Anxiety and stress in mothers and fathers in the 24 h after their child's surgery

Using Consumer Wearable Devices to Profile Postoperative Complications After Pediatric Appendectomy

INTRODUCTION

Markers of postoperative recovery in pediatric patients are difficult for parents to evaluate after hospital discharge, who use subjective proxies to assess recovery and the onset of complications. Consumer-grade wearable devices (e.g., Fitbit) generate objective recovery data in near real time and thus may provide an opportunity to remotely monitor postoperative patients and identify complications beyond the initial hospitalization. The aim of this study was to use daily step counts from a Fitbit to compare recovery in patients with complications to those without complications after undergoing appendectomy for complicated appendicitis.

METHODS

Children ages 3-17 years old undergoing laparoscopic appendectomy for complicated appendicitis were recruited. Patients wore a Fitbit device for 21 d after operation. After collection, patient data were included in the analysis if minimum wear-time criteria were achieved. Postoperative complications were identified through chart review, and step count trajectories for patients recovering with and without complications were compared. Additionally, to account for the patients experiencing a complication on different postoperative days, median daily step count for pre- and post-complication were analyzed.

RESULTS

Eighty-six patients with complicated appendicitis were enrolled in the study, and fourteen children developed a postoperative complication. Three patients were excluded because they did not meet the minimum wear time requirements. Complications were divided into abscesses (n = 7, 64%), surgical site infections (n = 2, 18%), and other, which included small bowel obstruction and Clostridioides difficile infection (n = 2, 18%). Patients presented with a complication on mean postoperative day 8, while deviation from the normative recovery trajectory was evident 4 d prior. When compared to children with normative recovery, the patients with surgical complications experienced a slower increase in step count postoperatively, but the recovery trajectory was specific to each complication type. When corrected for day of presentation with complication, step count remained low prior to the discovery of the complication and increased after treatment resembling the normative recovery trajectory.

CONCLUSIONS

This study profiled variations from the normative recovery trajectory in patients with complication after appendectomy for complicated appendicitis, with distinct trajectory patterns by complication type. Our findings have potentially profound clinical implications for monitoring pediatric patients postoperatively, particularly in the outpatient setting, thus providing objective data for potentially earlier identification of complications after hospital discharge.

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.

Mothers' experiences of caring for their children with liver transplantation: From sorrow to new determination

This study aims to understand mothers' dynamic experiences of caring for their children with liver transplant. A descriptive phenomenological qualitative approach was applied to this study. A total of seven mothers participated in this study. Data were collected from April 2020 to June 2020 through face-to-face interviews. Data analysis was performed using Giorgi's phenomenological method. By grouping general meaning units, 8 themes and 19 subthemes were derived. Eight themes are as follows: sorrow and distress of accepting a child's diagnosis; difficulties in deciding to undergo liver transplantation; negative emotions before and after transplant; the support system before and after liver transplantation; achieving a sense of trust toward healthcare providers; new concerns about the child's life after undergoing liver transplantation; appreciation of the experience; and new determination and expectations for future life. This study can contribute to the guideline that describes the role and daily life experiences of caregiving for other parents whose children undergo liver transplantation and nurses who work with impacted families. Healthcare providers can refer to the results to provide liver transplantation childcare and hospital-based support groups for child's family to improve nurses' communication skills.

Effectiveness of a Mobile App Intervention for Preparing Preschool Children and Parents for Day Surgery: Randomized Controlled Trial

BACKGROUND

Day surgery allows families to return home quickly. Only a few approaches to preparing for day surgery have demonstrated how digital solutions can support families and children.

OBJECTIVE

This study aims to evaluate the effectiveness of a mobile app intervention on preschool children's fear and pain and parents' anxiety and stress in preparing children for day surgery.

METHODS

This study was conducted at the Pediatric Day Surgical Department of a university hospital in Finland between 2018 and 2020. Parents of children (aged 2-6 y) who were in a queue for elective day surgery were randomized into the intervention group (IG; n=36) and control group (CG; n=34). The CG received routine preparations, whereas the IG was prepared using a mobile app. Parents' and children's outcomes were measured using validated scales at 4 different points: at home (T1 and T4) and at the hospital (T2 and T3) before and after surgery. Group differences were analyzed using statistical methods suitable for the material.

RESULTS

Before surgery, parents in both groups experienced mild anxiety, which decreased after surgery. Parental anxiety did not differ between groups preoperatively (P=.78) or postoperatively (P=.63). Both groups had less anxiety at home after surgery compared with before. The IG showed a significant decrease (P=.003); the CG also improved (P=.002). Preoperatively at home, most parents in both groups experienced no stress or mild stress (P=.61). Preoperatively at the hospital, parents in both groups experienced mild stress; however, parents in the IG experienced more stress during this phase (P=.02). Parents in the IG experienced significantly less stress postoperatively than those in the CG (P=.05). Both groups showed decreased stress levels from before to after surgery (IG: P=.003; CG: P=.004) within each group. There were no significant differences in children's pain levels between the groups and measurement points. This was observed before surgery at home (P=.25), before surgery at the hospital (P=.98), and after surgery at the hospital (P=.72). Children's fear decreased more in the IG (P=.006) than in the CG (P=.44) comparing the phases before and after surgery at home. Fear did not differ between the IG and CG preoperatively at home (P=.20) or at the hospital (P=.59) or postoperatively at the hospital (P=.62) or at home (P=.81).

CONCLUSIONS

The mobile app intervention did not reduce anxiety or pain. However, it was observed that parents in the IG experienced substantially heightened stress levels before surgery at the hospital, which decreased significantly after surgery at home. In addition, fear levels in children in the IG decreased over time, whereas no significant change was observed in the CG. These results are important for developing health care service chains and providing families with innovative and customer-oriented preparation methods.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03774303; https://classic.clinicaltrials.gov/ct2/show/NCT03774303.

Evaluation of a Video-Based Education Intervention for Parents of Children Undergoing Fontan Surgery: A Cluster Randomized Controlled Trial

Background

Fontan surgery is performed at 2-4 years of age and is the third planned surgical intervention for children with a univentricular heart. Major challenges for children and parents after Fontan include (a) psychological distress, (b) prolonged pleural drainage, and (c) the need for postoperative anticoagulation. The aim of this study was to evaluate a pre-Fontan video-based intervention for parents to address these challenges.

Methods

This study is a single-centre mixed-methods cluster randomized controlled trial. The intervention consisted of 3 brief whiteboard videos offered online from preadmission clinic to 1 month postoperatively. The parent's State Trait Anxiety Inventory score and the child's Post Hospital Behaviour Questionnaire score were measured 1 week and 1 month postoperatively. Semistructured interviews were conducted to obtain parental feedback on the videos.

Results

We enrolled 26 children (13 female patients; 16 intervention group) and 1 parent per child. Mean State Trait Anxiety Inventory scores were similar between groups at both 1 week (52.8 vs 55.5, P = 0.25) and 1 month postoperatively (50.9 vs 53.9, P = 0.25). Post Hospital Behaviour Questionnaire scores were in the maladaptive range but did not differ between groups. Parents agreed or strongly agreed that the videos were helpful but should be provided earlier in the preoperative process. The main value of the videos was recognized as being a method for standardizing information provided to parents.

Conclusions

A video-based education intervention did not impact State Trait Anxiety Inventory or Post Hospital Behaviour Questionnaire scores. However, the majority of parents agreed that the videos were helpful.

A Cross-Sectional Assessment of Parental Concerns in the Pediatric Surgery Department during the COVID-19 Pandemic

The COVID-19 pandemic has impacted various aspects of healthcare, including pediatric surgery. This study aimed to assess parental concerns and stress levels in pediatric surgery during the COVID-19 pandemic, identify factors associated with increased parental anxiety or concern, and provide recommendations for healthcare providers. A cross-sectional study was conducted in a tertiary pediatric hospital in Timisoara, Romania, involving 174 parents of pediatric patients requiring elective or emergency surgery, with a mean age of 37.6 (25-47) years, out of which 89.1% of respondents were women. Parental concerns were assessed using the Parental Concerns Questionnaire (PCQ), the Hospital Anxiety and Depression Scale (HADS), and the Perceived Stress Scale (PSS-10). Parents of children undergoing emergency surgery (n = 108) reported higher levels on the practical impact domain of the PCQ scale (3.4 vs. 2.2, p < 0.001), emotional impact (2.7 vs. 2.2, p = 0.002), and total PCQ score (9.5 vs. 7.7, p < 0.001) compared to parents of children undergoing elective surgery (n = 66). Parents in the emergent surgery group also reported higher anxiety scores on the HADS questionnaire (7.9 vs. 6.5, p = 0.009) and higher perceived stress and total score on the PSS-10 survey (7.8 vs. 5.6, p = 0.046) (10.5 vs. 9.1, p = 0.047), respectively. A significantly higher proportion of parents in the emergent surgery group were concerned about restricted visitation policies (p = 0.013) and reported delaying or considering delaying their child's surgery due to the pandemic (p = 0.036). The results demonstrate heightened concerns, anxiety, and stress among parents of children undergoing emergency surgery during the COVID-19 pandemic. Healthcare providers should address parental concerns, provide clear communication, and ensure adequate support for families. Recommendations include enhancing information about COVID-19 precautions, reassuring parents about personal protective equipment availability, and facilitating family support within visitation restrictions.

The understated issue of caregiver anxiety for pediatric surgical hospital admissions: opening the blindfolds

KEY MESSAGE

Hospitalization is a nerve-wrecking experience for patients and their families (Lam et al. in Int J Nurs Stud 43:535-545, 2006). The financial burden of hospitalization is the prime perpetrator, however, multiple other factors also contribute significantly to the underlying problem which can be eliminated by efforts of the doctors and other healthcare workers and by modifying the hospital policies (Bassett et al. in J Hosp Med 15:652-658, 2020). We can reduce the number of outpatient visits and switch to telemedicine for rescheduling the cases. The pre-anaesthetic clearance and all the relevant investigations can be done on a single OPD visit thereby reducing the requirement of repeated commutes to the hospital. The free of charge category of the hospital can be extended to the patient requiring prolonged hospital stay or for solid tumor patients who require repeated hospital admissions for chemotherapy. Association with child welfare Non-government organizations (NGO's) can also solve major monetary issues for parents of patients suffering from complex congenital anomalies and solid tumors. The pre-operative NPO period can be shortened to 2-4 h, antibiotic use can be completely avoided or minimized in clean elective cases, children living in the same city requiring dressing/catheter removal after a few days (e.g. hypospadias, posterior sagittal anorectoplasty) can be discharged and called for a OPD visit after 5-7 days if the parents are willing to take care of the child at home. Patients undergoing minor elective surgeries can be followed up on telemedicine visits only. Parents of patients suffering from complex congenital anomalies should be referred to a clinical psychologist and receive periodic counseling sessions. A child psychologist should also be included in the management of cases which have social stigma attached as bladder exstrophy, anorectal malformations, spina bifida requiring lifelong follow-up and bowel washes or repeated clean intermittent catheterisation. Anxiety assessment questionnaires must be incorporated in the management of chronic patients and high-risk parents must be identified (Tiedeman in J Pediatr Nurs 12:110-119, 1997). We hereby propose adoption of family centric approach during the management of a patient as this may minimize the overall burden of the hospitalization of the family.

BACKGROUND

Hospital admission of a child leads to a myriad responses in the parents. Thus, we conducted a hospital-based cross-sectional study to determine the prevalence of anxiety and depression among the primary caregivers of hospitalized children and the factors causing it.

METHODS

Parents of 228 children admitted in the pediatric surgery ward at a tertiary care hospital were interviewed using the HADS-A and Hamilton Anxiety Questionnaire to assess the prevalence of anxiety and depression during hospital admission. They were also subjected to a questionnaire comprising of 52 questions spread over 5 segments-demographic details, monetary burden, effect on siblings and other family members, practical problems faced, and surgery-specific concerns.

FINDINGS

Thirty percent of the parents had severe anxiety and 20% developed depression due to the hospitalization of their child. We tested the association of this depression and anxiety against 56 variables in this study. Exorbitant loan amounts (r^a - 0.449, r^d- 0.557), repeated commute to the hospital (r^a - 0.274, r^d - 0.231), monetary burden (r^a - 0.193, r^d - 0.186), repetitive sampling (r^a - 0.248, r^d - 0.203), prolonged absence from work (r^a - 0.440, r^d - 0.424) were found to be the chief perpetrators of this anxiety and depression.

INTERPRETATION

The burden of anxiety and depression in the primary caregivers of pediatric surgical patients is enormous. Identification of the implicating factors is essential. Simple reforms such as reduction in the number of OPD visits, extension of free of charge category, association with non-governmental organizations and involvement of a clinical psychologist can significantly meliorate the hospital journey of both the patients and their parents. (r^d-correlation coefficient of for depression, r^a-correlation coefficient of for anxiety).

Factors Related to Anxiety in Paediatric Patients and Their Parents before and after a Modified Ravitch Procedure-A Single-Centre Cohort Study

OBJECTIVE

To assess the factors related to perioperative state anxiety in paediatric patients and their parents.

METHODS

A cohort study was conducted on paediatric patients 9-17 years of age, who underwent the modified Ravitch procedure (n = 96), and their parents (n = 96). The level of anxiety was measured using the State-Trait Anxiety Inventory questionnaire. Multivariable linear regression models were calculated to find the relationships between the pre- and postoperative state anxiety of the patients/parents and the independent variables, both demographic (age, gender) and clinical (e.g., postoperative pain, trait anxiety).

RESULTS

Preoperative anxiety in the paediatric patients was positively correlated with their trait anxiety (β = 0.47; 95% CI: 0.29 to 0.64) and preoperative parental anxiety (β = 0.24; 95% CI: 0.07 to 0.42). The high level of preoperative anxiety (vs. low and moderate) (β = 0.40; 95% CI: 0.22 to 0.58), trait anxiety (β = 0.22; 95% CI: 0.04 to 0.40) and average postoperative pain at rest (β = 0.18; 95% CI: 0.01 to 0.34) had a positive impact on the postoperative anxiety in patients. However, the patients' age was negatively correlated with postoperative anxiety (β = -0.19; 95% CI: -0.35 to -0.02). Three variables were found to predict preoperative parental anxiety: their trait anxiety (β = 0.41; 95% CI: 0.23 to 0.59), female gender (β = 0.18; 95% CI: 0.002 to 0.36) and the intravenous route for the postoperative pain management in the patients (β = -0.18; 95% CI: -0.36 to -0.001). The parental postoperative anxiety was influenced by their trait anxiety (β = 0.24; 95% CI: 0.04 to 0.43), preoperative anxiety in patients (β = 0.21; 95% CI: 0.02 to 0.40) and female gender of children (β = 0.19; 95% CI: 0.001 to 0.39).

CONCLUSIONS

Trait anxiety was a strong factor positively affecting the perioperative state anxiety. In addition, paediatric patient anxiety before surgery was related to their parents' anxiety, and, after surgery, this was associated with high preoperative anxiety, pain and age. The parents' anxiety before surgery was influenced by gender and the type of postoperative analgesia in the patients, while, after surgery, this was influenced by the patients' preoperative anxiety/gender.

Condition notification assisted by virtual reality technology reduces the anxiety levels of parents of children with simple CHD: a prospective randomised controlled study

PURPOSE

This study explored the effects of condition notification based on virtual reality technology on the anxiety levels of parents of children with simple CHD.

METHODS

The subjects of the study were the parents of 60 children with simple CHD who were treated in our centre. The state anxiety scale was used to assess the anxiety status of the parents of the children before and after the condition notification in different ways (based on virtual reality explanations and written explanations).

RESULTS

In this study, a total of 55 parents of children with CHD successfully completed the survey. At the time of admission, there was no significant difference in the state anxiety scale scores of the parents between the two groups. The anxiety status of the virtual reality group was relieved after the condition notification assisted by virtual reality technology, and there was a significant difference compared with the control group.

CONCLUSION

Condition notification based on virtual reality technology can effectively alleviate the anxiety of parents of children with simple CHD, which is worthy of clinical application.

Pain management communication between parents and nurses after pediatric outpatient surgery

PURPOSE

The purpose of this study was to explore parent-nurse pain management communication during a child's discharge process following pediatric outpatient surgery.

DESIGN AND METHODS

Thirty-two clinical encounters at discharge between parents (N = 40) and nurses (N = 25) at BC Children's Hospital were audio recorded and transcribed verbatim. Content analysis was applied on the audio recordings and corresponding transcripts using MAXQDA qualitative research software and Microsoft Excel.

RESULTS

Overall, nurses delivered pain management instructions at an average sixth grade readability level and frequently used communication elements of reassurance, optimism, and question-asking. Less consistent communication elements included open-ended questions, interruptions, and promotion of parental decision-making. Parents most frequently asked one to five questions, with pain medication being the most inquired topic.

CONCLUSIONS

Several strengths of the nurse communication approach were identified, and parent questions highlighted a need for greater understanding around pain medication.

PRACTICE IMPLICATIONS

These findings will help guide effective pain management communication and care for young patients and their families.

Design and implementation of a novel patient-centered empowerment approach for pain optimisation in children undergoing major surgery

Background

Paediatric surgery is a stressful experience for patients and caregivers. While standardised protocols are the norm, patient-centred approaches are needed to empower patients/caregivers for an optimal perioperative pain experience. To address this gap, we employed a patient-centred approach using design thinking (DT) methodology to develop insights, map processes, identify opportunities and design solutions for individualised empowerment tools.

Methods

In consultation with DT experts, a multidisciplinary team of stakeholders (healthcare providers, patients who underwent pectus excavatum/scoliosis surgery and their caregivers), were invited to participate in surveys, interviews and focus groups. The project was conducted in two sequential stages each over 24 weeks—involving 7 families in stage 1 and 16 patients/17 caregivers in stage 2. Each stage consisted of three phases: design research (focus groups with key stakeholders to review and apply collective learnings, map processes, stressors, identify influencing factors and opportunities), concept ideation (benchmarking and co-creation of new solutions) and concept refinement.

Results

In stage 1, mapping of stress/anxiety peaks identified target intervention times. We identified positive and negative influencers as well as the need for consistent messaging from the healthcare team in our design research. Current educational tools were benchmarked, parent-child engagement dyads determined and healthcare-based technology-based solutions conceived. The ‘hero’s journey’ concept which has been applied to other illness paradigms for motivation successfully the was adapted to describe surgery as a transformative experience. In stage 2, patient and caregiver expectations, distinct personas and responses to perioperative experience were categorised. Educational tools and an empowerment tool kit based on sensorial, thinking, relaxation and activity themes, tailored to parent/child categories were conceptualised.

Conclusion

DT methodology provided novel family centred insights, enabling design of tailored empowerment toolkits to optimise perioperative experience. Adapting the hero’s journey call to adventure may motivate and build resilience among children undergoing surgery.

The Relationship Between Neonatal Surgery, Postpartum Depression, and Infant Clinical Course

OBJECTIVE

Postpartum depression (PPD) affects 10-15% of mothers in the general population, and studies show increased incidence for mothers of infants with serious health conditions. This study investigates incidence of PPD in mothers of surgical patients in the neonatal intensive care unit (NICU) and characterizes these patients' clinical and neurodevelopmental outcomes.

METHODS

This retrospective cohort study analyzed Nebraska's Tracking Infant Progress Statewide (TIPS) database and referring hospital medical records from February 2013 to June 2018. Upon NICU discharge, children were referred to the TIPS program, with scheduled follow-up appointments at approximately 6 months corrected age. All patients seen in NICU follow-up clinic with recorded scores for maternal Edinburgh postnatal depression screen (EPDS) were eligible except infants with congenital heart disease as this cohort was previously studied. Patients were stratified into groups based on presence or absence of a general surgical procedure within the first 6 months of life and positive (≥ 10) or negative (< 10) EPDS score. Statistical analyses assessed for significant differences between groups regarding gestational age, birth weight, maternal age, length of NICU stay (LOS), number of days on a ventilator, payment method, ethnicity, developmental testing, and rate of referral for early intervention services.

RESULTS

Of 436 patients, 83 were surgical patients (16 with positive EPDS; 19.3% incidence), and 353 were non-surgical patients (44 with positive EPDS; 12.5% incidence). Statistical analysis showed no significant relationship between neonatal surgery and positive EPDS (χ² = 2.6, p = 0.1). While the surgical cohort had longer LOS and days on ventilator, maternal EPDS did not predict these factors. In the surgical cohort, mothers of children not independent on oral feeding at discharge were more likely to screen positive for depression (7/14, 50% vs. 7/61, 11%; p < 0.05).

CONCLUSION

Mothers of surgical patients are not significantly more likely to screen positive for post-partum depression compared to other NICU mothers. This underscores the importance of routine screening for PPD in mothers of both surgical and non-surgical NICU patients in order to identify parents and children at risk.

Smartphone Interventions Effect in Pediatric Subjects on the Day of Surgery: A Meta-Analysis

Background: A meta-analysis was performed to evaluate the effect of smartphone interventions on the anxiety of the pediatric subjects at induction on the day of surgery compared to oral midazolam or standard care as control. Methods: A systematic literature search up to June 2021 was performed and nine studies selected 785 pediatric subjects on the day of surgery at the start of the study; 390 of them were using smartphone interventions, 192 were control, and 203 were using oral midazolam. They were reporting relationships between the effects of smartphone interventions on the anxiety of the pediatric subjects at induction on the day of surgery compared to oral midazolam or control. The mean difference (MD) with its 95% CIs was calculated to assess the effect of smartphone interventions on the anxiety of the pediatric subjects at induction on the day of surgery compared to oral midazolam or control using the continuous method with a fixed or a random-effects model. Results: Smartphone interventions in pediatric subjects were significantly related to lower anxiety at induction on the day of surgery (MD, -19.74; 95% CI, -29.87 to -9.61, p < 0.001) compared to control and significantly related to lower anxiety at induction on the day of surgery (MD, -7.81; 95% CI, -14.49 to -1.14, p = 0.02) compared to oral midazolam. Conclusion: Smartphone interventions in pediatric subjects on the day of surgery may have lower anxiety at induction compared to control and oral midazolam. Further studies are needed to confirm these findings.

Therapy preference of 131 parents confronted with a pediatric femoral fracture

BACKGROUND

The management of femoral fractures in children between 3 and 5 years of age is still vividly debated. Therefore, we aimed to assess the basic attitude of parents if confronted with a hypothetical femoral fracture of their toddler.

MATERIALS AND METHODS

Parents of children aged between 12 and 36 months were asked for their preference after receiving detailed information on conservative and surgical treatment of femoral shaft fractures. Furthermore, we obtained information regarding the parents' gender, marital status, medical background, highest level of education and profession in a leading or non-leading position and if any of their children already had undergone any operations. The Freiburg Personality Inventory (FPI-R) questionnaire was used to assess parents' personality traits.

RESULTS

In total, 131 participants were included in this study. The vast majority (n = 116, 88.5%) preferred surgical treatment. The most frequently mentioned reasons for this decision were lack of acceptance, followed by faster reconvalescence, shorter hospital stay, less deformity or growth disorders and less stress on the child. The only reason stated against surgical treatment was the need of general anesthesia. A significantly higher rate of conservative procedures was noticed in self-employed participants and stress was found to significantly influence the treatment decision of the parents toward conservative treatment.

CONCLUSION

The majority of parents confronted with a hypothetical femoral fracture of their child questioned in this study opted for a surgical approach with elastic stable intramedullary nailing (ESIN). This corresponds with trends toward surgery in these cases in major trauma centers in Europe.

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.

Nurse anesthetist attitudes towards parental presence during anesthesia induction- a nationwide survey

AIMS

To describe nurse anesthetists' attitudes towards the importance of parental presence during their child's anaesthesia induction and to explore associating factors.

DESIGN

A cross-sectional design.

METHODS

Nurse anesthetists from 55 Swedish hospitals were asked to participate (n = 1,285). A total of 809 completed the questionnaire, Families' Importance in Nursing Care-Nurses' Attitudes (FINC-NA) during 2018. Data were analysed by descriptive statistics and multiple linear regression analysis.

RESULTS

Nurse anesthetists generally had a positive attitude towards the importance of parental presence. They reported a more positive attitude in family as a resource in nursing care (median = 40) followed by family as a conversational partner (median = 25), family not as a burden (median = 17) and family as its own resource (median = 13). Multiple linear regression analyses showed that working in a district hospital, working only with children, having routines/memorandum about parental presence, being a woman, allowing both parents to be present in their child's anaesthesia and greater experience of children's anesthesia, were associated with a more positive attitude.

CONCLUSION

This nationwide survey contributes important knowledge for understanding nurse anesthetists' attitudes and the result shows that nurse anesthetists generally have a positive attitude towards the importance of parents. Areas of improvement were, however, identified; the nurses tend to not value family as its own resource and family as a conversational partner highly.

IMPACT

Nurse anesthetists have a crucial role in children's anesthesia care since the quality of parental presence experience depends on a positive attitude from the nurses. Parental involvement is important to establish a child-centered anaesthesia care, which should be highlighted in the education of nurse anesthetists. Parental involvement should also be addressed in healthcare policies and routines should be established.

Effect of care programme based on Comfort Theory on reducing parental anxiety in the paediatric day surgery: Randomised controlled trial

AIMS AND OBJECTIVES

The aim of the study was to determine the effect of a care programme based on the Comfort Theory on reducing parental anxiety forming during the perioperative process of paediatric day surgery.

BACKGROUND

According to the Comfort Theory, nurses provide comfort and take precautions related to comfort, and they provide care and assistance by encouraging individuals/families/society and supporting coping methods. This study is the first randomised controlled study to test the effect of a nursing care programme based on the Comfort Theory for paediatric day surgery.

DESIGN

Randomised controlled trial.

METHODS

The research was completed from June-September 2019 with participation of parents whose children were undergoing paediatric day surgery at a hospital in the Mediterranean region of Turkey. A total of 120 participants were randomly assigned to two equal groups. The intervention group received care programme based on Comfort Theory. The control group received nursing care routinely provided in the clinic. Data were collected using the State-Trait Anxiety Inventory. Measures were obtained at six points, at baseline, at four interval observations after the initial point and during follow-up on the 10th postoperative day. The repeated measures ANOVA test and t-test for independent samples were used to compare the anxiety levels between the intervention and control groups.

RESULTS

There was a statistically significant difference in favour of the group receiving the care programme based on the Comfort Theory when the anxiety levels between the intervention and control groups were compared.

CONCLUSIONS

The care programme based on the Comfort Theory was effective in reducing parental anxiety forming in the perioperative process of paediatric day surgery.

RELEVANCE TO CLINICAL PRACTICE

The results of this study show the applicability of the care programme for paediatric day surgery. It is recommended that this programme be introduced to nurses in paediatric day 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.

Institution-initiated text messaging can reduce unplanned emergency department visits after appendectomy

BACKGROUND/PURPOSE

The purpose of this study was to reduce unplanned Emergency Department (ED) visits for minor complaints in children after appendectomy through proactive institution-driven communication and utilization of telehealth resources.

METHODS

We developed a text messaging system to initiate communication with parents of postappendectomy patients and connect them with a telehealth visit or a phone call with a surgical provider as needed. Using descriptive statistics, chi square, and statistical process control analytics, we compared rates of postoperative ED visits for the 8 months pre- and post-implementation of the messaging system and summarized the feedback we received from patients.

RESULTS

A total of 791 laparoscopic appendectomies were performed in two institutions (preintervention = 382, post-intervention = 409). The postoperative ED visit rate decreased from 5.8% preimplementation to 2.4% post-implementation (p = 0.02). Over one-fifth of families messaged (21.6%) had questions in the postoperative period. The majority expressed interest in a video visit (52.5%), while some preferred to speak with the surgeon's office (25%). Over 90% of respondents found the system helpful, and 4.9% opted out.

CONCLUSION

Implementation of a hospital-initiated text messaging system has the potential to reduce ED visits in the immediate postoperative period after appendectomy. This system can be scaled to include different surgeries across multiple disciplines.

LEVEL OF EVIDENCE

III.

TYPE OF STUDY

Clinical Retrospective Pre/Post Intervention Study.

Prevalence of traumatic psychological stress reactions in children and parents following paediatric surgery: a systematic review and meta-analysis

BACKGROUND

Children undergoing surgery and their parents are at risk of developing post-traumatic stress reactions. We systematically reviewed the literature to understand the prevalence of this issue, as well as potential risk factors.

METHODS

We conducted a systematic review and meta-analysis, using PubMed, PsycInfo, Web of Science and Google Scholar, with searches conducted in February 2021. Papers were included if they measured post-traumatic stress in children and/or parents following paediatric surgery and were excluded if they did not use a validated measure of post-traumatic stress. Data were extracted from published reports.

FINDINGS

Our search yielded a total of 1672 papers, of which 16 met our inclusion criteria. In meta-analysis, pooled studies of children estimated an overall prevalence of 16% meeting criteria for post-traumatic stress disorder post surgery (N=187, 95% CI 5% to 31%, I²=80%). After pooling studies of parents, overall prevalence was estimated at 23% (N=1444, 95% CI 16% to 31%, I²=91%). Prevalence rates were higher than those reported in the general population. Risk factors reported within studies included length of stay, level of social support and parental mental health.

INTERPRETATION

There is consistent evidence of traumatic stress following surgery in childhood which warrants further investigation. Those delivering surgical care to children would benefit from a raised awareness of the potential for post-traumatic stress in their patients and their families, including offering screening and support.

Parental Experiences of the Pediatric Day Surgery Pathway and the Needs for a Digital Gaming Solution: Qualitative Study

BACKGROUND

The parents of hospitalized children are often dissatisfied with waiting times, fasting, discharge criteria, postoperative pain relief, and postoperative guidance. Parents' experiences help care providers to provide effective, family-centered care that responds to parents' needs throughout the day surgery pathway.

OBJECTIVE

The objective of our study was to describe parental experiences of the pediatric day surgery pathway and the needs for a digital gaming solution in order to facilitate the digitalization of these pathways.

METHODS

This was a descriptive qualitative study. The participants (N=31) were parents whose children were admitted to the hospital for the day surgical treatments or magnetic resonance imaging. The data were collected through an unstructured, open-ended questionnaire; an inductive content analysis was conducted to analyze the qualitative data. Reporting of the study findings adheres to the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist.

RESULTS

Parental experiences of the children's day surgery pathway included 3 main categories: (1) needs for parental guidance, (2) needs for support, and (3) child involved in his or her own pathway (eg, consideration of an individual child and preparation of child for treatment). The needs for a digital gaming solution were identified as 1 main category-the digital gaming solution for children and families to support care. This main category included 3 upper categories: (1) preparing children and families for the day surgery via the solution, (2) gamification in the solution, and (3) connecting people through the solution.

CONCLUSIONS

Parents need guidance and support for their children's day surgery care pathways. A digital gaming solution may be a relevant tool to support communication and to provide information on day surgeries. Families are ready for and are open to digital gaming solutions that provide support and guidance and engage children in the day surgery pathways.

Parental decision regret in childhood hypospadias surgery: A systematic review

We conducted a systematic review of the literature to establish the prevalence of and predictive factors for parental decision regret in hypospadias surgery. A search strategy without language restrictions was developed with expert help, and two reviewers undertook independent study selection. Five studies were included in this review (four for quantitative analysis) with a total of 783 participants. The mean overall prevalence of parental decision regret was 65.2% (moderate to severe - 20.3%). Although significant predictors of regret were identified (post-operative complications, small size glans, meatal location, decision conflict between parents, parental educational level and others), they had unexplained discordance between studies. Parental decision regret after proximal hypospadias surgery and refusing surgery was inadequately reported. In conclusion, even though the prevalence of parental decision regret after consenting for the hypospadias repair appears to be high, risk factors associated with it were discordant suggesting imprecision in estimates due to unknown confounders.

The effects of primary and recurrent pediatric urological surgeries on parental anxiety levels

INTRODUCTION

Invasive diagnostic and therapeutic procedures in pediatric urology may generally cause distress and pain in children. As a result, it may have a negative effect on adult and child behaviors. The anxiety, depression levels or distress and fear status caused by recurrent diseases or repetitive medical interventions in adult patients or the parents of pediatric patients have been investigated previously.

OBJECTIVE

To the best of our knowledge, we have not found a study evaluating the effects of primary or recurrent pediatric urological operations on parental anxiety. Our main aim was to compare the effects of primary and repetitive pediatric urological surgeries on the anxiety levels of both mothers and fathers. We also aimed to investigate the effects of other factors related to parents and children on parental anxiety.

DESIGN

A total of 163 patients under 14 years old who had undergone primary or recurrent pediatric urological operations and also their parents were included in a prospective, cross-sectional study. Demographic and clinical data of the patients and their parents were recorded. Before the surgeries, the Children's Fear Scale was applied to all patients over 3 years old and the State-Trait Anxiety Inventory was applied to all parents. The participants were divided into two main groups: primary surgery group (n:84) and recurrent surgery group (n:79). A subgroup analysis was performed according to surgery type (day surgery, minor surgery and major surgery).

RESULTS

We found that repetitive surgeries, higher fear scores of children, parents' being younger, having low education level, not having enough information about the surgeries and presence of someone in the immediate vicinity who previously experienced the same surgery increased parental anxiety levels. Day surgeries did not affect fathers' state anxiety levels as much as minor and major surgeries, whereas mothers' state anxiety levels were higher than fathers' regardless of the surgery type. Children's fear level was not affected by child age, gender, surgery type or previous history of surgery.

DISCUSSION

The majority of studies in the literature show no significant difference in terms of pain and fear levels in pediatric patients undergoing repeated diagnostic interventions but there are contradictory results about parental anxiety levels. There is also a lack of studies on the effects of recurrent surgeries.

CONCLUSION

According to our findings, repetitive surgeries and presence of someone who previously experienced the same surgery are the most significant predictive factors increasing parental anxiety levels.

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.

Early morbidities following paediatric cardiac surgery: a mixed-methods study

Background

Over 5000 paediatric cardiac surgeries are performed in the UK each year and early survival has improved to > 98%.

Objectives

We aimed to identify the surgical morbidities that present the greatest burden for patients and health services and to develop and pilot routine monitoring and feedback.

Design and setting

Our multidisciplinary mixed-methods study took place over 52 months across five UK paediatric cardiac surgery centres.

Participants

The participants were children aged < 17 years.

Methods

We reviewed existing literature, ran three focus groups and undertook a family online discussion forum moderated by the Children’s Heart Federation. A multidisciplinary group, with patient and carer involvement, then ranked and selected nine key morbidities informed by clinical views on definitions and feasibility of routine monitoring. We validated a new, nurse-administered early warning tool for assessing preoperative and postoperative child development, called the brief developmental assessment, by testing this among 1200 children. We measured morbidity incidence in 3090 consecutive surgical admissions over 21 months and explored risk factors for morbidity. We measured the impact of morbidities on quality of life, clinical burden and costs to the NHS and families over 6 months in 666 children, 340 (51%) of whom had at least one morbidity. We developed and piloted methods suitable for routine monitoring of morbidity by centres and co-developed new patient information about morbidities with parents and user groups.

Results

Families and clinicians prioritised overlapping but also different morbidities, leading to a final list of acute neurological event, unplanned reoperation, feeding problems, renal replacement therapy, major adverse events, extracorporeal life support, necrotising enterocolitis, surgical infection and prolonged pleural effusion. The brief developmental assessment was valid in children aged between 4 months and 5 years, but not in the youngest babies or 5- to 17-year-olds. A total of 2415 (78.2%) procedures had no measured morbidity. There was a higher risk of morbidity in neonates, complex congenital heart disease, increased preoperative severity of illness and with prolonged bypass. Patients with any morbidity had a 6-month survival of 81.5% compared with 99.1% with no morbidity. Patients with any morbidity scored 5.2 points lower on their total quality of life score at 6 weeks, but this difference had narrowed by 6 months. Morbidity led to fewer days at home by 6 months and higher costs. Extracorporeal life support patients had the lowest days at home (median: 43 days out of 183 days) and highest costs (£71,051 higher than no morbidity).

Limitations

Monitoring of morbidity is more complex than mortality, and hence this requires resources and clinician buy-in.

Conclusions

Evaluation of postoperative morbidity provides important information over and above 30-day survival and should become the focus of audit and quality improvement.

Future work

National audit of morbidities has been initiated. Further research is needed to understand the implications of feeding problems and renal failure and to evaluate the brief developmental assessment.

Funding

This project was funded by the NIHR Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 30. See the NIHR Journals Library website for further project information.

The effectiveness of web-based mobile health interventions in paediatric outpatient surgery: A systematic review and meta-analysis of randomized controlled trials

AIMS

To evaluate the effectiveness of web-based mobile health interventions on paediatric patients and their parents in the day surgery context, where the primary outcome was children's pre-operative anxiety and secondary outcomes were postoperative pain and parents' anxiety and satisfaction with entire course of the day surgery.

DESIGN

A systematic review and meta-analysis of randomized controlled trials.

DATA SOURCES

CENTRAL, CINAHL, Scopus, Ovid MEDLINE, and Web of Science were systematically searched without time limits (up to December 2018).

REVIEW METHODS

Studies were appraised using the Cochrane risk of bias tool. A random effect meta-analysis of children's pre-operative anxiety was performed.

RESULTS

Eight studies with a total of 722 patients were included in the analysis. The effectiveness of web-based mobile health interventions, including age-appropriate videos, web-based game apps, and educational preparation games made for the hospital environment, was examined in pre-operative settings. A meta-analysis (N = 560 children) based on six studies found a statistically significant reduction in pre-operative anxiety measured by the Modified Yale Pre-operative Anxiety Scale with a moderate effect size. Three studies reported parental satisfaction.

CONCLUSION

Web-based mobile health interventions can reduce children's pre-operative anxiety and increase parental satisfaction. Web-based mobile health interventions could be considered as non-pharmacological distraction tools for children in nursing. There is not enough evidence regarding the effectiveness of reducing children's postoperative pain and parental anxiety using similar interventions.

IMPACT

Web-based mobile health interventions reduce children´s pre-operative anxiety and could therefore be considered as non-pharmacological distraction tools for children in nursing.

Parental understanding of our communication of morbidity associated with paediatric cardiac surgery: a qualitative study

BACKGROUND

Following paediatric cardiac surgery, quality of life may be significantly impacted by morbidities associated with cardiac surgery. Parental understanding of the potential for postoperative morbidity is important for informed decision making. As part of a broader research study, we aimed to elicit parental understanding and experience of the communication of morbidities following their child's cardiac surgery, using traditional focus groups together with an online forum.

METHODS

The Children's Heart Federation set up and moderated a closed, anonymous online discussion group via their Facebook page, focusing on complications, information needs and methods of providing families with information. Additionally, we ran three focus groups with parents/carers, moderated by an experienced independent professional. Focus groups were recorded and transcribed and a single transcript was generated from the online forum. All transcripts were thematically analysed.

RESULTS

All data were collected in 2014. The forum ran over 3 months in 2014 and involved 72 participants. Focus groups involved 13 participants. Three broad themes were identified: (1) clinicians' use of language, (2) feeling unprepared for complications and (3) information needs of families.

CONCLUSIONS

Clinicians' language is often misunderstood, with wide variability in the way morbidities are described, and between differing teams looking after the same child. Information may not be easily absorbed or retained by families, who often felt unprepared for morbidities that arose after their child's heart surgery. Here, we propose key principles of good communication tailored to the individual receiving it.

Congenital Cardiac Surgery and Parental Perception of Risk: A Quantitative Analysis

INTRODUCTION

Interpretation of risk by parents of children undergoing congenital cardiac surgery is poorly documented. The available evidence highlights a dichotomy where clinicians suggest parents may not grasp the complexity and risk associated with procedures, while some parents suggest risk is unnecessarily overemphasized.

AIM

To quantify how risk is perceived by parents.

METHODS

One hundred six parents of children undergoing cardiac surgery were recruited and completed a Likert-type scale from 1 (perceived low risk) to 6 (perceived high risk), at 5 points: arrival at preadmission, post discussion with anethetist/surgeon, day of surgery, discharge from intensive care, and at outpatient follow-up. The surgical sample was stratified according to Risk Adjustment in Congenital Heart Surgery level.

ANALYSIS

Data were analyzed using Wilcoxon rank tests for differences in distributions of scores and Krippendorff α to examine the level of agreement.

RESULTS

Median parental risk scores varied over time, with no consistent risk scores observed. Maternal scores were consistently higher than paternal scores at every time point (P < .001). Postoperative complications resulted in a persistent rise in risk perception at follow-up (P < .001). Analysis of parental risk scores and objective measures of surgical risk highlighted poor agreement that was particularly marked at the extremes of risk.

CONCLUSIONS

Parents perceived higher risk scores than those reported by the clinical team. Mothers reported statistically significantly higher scores than their partners, highlighting potential tensions. In addition, the changing perception of risk over time emphasizes the need for flexible levels of support and information as parents navigate uncertainty.

Discovering dad: paternal roles, responsibilities, and support needs as defined by fathers of children with complex cardiac conditions perioperatively

BACKGROUND

Understanding perceptions of family caregivers' roles and responsibilities regarding their child with complex cardiac needs has potential to help care teams better support parents. Paternal experience has been under-explored in pediatric cardiac cohorts.

METHODS

Ten fathers of children undergoing cardiac surgery completed quantitative surveys on their knowledge needs and preferred format of communication. In face-to-face recorded interviews, they responded to open-ended questions about the definition of being a good father to a child with a complex cardiac condition, perceived paternal responsibilities, personal growth as a parent to a child with a complex heart condition, support needs, and recommendations to medical staff for paternal inclusion. Semantic content analysis was utilised. The study reports strictly followed COnsolidated criteria for REporting Qualitative research guidelines.

RESULTS

The fathers reported high preference for knowledge about the child's heart condition, communication about the treatment plan, and desire for inclusion in the care of their child. Paternal role was defined thematically as: providing a supportive presence, being there, offering bonded insight, serving as strong provider, and acting as an informed advocate. The fathers revealed that their responsibilities sometimes conflicted as they strove to serve as an emotional and economic stabiliser for their family, while also wanting to be foundationally present for their child perioperatively.

CONCLUSION

This study provides insight into paternal experience and strategies for paternal inclusion. This summary of the self-defined experience of the fathers of pediatric cardiac patients offers constructive and specific advice for medical teams.

Medical Stress Reactions and Personal Growth in Parents of Children With a Rare Craniofacial Condition

BACKGROUND

The birth of a child with a congenital craniofacial anomaly (CFA) can have a profound psychological impact on the family. Despite the complexity and variability in treatment for these rare conditions, few studies have been conducted into parents' emotional responses to health-care experiences. The aim of the present study was to investigate parents' subjective experiences of their child's condition and treatment using an in-depth qualitative approach.

METHODS

Individual semistructured interviews were conducted in person or over the telephone with 48 parents of children with a range of rare CFAs. Interviews were transcribed verbatim, translated into English, and analyzed using inductive thematic analysis.

RESULTS

Participants reported physical and psychological symptoms that could be indicative of medical traumatic stress in relation to their child's diagnosis and treatment. Participants described feelings of powerlessness and the weight of being responsible for their child's care. Yet, participants also reported that as a result of their experiences, their perspective on life had changed and they had grown in self-confidence.

CONCLUSIONS

The findings provide insight into the complex physical and psychological effects experienced by parents in response to their child's diagnosis and medical treatment, as well as an understanding of how these experiences may also result in personal growth over time. Implementation of trauma-informed evidence-based resources should be considered in craniofacial care and future research, particularly in regard to prevention and treatment of psychological distress.

Distribution of a photographic atlas did not reduce postoperative care utilization after pediatric circumcision or the indispensability of the pediatric urology clinic nurse

BACKGROUND

Surgery in children is increasingly ambulatory, and caregiver responsibilities for postoperative care can produce anxiety. Prior studies have suggested the distribution of a photographic atlas can mitigate caregiver anxiety and reduce clinic phone calls and in-person presentations after pediatric penile surgery.

OBJECTIVE

A pilot study of the ability of a photographic atlas, distributed to caregivers, was aimed to be conducted to reduce postoperative resource utilization.

STUDY DESIGN

Patients undergoing circumcision or revision circumcision were randomized to standard postoperative instructions vs. standard instructions with a photographic atlas representing appropriate penile appearance at successive time points. Electronic records were reviewed for phone calls or in-person presentations to the clinic or emergency department (ED) within 1 month of surgery.

RESULTS

Fourteen patients (44%) received the atlas, and 18 (56%) did not. Patients who received the atlas did not differ significantly from patients who did not receive it in their rate of clinic phone calls (36% vs 39%, p = 0.85), calls per patient (0.5 vs. 0.7, p = 0.78), ED visits (7% vs. 11%, p = 0.70), calls and visits combined (44% vs. 43%, p = 0.93), or the proportion of calls and emergency room presentations related to concerns about the penile appearance (22% vs. 36%, p = 0.66). Overall, 19 postoperative phone calls were received from 12 patients, and 4 visits to the ED were made by 3 patients. Reasons for calls to the clinic were diverse, and 9 distinct categories of concern were identified apart from wound appearance.

DISCUSSION

The impressive diversity of caregiver concerns prompting postoperative communication may partly underlie the failure of the atlas to reduce resource utilization in this study. Most postoperative calls or visits were unrelated to concern about the penile appearance, which limits the degree to which this or any visual guide to wound healing can reduce the need for postoperative attention.

CONCLUSION

Receipt of the atlas did not significantly reduce postoperative contacts or affect the proportion of contacts represented by concerns about penile appearance. Resources must remain directed toward individualized attention to caregiver concerns, delivered by experienced urologic support staffs, who remain the mainstay of postoperative support.

Obstructive sleep apnea in children: How it affects parental psychological status?

PURPOSE OF THE STUDY

The aim of this study was to evaluate the influence of obstructive sleep apnea (OSA) in children on maternal and paternal anxiety.

PATIENTS AND METHODS

This prospective study was conducted from January 2013 until January 2016 in the Ear, Nose and Throat (ENT) Department at the University Hospital of Split, Croatia. The parents of 59 children with a median age of 5 years (range: 2-9) who were suffering from obstructive sleep apnea (OSA) due to adenotonsillar hypertrophy were enrolled into the study. All children were scheduled for adenoidectomy or adenotonsillectomy because of airway obstruction. In addition, their parents completed the 20-item State-Trait Anxiety Inventory-1 (STAI-1) and 20-item State-Trait Anxiety Inventory-2 (STAI-2) questionnaires before the operation and 30 days after the surgery when their children had considerable improvements in breathing during their sleep. The STAI is an instrument that quantifies both state (STAI-1) and trait (STAI-2) anxiety. State-Trait Anxiety Inventory-1 (state anxiety) is intended to measure transitory anxiety at a specific time (related to OSA symptoms in our study), whereas STAI-2 (trait anxiety) measures long-term anxiety.

RESULTS

Overall, the study included 57 mothers and 53 fathers of 59 children diagnosed with OSA. The mean preoperative STAI-2 score of parents was 31.1 ± 7.5; for fathers it was 28.2 ± 6.3, and for mothers it was 33.7 ± 7.6. The STAI-1 and STAI-2 scores showed significant differences before and after the surgery according to gender. The mean score of mothers was 5.5 (95% CI: 2.8 to 8.1) higher than the mean score of fathers (t = 4.1, p < 0.001) on the STAI-2 scale. The mean score of mothers was 5.6 (95% CI: 0.48 to 0.7) higher than the mean score of fathers (t = 2.2; p = 0.032) on the preoperative STAI-1 scale. The mean score of mothers was 1.95 (95% CI: 0.35 to 3.6) higher than the mean score of fathers (t = 2.4; p = 0.017) on the postoperative STAI-1 scale. The mean score of mothers was 6.22 higher than the mean score of fathers (p = 0.029) on the preoperative STAI-1 scale, adjusted for the STAI-2 scale. The mean score of mothers was 1.8 higher than the mean score of fathers (p = 0.039) on the postoperative STAI-1 scale, adjusted for the STAI-2 scale. These data suggest that differences between the preoperative and postoperative STAI-1 score for mothers was the highest (51 ± 7) in children with severe OSA and the lowest (28 ± 14) in children with mild OSA (p < 0.001). The difference between the preoperative and postoperative STAI-1 score for fathers was the highest (48 ± 6.6) in children with severe OSA and the lowest (25 ± 10) in children with mild OSA.

CONCLUSION

The results of our study suggest that obstructive sleep apnea in children is a disturbing symptom for parents and is associated with a significant level of anxiety that depends on OSA severity. After the surgical treatment of the children (adenoidectomy or adenotonsillectomy), the anxiety level of both parents decreased. We suggest that preoperative psychological intervention should be considered in selected cases for mothers and fathers of children with severe OSA in order to diminish the symptoms of anxiety that can compromise normal postoperative recovery in operated children.

Parental stress and resilience in CHD: a new frontier for health disparities research

Parental stress is a universal experience for parents who have children diagnosed with CHD and has been studied within the context of the child's illness, but not through a broader health disparity lens. This paper provides a thorough synthesis of the current literature on parental stress addressing disparities in parents of children with CHD. Several theories and models from within this literature are described and a new comprehensive framework, the Parental Stress and Resilience in CHD Model, is presented. Future research and clinical implications are discussed.

Clinic-day surgery for children: a patient and staff perspective

INTRODUCTION

For the past 3 years, our institution has implemented a same clinic-day surgery (CDS) program, where common surgical procedures are performed the same day as the initial clinic evaluation. We sought to evaluate the patient and faculty/staff satisfaction following the implementation of this program.

METHODS

After IRB approval, patients presenting for the CDS between 2014 and 2017 were retrospectively reviewed. Of these, patient families who received CDS were contacted to perform a telephone survey focusing on their overall satisfaction and to obtain feedback. In addition, feedback from faculty/staff members directly involved in the program was obtained to determine barriers and satisfaction with the program.

RESULTS

Twenty-nine patients received CDS, with the most commonly performed procedures being inguinal hernia repair (34%) and umbilical hernia repair (24%). Twenty (69%) patients agreed to perform the telephone survey. Parents were overall satisfied with the CDS program, agreeing that the instructions were easy to understand. Overall, 79% of parents indicated that it decreased overall stress/anxiety, with 75% saying it allowed for less time away from work, and 95% agreeing to pursue CDS again if offered. The most common negative feedback was an unspecified operative start time (15%). While faculty/staff members agreed the program was patient-centered, there were concerns over low enrollment and surgeon continuity, because there were different evaluating and operating surgeons.

CONCLUSION

This study successfully evaluated the satisfaction of patients and faculty/staff members after implementing a clinic-day surgery program. Our results demonstrated improved patient family satisfaction, with families reporting decreased anxiety and less time away from work. Despite this, faculty and staff members reported challenges with enrollment and surgeon continuity.

The Pediatric Cardiac Intensive Care Unit Parental Stress Model: Refinement Using Directed Content Analysis

This descriptive, qualitative study used directed content analysis to explore and clarify specific foci of parental stress for mothers of infants with complex congenital heart disease in the pediatric cardiac intensive care unit (PCICU). The PCICU Parental Stress Model was used as the guiding theoretical framework. Three focus groups were conducted with 14 mothers of infants who were being cared for in a PCICU at a large mid-Atlantic children's hospital. Data provided themes to support and refine the PCICU Parental Stress Model that can be used to guide practice, education, and future research in this unique population and setting.

The Evaluation Acute Traumatic Stress Level in Close Relatives of Stroke Patients

OBJECTIVE

Stroke is the second most common cause of death and the leading cause of adult disability. Both stroke patients and their family can therefore experience increased traumatic stress level.

METHODS

The participants are close relatives of patients (n=65) who had a first time stroke (CRPWS) hospitalized. A control group (CG) (n=61), who had no history of chronic illness in their family and had at least one traumatic life event experience. The National Institutes of Health Stroke Scale, Modified Rankin Scale, Personal Information Form, Life Events Checklist, Traumatic Stress Symptom Scale, and Multidimensional Scale of Perceived Social Support, were used in the study.

RESULTS

We found no significant association between NIHSS and MRS of patients and traumatic stress level of the family member. The traumatic stress level was significantly higher in the CRPWS group than in the CG group. Traumatic stress level was higher in women than men and was not associated with perceived social support in the CRPWS group.

CONCLUSION

The traumatic stress level of the relatives was not associated with the clinical features of the stroke patients. In the early phase, after the diagnosis of stroke, psychological support may be important to prevent CRPWS from PTSD.

Comparative Analysis: Implementation of a Pre-operative Educational Intervention to Decrease Anxiety Among Parents of Children With Congenital Heart Disease

PURPOSE

The present study evaluated the efficacy of a nursing educational intervention in alleviating the level of parental anxiety in the parents of children who required heart surgery for the first time.

DESIGN AND METHODS

A comparative study was used to explore the parents of children who had to undergo cardiac surgery. Parents of children were randomized into 2 groups: 1) control group and 2) experimental group or parents that received the educational intervention about PICU stay.

RESULT

The results of STAY-1 showed that the average anxiety score of group 1 was lower than that of group 2 (63.0 [SD=3.5] vs. 70.4 [SD=2.8]).

CONCLUSION

In order to decrease levels of parental anxiety and stress prior to paediatric surgery, parents should be adequately informed about planned therapeutic procedures.

PRACTICE IMPLICATIONS

We speculate that pre-surgery parent education on what to expect before, during and after their child's cardiac surgery may improve parents' knowledge and satisfaction and decrease anxiety.

Factors Predicting Parent Anxiety Around Infant and Toddler Postoperative and Pain

BACKGROUND AND OBJECTIVES

Understanding of parent anxiety and its effect on infant postoperative pain is limited. We sought to identify psychological factors associated with preoperative anxiety for parents of infants and toddlers undergoing elective surgery and to determine whether parent anxiety is associated with child postoperative pain.

METHODS

This was a prospective cohort study of consecutively eligible patients aged ≤18 months undergoing craniofacial surgery and their parents. Preoperative parent assessment included anxiety, coping, parent health locus of control, and self-efficacy. Postoperative inpatient child pain scores and medication use were collected. Analyses included hierarchical multivariable logistic and linear regression models.

RESULTS

Parents (n = 71, 90% female) of young children (mean age 6.6 months) undergoing cleft lip or palate (n = 59) or cranial vault repair (n = 13) were enrolled. Maladaptive coping (odds ratio 1.3; 95% confidence interval, 1.1-1.6), low parent self-efficacy (odds ratio 2.4; 95% confidence interval, 1.3-4.5), and external locus of control (odds ratio 1.74; 95% confidence interval, 1.1-2.9) were independently associated with high parental anxiety. The adjusted odds of moderate/severe parent anxiety was 3.6 (95% confidence interval, 1.5-9.1) higher with each SD increase in maladaptive coping. High parental anxiety was correlated with significantly higher hospital mean child pain scores (1.87 points on 0-10 scale; 95% confidence interval, 0.42-3.70; P = .045).

CONCLUSIONS

Coping and self-efficacy are modifiable factors that contribute to parent anxiety before and during hospitalization and may be targets for intervention. Infants and toddlers undergoing elective craniofacial surgery with highly anxious parents may be at greater risk for higher postoperative pain.

Psychological Adjustment of Parents of Children Born with Atypical Genitalia 1 Year after Genitoplasty

PURPOSE

We examined the psychological adjustment of parents of children born with moderate to severe genital atypia 12 months after their child underwent genitoplasty.

MATERIALS AND METHODS

Parents were recruited longitudinally from a multicenter collaboration of 10 pediatric hospitals with specialty care for children with disorders/differences of sex development and/or congenital adrenal hyperplasia. Parents completed measures of depressive and anxious symptoms, illness uncertainty, quality of life, posttraumatic stress and decisional regret.

RESULTS

Compared to levels of distress at baseline (before genitoplasty) and 6 months after genitoplasty, data from 25 mothers and 20 fathers indicated significant improvements in all psychological distress variables. However, a subset of parents continued endorsing clinically relevant distress. Some level of decisional regret was endorsed by 28% of parents, although the specific decision that caused regret was not specified.

CONCLUSIONS

Overall the majority of parents were coping well 1 year after their child underwent genitoplasty. Level of decisional regret was related to having a bachelor's level of education, increased levels of illness uncertainty preoperatively and persistent illness uncertainty at 12 months after genitoplasty but was unrelated to postoperative complications.

Parents' preparedness for their infants' discharge following first-stage cardiac surgery: development of a parental early warning tool

Aim The aim of this study was to explore parental preparedness for discharge and their experiences of going home with their infant after the first-stage surgery for a functionally univentricular heart.

BACKGROUND

Technological advances worldwide have improved outcomes for infants with a functionally univentricular heart over the last 3 decades; however, concern remains regarding mortality in the period between the first and second stages of surgery. The implementation of home monitoring programmes for this group of infants has improved this initial inter-stage survival; however, little is known about parents' experiences of going home, their preparedness for discharge, and parents' recognition of deterioration in their fragile infant.

METHOD

This study was conducted in 2011-2013; eight sets of parents were consulted in the research planning stage in September, 2011, and 22 parents with children aged 0-2 years responded to an online survey during November, 2012-March, 2013. Description of categorical data and deductive thematic analysis of the open-ended questions were undertaken.

RESULTS

Not all parents were taught signs of deterioration or given written information specific to their baby. The following three themes emerged from the qualitative data: mixed emotions about going home, knowledge and preparedness, and support systems.

CONCLUSIONS

Parents are not adequately prepared for discharge and are not well equipped to recognise deterioration in their child. There is a role for greater parental education through development of an early warning tool to address the gap in parents' understanding of signs of deterioration, enabling appropriate contact and earlier management by clinicians.

Caregiver anxiety due to interstage feeding concerns

INTRODUCTION

Improved weight gain during the interstage (IS) period has been shown to improve overall outcomes in patients with single ventricle physiology (SVP). This emphasis on nutrition may have untoward effects, such as increasing anxiety/stress levels in caregivers, who are already known to be at risk for increased anxiety/stress levels. The goal of this study was to evaluate anxiety/stress levels of caregivers as it pertains to feeding during the IS period and to determine if certain characteristics were associated with higher anxiety/stress scores.

METHODS

Caregivers of children with SVP who completed the IS period, defined as the time between the first and second cardiac surgeries, were recruited. Baseline demographics were obtained. Anxiety/stress levels were measured via eight questions using a 0- to 10-point scale. Correlations were performed between demographic variables and anxiety/stress level scores.

RESULTS

Fifty-six surveys were completed (39 males, 27 females) on 43 children. Fourteen children required tube feeds during the IS period. There were significant correlations between anxiety/stress scores and caregiver's gender, caregiver's age, caregiver's level of education, percent of time a caregiver spent feeding the child, if caregivers were taking medications for anxiety, and if the child was seen in the emergency room during the IS period. There were no correlation of anxiety/stress scores with caregiver's race, child's underlying cardiac diagnosis, age of child, route of feeding during the IS period, birth order of the child or number of children in the family, relationship status, or distance from the hospital.

CONCLUSION

In general, caregivers of children with SVP experience anxiety/stress during the IS period specifically due to feeding concerns. Certain intrinsic and extrinsic characteristics were associated with higher anxiety/stress levels. Future studies are needed to determine how to minimize anxiety/stress levels during this stressful time period.

Severe congenital malformations, family functioning and parents' separation/divorce: a longitudinal study

BACKGROUND

We aim to explore the association of a severe congenital malformation (SCM) with postnatal family functioning and parents' separation/divorce and to examine if this association might be moderated by birth order of the child and parental level of education. SCM refers to malformations that, without medical intervention, cause handicap or death.

METHODS

Using the Quebec Longitudinal Study of Child Development, an ongoing population-based birth cohort study initiated in 1998, we compared 1675 families of children with and without a SCM to identify if having a child with a SCM was associated with maternal perception of family functioning. We examined if an SCM was associated with parents' separation and examined parents' education level and birth order of the children to evaluate whether these factors had any moderating effect on the results.

RESULTS

There were no significant differences in family functioning between families with and without a SCM child at 5 and 17 months. At 5 months, family functioning was significantly better (P = 0.03) for families with a SCM firstborn child than for families with a SCM child that is not firstborn. For parental separation, no significant differences were observed at 5 and 29 months and 4 years. No significant moderating effects were observed for birth order and parental education on parental separation.

CONCLUSIONS

Families of children with a SCM do not appear to be at higher risk of family dysfunction within the first 17 months after birth nor of parental separation within the first 4 years after birth. Family functioning tends to be worst in families where the child with SCM is the second or subsequent child born.