Cardiac Arrest in Children: Long-term Health Status and HRQoL
The target population consisted of 145 surviving patients who had survived to hospital discharge, of whom 13 (9%) had subsequently died and 25 (17%) who were lost to follow-up (Fig. 1). Causes of death after hospital discharge were another CA without ROSC (n = 3), underlying disease (n = 2), severe cerebral damage (n = 1), or unknown (n = 7).
(Enlarge Image)
Figure 1.
Flowchart of patient inclusion. The overall response rate was 53% (57/107). Lost to follow-up: moved abroad n = 7, untraceable n = 18. CHQ = Child Health Questionnaire, HUI = Health Utility Index, SF-36 = Short-Form 36.
The median follow-up interval of children visiting the outpatient clinic was 5.6 years (1.8–11.9 yr) with a median age at follow-up of 8.7 years (2.4–18.3 yr). Participants and nonparticipants differed significantly on SES (Table 1).
Neurologic impairments had developed in six of the 47 children (13%) after CA: n = 2 severe mental and physical retardation (n = 1 with epilepsy, n = 1 with visual impairments); n = 2 motor skill deficit; n = 1 quadriplegia with mental disability; and n = 1 epilepsy. Fourteen children (30%) still needed follow-up care by a rehabilitation physician, physiotherapist, speech therapist, and/or occupational therapist for physical impairments starting after the CA. One patient (2%) lived in a healthcare facility due to severe physical impairments. Chronic symptoms with onset after the CA were reported for 16 children (34%): n = 7 (15%) fatigue (mild to severe); n = 10 (21%) headache (mild to severe); n = 3 (6%) abdominal pain (moderate to severe). Permanent change in the child's behavior was reported in 15% of the children (n = 7) after CA, for example, changes from normal to more childlike, quieter, difficulties in emotional regulation, or severe mental and physical retardation. For 21 children, this was unknown, as they were very young at time of CA. Ten children (21%) had had professional assistance for emotional/behavioral problems. In total, seven children (15%) needed special education after CA, mostly due to behavioral problems or cognitive impairments. One child is not able to go to school due to severe mental and physical impairments.
Renal function was measured in 43 children (91%), in whom median eGFR was 122.0 mL/min/1.73 m (interquartile range [IQR], 109.1–134.5). Nine children (19%) had at least one symptom suggestive of CKD: n = 4 proteinuria (median, 36.0 mg/mmol; IQR, 29.4–60.9), n = 5 DBP and/or SBP above 95th percentile (n = 1 with proteinuria), n = 1 eGFR less than 90 mL/min/1.73 m (86 mL/min/1.73 m) (Supplemental Table 2, Supplemental Digital Content 2, http://links.lww.com/PCC/A169) for long-term outcome and related CA characteristics.
On HUI2, HUI3 attributes, and the overall HUI3 multiattribute, scores were significantly lower (medium and large effect sizes) compared with normative data, indicating poorer health status ( Table 2 ).
Parent-reported HR-QoL scores were significantly lower on role functioning (physical), general health perceptions, parental impact (emotion), and overall physical summary and significantly higher on family cohesion, when compared with normative data (small to large effect sizes) ( Table 3 ). Self-reports of children aged 12–17 years (CHQ-CF87) showed no significant differences with normative data ( Table 4 ).
Subanalysis directly comparing parents' results and children's results within the CPR population showed no differences. Subanalysis to test differences between in-hospital CA and out-of-hospital CA on HR-QoL outcomes is shown in Supplemental Table 3 (Supplemental Digital Content 3, http://links.lww.com/PCC/A170).
The median age of parents was 40 years (range, 22–60 yr). On semistructured questions during the interview at the outpatient clinic, nine of 47 parents (19%) reported limitations in their daily activities (e.g., job, holidays, hobbies, and social visits) after the CA.
On HR-QoL, parents showed a better physical functioning, general mental health, social functioning, physical and emotional role functioning, and less bodily pain, when compared with normative data (small and medium effect sizes) ( Table 5 ).
Univariate analysis of the neurologic impairments, renal impairments, and CA-induced behavioral changes showed no significant relationship with predictor variables. Children with chronic symptoms had BLS (no APLS) more often (chi-square = 4.691; p = 0.037).
On the HUI, males scored worse than females on both cognition scores (HUI3: z = –2.320, p = 0.033; HUI2 z = –2.468, p = 0.024) and the HUI3 multiattribute score (z = –2.418, p = 0.016). On the CHQ-PF50, CA-related preexisting condition was associated with worse patients' general health perceptions (z = –2.443, p = 0.015) and physical summary (z = –2.003, p = 0.045). Family cohesion was significantly worse in children with an out-of-hospital CA (z = –2.264, p = 0.024). On the SF-36, parents' physical functioning was significantly worse when their child had an out-of-hospital CA (z = –2.049, p = 0.040). Social functioning was significantly higher in parents with a high SES compared with those with a middle SES (chi-square= 7.024, p = 0.030).
Results
Patient Sample
The target population consisted of 145 surviving patients who had survived to hospital discharge, of whom 13 (9%) had subsequently died and 25 (17%) who were lost to follow-up (Fig. 1). Causes of death after hospital discharge were another CA without ROSC (n = 3), underlying disease (n = 2), severe cerebral damage (n = 1), or unknown (n = 7).
(Enlarge Image)
Figure 1.
Flowchart of patient inclusion. The overall response rate was 53% (57/107). Lost to follow-up: moved abroad n = 7, untraceable n = 18. CHQ = Child Health Questionnaire, HUI = Health Utility Index, SF-36 = Short-Form 36.
The median follow-up interval of children visiting the outpatient clinic was 5.6 years (1.8–11.9 yr) with a median age at follow-up of 8.7 years (2.4–18.3 yr). Participants and nonparticipants differed significantly on SES (Table 1).
Health Status at Follow-up
Neurologic impairments had developed in six of the 47 children (13%) after CA: n = 2 severe mental and physical retardation (n = 1 with epilepsy, n = 1 with visual impairments); n = 2 motor skill deficit; n = 1 quadriplegia with mental disability; and n = 1 epilepsy. Fourteen children (30%) still needed follow-up care by a rehabilitation physician, physiotherapist, speech therapist, and/or occupational therapist for physical impairments starting after the CA. One patient (2%) lived in a healthcare facility due to severe physical impairments. Chronic symptoms with onset after the CA were reported for 16 children (34%): n = 7 (15%) fatigue (mild to severe); n = 10 (21%) headache (mild to severe); n = 3 (6%) abdominal pain (moderate to severe). Permanent change in the child's behavior was reported in 15% of the children (n = 7) after CA, for example, changes from normal to more childlike, quieter, difficulties in emotional regulation, or severe mental and physical retardation. For 21 children, this was unknown, as they were very young at time of CA. Ten children (21%) had had professional assistance for emotional/behavioral problems. In total, seven children (15%) needed special education after CA, mostly due to behavioral problems or cognitive impairments. One child is not able to go to school due to severe mental and physical impairments.
Renal function was measured in 43 children (91%), in whom median eGFR was 122.0 mL/min/1.73 m (interquartile range [IQR], 109.1–134.5). Nine children (19%) had at least one symptom suggestive of CKD: n = 4 proteinuria (median, 36.0 mg/mmol; IQR, 29.4–60.9), n = 5 DBP and/or SBP above 95th percentile (n = 1 with proteinuria), n = 1 eGFR less than 90 mL/min/1.73 m (86 mL/min/1.73 m) (Supplemental Table 2, Supplemental Digital Content 2, http://links.lww.com/PCC/A169) for long-term outcome and related CA characteristics.
Questionnaires: Children's Outcome
On HUI2, HUI3 attributes, and the overall HUI3 multiattribute, scores were significantly lower (medium and large effect sizes) compared with normative data, indicating poorer health status ( Table 2 ).
Parent-reported HR-QoL scores were significantly lower on role functioning (physical), general health perceptions, parental impact (emotion), and overall physical summary and significantly higher on family cohesion, when compared with normative data (small to large effect sizes) ( Table 3 ). Self-reports of children aged 12–17 years (CHQ-CF87) showed no significant differences with normative data ( Table 4 ).
Subanalysis directly comparing parents' results and children's results within the CPR population showed no differences. Subanalysis to test differences between in-hospital CA and out-of-hospital CA on HR-QoL outcomes is shown in Supplemental Table 3 (Supplemental Digital Content 3, http://links.lww.com/PCC/A170).
Health Status and HR-QoL in Parents
The median age of parents was 40 years (range, 22–60 yr). On semistructured questions during the interview at the outpatient clinic, nine of 47 parents (19%) reported limitations in their daily activities (e.g., job, holidays, hobbies, and social visits) after the CA.
On HR-QoL, parents showed a better physical functioning, general mental health, social functioning, physical and emotional role functioning, and less bodily pain, when compared with normative data (small and medium effect sizes) ( Table 5 ).
Predictors of Health Status and HR-QoL in Children and Parents
Univariate analysis of the neurologic impairments, renal impairments, and CA-induced behavioral changes showed no significant relationship with predictor variables. Children with chronic symptoms had BLS (no APLS) more often (chi-square = 4.691; p = 0.037).
On the HUI, males scored worse than females on both cognition scores (HUI3: z = –2.320, p = 0.033; HUI2 z = –2.468, p = 0.024) and the HUI3 multiattribute score (z = –2.418, p = 0.016). On the CHQ-PF50, CA-related preexisting condition was associated with worse patients' general health perceptions (z = –2.443, p = 0.015) and physical summary (z = –2.003, p = 0.045). Family cohesion was significantly worse in children with an out-of-hospital CA (z = –2.264, p = 0.024). On the SF-36, parents' physical functioning was significantly worse when their child had an out-of-hospital CA (z = –2.049, p = 0.040). Social functioning was significantly higher in parents with a high SES compared with those with a middle SES (chi-square= 7.024, p = 0.030).
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