Is Doppler echocardiography useful for estimating left ventricular filling pressures in pediatric heart transplant recipients?

LV E/E′ ratio obtained using Doppler echocardiography is considered a surrogate for LV filling pressure in adults but has performed poorly in children. We hypothesized that LV E/E′ ratio Z‐score, adjusted for age, will relate more strongly to LV filling pressures than LV E/E′ ratio in pediatric HT recipients. We analyzed 751 echocardiograms performed within 24 hours of a heart catheterization in 122 pediatric HT recipients (median age at HT 13 years, median 6 studies per patient). The primary end‐point was PCWP, assessed both as a continuous and a binary variable. Associations with LV E/E′ ratios and z‐scores were assessed using generalized estimating equations models. PCWP, LV E/E′ ratios (using E′ from LV free wall, septum, and their average), and LV E/E′ ratio Z‐scores, all declined over time after HT. LV E/E′ ratios and their Z‐scores were significantly associated with PCWP assessed as a continuous variable (P < 0.001 for all); however, the relationship was weak (R² range, 0.083 to 0.121). LV E/E′ ratios and their Z‐scores were also significantly associated with PCWP as a binary variable (P < 0.001 for all) but with only modest ability to discriminate PCWP ≥15 mm Hg (c‐statistic range, 0.660 to 0.695). The association between LV E/E′ ratio and PCWP in pediatric HT recipients is modest. Using a LV E/E′ ratio Z‐score did not result in significantly improved association with PCWP. Current Doppler echocardiographic methods are unreliable for estimating LV filling pressures in pediatric HT recipients.     

Looking to the future of ventricular assist devices in pediatric cardiomyopathy

The field of mechanical circulatory support, in particular ventricular assist devices (VADs), has evolved rapidly over the past decade. Recently, experts and investigators with interest in pediatric cardiomyopathy met and discussed the future and challenges of research for pediatric VADs, amongst other topics, at the 3rd International Conference on Cardiomyopathy in Children sponsored by the Children's Cardiomyopathy Foundation. In regards to the future research and development of VADs for this population, several priorities were emphasized including 1) the development of integrated registries and databases that would allow for improved understanding across the spectrum of VAD support in children, 2) the design of studies to better understand myocardial recovery and the role of VAD support in myocardial recovery, and 3) collaboration amongst medical experts in the field of pediatric cardiomyopathy, biomedical engineers, and industry to foster development of smaller and improved VADs that meet the needs of pediatric patients. This commentary reviews existing literature and the rationale for such priorities.     

Impact of maternal anxiety level on the childhood vaccination coverage

The mother’s mental state as a risk factor for the children’s vaccination status in developing countries has received little attention. The aim of this study was to determine the association between childhood vaccination coverage and maternal anxiety. A total of 195 consecutive infants and their mothers attending a tertiary teaching hospital, department of pediatric outpatient center between January 2008 and September 2009 were included in the study. One hundred five infants who have incomplete vaccination schedule (according to the National Immunization Schedule) were matched with 90 controls (fully vaccinated) and their mothers self-report measure of anxiety level using the State-Trait Anxiety Inventory (STAI), a psychiatric screening instrument. The chi-square test and the logistic regression were used in the statistical analysis. High maternal anxiety levels determined by STAI was associated with increased risk of incomplete vaccination status in infants (odds ratio 4.35, 95% confidence interval 1.87–8.79).This association remained significant after controlling for sociodemographic factors. High maternal anxiety scores may result in incomplete vaccination status in children younger than 3 years.     

Talking with caregivers of children living in the community with ventricular assist devices

A VAD is a mechanical pump used to support the functioning of a failing heart. As a pediatric therapy, a VAD is used as a temporary solution for poor heart function, a bridge to transplantation or recovery, or a destination therapy. The goal of this qualitative study was to explore the perspectives of family and professional caregivers of children who are supported by VADs in outpatient settings. Semi‐structured interviews were conducted with 22 caregivers of school‐aged children discharged home on VAD support. Interviews were transcribed, and data were analyzed using qualitative content analysis. Caregivers identified issues facing children on VAD support in the contexts of home, school, and other childhood places including being physically connected to a device; experiencing changes; living a medical life; negotiating restrictions; cost of care; family, kinship, and community; and, present and future living. While a child with a VAD may have much in common with other medically complex children, the technological complications and risks of living with a VAD are uniquely identified by caregivers as an issue, especially when considering the way that children with a VAD are connected to their device—implanted yet exterior, mobile yet restricted, and autonomous yet dependent.     

Mothers' depression and health‐related quality of life in neuromuscular diseases: Role of functional independence level of the children

Background: In the literature there have been studies about quality of life of parents who have children with chronic diseases. Most of these studies have focused on the stress of parents of children with neuromuscular disease (NMD), and there was no evidence to support hypothesized relationships between caregiving demands and health‐related quality of life (HRQOL). The aim of the present study was therefore to evaluate the relations between maternal depression and HRQOL and functional limitations of the children with NMD. Methods: Forty children with a diagnosis of NMD and their mothers were included in the study. HRQOL of the mothers was assessed on the Turkish version of the Nottingham Health Profile (NHP); potential cases of depressive illness were identified on Beck Depression Inventory (BDI); and Wee‐Functional Independence Measure (Wee‐FIM) was used to evaluate of functional independence level of the children. Results: It was found that mean total NHP score of the mothers was moderately correlated with the total FIM score and sphincter control of the child, and weakly correlated with the locomotion of the child (P < 0.001). There was moderate correlation between mothers' social isolation and children's sphincter control, social integration and total Wee‐FIM score and a weak correlation between mobility and communication scores (P < 0.001). In contrast there was no correlation between BDI scores of mothers and Wee‐FIM scores of children (P > 0.05). Conclusion: The functional level of children with NMD is one of the factors that affect the quality of life of mothers.     

Adolescent subthreshold‐depression and anxiety: psychopathology,functional impairment and increased suicide risk

Background: Subthreshold‐depression and anxiety have been associated with significant impairments in adults. This study investigates the characteristics of adolescent subthreshold‐depression and anxiety with a focus on suicidality, using both categorical and dimensional diagnostic models. Methods: Data were drawn from the Saving and Empowering Young Lives in Europe (SEYLE) study, comprising 12,395 adolescents from 11 countries. Based on self‐report, including Beck Depression Inventory‐II (BDI‐II), Zung Self‐Rating Anxiety Scale (SAS), Strengths and Difficulties Questionnaire (SDQ) and Paykel Suicide Scale (PSS) were administered to students. Based on BDI‐II, adolescents were divided into three groups: nondepressed, subthreshold‐depressed and depressed; based on the SAS, they were divided into nonanxiety, subthreshold‐anxiety and anxiety groups. Analyses of Covariance were conducted on SDQ scores to explore psychopathology of the defined groups. Logistic regression analyses were conducted to explore the relationships between functional impairments, suicidality and subthreshold and full syndromes. Results: Thirty‐two percent of the adolescents were subthreshold‐anxious and 5.8% anxious, 29.2% subthreshold‐depressed and 10.5% depressed, with high comorbidity. Mean scores of SDQ of subthreshold‐depressed/anxious were significantly higher than the mean scores of the nondepressed/nonanxious groups and significantly lower than those of the depressed/anxious groups. Both subthreshold and threshold‐anxiety and depression were related to functional impairment and suicidality. Conclusions: Subthreshold‐depression and subthreshold‐anxiety are associated with an increased burden of disease and suicide risk. These results highlight the importance of early identification of adolescent subthreshold‐depression and anxiety to minimize suicide. Incorporating these subthreshold disorders into a diagnosis could provide a bridge between categorical and dimensional diagnostic models.     

Symptomatic mitral valve prolapse in children and adolescents: catecholamines, anxiety, and biofeedback

It has been proposed that symptomatic mitral valve prolapse may be associated with a hyperadrenergic state and/or increased anxiety. To test this hypothesis, Spielberger State-Trait Anxiety (STAI) scores and 24-hour urinary catecholamine collections were gathered from 11 children and adolescents without mitral valve prolapse, 6 with asymptomatic mitral valve prolapse, and 14 who had chest pain (some with additional symptoms of shortness of breath, palpitations, and fatigue). STAI scores and catecholamine excretion values were not significantly different between groups. Ten symptomatic patients were randomly assigned to either eight sessions of skin temperature biofeedback with daily home practice of relaxation-mental imagery techniques or an attention-placebo condition. Change in 24-hour urinary catecholamine excretion values and STAI scores from baseline to end of treatment did not differ significantly between treatment and placebo conditions. Although not evident at the end of treatment, a significant decrease in chest pain was found in the biofeedback group at 6-month follow-up evaluation. In summary, results of this study did not show evidence of increased sympathetic tone or levels of anxiety in symptomatic pediatric patients with mitral valve prolapse. A behavioral treatment program using biofeedback and relaxation-mental imagery techniques was associated with decreased chest pain at 6-month follow-up.     

Maternal outcomes of a randomized controlled trial of a community-based support program for families of children with chronic illnesses.

BACKGROUND: Parents of children with chronic illnesses are at high risk for secondary mental health problems, such as anxiety and depression. OBJECTIVE: To evaluate maternal outcomes of a support intervention for families of children with selected chronic illnesses. DESIGN: A randomized controlled clinical trial design with repeated measures 1 year apart. SETTING: A community-based family support intervention linked to subspecialty and general pediatric clinics and practices in a metropolitan area. PARTICIPANTS: A population-based sample of 193 mothers of children aged 7 to 11 years; the children were diagnosed as having diabetes, sickle cell anemia, cystic fibrosis, or moderate to severe asthma. About 15% of the persons contacted refused to participate in the research, and 14% of the families were lost to follow-up. INTERVENTION: The 15-month intervention, the Family-to-Family Network, was designed to enhance mothers' mental health by linking mothers of school-aged children with selected chronic illnesses with mothers of older children with the same condition. The program included telephone contacts, face-to-face visits, and special family events. MAIN OUTCOME MEASURES: Beck Depression Inventory score and the Psychiatric Symptom Index. RESULTS: Maternal anxiety scores for participants in the experimental group decreased during the intervention period for all diagnostic groups and for the total group; scores for the control group increased (F = 5.07, P =.03). In multiple regression analyses, the intervention group was a significant predictor of posttest anxiety scores (P =.03). Effects were greater for mothers with high baseline anxiety (P<.001) and for those who were themselves in poor health (P<.01). CONCLUSIONS: A family support intervention can have beneficial effects on the mental health status of mothers of children with chronic illnesses. This type of intervention can be implemented in diverse pediatric settings.     

Post‐traumatic stress disorder and health‐related quality of life in the siblings of the pediatric bone marrow transplantation survivors and post‐traumatic stress disorder in their mothers

Although BMT is lifesaving in many childhood diseases, it was found to be related to anxiety, depression, and PTSD in parents, and PTSD, anxiety and overall low self‐esteem in siblings. Research on siblings' HRQoL is limited. The aim of this study was to investigate PTSD and HRQoL in siblings (donor and non‐donor) of pediatric BMT survivors and PTSD in their mothers, compared to the healthy controls. Thirty‐five siblings and their mothers and 35 healthy peers and their mothers were recruited as the study group and as the comparison group, respectively. In children, Child PTSD‐Reaction Index for PTSD and PedsQL for HRQoL were used. PTSD Checklist‐Civilian Version was used for PTSD in mothers. The study group, both children and mothers, obtained significantly higher PTSD rates than the control group. Children in the study group also reported significantly poorer HRQoL than the control group in all scales. As a novel finding, there was a significant negative correlation between siblings' and mothers' PTSD scores and siblings' PedsQL scores, indicating that PTSD symptoms in siblings and mothers significantly led to impairment in siblings' HRQoL or vice versa. Thus, the identification and treatment of siblings and mothers with PTSD seems imperative.     

Effectiveness of the national food supplementary program on children growth and nutritional status in Iran

This study aimed to evaluate the effectiveness of the national food distribution program on the growth and nutritional status of malnourished or growth‐retarded children in 2 provinces of Iran. A quasi‐experimental design was used for the effectiveness evaluation. Qualitative data were gathered to explain the results. An intervention group consisted of 362 children aged 6–72 months who were under coverage of the program. These children received monthly food as foodstuff, food vouchers, or cash. A comparison group included 409 children aged 6–72 months who were selected from those covered by the Primary Health Care system. Children anthropometric indices were measured at the baseline and also 6 months later. Twelve focus group discussions were held with mothers who had at least 1 child under the coverage of the program. At the end of the study, the mean weight‐for‐age Z scores, height‐for‐age Z scores, and weight‐for‐height Z scores increased compared with the baselines in both groups (p < .001). The differences between 2 groups in weight‐for‐age Z scores, height‐for‐age Z scores, and weight‐for‐height Z scores were not significant at the end of the study (p = .62, p = .91, and p = .94, respectively). According to the mothers' reports, factors affected the program outcome, that is, children anthropometric indices were low income, intrahousehold food sharing, irregular distribution, quantity and quality of the distributed food, and insufficient training. Providing foods for the malnourished children living in low‐income families helped to prevent a worsening of their nutritional status; however, it has not been effective in solving the problem, probably due to the weak implementation and lack of empowerment strategies.     

Prognostic significance of tissue Doppler imaging–derived myocardial performance index in pediatric patients with dilated cardiomyopathy

TDI–MPI has been shown to predict cardiovascular mortality in adults; there are a paucity of data on its use in children. We sought to determine the prognostic significance of TDI‐MPI at time of DCM diagnosis in children. Patients aged ≤18 years diagnosed with DCM were included along with age‐ and sex‐matched controls. Echo at diagnosis was analyzed to obtain standard measures of LV function, PW‐MPI, and septal and LV free wall TDI‐MPI. Survival analysis was used to assess the time to composite outcome of death, VAD, or transplant, stratified by TDI‐MPI z‐score. The study included 79 patients with DCM and 79 controls. During a median follow‐up of 182 days (IQR 41‐815 days), 16 underwent VAD placement, 21 underwent cardiac transplant, 6 died, and 36 had event‐free survival. The median septal TDI‐MPI for cases was 0.70 for patients with DCM vs 0.45 for controls (P < .001). Those with septal TDI‐MPI z‐scores ≥2 develop events significantly earlier than those with z‐score <2 (P = .014). In multivariable analysis, TDI‐MPI z‐score ≥2 was significantly associated with poor outcomes (HR 2.12, 95% CI 1.06‐4.23). TDI‐MPI can be reliably performed in pediatric patients with DCM. A TDI‐MPI z‐score ≥2 at diagnosis may be associated with earlier poor outcome. Further studies evaluating the use of TDI‐MPI in longitudinal follow‐up of patients with DCM may be helpful in refining its clinical use.     

Maternal anxiety and diet quality among mothers and toddlers from low‐income households

We evaluated the association between maternal anxiety score and diet quality over time among mothers and toddlers in low‐income families. Longitudinal data were collected from 267 mother–toddler dyads in an obesity prevention trial. Participants were recruited from the Special Supplemental Nutrition Program for Women, Infants and Children and paediatric clinics between 2007 and 2010. Dyads were assessed at study enrolment (Time 1), 6‐month (Time 2), and 12‐month follow‐up (Time 3). On the basis of a 1‐day 24‐hr dietary recall, we estimated maternal and toddler diet quality using the Healthy Eating Index 2015. Anxiety, a time‐varying variable, was assessed via the State–Trait Anxiety Inventory. Associations between maternal anxiety score and maternal and toddler diet quality over time were assessed in adjusted mixed models. Maternal and toddler diet quality were positively correlated (r = .48, p < .001). Higher maternal anxiety scores were related to lower toddler Healthy Eating Index scores (b = ?0.51, 95% confidence interval, CI [?0.87, ?0.15]) with no significant variation over time. The relation between maternal diet quality and anxiety score varied over time (b = 0.28, p = .03, for time–anxiety interaction). Higher maternal anxiety scores were associated with lower maternal diet quality at Time 1 (b = ?0.71, 95% CI [?1.09, 0.34]) and at Time 2 (b = ?0.51, 95% CI [?0.97, ?0.05]), but not at Time 3 (b = ?0.14, 95% CI [?0.54, 0.26]). Findings suggest that mothers and toddlers exhibited similar low‐quality dietary patterns and that lower diet quality was associated with higher maternal anxiety scores. Approaches to enhance diet quality may consider incorporating anxiety‐reducing strategies into maternal and toddler care and feeding behaviour guidelines.     

Ventricular assist devices in children: current achievements and future perspectives

Mechanical circulatory support systems for the treatment of acute and chronic heart failure are now available for use in several clinical situations and are designed for different indications and support times. In children, particularly in small infants, extracorporeal membrane oxygenation and centrifugal pumps have been most widely used in the past. These systems are preferred for support after cardiac operations and for use in patients who have concomitant respiratory failure, but they are suitable for short-term application only and intensive care is obligatory. VADs are designed for long-term application and allow patients to be discharged home. Pneumatic pulsatile VADs have been available in pediatric sizes since 1992. Currently at our institution, 74 children have been supported with pediatric extracorporeal VADs for up to 14 months. In the past five yr, a notable rise in survival has been achieved by improvements in pump design and pre- and post-operative management. We have been able to discharge 78% of the infants under one yr old. In this review, our current VAD experience in children will be presented in the light of improvements in decision-making, device technology, and implantation techniques, and in coagulation monitoring and anticoagulation. Additionally, new developments in the field of pediatric assist devices will be presented.     

Postoperative psychological status of children with anorectal malformations

Our purpose was to clarify factors that influence the level of depression of Japanese children with anorectal malformations (ARM). The subjects comprised 66 children with ARM, aged 0–16 years, and their mothers. Patients were divided into three groups (Group 1: aged 0–5 years, Group 2: 6–11 years, and Group 3: 12–16 years). The level of depression of the children aged 6–16 years was investigated by Kovac’s children’s depression inventory (CDI). The psychological status of their mothers was assessed by Spielberger’s state-trait anxiety index (STAI) and Zung’s self-rating depression scale (SDS). The classification of ARM and the clinical condition were also investigated. Defecation scores were assigned for the degree of bowel dysfunction. The level of depression in the patients was more marked in Group 3 than in Group 2 according to the CDI score. Significant correlations between the CDI score of the child and the STAI-1, STAI-2 and SDS scores of the mother were observed in Group 2, but not in Group 3. In Group 2, the STAI-1 score of the mothers was significantly influenced by the degree of bowel dysfunction in her child. In Group 3, the CDI score was significantly correlated with the constipation score. This study revealed that bowel dysfunction is the important factor that influences the level of depression of the children with ARM. In the period of childhood during which the child attends primary school, bowel dysfunction indirectly influences the level of depression of children through the psychological status of mothers. However, bowel dysfunction directly influences the level of depression of children in adolescent patients.     

Post‐transplant glucose status in 61 pediatric renal transplant recipients: Preliminary results of five Turkish pediatric nephrology centers

Buyan N, Bilge I, Turkmen MA, Bayrakci U, Emre S, Fidan K, Baskin E, Gok F, Bas F, Bideci A. Post‐transplant glucose status in 61 pediatric renal transplant recipients: Preliminary results of five Turkish pediatric nephrology centers.
Pediatr Transplantation 2010:14:203–211 © 2009 John Wiley & Sons A/S. Abstract: To assess the incidence, risk factors and outcomes of PTDM, a total of 61 non‐diabetic children (24 girls, 37 boys, age: 14.5 ± 2.1 yr) were examined after their first kidney transplantation (37.3 ± 21.6 months) with an OGTT. At baseline, 16 (26.2%) patients had IGT, 45 (73.8%) had NGT, and no patient had PTDM. No significant difference was shown between TAC‐ and CSA‐treated patients in terms of IGT. Higher BMI z‐scores (p = 0.011), LDL‐cholesterol (p < 0.05) and triglyceride levels (p < 0.01), HOMA‐IR (p = 0.013) and lower HOMA‐%β (p = 0.011) were significantly associated with IGT. Fifty‐four patients were re‐evaluated after six months; eight patients with baseline IGT (50%) improved to NGT, three (19%) developed PTDM requiring insulin therapy, five (31%) remained with IGT, and four patients progressed from NGT to either IGT (two) or PTDM (two). These 12 progressive patients had significantly higher total cholesterol (p < 0.05), triglycerides (p < 0.05), HOMA‐IR (p < 0.01) and lower HOMA‐%β (p < 0.0) than non‐progressive patients at baseline. We can conclude that post‐transplantation glucose abnormalities are common in Turkish pediatric kidney recipients, and higher BMI z‐scores and triglyceride concentrations are the main risk factors. Considering that the progressive patients are significantly more insulin resistant at baseline, we suggest that the utility of both HOMA‐IR and HOMA‐%β in predicting future risk of PTDM and/or IGT should be evaluated in children.     

Association Between Parental Anxiety and Compliance With Preoperative Requirements for Pediatric Outpatient Surgery

PurposeThe purpose of this study was to determine if parental anxiety interferes with the ability to follow preoperative requirements.MethodIn a single center observational study of parents of children admitted to a same-day surgical unit at a tertiary pediatric hospital, parental preoperative anxiety was measured by the State-Trait Anxiety Inventory (STAI) questionnaire. Anxiety was correlated to a four points assessment of adherence with the following preoperative requirements: dietary restrictions, timely arrival at the hospital, arrival at the assigned room, and completion of required medical forms, because those requirements are the greatest external contributors to surgical cancellation according to hospital statistics.ResultsA total of 203 families completed the study. The average STAI score on the day of surgery was 38±12 (population average, 36±11). Only 130 families (66%) complied with all four preoperative requirements. A higher level of anxiety was significantly associated with lower probability of compliance (odds ratio, 0.88; 95% confidence interval, 0.78-1.00, P=05). In univariate models, factors associated with higher STAI scores included younger parent age, younger children, only child, child's first surgery, and no medical consultation between surgical assessment and surgery.DiscussionParental anxiety could be associated with a lower likelihood of parents following preoperative requirements and could contribute to increased likelihood of surgical cancellation.     

The Quality of Life and Psychological Status of Mothers of Hospitalized Pediatric Oncology Patients

This study compares the quality of life (QoL) and psychological status of mothers of children with cancer with those of mothers of children without cancer. One hundred hospitalized children and their mothers, as primary caregivers, were included in this study. Fifty mothers with healthy children were enrolled as the control group. A children and mother query form was used to obtain demographical data. The disease histories were extracted from patient records. QoL was measured with the Medical Outcomes Study 36-item Short Form Survey (SF-36) and the State-Trait Anxiety Inventory (STAI) in order to assess the psychological symptoms of the mothers in the study and in the control groups. The mean age of the caregivers was 35.93 ± 8.27 years, whereas the mean age of the mothers in the control group was 39.72 ± 6.88 years. The general health, vitality, social functioning, and mental health scores from the SF-36 and the STAI-trait scores were significantly poorer among the mothers of children with cancer as compared with the scores of the mothers of children without cancer (P < .05). Significant negative correlations were found between the age of the children, the age at diagnosis, and the SF-36 subscores for physical functioning, physical role, and pain (P < .05). The mothers of children with cancer, who require hospital care, have poorer QoL and psychological health than the mothers of healthy children. These results suggest that the current system for treating cancer in Turkish children should also include close monitoring of the care-giving mothers’ QoL and psychological health.     

Nutritional status and cognitive performance of mother–child pairs in Sidama,Southern Ethiopia

The purpose of this study was to assess the nutritional status and cognitive performance of women and their 5‐year‐old children using a cross‐sectional design. Cognitive performance of mothers and children was assessed with Raven's Colored Progressive Matrices (CPM) and Kaufman Assessment Battery for Children‐II (KABC‐II). Demographic characteristics, food consumption patterns and anthropometry were also measured. Four rural districts in Sidama, southern Ethiopia served as the setting for this study. Subjects were one hundred women and their 5‐year‐old children. Mean ± standard deviation age of the mothers was 29 ± 6 years and family size was 7.0 ± 2.6. Maternal body mass index (BMI) ranged from 15.3 to 29.0 with 14% of the mothers having BMI < 18.5. Anthropometric assessment of children revealed 29% to be stunted (height‐for‐age z‐score < ?2) and 12% to be underweight (weight‐for‐age z‐score < ?2). Mothers' education significantly contributed to prediction of both mothers' and children's cognitive test scores. There were significant differences in mean cognitive test scores between stunted and non‐stunted, and between underweight and normal‐weight children. Height‐for‐age z‐scores were correlated with scores for short‐term memory (r = 0.42, P < 0.001), and visual processing (r = 0.42, P < 0.001) indices and weight‐for‐age z‐scores were also correlated with scores of short‐term memory (r = 0.41, P < 0.001) and visual processing (r = 0.43, P < 0.001) indices. Malnutrition in the community likely contributed to the cognitive performance of the subjects. Performance on memory and visual processing tasks was significantly lower in children with growth deficits suggesting that efficient and cost effective methods to alleviate malnutrition and food insecurity would impact not only child health but also cognitive function.