booklet in a hospital; post-test and validation occurred after hospital discharge. Wilcoxon non-parametric statistics were used.

RESULTS

nineteen family members of children with heart disease participated. The average of correct answers increased 14 percentage points from pre- to post-test; most were medication errors. There was a significant difference (p <0.0001) in the comparison between cognitive knowledge prior to using the booklet and learning acquired from its use. All items received a positive rating, except font size.

CONCLUSIONS

the booklet helps family members to understand a child's needs after cardiac surgery, and can be used to prevent unwanted occurrences and enable safe care at home.

Family Function, Quality of Life, and Well-Being in Parents of Infants With Hypoplastic Left Heart Syndrome

Survival for hypoplastic left heart syndrome (HLHS) has improved dramatically. Little is known about early family function, quality of life (QOL), or well-being/adjustment for parents of infants with HLHS. Parent/family outcomes over time, predictors, and differences in 143 mothers and 72 fathers were examined. Parents reported better family function compared with published norms, but 26% experienced family dysfunction. QOL and well-being were significantly lower than adult norms. QOL scores generally declined over time, whereas self-reported well-being improved. Responses from mothers and fathers showed different trends, with mothers having worse scores on most measures and at most time points. Being a single parent was a risk factor for poorer family function, but not for lower individual QOL or well-being. Family characteristics, stress, and coping skills were predictive of outcomes. Parents' psychosocial responses to the challenges of life with infants with HLHS change over time. Individually tailored psychosocial support is needed.

Exploratory model of parental stress during children's hospitalisation in a paediatric intensive care unit

OBJECTIVES

This exploratory study (a) examined pre-existing and peri-trauma risk factors of parental stress during a child's PICU hospitalisation using the Integrative Trajectory Model of Paediatric Medical Traumatic Stress and (b) identified the type of PICU-related stressors that predicted parental stress during the child's PICU hospitalisation.

METHODS

A cross-sectional, descriptive correlational design with 81 parents of children admitted 48 or more hours to a Paediatric Intensive Care Unit (PICU). Questionnaires measured parent's and child's demographic and clinical characteristics and parent-reported stressors using the Parental Stressors Scale (PSS:PICU). Analysis included descriptive statistics and multiple linear regression analyses with simultaneous predictor entry.

RESULTS

Male parents tended to be significantly more stressed than female parents. Parental stress was significantly increased when parents had one or more stressful life events one-month prior to PICU admission, when the child required ventilatory support, or the child had a cardiovascular diagnosis. Parental stress was also predicted by the child's appearance, procedures, child's behaviour, behaviour of staff, and parental role.

CONCLUSION

Nurses are in a prime position to identify parents at potentially high risk for psychological morbidity when they know a parent has had a stressful life event prior to admission, has a child with a cardiovascular diagnosis or requires ventilatory assistance. Nurses can diminish parental stress by interpreting the child's appearance for parents, helping parents understand the procedures being done for the child, interpreting the child's behaviour, explaining the staff's behaviour, and assisting parents to define their parental role during the child's hospitalisation.

Racial/Ethnic Differences in Stress, Coping, and Distress Among Mothers With a Child in the ICU

BACKGROUND

Having a child in the intensive care unit (ICU) is a stressful event that can cause negative mental health outcomes for parents, but little is known about the experience of parental stress among members of racial/ethnic minority groups.

OBJECTIVE

To examine the stress and coping process in a racially/ethnically diverse sample of mothers of a child who was acutely admitted to an ICU.

METHODS

Participants (N = 103) completed a cross-sectional self-report survey; 86.4% completed it within a week of their child's ICU admission. Analysis of variance was used to examine racial/ethnic differences in perceived ICU-related stressors, coping behaviors, and distress level. Linear regression was used to examine the moderating effects of race/ethnicity on the relationships between stressors, coping behaviors, and distress.

RESULTS

Mothers across racial group experienced similar stressors during the acute phase of their child's ICU admission. African American mothers reported greater overall use of coping behaviors, particularly avoidance coping, and experienced higher levels of distress than did Hispanic or non-Hispanic White mothers. Hispanic mothers experienced the least distress. The interaction of race/ethnicity and emotion-focused coping moderated the stress and coping process.

CONCLUSIONS

Racial and ethnic diversity in sampling should be a priority in future studies of the stress and coping process of mothers with a child in an ICU. Critical care nurses should minimize known stressors for these mothers and encourage and support their preferred coping behaviors, recognizing that these may differ across racial/ethnic groups.

Parent mental health and family functioning following diagnosis of CHD: a research agenda and recommendations from the Cardiac Neurodevelopmental Outcome Collaborative

Diagnosis of CHD substantially affects parent mental health and family functioning, thereby influencing child neurodevelopmental and psychosocial outcomes. Recognition of the need to proactively support parent mental health and family functioning following cardiac diagnosis to promote psychosocial adaptation has increased substantially over recent years. However, significant gaps in knowledge remain and families continue to report critical unmet psychosocial needs. The Parent Mental Health and Family Functioning Working Group of the Cardiac Neurodevelopmental Outcome Collaborative was formed in 2018 through support from an R13 grant from the National Heart, Lung, and Blood Institute to identify significant knowledge gaps related to parent mental health and family functioning, as well as critical questions that must be answered to further knowledge, policy, care, and outcomes. Conceptually driven investigations are needed to identify parent mental health and family functioning factors with the strongest influence on child outcomes, to obtain a deeper understanding of the biomarkers associated with these factors, and to better understand how parent mental health and family functioning influence child outcomes over time. Investigations are also needed to develop, test, and implement sustainable models of mental health screening and assessment, as well as effective interventions to optimise parent mental health and family functioning to promote psychosocial adaptation. The critical questions and investigations outlined in this paper provide a roadmap for future research to close gaps in knowledge, improve care, and promote positive outcomes for families of children with CHD.

Disruptions in the development of feeding for infants with congenital heart disease

Congenital heart disease (CHD) is the most common birth defect for infants born in the United States, with approximately 36,000 affected infants born annually. While mortality rates for children with CHD have significantly declined, there is a growing population of individuals with CHD living into adulthood prompting the need to optimise long-term development and quality of life. For infants with CHD, pre- and post-surgery, there is an increased risk of developmental challenges and feeding difficulties. Feeding challenges carry profound implications for the quality of life for individuals with CHD and their families as they impact short- and long-term neurodevelopment related to growth and nutrition, sensory regulation, and social-emotional bonding with parents and other caregivers. Oral feeding challenges in children with CHD are often the result of medical complications, delayed transition to oral feeding, reduced stamina, oral feeding refusal, developmental delay, and consequences of the overwhelming intensive care unit (ICU) environment. This article aims to characterise the disruptions in feeding development for infants with CHD and describe neurodevelopmental factors that may contribute to short- and long-term oral feeding difficulties.

Parental role alteration strongly influences depressive symptoms in mothers of preoperative infants with congenital heart disease

BACKGROUND

Mothers of infants with congenital heart disease are at risk for depression.

OBJECTIVES

This study explored the influence on maternal depressive symptoms of several known factors for mothers in the pediatric cardiac intensive care unit, including perceived stressors, attachment, and anxiety.

METHODS

This study was a secondary analysis of 30 mothers of infants awaiting cardiac surgery. Linear regressions were calculated to determine the relationships between perceived stressors, maternal attachment, anxiety, and maternal depressive symptoms.

RESULTS

Nearly half of mothers reported depressive symptoms above the measure cut-off score, indicating they were at risk for likely clinical depression. Subscales of perceived stress explained 61.7% of the variance in depressive symptoms (F = 11.815, p<0.0001) with parental role alteration subscale as the strongest predictor (standardized beta=0.694, p = 0.03).

CONCLUSIONS

Findings underscore the importance of mental health screening and instituting nursing practices to enhance parental role for mothers of infants awaiting cardiac surgery.

Parental and Child Anxiety Perioperatively: Relationship, Repercussions, and Recommendations

PURPOSE

Elective surgical procedures predictably cause stress and anxiety for children and their parents. This can have a negative effect on the child's short-term and long-term psychological and physiological outcomes. This narrative review examines perioperative child anxiety and existing interventions to reduce child and parent perioperative anxiety. The aim was to identify a need and gaps in knowledge for future study.

DESIGN

Peer-reviewed articles were examined to identify themes in the literature on interventions in place to reduce child and parent perioperative anxiety and to identify any gaps in knowledge for future study.

METHODS

A narrative review of 62 peer-reviewed articles was conducted.

FINDINGS

Evidence of themes aimed at lowering perioperative child anxiety using medication, cognitive educational, and play therapy approaches emerged through the literature search. A relationship between parental anxiety and the effect on the child's anxiety was supported, yet interventions that target the parent were limited cognitive education interventions and were found to be implemented only in a small number of hospitals.

CONCLUSIONS

A clear gap is the lack of research on the effects of parental interventions on the short-term and long-term negative behavioral and physiological outcomes of child perioperative anxiety. Research is needed to further explore the effect of a preoperative psychotherapeutic intervention to allow parents to express anxieties and discuss them with a trained professional in the absence of children. A systematic review or further research would help determine if a psychotherapeutic intervention for the parents would lower child anxiety perioperatively.

Nursing Interventions to Reduce Stress in Families of Critical Care Patients: An Integrative Review

BACKGROUND

Having a family member admitted to an intensive care unit is a stressful experience that may lead to psychological symptoms including depression, anxiety, and posttraumatic stress disorder.

OBJECTIVE

To better understand the phenomenon of stress experienced by families of intensive care unit patients and identify nursing interventions that may help reduce it.

METHODS

An integrative literature review was performed to identify principal stressors for families of patients receiving care in neonatal, pediatric, and adult intensive care units and recommended nursing interventions.

RESULTS

The principal stressors in the 3 types of intensive care units were change in parental role or family dynamics, appearance and behavior of the patient, the care setting, and communication with the health care staff. Nursing interventions should focus on valuing the role of family members in patient care, improving communication, and providing accurate information.

CLINICAL RELEVANCE

Family members of intensive care patients will benefit from nursing interventions that adequately acknowledge and address the stress they experience.

CONCLUSION

Nurses play a crucial role in helping to reduce the stress experienced by family members of intensive care unit patients.

Parents' Views of Family-Centered Care at a Pediatric Intensive Care Unit-A Qualitative Study

Purpose: To describe parents' views of family-centered care at a pediatric intensive care unit. Design and Methods: A qualitative descriptive study with a deductive and inductive approach was conducted based on the principles of family-centered care. Inclusion criteria were parents of children cared for at a pediatric intensive care unit for at least 48 h. Parents of children who died during the hospital stay were excluded. The sample consisted of spontaneous responses from 70 parents to five open questions in the EMpowerment of PArents in THe Intensive Care questionnaire, which was completed at discharge. The spontaneous responses were analyzed using thematic analysis. Results: The analysis of the parents' statement illuminated that partnership, the essence of family-centered care, appeared incomplete. Partnership was particularly evident regarding parents' experiences of being treated with empathy and respect. It also seemed prominent in situations where the professional team provided support to the child, parents, and family. Based on the parents' statements there was potential for development of the family-centered care approach in aspects such as decision-making concerning care and treatment, as well as improving person-centered communication on order to capture parents' experiences and needs in the highly technological pediatric intensive care unit environment. Conclusions: Although in general parents were satisfied with the care, areas for improvement were identified such as participation in decision-making about care and treatment as well as person-centered communication. The results can contribute to future quality improvement interventions focusing family centered care at pediatric intensive care units.

Skin-to-Skin Care is Associated with Reduced Stress, Anxiety, and Salivary Cortisol and Improved Attachment for Mothers of Infants With Critical Congenital Heart Disease

OBJECTIVE

To estimate the effect of skin-to-skin care (SSC) on biobehavioral measures of stress (anxiety and salivary cortisol) and attachment (attachment scores and salivary oxytocin) of mothers before and after their infants' neonatal cardiac surgery.

DESIGN

A prospective interventional, baseline response-paired pilot study.

SETTING

Cardiac center of a large, metropolitan, freestanding children's hospital.

PARTICIPANTS

Thirty women whose infants were hospitalized for neonatal cardiac surgery.

METHODS

Participants acted as their own controls before, during, and after SSC at two time points: once before and once after surgery. We measured the stress response of mothers, as indicated by self-reported scores of anxiety and maternal salivary cortisol, and maternal-infant attachment, as indicated by self-reported scores and maternal salivary oxytocin.

RESULTS

Significant reductions in self-reported scores of anxiety and salivary cortisol were found as a result of SSC at each time point, as well as increased self-reported attachment. No significant differences were found in oxytocin.

CONCLUSION

Our findings provide initial evidence of the benefits of SSC as a nurse-led intervention to support maternal attachment and reduce physiologic and psychological stress responses in mothers of infants with critical congenital heart disease before and after neonatal cardiac surgery.

Fathers of Children With Congenital Heart Disease: Sources of Stress and Opportunities for Intervention

OBJECTIVES

To examine sources of stress for fathers of children with congenital heart disease and opportunities for intervention to prevent or reduce paternal mental health problems.

DESIGN

Qualitative study using online crowdsourcing, an innovative research methodology to create an online community to serve as a research sample.

SETTING

Yammer, an online social networking site.

SUBJECTS

Geographically diverse sample of 70 parents (25 fathers and 45 mothers) of young children with congenital heart disease.

INTERVENTIONS

Participants joined a private group on Yammer and responded to 37 open-ended study questions over a 6-month period. Qualitative data were coded and analyzed using an iterative process, and themes regarding sources of stress for fathers of children with congenital heart disease and opportunities for intervention were identified.

MEASUREMENTS AND MAIN RESULTS

Four broad themes regarding sources of stress for fathers of children with congenital heart disease emerged from the qualitative data from both mothers and fathers: societal expectations for fatherhood and standards of masculinity, balancing work and family responsibilities, feeling overlooked as a partner in care, and lack of father supports. To begin to address these sources of stress, participants recommended that care teams acknowledge and normalize the impact of congenital heart disease on fathers, provide support for balancing work and family responsibilities, recognize and promote father knowledge and engagement, and provide formal and informal supports for fathers of children with congential heart disease.

CONCLUSIONS

Fathers of children with congenital heart disease experience unique sources of stress in the absence of targeted interventions to meet their needs. Care teams play an important role in acknowledging the experiences of fathers and including and engaging fathers in care.

Quality of Life in Parents of Children With Biliary Atresia

OBJECTIVES

The aim of the study was to determine quality of life (QoL), stress, and anxiety levels in parents of children with biliary atresia (BA), and to assess factors associated with parental QoL.

METHODS

Parents of children (6-16 years) with BA were included in this cross-sectional study. We used validated questionnaires to assess parental QoL, stress, and anxiety levels. We compared the results with reference data from the general population and determined associated factors using generalized linear mixed model analysis. Results are given as mean ± SD or median [min-max].

RESULTS

We included 61 parents of 39 children (aged 11 ± 3 years). Thirty-one children (79%) had undergone a liver transplantation (LTx). Parents reported reduced family activities (88 [8-100] vs 95 [30-100], P = 0.002) and more emotional worry (83 [17-100] vs 92 [95-100], P < 0.001) compared with reference data, but a stronger family cohesion (85 [30-100] vs 60 [30-100], P = 0.05). Scores on parental QoL, anxiety and stress were similar to reference data. Fathers (16.0 [11-19]) and mothers (15.4 ± 1.4) scored higher on the psychological domain compared with reference data (vs 14.7 ± 2.2, P < 0.01). There was no significant difference in QoL of parents with children with native liver or those who had undergone LTx. Older age and high anxiety trait in parents were adversely associated with physical QoL. Household income below &OV0556;35 000/year and high anxiety trait were adversely associated with environmental QoL.

CONCLUSIONS

QoL in parents of school-aged children with BA appears to be unaffected. Parents with high-anxiety personality trait, older age, and low household income are at increased risk of impaired QoL.