Echocardiographic Findings in Pediatric Multisystem Inflammatory Syndrome Associated With COVID-19 in the United States.

BACKGROUND: Centers from Europe and United States have reported an exceedingly high number of children with a severe inflammatory syndrome in the setting of coronavirus disease 2019, which has been termed multisystem inflammatory syndrome in children (MIS-C). OBJECTIVES: This study aimed to analyze echocardiographic manifestations in MIS-C. METHODS: A total of 28 MIS-C, 20 healthy control subjects and 20 classic Kawasaki disease (KD) patients were retrospectively reviewed. The study reviewed echocardiographic parameters in the acute phase of the MIS-C and KD groups, and during the subacute period in the MIS-C group (interval 5.2 ± 3 days). RESULTS: Only 1 case in the MIS-C group (4%) manifested coronary artery dilatation (z score = 3.15) in the acute phase, showing resolution during early follow-up. Left ventricular (LV) systolic and diastolic function measured by deformation parameters were worse in patients with MIS-C compared with KD. Moreover, MIS-C patients with myocardial injury were more affected than those without myocardial injury with respect to all functional parameters. The strongest parameters to predict myocardial injury in MIS-C were global longitudinal strain, global circumferential strain, peak left atrial strain, and peak longitudinal strain of right ventricular free wall (odds ratios: 1.45 [95% confidence interval (CI): 1.08 to 1.95], 1.39 [95% CI: 1.04 to 1.88], 0.84 [95% CI: 0.73 to 0.96], and 1.59 [95% CI: 1.09 to 2.34], respectively). The preserved LV ejection fraction (EF) group in MIS-C showed diastolic dysfunction. During the subacute period, LVEF returned to normal (median from 54% to 64%; p < 0.001) but diastolic dysfunction persisted. CONCLUSIONS: Unlike classic KD, coronary arteries may be spared in early MIS-C; however, myocardial injury is common. Even preserved EF patients showed subtle changes in myocardial deformation, suggesting subclinical myocardial injury. During an abbreviated follow-up, there was good recovery of systolic function but persistence of diastolic dysfunction and no coronary aneurysms.

Association of a Home Monitoring Program With Interstage and Stage 2 Outcomes.

Background In shunt-dependent, single-ventricle patients, mortality remains high in the interstage period between discharge after neonatal surgery and stage 2 operation. We sought to evaluate the impact of our infant single-ventricle management and monitoring program ( ISVMP ) on interstage mortality and stage 2 outcomes. Methods and Results This retrospective single-center cohort study compared patients enrolled in ISVMP at hospital discharge with historical controls. The relationship of ISVMP to interstage mortality was determined with a bivariate probit model for the joint modeling of both groups, using an instrumental variables approach. We included 166 ISVMP participants (December 1, 2010, to June 30, 2015) and 168 controls (January 1, 2007, to November 30, 2010). The groups did not differ by anatomy, gender, race, or genetic syndrome. Mortality was lower in the ISVMP group (5.4%) versus controls (13%). An ISVMP infant compared with a historical control had an average 29% lower predicted probability of interstage death (adjusted probability: -0.29; 95% CI , -0.52 to -0.057; P=0.015). On stratified analysis, mortality was lower in the hypoplastic left heart syndrome subgroup undergoing Norwood operation (4/84 [4.8%] versus 12/90 [14%], P=0.03) but not in those with initial palliation of shunt only ( P=0.90). ISVMP participants were younger at the time of the stage 2 operation (138 versus 160 days, P<0.001), with no difference in postoperative mortality or length of stay. Conclusions In this single-center study, we report significantly lower interstage mortality for participants with hypoplastic left heart syndrome enrolled in ISVMP . Younger age at stage 2 operation was not associated with postoperative mortality or longer length of stay.

The REACH protocol: an innovative strategy for home management of infants with complex CHD.

Approximately 32,000 infants are born with CHDs each year in the United States of America. Of every 1000 live births, 2.3 require surgical or transcatheter intervention in the first year of life. There are few more stressful times for parents than when their neonate receives a diagnosis of complex CHD requiring surgery. The stress of caring for these infants is often unrelenting and may last for weeks, months, and often years, placing parents at risk for developing post-traumatic stress disorder, as well as a drastic decrease in quality of life. Anxiety often peaks in the days and weeks after discharge from the hospital as families no longer have immediate access to nursing and medical staff. The purpose of this paper is to describe the methods of a randomised controlled trial that was designed to determine whether REACH would favourably affect parental and infant outcomes by decreasing parental stress, improve parental quality of life, increase infant stability, and decrease resource utilisation in infants with complex CHD.

Human milk and breastfeeding outcomes in infants with congenital heart disease.

BACKGROUND: Although human milk (HM) is the recommended form of infant nutrition, the provision of HM feeding among infants with congenital heart disease in the cardiac intensive care unit is unknown. Therefore the aim of the study was to understand the prevalence of pumping initiation, HM feeding, and breastfeeding patterns of mothers and their infants born with congenital heart disease. SUBJECTS AND METHODS: This was a prospective cohort study conducted a large children's hospital with a cardiac referral program and unit. All women with infants with congenital heart disease were approached for enrollment in order to document HM prevalence. RESULTS: The majority of women (89%) initiated lactation via pumping for their infants. On average, mothers pumped five to six times per day, and mothers were able to achieve a milk supply of over 500 mL/day. Once infants received enteral feeds, over 70% of the infant diet was HM. Very few (13%) infants fed via direct breastfeedings; rather, they received HM via gavage or bottle. There was a significant difference in pumping initiation based on where the infant was born, with mothers delivering in the hospital having a significantly higher pumping initiation rate (96% born in this hospital, 67% born in an outside hospital). CONCLUSIONS: Mothers who have infants diagnosed with congenital heart disease should be encouraged to initiate pumping for their infants. Future research is warranted regarding the dose response of HM and specific health outcomes and the need for postdischarge services for these families.

A developmental care framework for a cardiac intensive care unit: a paradigm shift.

Within the past several decades, medical and surgical advancements have dramatically decreased mortality rates in neonates and infants with congenital heart disease. Although patients are surviving in greater numbers, little research is reported on issues related to newborn care for these at-risk infants. A developmental care model was introduced to the nursing staff at the Children's Hospital of Philadelphia, which included 5 core measures to support evidence-based developmental care practices: (1) sleep, pain, and stress assessment; (2) management of daily living; (3) positioning, feeding, and skin care; (4) family-centered care; and (5) a healing environment. The care practices were adapted to the specific issues of the late preterm and full-term infant who has experienced neonatal cardiac surgery. The purpose of this article is to review the process of implementing a development model of care in a cardiac intensive care unit.

New knowledge, innovations, and improvement in a Magnet® Children's Hospital Cardiac Center.

Bedside nurses involved in research and evidence-based practice (EBP) have the ability to change policies, patient care, and outcomes. This article describes the journey of a research committee using the Magnet® component of new knowledge, innovation, and improvements. Using several tools, the unit-based committee developed skills in meeting management, nursing research methods, and EBP. Focusing to improve family and nurse communication about the plan of care, the committee recommended changes in the existing Plan of Care tool, including family input and recommendations for families to view and add to the sheet and participate in daily rounds, which was not the standard practice. Since this intervention was implemented, patient satisfaction has increased, as well as nurse engagement and intent to stay. This project exemplifies how nurse-driven innovations and family partnership led to new knowledge, innovations in learning about research, applying it to practice, and improving practice.

Onboarding advanced practice nurses: development of an orientation program in a cardiac center.

The advanced practice nurse (APN) is critical to continuity of patient care, particularly in an innovative and research-intensive environment. The intensity of the environment, steep learning curve, and lack of a structured orientation can lead to difficulties in role assimilation and feelings of disconnectedness. This led the authors to undertake an improvement project to develop an onboarding program for APNs and develop strategies to orient them to their role. The authors describe the program and discuss how it was perceived by the APNs. Program evaluation and suggestions for future nursing research are identified.

Feeding, growth, and nutrition in children with congenitally malformed hearts.

In the United States of America, approximately 40,000 infants are born annually with congenitally malformed hearts. Children with defects that require complex surgical palliation, or definitive repair, face many challenges in achieving optimal short-term and long-term growth. The presence of associated chromosomal abnormalities, cyanosis, and cardiac failure adds to the complexity and challenge. In this review, we address three themes related to feeding, growth, and nutrition of infants after neonatal cardiac surgery: nutritional challenges after chylothorax; breastfeeding after surgery; and the challenges of feeding after discharge. Chylothorax is a rare complication following cardiothoracic surgery in children. Children with chylothorax have nutritional depletion secondary to protein losses in chylous fluid, hypovolaemia, and electrolyte losses. In spite of the evidence supporting the use of human milk and breastfeeding in preterm infants, barriers to its use appear to persist in infants with critical cardiac disease. Yet, human milk is the preferred form of nutrition for well, preterm, or ill infants. It is well documented that after complex neonatal cardiac surgery medical teams and families struggle with infant feeding problems. Parents have described feeding their children as difficult, time consuming, and anxiety producing. Medical complications such as chylothorax, limited access to human milk, and parental concerns and stress about feeding are but three of the myriad of factors that may contribute to poor outcomes regarding nutrition and growth. Compelling evidence exists that this multi-factorial problem must be addressed with both physiological and behavioural strategies.

Infant temperament and parental stress in 3-month-old infants after surgery for complex congenital heart disease.

OBJECTIVE: This study aimed to identify and compare differences in temperament and maternal stress between infants with complex congenital heart disease and healthy controls at 3 months of age. METHODS: Study sample was drawn from an existing longitudinal study examining growth in infants with congenital heart disease when compared with healthy controls. Infant temperament and parental stress were measured in 129 mother-infant dyads. Inclusion criteria for infants with congenital heart disease were > or = 36-week postmenstrual age, > or = 2500 g at birth, surgery in first 6 weeks of life, and no major congenital anomalies or genetic syndromes. The Early Infancy Temperament Questionnaire and Parent Stress Index were the assessment tools used. RESULTS: Infants with single ventricular (SV) physiology were more negative in mood (F = 7.14, p < .001) and less distractible (F = 5.00, p < .008) than the biventricular physiology or Control (C) infant groups. The demands of care for infants with congenital heart disease were a source of stress when compared with Control infants (p < .05). Five of 6 subscales of the Child Domain were significant sources of stress in the SV group compared with biventricle and Control groups. Negative mood and difficulty to soothe were predictors for Child Domain and Total Life Stress in SV infants. CONCLUSION: The demands of parenting an irritable infant with SV physiology put these mothers at risk for high levels of stress. Results suggest the need for predischarge anticipatory guidance for parents to better understand and respond to the behavioral style of their infants, in particular, infants with SV physiology.

Effects of a pharmacist-led pediatrics medication safety team on medication-error reporting.

PURPOSE: The effects of a pharmacist-led pediatrics medication safety team (PMST) on the frequency and severity of medication errors reported were studied. METHODS: This study was conducted in a pediatric critical care center (PCCC) in three phases. Phase 1 consisted of retrospective collection of medication-error reports before any interventions were made. Phases 2 and 3 included prospective collection of medication-error reports after several interventions. Phase 2 introduced a pediatrics clinical pharmacist to the PCCC. A pediatrics clinical pharmacist-led PMST (including a pediatrics critical care nurse and pediatrics intensivist), a new reporting form, and educational forums were added during phase 3 of the study. In addition, education focus groups were held for all intensive care unit staff. Outcomes for all phases were measured by the number of medication-error reports processed, the number of incidents, error severity, and the specialty of the reporter. RESULTS: Medication-error reporting increased twofold, threefold, and sixfold between phases 1 and 2, phases 2 and 3, and phases 1 and 3, respectively. Error severity decreased over the three time periods. In phases 1, 2, and 3, 46%, 8%, and 0% of the errors were classified as category D or E, respectively. Conversely, the reporting of near-miss errors increased from 9% in phase 1 to 38% in phase 2 and to 51% in phase 3. CONCLUSION: An increase in the number of medication errors reported and a decrease in the severity of errors reported were observed in a PCCC after implementation of a PMST, provision of education to health care providers, and addition of a clinical pharmacist.

Skin-to-skin contact (Kangaroo Care) analgesia for preterm infant heel stick.

The purpose of the study was to compare a heel stick conducted during Kangaroo Care (skin-to-skin contact) with the mother to a heel stick in a warmer in reducing premature infant physiologic and behavioral pain responses. Twenty-four premature infants in a university-based neonatal intensive care unit were recruited and randomized to 2 sequences: sequence A group received 3 hours of Kangaroo Care (with a heel stick in Kangaroo Care) followed by 3 hours in a warmer (with a heel stick in the warmer). Sequence B group had warmer care and a heel stick (in the warmer) before Kangaroo Care and a heel stick (in Kangaroo Care). Heart rate, respiratory rate, oxygen saturation, crying time, and behavioral state were measured before, during, and after heel stick. Repeated measures ANOVA and Mann Whitney U statistics were performed. Heart rate and length of crying in response to pain were significantly reduced during Kangaroo Care and the Kangaroo Care heel stick as compared to when infants were in the warmer and had a heel stick in the warmer. Three infants did not cry at all during the Kangaroo Care heel stick; infants slept more during Kangaroo Care than in the warmer. Kangaroo Care positioning before and during heel stick is a simple and inexpensive analgesic intervention to ameliorate pain in stable premature infants.