Neurodevelopmental assessment of infants with congenital heart disease in the early postoperative period

Abstract

Objective: Mortality rates for children with congenital heart disease (CHD) have significantly declined, resulting in a growing population with associated neurodevelopmental disabilities.American Heart Association guidelines recommend systematic developmental screening for children with CHD. The present study describes results of inpatient newborn neurodevelopmental assessment of infants after open heart surgery. Outcome measures:We evaluated the neurodevelopment of a convenience sample of high-risk infants following cardiac surgery but before hospital discharge using an adaptation of the Newborn Behavioral Observation. Factor analysis examined relationships among assessment items and consolidated them into domains of development. Results:We assessed 237 infants at a median of 11 days (interquartile range [IQR]: 7-19 days) after cardiac surgery and median corrected age of 21 days (IQR: 13-33 days). Autonomic regulation was minimally stressed or well organized in 14% of infants. Upper and lower muscle tone was appropriate in 33% and 35%, respectively. Appropriate response to social stimulation ranged between 7% and 12% depending on task, and state regulation was well organized in 14%. The vast majority (87%) required enhanced examiner facilitation for participation. Factor analyses of assessment items aligned into four domains of development (autonomic, motor, oral motor, and attention organization).Conclusion: At discharge, postoperative infants with CHD had impairments in autonomic, motor, attention, and state regulation following cardiac surgery. Findings highlight the challenges faced by children with CHD relative to healthy peers, suggesting that neurodevelopmental follow-up and intervention should begin early in infancy. K E Y W O R D Sassessment, cardiac, developmental impairments, infancy, neurodevelopment

Filling a significant gap in the cardiac ICU: implementation of individualised developmental care

“…23,40 For newborns, parent support and anticipatory guidance was provided using segments of the Assessment of Preterm Infants' Behavior, 41 which is an infant assessment tool of mutually interacting behavioural subsystems in simultaneous interaction with the environment, and the Newborn Behavioral Observation, 42 which used infant assessment as an intervention with the family. 4 For older infants and children, the Bayley Scales of Infant and Toddler Development Screening Test ® , 43 was used when appropriate. Often the Bayley Screener was completed in the step-down unit closer to discharge.…”

“…3 Postsurgically, infants with CHD are hypersensitive, easily overwhelmed in terms of self-regulation and state management, and show difficulties in growth and feeding. 4 Although mortality rates in children with CHD have significantly declined, the incidence of neurological abnormalities and neurodevelopmental impairment has increased. Neurodevelopmental deficits are noted in preschool and school-aged children, including developmental delays, learning disabilities, and behavioural problems.…”

“…Although many children are now referred for neurodevelopmental assessment after discharge, few are evaluated while inpatient, when prevention and amelioration is likely to be more effective. 4,16,17 Understanding developmental care Environmental factors such as high sound and light levels elicit physiological changes in newborns, including increases in heart rate, respiratory rate, and blood pressure, as well as decreases in oxygen saturation. All of these adversely affect growth and development.…”

“…Further, most units identified being ill-equipped to provide developmental care without additional education and allocation of resources, a formal developmental task force or committee, and regularly scheduled developmental rounds. 4,17 An example of developmental care introduction and implementation in the cardiac ICU This paper describes the successful introduction and practice of individualised developmental care in the cardiac ICU of a large urban tertiary care children's hospital. The cardiac inpatient setting includes a 31-bed cardiac ICU and a 42-bed medical and surgical cardiovascular unit.…”

“…Many infants undergoing surgical or interventional treatment for CHD require extended periods of sedation and pain management that involve careful weaning of medications and control of withdrawal symptoms 3 . Postsurgically, infants with CHD are hypersensitive, easily overwhelmed in terms of self-regulation and state management, and show difficulties in growth and feeding 4 . Although mortality rates in children with CHD have significantly declined, the incidence of neurological abnormalities and neurodevelopmental impairment has increased.…”