1. Before your surgery

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2. WHAT YOU NEED TO BRING TO THE HOSPITAL:

• Loose-fitting pants, skirts.
• Blouses, shirts closed at the front.
• Pyjama, underwear, stockings/socks.
• Dressing gown.
• Comfortable, safe slip-on shoes without laces to tie, or slippers.
• Chest support belt and accessories - Women: purpose-designed bra.
• Toiletries (brush/comb, toothbrush, toothpaste, shaving equipment, deodorant, shampoo, wet wipes, tissues, moisturiser, hand cream, makeup, compact mirror).
• ID and relevant documents, list of prescriptions, medications.
• Mobile phone/tablet, extra-long charging leads, powerbank charger.
• Important phone numbers for family members, friends and your GP.
• Reading glasses, paper and pen.
• Booklet for “Guidelines for cardiac patients after surgery”.
• Favorite magazine/book for reading, puzzle book.
• Consider eye mask and ear plugs if you are sensitive to noises when resting.
• Something loose and comfortable to wear when it's time to go home.

Recover with comfort — try our QualiBreath support.

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The Infographic below summarizes how to prepare yourself for open heart surgery.

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At the hospital:

In order to perform the surgical procedure the surgeon has to cut through the breastbone (sternum) to get access to your heart. After surgery the sternum will be held together by steel wires so it can heal properly.

The breastbone is like any other broken bone, however it cannot be put into a cast like other bones in your body. This is why a purpose- designed external chest support is an important additional tool to support your healing breastbone.

You have to be very mindful about your physical activity during the first six to eight weeks of your recovery. This is why we strongly advise you to learn about how to look after your breastbone BEFORE surgery. We will cover this topic next.

The following activities may vary somewhat from hospital to hospital and will depend on each individual patient’s condition.

 

First day after surgery:

You will be asked to sit up on the side of the bed. You will also be asked to cough and do deep breathing exercises frequently to prevent lung infections. Wearing a comfortable chest support such as QualiBreath or QualiBra Advanced during these activities will make this easier for you.

The second and the following days after surgery:

You will be asked to eat your meals out of bed sitting in a chair and you will also be asked to get out of bed several times per day. You will be encouraged to walk a short distance in the hallway. 

Each walk should gradually increase step by step. Walking is your most important activity in the first days after surgery and it helps to prevent complications such as pneumonia (infection in the lungs) and constipation.

The number of days you will be in the hospital after open heart surgery will depend on how well you progress with activities and whether you have any complications such as wound or lung infections. It will also depend on whether you have had bowel
movements.

Walking is an effective way to stimulate bowel movement.
Remember that a chest support such as QualiBreath or QualiBra Advanced has integrated handles/pockets to grasp for protection of your breastbone if you are straining during visits to the bathroom. 

Typically you would spend between three to five days in the hospital after been moved from the ICU/CICU. However, no patients are alike and how they recover and the time it takes will differ, so do not worry if you feel you progress with a slower rate than other patients.

 

3. GOING HOME:

Surgeons use different techniques and have different requirements after surgery. Your surgeon and healthcare team will evaluate how well your are recovering and decide when it’s time to go home.

Before leaving the hospital, you will be scheduled for follow-up appointments with your cardiologist. If your cardiologist is not at the hospital where you had surgery you will receive a report about your surgery and hospital stay to bring along for him/her.

What typical follow-up appointments may look like:

The first appointment: Three to seven days after discharge. Depending on how “satisfied” your cardiologist is with your recovery progress, the schedule for subsequent appointments could be changed.

The second appointment: Six weeks after the initial appointment.

The third appointment: Usually 3 months after the initial appointment.

Annual follow-ups: Once you're recovered, your cardiologist will want to see you regularly, probably once per year.

Your cardiologist evaluates how your recovery is going and gives you instructions on “sternal precautions”, your exercise schedule and your diet. He/she will also advise you when you can be allowed to drive and return to work.

If needed, your cardiologist will enroll you in a Cardiac Rehabilitation program with the goal to maximise your physical, psychological and social recovery. This will also help you to make lifestyle changes to reduce your risk of future heart problems. Furthermore it will help you to get physically active to a degree tailored just for you.

A typical Cardiac Rehabilitation program consists of:

• Instructions on “Sternal precautions”.
• A structured exercise program with increase of your physical activity under medical supervision.
• Information on how to improve your diet to be heart healthy, rich in lean protein, whole grains, fruits, vegetables, legumes and low in saturated fats.
• Information on how to implement a long-term heart healthy lifestyle integrating diet and exercise into your daily life.
• Information on how to get help from occupational therapists or psychologists as needed.

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4. STERNAL PRECAUTIONS:

Sternal precautions are adjustments to your daily routine to help prevent the breastbone (sternum) from being pulled apart during healing (separated - called dehiscence), and to prevent excessive pulling on the surgical wound (incision). These precautions also help to reduce the risk of wound infection which would slow the healing process of the bone.

Basically “Sternal precautions” are simple rules to take good care of your healing breastbone which is important to do for the first 6 to 8 weeks after your operation or longer as instructed by your cardiologist.

The 3 most important rules to remember are::

1. Do not do anything that places more stress on one side of your chest than the other which means use both hands and arms simultaneously.
2. Keep your elbows close to your body when you push, pull or lift anything.
3. Use your leg muscles to sit or lay down and to get back up again.

Sternal precautions may vary somewhat from one hospital to another. The following list shows typical precautions:

• Avoid reaching your arms above your head, behind your back, or to the sides.
  Do not sleep with your hands behind you head.

•  

  Always keep your elbows close to your body when you push, pull or lift anything to avoid straining your chest and increasing pain.

• Avoid lifting, pushing, or pulling objects heavier than 5 kg (10 pounds).
  Weight examples: Average 3-months-old baby, a cat or small dog, a filled laundry basket, a traditional vacuum cleaner, a large watermelon, three 2 liter bottles of soda, a sack of potatoes.

• Do not push through or with your arms when you stand up.

• Avoid doing things that place more stress on one side of your chest than the other, like walking with pets on a leash, using a walking stick, carrying an item in one hand, mopping the floor, vacuuming or mowing.

• When lifting do it safely by always bending your knees, not your back, and use both hands to pick up objects and keep them close to your body. 

• Avoid lifting toddlers or small children. Have them placed on your lap for a cuddle. 

• When picking up small objects on a table or countertop, pull them first close to you with both hands and lift with both hands. 

• Do not allow others to pull on your arms when helping you to move. 

• Use the weight of your whole body to open heavy/large or sealed doors (refrigerator) or when pushing shopping carts. 

• Avoid any type of hard exercise that could strain your chest or upper arms, such as swinging a golf club, or playing tennis.
  
  

The Infographic below is an overview on how to protect your sternum.

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Some hospitals provide heart surgery patients with a heart shaped pillow and may tell patients to hug it while coughing or sneezing to protect the breastbone. It is important to understand that pillows used in this way can cause more harm than good since pressing inwards on a broken bone could delay healing.

Patients can also not walk around with a pillow at all times. A cough or sneeze appears in a split second, which may cause patients to make a sudden move to reach for the pillow. Such move puts uneven stress on the breastbone and may be harmful for the healing process.

Another issue is the risk of infections, since a pillow easily can fall on the floor or be exposed to infection sources during visits to the bathroom.

These are important reasons for using a purpose-designed chest support such as QualiBreath or QualiBra Advanced that is in position on your chest at all times for constant support, and has handles/ pockets always ready to be grasped in a split second for stronger support during a cough or sneeze.

You can read more about pillows and chest supports in chapter 13 and in this blog post here: Heart pillow talk

There are other commercially available chest supports that some hospitals may offer you. It is important to evaluate what these products can do and check if they are comfortable. Do they give continuous support to your ribs and muscles, can you sleep with them? Can they decrease pain by having tools to gain additional support during coughing, sneezing, straining?

It is important for your recovery that you get to use a chest support that you feel provides you with as many advantages as possible and that you can wear for several months.

Check out the main differences between QualiBreath and other chest supports in this blog post by clicking here.

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5. EXERCISE

Exercise is an important factor in your recovery progress after heart surgery. Try to be as active at home as you were on your last day in the hospital and remember to continue with the breathing exercises you were taught.

Walking is the most simple and effective exercise and you need make it part of your daily routine. Check with your cardiologist before you start other more vigorous forms of activity.

You need to build up your activity little by little over the first 6 to 8 weeks. Follow the guidelines your cardiologist or cardiac rehabilitation specialist gives you.

The following guidelines are typical recommendations from Heart Foundations which recommends that you do at least 30 minutes of moderate physical activity such as brisk walking every day. It does not have to be done in one session but can be split up into 3 x 10 minute sessions a day.

Choose a time for walking that is convenient for you but wait for 1.5 hours after eating. Wear comfortable walking shoes and clothing that is suitable for the weather. If the weather is severe or the temperature makes you uncomfortable then use your treadmill if you have one, or walk indoors at a shopping mall or at a health club.

Begin your activity slowly and try to increase the amount of walking you do a little each day. You may get a little breathless during your activity. This is acceptable but should not exhaust you. If you can talk at the same time as exercising, you are doing fine. Drink plenty of water to replace the amount of sweat lost through exercising.

When you exercise remember it is usual to get aches and pains. Specially the ligaments and muscles around your neck, shoulders, chest and your back might still be sore. When you continue with the exercises this discomfort will disappear.

Make sure to rest in between your exercise schedule. You might be overdoing your activity if you feel you get easily tired. Then walk shorter distances or reduce the activity you do. Rest immediately if you get short of breath or dizzy, or begin to feel very tired.

If you get a headache, pain in your chest, arms, jaws or ears, feel nausea or need to vomit, contact your cardiologist and do not start your activity again before he/she approves.

It is very variable what amount and type of exercise patients can do in the first weeks after surgery. Most patients are able to walk about 1.5 - 2.5 km (1-1.5 miles) daily 4 weeks after surgery. The best is to do what you can without becoming too tired or too short of breath and to make sure to get as much rest as you need including a good nights sleep.

Although you might be anxious to get back to your daily routine do not overdo your activities as that can slow your recovery. You body must have time to heal properly.

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6. HEALTHY DIET WITH HEALTHY FOOD CHOICES

A healthy diet with healthy food choices help the healing process. It is common not to feel like eating right after your surgery. Try to eat smaller meals more often and you appetite should come back in a few weeks. Tell you cardiologist if you keep having a poor appetite.

Healthy foods and drinks are very important for your healing process and for your future health. The wrong foods and drinks can lead to high blood fats (cholesterol), high blood pressure, diabetes, being overweight and other severe illnesses. Wrong foods and drinks increase the risk of heart disease.

See the first section of this guide “Before your surgery” where we discussed how to start enjoying a heart healthy balanced diet before your surgery to make it easier during your recovery.

What you need to know about fats:

Fats are an important part of a healthy balanced diet but it is very important to pay attention to the type of fats you eat.

• The “good” fats are unsaturated fats (Monounsaturated and polyunsaturated fats). Examples of foods high in good fats: Olive and canola oils, soy, nuts, seeds, and fish.
• The “bad” fats are saturated and trans fats which increase risk of diseases, even when eaten in small quantities. Examples of foods high in bad fats that you should avoid: coconut and palm oils, lard, butter, milk fat, meat, skin from chicken and pork, ice cream and cheese.

Furthermore:

• Commercially-baked pastries, cookies, doughnuts, muffins, cakes, pizza dough.
• Packaged snack foods (crackers, microwave popcorn, chips).
• Stick margarine, vegetable shortening.
• Fried foods (French fries, fried chicken, chicken nuggets, breaded fish).

Besides what we described in the diet section of “Before your surgery”, here are additional tips to eating healthy:

• Make it a habit to read nutrition labels when you shop. Look for foods with fat content less than 10-15% per 100g, low sodium (salt), no added sugar, no artificial sugars, high in fiber and protein.
• Make grains, legumes, pulses, and vegetables the major part of each meal to get fibre, proteins, vitamins and minerals.
• Learn to use the huge variety of legumes and pulses and include canned beans (e.g., kidney beans and three bean mix), dried peas and beans, chickpeas and lentils.
• Choose wholegrain breads, pasta, noodles and rice.
• Eat lean meats (veal) and poultry without skin, fish, egg whites, tofu, nuts and seeds.
• Use hummus or avocado instead of spreads.
• Make salad dressings from canola or olive oils and fresh lemon juice instead of mayonnaise.
• Limit processed meats (e.g. sausages) and deli meats (e.g. ham or salami).
• Avoid sugary, fatty and salty take-away meals and snacks including pastries, pies, pizza, fried fish, hamburgers, hot chips and creamy pasta dishes. Healthier take-away choices include sushi or sashimi, Asian stir-fries, tomato-based pasta dishes, grilled fish, chicken and lean meat.
• Avoid fat cheese. Lower fat cheeses such as light cheddar, ricotta, cottage and light mozzarella are healthier choices.
• Flavor with herbs and spices instead of salt.
• Snacks: limit snacks and instead of cake, biscuits or crisps, choose fresh fruit, raw vegetables with hummus, unsalted nuts, seeds, rice cakes and low fat dairy products.
• Drink plenty of water. Avoid drinks containing added sugars, sugar-sweetened soft drinks, fruit drinks, vitamin waters, energy and sports drinks.
• Drink coffee and tea in moderation. If you use milk, choose low or no fat milk.
• Limit alcohol intake. Current recommendations for men and women: No more than 2 standard drinks a day on average. Include 1–2 alcohol free days per week.

When you start on your healthy way of nutrition you will quickly find that your body and you feel much better which will inspire you to continue.

Vegetables, legumes and fruits are packed with nutrients (antioxidants, vitamins, minerals and fibre) and help you maintain a healthy weight by keeping you full longer.

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7. WOUND CARE

The breastbone is typically held together by metal wires after open heart surgery. They are usually not removed, but some people may experience persistent pain or allergic reactions related to the wires. Removal of the wires usually resolve these symptom and it is generally an uncomplicated procedure.

The tissue and skin over your breastbone is held together by stitches or staples while it heals. Depending on the type of stitches used, they dissolve on their own. Non-dissolvable stitches and staples need to be removed about a week later.

Your skin normally seals within the first days after surgery. Some bruising around the incision is normal. The wound may itch and feel sore, tight or numb for a few weeks.

If you have had a bypass surgery where the surgeon used a vein from your leg as grafts, your leg could hurt more than your chest and be sore and stiff. This will go away with time. Modest exercise and daily activities will help ease these symptoms.

Before you leave the hospital, you will be instructed how to care for your wound(s) on your chest and the site where the grafted blood vessel was removed from your leg or forearm.

It’s important to:

• Check your wounds at home.
• Always wash your hands before touching your wounds.
• Your wounds will heal and scab over in the next couple of weeks. If the wounds are itchy, do not scratch them. The scab will gradually fall away and the scar will begin to fade over the next few months.
• Keep the wound(s) clean and dry. You can shower but avoid using soap directly on your wound(s) and carefully pat the incision(s) dry afterward.
• Use a fresh towel each time you shower.
• Do not use creams, talcum powder, or lotions on your wounds until they have fully healed.
• Some fluid may leak from your chest tube sites the first week after surgery and must be covered with sterile bandages. Call your surgeon's office if you have to change the bandages more than once per day.
• Avoid bathing and swimming until your wounds are completely healed or until your cardiologist gives the OK.
• Avoid direct sun on your wound(s) for the first year. Sun exposure can cause the scar to darken.
• If you have wounds from graft sites on your legs: Put your legs up on a foot rest or stool when you are sitting down. This will reduce swelling and will help the wounds to heal more quickly. Wear compression stockings for six weeks after surgery or for as long as your cardiologist advises.

Check your wound for signs of infection:

• Increased oozing
• Wound edges pull apart
• Redness and warmth around the cut
• Pain
• Fever higher than 38°C (101°F)
• Increased swelling/tenderness along incision line
• Bad odor
• Grinding/clicking sensation

If you have any of these signs, or if your breastbone feels like it shifts, pops or cracks when you move, call your cardiologist immediately.

The wound will leave a scar in the chest area and at the graft site (if you had a bypass surgery). It is normal that the scar will be red during the healing period. It will fade and become lighter over time.

Check list for things you should do every day at home:

• Check your resting pulse and keep a record to bring to your follow-up appointments. Your pulse should be within the range of 60 - 100 beats per minute. Call your cardiologist if your pulse is out of this range.
• Weigh yourself and keep a record of your weight to bring to your follow-up appointments. If you experience a sudden increase in your weight it could be a sign of fluid retention and that your heart is not pumping efficiently. Inform your cardiologist if you gain 1 - 1.5 kg (2-3 pounds) or more in one day, or 2 -3 kg (4 -6 pounds) or more in one week.
• Take your temperature. If you feel warm or chilled, measure your temperature 3 times a day (morning, afternoon and evening) and keep a record. Call your cardiologist if your temperature exceeds 38°C (101°F).
• Take your medications as prescribed. Continue to take your prescribed medications at home. Talk to your cardiologist before making any changes.
• Follow the heart healthy diet recommendations and work on making it a habit.
• Follow your exercise program and make it part of your daily routine.

Listen to your body. Call your doctor, or go to your hospital if you get warning signs like:

• Chest pain not caused by your incision, pain in your arms, jaws, or ears.
• Shortness of breath, nausea or vomiting, a severe headache, fainting.
• Palpitations or an irregular heartbeat and dizziness.
• Increased swelling of legs, ankles and/or feet.
• Wound pain that is getting worse and not relieved by medication.
• Wounds that become red, swollen, inflamed, begin to ooze or start to open.
• Chills, or fever above 38°C (101°F).
• Coughs and colds that don’t go away.
• Blood in urine or stool.

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8. GETTING THROUGH THE FIRST WEEKS AT HOME

The first few weeks after hospital discharge can be tough both physically and emotionally for many who have had heart surgery.

Fear of pain, fatigue, worry, stress, or being overwhelmed about how to comply with drastic changes in lifestyle including a new diet may create common emotions like:

• Mood swings, Irritability, sadness, crying frequently
• Distressed about not yet being able to return to work
• Frustration about having strict activity limitations such as lifting and
• driving restrictions
• Difficulty concentrating, low or lack of energy, easily fatigued
• Intermittent pain with the need for pain medication
• Sleep disturbances
• Common symptoms of depression

If you go through some or all of these feelings it is important you remember that they are very normal and usually do not last long. A change in our health situation has an effect on our feelings too, not only on our bodies. You will experience good days and bad days. As you increase your daily activity, follow your exercise plan and get plenty of rest. This will help you to an emotional recovery as well.

Start seeing family and friends with visits limited to 15 minutes the first week at home. Talk over your feelings and progress with your loved ones. As you start feeling stronger and less tired, you can increase your time with visitors.

If the feelings of sadness or depression do not disappear, it is important to talk to your cardiologist about a possible referral to a licensed counselor or a clinical therapist. You may want to join a local or online support group. Talking with others who are going through similar experiences can help. There is a wealth of educational information and resources available from national heart foundations. You can find your national organization by searching online. Look also for patient support organizations that give very helpful information.

During the first week or two at home, you should have a caregiver helping you. This can be a family member, friend or a home care helper. Make sure you get dressed every day and walk daily and follow other activities that might be recommended for you. This will help to keep your spirits up.

Pain medication

It is common to experience some pain in your wounds after your surgery. Pain may also be caused by sore muscles and ribs. It should not be like the angina pain you may have experienced before your operation. Most people also move more once they get home which may result in more pain during your first few days back home.

Pain is normally worse at night time and in the morning after sleeping in the same position. Continue to follow your exercise program as this will help you to move your joints and muscles and make you feel better.

Most likely your cardiologist will prescribe pain medication for you to use at home. Make sure to follow the instructions strictly how to take them. See also section 1. of this guide “Plan for how to cope with pain at home”.

Wear a comfortable and effective chest support such as QualiBreath or QualiBra Advanced to help your healing breastbone and to make you feel physically supported around your chest. It will help relieve pain from sore ribs and muscles.

It is also a tool to get more support and to control pain during coughing, sneezing, straining and when you do respiratory exercises. It will give you a good feeling of being held together and give you more peace of mind about your breastbone being safe.

Use also the CryoPouch to apply frozen gel packs over your incision to deal with incision pain. Both the chest supports and CryoPouch are “non-drug” pain relieving tools that can help to avoid unnecessary amounts of pain medication.

Rest and Sleep

You should rest after activities, but don’t take a lot of naps during the day as it could give you difficulties to sleep at night. Sleep will help your body to recover and help to restore your energy.

Try to get 6 to 8 hours of sleep every night. You should sleep less than an hour every afternoon for the first month after surgery.

If you have trouble sleeping at night, try the following:

• Go to bed and get up at the same time every day.
• Start a routine to let your body know it’s bedtime, like reading or listening to relaxing music.
• Avoid caffeine like coffee, tea, and sodas before bedtime.
• Arrange the pillows so you can stay in a comfortable position.
• Make sure to sleep with your chest support such as QualiBreath or QualiBra Advanced so you always have help at hand when you need to cough or sneeze at night.
• Use the CryoPouch cold treatment if you have incision pain.
• Sleep on your back as much as possible for the first months while your breastbone heals.

If you continue to have trouble sleeping at night and it affects your mood or behavior, call your cardiologist for advice.

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9. SIX WEEKS AFTER YOUR HEART SURGERY

Six weeks after your surgery you might feel you can do many of the activities you used to before your surgery. This may also be the time you undergo the critical test whether you can be serious about sticking to lifestyle changes.

Do it for you! Read motivating books and surround you with people who support your lifestyle changes.

At this time make sure your cardiologist agrees when it’s okay to perform activities like:

Important: Do not assume that when the wound has healed nicely the breastbone is also healed. The breastbone takes much longer to heal than the wound. How long will depend on your age, whether you have diabetes, or other health conditions that delay bone healing. At best the breast bone heals in about 8 weeks, at worst it may take up to 2 years.

Therefore, be mindful about the stress you expose to your breastbone.

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10. TWELVE WEEKS AFTER HEART SURGERY

Most people find that it takes around 3 months after the surgery for them to fully recover and return to a new normal with lifestyle changes. Obviously there is considerable variation for each individual depending on how fit you were before your operation and the type of operation performed. Older people may have a longer recovery time than younger people.

Even after twelve weeks you should still make sure your surgeon or cardiologist agrees with the type of exercise you want to do, or any other hard work you have plans to perform.

You should also continue to use your external chest support for protection of your breastbone until you are completely free from any pain during exercise or work.

Useful tips:

• Prioritize your daily activities to conserve energy. Do the most important jobs first just in case you should run out of time or energy. Planning your tasks and your time will help you to protect your energy levels.
• Plan activities when you know your energy level is high and rest in between the tasks you have to do. If you need to rest more than an hour after an activity, you might push yourself too hard and have waited too long to take a break.
• Make sure to have a good posture at all times. It is very important for a healthy effective breathing which helps decreasing risk of lung infections. Keep a good posture during the activities you are doing. A poor posture can lead to joint fatigue and pain.
• When doing activities such as lifting an object from the floor, place your feet apart at shoulder distance, keep your head and back straight, then bend your knees and hips (not your waist) and do not twist your upper body. Pick up the object with both hands and keep it close to your body when you get up.
• Avoid rapid change of position as it could make you dizzy e.g. sitting to standing or vice versa.
• Use your leg muscles to get in or out of a chair or bed. Do not put stress on your breastbone by using your arms to lower or raise yourself from your chair.

Important! Know your limitations! Do not continue a task to the point of exhaustion, - stop for a break before you get tired.

There are many things to keep in mind while your body is healing. Do not get overwhelmed. Having the proper knowledge and making use of purpose-designed tools for open heart patients will make your journey easier and help you to skillfully manage every step along the way to full recovery.

The following sections are made for patients that have a condition that puts them in higher risk of getting complications after open heart surgery. These patients can especially benefit from paying extra attention to and strictly follow guidelines for the recovery period.

Patients with one or more of the following conditions have a higher possibility for complications:

• Women with a large breast size.
• Overweight
• Diabetes
• Current smokers
• Chronic cough
• Osteoporosis
• COPD (Chronic Obstructive Pulmonary Disease)

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11. IMPORTANT INFORMATION FOR WOMEN

If you are a woman who needs open heart surgery, it is important to be aware that women have a significant increased risk of getting wound infections. This risk increases with the degree of breast size and obesity.

It has been shown that women who wear size C bra cups are 12 times more at risk of getting complications than those who wear A or B bra cup sizes. Bra cup D or higher sizes showed more than 38 times higher risk of being affected by complications such as infections or pain.

The reasons for such higher incidence of complications in women with larger breast sizes seem to be related to the position of the breast bone wound right in the cleavage area. Heavy breasts pull downward and sidewards on the wound.

Such pull causes excessive stress on the sutures thereby risking a cut-through of the edge of the wound. This could open the wound at sections increasing the risk of infection and dehiscence.

It is important to support the breasts after heart surgery. Although standard bras, post-surgical bras, or sports bras may give good breast support, the risk of infection is most likely not reduced. That is because these bras squeeze the breast tissue against the breast bone wound which generates moisture and heat. This is a condition which promotes bacterial growth that easily can result in an infected wound.

The other issue with these bra types is they usually do not prevent pulling on the wound by heavy breasts specially when a woman is lying down.

For these reasons it is especially important that women with larger breast size and those who are overweight are aware of how to prevent and decrease the potential for such wound complications.

The odds for recovering without complications would most likely be increased by wearing a bra that is specially designed to deal with these two key issues: heat and moisture accumulation, and pulling on the wound.

The QualiBra Advanced sternum and breast support has been created to do exactly that, and it is dedicated to women who need heart surgery.

The device has two wide elastic bands that are adjustable placed on each side of each breast.

The two central bands gently keep the sternal wound clear and untouched by the breasts. The two lateral bands prevent pulling on the wound.

Wearing a bra that does not squeeze the breasts against the breast bone wound also results in a more esthetic healing. Having a nicer looking wound is important for women of all ages since the position of this wound is very visible in the cleavage.

The design features of the QualiBra Advanced is shown in the cartoon explainer here below.

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12. IF STERNAL NON-UNION HAPPENS - WHAT CHOICES DO PATIENTS HAVE?

This section describes more in detail how the breast bone heals, why it sometimes happens that it does not grow properly back together, and what can be done about it.

The heart is protected behind the breast bone called the sternum, which must be cut open if heart surgery is needed so the surgeons can get access. This procedure is referred to as a median sternotomy and is still the most commonly used access method for heart surgery.

After surgery the breast bone is a broken bone, and it needs to heal like any other broken bone in the body does. Other bones can be safely positioned in a cast during the healing period. This is obviously not possible to do with the breast bone, and other stabilization methods are needed.

When the surgeon has finished repairing the heart the breast bone is put back together, most often with stainless steel wires. Other methods are available like stainless steel bands, cables, clamps or a rigid plate fixation. The surgeon will determine what the best fixation method should be which will depend on the condition of the breast bone.

It is important to be aware of the timing involved in the healing process of a bone. It involves 4 stages:

• Stage 1: Inflammatory stage with swelling of clotted blood - last about 1 to 2 weeks.
• Stage 2: Formation of soft callus - over the next couple of weeks.
• Stage 3: Hard callus formation - from 4 to 16 weeks after surgery.
• Stage 4: Remodeling - from week 17 to at least 4 months after surgery.

The time frame for each healing stage depends on whether the patients have healthy bones. Each stage may be longer for patients with conditions like diabetes, obesity, high age, osteoporosis and smokers.

Healing may be longer when a blood vessel from the inside of the chest (internal mammary artery) has been used for creating a bypass to restore blood supply to areas of the heart. In this case bone healing may be delayed due to less blood supply to the breast bone area.

Delayed bone healing may also be caused by patients’ diet and use of certain drugs like steroids and non-steroidal anti-inflammatory drugs.

A healthy healing is dependent on a careful surgical alignment of the breast bone, the type of sternal fixation used, and that the breast bone parts continue to be closely positioned together and supported in the postoperative period.

Micro-motion between two bone segments has been shown to promote bone healing. However, if the movement is more than 2 mm it can result in delayed healing of the breast bone, or it may create a critical-sized gap leading to a so-called non-union of the breast bone.

Rigid plate fixation of the breast bone can prevent excessive motion, however, it is not appropriate for all patients, as for example patients with osteoporosis, lower bone mass, elderly and many women after menopause.

It is important to realize that the healing of the breastbone is usually the slowest part of the recovery process after heart surgery. While the skin incision and soft tissue over the breast bone visibly heals within 3-4 weeks, the healing of the bone takes much longer and cannot be followed by the naked eye. This may tempt patients to begin strenuous activities before the breast bone is strong enough.

If patients do not follow sternal precautions and other instructions for postoperative recovery and begin work or initiate other activities sooner than recommended, the risk of getting a sternal non-union or an unstable chest is increased and healing may be delayed considerably.

Sternal non-union and instability

The breast bone grows back together without any complications in the majority of cases. Only 1% to 4% of patients get wound complications such as deep sternal wound infections, superficial wound infections, sternal dehiscence or non-union. All these are complications that cause delayed healing and a significant increase in costs.

Good stabilization of the breast bone is crucial for prevention of complications. Ideally the stabilization should not only be done surgically on the inside but also from the outside. The surgical alignment and fixation of the breast bone should be combined with an efficient chest support. This would not only give a constant lateral support to the breast bone but would also be a constant reminder for patients to take good care of their healing breast bone.

The external chest stabilization is an important adjunctive treatment during the entire healing period after surgery. The chest expands during breathing, and a lot more during coughing, sneezing or straining. If the chest is not supported from the outside, the constant movements of the chest and occasional increase in inside pressure when coughing etc. may loosen the internal sternum fixation over time and result in incomplete healing of the breast bone.

Such incomplete healing is referred to as sternal non-union and instability. Sternal non-union happens in less than 1% of patients, but prolongs healing much more than other complications.

Having a non-union breast bone or unstable chest wall can be painful and very uncomfortable for the patient. If the condition is not given medical care it can result in possible infection, continued pain, and a persistent delay in the healing of the breast bone.

Until medical attention can be given, external stabilization of the chest wall with a dedicated chest support can relieve the symptoms associated with sternal nonunion.

Symptoms of a non-union breast bone

The symptoms of improper healing of the breast bone usually appear as pain when patients are active in their daily tasks, like when reaching out or lifting something, getting up from a chair, or rolling over in bed.

The two halves of the breast bone may be popping or grinding together during such movements, and there may be a clicking or clunking sensation as well as an unstable feeling in the chest. In addition, the rib cage may move irregularly when breathing.

Non-union can happen with or without infection, and may occur with or without sternal dehiscence. A sternal non-union without infection is called a “sterile non-union” and defined as sternal pain with clicking, instability, or both for more than 6 months.

Treatment of sternal non-union

When possible, a sternal non-union requires a surgical intervention to do a second fixation and stabilization of the breast bone eventually combined with bone grafting. However, some patients have conditions that makes a second surgical procedure too risky to perform, or some patients may reject this option.

Fortunately an external chest support can be an alternative practical and inexpensive option which can give these patients instant pain relief and functionality in their daily activities. This was described in a publication where constant use of a chest support over a period of 2 years resulted in healing of a non-union breast bone.

The patient described had reported pain, clicking and excessive movement of the breast bone when doing everyday tasks 4 months after he had his third open-heart surgery. The patient also felt a ‘“loud crunching sound" and pain when he attempted to lift a moderately heavy object.

Instead of performing a 4th surgery, the surgeon decided to give this patient a conservative treatment and prescribed him to use the QualiBreath sternum and thorax support. This immediately reduced pain significantly, increased activity, made uninterrupted sleep possible and improved confidence in completing everyday tasks.

After the patient had used the chest support for 2 years day and night, ultrasound imaging showed the edges of the breast bone were linked together by extensive connective tissue that looked like a “railway track”.

The two halves of the breast bone had been united by the formation of fibrous material. It was concluded that the stabilization of the breast bone with QualiBreath had helped it growing this connective tissue.

When considering external chest supports as a conservative treatment for long term usage in non-union patients, it is important to know there are considerable differences in design of devices that can have a significant effect on the success.

The decision to use a specific device must be based on several important aspects:

• Does it constantly stabilize the breast bone?
• Does it relieve pain?
• Does it ease breathing?
• Can it improve patient function and ease activities and exercise?
• Is it comfortable to wear 24/7?
• Is it comfortable to sleep with?
• Is it discreet to wear?
• Is it easy to wash and quick to dry?

The answer must be YES to all these factors so patients can function and go about with their daily activities and enjoy as normal a life as possible.

The design and choice of material of the QualiBreath sternum and thorax support makes it ideal to help non-union patients as described in the publication: Clinical management and rehabilitation of persistent sternal instability.

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13. IMPORTANT TO KNOW ABOUT HEART PILLOWS

In this section you will learn what happens during a cough and get to understand the facts about pillows and their use by heart surgery patients.

Heart pillows are also known as cough pillows or cardiac pillows. They are usually red, heart-shaped and provided by some hospitals to open heart surgery patients with the instruction to hug the pillow when coughing or sneezing. Charity organizations are often providing various types and shapes of pillows to patients needing heart surgery.

There may be anatomical drawings of the heart on the pillows which helps health care staff to explain the surgical procedure to the patient. The surgeon and other care givers may write their signature on the pillows and patients often keep them for years as treasured memorabilia after their surgical experience.

Pillows have been provided to patients for decades and have become a tradition within some cardiac care units. Using pillows for coughing may even be integrated into post-surgical care instructions at some institutions, or included in the hospital guidelines for patients.

It is important to understand what happens when coughing or sneezing. A cough places approximately 60 pounds (about 27 kg) pressure on the breast bone from the inside, and a sneeze approximately 90 pounds (41 kg) pressure. Coughing and deep breathing are important exercises during the recovery period. Therefore the effects of these high pressures on the breast bone during coughing and sneezing must be considered.

In many cases in which wires alone are used to close the breast bone, there is the recognition that additional external support is needed during coughing.

Until the development of dedicated external chest supports for open heart surgery, patients were instructed to use a self-hugging maneuver, or to hug a pillow when coughing to give counter pressure on the broken breast bone to the coughing force.

The benefit of self-hugging or use of a pillow as a breast bone support has not been studied. Let’s therefore take a practical look at the situation when one is about to cough:

Imagine you need to cough and want to press the pillow against your chest. A cough or sneeze happens in a split second. Unless you constantly hug a pillow, you will need to make a sudden reach for it. Where is it? It may be on the bed, on a chair, or even on the floor.

Making a sudden movement to reach for the pillow increases the danger of the two breast bone halves shifting or moving against each other. This may lead to irritation, infections or dehiscence. Furthermore pressing a pillow in a 90° angle inwards against the freshly broken breast bone could cause delayed bone healing.

You can read more in the blog post called “After open-heart surgery, the sternum is a fractured bone. Is it treated like one?”

In addition, it seems counter-intuitive that a patient would be encouraged to be active and resume daily activities if a pillow has to provide breast bone support during sudden coughs and sneezes. The use of the pillow may decrease activity, since patients may be tempted to stay seated to be within reach of the pillow if the act of hugging it decreases pain of the cough.

Now imagine again you are about to cough, but now you are wearing an external chest support around your chest, a device specially designed for open heart surgery patients. It provides you with a constant lateral support on the breast bone and has integrated handles to grasp if you want to get even stronger support around your rib cage. When you need to cough, you do not need to look around to find help, - you simply grasp the handles and bring them together to get pain relief in a safe manner.

Since the wearable chest support moves with the patient unlike the pillow, it provides constant stabilizing support to the breast bone, and pain relief to sore muscles in the chest. This may promote activity and earlier rehabilitation and return to daily day life.

Pillows cannot replace external chest supports and chest supports should not replace the pillows. It’s two completely different products with very different functions that complements each other perfectly, each one with their important role in advancing a patients recovery.

Heart pillows should be used for what pillows do best: provide comfort emotionally and physically by giving rest to your head or arm. Relying on a pillow alone as a protection device for the breast bone could create problems instead of solutions. The combination of a pain-relieving, comfortable device specially made for protection of the breast bone, and a nice, comforting pillow offer patients an optimum potential for recovery after heart surgery.

Most importantly, it may be an effective way to decrease the use of opioids. If you want to know more about this see the blog post called “Non-opioid approaches to pain management: Here are the best alternatives”

The following section explains how your chest is moving during breathing, and how an external chest support, like QualiBreath can assist your breathing.

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14. IMPORTANT TO KNOW ABOUT BREATHING

The diaphragm is the most important muscle that helps us to breathe. It separates the chest cavity from the belly area. When it contracts it moves downwards and the chest cavity expands. This will create a negative pressure which sucks air into our lungs. Likewise, when the diaphragm relaxes the chest cavity becomes smaller pressing air out of the lungs.

When you breathe air in your chest cavity does not only expand downwards, - it expands in 3 dimensions:

1. Your diaphragm muscle will contract expanding the chest cavity downwards.
2. Your lower 7-10th ribs move laterally like a bucket handle.
3. Your upper 1-6th ribs and the breast bone move upwards like a pump handle.

When you rest the diaphragm does most of the breathing work and the chest wall moves very little (called belly breathing). When you exercise or are stressed, the movements of the chest wall increase (chest breathing).

Deep breathing exercises and coughing after any type of surgery is important in order to clear secretions and prevent infection in the lungs. If patients have pain they naturally are reluctant to breathe as deeply as they should to cough efficiently.

Patients get pain medication to cope with incision pain, sore ribs and respiratory muscles after surgery so they can breathe and make these exercises without pain.

It is important to understand that too much pain medication can suppress breathing. It has to be carefully administered and adjusted to each individual patient’s need. In addition, the risk of addiction to pain killers makes both care givers and patients extra careful when considering the need for medication.

This is why an external chest support such as QualiBreath is fundamental to assist the patient to breathe while stabilizing the breast bone at the same time. The chest brace relieves pain by giving a firm elastic support to sore ribs and respiratory muscles, while the breast bone is constantly supported from both sides.

The height of the elastic material is calculated to not cover the lower parts of the lungs or the upper belly area. This means the diaphragm can work unhindered resulting in unrestricted breathing.

The diagram on the next page shows schematically the position of the QualiBreath chest support on the chest and how it works. The drawings on the right side of the diagram shows the chest cavity looking at it from above. The blue line on the outside of the rib cage is the chest brace and it is indicated by arrows how it gives a constant support all around the rib cage.

The drawing below shows the increased pressure on the inside of the chest during a cough or sneeze (thicker arrows) and how grasping the handles the brace increases the support from the outside to counteract the higher pressure caused by the cough.

This is how QualiBreath can help a you to perform deeper belly breathing while the breast bone is constantly stabilized. It supports the healing breast bone and helps to withstand the bio-mechanical forces during coughing. It also reduces pain when moving and helps you to regain mobility.

Steering clear of complications after open heart surgery means safeguarding every step of your road to recovery. It also means understanding your physical needs and emotional experience.

This booklet has till now referred to adults in need of open heart surgery. The last section is for parents with children of all ages that need open heart surgery.

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15. WHEN YOUR CHILD NEEDS OPEN HEART SURGERY

Being well informed gives you as parent or caregiver the power to understand and improve your child’s road to recovery. Read on to get familiar with the practical things you can do for your child before and after the hospital stay.

Learn also about purpose-designed tools that can help making your child more comfortable and secure and recover with less pain.

What you should know about anxiety

It is a stressful situation for parents (or caregivers) when their child needs open heart surgery. They worry about the health, the normal development, schoolwork and the future of their child. They also worry about the surgery, potential complications and how to handle care after surgery. Parents might have other issues that increase this stress, such as work conditions, knowing they will need extra time off to be with their child in the hospital and once the child gets home.

It has been shown that children who are anxious before surgery can experience a more painful recovery with higher risk of complications. That is why it is important that you stay calm and confident when you explain the surgery and comfort your child - without showing your own anxiety. Children can immediately feel when something is worrying Mom and Dad, family or other caretakers, and this sense can severely heighten the nervousness of your child.

Depending on the age of your child and what he/she can understand you have to talk about the surgery. Involve also siblings if there are any so they don’t feel worried or neglected. They too have to deal with that you will be away for some time and need to talk about it.

The younger your child is, the longer you can wait talking about going to the hospital, perhaps just till a few days before. Pre-schoolers and kids (5 - 9 years) should be informed earlier, at least a week in advance. Make sure you talk with a confident and calm voice. Explain that doctors are going to fix the heart so it can work better, and that he/she will need to stay at the hospital for some days.

Take good time to answer any questions your child may bring up and continue to talk relaxed and cheerful. It may also be helpful to read stories or books to your child about kids going to the hospital.

You may want to talk with your child’s surgeon and the healthcare staff about best ways to explain the surgery.

Most hospitals have written materials and drawings to help you understand the surgical procedure and what your child will experience during and after surgery. This will be useful and make it easier for you when you talk to your child about the upcoming surgery.

Tweens and teenagers should be involved from the beginning and usually they will want to know more. Together you may want to check out the websites from the largest and well-known heart hospitals where you can find helpful information. Also encourage your child to ask questions when you are at the pre-admission meetings.

It is important to ease any anxiety in your child and to start doing that before the surgery. It can be as simple as making sure your younger child has a plush toy. It gives your child something physical to hold on to and feel secure with. Studies have shown that “providing toys for children and informing the parents about medical information has a major effect in reducing children's and other's anxiety”.

For older children other toys or gadgets can help them to deal with the situation or distract and occupy their mind. It can be a toy medical kit, coloring books about the surgery, puzzles putting “pieces” back together, or digital games to repair body parts. Providing educational information that fits to your child’s level of development can help easing anxiety.

Preparing for surgery

If your child is older than 18 months, most hospitals will ask for a dental check. The reason for this is that children with unhealthy teeth have a higher risk of getting an infection in the heart (endocarditis). So to avoid any delay of the surgery, make sure you help your child to have a good oral hygiene routine.

Usually you will be asked to bring your child to the hospital for a pre-admission visit some days or perhaps a week before the surgery for various exams, blood tests and X-rays. This visit may take the most of the day, so bring toys, games, tablets etc. to distract your child and yourself while you are waiting in between exams.

This visit is a good occasion for you and your child to become familiar with the hospital. You will get information about how to prepare your child for the surgery. This will include instructions about fasting, special washing and medication before surgery. You will also be told about what normally happens during the whole stay at the hospital.

At the pre-admission visit you might receive information about how to take care of your child in the recovery period at home. Some hospitals may wait sharing these instructions with you until your child is ready to go home after surgery - just in order not to overwhelm you with too much information at one time. However, receiving such advice already before the surgery enable you to carefully read it at home and make the necessary preparations. It will also help you to feel more in control and prepared for caring the best way for your child.

If you don’t receive the advice you can ask the surgeon or hospital staff for recovery instructions for your child. There may be variations in these from hospital to hospital and the content may depend on each child’s heart disease and condition.

The advice you are reading in this guide is not a replacement for the information you will receive from the hospital. Our advice is complementary information focused on practical ways to prepare and help your child to a safe recovery at home.

Make sure you discuss our advice with your child’s surgeon or cardiologist to check that he/she is in agreement. Depending on your child’s heart problem and health conditions there could be specific additional information you need to be aware of.

Preparation and what to bring to the hospital

For at least a week before the surgery you should avoid that your child gets in contact with people that has a cold or other illnesses. Even a simple cold could delay surgery.

If your child is at home until the day of the surgery you most likely will be concerned about following the instructions correctly for the fasting, special washing, and medication before surgery. On top of that it may be tough to also put your mind to what you should bring with your child and yourself to the hospital.

The following is a general reminder list with suggestions for what to bring. Items will depend on the age of your child:

• Favorite plushy toy, blanket, other toys, coloring books/pencils, reading books, family photos.
• Loose-fitting garments like tops closed at the front and loose-fitting pants.
• Pyjama, underwear, socks.
• For older children: Dressing gown and comfortable, safe slip-on shoes without laces to tie.
• Toiletries (brush/comb, toothbrush, toothpaste, shampoo, wet wipes, tissues, moisturizer).
• Chest brace (see Sternal Precautions later).
• Case for glasses or contact lenses. If your child uses contact lenses, it might be more convenient to use glasses during the hospital stay.
• ID and relevant documents, medications.
• Mobile phone/tablet, extra-long charging leads, power bank charger.
• Something loose and comfortable to wear when it's time to go home.

Since you most likely will stay with your child in the hospital, bring comfortable clothes and shoes for yourself, overnight clothes, toiletries, medications, mobile phone, tablet, books or other hobby items to keep you occupied during hours of waiting and when your child is sleeping.

The length of the hospital stay is typically from 4 to 10 days. It may vary as it depends on your child’s type of heart disease and the surgery needed. Each child also recovers at different rates. Therefore do not compare your child’s length of recovery with other kids at the hospital.

At the hospital

In order to get access to your child’s heart the surgeon has to cut through the breastbone (sternum) to perform the surgical procedure. When the surgeon has fixed the heart, the sternum will usually be held together again by absorbable sutures in the smaller patients, while stainless steel wires or cables are mostly used for larger tweens and teens.

The breastbone is like any other broken bone, but it cannot be put into a cast like other bones. This is why a purpose-designed external chest brace is an important additional method to support your child's breastbone while it heals.

This is also why you and your child need to learn how to look after your child’s breastbone and what physical activities your child can do and should not do during the first six to eight weeks of recovery. Such instructions are referred to as “Sternal precautions”. We will cover this topic in the next section.

After surgery children usually stay in the intensive care unit (ICU) for 2 to 4 days and additional 5 to 7 days in a children’s ward after they leave the ICU. However, it all depends on the complexity of your child’s heart disease and more time, like weeks or sometimes months might be required before your child can leave the hospital and go home.

You will have received information from the surgeon and the hospital staff about the surgical procedure and the tubes and lines connected to your child after surgery. When you see your child for the first time after surgery it is totally normal to be nervous about how to touch or talk to your child.

As long as the breathing tube is in place, your child cannot talk to you and you should help your child not to try. This is the time where your soothing and caring voice is so important for your child and will help making him/her feeling more secure.

The hospital staff will advise you when you can touch, kiss and caress your child and when you will be able to hold him/her and they will teach you how. This is normally when the breathing tube has been removed.

It is important to understand that parents or caregivers play a major role for a child’s recovery. Your child will receive pain medication to relax which will support rest and healing. You are the one that know your child better than anyone else and can help to advise the hospital staff if your child is in pain and may require additional pain medication.

It has been shown that pain in children can be decreased just by you being there to touch, caress and talk to your child with a calm and soothing voice. You can also comfort your child by distracting with reading stories, singing, or playing with toys. If your child is older other items can help to distract such as a tablet, music, books, or other tools.

It is important that you are aware that many parents or caregivers and their children can become depressed, introverted or isolated during the post-operative recovery. This is quite normal after open heart surgery or other major surgeries. Usually the hospital has counseling resources available. Do not hesitate to make use of such services if you, your family or your child need it.

As a parent you are involved in the planning of the postoperative therapy which includes pain relief, personal care, activity, nutrition and when it’s time to go home.

Going home

Before the day arrives when you can bring your child home, the hospital staff will teach you how to care for him/her in the healing period. You will normally also receive all instructions in writing.

It is important to follow closely the instructions from the hospital. The advice you get in this booklet is complementary and focused on practical and generally accepted guidelines.

When you bring your child home from the hospital, he/she will need a child car seat or use the seatbelt. This can be uncomfortable and cause your child pain since the belts will be just over the breast bone.

This is why it is a good idea to use a seatbelt padding such as QualiPad which is designed specially for children that have had open heart surgery. It provides comfort and is a buffer in case of a sudden halt of the car. Alternatively, make sure to place a soft, small pillow between the chest of your child and the seatbelt.

If it is your new baby you are bringing home for the first time you should remember that like any other new parent you will be occupied with thoughts about how to take care of your baby and make sure he/she gets enough food, gains weight, sleeps well and develops normally. In addition, it is normal that you also worry about your child’s heart condition.

Make use of all support you can get from the health care staff, counseling services and home care. Do not hesitate to ask them questions if you have doubts about anything.

At home dress your child in clothes that are easy to put on and take off. Choose loose fitting garments that do not require to bring your child’s arms above the head and that do not rub against the wound.

It is important that you learn the correct way to lift your baby or toddler and how to help your child with activities after surgery. Just like sternal precautions for adults are necessary to secure a healthy healing of the breast bone, it is just as crucial for children of all ages.

The chest wound is normally healed in 3 - 4 weeks, but the breast bone underneath the soft skin and muscles takes about 8 to 12 weeks to heal. This is important to remember as it is easy to think that healing is complete when the visual wound has grown together.

This is why your child should avoid strenuous activities and follow “sternal precautions” until the breast bone is stabilized and has grow back together. This means for about 4 to 6 weeks after surgery or as long as the cardiologist recommends.

It is a good idea to consider a chest brace to help stabilizing and protecting your child's breast bone. Such brace will also help to make your child feel comfortable and supported, and it can function as a physical “reminder” to protect the chest.

See more details about the QualiBreath chest brace for infants, toddlers and older children HERE

Sternal precautions are adjustments to the activities your child does and they serve to prevent the breastbone from being pulled apart during healing, and to prevent excessive pulling on the wound. The precautions also help to reduce the risk of wound infection which would slow the healing process of the bone. The precautions may vary somewhat from one hospital to another and there may be differences depending on how old your child is.

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Sternal precautions for children

The following lists show typical sternal precautions.

Babies, toddlers and preschoolers – the first 2 weeks:

• Your baby should always sleep on their back to prevent sudden infant death syndrome (SIDS).
• Your baby should not be placed on the tummy the first 2 weeks after surgery.
• It’s OK to let your baby sleep slightly on the side by placing a soft, rolled towel for support under the shoulders and the side of the body.
• To prevent “flat head syndrome” (positional skull deformity) make sure to change your baby’s head position often throughout the day.
• Do not lift your child under the arms or pull up by the arms. Such lift or pull can stretch the breast bone wound, possibly separate it and cause pain.
• Lift instead your baby by supporting the head, back, shoulders, and hips. Observe the face and body language of your baby for any pain.
• Let your baby burp by holding him/her against your chest in upright position.
• Stimulate your baby visually and play with him/her by placing a crib mobile above the chest area.
• Let your baby reach for toys with both hands in the middle over the chest, not over the head. Try to keep the baby’s head centered when looking at you.
• Stimulate and connect with your child by talking, reading, or singing. It has been shown that a parent’s voice is very important for children’s healing and development of language, even in the first weeks of their life.
• Exercise your baby by bending the legs up and down together or one at a time.
• Check with the cardiologist when it is OK to start giving your baby “tummy time”. Usually it is around 1 - 2 weeks after surgery. Begin carefully with 5 minutes a few times daily and increase gradually.

Babies, toddlers and preschoolers – from 2 weeks after surgery:

• Tummy time is an important exercise for your baby to develop their muscles, bones and nervous system. Babies will naturally try to lift their head and upper body and look around. This helps to strengthen their back, neck and core muscles.
• Do not leave your baby unobserved during tummy time, and do not place anything like a rolled towel under his/her chest which can hurt and delay healing of the wound.
• Remember not to overdue the time your baby is on his/her tummy to prevent that he/she gets exhausted.
• If your baby is old enough to sit, make sure to support your child’s waist and back by your hands.
• It is important that your child also is supported with a dedicated chest brace which helps to protect the breast bone, decreases pain, increases comfort and improves the child’s posture for better breathing.
• Walking is a very important exercise after heart surgery for all ages, also children. When you help your child to walk do not hold the arms over his/her head. Support instead by holding your child's waist.
• If you have a very active child, it is important that you or another adult stay with him/her to help reminding what moves are OK to do and which are not yet allowed.
• Your child should not extend his/her arms above the head, to the sides or backward.
• Your child should not push through the arms to get up from a chair or bed. Help him/her and teach how to use the leg muscles to get up. See the illustrations of “How to get out and in bed” at the end of this guide.
• Don’t let your child play games or sports that require throwing or catching balls or other items that risk hitting your child's chest.
• Your child must not swing or hang by the arms until the breast bone is healed and the cardiologist gives the green light for such activities.
• Make sure your child always use both hands and arms simultaneously and that they keep the elbows close towards their body to do whatever they do, including lifting things.
• Don’t let your child lift things heavier than 10% of their body weight. Calculate what it corresponds to and give examples to your child so he/she knows what favorite items are OK to lift.

Tweens and teens (5 to 12 years):

Except for the points about tummy time, the “Sternal precautions” for 5 to 12 years tweens and teens are the same as listed above. Make sure your child understands the precautions and why it is important to follow them. You should prevent your child from doing activities that may cause pain, like twisting, straining, or throwing.

Although the precautions listed are generally accepted guidelines for recovery after heart surgery, your child could have conditions that require additional precautions. Please check that your child's cardiologist is in agreement with the sternal precautions shown here.

Wound care and washing

The tissue and skin over your child’s breastbone is held together by stitches or staples while it heals. Depending on the type of stitches used, they dissolve on their own. Non-dissolvable stitches and staples will be removed about a week later.

The skin normally seals within the first few days after surgery. Before your can go home with your child, hospital staff will instruct you how to care for your child’s wound.

• Check the wound regularly at home.
• It is important to keep your child’s wound and the skin around it dry and clean. Always wash your hands before touching the area around the wound and use a fresh towel each time you wash your child.
• You should wash your child every day with clean water. Avoid using soap directly on the wound and let it air dry, or carefully pat the incision dry afterwards.
• Avoid drenching the wound until there are no more scabs. The scabs will gradually fall away after a few weeks and the scar will begin to fade over a few months.
• Let your child wear clean cotton clothing while the wound is healing.
• Do not use creams, talcum powder, or lotions on the wound until it has fully healed.
• Your child should not go bathing or swimming until the wound is completely healed or until the cardiologist gives the OK.
• It is also important that your child avoids direct sun on the wound for the first year. Sun exposure can cause the scar to darken.

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Once older tweens or teens have the stitches removed, they can normally start having a quick shower without soaking the wound. You should ensure that the wound just has a quick rinse with clean fresh warm water. Let it air dry, or carefully pat the incision dry afterwards.

How to check your child’s wound for signs of infection

• Increased oozing
• Wound edges pull apart
• Redness and warmth around the cut
• Pain
• Fever higher than 38°C (101°F)
• Increased swelling/tenderness along incision line
• Bad odor

If you notice any of these signs, or if your child’s breastbone pops or cracks when moving, call the cardiologist immediately.

The wound will leave a scar in the chest area. It is normal that the scar will be red during the healing period. It will fade and become lighter over time.

Children feel pain just like adults do

Here is the background information to explain such obvious statement:

During the most part of the 20th century it was doubted that babies and toddlers could feel pain. This “pain denial” was caused by experimental research in the 19th and early 20th centuries using pinprick and electric shock to evaluate the response.

When these harmful stimuli caused clear reactions they were often disregarded as reflex responding and explained as proof that babies’ brains were not yet fully developed and therefore could not sense pain.

This research lead anesthesiologists to use less or sometimes no anesthesia for babies and younger kids up till the 1980’s.

Another factor that played a role in under-management of pain in these small patients was the fear of addiction and negative aftereffect related to the use of drugs containing opium.

Change in attitude started in the 1980’s. Ground breaking studies documented pain in babies by measuring hormonal-metabolic responses to surgery done using minimal anesthesia. In addition, it was shown that pain early in life severely increased the risk for developing anxiety, depression and post-traumatic stress disorder (PTSD) later in life.

Today, 30-40 years after these studies, still some misperception remains that babies and children do not feel as much pain as adults. At the same time there is increased recognition that these small patients indeed feel pain.

Better strategies for pain management in children have increased. It is crucial to carefully administer the appropriate analgesic/anesthetic regimes for babies and young children, as indeed for all patients.

Pain medication and non-drug methods are continuously being investigated. However, it’s reported that non-drug approaches to pain relief for babies, toddlers and older children are under-appreciated, under-utilized, and under-studied.

Opening of the breast bone for access to the heart for repair causes tremendous stress on the chest, the ribs and the respiratory muscles that all will be sore and cause pain after surgery - also in infants, toddlers and children.

Your child will most likely need regular pain relief medication for some days after surgery. It is important to make sure your child’s pain is well controlled. Each child will have different needs. You will receive details what is needed for your child before going home.

It can be quite challenging to identify pain in babies and toddlers and to judge how severe the pain is, - just like in patients that for various reasons are not able to communicate or show where the pain is and how much it hurts.

Hospital staff have different charts available that can help them with this task. For babies less than 1 year old and patients that are unable to communicate, they can use the NIPS scale (neonatal infant pain scale), or the FLACC scale (face, legs, activity, cry, consolability).

The NCCPC scale (Non-communicating children’s pain checklist) shown next is another more complex chart that also can be used to closely monitor pain.