Caregiver Observations of Infant Well-Being Before and After Cleft Lip Surgery

OBJECTIVE

To evaluate the sensitivity to change of daily ratings of the comfort (COMF) and behavioral/emotional health (BEH) domains of the Infants with Clefts Observation Outcomes Instrument (iCOO) at 3 time points, and to assess the association of post-surgical interventions on iCOO ratings.

DESIGN

The COMF and BEH domains were completed by caregivers before (T0), immediately after (T1), and 2-months after (T2) cleft lip (CL) surgery. Analyses included descriptive statistics, correlations, t-tests, and generalized estimating equations.

PARTICIPANTS

Caregivers (N  =  140) of infants with CL with/without cleft palate.

MAIN OUTCOME MEASURES

The COMF and BEH domain scores of the iCOO: Scale (SCALE), a summary of observable signs; and Global Impression (IMPR), a single item measuring caregivers' overall impression.

RESULTS

Daily COMF and BEH SCALE and IMPR scores changed significantly during T1 (P's < 0.001) but not T0 or T2. Day 1 and 7 T0 scores were significantly higher than Day 1 and 7 T1 scores (P's <0.001 to <0.012) but similar at T2 (P's > 0.05). After CL surgery, the combined use of immobilizers and nasal stents and the use of multiple feeding methods with treatment for gastroesophageal reflux were associated with lower daily scores in COMF and BEH SCALE and IMPR (P's: 0.040 to <0.001).

CONCLUSIONS

COMF and BEH iCOO scores were sensitive to daily changes in infant well-being following CL surgery. Future studies should further investigate impact of post-surgical treatments on infant well-being.

Exploration of Caregiver Interrater Agreement and Test-Retest Reliability on the Infant Cleft Observer Outcomes (iCOO)

Caregiver and observer-reported measures are frequently used as outcomes for research on infants and young children who are unable to report on their own health. Our team developed the Infant with Clefts Observation Outcomes Instrument (iCOO) for infants with cleft lip with or without cleft palate. This exploratory study compared test-retest and interrater reliabilities to inform whether differences in caregiver perspective might affect the iCOO.

This study is a secondary analysis comparing caregiver interrater agreement to test-retest reliability. Twenty-five pairs of caregivers completed the iCOO before surgery, 1 week later for test-retest reliability, 2 days after surgery, and 2 months after surgery. Reliability was assessed using intraclass correlations (ICCs) and t-tests were used to compare ratings between caregivers.

Infants had cleft lip (28%) or cleft lip and palate (72%). Primary caregivers were predominantly mothers (92%) and secondary caregivers were predominantly fathers (80%). Test-retest reliability met psychometric standards for most items on the iCOO (81%-86% of items). Caregiver agreement on the iCOO items was lower than test-retest reliability (33%-46% of items met psychometric standards). Caregivers did not systematically differ in whether they rated infants as healthier or less healthy than the other caregiver (5%-16% of items had statistically significant differences).

Caregivers used the measure consistently, but had different experiences and perceptions of their infant's health and functioning. Future studies are needed to explore mechanisms for the differences in test-retest and interrater reliability. Whenever possible, the same caregiver should provide ratings of the infant, including on the iCOO.

Infant with Clefts Observation Outcomes Instrument (iCOO): A New Outcome for Infants and Young Children with Orofacial Clefts

OBJECTIVE

We evaluated the measurement properties for item and domain scores of the Infant with Clefts Observation Outcomes Instrument (iCOO).

DESIGN

Cross-sectional (before lip surgery) and longitudinal study (preoperative baseline and 2 days and 2 months after lip surgery).

SETTING

Three academic craniofacial centers and national online advertisements.

PARTICIPANTS

Primary caregivers with an infant with cleft lip with or without cleft palate (CL  ±  P) scheduled to undergo primary lip repair. There were 133 primary caregivers at baseline, 115 at 2 days postsurgery, and 112 at 2 months postsurgery.

MAIN OUTCOME MEASURE(S)

Caregiver observation items (n = 61) and global impression of health and function items (n = 8) across eight health domains.

RESULTS

Mean age at surgery was 6.0 months (range 2.7-11.8 months). Five of eight iCOO domains have scale scores, with Cronbach's alphas ranging from 0.67 to 0.87. Except for the Facial Skin and Mouth domain, iCOO scales had acceptable intraclass correlation coefficients (ICCs) ranging from 0.76 to 0.84. The internal consistency of the Global Impression items across all domains was 0.90 and had acceptable ICCs (range 0.76-0.91). Sixteen out of 20 (nonscale) items had acceptable ICCs (range 0.66-0.96). As anticipated, iCOO scores 2 days postoperatively were generally lower than baseline and scores 2 months postsurgery were consistent with baseline or higher. The iCOO took approximately 10 min to complete.

CONCLUSIONS

The iCOO meets measurement standards and may be used for assessing the impact of cleft-related treatments in clinical research and care. More research is needed on its use in various treatment contexts.

Development of an Outcome Measure of Observable Signs of Health and Well-Being in Infants With Orofacial Clefts

OBJECTIVE

To develop an outcomes instrument that assesses observations that can be reliably reported by caregivers and can be used to assess health of infants with a cleft lip or cleft lip and cleft palate (CL±P) and impacts of treatments.

DESIGN

Cross-sectional, mixed methods study.

SETTING

Caregivers and health-care providers were recruited from 3 academic craniofacial centers and national advertisements. Most interviews were conducted by telephone, and surveys were completed online.

PARTICIPANTS

Caregivers had a child less than 3 years of age with CL±P and spoke either English or Spanish. Health-care providers were members of a cleft team. Caregivers (n = 492) and health-care professionals (n = 75) participated in at least one component of this study.

MAIN OUTCOME MEASURE(S)

Caregivers and health-care providers participated in tasks related to instrument development: concept elicitation for items within relevant health domains, prioritization of items, and item review.

RESULTS

We identified 295 observations of infant well-being across 9 health areas. Research staff and specialists evaluated items for clarity, specificity to CL±P, and responsiveness to treatment. Caregivers and health-care providers rated the resulting list of 104 observations and developed the final instrument of 65 items.

CONCLUSIONS

In this phase of development of the Infant with Clefts Observation Outcomes (iCOO) instrument, items were developed to collect caregiver observations about indicators of children's health and well-being across multiple domains allowing for psychometric testing, sensitivity to changes associated with treatment, and documentation of the effects of treatment.

Facilitating Positive Psychosocial Outcomes in Craniofacial Team Care: Strategies for Medical Providers

Objective:

Psychosocial issues associated with craniofacial diagnoses and the ongoing burden of care can impact the quality of life of patients and families, as well as treatment adherence and outcomes. Utilizing available literature and clinical expertise across 6 centers, the present article summarizes key psychosocial issues for the benefit of nonmental health medical providers and offers suggestions as to how all members of craniofacial teams can promote positive psychosocial outcomes.

Results:

Family adjustment across developmental phases is outlined, with strategies to support adaptive parental coping. Teasing is a common concern in craniofacial populations and medical providers can promote coping and social skills, as well as link families to mental health services when needed. Academic issues are described, alongside suggestions for medical providers to assist families with school advocacy and ensure access to appropriate services within the school setting. Medical providers are key in preparing patients and families for surgery, including consideration of medical, social, and logistical supports and barriers. As craniofacial care spans infancy to adulthood, medical providers are instrumental in assisting patients and families to navigate treatment transition periods. In addition to ongoing clinical team assessments, medical providers may utilize screening measures to identify and track patient and family adjustment in multiple areas of team care.

Conclusions:

Multidisciplinary providers play an important role in supporting positive adjustment in patients affected by craniofacial conditions and their families.

Disorders of Sex Development: Lessons to be Learned from Studies of Spina Bifida and Craniofacial Conditions

The purpose of this review is to discuss research methods and clinical management strategies employed with other conditions (i. e., spina bifida and craniofacial conditions) and how these methods and strategies could be applied to youth with disorders of sex development (DSD). The review focuses specifically on the potential overlap between DSD and these other conditions across the following 3 areas: (1) developmentally-oriented theories that underlie the research base for chronic physical conditions; (2) research designs and methodological features that have proved fruitful in these areas; and (3) the potential applicability to DSD of clinical management practices for youth with craniofacial conditions.

What Difference Can a Minute Make? Social Skills and First Impressions of Youth with Craniofacial Differences

Objective

To determine whether raters' first impressions of youth with craniofacial differences are modifiable.

Design

Observational study of the association between first impressions and social skills as related to youth aged 11 to 18 years with craniofacial differences.

Setting

University research offices and clinics.

Participants

Youth aged 11 to 18 years with (n = 29) and without (n = 31) craniofacial differences; adults (n = 40), dental/medical students (n = 46), and education students (n = 29), all without craniofacial differences. Participants were recruited from medical clinics and through community advertising at all three study sites.

Outcome Measures

The First Impressions Rating Scale.

Results

After viewing 1-minute portrayals of positive social skills by actors with craniofacial differences, raters' perceptions moved significantly in the positive direction for all 26 attributes on the First Impressions Rating Scale; whereas, after viewing negative social skills, ratings moved significantly in the negative direction for 25 of 26 First Impressions Rating Scale attributes.

Conclusions

It appears that first impressions others have of youth with craniofacial differences are significantly affected by how these youth present themselves in social situations, suggesting that positive social skills may help reduce the amount of stigma that youth with craniofacial differences encounter.

Measuring the quality of life of youth with facial differences

OBJECTIVE

To describe the Facial Differences Module of the Youth Quality of Life Instruments (YQOL-FD) and present results evaluating domain structure, internal consistency, reproducibility, validity, and respondent burden.

DESIGN

A multisite observational study of youth aged 11 to 18 years with acquired or congenital facial differences.

PARTICIPANTS

Three hundred seven youth recruited through clinics at four U.S. sites and one U.K. site. Eligible youth were aged 11 to 18 years, had a noticeable facial difference, could read at the fifth-grade level, and, for youth with facial burns, were at least 2 years posttrauma.

MEASURES

Included were the newly developed YQOL-FD, the generic Youth Quality of Life Instrument, the Children's Depression Inventory, and demographics.

RESULTS

Principal components analysis showed five significant factors that closely matched the domain structure hypothesized a priori. Domain scores of the YQOL-FD showed acceptable internal consistency and reproducibility. Scores were more strongly correlated with the Children's Depression Inventory score than with self-rating of health as predicted. All domain scores showed adequate discrimination among levels of general quality of life (Wilks lambda = 0.84, p = .001). The median time to complete the module was 10 minutes.

DISCUSSION

The YQOL Facial Differences Module augmented information obtained from the generic YQOL measure by addressing specific concerns. The module was well received by youth and showed acceptable measurement properties for evaluating the perceived quality-of-life status of youth facial differences. Future use in longitudinal studies and clinical trials is anticipated to evaluate the ability to detect change.

Approaches to craniofacial-specific quality of life assessment in adolescents

OBJECTIVE

To ascertain the domains that adolescents aged 11 to 18 years with congenital and acquired craniofacial differences (CFDs) consider important to their quality of life (QoL) to create a craniofacial-specific module.

DESIGN

Interviews and inductive qualitative methods were used to guide the development of a conceptual and measurement model of QoL among adolescents with CFDs.

SETTING

The Craniofacial Center at Children's Hospital and Regional Medical Center in Seattle, Washington.

PATIENTS, PARTICIPANTS

Thirty-three in-depth interviews with adolescents (aged 11 to 18 years), one young adult interview (age 19 years), 14 in-depth interviews with parents, one young adult focus group, one parent focus group, and one panel of researchers and clinical professionals working in the field.

RESULTS

Using the qualitative methodology, grounded theory, seven domains that adolescents with CFDs perceive are important to having a good QoL were found. Six of the domains (coping, stigma and isolation, intimacy and trust, positive consequences, self-image, and negative emotions) comprised the Youth Quality of Life Instrument-Facial Differences module. One other domain, surgery, was a salient issue for many of the youth, but not all, so it was made into a separate module, the Youth Quality of Life Instrument- Craniofacial Surgery module. This module relates to the experience of surgery, outcomes of surgery, and preferences for future surgery.

CONCLUSIONS

Using an established qualitative methodology, two QoL modules specific to adolescents with CFDs were developed and are ready for psychometric validation. Potential uses of the instruments are discussed.

Dealing with the prenatal diagnosis of clefting: a parent's perspective

OBJECTIVES

Prenatal testing and information is available on an increasing basis for a variety of reasons. There are conflicting standards of care in the delivery of this type of evaluation and even more confusion around access to such services. As physicians and patients evaluate which tests will generate useful information with acceptable levels of risk, the rules of the game constantly shift. Presenting the situation from the viewpoints of both a professional and a parent, issues revolving around uncertainty and reassurance are evaluated. A description of the personal experience of the impact of the discovery of a cleft prenatally is provided.

CONCLUSIONS

Finally, efforts are made to raise questions about our motivations behind conducting prenatal testing and also developing some suggestions about how to support families better in our regular clinical work. A challenge is made to providers and patients to do more work prior to examination to explore how the unexpected will be handled. The dilemma about how to facilitate informed consent through full disclosure without overwhelming the patient is also discussed.

Initial experience with intravenous pentobarbital sedation for children undergoing MRI at a tertiary care pediatric hospital: the learning curve

OBJECTIVE

Our purpose is to describe the initial experience with intravenous pentobarbital sedation in children undergoing MRI at a tertiary pediatric hospital to identify errors associated with inexperience.

SUBJECTS AND METHODS

The study included the first 100 children sedated with intravenous pentobarbital prior to magnetic resonance examination at a tertiary pediatric hospital. The protocol included a maximum dose of 6 mg/kg administered in three divided doses with the total dose not to exceed 200 mg. Flow sheets documenting vital signs, administered drug doses, and adverse reactions were maintained contemporaneous to sedation.

RESULTS

Sedation was successful in 92 children. Of the eight children who failed sedation, three were at least 12 years old and three weighed more than 50 kg. chi2 tests identified significantly greater failure rates in children older than 11 years or weight greater than 50 kg. Two children had prolonged sedation after the maximum suggested dose was exceeded.

CONCLUSIONS

The success rate was good, but could have been improved by restricting the use of pentobarbital to children less than 12 years of age and weighing less than 50 kg. Radiologists inexperienced with intravenous sedation should strictly observe the maximum suggested dose of pentobarbital to prevent prolonged sedation.

Family focused ethics

It is my intent to explore the family, parent, patient, social work relationships as a focus central to the solution of ethical dilemmas. In today's environment, patient selection continues to reflect persistent patterns of biased allocation of services. The ability of a family to make a decision about medical treatment begins with an understanding of how choices regarding that treatment are shared. Without taking appropriate precautions, an increased risk arises of providing surgical procedures involving real medical risk, yet unresolved psychological trauma remains unassessed. The unrelenting questions of, When?, How?, and Why?, a family should be involved in the process of ethical decision-making, begs the inherent prejudice involved.

Sedation of difficult-to-sedate children undergoing MR imaging: value of thioridazine as an adjunct to chloral hydrate

OBJECTIVE

The purpose of this prospective study was to evaluate the safety and efficacy of thioridazine as an adjunct to chloral hydrate sedation when children undergoing MR imaging are difficult to sedate.

SUBJECTS AND METHODS

All 87 children in the study either could not be sedated with chloral hydrate alone or were mentally retarded. Thioridazine (2-4 mg/kg) was administered orally 2 hr before and chloral hydrate (50-100 mg/kg) was administered orally 30 min before the 104 MR examinations. All children were monitored by continuous pulse oximetry. All images were individually evaluated by pediatric radiologists and were graded acceptable if they contained only minimal motion artifact or no motion artifact. Studies were considered successful only when 95% or more of the images were acceptable.

RESULTS

MR imaging was successful in 93 (89%) of 104 examinations. The success rate for children entered into the study because of prior failure of chloral hydrate sedation was not significantly different from the success rate for children with mental retardation. A tendency for increasing failure rate with age was not significant. No serious complications occurred during the study. The most common adverse reaction, transient reduced oxygen saturation, was seen in five children. Other adverse effects encountered were vomiting in four children, hyperactivity in two children, transient tachycardia in one child, and prolonged sedation in one child. No child required hospitalization because of an adverse reaction to sedation.

CONCLUSION

The study indicates that thioridazine is a safe and effective adjunct to chloral hydrate when a child undergoing MR imaging is difficult to sedate.

High-dose chloral hydrate sedation for children undergoing MR imaging: safety and efficacy in relation to age

OBJECTIVE

Sedation is frequently essential for successful MR imaging, and chloral hydrate is the most commonly used drug for this purpose in infants and children. Our experience with these patients suggested that this sedative is less effective in older children, even when administered in high doses. However, no prospective study comparing the efficacy of chloral hydrate sedation for children of different ages undergoing MR imaging has been reported. Accordingly, we performed a study to evaluate the effectiveness and safety of chloral hydrate sedation in children of various ages.

SUBJECTS AND METHODS

The study included 300 infants and children, 1 month to 11 years old (mean, 3 years), who were given oral chloral hydrate, 100 mg/kg, for sedation before MR imaging. The maximum total dose administered was 2.5 g, which limited the study to children who weighed 25 kg or less. Sedation was considered successful when MR studies were completed and at least 95% of the images had little or no motion artifact.

RESULTS

Sedation was successful in 273 (91%) of 300 children. It was unsuccessful in nine of the 203 children who were 48 months old or younger (96% success rate) and in 18 of the 97 children who were more than 48 months old (81% success rate). A single-tailed t-test showed that the children in whom sedation was unsuccessful were significantly older than those in whom it was successful to the .0005 level of significance. The failure rate increased steadily for children more than 48 months old. Several failures may also have resulted from lengthy examination times. Adverse reactions to chloral hydrate sedation included hyperactivity (6%), vomiting (4%), and mild respiratory depression (4%). No adverse reaction was severe enough to require hospitalization.

CONCLUSION

The higher failure rate for chloral hydrate sedation in children more than 48 months old suggests that the patient's age is an important limitation to the usefulness of chloral hydrate sedation for children undergoing MR imaging. However, the low rate of adverse reactions makes chloral hydrate a safe drug for sedation of children undergoing MR imaging.

High dose chloral hydrate sedation for children undergoing CT

Chloral hydrate is commonly used to sedate children before CT. However, no prospective study has been published of the safety and efficacy of chloral hydrate at high dose levels for children undergoing CT. We define high dose levels of oral chloral hydrate to be 80-100 mg/kg, with a maximum total dose of 2 g. High dose chloral hydrate sedation was administered orally to 295 children for 326 CT examinations. Adverse reactions occurred in 7% of the children, with vomiting being the most common (4.3% of children). Hyperactivity and respiratory symptoms each occurred in less than 2% of children. Prolonged sedation ( greater than 2 h) was not encountered in our series. Sedation was successful in producing motion free CT examinations, so that in 303 (93%) of the cases, no repeat CT scans were needed. We conclude that high dose oral chloral hydrate provides safe and effective sedation for children undergoing CT.