Date Presented 04/05/19
Primary Author and Speaker: Patty Coker-Bolt
Additional Authors and Speakers: Rachel Fleming, Evie Needle, Turki Aljuhani, Dorothea Jenkins
BACKGROUND: Infants born with congenital heart defects (CHD) post-cardiac surgery are at high risk of delays yet do not routinely undergo standard early assessment prior to hospital discharge due to poor tolerance to handling (Mussatto et al., 2014; Wray et al., 2018). Studies have reported that many infants with CHD do not receive early intervention services prior to 4 years due to lack of early assessment (Mussatto et al., 2018). The Specific Test of Early Infant Motor Performance (STEP) can predict motor and cognitive outcomes at 1 year in preterm infants (Gower, Jenkins, Fraser, Ramakrishnan, & Coker-Bolt, 2018), but has not been used with infants with CHD. Aim 1: determine the clinical utility of the STEP assessment when administered to high-risk, preterm, and CHD infants. Aim 2: determine if infants with CHD can tolerate STEP administered between term and 3 months. We hypothesized that infants with CHD could tolerate STEP assessment with no significant change in heart rate (HR) and O2 saturation (O2 Sats) before, during, and after STEP administration.
DESIGN/METHODS: Aim 1: prospective study with occupational therapists (OT) from the Medical University of South Carolina (MUSC) who use STEP clinically in newborn nurseries. Instrument: 10-question survey with Likert scale and open-ended questions regarding time to administer STEP, ease of interpretation, and flow of items. Data analyzed using descriptive statistics. Aim 2: prospective cohort study. Participants: infants with CHD born greater than 34 weeks gestation, pre or post-surgery recruited from the MUSC cardiac units. Data for HR and O2 Sats collected for 5 minutes before, during, and 5 minutes after STEP administration. Safety protocol implemented and if HR <100 bpm or O2 Sats <85% during STEP administration, testing paused until baseline vitals re-established. Data analyzed using repeated measures ANOVA.
RESULTS: Aim 1: Three OTs completed survey after administration of STEP to 18 infants (CHD, Hypoxic Ischemic Encephalopathy, prematurity). Therapists agreed to strongly agreed STEP was easy to learn, administer, and score. Therapists thought STEP was beneficial for identifying patterns of weakness. Therapists report the average time to administer STEP was 5-10 minutes for HIE/premature infants, but average time to administer STEP for infants with CHD was 15-20 min. due to reported “fragility of infants”. Aim 2: Five infants with CHD were enrolled, 4 were post-surgery. Mean age at cardiac surgery was 29.5 days, mean age at STEP administration was 37.5 days, and mean length of hospital stay was 54.6 days. Modifications were made to the STEP items for infants post-surgery. For example, to adhere to sternal precautions for the pull-to-sit item, the examiner transitioned infant from supine to sit by holding around trunk versus pulling on arms. Overall, minor modifications reduced avg. time to administer STEP to 10 min. There was no significant change in mean HR or O2 Sats 5 min. before, during, or 5 min. after STEP administration (p = 0.28; p=0.40 respectively).
CONCLUSION: The STEP has good clinical utility for high-risk, preterm, and CHD infants. Preliminary data revealed that infants with CHD tolerate the STEP post-surgery with minor modifications. Special considerations when assessing infants with CHD include monitoring fatigue, adhering to post-surgery precautions and administering assessment near discharge after feeds are well-established. We continue to enroll infants with CHD and will conduct long-term follow-up assessments of all infants at 1 year in our cardiology clinic.
IMPACT: Early identification of infants with delays can lead to earlier referrals for OT services and targeted intervention including education for families to promote family-centered care.
References
Gower, L., Jenkins, D., Fraser, J., Ramakrishnan, V., & Coker-Bolt, P. (2018). Early developmental assessment with a short screening test, the STEP, predicts one-year outcomes. Journal of Perinatology. doi.org/10.1038/s41372-018-0234-4.
Mussatto, K. A., Hoffmann, R. G., Hoffman, G. M., Tweddell, J. S., Bear, L., Cao, Y., & Brosig, C. (2014). Risk and prevalence of developmental delay in young children with congenital heart disease. PEDIATRICS, 133(3), e570-577. doi:10.1542/peds.2013-2309.
Mussatto, K., Hollenbeck-Pringle, D., Trachtenberg, F., Sood, E., Sananes, R., Pike, N., . . . Pemberton, V. (2018). Utilisation of early intervention services in young children with hypoplastic left heart syndrome. Cardiology in the Young, 28(1), 126-133. doi:10.1017/S104795111700169X.
Wray, J., Brown, K. L., Ridout, D., Lakhanpaul, M., Smith, L., Scarisbrick, A., . . . Hoskote, A. (2018). Development and preliminary testing of the Brief Developmental Assessment: An early recognition tool for children with heart disease. Cardiology in the Young, 28(04), 582-591. doi:10.1017/s1047951117002918.
