Catch-up growth in term and preterm infants after surgical closure of ventricular septal defect in the first year of life

How do Age at the Surgery and Birth Weight Influence Post-Operative Anthropometric Parameters in Infants with Surgical Closure of Large Ventricular Septal Defects? A Prospective Cohort Study from a Lower-Middle-Income Country

Closure of the large ventricular septal defects (VSD) in infancy can lead to normalization of growth, but data are limited. Our study is done to assess the growth pattern in different age groups of children and lower birth weight babies after shunt closure. This is a prospective observational study that included infants with isolated large VSD operated in infancy. Anthropometric data were collected at baseline and at follow-up, and growth patterns were analyzed. 99 infants were included in the study. The mean age and weight at the time of surgery were 6.97 ± 2.79 months and 5.07 ± 1.16 kg, respectively. The mean follow-up duration was 8.99 ± 2.31 months. The weight for age (W/A) was the most adversely affected parameter preoperatively, and there was significant improvement noted in the mean Z score for W/A after shunt closure (- 3.67 ± 1.18 vs. - 1.76 ± 1.14, p = 0.0012). There was improvement in Z-scores for length for age (L/A) and weight for length (W/L), although it was not statistically significant. The infants from all the age groups had statistically significant growth in the anthropometric parameters. The rate of weight gain was maximum in the infants operated below 8 months of age (2-4 months = 3588 g, 5-6 months = 3592 g, 7-8 months = 3606 g, 9-10 months = 2590 g, 11-12 months = 2250 g). Low birth weight and normal birth weight infants had similar Z-scores at the time of surgery and at follow-up in all 3 anthropometric parameters, and birth weight did not affect pre- as well as post-operative growth parameters. Suboptimal improvement in weight and length was seen in 40 and 20% of babies even after successful surgical repair, respectively. Growth failure in infants with a large VSD can be multifactorial. Early surgical closure of the shunt can lead to early normalization of growth parameters and faster catch-up growth. Few babies may fail to demonstrate a positive growth response even after timely surgical correction, and may be related to intrauterine and genetic factors or faulty feeding habits.

Failure to thrive in pediatric patients with congenital heart disease: a cross-sectional study of 13,256 patients

Background

The prevalence and risk factors for failure to thrive (FTT) in pediatric patients with congenital heart disease (CHD) remain ambiguous. We aimed to investigate the prevalence, growth profiles, risk factors, and vulnerable subtypes of CHD associated with FTT in pediatric patients with CHD.

Methods

This was a cross-sectional study based on Chinese Database for Congenital Heart Surgery. FTT was defined as either stunting or underweight (height or weight standard deviation score <-2), and they were standardized by references of normal Chinese population. Risk factors was determined with logistic regression model, and growth profiles were delineated in each subgroup.

Findings

A total of 13,256 CHD patients were included in this study, with 3994 patients of mild CHD, 7195 patients of moderate CHD and 2067 patients of complex CHD. The prevalence of stunting, underweight and FTT was 24%, 29.3% and 36.9%, respectively. Preoperative anaemia, left ventricle systolic dysfunction, younger age, more complex CHD types, lower birth weight and genetic syndrome were found to be the risk factors for FTT in CHD patients. Interrupted aortic arch was revealed to be the most severe group associated with FTT.

Interpretation

FTT is ubiquitous in patients with CHD and exacerbated in high-risk subgroups. Our findings hinted the necessity of early identification and intervention for FTT in patients with CHD during daily practice of pediatrics, as it has the potential to improve outcomes and enhance their quality of life. Furthermore, we advocate for the initiation of prospective research with longitudinal data to comprehensively investigate the association between FTT and CHD across the lifespan.

Funding

This study was supported by National High Level Hospital Research Funding (2022-GSP-GG-19), Capital Health Research and Development of Special Fund (2022-1-4032) and National Key R&D Program of China (2022YFC3600202 and 2022YFC3600203).

Prevalence and predictive factors of malnutrition in Thai children with congenital heart disease and short-term postoperative growth outcomes

Background: Growth restriction is still a common problem in children with congenital heart disease (CHD). Evidence demonstrates that performing cardiac surgery in appropriate timing may result in better growth outcome. Aim: To investigate prevalence and associated factors of malnutrition in pediatric patients with CHD who underwent cardiac surgery. In addition, post-operative growth outcomes at two weeks following cardiac surgery were also assessed. Methods: A retrospective cohort study was conducted in pediatric patients who underwent cardiac surgery at Chiang Mai University Hospital between January and September 2014. Results: One hundred patients with a median age of 28.5 months (range 14-62 months) were enrolled. Two-third of these patients had at least one form of malnutrition before receiving surgical treatment while wasting, stunting and combined wasting-stunting accounted for 23%, 28%, and 15% of patients, respectively. Multiple logistic regression analysis demonstrated that congestive heart failure-related symptoms were significantly associated with increasing risk of malnutrition (adjusted OR 4.4; 95% CI 1.78-11.26, p = 0.001). Two weeks after hospital discharge, wasting patients with regardless of stunting had significantly improved weight for height (WHZ) and weight for length Z-scores (WLZ) compared to growth parameters at the time of cardiac surgery, p = 0.012 and p < 0.001, respectively. Conclusion: The prevalence of acute and chronic malnutrition in pediatric patients with CHD who underwent cardiac surgery was very high in this study. Children with congestive heart failure had a four-time at risk of undernutrition. In short-term, cardiac surgery may mitigate acute malnutrition of these patients.

The 'Ironclad friendship' of China-Cambodia, lays the first step in the foundation of early diagnosis and treatment of asymptomatic congenital heart Defects- A multi-national screening and intervention project, 2017-2020

BACKGROUND

Congenital heart disease (CHD) is the leading cause of mortality in childhood worldwide. However, a large number of children with CHD are not diagnosed promptly in low- and middle-income regions, due to limited healthcare resources and lack the ability of prenatal and postnatal ultrasound examinations. The research on asymptomatic CHD in the community is still blank, resulting in a large number of children with asymptomatic CHD can not be found and treated in time. Through the China-Cambodia collaborative health care initiative, the project team conducted research, screened children's CHD through a sampling survey in China and Cambodia, collected relevant data, and retrospectively analyzed the data of all eligible patients.

OBJECTIVES

The project aimed to evaluate the prevalence of asymptomatic CHD in a sample population of 3-18years old and effects on their growth status and treatment outcomes.

METHODS

We examined the prevalence of 'asymptomatic CHD' among 3-18years old children and adolescents at the township/county levels in the two participating. A total of eight provinces in China and five provinces in Cambodia were analyzed from 2017 to 2020. During 1 year follow-up after treatment, the differences in heights and weights of the treated and control groups were evaluated.

RESULTS

Among the 3,068,075 participants screened from 2017 to 2020, 3967 patients with asymptomatic CHD requiring treatment were identified [0.130%, 95% confidence interval (CI) 0.126 -0.134%]. The prevalence rate of CHD ranged from 0.02 to 0.88%, and was negatively related to local per capita GDP (p = 0.028). The average height of 3310 treated CHD patients were 2.23% (95% CI: -2.51%~-1.9%) lower than that of the standard group and the average weight was - 6.41% (95% CI: -7.17%~-5.65%) lower, the developmental gap widening with advancing age. One year after treatment, the relative height difference remained comparable while that, in weight was reduced by 5.68% (95% CI: 4.27% ~7.09%).

CONCLUSIONS

Asymptomatic CHD now is often overlooked and is an emerging public health challenge. Early detection and treatment are essential to lower the potential burden of heart diseases in children and adolescents.

Prescriptions for insulin and insulin analogues in children with and without major congenital anomalies: a data linkage cohort study across six European regions

Are children with major congenital anomalies more likely to develop diabetes requiring insulin therapy, as indicated by prescriptions for insulin, than children without congenital anomalies? The aim of this study is to evaluate prescription rates of insulin/insulin analogues in children aged 0-9 years with and without major congenital anomalies. A EUROlinkCAT data linkage cohort study, involving six population-based congenital anomaly registries in five countries. Data on children with major congenital anomalies (60,662) and children without congenital anomalies (1,722,912), the reference group, were linked to prescription records. Birth cohort and gestational age were examined. The mean follow-up for all children was 6.2 years. In children with congenital anomalies aged 0-3 years, 0.04 per 100 child-years (95% CIs 0.01-0.07) had > 1 prescription for insulin/insulin analogues compared with 0.03 (95% CIs 0.01-0.06) in reference children, increasing ten-fold by age 8-9 years. The risk of > 1 prescription for insulin/insulin analogues aged 0-9 years in children with non-chromosomal anomalies (RR 0.92, 95% CI 0.84-1.00) was similar to that of reference children. However, children with chromosomal anomalies (RR 2.37, 95% CI 1.91-2.96), and specifically children with Down syndrome (RR 3.44, 95% CIs 2.70-4.37), Down syndrome with congenital heart defects (RR 3.86, 95% CIs 2.88-5.16) and Down syndrome without congenital heart defects (RR 2.78, 95% CIs 1.82-4.27), had a significantly increased risk of > 1 prescription for insulin/insulin analogues aged 0-9 years compared to reference children. Female children had a reduced risk of > 1 prescription aged 0-9 years compared with male children (RR 0.76, 95% CI 0.64-0.90 for children with congenital anomalies and RR 0.90, 95% CI 0.87-0.93 for reference children). Children without congenital anomalies born preterm (< 37 weeks) were more likely to have > 1 insulin/insulin analogue prescription compared to term births (RR 1.28, 95% CIs 1.20-1.36).

CONCLUSION

This is the first population-based study using a standardised methodology across multiple countries. Males, children without congenital anomalies born preterm and those with chromosomal anomalies had an increased risk of being prescribed insulin/insulin analogues. These results will help clinicians to identify which congenital anomalies are associated with an increased risk of developing diabetes requiring insulin therapy and allow them to reassure families of children who have non-chromosomal anomalies that their risk is similar to that of the general population.

WHAT IS KNOWN

• Children and young adults with Down syndrome have an increased risk of diabetes requiring insulin therapy. • Children born prematurely have an increased risk of developing diabetes requiring insulin therapy.

WHAT IS NEW

• Children with non-chromosomal anomalies do not have an increased risk of developing diabetes requiring insulin therapy compared to children without congenital anomalies. • Female children, with or without major congenital anomalies, are less likely to develop diabetes requiring insulin therapy before the age of 10 compared to male children.

Growth assessment in down syndrome after cardiac surgery

Objective

To assess the effect of cardiac surgery on growth catch-up of Down syndrome (DS) children with failure to thrive (FTT) and congenital heart disease (CHD) and investigate other causes of FTT in DS children.

Method

We conducted a retrospective observational study in tertiary cardiac center from 2015 to 2018. We included all cases of DS diagnosed with CHD and FTT who completed a 1-year follow-up after cardiac surgery. We divided the cases into two groups; “normalize group” includes children who normalized their growth parameters and “underweight group” includes those who remained in FTT category during the follow-up period. We compared both groups for multiple risk factors.

Result

Most of DS had FTT upon surgery. Fifty percent of cases completed 1-year follow-up including 29 (60%) in the normalized group and 19 (40%) in underweight group. Within 6 months post-surgery, the normalized group though did not reach yet normalization of growth parameters, demonstrated statically significant improvement in weight for age, weight Z-score in compared to underweight group.

Within 12 months post-surgery, the normalized group achieved normalization of growth parameters and continue to show more statistically significant differences in growth parameters.

Both groups had comparable post-operation course. Univariate analysis of possible peri-operative risk factors showed no difference between both groups except for presence of untreated subclinical hypothyroidism in 58% of the underweight group versus 17% in control group (p = 0.005).

Conclusion

FTT in DS patient is multifactorial which needs thorough investigation and work up by multidisciplinary team. Cardiac surgery may not guarantee the improvement of growth parameters.

Impact of Management Strategy on Feeding and Somatic Growth in Neonates with Symptomatic Tetralogy of Fallot: Results from the Congenital Cardiac Research Collaborative

OBJECTIVE

To evaluate early growth following primary or staged repair of neonatal symptomatic tetralogy of Fallot (sTOF).

STUDY DESIGN

We performed a retrospective, multicenter cohort study of consecutive infants with sTOF who underwent initial intervention at age ≤30 days, from 2005 to 2017. Management strategies were either primary repair or staged repair (ie, initial palliation followed by complete repair). The primary outcome was change in weight-for-age z-score (ΔWAZ) from the initial intervention to age 6 ± 2 months. Secondary outcomes included method and mode of feeding, feeding-related medications, and feeding-related readmissions. Propensity score adjustment was used to account for baseline differences between groups. A secondary analysis was performed comparing patients stratified by the presence of adequate growth (6-month ΔWAZ > -0.5) or inadequate growth (6-month ΔWAZ ≤ -0.5), independent of treatment strategy.

RESULTS

The study cohort included 143 primary repair subjects and 240 staged repair subjects. Prematurity was more common in the staged repair group. After adjustment, median ΔWAZ did not differ between treatment groups over the first 6 months of life (primary: -0.43 [IQR, -1.17 to 0.50]; staged: -0.31 [IQR, -1.31 to 0.71]; P = .55). For the entire cohort, ΔWAZ was negative (-0.36; IQR, -1.21 to 0.63). There were no between-group differences in the secondary outcomes. Secondary analysis revealed that the subjects with adequate growth were more likely to be orally fed at initial hospital discharge (P = .04).

CONCLUSIONS

In neonates with sTOF, growth trajectory over the first 6 months of life was substandard, irrespective of treatment strategy. Those patients with adequate growth were more likely to be discharged from the index procedure on oral feeds.

Risk factors for insufficient weight and height gain in children with congenital heart disease followed up at a nutrition outpatient clinic

OBJECTIVE

To describe weight and height evolution and to identify risk factors for insufficient anthropometric growth in children with congenital heart disease.

METHODS

Historical cohort study including 131 children with congenital heart disease, followed up at a nutrition outpatient clinic. The anthropometric indices over time (initial score, after 12 and 24 months of follow-up) were analyzed using generalized estimating equations. The outcome was 'insufficient weight-height gain', defined as an increase of ≤0.5 in the z-score of weight-for-age (W/A), height-for-age (H/A) or body mass index-for-age (BMI/A) after 12 months of follow-up. Multiple logistic regression models were applied to identify risk and confounding factors.

RESULTS

The z-scores of W/A (p<0.001) and BMI/A (p<0.001) improved after 12 months, as well as the three indexes after 24 months (p<0.001). At the end of this period, 55.7% of the patients did not achieve an increase of >0.5 in the Z score of W/A; 77.1%, of H/A; and 45.8%, of BMI/A. A follow-up of less than five appointments was associated with insufficient gain in W/A (OR 7.78; 95%CI 3.04-19.88), H/A (OR 10.79; 95%CI 2.22-52.45) and BMI/A (OR 2.54; 95%CI 1.12-5.75). Not having undergone cardiac surgery and being aged ≥12 months were factors associated with insufficient W/A gain (OR 3.95; 95%CI 1.38-11.29/OR 3.60; 95%CI 1.33-9.72) and BMI/A (OR 2.81; 95%CI 1.08-7.28/OR 3.39; 95%CI 1.34-8.56). Low income was associated with insufficient H/A gain (OR 4.11; 95%CI 1.25-13.46).

CONCLUSIONS

Being aged less than or 12 months, the lowest number of appointments, absence of surgical treatment and low family income were risk factors for insufficient weight and height gain in children with congenital heart disease.

Current Strategies to Optimize Nutrition and Growth in Newborns and Infants with Congenital Heart Disease: A Narrative Review

(1) Objective: This review aims to identify the clinical and practical barriers to optimizing nutrition in newborn infants with congenital heart disease (CHD) and to describe updated evidence-based recommendations for clinical and nutritional management of these patients in a narrative review. (2) Research Methods and Procedures: We conducted a search of the relevant literature published from 2000 to December 2021. (3) Results: CHD patients undergo several nutritional challenges related to the underlying cardiac disease anomaly, the potential increased risk of NEC, and delayed enteral feeding, resulting in inadequate energy intake and sub-optimal growth, increased morbidity and mortality. (4) Conclusions: To optimize nutrition and growth in newborn infants with CHD, standardized protocols should be implemented. Regular nutritional and growth assessment with a multi-disciplinary team is essential. We propose a decisional algorithm that may represent a potentially useful tool to guide clinicians to optimize growth and nutrition.

Fatores de risco para evolução pôndero-estatural insuficiente de crianças com cardiopatia congênita acompanhadas em ambulatório de nutrição clínica

Resumo Objetivo: Descrever a evolução pôndero-estatural e identificar fatores de risco para o crescimento antropométrico insuficiente de crianças com cardiopatia congênita. Métodos: Coorte histórica de 131 crianças com cardiopatia congênita acompanhadas em ambulatório de nutrição clínica. Os escores dos índices antropométricos ao longo do tempo (inicial, após 12 e 24 meses de acompanhamento) foram analisados por equações de estimativas generalizadas. O desfecho foi o ganho pôndero-estatural insuficiente, definido como aumento ≤0,5 nos escores Z de peso para idade (P/I), estatura para idade (E/I) e índice de massa corpórea para idade (IMC/I) em 12 meses de acompanhamento. Foram aplicados modelos de regressão logística múltipla para identificação dos fatores de risco e controle dos fatores de confusão. Resultados: Os escores Z de P/I (p<0,001) e IMC/I (p<0,001) melhoraram após 12 meses, e os três índices após 24 meses (p<0,001). Ao final desse período, 55,7% dos pacientes não alcançaram aumento >0,5 escore Z de P/I; 77,1%, de E/I; e 45,8%, de IMC/I. O acompanhamento inferior a cinco consultas associou-se ao ganho insuficiente de P/I (OR 7,78, IC95% 3,04–19,88), E/I (OR 10,79, IC95% 2,22–52,45) e IMC/I (OR 2,54, IC95% 1,12–5,75). Não ter sido submetido à cirurgia cardíaca e ter idade ≥12 meses estiveram associados ao ganho insuficiente de P/I (OR 3,95, IC95% 1,38–11,29/ OR 3,60, IC95% 1,33–9,72) e IMC/I (OR 2,81, IC95% 1,08–7,28/OR 3,39, IC95% 1,34–8,56), e a baixa renda, ao ganho insuficiente de E/I (OR 4,11, IC95% 1,25–13,46). Conclusões: Idade ≥12 meses, menor número de consultas, ausência de tratamento cirúrgico e baixa renda familiar foram fatores de risco para a evolução pôndero-estatural insuficiente em crianças com cardiopatia congênita.

Weight gain velocity and adequate amount of nutrition for infants with congenital diaphragmatic hernia

PURPOSE

Growth retardation is a severe morbidity in infants with congenital diaphragmatic hernia (CDH). This study aimed to determine when catch-up growth starts in infants with CDH and to determine the adequate amount of nutrition required during catch-up growth.

METHODS

This was a multicenter retrospective cohort study involving neonates with isolated CDH (born 2006-2010; n = 98). Weight gain velocity (WGV) was calculated using body weight Z-scores. The minimum required weight gain was defined as WGV ≥ 0. Patients were dichotomized into severe and non-severe cases according to diaphragmatic defects.

RESULTS

Average monthly WGV changed from < 0 to ≥ 0 at 2 months of age. Total caloric intake at 2 months of age was lower when the WGV between 1 and 3 months was < 0 in both severe cases [122 (95% confidence interval (CI) 116-128) vs. 97 (95% CI 84-110) kcal/kg/day, p = 0.02] and non-severe cases [115 (95% CI 110-120) vs. 99 (95% CI 87-111) kcal/kg/day, p < 0.001)].

CONCLUSION

Catch-up growth started at approximately 2 months of age. During this period, total caloric intake of > 122 kcal/kg/day was needed to avoid decreases in the body weight Z-score in severe cases.

The Effect of Perioperative Administration of Treprostinil in Infants with Non-restrictive Ventricular Septal Defect and Severe Pulmonary Arterial Hypertension

This study investigated the efficacy and safety of intravenous treprostinil during the perioperative period in infants with non-restrictive ventricular septal defect (VSD) and severe pulmonary arterial hypertension (PAH) undergoing surgical VSD repair. This was a retrospective study. There were 79 infants with non-restrictive VSD and severe PAH receiving surgical treatment from January to December 2019 in our cardiac center. The patients were divided into the treprostinil group and control group according to whether intravenous treprostinil was used during the perioperative period. There were no significant differences in the preoperative characteristics, including age, sex, weight, ventricular size, or preoperative pulmonary artery pressure, between the two groups. Although the pulmonary artery pressure in both groups was significantly lower postoperatively than preoperatively, the postoperative pulmonary artery systolic pressure was significantly lower in group T than in group C. The postoperative mechanical ventilation time, ICU stay, and hospital stay in group T were shorter than those in group C. Treprostinil can be used effectively and safely to reduce the perioperative pulmonary artery pressure in infants with non-restrictive VSD and severe PAH undergoing surgical VSD repair.

Impact of Palliation Strategy on Interstage Feeding and Somatic Growth for Infants With Ductal-Dependent Pulmonary Blood Flow: Results from the Congenital Catheterization Research Collaborative

Background

In infants with ductal‐dependent pulmonary blood flow, the impact of palliation strategy on interstage growth and feeding regimen is unknown.

Methods and Results

This was a retrospective multicenter study of infants with ductal‐dependent pulmonary blood flow palliated with patent ductus arteriosus (PDA) stent or Blalock‐Taussig shunt (BTS) from 2008 to 2015. Subjects with a defined interstage, the time between initial palliation and subsequent palliation or repair, were included. Primary outcome was change in weight‐for‐age Z‐score. Secondary outcomes included % of patients on: all oral feeds, feeding‐related medications, higher calorie feeds, and feeding‐related readmission. Propensity score was used to account for baseline differences. Subgroup analysis was performed in 1‐ (1V) and 2‐ventricle (2V) groups. The cohort included 66 PDA stent (43.9% 1V) and 195 BTS (54.4% 1V) subjects. Prematurity was more common in the PDA stent group (P=0.051). After adjustment, change in weight‐for‐age Z‐score did not differ between groups over the entire interstage. However, change in weight‐for‐age Z‐score favored PDA stent during the inpatient interstage (P=0.005) and BTS during the outpatient interstage (P=0.032). At initial hospital discharge, PDA stent treatment was associated with all oral feeds (P<0.001) and absence of feeding‐related medications (P=0.002). Subgroup analysis revealed that 2V but not 1V patients demonstrated significant increase in weight‐for‐age Z‐score. In the 2V cohort, feeding‐related readmissions were more common in the BTS group (P=0.008).

Conclusions

In infants with ductal‐dependent pulmonary blood flow who underwent palliation with PDA stent or BTS, there was no difference in interstage growth. PDA stent was associated with a simpler feeding regimen and fewer feeding‐related readmissions.

The development of a consensus-based nutritional pathway for infants with CHD before surgery using a modified Delphi process

IntroductionDespite improvements in the medical and surgical management of infants with CHD, growth failure before surgery in many infants continues to be a significant concern. A nutritional pathway was developed, the aim of which was to provide a structured approach to nutritional care for infants with CHD awaiting surgery.Materials and methodsThe modified Delphi process was development of a nutritional pathway; initial stakeholder meeting to finalise draft guidelines and develop questions; round 1 anonymous online survey; round 2 online survey; regional cardiac conference and pathway revision; and final expert meeting and pathway finalisation.

RESULTS

Paediatric Dietitians from all 11 of the paediatric cardiology surgical centres in the United Kingdom contributed to the guideline development. In all, 33% of participants had 9 or more years of experience working with infants with CHD. By the end of rounds 1 and 2, 76 and 96% of participants, respectively, were in agreement with the statements. Three statements where consensus was not achieved by the end of round 2 were discussed and agreed at the final expert group meeting.

CONCLUSIONS

Nutrition guidelines were developed for infants with CHD awaiting surgery, using a modified Delphi process, incorporating the best available evidence and expert opinion with regard to nutritional support in this group.

The impact of co-morbidity in childhood cystic fibrosis

A number of risk factors have been identified for deterioration of lung disease in children with Cystic Fibrosis (CF), and current management strategies are based on the prevention and treatment of such elements. Further challenge ensues when a patient has co-morbid disease in addition to CF, particularly when faced with rapidly deteriorating pulmonary status. It is difficult to measure the contribution of other pathologies to this decline and optimisation of both CF care and co-morbidity is paramount. This review explores the challenges faced when treating children with CF and co-morbid conditions, focussing on gastroesophageal reflux disease pre- and post-lung transplantation.