Abstract
Objective
This study aimed to explore the effect of telehealth education on improving the parental care ability and postoperative nutritional status of infants after congenital heart disease surgery.
Methods
A prospective randomized controlled study was conducted at a provincial maternal and child hospital in southeastern China. A total of 84 infants were enrolled in the study, with 42 infants in the intervention group and 42 infants in the control group.
Results
Body weight, albumin, prealbumin, and hemoglobin of infants in the intervention group were significantly higher than those in the control group one month after discharge (P<0.05). The STRONGkids score of infants in the intervention group was significantly higher than that of those in the control group one month after discharge (P<0.05). The Family Caregiver Task Inventory score of infants in the intervention group was significantly lower than that of those in the control group one month after discharge (P<0.05).
Conclusion
Performing telehealth education about home feeding and care guidance for parents of infants after congenital heart disease surgery can greatly improve parental care ability so that infants get better feeding and care, which can effectively improve the postoperative nutritional status of the infants.
Keywords: Care ability, Congenital heart disease, Nutritional status, Telehealth education, WeChat
Congenital heart disease (CHD) accounts for one-third of all major congenital structural abnormalities worldwide (1). Due to cardiac insufficiency caused by haemodynamic abnormalities of CHD, infants experience malnutrition before surgery caused by feeding difficulties, limited food intake, and intestinal barrier dysfunction. After CHD surgery, the state of malnutrition for infants worsens due to the trauma associated with the operation and cardiopulmonary bypass, high metabolism state, and high energy expenditure (2–7).
After CHD surgery, infants experience a long recovery period, and complications in the postoperative period occur early. Thus, it is more difficult to care for infants at home, and most parents experience difficulties feeding and caring for infants after CHD surgery (8,9). The lack of knowledge about CHD and at home care among parents is an important cause of difficulties associated with the postoperative care of infants with CHD and an important factor that exacerbates postoperative malnutrition (10). Parents of infants who undergo CHD surgery are eager to obtain professional guidance and support from medical staff when their infants are discharged to improve their caring ability and nutritional status of their infants early after surgery. Many studies have shown that it is simple and easy to provide health education via telemedicine and that this method can effectively improve the level of family care, reduce complications, and improve the prognosis of patients (11–13). Our previous studies have shown that telehealth education via WeChat can effectively improve the preoperative care ability of parents of children with CHD; thus, children can obtain better preoperative care and reduce preoperative complications (14,15). To investigate whether telehealth education via WeChat can improve the parental care ability and postoperative nutritional status of infants after CHD surgery, we conducted a prospective randomized controlled study.
METHOD
This study was approved by the ethics committee of the hospital and strictly adhered to the tenets of the Declaration of Helsinki (Code of Ethical approval for scientific research project: 2019 Ethical Scientific Research Approval No. 2020KY039). In addition, all patients’ guardians signed an informed consent form before the study.
Research design
A prospective randomized controlled study was conducted at a provincial maternal and child hospital in southeastern China from January 2020 to November 2020. Based on the weight difference of infants between the two groups in the pre-experiment (the intervention group: 6.73±1.44 kg versus the control group: 5.82±1.32 kg) and assuming that the alpha value was set at 0.05 with a power of 80%, the required number of participants was calculated to be 38 in each group. Assuming a 10% missing rate, the total sample size was set as 84 (42 per group). Participants who were eligible were randomized to either the intervention group or the control group by an independent member of our research team using a 1:1 randomization ratio based on computer-generated random numbers and a randomization list blinded to the researchers (Figure 1).
Figure 1.
The framework of the study.
The clinical background characteristics included RACHS-1 category (16), which is a risk-predicting scoring system for congenital heart surgery and is based on age, surgical procedure, major noncardiac structural anomaly, prematurity, and a combination of cardiac surgical procedures at a single operation. After discharge, all patients were treated with 1 mg/kg.d hydrochlorothiazide for one month without taking iron or other drugs that affected their nutritional status.
The inclusion criteria were as follows: (1) infants after CHD surgery; (2) parents serve as the primary caregivers; (3) parents with smartphones who could use WeChat correctly; and (4) convenient access to the Internet at home. The exclusion criteria were as follows: (1) other serious diseases; (2) postoperative death; and (3) refusal to participate in the study or follow-up plan.
Telehealth education tool
We used WeChat to provide telehealth education. WeChat (Tencent Ltd., Shenzhen, China) is a popular smartphone-based social media application that is similar to Facebook, Twitter, and WhatsApp. WeChat is a convenient and intuitive method of information exchange, and it integrates various functions, such as graphics, text, audio, and video to maximize information coverage.
Intervention methods
Parents in the intervention group were provided with remote health education and feeding guidance via WeChat. At the time of discharge, parents were guided to join the WeChat platform, and taught to use WeChat functions correctly and skillfully by the doctor. The health education content in the WeChat group mainly included two parts: education module and question and answer module. (1) The education module included related knowledge of CHD disease, postoperative care, family care and feeding, and the management of complications. Parents could view it and learn at any convenient time. (2) Question and answer module: one medical staff on our team was on duty every day, and he was online in the WeChat group at 18:00 to 21:00 to explain parents’ problems. The medical staff also guided the family members in the WeChat group to communicate, discuss, and share the care experience and encourage each other actively.
Parents in the control group were provided with health education and feeding guidance based on outpatient follow-up. They obtained a leaflet that contained the same educational information as the intervention group at the time of discharge. At the time of discharge, we gave the parents an introduction regarding what was on the leaflet, and told parents to study it at home. When they had problems, they could refer to the leaflet to find solutions or go to our outpatient centre for consultation, and they were also told to visit the hospital immediately in the event of an emergency.
Research tool
Family Caregiver Task Inventory (FCTI): The FCTI scale was compiled by Clark et al. The scale consists of 25 items and includes five dimensions: adapting to care roles, responding and providing assistance, addressing personal emotional needs, assessing family and community resources, and adjusting personal life and care needs. Each entry is assessed based on the Likert 3-grade scoring method: 0 points indicates not difficult, 1 point indicates difficult, and 2 points indicates extremely difficult. The total score of the scale is 50 points. The higher the score, the more difficulties the caregiver faces, and the lower the care ability (17).
The STRONGkids scoring scale was developed by Hulst et al. for nutritional status assessment. The scale accounts for various factors, such as high-risk diseases, subjective clinical assessment, nutritional intake or loss, and a decrease or no increase in body weight. The content of subjective clinical assessment includes the loss of subcutaneous fat or muscle and face thinness. The nutritional intake or loss content includes the following problems: (1) In recent days, defecation has occurred more than four times/day or vomiting has occurred more than three times/day; (2) Active feeding has decreased in recent days; (3) Lack of adequate intake due to pain. The scoring standard is 2 points for high-risk diseases, 1 point for subjective clinical assessment, 1 point for nutritional intake or loss, and 1 point for decrease or no increase in body weight. The total score ranges from 0 to 5 points. A score of 0 to 1 points indicates low nutritional risk, 2 to 3 points indicates moderate nutritional risk, and 4 to 5 points indicates moderate nutritional risk (18).
Statistical analysis
We use SPSS25.0 software for statistical analysis. Continuous data were presented as mean± standard deviation and range. Clinical parameters between the two groups were compared with the independent samples t-test. And the χ 2 or Fisher’s test to categorical variables. A P value of <0.05 was defined as statistical significance.
RESULTS
No significant difference in the clinical data of infants (including age, sex, weight, disease, albumin, prealbumin, haemoglobin, and STRONGkids score) or parents’ general data (including age, education level, family income, living environment, and FCTI score) were noted between the two groups at the time of discharge (P<0.05). There was no significant difference in postoperative complications between the two groups. These findings indicate that the dates of the two groups were homogenous and comparable between groups (Table 1).
Table 1.
Comparison of general date of infants and parents in the two groups at discharge
| Intervention group | Control group | P value | |
|---|---|---|---|
| Demographic data of infants | |||
| Age (month) | 3.3±3.1 | 3.6±3.3 | 0.216 |
| Boys/girls | 24/18 | 23/19 | 0.826 |
| Data about the infant’s cardiac condition | |||
| Diseases | |||
| Ventricular septal defect | 24 | 25 | 0.976 |
| Patent ductus arteriosus | 8 | 9 | |
| Pulmonary stenosis | 3 | 4 | |
| Tetralogy of fallot | 2 | 1 | |
| Endocardial cushion defect | 2 | 1 | |
| Total anomalous pulmonary venous connect | 2 | 1 | |
| Aortic arch interrupt | 1 | 1 | |
| RACHS-1 category | 0.959 | ||
| Risk category 1 | 6 | 8 | |
| Risk category 2 | 32 | 31 | |
| Risk category 3 | 1 | 1 | |
| Risk category 4 | 2 | 1 | |
| Risk category 5 | 1 | 1 | |
| Risk category 6 | 0 | 0 | |
| Preoperation nutritional data | |||
| Weight (kg) | 5.3±1.5 | 5.6±1.8 | 0.463 |
| Infants’ STRONGkids score | 3.5±1.0 | 3.6±0.7 | 0.836 |
| Albumin (g/L) | 33.2±3.4 | 32.8±4.6 | 0.763 |
| Prealbumin (mg/L) | 163.2±19.3 | 171.6±21.8 | 0.605 |
| Hemoglobin (g/L) | 108.6±9.6 | 110.7±10.5 | 0.688 |
| Surgical complications | |||
| Heart failure | 1 | 2 | 0.557 |
| Arrhythmology | 5 | 3 | 0.457 |
| Low cardiac output syndrome | 2 | 3 | 0.645 |
| Pneumonia | 18 | 15 | 0.503 |
| Liver dysfunction | 3 | 2 | 0.645 |
| Renal insufficiency | 1 | 2 | 0.557 |
| Gastrointestinal hemorrhage | 0 | 0 | - |
| Postoperation nutritional data | |||
| Weight at discharge(kg) | 5.2±1.8 | 5.4±2.1 | 0.345 |
| Albumin at discharge (g/L) | 36.1±4.6 | 35.3±5.2 | 0.734 |
| Prealbumin at discharge (mg/L) | 170.5±27.5 | 183.4±22.6 | 0.582 |
| Hemoglobin at discharge (g/L) | 115.3±11.6 | 112.3±14.2 | 0.623 |
| Infants’ STRONGkids score | 3.6±1.1 | 3.7±0.9 | 0.864 |
| Demographic and socio-economic data of parents | |||
| Age of parents (year) | 28.5±5.2 | 28.7±7.6 | 0.566 |
| Education level | |||
| Under high school | 6 | 7 | 0.972 |
| High school | 18 | 16 | |
| Junior college | 13 | 14 | |
| Bachelor degree or higher | 5 | 5 | |
| Income level of family | |||
| Low income | 16 | 18 | 0.902 |
| Middle income | 17 | 16 | |
| High income | 9 | 8 | |
| Living condition | |||
| Rural area | 29 | 27 | 0.643 |
| City | 13 | 15 | |
| Parents’ FCTI score | 38.6±6.1 | 37.4±7.8 | 0.452 |
All infants in the two groups were followed up one month after discharge. The body weight, albumin, prealbumin, and haemoglobin of infants in the intervention group were significantly higher than those in the control group 1 month after discharge (P<0.05). The STRONGkids score of infants in the intervention group was significantly higher than that of those in the control group one month after discharge (P<0.05). Compared with the STRONGkids score at the time of discharge, the score of infants in the intervention group one month after discharge improved significantly (P<0.05), but the scores of infants in the control group were similar (P>0.05). The FCTI score of infants in the intervention group was significantly lower than that of those in the control group one month after discharge (P<0.05). Compared with the FCTI score at the time of discharge, the score of infants in the intervention group one month after discharge descended significantly (P<0.05), but the infants in the control group were similar (P>0.05) (Table 2).
Table 2.
Comparison of nutritional status of infants and parents’ FCTI score in the two groups at one month after the discharge
| Intervention group | Control group | P value | |
|---|---|---|---|
| Weight (kg) | 6.6±1.7 | 5.9±1.9 | 0.033 |
| Albumin (g/L) | 44.8±4.5 | 38.2±5.4 | 0.035 |
| Prealbumin (mg/L) | 254.6±30.2 | 203.5±28.2 | 0.027 |
| Hemoglobin (g/L) | 125.6±12.2 | 116.1±11.7 | 0.036 |
| Infants’ STRONGkids score | 1.8±0.8 | 3.1±1.0 | 0.021 |
| Parents’ FCTI score | 23.1±5.2 | 33.8±7.5 | 0.019 |
DISCUSSION
With the development of medical technology over the past two decades, the outcome of surgery for CHD in infants has improved significantly, and long-term survival has also improved significantly (19). However, malnutrition remains a common problem in infants with CHD, especially in developing countries due to the lack of basic medical care. The problem of malnutrition in infants with CHD is more serious with an incidence of 50% to 90% (20–22). The problem of malnutrition is more serious in infants after CHD surgery at discharge than preoperation due to postoperative fluid limitation, the use of diuretics, and high metabolic status (23). Adequate nutrition is essential for growth and development, wound healing, immune function and intellectual development (24,25). Therefore, it is very important to improve the nutritional status of infants after CHD surgery.
The study showed that the greatest catch-up time of weight in infants after CHD surgery was the first year after surgery (26). Therefore, improving the nutritional status of infants after CHD surgery in the early postoperative period is very important to achieve weight and growth catch-up. Infants are discharged from the hospital as soon as cardiac function is restored and infection is controlled. Thus, the family home is the main location for catch-up growth, and parents are the main implementers. Many studies have shown that among factors causing malnutrition in infants after CHD surgery, poor feeding, and care of the caregivers are important factors. The study of Wei et al. showed that concern about feeding behaviour of children with CHD brought great pressure to the family due to the severity of the disease (27). Medoff-Cooper et al. reported that once the infant survives surgery, weight growth becomes the most obvious stressor for the parents (28).
Although medical staff provided health education and feeding guidance to parents and distributed a variety of educational materials before children were discharged from hospital, most parents could not effectively grasp the knowledge of child care, and their care ability was insufficient given their low education level. This would lead to infants not receiving sufficiently effective care, which was not conducive to early improvements in the postoperative nutritional status of children.
Numerous studies have shown that telemedicine can extend high-quality treatment from the hospital to families, which has the advantages of reducing time consumption, reducing economic costs, improving treatment compliance, reducing complications, and improving the patient’s condition (11–13). WeChat is the most popular and widely used social media app in China with 1.12 billion users (29). To explore the effect of telehealth education via WeChat on improving parental care ability and postoperative nutritional status of infants after congenital heart disease surgery, we conducted a prospective randomized controlled study. The results of our study showed that after one month of intervention, nutrition indicators (including weight, albumin, prealbumin, haemoglobin, and STRONGkids score) and parental FCTI score in the intervention group were significantly better than those in the control group. After one month of intervention, the nutritional indexes and parents’ care ability in the intervention group were significantly improved compared with those at discharge time. However, there was no significant change in the control group. This finding indicated that the implementation of remote health education via WeChat can effectively improve parents’ care ability of infants after CHD surgery, which was conducive to improving the early nutritional status of infants. This finding was attributed to the fact that parents in the intervention group could acquire knowledge about CHD, postoperative nursing, home care, home feeding, and complications from the WeChat education module anytime and anywhere. Once parents encounter a problem, they can ask medical staff in the WeChat group or other parents with experience for help. Parents can obtain professional medical support more easily, effectively and continuously. Thus, care ability is effectively improved via WeChat. Thus, infants can obtain a better quality of home care, and the early postoperative nutritional status is naturally improved.
Although telehealth management can provide medical services very conveniently and effectively, which is beneficial for home care, it cannot replace face-to-face care. The information obtained by such telemedicine is not as rich and accurate as that obtained by face-to-face follow-up. In the face of any vague or suspicious information or patients with serious symptoms, patients should be called into the hospital. There were some limitations of this study. First, some patients could not be included due to poor Internet support, especially in remote rural areas of China. Second, this was a single-centre study.
CONCLUSION
Providing telehealth education to facilitate home feeding and to provide care guidance for infants after CHD surgery can greatly improve the ability of parents to provide care. Thus, infants can obtain better feeding and care, and their nutritional status can be effectively improved.
ACKNOWLEDGEMENTS
We appreciate all doctors in our centre for providing fruitful advice and discussions. We hope humans eventually defeat COVID-19.
Contributor Information
Qi-Liang Zhang, Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China; Fujian Branch of Shanghai Children’s Medical Center, Fuzhou, China; Fujian Children’s Hospital, Fuzhou, China; Fujian Key Laboratory of Women and Children’s Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China.
Yu-Qing Lei, Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China; Fujian Branch of Shanghai Children’s Medical Center, Fuzhou, China; Fujian Children’s Hospital, Fuzhou, China; Fujian Key Laboratory of Women and Children’s Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China.
Jian-Feng Liu, Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China; Fujian Branch of Shanghai Children’s Medical Center, Fuzhou, China; Fujian Children’s Hospital, Fuzhou, China; Fujian Key Laboratory of Women and Children’s Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China.
Qiang Chen, Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China; Fujian Branch of Shanghai Children’s Medical Center, Fuzhou, China; Fujian Children’s Hospital, Fuzhou, China; Fujian Key Laboratory of Women and Children’s Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China.
Hua Cao, Department of Cardiac Surgery, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China; Fujian Branch of Shanghai Children’s Medical Center, Fuzhou, China; Fujian Children’s Hospital, Fuzhou, China; Fujian Key Laboratory of Women and Children’s Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China.
ETHICS APPROVAL AND CONSENT TO PARTICIPATE
This study was approved by the hospital’s ethics committee and strictly adhered to the tenets of the Declaration of Helsinki (Code of Ethical approval for scientific research project:2019 Ethical Scientific Research Approval No. 2020KY039). In addition, all patients’ guardians signed an informed consent form before the study.
AUTHOR CONTRIBUTIONS
ZQL and CH designed the study, collected the clinical data, performed the statistical analysis, participated in the operation, and drafted the manuscript. LYQ, LJF, and CH participated in the operation and revised the article.
CONSENT FOR PUBLICATION
All authors read and approved the final manuscript and publication.
FUNDING
There are no funders to report.
POTENTIAL CONFLICTS OF INTEREST
All authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
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