Assessment of Motor Development of Children with Congenital Heart Disease

Background: Children with congenital heart disease have a higher risk of presenting delay in development. This is why they must attend monitoring and assessment programs to identify such risks and for an early intervention. Objective: To assess the relationship between changes in the development of motor skills and congenital heart defects in children. Methods: Cross-sectional study with a quantitative approach involving 30 children of both sexes, with congenital heart disease. The motor development scale was used for the assessment of motor skills. Results: The motor skills assessed were found to be significantly below the normal average level (p<0.05). Three aspects of motor development revealed significant risk to development: body scheme, spatial organization and temporal organization. Conclusion: There was an association of abnormalities in the development of some motor aspects and the presence of congenital heart disease. It is essential to assess motor development from early childhood, considering the interference of clinical diagnosis and the need to monitor the development and any early intervention that may be required.


Introduction
Congenital cardiopathy is an abnormality in the structure or cardiovascular function that is present at birth, even if it is found out later.These congenital cardiovascular defects usually result from the abnormal embryonic development of a cardiovascular structure or lack of progression of such structure beyond an embrionary stage.¹Upon confirmation of clinical diagnosis of a congenital heart disease, the best course of action must be established and treatment must be initiated according to the health status of the patient, which may require catheterization or corrective heart surgery.²Young patients undergoing cardiac surgery have a higher risk of an impaired development, with repercussions throughout life.They may have cognitive and motor delay after cardiac surgery during childhood, with consequences in the final phase of childhood and adult life.³It is necessary, therefore, that children with congenital heart disease be included in monitoring and assessment programs to identify such risks and early intervention. 4owever, little has been invested in studies that reveal the impairments to the motor development of children with congenital heart diseases.
Motor development is considered an ongoing process resulting from interactions between the biological potentials genetically determined and environmental conditions, hence influenced by the interaction between individuals and the context in which they are inserted. 5e main causes of motor delay include low birth weight, respiratory and neurological disorders, neonatal infections, malnutrition, low socioeconomic status, prematurity and cardiovascular disorders. 6 these children present congenital heart diseases, they require special treatment and long hospital stays.It is important to identify whether beyond the limitations of the disease there are any motor problems associated.
This study aimed to evaluate the motor development of children with congenital heart diseases in ambulatory care and to assess the relationship between the development of motor skills and the presence of congenital heart diseases.

Methods
A cross-sectional quantitative study was conducted in outpatient facility of pediatric cardiology of Fundação Pública Estadual Hospital de Clínicas Gaspar Vianna, in Belém, PA, with children of both sexes, with congenital heart disease in ambulatory care.
This study has been approved by the Research Ethics Committee of the institution under no.015023/2015.All participants signed an Informed Consent Form according to Resolution CNS 466/12.

Fundação Pública Estadual Hospital de Clínicas Gaspar
Vianna is an institution of medium and high complexity that assists users of the Brazilian Public Healthcare System (SUS), from different specialties, particularly cardiology, nephrology and psychiatry, offering multidisciplinary care.The cardiology clinic of that institution has a large multidisciplinary team dedicated to monitoring pre-and post-operative care of children with congenital heart diseases.
The sample selection process was intentional, nonprobabilistic, including children of both sexes, with congenital heart diseases, followed up in the outpatient clinic of the institution.
According to the Clinical Archive Service of the institution, from January to September 2014, 133 children aged 0-12 underwent heart surgery, some of whom underwent more than one procedure.
The children were contacted by active search or during their visits to the Cardiopediatric Service from May to July 2015.There was parental consent and authorization of the medical staff.In this data collection period, 30 children aged 4-7 years were included in the study.
The Motor Development Scale (MDS) was applied to identify certain specific motor difficulties such as disturbances in motor coordination; specific disorders of psychomotor development and learning issues, testing: fine motor skills, global motor skills, balance, body scheme, spatial organization, temporal organization and laterality.This information helps developing more effective motor intervention and rehabilitation programs. 7cording to the MDS, the risk factors for children development are classified as: none, mild, moderate and severe (Chart 1). 8e tests were applied according to the children's chronological age.When they could not complete the stage, the test applicable to the immediately preceding age was applied.The skills were evaluated in the following sequence: fine motor skills, balance, body scheme, spatial organization, temporal organization and laterality.
Fine motor skills is the most frequent and most common human activity.It is used in the following activities: picking up an object, writing, drawing, transportation between hands, grabbing and manual handling, resulting in the interaction between object-eye-hand.It is a process of action related to the motor activity and visual stimulation.Motor skills take place progressively with the child's motor evolution and their learning. 7atial organization represents the physical relationship between the body and the environment.Sensory modalities, such as vision, hearing, touch, proprioception and smell are part of spatial perception.Temporal organization is described as the knowledge about the order and duration of temporary events, and perception and memory of duration of these events.It is essential when thought in combination with the learning process, as it facilitates the sequencing of actions, understanding contexts, sense of time and duration in the performance of activities. 8dy scheme is the association of environmental data and organization of sensations related to one's body, playing a key role in the child's development, allowing various possibilities of action. 7art 2 presents some terms that refer to the motor evaluation, which will be used for defining the motor profile of the children assessed.
MDS was applied in the outpatient facility, with a duration of 30 minutes.Considering the clinical diagnosis, resilience, fatigue, respiratory distress and the presence of cyanosis at the time of application of psychomotor battery, the MDS was partially used.Global motor skills were not evaluated.Some adjustments were necessary in the context of pediatric cardiology.The assessment produced a report that was submitted to those in charge and referrals were conducted when necessary.
Data were analyzed using the statistic software SPSS 18.0, drawing comparisons.
Motor age, motor quotient and motor profile were expressed in simple frequencies and percentages, maximum and minimum values, mean, standard deviation and Pearson correlation coefficient.The chi-square test was used to assess the relationship between congenital heart disease and psychomotor problems.

Results
30 children were evaluated: 53.3% males and 46,7% females.The main characteristics of this population are shown in Table 1.
The motor skills assessed, as measured using motor quotients, general motor ages and their classifications, according to a score evidencing developmental risk, are shown in Figure 1.
The general motor ages are classified as lower (between 70-79), indicating moderate risk to the development of the individuals assessed.
Therefore, the motor characteristics evaluated were found to be significantly below the normal average level (p <0.05) and revealed significant risk to development: body scheme (QM3), spatial organization (QM4) and temporal organization (QM5) (Figure 1).

Discussion
Most parents interviewed had only attended school until primary education, but some of them did not some factors are related to their development, such as the socioeconomic conditions. 9e results show that the motor quotients were developmental risk, revealing that the development of motor skills in children with congenital heart disease are at moderate risk for their development.
These findings confirm the study of Yilmaz et al. 10 who noted that motor delay can often be found in children with cyanotic congenital heart disease, for example.The authors indicate that these children can benefit from specific therapies that stimulate motor skills, language and educational therapies.Therefore, these children should be under regular monitoring for early detection of developmental problems.
When they present sensory, cardiac or respiratory difficulties, children may have difficulty with their own body or in the functional performance of daily activities, which may explain developmental risk results. 6 assessing a child's motor development, it can be seen that it can be influenced by several aspects, such as physiological, psycho-emotional and social conditions, and may or may not be according to their age group.
This study showed that MDS was sensitive enough to demonstrate the motor skills of the population tested, heterogeneous and with different congenital heart diseases.
In this study, children with congenital heart diseases are mostly with delayed motor development, with motor ages lower than expected, making it possible to associate these results to physiological factors, such as those found in cyanotic heart diseases, in which brain oxygenation becomes less efficient.
It is therefore necessary to provide early diagnosis of congenital heart diseases from an accurate prenatal examination to regular visits to the pediatrician.Once detected, it is essential to take action to initiate the treatment and minimize any future consequences and limitations for the children in their daily routine.complete primary education (53.3%) and they were responsible for looking after the children most of the time.Poor education is a factor that can influence the development of children with congenital heart disease, associated with motor performance below average (Table 2).
Motor development refers to changes in the child's performance skills, from birth to adulthood.It is related to both age and the environment.The larger the environment in which the child lives, the better exploited are their motor, cognitive and social skills.However, These results are also associated with low socioeconomic conditions, such as poor parental education, considered important factors that can influence the motor development of children, given the importance of providing kids with atmospheres that encourage exploring the environment in which they live.
Occupational therapists can provide advice and minimize these delays in motor development.As conducted in this study, some advice can be given to parents during the anamnesis, so that they can encourage and make the kid's environment favorable to the development of skills.
In addition to health education, occupational therapists must refer and direct the child with delayed motor development to the services that provide follow-up, appropriate stimulation and re-evaluation, to minimize the consequences for the remaining steps of development, for learning, socialization and adulthood.
Further studies are needed to evaluate the motor development of children with congenital heart disease with greater comprehensiveness, due to the relevance and impact of these skills for future life.

Conclusions
In this study, we observed relationship between abnormalities in the development of some motor aspects and the presence of congenital heart disease.It is essential to assess the motor development from early childhood, considering the interference of clinical diagnosis and the need to monitor development and promote any early interventions.

Figure 1
Figure 1 Motor quotients of the population studied Values expressed as mean±standard deviation 8

Table 1 General characteristics of the study population
*chi-square goodness of fit