EXPERIMENTAL AND CLINICAL TRANSPLANTATION

Objectives: Organ transplant is a vital treatment for pediatric patients. Kidney, liver, heart, and other organ transplants can significantly improve the quality of life for children with various chronic diseases and can improve long-term survival rates. However, the effects of transplant on cognitive and educational aspects should be considered, including the effects of pre- and posttransplant treatment protocols, medications, psychosocial stress, and surgical interventions. Learning disabilities can negatively affect the child's educational life, social relationships, and overall quality of life. We aimed to examine the prevalence of learning difficulties after organ transplant, the influencing factors, and the interventions aimed at solving these problems by conducting a systematic review of existing research on learning difficulties associated with pediatric organ transplant.
Materials and Methods: For this systematic review, We searched PubMed, Cochrane, Web of Science, Science Direct, and Scopus databases to examine studies conducted during the past decade. We used the key words organ transplantation, pediatrics, and learning disabilities for our search. We included English language, full-text articles in the study; meta-analyses, systematic reviews, and case reports for which the full text was not available in English were excluded from the study.
Results: Among an initial search result of 174 articles, 4 met the inclusion criteria. Across all studies, a consistent observation emerged that indicated a decline in neurocognitive functions among children who had undergone organ transplant. Specific areas affected included verbal intelligence, memory, reading/spelling skills, mathematical ability, motor skills, attention, and memory, collectively contributing to learning difficulties.
Conclusions: In light of the findings, minimizing learning difficulties in children after organ transplant necessitates strategies such as reducing transplant waiting times, seamlessly integrating children into the posttransplant school environment, and implementing specialized programs within educational institutions.

Key words : Cognitive ability, Education placement, Intellectual ability

Today, organ transplantation, which is a life-saving treatment method for pediatric patients, has a history of approximately 50 years. Because childhood is a period of neurological and cognitive development, the consequences of chronic organ failure in children are more complex.¹ The first examples of pediatric organ transplant, which started to develop in Turkey after the 1990s, were successfully performed by Prof. Dr. Mehmet Haberal and his team.² Organ transplants increase survival and quality of life.³

However, organ transplants affect individuals physiologically, psychologically, and socially. In addition, organ transplants in children also affect their growth and learning development.⁴ During the posttransplant period, attention to cognitive and educational processes in children is important, for the child's future, professional potential, and quality of life.⁵ A learning disability is seen when there is a disorder in one or more of the basic psychological processes that require understanding and using written and spoken words that are not related to mental, visual, hearing, or any other form of disability. Learning disabilities may occur in children with attention deficit, weakening of long-term memory, decreased processing speed, decreased mathematical skills, slowing of auditory-thought-speech, and reading and spelling skills.⁶

Studies have shown that children who have had organ transplant experience learning difficulties because of changes in their cognitive processes.^7-12 Learning difficulties in children undergoing organ transplant may be the result of pretransplant infections, increased chemical levels in the bloodstream as a result of organ failure, growth retardation, malnutrition, circulatory disorders, severity and complexity of chronic diseases, complications of the surgical procedure, duration of hospitalization after surgery, and intensive medical care.^5,13 In addition to these, the child's age at transplant and whether the child has started school and the child's family, environment, and socioeconomic status may also affect learning difficulties in children who need or who have had organ transplant.^3,9,14,15

In this study, studies conducted in the past 10 years on learning difficulties in children with organ transplant were reviewed.

Materials and Methods

The Preferred Reporting Items for Systematic Reviews and Meta Analysis (PRISMA) Checklist and Cochrane Guidelines were taken into consideration during our review process.^16,17

For this systematic review, we retrospectively examined studies published in English language between January 2013 and December 2023. We used the PubMed, Scopus, Science Direct, Web of Science, and Cochrane data bases. We used the following key words: “pediatric,” AND “organ transplantation,” AND “learning disabilities.” During the search, we applied the time period for publication and other such filters. This was a subject-specific search; we ultimately selected 4 published papers during our search.

Selection criteria

Filters were applied based on study inclusion or exclusion criteria. The authors assessed all the abstracts in terms of the following inclusion criteria: (1) subjects were individuals under 18 years of age who had transplants or were awaiting transplant, (2) research was descriptive with full text available online in English, and (3) studies were published in peer-reviewed journals from January 2013 through December 2023.

We excluded the following studies: (1) studies that were not descriptive (eg, thesis, dissertations, letters to the editor, committee reports, government reports, conference papers, systematic reviews), (2) not directly relevant and repetitive studies, (3) studies for which the full text was not available, and (4) studies with subjects ≥18 years of age who had transplant or were awaiting transplant.

We used the Population, Intervention, Control, Outcome, and Studies strategy for data search. Our research questions were formed as follows: population = sample group/population, intervention = intervention, control = comparison, outcome = result, study = study design, with population including sample characteristics and size of each study included in the review, outcome being learning difficulties experienced after pediatric transplant, and studies being 2 cross-sectional, 1 longitudinal, and 1 descriptive in design. Included studies are listed in Table 1.

Ethics committee approval was not required for this study, as the research articles included in the sample were obtained from open-source electronic databases accessible to the researchers during the study.

Statistical analyses

No statistical analyses were performed because the accepted articles did not meet the meta-analysis conditions.

The literature review on key words retrieved 174 studies. Of the 174 studies, 127 were not duplicates. The authors evaluated the titles and abstracts of the remaining 127 articles, and 103 of these were excluded because of nonconformity to the inclusion criteria. After the full-text review process of the remaining 24 studies, 12 were excluded because of limitations to reach full details of the research and 8 were excluded because they were not directly relevant. Finally, 4 studies were included in the current systematic reviews (Figure 1). The researchers used the PRISMA flowchart to control the study.

The studies examining learning disabilities experienced after pediatric organ transplant were conducted in Australia (n = 1), the United States (n = 2), and Canada (n = 1). Sample sizes of the included studies ranged from 25 to 1495.^9,12 Study samples consisted of pediatric patients with solid organ (heart, liver) transplant.^7,9,11,12 Age at transplant ranged from 5 to 18 years, and duration of posttransplant follow-up ranged from 1 to 4 years.

The included studies examined learning problems experienced by pediatric organ transplant recipients, children's academic achievements, cognitive and intellectual abilities, intelligence levels, and learning capacities. In addition, the effects of pretransplant and posttransplant factors, including wait time for transplant, disease severity, time elapsed posttransplant, incidence of infections, and duration of stay in the pediatric intensive care unit, on learning difficulties were also assessed.^7,9,11,12 Table 1 lists the results and summary characteristics of the studies included in this systematic review.

This systematic review focused on learning difficulties associated with pediatric organ transplant. Organ transplants in children, particularly liver and heart transplants, significantly affect long-term health outcomes of recipients. Cognitive functioning and academic achievement are critical areas also affected by these procedures. Research has indicated that, after transplant, children often exhibit reduced intellectual capacity and lower performance in mathematical, verbal, and cognitive domains compared with their peers. Furthermore, the side effects of certain medications can impair cognitive functions, further limiting learning abilities. These effects result in both early-onset and late-onset learning difficulties after transplant.

Children with learning disabilities typically achieve lower academic results throughout their educational journey. Such declines in academic performance can also negatively influence social interactions and self-esteem. The inability to compete academically with peers may lead to feelings of isolation and reduced self-worth. In addition, learning disabilities can profoundly affect overall quality of life and adherence to treatment protocols. Therefore, addressing learning difficulties is considered crucial among the potential complications following transplant, underscoring the need for targeted educational support and interventions.

Studies have indicated diminished cognitive and intellectual abilities in children following transplant.^7,9,11,12 Afshar and colleagues⁷ evaluated the intellectual and academic achievement outcomes of children after liver transplant. The research also assessed the effects of factors such as wait time for transplant, duration of stay in the pediatric intensive care unit, and the time elapsed posttransplant on intellectual and academic performance. The findings revealed that children who underwent liver transplant exhibited lower intelligence quotients, verbal intellectual abilities, and perceptual reasoning capabilities compared with the healthy population. Pediatric transplant recipients also performed significantly worse in mathematics and demonstrated poorer overall intellectual outcomes. In addition, longer times posttransplant were associated with decreased verbal intelligence and processing speeds. Extended waiting periods for organ transplant adversely affected verbal intellectual abilities, mathematical skills, and word reading capabilities. Furthermore, prolonged stays in the pediatric intensive care unit correlated with lower mathematical performance.⁷

In another study, cognitive and academic outcomes of pediatric liver transplant recipients were examined. The investigation reassessed cognitive functions at 2 years posttransplant of patients aged 5 and 6 years who had undergone liver transplant. At 2 years after transplant, children exhibited lower verbal comprehension and math skills, posing a high risk for enduring cognitive and academic deficits. The study also suggested that a variety of factors, including pretransplant conditions such as nutritional and growth deficits and the severity of liver disease, as well as peritransplant and posttransplant complications, ongoing medical complications, and prolonged exposure to calcineurin inhibitors dynamically influenced cognitive outcomes.¹¹

Learning difficulties in pediatric organ transplant recipients have also been observed in cases of heart transplant. In particular, school placement posttransplant, receipt of special education, and cognitive status at early school age were evaluated.^9,12 In their study, Brosbe and colleagues⁹ assessed the education and learning morbidities of pediatric heart transplant recipients, focusing on children who were placed in educational settings within 1 to 3 years posttransplant. The findings revealed that 88% of children were in typical educational placements (at grade level), whereas 12% were in modified educational placements (either delayed by a grade level or receiving special education). A modified educational placement was associated with longer hospital stays between transfer and discharge, the absence of private health insurance, the presence of a complex condition such as congenital heart disease, and a higher number of infections.⁹

In another study that assessed cognitive performance in early school-aged children after heart transplant, general intelligence, academic achievement, and visual and motor integration in pediatric heart transplant recipients were lower compared with peers in the healthy population.¹² In addition, more than half of the transplant recipients were diagnosed with mild intellectual disability, learning disabilities, language impairments, and attention deficit hyperactivity disorder. Factors such as having congenital heart disease and pretransplant neurological issues were linked to reduced cognitive performance posttransplant. However, in contrast to findings in other studies, duration of stay in the pediatric intensive care unit and waiting time for transplant did not affect cognitive performance.¹² The findings of studies have highlighted the risks to cognitive and academic development in children undergoing organ transplant, underscoring the importance of additional support and interventions in these areas.

This study has important implications. If learning disabilities are identified in the early period posttransplant, early interventions can lead to important results in the social and academic lives of children. It is vital to identify learning disabilities, which are urgent and important problems of this special group, and to share the risk factors with the child's family. Pediatric nurses, who are indispensable health professionals in the pediatric transplant process, can play a key role in treatment compliance and rehabilitation. In this context, it is important that pediatric nurses provide counseling to the family and lead education and rehabilitation processes to help improve child development and quality of life. Pediatric nurses can play a role to possibly reduce learning difficulties in children needing organ transplant and to reduce the disabilities of children.

Volume: 22 Issue: 10 October 2024 - Supplement - 5

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