Parental experience of the neuromotor development of children with congenital heart disease: an exploratory qualitative study

Neurodevelopmental follow-up care pathways and processes for children with congenital heart disease in Australia

BACKGROUND

International consensus exists for neurodevelopmental follow-up care of children with congenital heart disease (CHD) to support timely intervention for developmental delays. Yet, documentation of how this care is implemented in Australia is lacking. This study aimed to identify, categorise, and understand care pathways and services supporting neurodevelopmental follow-up of Australian children with CHD.

METHODS

A qualitative study, using semi-structured virtual interviews with healthcare professionals across Australia involved in neurodevelopmental care of children with CHD (n = 52) was conducted. Data was analysed using a rapid qualitative approach including structured templates, data reduction, and inductive-deductive analysis of matrices to synthesise data.

RESULTS

Most neurodevelopmental follow-up was delivered as pathways through existing healthcare services rather than centre-based cardiac programmes. Service availability and accessibility varied across the country. Community-based primary care services, paediatric clinics, child development services, neonatal follow-up programmes, and allied health providers were commonly accessed pathway components. However, participants reported a lack of formal structures to coordinate care pathways.

CONCLUSIONS

The study identifies how cardiac neurodevelopmental follow-up in Australia can be embedded into existing services and adapted to meet local needs and contexts. Future approaches will benefit from integrating, leveraging, and growing existing services, although adoption of new models may be needed.

IMPACT

This study found neurodevelopmental follow-up care for children with CHD in Australia to be delivered as pathways through existing services rather than the centre-based cardiac follow-up programmes common in North America. Our study describes alternate options, including providers in community settings, that can be used for follow-up care delivery and how these can adapted to local context. Future approaches will benefit from integrating, leveraging, and growing existing services, although adoption of new models may be needed. Greater systematic coordination of care pathways is still required to optimise service delivery, inform planning, and support implementation of national standards of care.

Prioritizing family-centered developmental care: insights from parents of children with critical congenital heart disease: a qualitative study

As survivors of early cardiac surgery are at high risk of neurodevelopmental impairments, systematic health observations of children with critical congenital heart disease (CCHD) throughout childhood are recommended to enable early diagnosis and offer interventions to optimize neurodevelopment. A qualitative study using thematic analysis was performed to explore parents' concerns, experiences, and needs regarding the development and received developmental care of their child (0-10 years) during hospital admission and beyond. Data were collected using semi-structured online interviews with 20 parents of children with CCHD. Four major themes were identified: (1) "impact of diagnosis and disease on the family-system," (2) "parental concerns from diagnoses and beyond," (3) "the need for information," and (4) "the need for individualized and family-centered care." The main themes can be divided into 13 sub-themes as impact, concerns, and needs are influenced by various impactful moments from diagnosis and afterwards.     Conclusion: This study confirms the importance of early identification of neurodevelopmental problems by experienced healthcare professionals, especially in the early years when parental expectations and concerns about their child's neurodevelopment are lower. A tailor-made family-centered follow-up program should be offered, which pays attention to both the neurodevelopment of patients with CCHD as well as the mental wellbeing of the entire family system. Furthermore, an online portal is recommended with a variety of reliable, controlled, understandable information from which parents can obtain the desired information to understand better the consequences of specific heart condition and to provide their child with the best possible guidance. What is Known: • Survivors of early cardiac surgery are at high risk of neurodevelopmental impairments; systematic health observations of children with CCHD throughout childhood are strongly recommended. What is New: • Parents need a tailor-made family-centered follow-up program, which pays attention to both the neurodevelopment of patients with CCHD as well as the mental wellbeing of the entire family system. • An online portal offering diverse, trustworthy information and sources would effectively meet parents' needs by providing accessible insights into the potential consequences of specific heart conditions and guiding them in supporting their child optimally.

The implementation of EMI-Heart, a family-tailored early motor intervention in infants with complex congenital heart disease, in practice: a feasibility RCT

BACKGROUND

Children with congenital heart disease (CHD) who undergo open-heart surgery are at risk of developmental impairment, including motor delay, which contributes to parental concerns. Additionally, parents experience prolonged stress associated with their child's disease. There is a lack of early motor interventions in infants with CHD accounting for parental burdens. We developed a family-tailored early motor intervention (EMI-Heart), aiming to promote motor development in infants with CHD and family well-being. The primary aim was to evaluate the feasibility of the study design and the intervention. The secondary aim was to evaluate differences between the intervention and the control group in motor outcomes and family well-being at baseline (3-5 months), post-treatment (6-8 months), and at follow-up (12 months).

METHOD

In this single-centre feasibility randomized control trial (RCT), infants with CHD after open-heart surgery without genetic or major neurological comorbidities were randomly allocated to EMI-Heart or the control group (standard of care). EMI-Heart's key elements promote postural functional activities and encourage parental sensitivity to infants' motor and behaviour cues. Infants assigned to EMI-Heart received nine sessions of early motor intervention at home, in the hospital, and online for a duration of 3 months by a paediatric physiotherapist. We performed descriptive statistics for feasibility and secondary outcomes.

RESULTS

The recruitment rate was 59% (10/17), all participating families completed the study (10/10), and the intervention duration was 3.9 months (± 0.54), including nine intervention sessions per family. Median acceptability to parents was 3.9 (1 = not agree-4 = totally agree, Likert scale). The paediatric physiotherapist considered the intervention as feasible. The comparison of motor outcomes did not show differences between groups. However, we detected improved reliable change scores in family well-being outcomes for families of the intervention group compared to the controls.

CONCLUSIONS

Our research indicates that EMI-Heart is a feasible intervention for infants with CHD after open-heart surgery. The intervention was highly acceptable both to parents and to the paediatric physiotherapist. Online treatment sessions offer a valuable alternative to home and hospital visits. This feasibility RCT provides a foundation for a future full trial.

TRIAL REGISTRATION

ClinicalTrials.gov, NCTT04666857. Registered 23.11.2020.

A remote parent-led early intervention protocol to promote motor development in infants with congenital heart disease: a feasibility pilot study of a randomized clinical trial

This study evaluated the feasibility of a parent-led, home-based early intervention for motor development in infants with Congenital Heart Disease (CHD), part of a larger multicenter, single-blind randomized controlled trial (ClinicalTrials.gov NCT05907109). Parents, supported by remote specialists weekly, engaged in multidomain stimulation activities five days a week, for six months. Feasibility was assessed via parental questionnaires, adherence rates, and infant motor development assessments. Despite high dropout and mortality rates, results showed 80% adherence, 91% parental satisfaction, 75% availability, and 60% self-efficacy. No significant motor skill differences were noted between the intervention (IG; n = 19) and control groups (CG; n = 11) at six months, but the higher baseline risk in IG suggests promotion of motor skills in the intervention group. Future studies in Brazil might extend the study duration to address high dropout and mortality rates.

Navigating the healthcare system with my child with CHD: parental perspectives on developmental follow-up practices

BACKGROUND

Parents of children with CHD face several barriers when trying to access the services needed to support their child's development. In fact, current developmental follow-up practices may not identify developmental challenges in a timely manner and important opportunities for interventions may be lost. This study aimed to explore the perspectives of parents of children and adolescents with CHD with respect to developmental follow-up in Canada.

METHODS

Interpretive description was used as a methodological approach for this qualitative study. Parents of children aged 5-15 years with complex CHD were eligible. Semi-structured interviews that aimed to explore their perspectives regarding their child's developmental follow-up were conducted.

RESULTS

Fifteen parents of children with CHD were recruited for this study. They expressed that the lack of systematic and responsive developmental follow-up services and limited access to resources to support their child's development placed an undue burden on their families, and as a result, they needed to assume new roles as case managers or advocates to address these limitations. This additional burden resulted in a high level of parental stress, which, in turn, affected the parent-child relationship and siblings.

CONCLUSIONS

The limitations of the current Canadian developmental follow-up practices put undue pressure on the parents of children with complex CHD. The parents stressed the importance of implementing a universal and systematic approach to developmental follow-up to allow for the timely identification of challenges, enabling the initiation of interventions and supports and promoting more positive parent-child relationships.

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

BACKGROUND

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

PURPOSE

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

CONCLUSIONS

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

A systematic review of early motor interventions for infants with congenital heart disease and open-heart surgery

BACKGROUND

Motor development delay is the first neurodevelopmental impairment that becomes apparent in infants with congenital heart disease (CHD). Early interventions have addressed high-risk groups like infants born preterm, but little is known about interventions to improve motor outcome in CHD infants at risk of motor delay. The purpose of this review was to systematically review the literature on type and effect of motor intervention applied during the first year of life in infants with CHD following open-heart surgery.

METHODS

Scoping searches were performed in May 2020 and April 2023 via MEDLINE, Embase, CINAHL, Cochrane, PsycINFO, PEDro, and Scopus. The review included studies published in English from 2015 to 2022. Primary outcome was infants' motor development measured by standardized and non-standardized motor assessments, and if available, infants' language and cognitive development, and any parental quality-of-life assessments as secondary outcomes. The studies' quality was evaluated with a modified Newcastle-Ottawa scale.

RESULTS

Four papers with low to high methodological quality met inclusion criteria. All studies investigated the influence of early physiotherapy. Four studies involved parents, and three studies used standardized tools to assess motor outcomes. No conclusion can be drawn about any positive effect of early motor interventions.

CONCLUSIONS

Early motor intervention in CHD infants may improve motor development; however, the few existing studies do not provide clear evidence. Thus, more prospective early intervention studies are needed.

TRIAL REGISTRATION

PROSPERO CRD42020200981.

Life situation of a caregiver of a child with congenital heart defect and/or other cardiac problems: structure and preliminary validation of a new questionnaire

Background

Illness in a child with cardiac disease causes stress, brings additional responsibilities, reorganizes family life, and changes the functioning of the family.

Aim

This study aimed to validate a new questionnaire evaluating the life situations of caregivers/parents of children with congenital heart disease (CHD) and/or other cardiac diseases (OCD).

Materials and methods

The questionnaire comprised 10 questions aimed at assessing the life situation of an ill child's caregiver in two main areas: personal and spiritual. The total score of the questionnaire assessing the life situation of the caregiver of a child with a CHD and/or OCD can range from 0 to 32 points, with scores <26 indicating a poor, 25 to 32 indicating an average, and >32 indicating a good level of life situation in the personal sphere of the caregiver. The questionnaire was assessed using Cronbach's alpha tests, and repeatability was assessed using Cohen's Kappa test (retest) within a time interval of two to 4  weeks from the first measurement.

Results

The research covered 50 respondents. Cohesion in the personal sphere obtained a satisfactory value of Cronbach's α = 0.72, in the spiritual sphere: Cronbach's α = 0.83, and the result common for both sections was: Cronbach's α = 0.66.

Conclusion

The Life Situation Assessment Questionnaire for caregivers of children with CHD and OCD is a reliable and homogeneous tool for measuring the functioning of parents in the event of a child's illness.

Motor development in infants with complex congenital heart disease: A longitudinal study

AIM

To evaluate whether infants with complex congenital heart disease (CCHD) have an increased risk of impaired quality of motor behavior and delayed motor milestones.

METHOD

A cohort of 69 infants with CCHD (43 males, 26 females) were assessed with the Infant Motor Profile (IMP) at three time periods between 6 to 18 months, mean ages in months (SD): 6.4 (0.7); 12.7 (1.0); 18.5 (0.7) IMP data were available from a reference sample of 300 Dutch infants. Analyses included multivariable logistic regression analysis to estimate differences in IMP scores below the 15th centile between children with CCHD and the reference group, and linear mixed-effects models to assess the effect of ventricular physiology and systemic oxygen saturation (SpO2) of less than 90% on IMP outcomes.

RESULTS

Infants with CCHD had increased risks of total IMP scores below the 15th centile (lowest odds ratio [OR] at 18mo: 6.82 [95% confidence interval {CI} 2.87-16.19]), especially because of lower scores in the domains of variation, adaptability, and performance. Children with single ventricle CCHD scored consistently 3.03% (95% CI 1.00-5.07) lower than those with two ventricle physiology, mainly from contributions of the variation and performance domains. SpO2 of less than 90% was associated with 2.52% (95% CI 0.49-4.54) lower IMP scores.

INTERPRETATION

CCHD, especially single ventricle physiology, increases risk of impaired motor development.

WHAT THIS PAPER ADDS

Complex congenital heart disease (CCHD) substantially increases risk of impaired motor development. CCHD is associated with motor delay and reduced motor variation and adaptability. Single ventricle physiology increases the risk of impaired motor behavior.

A family-tailored early motor intervention (EMI-Heart) for infants with complex congenital heart disease: study protocol for a feasibility RCT

BACKGROUND

Children with congenital heart disease (CHD) undergoing open-heart surgery are at risk for developmental impairments with motor delay manifesting first and contributing to parental concerns. Only a few interventional studies aim to improve neuromotor development in infants with CHD with inconclusive results. We thus developed a family-tailored early motor intervention (EMI-Heart), which aims to promote motor development and family well-being in the first year of life after open-heart surgery. The primary aim described in this protocol is to evaluate feasibility of EMI-Heart. The secondary aim is to describe the difference between the intervention and control group in motor outcomes and family well-being at baseline, post-treatment, and follow-up.

METHODS

This prospective, parallel single-center feasibility randomized controlled trial (RCT) will compare EMI-Heart with standard of care in infants with complex CHD. Sixteen infants and their families, randomly allocated to EMI-Heart or the control group, will participate within the first 5 months of life. Infants assigned to EMI-Heart will receive early motor intervention for 3 months. The intervention's key is to promote infants' postural control to enhance motor development and partnering with parents to encourage family well-being. Feasibility outcomes will be (a) clinical recruitment rate and percentage of families completing EMI-Heart, (b) average duration and number of sessions, and (c) acceptability of EMI-Heart using a parental questionnaire post-treatment, and descriptive acceptability of EMI-Heart to the pediatric physiotherapist. Secondary outcomes of the intervention and control group will be infants' motor outcomes and questionnaires assessing family well-being at 3-5 months (baseline), at 6-8 months (post-treatment), and at 12 months of age (follow-up). We will evaluate feasibility using descriptive statistics. Non-parametric statistical analysis of secondary outcomes will assess differences between the groups at baseline, post-treatment, and follow-up.

DISCUSSION

This feasibility RCT will provide information about a newly developed family-tailored early motor intervention in infants with complex CHD. The RCT design will provide a foundation for a future large-scale interventional trial for infants with CHD after open-heart surgery.

TRIAL REGISTRATION

This study protocol (version 1.3, 01.02.2022) was approved by the Cantonal Ethics Commission Zurich (BASEC-Nr. 2019-01,787) and is registered by Clinicaltrials.gov (NCTT04666857).