CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 3, May/June 2022 AFRICA 145 Pre-operative neurodevelopmental assessment in young children undergoing cardiac surgery in central South Africa: feasibility and clinical value Robyn Smith, Veronica Ntsiea, Stephen Brown, Joanne Potterton Abstract Background: Pre-operative neurodevelopmental assessment in children with congenital heart disease may assist in the early identification of children at risk for or presenting with developmental delays. This study determined the pre-operative neurodevelopmental status of young children undergoing cardiac surgery in central South Africa. Feasibility and clinical value of pre-operative assessment were also evaluated. Methods: Children 30 months and younger, scheduled to undergo cardiac surgery, were recruited into this prospective observational analytical study. Neurodevelopmental status was assessed using the Bayley-III and neuromotor examination. Variables associated with developmental performance were determined using ANOVAs. Sociodemographic and medical information were collected using a self-developed questionnaire. Pre-operative neurodevelopmental assessment was completed for 40 children at a median age of 7.4 months, including 30 children without and 10 with Down syndrome. Mean cardiac disease severity was moderate. The inclusion rate for pre-operative developmental assessment was 68%, limited mainly by environmental barriers. Results: Children with Down syndrome had significantly poorer motor (p < 0.0001), cognitive (p < 0.0001) and language performance (p < 0.001) compared to children without Down syndrome. Apart from Down syndrome, disease severity (p = 0.02), younger age at first cardiac surgery (p < 0.01) and growth failure (p = 0.04) were significantly associated with poorer cognitive, language and motor performance, respectively. Just more than half of the children without (n = 16) and all children with Down syndrome (n = 10) scored below one standard deviation of the test mean score (scores < 85) on at least one of the Bayley-III subscales, meeting the criteria for referral to rehabilitation therapies, including physiotherapy, occupational therapy and/or speech therapy. Conclusion: Pre-operative neurodevelopmental assessment may be of high importance in South Africa to identify children at developmental risk, facilitating early referral to rehabilitation therapies. Keywords: congenital heart disease, pre-operative neurodevelopmental assessment, developmental delay, rehabilitation therapies Submitted 29/9/20, accepted 6/11/22 Published online 13/1/22 Cardiovasc J Afr 2022; 33: 145–152 www.cvja.co.za DOI: 10.5830/CVJA-2021-057 Medical and surgical advances have significantly reduced mortality rates in children born with congenital heart disease (CHD), leading to improved survival rates.1-3 This has shifted the focus to longer-term outcomes, including neurodevelopment.4 There is convincing evidence that CHD survivors are at higher risk for developmental delay than the general population, with as many as half of children presenting with neurodevelopmental difficulties.2,4-6 Early developmental difficulties include impairments in gross and fine motor skills, cognition and language.1,2,7,8 Pre-operative growth failure is common in children with CHD and is associated with developmental delay.9-11 Aspects contributing to developmental delays are often multifactorial, interrelated and cumulative over time.7,12,13 Until recently neurodevelopmental outcome-based research in the CHD population has focused on the impact of peri- and post-operative factors on neurodevelopmental outcome, based on the premise that the central nervous system was intact prior to cardiac surgery.14 There is growing evidence that many children with CHD have abnormal or delayed brain development, making them more vulnerable to acquired brain injury.1,7,15 Prenatal genetic disorders and altered foetal circulation can cause delayed brain development, while postnatal hypoxia and haemodynamic disturbances can result in white matter and focal brain injury.5,16-18 Contemporaneous to surgical and medical advances and improved survival, neurodevelopmental problems were increasingly being identified in survivors, suggesting that risks related to the cardiac surgery itself played a limited role in the neurodevelopmental morbidity seen in CHD survivors. This served to highlight the possible importance of abnormal brain development in determining neurodevelopmental outcomes.1,19 Pre-operative screening for brain abnormalities and neurodevelopmental delay rarely occur in clinical practice, with only a few research studies having reported on neurodevelopmental performance in children with CHD prior to cardiac surgery.18,20-27 CHD disease severity is variable. For children who are critically ill or require emergency cardiac surgery, pre-operative neurodevelopmental assessment is not feasible. However, for those children who are medically stable, the feasibility, clinical value and format of pre-operative neurodevelopmental assessment remains poorly established.20,21,27 Department of Physiotherapy, University of the Witwatersrand, Johannesburg, South Africa Robyn Smith, PhD Veronica Ntsiea, PhD Joanne Potterton, PhD Department of Paediatrics and Child Health, University of the Free State, Bloemfontein, South Africa Robyn Smith, PhD, SmithRobyn@ufs.ac.za Stephen Brown, MD
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