Management of asymptomatic ventricular septal defect

A patient with a small ventricular septal defect should not be subjected to operative closure of the defect. Such a ventricular septal defect is characterized by a normal second sound, normal electrocardiorgram, normal thoracic roentgenogram and echocardiogram. If the patient is catheterised, the pulmonary and right ventricular pressures are normal and the pulmonary blood flow is less than twice the systemic blood flow. If left alone a patient with such a defect is not likely to develop any difficulty throughout his life because of the defect itself, however, a periodic assessment of the patient is necessary. The patient and the parents should be advised regarding prophylaxis against infective endocarditis.     

Management of asymptomatic ventricular septal defect

A patient with a small ventricular septal defect should not be subjected to operative closure of the defect. Such a ventricular septal defect is characterized by a normal second sound, normal electrocardiorgram, normal thoracic roentgenogram and echocardiogram. If the patient is catheterised, the pulmonary and right ventricular pressures are normal and the pulmonary blood flow is less than twice the systemic blood flow. If left alone a patient with such a defect is not likely to develop any difficulty throughout his life because of the defect itself, however, a periodic assessment of the patient is necessary. The patient and the parents should be advised regarding prophylaxis against infective endocarditis.     

Pregnancy termination following prenatal diagnosis of serious heart disease in the fetus

BACKGROUND AND AIMS: The fetal diagnosis of complex congenital heart disease (CHD) leads to a crisis for the affected couple. How much more so when a decision is made to terminate the pregnancy? In making that decision do the parents understand the anomaly, its consequences and possible outcome and does that information influence their decision process? METHODS AND SUBJECTS: Questionnaires were developed. They were forwarded to parents seen in a private obstetric ultrasound practice, diagnosed with, or specifically referred, because of the diagnosis of a complex cardiac anomaly in the fetus. The diagnosis was subsequently confirmed by ultrasound examination in the presence of a paediatric cardiologist, in all but one patient. Once confirmed, both the obstetric ultrasonologist and cardiologist explained the anomaly, both working off each other, the obstetrician acting as the parent's advocate, asking and "demanding" explanations in lay terms, clarifying the nature of the anomaly, its possible consequences in the newborn and childhood, the need for intervention, and the short- and long-term risks, concentrating on quality of life issues. The parents were given the opportunity to meet with the cardiologist separately to clarify the diagnosis and management, before coming to a final decision to continue or terminate the pregnancy. RESULTS: Over a 3-year period, 40 such patients were included in the study, of which 13 opted for termination. The anomalies were complex and included hypoplastic left heart syndrome, univentricular heart and atrioventricular septal defect. The three autopsies carried out confirmed the prenatal diagnosis.Completed questionnaires were received from nine couples, two being lost to follow up and two refusing to complete the questionnaire despite telephone contact. All nine responses stated the explanation given was "very clear" or "clear", the detail covered was "just right", and their understanding of the diagnosis was "good " to "excellent". Eight stated they were very distressed following the diagnosis, and seven experienced great difficulty in arriving at a decision. In contrast, two stated that the decision was "easy" or "very easy". The reasons for termination included concern for the welfare of the affected child, other siblings in the family and because of the distress of the parents themselves. Intellectual disability was given as an additional reason in the three who had associated chromosomal abnormalities. CONCLUSIONS: Although the numbers were small, it would appear that the above approach used by an obstetric ultrasonologist and cardiologist, working together, explaining complex congenital heart disease in lay terms and focusing on the need for intervention, functional outcome and quality of life issues, provided the parents with a reasonable understanding of the anomaly. Nevertheless, the decision to terminate, very difficult for nearly all the couples, seemed to be based on the perceived distress of the affected infant/child, the siblings and parents themselves. While three couples were grateful for an opportunity to respond, two refused, suggesting the need for more detailed follow up and support for those parents who decide to terminate an apparently wanted pregnancy.     

Maternal attributions and expressed emotion as predictors of attendance at parent management training

BACKGROUND: The effectiveness of parent management training (PMT) as a treatment for child behaviour problems is reduced by high attrition rates. One difficulty with engaging mothers is that, by definition, PMT is directed at the parent, yet many parents believe the cause of the problem lies within the child. Hence the model of therapy offered contradicts their understanding about the cause and nature of the problem. Moreover, the emotional consequence of holding child-responsibility causal attributions is associated with high expressed emotion (EE), a known predictor of poor compliance with therapy in other child psychiatric disorders. METHODS: Seventy-five consecutive referrals of mothers to a PMT programme were recruited. EE was assessed using the Camberwell Family Interview methodology. Spontaneous causal attributions about their child's problem behaviour were collected from the same interview material and independently coded using the Leeds Attributional Coding System. Attendance data at the PMT programme was collected following completion of programmes. RESULTS: Contrary to expectations, mothers who made child-responsibility attributions and were highly critical about their child's behaviour were no more likely than non-blaming, low EE parents to drop out prematurely from a course of PMT. However, expressing an understanding of their own role in managing their child's behaviour was predictive of attendance. Two factors were, however, more closely associated with greater attrition: having been offered a clinical diagnosis and being from a lower socio-economic family. CONCLUSIONS: Socio-economic factors should be viewed as barriers to uptake of services and successful strategies for increasing engagement of families are likely to be economical rather than psychological. However, although the causal attributions mothers make about their child's behaviour did not predict whether they were likely to attend PMT, an exploratory analysis found evidence to suggest that successful engagement with PMT begins early in the referral process and that referring clinicians should ensure treatment options are aligned with diagnoses provided.     

Ventricular septal defect with silent discrete subaortic stenosis

Summary Subaortic stenosis is rarely mentioned as a lesion that may be associated with a ventricular septal defect. We have encountered 4 patients with discrete subaortic stenosis adjacent to a ventricular septal defect, all of whom posed significant problems in diagnosis. In all 4 patients the subaortic stenosis was silent clinically and in 3 cases the obstruction was also not detected at the initial cardiac catheterization and angiocardiography. In the latter 3 cases, after surgical closure of the ventricular septal defect, there was a loud systolic murmur initially thought to be due to a small residual ventricular septal defect. In time, the clinical findings became more typical of isolated subaortic stenosis. In each of these cases the obstruction was verified at cardiac catheterization with peak systolic pressure gradients of 145, 45, and 70 mm Hg. During reoperation, a discrete subaortic shelf was found opposite the patch used to close the ventricular septal defect. In the 4th case, the subaortic stenosis was unsuspected by clinical evaluation but was diagnosed by echocardiography as well as at cardiac catheterization, and both the ventricular septal defect and subaortic stenosis were corrected at the initial operation. A discrete subaortic shelf situated adjacent to a ventricular septal defect may be “silent,” producing minimal, if any, pressure gradient and may pose diagnostic difficulties. Failure to recognize such a shelf and to remove it at the time of surgical closure of the ventricular septal defect, may result in the creation of a severe subaortic obstruction.     

Perception of fear, distress and pain by parents of children undergoing a micturating cystourethrogram: a prospective study

OBJECTIVES: To investigate whether parents' expectations of their child's fear, distress or pain during a micturating cystourethrogram (MCU) are realized. METHODOLOGY: Prospective study in which parents were asked to fill out two questionnaires using a visual analogue scale, one before (pre) and the other after the MCU procedure (post), was conducted at a tertiary level paediatric hospital in Sydney, Australia. The questionnaires were designed to compare the parents' anticipated and experienced anxiety about their child's procedure and their perception of fear, distress and pain in their child during and after the procedure. The parents' satisfaction with information provided to them on the procedure was also recorded. Twenty-five parents participated in the study. RESULTS: There were significant differences between anticipated and experienced parental anxiety. Parents' reporting of fear, distress and pain in their child during the MCU and after the procedure was lower than they had anticipated. There was a significant correlation between the parents' anxiety and their perception of severity of their child's fear (r = 0.52, P = 0.009), distress (r = 0.48, P = 0.017) and pain (r = 0.50, P = 0.01) during the procedure, but less so with the child's distress after the procedure (r = 0.39, P = 0.059). The parents were satisfied with the information given to them regarding the MCU procedure. CONCLUSIONS: Parents' perception of their child's fear, distress and pain during the MCU, as well as distress following the MCU, was not as severe as they had anticipated. Parental anxiety is an important factor in the perception of fear, distress and pain in children during and after the procedure.     

Parental knowledge of bacterial endocarditis prophylaxis

Summary The aim of this study was to determine parental knowledge of bacterial endocarditis prophylaxis (BEP).Parents of 135 patients attending a pediatric cardiology clinic in a university center were mailed an eight-question survey pertaining to their knowledge of their child's cardiac disease, medications, and BEP. The patients' cardiac lesions and current medications were verified by a review of clinic and echocardiographic records. Each patient's need for BEP was determined according to American Heart Association (AHA) recommendations [3].Eighty-four (62%) parents returned complete surveys. The patients' mean age was 5 years with a range of 9 weeks to 19 years. Eighty-two (98%) respondents were high school graduates. Fifty-two (62%) respondents correctly defined endocarditis. Eighty-two (98%) parents knew the correct name of their child's cardiac condition and 27/32 (84%) knew the names of their child's current medications. Only 36/64 (56%) parents of at-risk children knew measures to prevent endocarditis.While most parents know the name of their child's heart lesion and current medications, parental knowledge of endocarditis and BEP was limited. Intensified education and awareness programs are needed in order to prevent potential marbidity and mortality for pediatric patients with heart disease.     

A Triple Challenge: Thrombocytopenia in a 7-Year-Old Girl With Unrepaired d-Transposition of the Great Arteries, Ventricular Septal Defect, and Pulmonary Hypertension

Thrombocytopenia can be a real challenge during cardiac surgery in children with cyanotic congenital heart disease. This report describes a 7-year-old girl with d-transposition of the great arteries, ventricular septal defect, pulmonary hypertension, chronic thrombocytopenia, polycythemia, and chronic renal impairment. The thrombocytopenia improved several days after splenectomy. The child then underwent a successful arterial switch operation with ventricular septal defect closure.     

Infective endocarditis following cardiac catheterization in infancy. A case report and review

A 4.5-month-old infant with transposition of great vessels and large ventricular septal defect developed acute infective endocarditis following cardiac catheterization. Beta-hemolytic streptococcus was recovered from three blood cultures. The infant survived after 6 weeks intravenous antibiotic therapy. The occurrence of infective endocarditis following cardiac catheterization during infancy is briefly reviewed and discussed. The importance of distinguishing febrile episodes of infancy from infective endocarditis and the use of two-dimensional echocardiography for diagnosis is re-emphasized.     

Developmental intervention: a pediatric clinical review

We have attempted to review developmental intervention for pediatricians in a way that is of clinical relevance to primary care pediatricians. In so doing, we chose not to evaluate certain topics such as therapeutic intervention for handicapped children or center-based educational programs because these have been adequately addressed elsewhere. It is clear that pediatricians have a unique and important role to play in developmental intervention for the following reasons: pediatricians have easy and routinely accepted access to infants and families in the prenatal, perinatal, and preschool periods: pediatricians possess a socially accepted role of authority; and pediatricians can integrate understanding of the child's health and developmental status within the context of the family and social environment to make clinical interpretation regarding the child's developmental status and prognosis. Pediatricians are thus in the best position to convince parents of their impact on their child's development. The following general roles have been identified for pediatricians. First, pediatricians should be aware of the child's biologic status and family environmental situation and the relative degree of risk for developmental problems. This clinical awareness, in combination with the use of appropriate screening instruments of the child's development and family environment, will allow clinical judgment regarding the frequency and type of child health supervision, the need for further diagnostic evaluation, and the need for referral to intervention programs and other resources. Second, the pediatrician should develop an approach for developmental intervention for all children, whatever their degree of biological risk. This review of medical, educational, and psychological literature demonstrate the following recurring important themes as goals for primary intervention: Improve parental understanding of normal child development and developmental expectations. Assist parent's understanding of the individual developmental characteristics and temperamental style of their child. Promote parental sensitivity to the social nature of infant behaviors. Encourage parent responsiveness to the social behaviors. Improve parental feelings of confidence and competence to affect their child's development. Pediatricians can be influential in supporting structural changes that can have beneficial effects on children's development. Support of humanization of obstetric and nursery practices, and the increased use of child health supervision to parents in groups are examples of such efforts.(ABSTRACT TRUNCATED AT 400 WORDS)     

Clinical use of temperament data in pediatrics

Temperament data can aid the clinician in fostering parent-child relationships on three levels. First, general educational discussions about temperament between the clinician and parents provide background information, which increases parents' awareness and understanding of individual differences. Second, identification of the temperament profile of the particular child provides the parents with a more organized picture of the child's behavioral style and of possible distortions in their perceptions of it. This is primarily useful to the clinician when the child is rather difficult or when, for example the mother's perception of the child makes the child seem more difficult than her own ratings suggest. This clarification process may provide parents with enough insight for them to make their own shifts in interaction patterns. Third, the clinician may attempt to influence the temperament-environment interaction, when its dissonance is leading to reactive symptoms, by suggesting alternative methods of parental management. If this is successful, the stress of the interaction should diminish and the reactive symptoms disappear. At the same time parents and teachers must learn to live in a more tolerant and flexible manner with the child's relatively less changeable temperament.     

The diagnosis of child sexual abuse.

OBJECTIVE--To examine how the history, psychological evaluation, medical examination, and child's response to the examination contributed to a diagnosis of child sexual abuse by an interdisciplinary team. DESIGN--Patient series. SETTING--Subspecialty clinic for evaluating prepubertal children alleged to have been sexually abused. PARTICIPANTS--One hundred thirty-two children alleged to have been sexually abused and their parents or guardian, evaluated consecutively in a subspecialty clinic between September 1989 and June 1990. MEASUREMENTS/MAIN RESULTS--A social worker interviewed the parents, a psychologist interviewed the child, and a pediatrician obtained a medical history and examined the child. Parents completed a Child Behavior Check list and the child's response to the physical examination was noted. Both a disclosure by the child and abnormal physical findings were significantly and independently associated with the team's diagnosis of sexual abuse, whereas the presence of sexualized behavior, somatic problems, and the child's response to the examination did not make an additional contribution to the diagnosis. CONCLUSIONS--The findings support the need for a skilled psychological interview and a medical examination of a child alleged to have been sexually abused to make the diagnosis of sexual abuse. An interdisciplinary team appears to be a valuable approach for evaluating these children and their families.     

Endocarditis after closure of ventricular septal defect by transcatheter device

Advances in interventional cardiology have enabled the treatment of severe congenital heart defects without the need for surgery. The percutaneous closure of atrial septal defects and, more recently, ventricular septal defects is considered a safe procedure with fewer complications and less morbidity compared with surgery. We report on a 2-year-old child who developed endocarditis after ventricular septal defect closure with an Amplatzer device. The patient recovered after intravenous antibiotics and anticoagulation. To the best of our knowledge, this is the first report of endocarditis associated with ventricular septal defect closure device insertion.     

Maternal perception of excess weight in children: a survey conducted by paediatricians in the province of Milan

OBJECTIVE: To establish whether maternal perception of a child's body weight (BW) and food intake is related to the level of maternal education. STUDY DESIGN: Height and BW of 569 mother/child couples were measured, and mothers received a questionnaire regarding their perception of their own weight and their child's BW and food intake. RESULTS: Twenty-nine percent of mothers and 35% of children were overweight or obese. Only 10% of the mothers underestimated their own weight, while 37% overestimated it. In contrast, 28% of mothers underestimated their child's BW, while 9% overestimated it. Higher maternal instruction level was significantly associated to a lower weight class in both mothers and children, and to a correct perception of the child's weight. Fifty-seven per cent of the mothers who perceived their child to be overweight or obese were not concerned. Forty-four per cent of the mothers with overweight or obese children believed that their child was eating correctly. CONCLUSIONS: A better understanding of how mothers perceive the problem of excess weight in their children is relevant to the success of preventive interventions in childhood obesity.     

胎儿心脏结构异常的超声诊断研究

目的：探讨超声心动图检测胎儿心脏结构异常的诊断价值及临床意义。方法：总结分析我院9 352 例胎儿超声心动图资料。结果：检出472例胎儿心脏结构异常,其中室间隔缺损97例,房室共同通道53例,房间隔缺损49例,法洛四联症26例,永存动脉干21例,三尖瓣下移畸形20例,其他类型心脏结构异常206例。其中17例伴有胎儿心律失常。初次胎儿超声心动图检查发现伴有胎儿心力衰竭9例、胎儿水肿5例。结论：胎儿超声心动图的应用有助于早期检出心脏结构异常并指导患胎的处理。胎儿超声心动图对胎儿先天性心血管畸形准确的诊断及评价是胎儿心脏宫内干预和监测的基础。［中国当代儿科杂志,2010,12（2）：99-102］     

The spiritual needs of parents at the time of their child's death in the pediatric intensive care unit and during bereavement: a qualitative study.

OBJECTIVE: Death is common in pediatric intensive care units. A child's death can shatter parents' personal identities, disrupt their relationships, and challenge their worldviews. Spirituality is a human characteristic that engenders transcendence; seeks meaning, purpose, and connection to others; and helps to construct a coherent worldview. Greater attention to spiritual needs may help parents cope with their loss. Our objective is to gain a deeper understanding of parents' spiritual needs during their child's death and bereavement. DESIGN: Prospective, qualitative study. SETTING: University-affiliated children's hospital. Participants: Thirty-three parents of 26 children who died in the pediatric intensive care unit between January 1, 1999, and August 31, 2000. INTERVENTIONS: Semistructured, in-depth, videotaped interviews with parents 2 yrs after their child's death. MEASUREMENTS AND MAIN RESULTS: The main spiritual need described by parents was that of maintaining connection with their child. Parents maintained connection at the time of death by physical presence. Parents maintained connection after the death through memories, mementos, memorials, and altruistic acts such as organ donation, volunteer work, charitable fund raising, support group development, and adoption. Other spiritual needs included the need for truth; compassion; prayer, ritual, and sacred texts; connection with others; bereavement support; gratitude; meaning and purpose; trust; anger and blame; and dignity. CONCLUSIONS: Bereaved parents have intense spiritual needs. Health care providers can help to support parents' spiritual needs through words and actions that demonstrate a caring presence, impart truth, and foster trust; by providing opportunity to stay connected with the child at the time of death; and by creating memories that will bring comfort in the future.     

Atrioventricular Septal Defect with Cor Triatriatum: Case Report and Review of the Literature

Atrioventricular septal defect with cor triatriatum is a rare combination, with only nine cases reported so far. Cor triatriatum, a potentially correctable cause of pulmonary arterial hypertension in atrioventricular septal defect patients, was missed in a few earlier case reports, leading to death and subsequent diagnosis at autopsy. We report the case of 3-year-old female child with this combination (partial atrioventricular septal defect with cor triatriatum) wherein the final diagnosis was made at cardiac catheterization. Successful surgical correction was performed.     

A social study of dwarfing conditions I. The reactions and questions of parents of children with bone dysplasias

ABSTRACT. The parents of the dwarfed children found that they wanted and needed more time to discuss their questions and concerns with their doctor and other professionals than was generally provided. They needed time not only when the initial diagnosis was given, but again at different stages of both their child's development and their acceptance of the condition.
The reactions of parents to their child's abnormality varied and was affected by how information was presented to them. The majority of parents wanted a chance to form some relationship with their child before being told the diagnosis and more parents preferred to be told when the doctor is sure a dwarfing condition is present rather than when he just suspects one.
In the early stages after diagnosis the most frequent questions concerned the availability of a cure, expected adult height, and intelligence. Cause and inheritance, and family planning questions usually followed. As the children developed, the parents' most pressing questions concerned quality of life that they could expect for their child. The study found a high incidence of mental and behavioural disturbance in families with a dwarfed individual, which suggests that the whole family may need professional assistance.     

Cosleeping in a community sample of 2- and 3-year-old children

A randomly selected community sample of 303 parents of 2- and 3-year-olds were interviewed about child sleep behaviors and completed the Child Behavior Checklist for Ages 2-3, a standardized rating scale for child problem behaviors. Most parents (55%) reported that the child slept in their bed at least occasionally and for at least part of the night, particularly during periods of minor stress or disruption of the family routine. The prevalence of cosleeping did not vary by the child's age or sex, but frequent cosleeping (more than once per week) was more common among nonwhite families and single-mother households. Cosleeping was not significantly related to child behavior problems, but frequent cosleepers were more likely to report sleep problems, including difficulty getting to sleep and night waking. Children who were still cosleeping frequently 1 year after the initial assessment maintained high levels of sleep problems, compared with those who stopped cosleeping and non-cosleepers. Cosleeping is common at this age and is not related to general maladjustment. However, frequent cosleeping is closely intertwined with child sleep problems.     

Chronic Outpatient Sildenafil Therapy for Pulmonary Hypertension in a Child After Cardiac Surgery

We report the case of a 14-month-old male with d-transposition of the great arteries, ventricular septal defect, and pulmonary hypertension successfully treated with long-term sildenafil following cardiac surgery. To our knowledge, this is the first published report of long-term sildenafil treatment in a child after corrective cardiac surgery.