Lessons on Cardiac Neonatal Care at the 8th World Congress of Pediatric Cardiology and Cardiac Surgery

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The 8th World Congress of Pediatric Cardiology and Cardiac Surgery (WCPCCS) had more than 5000 attendees representing cardiology, cardiac surgery, critical care medicine, neonatology, and other health care domains. Additionally, some of the attendees were parents of children with congenital heart disease (CHD) or were survivors of CHD themselves. While representing my institution’s booth at the WCPCCS, I had a chance to speak with a former cardiac nurse whose own daughter was born with complex CHD. She survived neonatal repair as well as subsequent complications, and had what many would consider a successful recovery. She went on to attend college and did not require re-intervention or hospitalization for many years. Yet, even with these successes, she struggled to lead an independent life as a young adult, which was a constant source of frustration for herself and her family. After attending the 8th WCPCCS and learning multiple mechanisms of neurodevelopmental injuries in fetuses and neonates with CHD, her mother expressed her wish that she had known about these findings earlier as it might have given her solace in understanding what her daughter’s body and brain had to overcome.

This interaction made me reflect on what we have recently learned about management of neonates with CHD. We are learning more about the impact of CHD on neurodevelopment, but without a clear one-size-fits-all answer for a better outcome. Even when children with CHD have normal intelligence quotients, they are at higher risks of executive function deficits or mental health issues.1 Many questions remain unanswered, but there are palpable efforts being made to answer them. Throughout the 8th WCPCCS, there were constant discussions on neonatal cardiovascular management. Not only was there a track dedicated to cardiovascular disease in the neonates, but there were also intriguing discussions on newborns from the perspectives of neurodevelopment, nursing care, and pulmonary hypertension. It was unmistakable that we have been pushing the boundaries to advance cardiac neonatal care, a few of which I would like to mention.

Dr. Paulomi Chaudhry at Indiana University highlighted the importance of taking multiple organ systems into consideration—including immature brain, kidney, gut, and adrenal glands—as we offer interventions on younger and smaller neonates. Catheter-based interventions in extremely low birth weight (ELBW) neonates have become more common. Leah Apalodimas, a pediatric interventional cardiology nurse practitioner at Le Bonheur Children’s Hospital, shared specific nursing challenges surrounding catheter interventions in ELBW from temperature control to positioning, demonstrating the importance of attention to detail.

Initiating enteral nutrition during the pre-operative period for neonates with left-sided obstructive lesions, once a taboo, has now become common practice. Julianna Amorese, a pediatric cardiac critical care nurse practitioner at John Hopkins Children’s Center, shared her Pediatric Cardiac Intensive Care Unit (PCICU)’s pre-operative feeding initiatives and guidelines which resulted in decreased length of stay. The discussion on enteral nutrition expanded to improving oral feeding and decreasing discharge with tube feeding throughout the conference.

There has been increasing interest in addressing neonatal pain and agitation while being mindful of the potential neurologic impact of pharmacologic interventions.2 Reducing opioid duration after neonatal cardiac surgery has played a prominent role. Dr. Barbara-Jo Achuff’s research demonstrated that protocolized opioid wean at Texas Children’s Hospital PCICU was associated with 65% shorter opioid duration in neonates after Norwood procedure.3 This echoed the outcomes of nurse-implemented, goal-directed pain and sedation management named Cardiac-RESTORE (Randomized Evaluation of Sedation Titration for Respiratory Failure) from Lincoln and colleagues at Boston Children’s Hospital PCICU published in 2020.4

The variety of these examples showed me that it takes multidisciplinary work to improve the overall outcome of children with CHD. With concerted efforts, the small advances we see today will have additive impacts on the neonates born tomorrow. I hope that the story from parents with CHD can move beyond “I wish I knew these earlier” to their children overcoming challenges and living fuller lives with higher potential.

References

  1. Feldmann M, Bataillard C, Ehrler M, Ullrich C, Knirsch W, Gosteli-Peter MA, Held U, Latal B. Cognitive and Executive Function in Congenital Heart Disease: A Meta-analysis. Pediatrics. 2021;148(4):e2021050875.
  2. McPherson C, Miller SP, El-Dib M, Massaro AN, Inder TE. The influence of pain, agitation, and their management on the immature brain. Pediatr Res. 2020;88(2):168-175.
  3. Achuff BJ, Lemming K, Causey JC, Sembera KA, Checcia PA, Heinle JS, Ghanayem NS. Opioid weaning protocol using morphine compared with nonprotocolized methadone associated With decreased dose and duration of opioid after Norwood procedure. Pediatr Crit Care Med. 2022;23(5):361-370.
  4. Lincoln PA, Whelan K, Hartwell LP, Gauvreau K, Dodsen BL, LaRovere JM, Thiagarajan RR, Hickey PA, Curley MAQ. Nurse-Implemented Goal-Directed Strategy to Improve Pain and Sedation Management in a Pediatric Cardiac ICU. Pediatr Crit Care Med. 2020;21(12):1064-1070.
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Minso Kim MD

Neonatal Cardiac Intensivist
UCSF Benioff Children’s Hospital