Daryl Buchanan | News & Views

Exercise therapy is widely accepted as an excellent way to help adults recover from a medical heart emergency or surgery. However, cardiac rehabilitation (CR) treatment methods and standards of care specifically for the pediatric population have been slower to develop. Experts in the field say significant advances are being made, although there is a need for greater investment and collaboration among those who care for children with cardiac issues.

Adam Powell, MD, MS, FACC, Cincinnati Children’s Hospital Medical Center, and Alan Wang, MD, Mayo Clinic, want to shine a light on this vital segment of CR that is filling a gap for young patients.

The Challenges of Caring for Pediatric CR Patients

Powell says one of the primary causes of that gap is the difference between treating a child and an adult. In addition, the overall guidelines for pediatric CR are not as widely developed as they are for adults. “Prior to a stronger focus being placed on pediatric cardiac rehab programs, if a child was in a hospital they would get physical therapy and leave the hospital with instructions to be active and exercise. However, those patients may not have been told how to exercise — what form and amount of exercise is safe. Those are important things to know for a cardiac rehab patient,” says Powell.

He continues, “There was not a lot of investment in giving the patient everything they needed to know to stay healthy and active. So, pediatric exercise medicine as a whole was pretty limited.” He also notes that the medical guidance given to adults is not always applicable to children. For example, a doctor would not usually spend much time talking to a child with congenital heart disease about high blood pressure, high cholesterol, or the need to stop smoking.

Despite these challenges, Powell says the field has grown substantially over the years, especially when it comes to prescriptive exercise and providing customized wellness guidance. He estimates there are now about 30 to 35 pediatric fitness programs nationwide. Among them is Cincinnati Children’s Hospital Medical Center Patient’s individualized treatment plans include 36 total sessions, two to three sessions a week. Each session lasts an hour. The sessions also include a 10-minute warm-up stretch, 20 minutes of aerobics, 20 minutes of resistance, and a 10-minute cool down stretch,” states Powell.

However, evaluations are designed specifically for children. He says, “We are doing pediatric specific developmental screenings, mood and activity surveys, and age-appropriate physical assessments.” Some rehabilitation work is even camouflaged as a fun activity. An effort is also made to gamify exercises while still making sure patients are working towards their rehab goals.

This work may seem complicated because children may not initially understand the importance of their cardiac rehabilitation. But previous experiences have shown him that younger patients are often willing to take part in these programs.

Meeting Young Patients Where They Are Helps Facilitate Treatment

Powell says, “The nice thing about working with children is that they are still children and they want to be able to do things that other kids are doing. So, for younger kids in that 5- to 12-year-old range, it can be easy to get them invested in exercise or physical activity. This interest continues as they get older because they begin to set personal goals such as wanting to spend more time with friends or joining a high school athletic team.”

“When the older pediatric patients identify a goal it becomes easy to motivate them because we can then tailor a program to help them achieve their long-term fitness goals,” says Powell.

Wang, a board-certified pediatric cardiologist who has conducted extensive research on exercise in this patient population, adds that understanding the physical activity history of minor participants can help guide their rehabilitation and exercise programs.

“We’ll ask them what physical activities they enjoyed doing before their heart disease got worse. There are some who did cheerleading, soccer, or played basketball. For those who had a major surgery, a common goal is getting them healthy enough to play competitively or take part in more strenuous activities,” says Wang.

“Knowing what they liked to do and their hobbies is really helpful, because we can tailor their exercise plans. And helping meet these goals does not require major capital investment. It doesn’t cost a lot to get a basketball hoop or other athletic equipment to keep pediatric patients engaged.”

While progress is slowly being made on how pediatric cardiac rehabilitation patients are cared for, Powell and Wang say the field still needs more investment in research and funding.

That is particularly true, Wang adds, given the lack of consensus on a rehab model for children that may work better.

“There are no set standards in the U.S., or in the world, that establishes how we should be working to make sure kids are continuing to get better. So, one question that needs to be answered is what’s the structure of rehab? And, then, how do we measure that kids are getting better during and after rehab?” he elaborates.

Despite the lack of standardization, Wang says the field is moving in the right direction, as pediatric patients are making full recoveries and even reaching new physical potentials.

Wang says, “One of our main messages with kids during rehab is we want to see what your potential is. We tell them you did a lot of physical activity with a hole in your heart or heart disease. Now that we fixed it, you can do a lot better than what you were capable of. Once they are comfortable with rehab and exercise, we can see what that potential is and even exceed it. We are capable of getting patients well beyond their baseline before their operation or rehabilitation began.”