Individualized Family-Centered Developmental Care: An Essential Model to Address the Unique Needs of Infants With Congenital Heart Disease

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.

Supporting parenting during infant hospitalisation for CHD

OBJECTIVE

To characterise the parenting priorities of mothers and fathers of infants hospitalised with CHD and generate recommendations to support parenting during infant hospitalisation.

STUDY DESIGN

Through online crowdsourcing, an innovative research methodology to create an online community to serve as a research sample, 79 parents of young children with CHD responded to questions about parenting during hospitalisation via private social networking site. Responses were analysed using qualitative research methods.

RESULTS

Three broad themes were identified: (1) establishing a bond with my baby, (2) asserting the parental role, and (3) coping with fear and uncertainty. Parents value provider support in restoring normalcy to the parenting experience during infant hospitalisation.

CONCLUSIONS

Care teams can support parenting during infant hospitalisation by promoting parents' roles as primary caretakers and decision-makers and attending to the emotional impact of infant hospitalisation on the family.

Skin-to-Skin Care Is a Safe and Effective Comfort Measure for Infants Before and After Neonatal Cardiac Surgery

OBJECTIVES

To determine the effect of skin-to-skin care on stress, pain, behavioral organization, and physiologic stability of infants with critical congenital heart disease before and after neonatal cardiac surgery.

DESIGN

A baseline response-paired design was used, with infants acting as their own controls before, during, and after skin-to-skin care at two distinct time points: once in the preoperative period (T1) and once in the postoperative period (T2).

SETTING

Cardiac ICU and step-down unit in a large metropolitan freestanding children's hospital.

SUBJECTS

Convenience sample of 30 infants admitted preoperatively for critical congenital heart disease.

INTERVENTIONS

Eligible infants were placed into skin-to-skin care for 1 hour with their biological mothers once each at T1 and T2.

MEASUREMENTS AND MAIN RESULTS

Measurements of stress (salivary cortisol), pain and behavior state (COMFORT scale), and physiologic stability (vital signs) were assessed immediately before skin-to-skin care, 30 minutes into skin-to-skin care, and 30 minutes after skin-to-skin care ended.At both T1 and T2, infant pain scores were significantly decreased (p < 0.0001) and infants moved into a calmer behavior state (p < 0.0001) during skin-to-skin care as compared to baseline. At T1, infants also had significantly reduced heart rate (p = 0.002) and respiratory rate (p < 0.0001) and increased systolic blood pressure (p = 0.033) during skin-to-skin care. At both T1 and T2, infant cortisol remained stable and unchanged from pre-skin-to-skin care to during skin-to-skin care (p = 0.096 and p = 0.356, respectively), and significantly increased from during skin-to-skin care to post-skin-to-skin care (p = 0.001 and p = 0.023, respectively). Exploratory analysis revealed differences in cortisol reactivity for infants with higher baseline cortisol (> 0.3 μg/dL) versus lower (≤ 0.3 μg/dL) prior to skin-to-skin care. Infants with higher baseline cortisol at T2 experienced significantly reduced cortisol during skin-to-skin care (p = 0.025). No significant differences in demographics or baseline variables were found between infants in either group.

CONCLUSIONS

Skin-to-skin care is a low-cost, low-risk intervention that promotes comfort and supports physiologic stability in infants before and after neonatal cardiac surgery.

Holding and Mobility of Pediatric Patients With Transthoracic Intracardiac Catheters

BACKGROUND

Nursing care of pediatric patients after cardiac surgery consists of close hemodynamic monitoring, often through transthoracic intracardiac catheters, requiring patients to remain on bed rest and limiting holding and mobility.

OBJECTIVES

The primary aim of this quality improvement project was to determine the feasibility of safely mobilizing pediatric patients with transthoracic intracardiac catheters out of bed. Once feasibility was established, the secondary aim was to increase the number of days such patients were out of bed.

METHODS AND INTERVENTIONS

New standards and procedures were implemented in July 2015 for pediatric patients with transthoracic intracardiac catheters. After initiation of the new policies, complications were tracked prospectively. Nursing documentation of activity and positioning for all patients with transthoracic intracardiac catheters was extracted from electronic health records for 2 fiscal years before and 3 fiscal years after the new policies were implemented. The Cochran-Armitage test for trend was used to determine whether patterns of out-of-bed documentation changed over time.

RESULTS

A total of 1358 patients (approximately 250 to 300 patients each fiscal year) had activity and positioning documented while transthoracic intracardiac catheters were in place. The Cochran-Armitage test for trend revealed that out-of-bed documentation significantly increased after the new policies and procedures were initiated (P < .001). No major complications were noted resulting from patient mobility with transthoracic intracardiac catheters.

CONCLUSION

Pediatric patients with transthoracic intracardiac catheters can be safely held and mobilized out of bed.

Symptom Frequency in Children with Congenital Heart Disease and Parental Care Burden in Predicting the Quality of Life of Parents in Turkey

PURPOSE

This study was conducted to investigate the symptom frequency and parental care burden of the children with congenital heart disease in predicting the quality of life of parents in Turkey.

DESIGN AND METHOD

The study subjects for the present study included 124 parents whose children were suffering from heart disease. The data for the study were collected from these parents using parent information form, the questionnaire of the frequency of heart disease-related symptoms of the child, the caregiver burden scale, and the quality of life scale. The level by which the heart disease-related symptoms of the child and caregiver burden predicted the quality of life was analyzed using the regression analysis.

RESULTS

The most common symptoms in children were found to be anorexia, difficulty in activities, palpitations, shortness of breath, weakness, and fatigue. The number of symptoms observed in children and the care burden of the parents were determined to explain 27.1% of the psychological health sub-dimension, 14.4% of the social relations sub-dimension, and 34.9% of the environment sub-dimension. When the variables were examined separately, the number of symptoms was found to significantly predict only social relations sub-dimensions.

CONCLUSION

Increased number of symptoms increased parental care burden. Increased number of symptoms and care burden of parents reduced the quality of life of parents.

PRACTICE IMPLICATIONS

Symptom management is one of the important responsibilities of nurses in improving care burden and quality of life for parents of children with heart disease.

A Collaborative Learning Assessment of Developmental Care Practices for Infants in the Cardiac Intensive Care Unit

OBJECTIVE

Assess differences in approaches to and provision of developmental care for infants undergoing surgery for congenital heart disease.

STUDY DESIGN

A collaborative learning approach was used to stratify, assess, and compare individualized developmental care practices among multidisciplinary teams at 6 pediatric heart centers. Round robin site visits were completed with structured site visit goals and postvisit reporting. Practices of the hosting site were assessed by the visiting team and reviewed along with center self-assessments across specific domains including pain management, environment, cue-based care, and family based care coordination.

RESULTS

Developmental care for infants in the cardiac intensive care unit (CICU) varies at both a center and individual level. Differences in care are primarily driven by variations in infrastructure and resources, composition of multidisciplinary teams, education of team members, and use of developmental care champions. Management of pain follows a protocol in most cardiac intensive care units, but the environment varies across centers, and the provision of cue-based infant care and family-based care coordination varies widely both within and across centers. The project led to proposed changes in clinical care and center infrastructure at each participating site.

CONCLUSIONS

A collaborative learning design fostered rapid dissemination, comparison, and sharing of strategies to approach a complex multidisciplinary care paradigm. Our assessment of experiences revealed marked variability across and within centers. The collaborative findings were a first step toward strategies to quantify and measure developmental care practices in the cardiac intensive care unit to assess the association of complex inpatient practices with long-term neurodevelopmental outcomes.

Promoting Parent Partnership in Developmentally Supportive Care for Infants in the Pediatric Cardiac Intensive Care Unit

BACKGROUND

Limited opportunities for parents to care for their critically ill infant after cardiac surgery can lead to parental unpreparedness and distress.

PURPOSE

This project aimed to create and test a bedside visual tool to increase parent partnership in developmentally supportive infant care after cardiac surgery.

METHODS

The Care Partnership Pyramid was created by a multidisciplinary team and incorporated feedback from nurses and parents. Three Plan-Do-Study-Act (PDSA) cycles tested its impact on parent partnership in care. Information about developmentally supportive care provided by parents during each 12-hour shift was extracted from nursing documentation. A staff survey evaluated perceptions of the tool and informed modifications.

RESULTS

Changes in parent partnership during PDSA 1 did not reach statistical significance. Staff perceived that the tool was generally useful for the patient/family but was sometimes overlooked, prompting its inclusion in the daily goals checklist. For PDSA 2 and 3, parents were more often observed participating in rounds, asking appropriate questions, providing environmental comfort, assisting with the daily care routine, and changing diapers.

IMPLICATIONS FOR PRACTICE

Use of a bedside visual tool may lead to increased parent partnership in care for infants after cardiac surgery.

IMPLICATIONS FOR RESEARCH

Future projects are needed to examine the impact of bedside care partnership interventions on parent preparedness, family well-being, and infant outcomes.

From Surviving to Thriving - Parental Experiences of Hospitalised Infants with Congenital Heart Disease Undergoing Cardiac Surgery: A Qualitative Synthesis

PROBLEM

Congenital heart disease (CHD) is the most common congenital abnormality in infants and over one third of these infants will require surgical intervention in the neonatal period. This qualitative synthesis aimed to explore parental experiences of surgery and hospitalisation in the intensive care environment for the treatment of their infant's CHD in the first year of life in order to inform practice.

ELIGIBILITY CRITERIA

Qualitative primary research and qualitative elements of mixed methods studies published in English between January 2009 and February 2019 were eligible if they addressed the experiences and perspectives of parents whose infants had CHD undergoing cardiac surgery in the first year of life.

SAMPLE

Three hundred and forty-nine papers were screened. Six papers, with three of them from the same larger study, were included.

RESULTS

Five themes were developed from thematic synthesis. They are (1) intense conflicting emotions from heartbreak to joy, (2) the helplessness and uncertainty of waiting, (3) making sense of it all, (4) the power of relationships, and (5) parenting despite the challenges.

CONCLUSION

Parents experienced intense and fluctuating emotions, and found ways of coping. The integral role of healthcare professionals/nurses during this period was also evident.

IMPLICATIONS

Healthcare professionals/nurses have the potential to positively impact the care and outcomes for this growing population of infants with CHD and their families, helping them to thrive. More research is needed with longitudinal and multi-centred studies and in middle and low income counties to broaden our understanding of this topic.

Kangaroo Care for Hospitalized Infants with Congenital Heart Disease

BACKGROUND

Kangaroo care (KC), or skin-to-skin care, occurs when an infant is dressed in a diaper and held to a parent's bare chest. This form of holding has been shown to have many benefits for hospitalized infants and has been shown to be a safe and feasible intervention to support infants with congenital heart disease. Despite known benefits, KC was not implemented routinely and consistently in our cardiac center for infants with congenital heart disease. The purpose of this project was to support use of KC as a nursing intervention for hospitalized infants with congenital heart disease and their parents.

METHODS

A KC quality improvement committee formed to develop strategies to increase frequency of KC, including the creation of a new nursing policy and procedure on KC for infants, adaptation of the electronic health record to facilitate KC documentation, education, and supporting translation of KC into practice through the cardiac center's first Kangaroo-A-Thon.

RESULTS

Twenty-six nurses initiated KC 43 times with 14 patients over the 8-week period for the Kangaroo-A-Thon. No adverse events were reported as a result of infants being held by their parents in KC.

CONCLUSION

Our local initiative provided preliminary evidence that KC can be safely integrated into standard care for hospitalized infants with congenital heart disease. Formal standards and procedures, along with creative initiatives such as a Kangaroo-A-Thon, can be a first step toward fostering the translation of KC into practice.

Mental health care for parents of babies with congenital heart disease during intensive care unit admission: Systematic review and statement of best practice

INTRODUCTION

Congenital heart disease (CHD) is one of the most common causes of infant admission to pediatric intensive care and is associated with profound psychological stress for mothers, fathers and their infants. Intensive care unit admission represents an opportunity to offer evidence-based strategies to prevent or minimize severe psychological distress and promote secure bonding and attachment, alongside high-quality infant medical care.

OBJECTIVES

We aimed to identify, synthesize and critically appraise published evidence on the efficacy and cost-effectiveness of mental health interventions delivered in neonatal, pediatric or cardiac intensive care units for parents of infants with CHD. A secondary goal was to develop recommendations for advancing health policy, practice and research in the field.

METHODS

In accordance with a prospectively registered protocol (CRD42019114507), six electronic databases were systematically searched for studies reporting results of a controlled trial of a mental health intervention for parents of infants aged 0-12 months with a congenital anomaly requiring intensive care unit admission. To maximize generalizability of results, trials involving infants with any type of structural congenital anomaly requiring surgery were included. Outcomes included intervention type, process, efficacy, and cost-effectiveness.

RESULTS

Across all forms of congenital anomaly, only five trials met inclusion criteria (four in CHD, one in gastrointestinal malformation). All interventions engaged parents face-to-face, but each had a distinct therapeutic approach (parent-infant interaction and bonding, early pediatric palliative care, psycho-education, parenting skills training, and family-centered nursing). Four of the five trials demonstrated efficacy in reducing maternal anxiety, although the quality of evidence was low. Positive results were also found for maternal coping, mother-infant attachment, parenting confidence and satisfaction with clinical care, as well as infant mental (but not psychomotor) development at 6 months. Mixed results were found for maternal depression and infant feeding. No evidence of efficacy was found for improving parent, infant or family quality of life, physical health or length of infant hospital stay, and there were no data on cost-effectiveness.

CONCLUSIONS

Stronger evidence for the efficacy of mental health interventions to buffer the effects of intensive care unit admission for parents of infants with CHD is urgently needed. Robust, high-quality trials are lacking, despite the established need and demand, and health policies prioritizing parent mental health care in the context of early childhood adversity are needed.

Recent advances in our understanding of neurodevelopmental outcomes in congenital heart disease

PURPOSE OF REVIEW

Patients with congenital heart disease (CHD) suffer from a pattern of neurodevelopmental abnormalities including deficits in language and executive function. In this review, we summarize recent studies that examine these outcomes, their risk factors, possible biomarkers, and attempts to develop therapeutic interventions.

RECENT FINDINGS

The latest literature has highlighted the role of genetics in determining neurologic prognosis, as we have increased our understanding of potentially modifiable perioperative risk factors. The role of potentially neurotoxic medical therapies has become more salient. One recent focus has been how neurodevelopment affects quality of life and leads to a high prevalence of mental illness. Neuroimaging advances have provided new insights into the pathogenesis of deficits.

SUMMARY

Although many risk factors in CHD are not modifiable, there is promise for interventions to improve neurodevelopmental outcomes in patients with CHD. Biomarkers are needed to better understand the timing and prognosis of injury and to direct therapy. Research into psychosocial interventions is urgently needed to benefit the many survivors with CHD.

Early palliative care reduces stress in parents of neonates with congenital heart disease: validation of the "Baby, Attachment, Comfort Interventions"

OBJECTIVE

To test our hypothesis that an innovative method of early palliative care called "Baby, Attachment, Comfort Interventions" reduces psychological distress in parents of neonates with congenital heart disease.

STUDY DESIGN

Prospective cohort study of parents of neonates with congenital heart disease. Distress was evaluated at admission and discharge using Neonatal Unit Parental Stressor Scale and Depression Anxiety Stress Index-21. Control parents received standard of care. Intervention parents received interdisciplinary interventions aimed at improving neonatal comfort and parenting experience.

RESULTS

Seventy-seven parents participated. Stress decreased in the intervention group (26 parents) but not in the control group (51 parents). There was no decrease in anxiety or depression in either group.

CONCLUSION

Early palliative care reduces stress in parents of neonates with congenital heart disease. Further work is needed to address depression/anxiety in this group of high-risk parents.

Neurodevelopmental Outcomes Among Children With Congenital Heart Disease: At-Risk Populations and Modifiable Risk Factors

As survivable outcomes among patients with complex congenital heart disease (cCHD) have continued to improve over the last several decades, more attention is being dedicated to interventions that impact not just survival but quality of life among patients with cCHD. In particular, patients with cCHD are at risk for impaired neurodevelopmental outcomes. In this review summarizing select presentations given at the 14th Annual Pediatric Cardiac Intensive Care Society's Annual Meeting in 2019, we discuss the neurodevelopmental phenotype of patients with cCHD, patients at greatest risk of impaired development, and three specific modifiable risk factors impacting development.

Improving neurodevelopment in infants with complex congenital heart disease

Worldwide, more than 400,000 infants are born each year with complex congenital heart disease (CCHD) requiring surgical intervention within the first months of life. Although improvements in perioperative care have resulted in increased rates of survival, more than half of infants with CCHD have neurodevelopmental impairments affecting subsequent educational achievements, job opportunities, and mental health. Brain maturity and impaired outcomes in infants with CCHD are similar to those of prematurely born infants. Developmentally supportive care, including foundational application of kangaroo care (KC), improves neurodevelopment in premature infants. Provision of developmentally supportive care with KC during the early hospitalization of infants with CCHD has the potential to similarly improve neurodevelopment. The purposes of the article are to describe common congenital heart defects, describe developmentally supportive care with an emphasis on KC, and to offer specific recommendations for KC and research in infants with CCHD.