CARDIOVASCULAR JOURNAL OF AFRICA • Volume 33, No 3, May/June 2022 146 AFRICA Pre-operative neurodevelopmental assessment in medically stable children with CHD may have several benefits, including the early detection of children at increased risk of brain injury and those presenting with neurodevelopmental delays prior to cardiac surgery.14,20,21,24 Pre-operative identification of children at risk for or presenting with developmental delays can inform future developmental care planning, including early referral for formal developmental evaluation, and where indicated, referral to rehabilitation therapies (physiotherapy, occupational and speech therapy) to address identified developmental delays.2,27,28 Furthermore, the availability of pre-operative neurodevelopmental data allows for the monitoring of changes in neurodevelopmental status after cardiac surgery, providing information on the impact of peri-operative and post-operative factors on neurodevelopmental outcome.20,21 The value of pre-operative neurodevelopmental assessment in predicting later developmental outcome is unknown as historically longitudinal outcome studies have only included post-operative neurodevelopmental assessments.27 Recently there has been increased focus on including pre-operative neurodevelopmental assessment where feasible and safe to do so, in order to better determine the value thereof as a potential indicator of later neurodevelopmental performance.20,21,27 Many children with CHD in South Africa are exposed to multiple risks for poor developmental outcome in addition to their CHD. These risks include poverty, maternal stress and depression, low levels of maternal education and poor socioeconomic environments.29,30 These risks are strongly associated with the long-term outcomes of children with CHD.31 Paediatric cardiac services in South Africa are overburdened, often resulting inextendedwaitingperiods for cardiac surgery.32-35 In light of this, it is considered important to determine the feasibility, clinical value and format of pre-operative neurodevelopmental assessment in medically stable children with CHD in South Africa as it may assist in the early identification of developmental delays and facilitate the initiation of individualised rehabilitation therapies and parent support while children are awaiting cardiac surgery, potentially improving later neurodevelopmental functioning.20 This study aimed to determine the pre-operative neurodevelopmental status of young children with CHD undergoing cardiac surgery in central South Africa. The study was also poised to provide the first developing-country perspective on recruitment, feasibility, clinical value and format of pre-operative neurodevelopmental assessment. Methods Forty-one consecutive children younger than 30 months were included in this prospective, observational, analytical study at a large tertiary academic hospital in central South Africa over a 17-month period. The main inclusion criteria were medically stable children with congenital heart defects requiring cardiac surgery. Pre-operative neurodevelopmental assessment was mandatory. Neonates, children who were critically ill, and those who had undergone previous or emergency cardiac surgery were excluded. Children with genetic disorders were included in the study as a sub-group of special interest. The presence of a genetic disorder is independently associated with developmental delay. The difference in pre-operative developmental status and need for rehabilitation therapies in children without and with Down syndrome (DS) was of interest.36-38 This article reports on the pre-operative phase of a larger longitudinal study that went on to follow up participants at three and six months post cardiac surgery.39 Ethical clearance was obtained from the Health Sciences Research Ethics Committee, University of the Free State (ECUFS 177/2013) and the Committee for Research on Human Subjects, University of the Witwatersrand (M131056). Parents provided written informed consent for their own and their children’s participation. All participant information was kept confidential. Development was assessed using the Bayley Scales of Infant and Toddler Development (third edition) (Bayley-III) prior to cardiac surgery.2 The Bayley-III scale assesses development across cognitive, language and motor subscales.40 Scores below one standard deviation of the test mean score of 100 (scores < 85) were used to identify children at risk, and below two standard deviations (scores < 70) as developmentally delayed, qualifying them for referral to rehabilitation therapies.6,41 Neuromotor examination included the assessment of muscle tone.2 Growth status was assessed using the World Health Organisation (WHO) child growth standards and DS-specific growth charts.2,42,43 Sociodemographic information was collected from parents using a verbally administered questionnaire. Medical information was collected from the child’s medical record. Cardiac disease was categorised according to the nature of the defect and the medical severity was rated using the Cardiologist’s Perception of Medical Severity scale.44,45 Socio-economic status was calculated using the Hollingshead index of social position.46 Parenting stress was measured using the Parenting Stress Index – Short Form (PSI-SF).47 All participant materials were available in Sesotho, English and Afrikaans in accordance with local language demographics. Statistical analysis Recruitment data were used to calculate the screening, eligibility and inclusion rates.48,49 Sample characteristics and clinical variables are presented as means with standard deviations, medians with ranges for continuous data, and frequencies with percentages for categorical data. Bayley-III subscale composite scores were classified according to the measure-specific classification system. Classification data is reported using frequencies with percentages. Difference between means and proportions for children without and with DS were calculated using a two-sample t-test and chi-squared test, respectively. Associations between known risk factors and cognitive, language and motor developmental outcomes for the entire sample were determined using analysis of variance (ANOVA). Results Seventy-two children, identified from the surgery lists, were screened for eligibility. Twelve children were ineligible and 11 were lost to enrolment. Forty-nine children were screened for inclusion, of whom eight could not be included due to unexpected changes to the surgery list or late hospital admission, preventing pre-operative assessment. Forty-one children were included in the study.
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