Measurement of health status and quality of life in neonatal follow-up studies

Public Attitudes Toward Ethics and Practices in End-of-Life Decision-Making for Neonates

Importance

Attitudes toward end-of-life decision-making in neonatology have been studied in physicians and other health care professionals and are mostly shaped by their clinical education and work experiences. In contrast, attitudes among the general public have not yet been investigated.

Objective

To assess (1) attitudes in the general public toward euthanasia and withdrawal of life-prolonging treatment in neonates with severe life-limiting conditions, (2) knowledge of current German recommendations, and (3) values in the German society regarding ethical issues and proxy decisions at the beginning of life.

Design, Setting, and Participants

This cross-sectional study was performed in Germany and used an exploratory design to analyze responses to an interview conducted by an independent, established commissioned polling institute in March and April 2022. Participants were 16 years or older, with German language fluency and comprehension and living in Germany.

Main Outcomes and Measures

Knowledge about recommendations for euthanasia and withdrawal of life-prolonging treatment as well as personal attitudes toward (1) euthanasia and withdrawal of life-prolonging treatment and (2) surrogate end-of-life decision-making for newborn infants were assessed.

Results

The study included 2116 participants (1077 females [50.9%]; mean [SD] age 52.1 [18.7] years). Of the participants, 16.8% (311 of 1851) reported knowing the German recommendations for euthanasia and withdrawal of life-prolonging treatment for neonates. Euthanasia and withdrawal of life-prolonging treatment were supported by 64.7% (1369 of 2116) and 77.9% (1649 of 2116) of respondents, respectively. Shared decision-making between parents and physicians for neonates in end-of-life situations was supported by 65.6% of participants (1388). In situations where shared decision-making was not possible, 73.4% of respondents (1019 of 1388) put the ultimate decision to the parents. The magnitude of the associations was low between sociodemographic factors and views on ethical issues and customary practices involved in end-of-life decisions for neonates.

Conclusions and Relevance

Results of this cross-sectional study suggested that most respondents were not aware of the national German recommendations for euthanasia and withdrawal of life-prolonging treatment for sick and extremely preterm newborns. When counseling parents of periviable newborns, clinicians may need to exert more effort in explaining the legal and ethical framework; a highly individualized approach is warranted.

Early intervention influences positively quality of life as reported by prematurely born children at age nine and their parents; a randomized clinical trial

Background

The Tromsø Intervention Study on Preterms evaluates an early, sensitizing intervention given to parents of prematurely born children (birth-weight < 2000 g). The current study investigated the potential influence of the intervention on children’s self-reported and parental proxy-reported quality of life (QoL) at children’s age of nine.

Methods

Participants were randomized to either intervention (PI, n = 72) or preterm control (PC, n = 74) in the neonatal care unit, while healthy term-born infants were recruited to a term reference group (TR, n = 75). The intervention was a modified version of the Mother-Infant Transaction Program, and comprised eight one-hour sessions during the last week before discharge and four home visits at 1, 2, 4 and 12 weeks post-discharge. The two control groups received care in accordance with written guidelines drawn up at the hospital. Participants and parents reported QoL independently on the Kinder Lebensqualität Fragebogen (KINDL) questionnaire. Differences between groups were analyzed by SPSS; Linear Mixed Models and parent–child agreement were analyzed and compared by intra-class correlations within each group.

Results

On average, children in all groups reported high levels of well-being. The PI children reported better physical well-being than the PC children (p = 0.002). In all other aspects of QoL both the PI and the PC children reported at similar levels as the term reference group. PI parents reported better emotional wellbeing (p = 0.05) and a higher level of contentment in school (p = 0.003) compared with PC parents. Parent–child agreement was significantly weaker in the PI group than in the PC group on dimensions such as emotional well-being and relationships with friends (p < 0.05). PI parents reported QoL similar to parents of terms on all aspects except the subscale self-esteem, while PC parents generally reported moderately lower QoL than TR parents.

Conclusions

This early intervention appears to have generated long-lasting positive effects, improving perceived physical well-being among prematurely born children and parent’s perception of these children’s QoL in middle childhood.

Trial registration

Clinical Trials Gov NCT00222456.

Informing the NHS Outcomes Framework: evaluating meaningful health outcomes for children with neurodisability using multiple methods including systematic review, qualitative research, Delphi survey and consensus meeting

Background

The identification of suitable outcome measures will improve the evaluation of integrated NHS care for the large number of children affected by neurodisability, and has the potential to encourage the provision of more appropriate and effective health care. This research sought to appraise the potential of patient-reported outcome measures (PROMs) for children and young people with neurodisability.

Aim

This research aimed (i) to identify key outcomes of health care for children with neurodisability, beyond morbidity and mortality, from the perspectives of children, parents and professionals; (ii) to critically appraise existing generic multidimensional PROMs; and (iii) to examine whether or not the key outcomes might be measured by existing PROMs. We also sought agreement on a definition of neurodisability.

Methods

Data were gathered in three main ways, (i) a systematic review identified eligible generic multidimensional PROMs and peer-reviewed studies evaluating psychometric performance using English-language questionnaires. Studies were appraised for methodological quality and psychometric performance was appraised using standard criteria. (ii) Focus groups and interviews with children and young people with neurodisability, and separately with parents, sought to identify important outcomes of NHS care, and their feedback on example PROM questionnaires. (iii) An online Delphi survey was conducted with a multidisciplinary sample of health professionals to seek agreement on appropriate NHS outcomes. In addition, we convened a consensus meeting with a small nominal group of young people, parents and professionals; the group sought agreement on a core set of important health outcomes.

Results

From the systematic review, we identified 126 papers that reported eligible evidence regarding the psychometric performance of 25 PROMs. Evidence of psychometric robustness was more favourable for a small number of PROMs: KIDSCREEN (generic), DISABKIDS (chronic-generic) and Child Health Utility 9D (preference-based measure). The Pediatric Quality of Life Inventory and KINDL offer both self-report and a proxy report version for a range of age bands, but evidence of their psychometric performance was weaker. Evidence was lacking in one or more respects for all candidate PROMs, in both general populations and those with neurodisability. Proxy reporting was found generally to be poorly correlated with self-report. Focus groups and interviews included 54 children and young people, and 53 parents. The more important health outcomes were felt to be communication, emotional well-being, pain, mobility, independence/self-care, worry/mental health, social activities and sleep. In addition, parents of children with intellectual impairment identified behaviour, toileting and safety as important outcomes. Participants suggested problems with the face validity of example PROM questionnaires for measuring NHS care. In the Delphi survey, 276 clinicians from a wide range of professions contributed to at least one of four rounds. Professionals rated pain, hearing, seeing, sleep, toileting, mobility and communication as key goals for the NHS but also identified treating neurological symptoms as important. Professionals in the Delphi survey and parents working with the research team agreed a proposed definition for neurodisability. The consensus meeting confirmed overlap between the outcomes identified as important by young people, parents and professionals, but not complete agreement.

Conclusions

There was agreement between young people, parents and professionals regarding a core suite of more important health outcomes: communication, emotional well-being, pain, mobility, independence/self-care, worry/mental health, social activities and sleep. In addition, behaviour, toileting and safety were identified as important by parents. This research suggests that it would be appropriate to measure these constructs using PROMs to assess health care. None of the candidate PROMs in the review adequately captures all of the identified constructs, and there is inadequate evidence that candidate PROMs are psychometrically robust for use across children with neurodisability. Further consultation with young people, families and professionals is warranted to support the use of PROMs to measure NHS outcomes. Research to test potential PROMs with different age groups and conditions would be valuable.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Quality of life of former premature infants during adolescence and beyond

Interest in determining the quality of life of children and adults is now considered a priority. This is a result of a shift in thinking with greater transparency in finding out not only the health outcomes, but also the personal burden of illness and life satisfaction for the individual. However, there is still no consensus on the definition of quality of life or the appropriate tools to measure the same. In the last three decades there has been an exponential increase in the number of publications measuring quality of life, particularly in former premature infants. Most studies show that despite disabilities, children rate their quality of life almost equivalent to that of children born at term, and higher than that predicted by health professionals. This review will focus on the conceptual framework and measurement of self-reported quality of life in the context of former premature infants at adolescence and young adulthood.

Long term follow-up of health-related quality of life in young adults born very preterm or with a very low birth weight

BACKGROUND

The purpose was, first, to evaluate changes in health-related quality of life (HRQL) in a cohort of very low birth weight (VLBW; <1500 g.) or very preterm (< 32 weeks of gestation) children between ages 14 and 19, and second, to identify correlates of HRQL at age 19.

METHODS

HRQL was assessed using the Health Utilities Index Mark 3 (HUI3). In order to explore correlates of HRQL, we performed a hierarchical regression analysis.

RESULTS

Surviving VLBW children (n = 959) from a 1983 Dutch nation-wide cohort were eligible; 630 participated both at age 14 and 19; 54 at age 19 only. The mean HRQL score decreased from 0.87 to 0.86. The HRQL of 45% was stable, 25% were better and 30% were worse. A regression model showed internalizing problems were related most strongly to HRQL.

CONCLUSIONS

In the transition from adolescence to young adulthood, HRQL in Dutch VLBW children was stable at the group level but varied at the individual level. HRQL was negatively associated with internalizing problems and also with physical handicaps. Long-term follow-up studies on the impact of VLBW on HRQL are all the more called for, given the growing number of vulnerable infants surviving the neonatal period.

Reliability in the ratings of quality of life between parents and their children of school age with cerebral palsy

BACKGROUND

Quality of life is recognized as an important outcome of health services. Ideally, the child's perspectives should be sought directly to define their quality of life; however, this may be limited by age and cognitive and language abilities.

PURPOSE

In a sample of school-aged children with cerebral palsy (CP), we compared a parent's perspective of their child's quality of life with their child's own perspective, when feasible.

METHODS

Forty-eight children completed the Pediatric Quality of Life Inventory (PedsQL) measure independently (n = 33/48, 69% Gross Motor Function Classification System (GMFCS) I; n = 6/48, 12% III-V). A parent completed the proxy version and the scores were compared.

RESULTS

Intraclass correlation (ICC) coefficients were high for physical (ICC = 0.72, confidence interval [CI]: 0.55-0.83) and moderate for psychosocial (ICC = 0.54, CI: 0.30-0.71) well-being, with the weakest agreement on school functioning and the strongest agreement for ratings of physical health. Parental ratings were more often lower, especially for social functioning, although children rated themselves lower on emotional functioning. Factors associated with a closer agreement between parent-child pairs included older age, male gender, higher social competency, functional abilities, and fewer emotional symptoms (r (2) = 0.07-0.30).

CONCLUSION

In children with CP, parents' ratings of their children's quality of life are generally comparable as a group to their child's self-report. Disparities do exist, particularly in psychosocial domains, and, therefore, the child's own perspective should be considered whenever feasible.

Contemporary outcomes research: tools of the trade

Outcomes are, simply put, why a surgeon comes to work each day. For decades, surgeons have insisted on a regular self-examination of outcomes to ensure the optimal treatment of our patients. Clinical research in pediatric surgery has largely subsisted on outcome analysis as it relates to the rudimentary end-result of an operation, utilizing variables such as mortality, operative time, specific complication rates, and hospital length of stay to name a few. Recently, outcomes research has become a more complex endeavor. This issue of Seminars in Pediatric Surgery addresses a wide array of these newfound complexities in contemporary outcomes research. The purpose of this review is to assist the pediatric surgeon in understanding the tools that are used in contemporary outcomes research and to be able to use this information to ask new questions of our patients and ourselves as we continue to strive for excellence in caring for sick infants and children.

Measurement of quality of life of survivors of neonatal intensive care: critique and implications

In recent years, an increasing number of studies on the quality of life (QoL) of adults and children have been published, mostly describing outcomes of various medical conditions. Yet, despite the wide interest, there is no universal consensus even on the very definition of what constitutes QoL, particularly for children. Herein, we discuss the conceptual framework and operational definitions of QoL and health-related quality of life (HRQL), address some methodological issues, and review the literature on QoL studies among premature infants. We also describe areas of research that are likely to be fruitful in advancing the consideration of QoL in future studies and in clinical practice.

Determinants of life quality in school-age children with cerebral palsy

OBJECTIVE

To characterize the quality of life of children with cerebral palsy from the parents' and children's perspectives.

STUDY DESIGN

Ninety-five children were recruited; a parent, and when feasible, the child also completed the Child Health Questionnaire and Pediatric Quality of Life Inventory. A range of predictor variables was measured relating to impairments, activity limitations, personal and environmental factors.

RESULTS

Mean age was 9.3 +/- 2.1 years; 63.2% were male, and almost half had mild motor impairment (47% Gross Motor Function Classification System level I). Mean physical well-being (Child Health Questionnaire) was 39.6 +/- 16.9 with 50% <40; and mean psychosocial well-being was 43.0 +/- 11.3 with 53.8% <40. Similarly, with the Pediatric Quality of Life Inventory, 61% had summary scores <1 SD. Scores of parents and their children were significantly correlated (physical: r = .59, P < .0001; psychosocial: r = .39, P = .01); however, children rated themselves higher.

CONCLUSIONS

Results indicate that quality of life is highly variable in children with cerebral palsy, with about half experiencing a life quality similar to typically developing children. Motor and other activity limitations are indicators of physical but not psychosocial well-being. Family functioning, behavioral difficulties, and motivation are important predictors of social-emotional adaptation. Determinants of life quality may guide resource allocation and health promotion initiatives to optimize health of the child and family.

Child or family assessed measures of activity performance and participation for children with cerebral palsy: a structured review

BACKGROUND

There is a need to measure children's 'activity performance and participation' as defined in the World Health Organization's International Classification of Functioning, Disability and Health for Children and Youth (WHO ICF). The aim of this review is to identify instruments that are suitable for use in postal surveys with families of children with cerebral palsy.

METHODS

We conducted a structured review of instruments that use child or family self-assessment of 'activity performance and participation'. The review involved a systematic search for instruments using multiple published sources. Appraisal of the instruments used the predefined criteria of appropriateness, validity, reliability, responsiveness, precision, interpretability, acceptability and feasibility.

RESULTS

There are relatively few child or family assessed instruments appropriate for measuring children's activities and participation. Seven instruments were identified that could potentially be administered by mail. The Assessment of Life Habits for Children (LIFE-H) was the most appropriate instrument as assessed by its content but the reliability of child or family self-assessment is not known. If the LIFE-H were shown to be a reliable self-report measure then the LIFE-H would be the recommended choice. Currently, the Activities Scale for Kids and the condition-specific Lifestyle Assessment Questionnaire for cerebral palsy (LAQ-CP) provide the broadest description of what and how frequently children with cerebral palsy perform a range of activities and thereby indicate participation. The LAQ-CP also provides additional contextual information on the impact of any disability on the participation of the family unit.

CONCLUSION

There remains much scope for developing valid and reliable self-assessed measures corresponding to the WHO ICF dimensions of activities and participation.

Quality of life of 6-year-old survivors from a regional neonatal unit

OBJECTIVE

Quality of life (QOL) of children who required treatment in a national neonatal intensive care unit (NICU) during the first week of life was determined at 6 years of age.

METHOD

QOL was assessed using a standardized questionnaire employing a multi-attribute scoring system including the functions: hearing, vision, speech, mobility, emotion, learning, self-care and pain. After excluding those with congenital neurodevelopmental disorders, questionnaire returns were analyzed from 177 children treated in the NICU in 1990 and a comparative age-matched group of 230 children who did not require neonatal care. Of these, returns were obtained from 143 (81%) cases and 171 (74%) of the non-treated group.

RESULTS

There was no difference in overall ability between the two groups, with 95 (66%) of cases and 126 (74%) of the comparison group reporting normal scores in all functions. Children treated in the NICU had decreased scores in individual functions including speech (p = 0.04), mobility (p = 0.009) and self-care (p = 0.006). For the study population, males had lower function in speech (p = 0.04) and learning (p = 0.001), with significantly worse function overall (p = 0.02) when compared with female cases. When compared with same-gender children who did not require NICU care, overall function was also significantly worse for male but not female cases (p = 0.0002), and this was largely contributed to by impairment in speech (p = 0.03), mobility (p = 0.04), learning abilities (p = 0.02) and self-care (p = 0.03). Eleven (7.7%) cases compared with just two (1.2%) children who were not treated in the NICU required assistance at school (p = 0.009). No difference was observed when QOL was assessed according to gestational age and birth weight.

CONCLUSION

Using a simple scoring system this study has shown that, for survivors who required early neonatal intensive care, the QOL at 6 years compared favorably with that of children not treated in the NICU, especially for girls.

Health-related quality of life of preterm children and their caregivers

As advances in medical science have extended the limit of viability downward to 23 or 24 weeks gestation, interest has turned from long-term health outcomes to quality of life for survivors. During the last decade, the first studies of the health-related quality of life (HRQOL) of children and young adults who were born extremely preterm were published. Taken from the fields of anthropology, economics, sociology, and psychology, the foundation of HRQOL is formed by theories of functionalism, positive well-being, and utility. HRQOL can be defined as the physical, psychological, and social domains of health, which can be influenced by an individual's experiences and perception. HRQOL instruments are generally composed of multiple domains and measure physical functioning, mental health, and social role functioning in some form. Utilities, or preferences for health outcomes under conditions of uncertainty, are also used. Studies of HRQOL to-date indicate that preterm children have, on average, poorer health than their normal birthweight peers, but the majority do not perceive their quality of life as significantly different than others of their own age. Measures of HRQOL should not replace the traditional measures of morbidity, but should become part of the standard battery of tools used to assess a preterm child's health and well-being. Ultimately, studies of the HRQOL of preterm children should identify aspects of life, physical, psychological, or social, that could be improved with intervention.

Child/parent-assessed population health outcome measures: a structured review

AIMS

To identify generic measures of health-related quality of life (HRQL) for children and adolescents developed for use within general populations. Instruments are evaluated on the basis of evidence relating to their reliability and validity.

METHODS

Systematic literature searches were used to identify instruments, which were then assessed against predefined criteria. Information relating to instrument content, population, reliability and validity was extracted from published papers.

RESULTS

Sixteen instruments were identified that had been evaluated among a general population of children or adolescents. Four instruments had reported data on both internal consistency and test-retest reliability. All except two instruments had undergone some degree of construct validation.

CONCLUSIONS

The evidence suggests that the Child Health Questionnaire (CHQ) has been the most extensively evaluated for younger populations but is available as a parent-completed measure only. The new version of the Child Health and Illness Profile (CHIP-CE) is particularly promising and has parallel child- and parent-completed versions for young ages. The weight of evidence suggests that versions of these two instruments are suitable for older children. The Warwick Child Health and Morbidity Profile could be used where information on morbidity and health service contacts is required. Once basic psychometric criteria are fulfilled, instruments should be chosen by assessing their content and design in the light of the prospective application.