Longitudinal Evaluation of the Prevalence of Overweight/Obesity in Children With Congenital Heart Disease

Strategies to Overcome Barriers to Physical Activity Participation in Children and Adults Living With Congenital Heart Disease: A Narrative Review

Physical activity participation is critical for optimal physical, psychological, and cognitive health in children and adults living with congenital heart disease (CHD). Majority of the general population are not sufficiently active, and with the added psychological, physical, and socioeconomic barriers faced by individuals with CHD, it is unsurprising that many people living with CHD do not meet the recommendations for physical activity either. The aim of this review is to outline lifelong physical activity barriers faced by individuals living with CHD and provide age-appropriate strategies that can be used to ensure the development of long-term positive physical activity behaviours. Barriers to physical activity include safety fears, lack of encouragement, low exercise self-efficacy, body image concerns, limited education, socioeconomic status, reduced access to resources, and cardiac diagnosis and severity. These barriers are multifaceted and often begin in early childhood and continue to develop well into adulthood. Therefore, it is important for children to participate in physical activity from early stages of life as it has been shown to improve cardiorespiratory fitness, muscular endurance, and quality of life. Current literature demonstrates that participation in physical activity and higher intensity exercise after appropriate screening is safe and should be encouraged rather than dissuaded in people born with a congenital heart condition.

Development and Initial Validation of a Frailty Score for Pediatric Patients with Congenital and Acquired Heart Disease

Frailty is a multi-dimensional clinical syndrome that is associated with increased morbidity and mortality and decreased quality of life. Children/adolescents with heart disease (HD) perform significantly worse for each frailty domain compared to non-HD peers. Our study aimed to create a composite frailty score (CFS) that can be applied to children/adolescents with HD and evaluate associations between the CFS and outcomes. Children and adolescents (n = 30) with HD (73% single ventricle, 20% heart failure, 7% pulmonary hypertension) were recruited from 2016 to 2017 (baseline). Five frailty domains were assessed at baseline using measures validated for pediatrics: (1) Slowness: 6-min walk test; (2) Weakness: handgrip strength; (3) Fatigue: PedsQL Multi-dimensional Fatigue Scale; (4) Body composition: triceps skinfold thickness; and (5) Physical activity questionnaire. Frailty points per domain (range = 0-5) were assigned based on z-scores or raw questionnaire scores and summed to produce a CFS (0 = least frail; 25 = most frail). Nonparametric bootstrapping was used to identify correlations between CFS and cross-sectional change in outcomes over 2.2 ± 0.2 years. The mean CFS was 12.5 ± 3.5. In cross-sectional analyses of baseline data, correlations (|r|≥ 0.30) were observed between CFS and NYHA class, the number of ancillary specialists, total prescribed medications, heart failure medications/day, exercise test derived chronotropic index and percent predicted VO2peak, and between child and parent proxy PEDsQL. At follow-up, CFS was correlated with an increase in the number of heart failure medications (r = 0.31). CFS was associated with cross-sectional outcomes in youth with heart disease. Longitudinal analyses were limited by small sample sizes due to loss to follow-up.

Factors Associated with Growth in a Cohort of Children with Complex Biventricular Congenital Heart Disease

OBJECTIVES

To evaluate patterns and determinants of longitudinal growth among children requiring complex biventricular repair for congenital heart disease, as well as to assess for associations of growth with early feeding modality, comorbidities, postoperative complications, and socioeconomic characteristics.

STUDY DESIGN

A single-institution retrospective cohort study was performed in children born February 1999 to March 2009 with complex congenital heart disease who underwent biventricular repair before age 4 years, defined by Risk Adjustment in Congenital Heart Surgery-1 category 3-5. Clinical characteristics, height, weight, and body mass index (BMI) from ages 2-12 years were collected by chart review. Neighborhood-level socioeconomic data were identified using a geographic information system approach. The adjusted association of covariates with growth outcomes was estimated using multivariable linear regression models using generalized estimating equations.

RESULTS

Compared with population growth curves, the cohort (n = 150) trended toward early decrease in age-adjusted weight and height. Early tube feeding was significantly associated with decreased BMI before adolescence (-0.539; 95% CI -1.02, -0.054; P = .029). In addition, other clinical and perioperative characteristics had significant associations with growth, including low birth weight, preoperative tube feeds, need for multiple bypass runs, and diagnosis of feeding disorder.

CONCLUSIONS

Early childhood growth in children with complex biventricular repair may be impaired. Early tube feeding was associated with decreased BMI over the course of early childhood, which may indicate a need for continued close nutrition follow-up and support even beyond the duration of tube feeds.

Use of new paediatric VO2max reference equations to evaluate aerobic fitness in overweight or obese children with congenital heart disease

AIMS

Overweight and obesity in children with congenital heart disease (CHD) represent an alarming cardiovascular risk. Promotion of physical activity and cardiac rehabilitation in this population requires assessing the level of aerobic fitness (VO2max) by a cardiopulmonary exercise test (CPET). Nevertheless, the interpretation of CPET in overweight/obese children with CHD remains challenging as VO2max is affected by both the cardiac condition and the body mass index (BMI). The new paediatric VO2max  Z-score reference equations, based on a logarithmic function of VO2max, height and BMI, were applied to overweight/obese children with a CHD and compared with overweight/obese children without any other chronic condition.

METHODS AND RESULTS

In this cross-sectional controlled study, 344 children with a BMI > 85th percentile underwent a CPET (54% boys; mean age 11.5 ± 3.1 years; 100 CHD; 244 controls). Using the VO2max  Z-score equations, aerobic fitness was significantly lower in obese/overweight CHD children than that in matched obese/overweight control children (-0.43 ± 1.27 vs. -0.01 ± 1.09; P = 0.02, respectively), and the proportion of children with impaired aerobic fitness was significantly more important in obese/overweight CHD children than in matched controls (17% vs.6%, P = 0.02, respectively). The paediatric VO2max  Z-score reference equations also identified specific complex CHD at risk of aerobic fitness impairment (univentricular heart and right outflow tract anomalies). Using Cooper's weight- and height-based linear equations, similar matched-comparisons analyses found no significant group differences.

CONCLUSIONS

As opposed to the existing linear models, the new paediatric VO2max  Z-score equations can discriminate the aerobic fitness of obese/overweight children with CHD from that of obese/overweight children without any chronic disease.

REGISTRATION

ClinicalTrials.gov NCT04815577.

Consumption and Breakfast Patterns in Children and Adolescents with Congenital Heart Disease

Little is known about skipping breakfast and breakfast patterns (BP) and their evaluation according to sociodemographic, clinical, lifestyle, cardiometabolic and nutritional data in children and adolescents with congenital heart disease (CHD). This cross-sectional study with 232 children and adolescents with CHD identified the prevalence and patterns of the breakfast, described these according to sociodemographic, clinical and lifestyle characteristics, and assessed their association with cardiometabolic and nutritional markers. Breakfast patterns were identified by principal components, and bivariate and linear regression analysis were applied. Breakfast consumption was observed in 73% of participants. Four BP were identified: pattern 1 "milk, ultra-processed bread, and chocolate milk", pattern 2 "margarine and processed bread", pattern 3 "cold meats/sausages, cheeses and butter/cream" and pattern 4 "fruits/fruit juices, breakfast cereals, yogurts, and homemade cakes/pies and sweet snacks". Family history for obesity and acyanotic CHD were associated with breakfast skipping. Younger participants and greater maternal education were associated with greater adherence to pattern 1 and pattern 4. Older participants and longer post-operative time showed greater adherence to pattern 3. No association between skipping breakfast or BP and cardiometabolic and nutritional markers was observed. Nonetheless, the findings reinforce the need for nutritional guidance for healthy breakfast, aiming to reduce the consumption of ultra-processed foods and to prioritize fresh and minimally processed foods.

Participation in physical activity of adolescents with congenital heart disease

BACKGROUND

Participation in physical activity improves health in individuals with congenital heart disease. However, most do not sufficiently engage in physical activity. The aim of this study was to collect information regarding the experiences of adolescents with congenital heart disease who practiced physical activities.

METHODS

French adolescents aged 13-18 years, diagnosed with congenital heart disease, class I or II dyspnoea on the NYHA scale and authorized physical activity were interviewed individually about their physical activity experiences using a semi-structured format. The qualitative interview transcript data were analysed using a phenomenological approach; data analysis was performed independently by three researchers and merged at each step until saturation.

RESULTS

Eleven adolescents with congenital heart disease participated. Three main themes emerged: 'own representation', 'physical activity (PA) set-up' and 'environment'. Adolescents had a generally positive view of physical activity, which was associated with positive experiences. However, they reported that their physical condition limited PA, and they wished for adapted activities. The results revealed the importance of environmental factors, for example, within the social and school environments. The participants indicated that they appreciated the social interactions that PA afforded, but that integration into a group could be difficult, especially in school, with some participants describing feelings such as anxiety, frustration or guilt when they could not participate fully. PA facilitators included familial support. However, participants noted a lack of clear medical guidance to help them choose suitable activities based on their circumstances and personal preferences. They wished for the public to be better informed about congenital heart disease to reduce stigmatism.

CONCLUSIONS

This study provides valuable information for clinicians, physical educators and policy makers to help them promote physical activity and support adolescents and their families in understanding their own condition, maximizing their potential and in their choice of activities.

Clusters of lifestyle behaviors associated with atherosclerosis risk factors in children and adolescents with congenital heart disease: Floripa CHild Study

Secondary cardiovascular disease is the main cause of mortality in congenital heart disease (CHD) patients. The cardiovascular risk could be widely prevented with adherence to a healthy lifestyle; however, clusters of lifestyle behaviors related to atherosclerosis risk factors in children and adolescents with CHD remain unclear. We aimed to describe the clusters of lifestyle behaviors of children and adolescents with CHD and to evaluate their association with atherosclerosis risk factors. We conducted a cross-sectional study on 227 children and adolescents with CHD (median age:10.02 [IQR:7.08-13.02] years). Dietary intake, physical activity (PA), and sedentary behavior (SB) were evaluated. Clusters of lifestyle behaviors were determined using a two-step cluster analysis. Atherosclerosis risk factors evaluated include body fat mass, central obesity, blood pressure, lipid parameters, glucose, C-reactive protein, and carotid intima-media thickness (cIMT). Multiple logistic regressions were used. The "unhealthy: high SB + low PA" cluster was associated with elevated body fat mass, central obesity, and elevated cIMT. Furthermore, the "unhealthy: low PA + unhealthy eating habits" cluster was associated with elevated body fat mass, central obesity, and elevated glucose. The unhealthier lifestyle behavior clusters were associated with atherosclerosis risk factors in children and adolescents with CHD. Multidisciplinary strategies to promote healthy behaviors are needed to prevent cardiovascular disease in later life.

Moderate and Severe Congenital Heart Diseases Adversely Affect the Growth of Children in Italy: A Retrospective Monocentric Study

Children with congenital heart disease (CHD) are at increased risk for undernutrition. The aim of our study was to describe the growth parameters of Italian children with CHD compared to healthy children. We performed a cross-sectional study collecting the anthropometric data of pediatric patients with CHD and healthy controls. WHO and Italian z-scores for weight for age (WZ), length/height for age (HZ), weight for height (WHZ) and body mass index (BMIZ) were collected. A total of 657 patients (566 with CHD and 91 healthy controls) were enrolled: 255 had mild CHD, 223 had moderate CHD and 88 had severe CHD. Compared to CHD patients, healthy children were younger (age: 7.5 ± 5.4 vs. 5.6 ± 4.3 years, p = 0.0009), taller/longer (HZ: 0.14 ± 1.41 vs. 0.62 ± 1.20, p < 0.002) and heavier (WZ: -0,07 ± 1.32 vs. 0.31 ± 1.13, p = 0.009) with no significant differences in BMIZ (-0,14 ± 1.24 vs. -0.07 ± 1.13, p = 0.64) and WHZ (0.05 ± 1.47 vs. 0.43 ± 1.07, p = 0.1187). Moderate and severe CHD patients presented lower z-scores at any age, with a more remarkable difference in children younger than 2 years (WZ) and older than 5 years (HZ, WZ and BMIZ). Stunting and underweight were significantly more present in children affected by CHD (p < 0.01). In conclusion, CHD negatively affects the growth of children based on the severity of the disease, even in a high-income country, resulting in a significant percentage of undernutrition in this population.

Cardiopulmonary Fitness of Preschoolers with Congenital Heart Disease: An Observational Study

With advancements in cardiopulmonary rehabilitation over the past few decades, the survival rate of patients with congenital heart disease (CHD) has increased. However, the Cardiopulmonary fitness (CPF) of these patients is poor. Here, we aimed to investigate CPF in preschoolers with CHD (aged 4 to 6 years) using cardiopulmonary exercise testing. We retrospectively compared 102 healthy preschoolers with 80 preschoolers with CHD. The latter had lower peak oxygen consumption, oxygen consumption at anaerobic threshold and metabolic equivalent at anaerobic threshold. The same result was observed in boys with CHD, but not in girls, when sex was sub-analyzed. Considering the body composition, children with CHD had a lower fat-free mass index (FFMI) than their healthy peers. Healthy preschoolers with a normal body mass index (BMI) had higher anaerobic threshold and peak metabolic equivalent values than overweight or underweight children. This was categorized under the BMI reference of the Ministry of Health and Welfare in Taiwan. In conclusion, the CPF difference between the CHD and healthy groups was identified as early as in preschool age, and better CPF in healthy preschoolers within the normal BMI range suggests the importance of weight control in young children.

Ultra-processed food intake is associated with children and adolescents with congenital heart disease clustered by high cardiovascular risk factors

The excessive intake of ultra-processed foods (UPF) is associated with an increase in cardiovascular risk. However, the effect of UPF intake on cardiovascular health in children and adolescents with congenital heart disease (CHD) is unknown. The aim of the present study was to describe UPF intake and evaluate associations with isolated cardiovascular risk factors and children and adolescents with CHD clustered by cardiovascular risk factors. A cross-sectional study was conducted involving 232 children and adolescents with CHD. Dietary intake was assessed using three 24-hour recalls. UPFs were categorized using the NOVA classification. The cardiovascular risk factors evaluated were central adiposity, elevated high-sensitivity C-reactive protein (hs-CRP) and subclinical atherosclerosis. The clustering of cardiovascular risk factors (waist circumference, hs-CRP and carotid intima-media thickness) was performed, allocating the participants to two groups (high versus low cardiovascular risk). UPFs contributed 40.69% (SD 6.21) to total energy intake. The main UPF groups were ready-to-eat and take-away/fast foods (22.2% energy from UPFs). The multivariable logistic regression revealed that an absolute increase of 10% in UPF intake (OR=1.90; 95% CI: 1.01;3.58) was associated with central adiposity. An absolute increase of 10% in UPF intake (OR=3.77; 95% CI: 1.80;7.87) was also associated with children and adolescents with CHD clustered by high cardiovascular risk after adjusting for confounding factors. Our findings demonstrate that UPF intake should be considered a modifiable risk factor for obesity and its cardiovascular consequences in children and adolescents with CHD.

Congenital Heart Disease: Growth Evaluation and Sport Activity in a Paediatric Population

(1) Objective: To evaluate: (i) the associations of age and disease severity with anthropometric indices and weight status, (ii) the difference in the frequency of sports activity among different levels of disease severity in paediatric patients with congenital heart disease (CHD). (2) Methods: Clinical data of Caucasian children (aged 2–18 years) diagnosed with CHD (2005–2018) were retrospectively collected from the electronic register of outpatient visits. Of the 475 children with CHD, 368 children and their 1690 complete anthropometric measurements were eligible for inclusion in our analysis. (3) Results: Significant increase with age was observed for weight z-score [beta (95%CI): 0.03 (0.02, 0.05) for one-unit of age] and BMI z-score [0.06 (0.03, 0.08)] but not for height z-score. The probability of being underweight and overweight/obese increased and decreased with disease severity, respectively. The obesity probability of patients with mild CHD (0.06 [95%CI: 0.03, 0.08]) was not statistically distinguishable from that of patients with moderate CHD (0.03 [95%CI: 0.02, 0.05]), whereas it was lower in patients with severe CHD (0.004 [95%CI: 0.0, 0.009]). No obese patients with a univentricular heart defect were observed. Days spent in sport activities were equal to 1.9 [95%CI: 1.6, 2.2] days/week, 1.9 [1.5, 2.2], 1.4 [1.1, 1.7] and 0.7 [0.1, 1.3] in patients with mild, moderate, severe and univentricular CHD, respectively. (4) Conclusions: The risk of being overweight and obese should not be underestimated in paediatric patients diagnosed with CHD, especially in children with mild or moderate heart defects. It could be prevented or reduced by promoting a healthy lifestyle.

Born to Age: When Adult Congenital Heart Disease Converges With Geroscience

Advances in imaging, catheter-based interventions, congenital heart disease surgery, and clinical management of congenital heart disease (CHD) have yielded a dramatic change in age distribution of the CHD population. This implores clinicians and researchers to gain a better understanding of aging, as this will be the cornerstone to how we plan and manage this rapidly evolving group of patients. In this article, we first review the demographic changes in the CHD population and then describe the systemic complications of disease observed in young patients with CHD, following which we discuss general concepts in aging that may be transferable to the CHD population. Finally, we review inflammation and its potential impact on aging. We provide a new lens on aging in CHD and its functional consequences in CHD, with the goal of stimulating an exchange of knowledge between geroscientists and CHD.

Anthropometry Based Growth and Body Composition in Infants with Complex Congenital Heart Disease

BACKGROUND

Infants with congenital heart disease (CHD) often have poor growth and altered body composition (fat and muscle accretion).

AIM

Describe growth patterns in infants with CHD using interval weight, length, head circumference (HC), triceps (TSF), subscapular skinfolds (SSSF), and mid-upper arm circumference (MUAC) measurements.

SUBJECTS AND METHODS

A total of 120 infants enrolled: 48% healthy and 58% with CHD (45% single ventricle [SV]; 55% two ventricle [2V] physiology). Weight, length, HC, TSF, SSSF, and MUAC measured at 3-, 6-, 9-, and 12-months of age.

RESULTS

CHD infants had lower weight, length, and HC z-scores at 3-, 6-, and 9-months. At 9-months, infants with SV physiology had larger TSF and SSSF z-scores over 2V and healthy infants. Overall MUAC z-scores were smaller at 3- and 6-months in infants with CHD.

CONCLUSISON

Infants with CHD have a complex pattern of growth. Longitudinal growth and body composition measurements provide information to better understand this pattern.

Activity During the COVID-19 Pandemic in Children with Cardiac Rhythm Management Devices

Decreased physical activity is associated with cardiovascular, metabolic and mental health disease. While decreases in physical activity during the COVID-19 pandemic have been described in the general population, there is a paucity of data regarding children with underlying cardiovascular disease. We hypothesized there would be a decrease in physical activity at the onset of the COVID-19 pandemic. Performed a single-center, retrospective cohort study of children aged < 19 years with cardiac rhythm management devices. Patients were included if they had device-measured physical activity data from > 80% of dates from February 3, 2020 through June 30, 2020. Patients with significant neurologic/neuromuscular disease were excluded. We identified 144 patients with a median age of 15.4 years. 47% were female. 34% had congenital heart disease, 20% had cardiomyopathy, 19% had an inherited arrhythmia syndrome and 5% had atrioventricular block without congenital heart disease. 47% of patients had an implantable loop recorder, 29% had a permanent pacemaker and 24% had an implantable cardioverter-defibrillator. We observed a significant decrease in device-measured physical activity from baseline (February 3-March 9), with up to a 21% decrease in physical activity during mid-March through early May. Activity levels returned to pre-pandemic levels in June. Physical activity sharply declined in children with cardiac rhythm management devices at the onset of the COVID-19 pandemic. These data highlight the importance of finding strategies to maintain physical activity during the current pandemic and future public health crises.

Physical activity and aerobic fitness in children with inherited cardiac diseases

BACKGROUND

Because of sports and exercise restrictions, children with inherited cardiac disease are at risk of physical deconditioning. Guidelines on sports participation in cardiovascular disease have become less restrictive over time, but their real-life application and behavioural impact have seldom been evaluated in children.

AIMS

We aimed to evaluate adherence to the 2020 European Society of Cardiology guidelines on sports and exercise in children with inherited cardiac arrhythmia and inherited cardiomyopathy; we also sought to evaluate their aerobic fitness, and the behavioural impact of inherited cardiac diseases on physical activity in children.

METHODS

Children aged 6-18 years with inherited cardiomyopathy or inherited cardiac arrhythmia were eligible for this cross-sectional study. Clinical, demographic and qualitative data were analysed.

RESULTS

A total of 32 children were included in the study (mean age 12.7±3.5 years). Most children (81.3%) complied with the 2020 European Society of Cardiology guidelines; they were physically active and had good overall aerobic fitness, with a mean peak oxygen uptake (VO₂) value of 36.5±8.0mL/kg/min (84.0±17.2% of theoretical value). As a result of personal or parental behaviour, some children at risk of sudden cardiac death did not comply with the recommended upper limit of physical activity intensity, whereas others at low risk did not comply with the lower limit.

CONCLUSION

Most children with inherited cardiac arrhythmia or inherited cardiomyopathy complied with current 2020 European Society of Cardiology guidelines on sports cardiology and exercise in cardiovascular disease.

Assessment of Nutritional Status of Children With Congenital Heart Disease: A Comparative Study

Background: Malnutrition poses a great burden to children in the tropics. However, this seems to be accentuated in children with congenital heart disease.

Objectives: The present study is therefore aimed at determining the nutritional status of children with congenital heart disease and to compare them with those without congenital heart disease.

Methods: This is a cross-sectional study, where congenital heart disease was diagnosed by means of echocardiograph. Anthro software was used to calculate Z scores for weight for age (WAZ), height for age (HAZ), and weight for height (WHZ). Body mass index (BMI) was calculated by the formula BMI = Weight (Kg)/height (M2).

Results: The body mass index-for-age z-score (BAZ) and height/length-for-age z-score (HAZ) were calculated for both subjects and controls to determine their nutritional status. It was observed that 38.5% (112/291) of the subjects were wasted (BAZ < −2SD) compared to 6.25% (16/256) of the controls and the difference was statistically significant (χ2 = 81.2, p < 0.001). Stunting (height/length-for-age z-score < −2SD) was also observed in a greater proportion of subjects than controls as 37.8% (107/291) of subjects were stunted compared with 7.0% (18/256) of the controls (χ2 = 69.9, p < 0.001). The under-five subjects had more cases of malnutrition than the controls of same age group as illustrated in Table 6. Whereas 42.9% (96/224) of the under-five subjects were wasted, only 6.2% (12/192) of the controls were wasted. On the other hand, 4.2% (8/192) of the under-five controls were obese compared to 0.9% (2/224) of the subjects of similar age group.

Conclusion: Children with congenital heart disease present with varying degrees of malnutrition that is worse compared with children without congenital heart disease. The impact of malnutrition is worse among children under the age of five. Wasting is more prevalent in children with cyanotic heart disease compared with those with acyanotic congenital heart disease. Overweight and obesity were notable features of malnutrition in children with congenital heart disease, but this is worse in children without congenital heart disease.

Early high-energy feeding in infants following cardiac surgery: a randomized controlled trial

BACKGROUND

Effective nutrition programs are beneficial for nutritional recovery in infants. Few studies have focused on the effect of early high-energy feeding after open heart surgery. This study sought to assess the effects of early high-energy feeding in infants after congenital heart surgery.

METHODS

Patients at a tertiary pediatric cardiology center who underwent open heart surgery between July 2016 and July 2018 were recruited and randomly allocated to 1 of the following 2 groups: (I) the intervention group (postoperative early high-energy feeding; n=124); and (II) the control group (no intervention; n=120).The primary endpoints of average energy delivery and growth Z-scores [i.e., weight-for-height Z-score (WHZ), weight-for-age Z-score (WAZ), and height-for-age Z-score (HAZ)] were recorded preoperatively, during the intensive care unit (ICU) stay, at discharge, and at 1 and 3 months postoperatively. The secondary endpoints of malnutrition recovery, ventilator support time, infection rate, and cardiac ICU (CICU) stay were also recorded.

RESULTS

A total of 244 infants were included in the study. There were no significant differences in the baseline features between the 2 groups. The intervention group received higher calories on average than the control group (44.5 vs. 34.7; P<0.001). At discharge from the ICU, the WHZ (-2.29 vs. -2.76; P<0.001) and WAZ (-3.08 vs. -3.43; P=0.005) of patients in the intervention group were higher than those of patients in the control group. Ventilator support time (P=0.004), CICU stay (P=0.045), and infection rate (P=0.001) were significantly lower in the intervention group than the control group. At 3 months post-surgery, the intervention group exhibited a higher malnutrition recovery rate than the control group (19.4% vs. 6.5%; P=0.002).

CONCLUSIONS

The administration of early high-energy feeding to infants after congenital heart surgery is associated with improved growth, reduced CICU stay, decreased ventilator support time, and reduced postoperative infection rates.

TRIAL REGISTRATION

ClinicalTrials NCT04609358.

Overweight and Obesity in Patients with Congenital Heart Disease: A Systematic Review

Background: Overweight and obesity have become a major public health concern in recent decades, particularly in patients with chronic health conditions like congenital heart disease (CHD). This systematic review elaborates on the prevalence and the longitudinal development of overweight and obesity in children and adults with CHD. Methods: A systematic literature search was conducted in PubMed, Cochrane, and Scopus from January 2010 to December 2020 on overweight and obesity prevalence in children and adults with CHD. Results: Of 30 included studies, 15 studies evaluated 5680 pediatric patients with CHD, 9 studies evaluated 6657 adults with CHD (ACHD) and 6 studies examined 9273 both pediatric patients and ACHD. Fifteen studies received the quality rating “good”, nine studies “fair”, and six studies “poor”. In children with CHD, overweight prevalence was between 9.5–31.5%, and obesity prevalence was between 9.5–26%; in ACHD, overweight prevalence was between 22–53%, and obesity was between 7–26%. The prevalence of overweight and obesity was thereby similar to the general population. Overweight and obesity have been shown to increase with age. Conclusion: The prevalence of overweight and obesity in children and adults with CHD is similar to the general population, demonstrating that the growing obesity pandemic is also affecting the CHD population.

Health-related quality of life and physical activity in children with inherited cardiac arrhythmia or inherited cardiomyopathy: the prospective multicentre controlled QUALIMYORYTHM study rationale, design and methods

Background

Advances in paediatric cardiology have improved the prognosis of children with inherited cardiac disorders. However, health-related quality of life (QoL) and physical activity have been scarcely analysed in children with inherited cardiac arrhythmia or inherited cardiomyopathy. Moreover, current guidelines on the eligibility of young athletes with inherited cardiac disorders for sports participation mainly rely on expert opinions and remain controversial.

Methods

The QUALIMYORYTHM trial is a multicentre observational controlled study. The main objective is to compare the QoL of children aged 6 to 17 years old with inherited cardiac arrhythmia (long QT syndrome, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia, or arrhythmogenic right ventricular dysplasia), or inherited cardiomyopathy (hypertrophic, dilated, or restrictive cardiomyopathy), to that of age and gender-matched healthy subjects. The secondary objective is to assess their QoL according to the disease’s clinical and genetic characteristics, the level of physical activity and motivation for sports, the exercise capacity, and the socio-demographic data. Participants will wear a fitness tracker (ActiGraph GT3X accelerometer) for 2 weeks. A total of 214 children are required to observe a significant difference of 7 ± 15 points in the PedsQL, with a power of 90% and an alpha risk of 5%.

Discussion

After focusing on the survival in children with inherited cardiac disorders, current research is expanding to patient-reported outcomes and secondary prevention. The QUALIMYORYTHM trial intends to improve the level of evidence for future guidelines on sports eligibility in this population.

Trial registration ClinicalTrials.gov Identifier: NCT04712136, registered on January 15th, 2021 (https://clinicaltrials.gov/ct2/show/NCT04712136).

Somatic growth in children with congenital heart disease at 10 years of age: Risk factors and longitudinal growth

BACKGROUND

Children with congenital heart disease (CHD) are at risk of impaired growth.

AIMS

To describe height, weight, head circumference (HC), and body mass index (BMI) at 10 years and identify risk factors for altered longitudinal growth in children with CHD.

STUDY DESIGN

Growth parameters were evaluated from birth until 10 years using z-scores. The impact of cardiac and noncardiac factors on longitudinal growth was investigated.

SUBJECTS

A total of 135 children with different types of CHD who underwent cardiopulmonary bypass surgery, no genetic disorder.

OUTCOME MEASURES

Head circumference, weight, height and BMI.

RESULTS

At 10 years, z-scores for height and BMI did not differ from the Swiss population (P > 0.1). Z-scores for weight and HC were significantly below the norm (-0.38 and - 0.71, P < 0.01). From 1 to 10 years, all growth parameters except BMI increased significantly (P ≤ 0.001, BMI: P = 0.14). Lower gestational age and longer length of hospitalization were associated with either impaired head circumference or length at 10 years, while lower socioeconomic status was associated with higher BMI and weight at 10 years (all P < 0.05).

CONCLUSION

Despite partial catch-up, somatic growth remains impaired in children with CHD with weight and HC below the norm at 10 years. The only cardiac factor associated with impaired longitudinal growth was duration of hospital stay. Furthermore, lower socioeconomic background may pose a risk of overweight at older age. Close monitoring of growth parameters and parental counselling in all CHD children is advisable beyond early childhood to ensure optimal somatic growth.

Overfeeding and obesity in young children with positive pressure ventilation via tracheostomy following cardiac surgery

OBJECTIVES

Infants with CHD requiring positive pressure ventilation via tracheostomy are especially vulnerable to malnutrition following cardiac surgery. Current post-operative feeding recommendations may overestimate the caloric needs.

DESIGN

We retrospectively studied infants requiring tracheostomy after cardiac surgery. Anthropometric and nutritional data were collected, including caloric goals, weight-for-age z score, length-for-age z score, and weight-for-length z score. Changes in anthropometrics over time were compared to ascertain the impact of nutritional interventions. Data were shown as mean ± standard deviation.

RESULTS

Nineteen infants with CHD required tracheostomy at 160 ± 109 days (7-364 days), 13 had reparative surgery, and 6 had palliative surgery for single ventricle. The indications for tracheostomy consisted of airway abnormality/obstruction (n = 13), chronic respiratory failure (n = 7), and/or vocal cord paresis (n = 2). Initial maintenance nutritional target was set at 100-130 cal/kg per day. Fourteen patients (73.7%) became obese (maximum weight-for-length z score: 2.59 ± 0.47) under tracheostomy and gastrostomy feeding, whereas five patients did not (weight-for-length z score: 0.2 ± 0.83). Eight obese patients (weight-for-length z score: 2.44 ± 0.85) showed effective reduction of obesity within 6 months (weight-for-length z score: 0.10 ± 0.20; p < 0.05 compared with pre-adjustment) after appropriate feeding adjustment (40-90 cal/kg per day). Overall mortality was high (31.6%) in this population.

CONCLUSION

Standard nutritional management resulted in overfeeding and obesity in young children with CHD requiring positive pressure ventilation via tracheostomy. Optimal nutritional management in this high-risk population requires close individualised management by multidisciplinary teams.

Obesity across the lifespan in congenital heart disease survivors: Prevalence and correlates

BACKGROUND

Congenital heart disease (CHD) survivors are at risk for cardiovascular comorbidities exacerbated by obesity.

OBJECTIVES

Determine relationships between overweight/obesity and medical factors across the lifespan of CHD.

METHODS

Lesion severity, weight, blood pressure, cardiac and other comorbidities, and cardiac medications were abstracted from the medical records of 3790 CHD patients, aged ≥6 years, who attended CHD care in the Midwestern U.S.

RESULTS

The proportion of patients with overweight/obesity increased across the lifespan, with 73% of adults affected by overweight/obesity. Obesity was more prevalent among patients with moderate lesions (29%). Overweight/obesity was associated with elevated blood pressure across age and lesion severity. Young adults with obesity and simple or moderate lesions had more comorbidities (simple: IRR = 3.1, moderate: IRR = 2.3) and cardiac medications (simple: IRR = 2.2, moderate: IRR = 1.7).

CONCLUSIONS

Obesity and its cardiovascular correlates are present across the lifespan for CHD survivors, highlighting the need for early prevention and intervention.

Pediatric Dyslipidemia-Beyond Familial Hypercholesterolemia

Dyslipidemia is seen with increasing prevalence in young Canadians, mainly mild to moderate hypertriglyceridemia secondary to obesity. This review focuses on pediatric dyslipidemias excluding familial hypercholesterolemia (FH), but including both severe and mild to moderate hypertriglyceridemia, combined hyperlipidemia, and elevated lipoprotein(a) [Lp(a)]. We suggest that for Canadian children and adolescents with dyslipidemia, atherosclerotic cardiovascular disease (ASCVD) risk assessment should include both low-density lipoprotein cholesterol and triglyceride measurement. To further stratify risk, determination of non-high-density lipoprotein cholesterol is recommended, for both its ability to predict ASCVD and convenience for the patient because fasting is not required. Similarly, apolipoprotein B measurement (fasting or nonfasting), where available, can be helpful. Lp(a) measurement should not be routine in childhood, but it can be considered in special circumstances. After ruling out secondary causes, the foundation for management of pediatric dyslipidemia includes weight regulation, optimizing diet, and increasing activity level. At present, randomized clinical trial data to guide pharmaceutical management of pediatric hypertriglyceridemia or other non-FH pediatric dyslipidemias are scarce. Pharmaceutical management should be reserved for special situations in which risk of complications such as acute pancreatitis or ASCVD over the intermediate term is high and conservative lifestyle-based interventions have been ineffective.

Negative Impact of Obesity on Ventricular Size and Function and Exercise Performance in Children and Adolescents With Repaired Tetralogy of Fallot

BACKGROUND

Up to 25% of children with congenital heart disease are obese, which may have negative physiologic consequences for patients with repaired tetralogy of Fallot (rTOF).

METHODS

Patients with rTOF who underwent cardiac magnetic resonance (CMR) imaging and cardiopulmonary exercise testing from 2007 to 2018 were reviewed. Complex rTOF patients were excluded. Obese patients (body mass index [BMI] ≥ 95th percentile) were compared with normal-weight patients (BMI < 85th percentile). CMR data were indexed to actual body surface area (aBSA), height, and BSA assuming ideal body weight (iBSA).

RESULTS

We compared 32 obese patients matched with 64 normal-weight patients. Obese vs normal-weight patients had significantly lower right (RV; median 45% [interquartile range 42%-48%] vs 52% [47%-55%]; P < 0.0001) and left (LV; 52% [47%-56%] vs 56% [54%-60%]; P < 0.0001) ventricular ejection fractions (EFs). There were no statistically significant differences regarding aBSA-indexed volumes of the RV or LV at either end-diastole (EDV) or end-systole (ESV). However, when indexed to either height or iBSA, obese patients had significantly greater RVEDV and LVEDV, greater LV mass, and higher RV and LV stroke volumes. Obese patients had lower peak oxygen consumption and oxygen consumption at anaerobic threshold. These results did not change after adjusting for degree of pulmonary regurgitation.

CONCLUSIONS

Obesity is associated with increased biventricular size, decreased biventricular EFs, and impaired exercise performance after rTOF. These data suggest a potential role for cardiac rehabilitation for weight management and to optimize fitness.

Added sugar and trans fatty acid intake and sedentary behavior were associated with excess total-body and central adiposity in children and adolescents with congenital heart disease

BACKGROUND

Over the past three decades, the prevalence rate of overweight and obesity has increased in survivors with congenital heart disease, and little is known about the body composition and its association with clinical characteristics and lifestyle factors.

OBJECTIVES

To evaluate excess total-body adiposity and central adiposity and, to describe associated factors.

METHODS

Cross-sectional study with children and adolescents who underwent procedure to treat congenital heart disease, from January to July 2017. Sociodemographic and clinical characteristics, and lifestyle factors (dietary intake, physical activity, and sedentary behavior) were assessed. Adiposity was assessed using air-displacement plethysmography and waist circumference. Factors associated with excess total-body adiposity and central adiposity were analyzed using logistic regression models.

RESULTS

Of 232 patients, 22.4% were identified with excess total-body adiposity and 24.6% with central adiposity. Significant factors positively associated with excess total-body adiposity were intake of added sugar and trans fatty acids, adjusted for confounding factors. Similarly, lifestyle factors were positively associated with central adiposity: intake of added sugar and trans fatty acids, sedentary behavior, and family history of obesity.

CONCLUSIONS

Lifestyle factors were associated with excess total-body adiposity and central adiposity. Assessment of body composition and healthy-lifestyle counseling into outpatient care may be the key point to prevent obesity in children and adolescents with congenital heart disease.

Energy Balance-Related Behaviors and Body Mass Index in Asian School-Aged Children With Congenital Heart Disease

BACKGROUND

Overweight/obesity is a substantial global public health concern, which can be caused by genetic factors and energy balance-related behaviors (EBRBs). If it occurs in children with congenital heart disease (CCHD), it can yield an extra burden on their health. Most studies on CCHD have taken place in Western societies, leaving Asian populations understudied, especially children.

OBJECTIVE

We sought (1) to determine body mass index distribution among school-aged CCHD in Taiwan, (2) to ascertain whether the body mass index of CCHD differs from that of the general population, (3) to describe EBRBs in CCHD, and (4) to identify factors associated with underweight and overweight/obesity among CCHD.

METHODS

In this cross-sectional study, 97 child-parent dyads (53.6% boys; mean age, 9.73 years; 25.8% moderate-to-severe heart conditions) were enrolled. Self-administered questionnaires were used to collect demographics, medical factors, food frequency, physical activity, and sedentary behaviors. Anthropometric measurements were taken in the hospital. Independent predictors of EBRBs and health conditions were calculated through logistic regression analysis.

RESULTS

Among Taiwanese CCHD, 19.6% were underweight and 14.4% were overweight/obese. Children with moderate-to-severe heart defects were more often underweight. Body mass index did not differ between CCHD and children in the general population. More complex heart defects and asthma were associated with being underweight, whereas sedentary behaviors, cardiomegaly, and the New York Heart Association classification II to IV were associated with being overweight/obese.

CONCLUSIONS

Sedentary lifestyle is seemingly the only EBRB correlated with being overweight. Physical activity programs for children may help prevent and treat overweight or obesity in Asian CCHD, similar to Western countries.

Does obesity affect the short-term outcomes after cardiothoracic surgery in adolescents with congenital heart disease?

BACKGROUND

Obesity is a modifiable, independent risk factor for mortality and morbidity after cardiovascular surgery in adults. Our objective was to evaluate the impact of obesity on short-term outcomes in adolescents undergoing surgery for congenital heart disease (CHD).

METHODS

This retrospective chart review included patients 10-18 years of age who underwent CHD surgery. Our exclusion criteria were patients with a known genetic syndrome, heart transplantation, and patients with incomplete medical records. The clinical data collected included baseline demographics and multiple perioperative variables. Charting the body mass index in the Centers for Disease Control and Prevention growth curves, the entire cohort was divided into three categories: obese (>95th percentile), overweight (85th-95th percentile), and normal weight (<85th percentile). The composite outcome included survival, arrhythmias, surgical wound infection, acute neurologic injury, and acute kidney injury.

RESULTS

The study cohort (n = 149) had a mean standard deviation (SD), body mass index (BMI) of 22.6 ± 6.5 g/m2, and 65% were male. There were 27 obese (18.1%), 24 overweight (16.1%), and 98 normal weight (65.8%) patients. Twenty-seven (18%) patients had composite adverse outcomes. Overweight and obese patients had significantly higher adverse outcomes compared with normal weight patients (odds ratio (OR): 2.9; confidence interval (CI): 1-8.5, p = 0.04 and OR: 3; CI: 1-8.5, p = 0.03, respectively). In multivariate analysis, obesity was an independent predictor of adverse outcome in our cohort (p = 0.04).

CONCLUSIONS

Obesity is associated with short-term adverse outcome and increased health resource utilisation in adolescents following surgery for CHD. Further studies should evaluate if intervention in the preoperative period can improve outcomes in this population.

Longitudinal growth in patients with single ventricle cardiac disease receiving tube-assisted feeds

OBJECTIVE

Children with single ventricle cardiac disease (SVCD) have poor growth in early life. Tube-assisted feeding (TF) is used to improve weight gain, but its impact on long-term growth remains unknown. We sought to compare the longitudinal growth of SVCD patients receiving TF after initial cardiac surgery with those fed entirely by mouth.

DESIGN

We conducted a retrospective cohort study of SVCD patients who underwent initial surgical palliation between 1999 and 2009. We defined TF as the use of nasogastric, gastrostomy, or jejunostomy TF. We compared maximal attained growth z-scores for each year of life between TF and non-TF patients. A secondary analysis compared surgical and clinical factors between groups.

RESULTS

A total of 134 patients were included; 64% were male and 68% underwent the Norwood operation. One third of patients (44) received TF. Adjusting for age, TF patients had an average of 0.56 lower weight-for-age z-score (WAZ) than non-TF patients (P = 0.007) through the age of 6 years. Longitudinal height was not affected by TF status (P = 0.15). In a subanalysis of Norwood patients, TF patients had lower WAZ at initial hospital discharge despite longer LOS. TF patients had diminished WAZ after adjusting for complications, interstage hospitalizations, and timing of subsequent operations.

CONCLUSIONS

In this single-center study, patients with SVCD requiring TF at discharge from initial surgical palliation had diminished WAZ at discharge and on long-term follow-up, despite controlling for other identifiable risk factors. Further investigation is needed to understand the mechanisms underlying this phenomenon and to risk stratify infants who go home on TF.

Impaired pulmonary function and its association with clinical outcomes, exercise capacity and quality of life in children with congenital heart disease

BACKGROUND

Impaired pulmonary function is an independent predictor of mortality in adult congenital heart disease (CHD), but has been scarcely studied in the paediatric CHD population.

AIMS

To compare the pulmonary function of children with CHD to healthy controls, and evaluate its association with clinical outcomes, exercise capacity, and quality of life.

METHODS

Cross-sectional multicentre study among 834 children (555 CHD and 279 control subjects) who underwent a complete spirometry and a cardiopulmonary exercise test (CPET). The 5th centile (Z-score = -1.64) was used to define the lower limit of normal. The association of clinical and CPET variables with spirometry was studied using a multivariate analysis. Children and their parents filled in the Kidscreen health-related quality of life questionnaire.

RESULTS

Forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1) Z-scores values were lower in children with CHD than controls (-0.4 ± 1.5 vs. 0.4 ± 1.3, P < 0.001 and -0.5 ± 1.4 vs. 0.4 ± 1.2, P < 0.001, respectively), without any obstructive airway disorder. Restrictive pattern was more frequent in CHD patients than in controls (20% vs. 4%, P < 0.0001). FVC Z-scores were predominantly impaired in complex CHD, such as heterotaxy (-1.1 ± 0.6), single ventricle (-1.0 ± 0.2), and complex anomalies of the ventricular outflow tracts (-0.9 ± 0.1). In multivariate analysis, FVC was associated with age, body mass index, peak oxygen uptake, genetic anomalies, the number of cardiac surgery and cardiac catheter procedures. FVC and FEV1 correlated with self and proxy-related quality of life scores.

CONCLUSION

These results suggest that pulmonary function should be monitored early in life, from childhood, in the CHD population.

TRIAL REGISTRATION NUMBER

NCT01202916, post-results.

Risk factors for development of obesity in an ethnically diverse CHD population

OBJECTIVES

Previous cross-sectional studies have demonstrated obesity rates in children with CHD and the general paediatric population. We reviewed longitudinal data to identify factors predisposing to the development of obesity in children, hypothesising that age may be an important risk factor for body mass index growth.Study designRetrospective electronic health records were reviewed in all 5-20-year-old CHD patients seen between 2011 and 2015, and in age-, sex-, and race/ethnicity-matched controls. Subjects were stratified into aged cohorts of 5-10, 11-15, and 15-20. Annualised change in body mass index percentile (BMI%) over this period was compared using paired Student's t-test. Linear regression analysis was performed with the CHD population.

RESULTS

A total of 223 CHD and 223 matched controls met the inclusion criteria for analysis. Prevalence of combined overweight/obesity did not differ significantly between the CHD cohort (24.6-25.8%) and matched controls (23.3-29.1%). Univariate analysis demonstrated a significant difference of BMI% change in the age cohort of 5-10 (CHD +4.1%/year, control +1.7%/year, p=0.04), in male sex (CHD +1.8%/year, control -0.3%/year, p=0.01), and status-post surgery (CHD 2.03%/year versus control 0.37%, p=0.02). Linear regression analysis within the CHD subgroup demonstrated that age 5-10 years (+4.80%/year, p&lt;0.001) and status-post surgery (+3.11%/year, p=0.013) were associated with increased BMI% growth.

CONCLUSIONS

Prevalence rates of overweight/obesity did not differ between children with CHD and general paediatric population over a 5-year period. Longitudinal data suggest that CHD patients in the age cohort 5-10 and status-post surgery may be at increased risk of BMI% growth relative to peers with structurally normal hearts.

Obesity trends in children, adolescents, and young adults with congenital heart disease

OBJECTIVES

To determine the prevalence, age of onset, and risk factors for overweight and obesity in children with congenital heart disease (CHD).

STUDY DESIGN

Children with CHD who were seen at our institution from 1996 to 2017 were studied. Patients were full-time residents of the United States and were receiving all cardiac care at our institution. Patients were categorized by age and CHD diagnosis. The date of last normal weight for age and the date of first recorded weight in the range of overweight and obese were documented.

RESULTS

Nine hundred sixty-eight patients with CHD were included. The prevalence of overweight and obesity was 31.5% and 16.4%, respectively. For patients who became overweight or obese, the last recorded normal weight was between 6 and 10 years of age. Electrophysiologic disease and older age were risk factors for obesity.

CONCLUSIONS

Children with CHD have an increasing risk of becoming overweight and obese in early childhood. This study provides important information and identifies critical period to implement preventative measures and counsel families about the risk of obesity in CHD.

Spiritually Sensitive Intervention to Mitigate Depressive Symptoms Among Hospitalized Children Affected With Congenital Heart Diseases: Insights for Holistic Pediatric Nursing

This article reports on an experiment in 28 pediatric hospitals across 14 African and Asian cities. The aim was to examine the effect of a customized spiritually sensitive intervention (SSI) on mitigating depressive symptoms among hospitalized children with congenital heart diseases (CHD). Results showed that post-SSI, 1,139 treatment group children were less depressed vis-à-vis the control group. The SSI was more effective for children from African cities, boys, middle class, Christians and Buddhists, those undergoing medical care for ventricular septal defects, children who stayed in the hospital for 2 to 3 weeks and who regularly self-practiced the lessons after hospital discharge. The SSI could be effectively used for holistic pediatric nursing and health care across contexts with CHD affected children, with some culture-specific variations for greater impact.

[Overweight and obesity in children treated for congenital heart disease]

INTRODUCTION

The negative impact of overweight and obesity is potentially greater in children affected by a congenital heart disease (CHD). The aim of this study is to calculate the proportion of overweight and obesity in children who underwent an intervention for CHD, and to investigate systolic arterial hypertension as a possible early cardiovascular complication.

PATIENTS AND METHODS

A retrospective study was conducted on patients aged 6-17 years treated for CHD, and healthy control subjects, followed-up in a Paediatric Cardiology Clinic. Body mass index percentiles were calculated according to the criteria of WHO. A review was performed on the anthropometric and clinical data, as well as the systolic blood pressure (SBP).

RESULTS

A total of 440 patients were included, of which 220 had CHD. The proportion of combined obesity and overweight (body mass index percentile ≥85) was 36.4% (37.3% in healthy subjects and 35.4% in patients with CHD, P=.738). A higher prevalence of obesity (body mass index percentile ≥97) was found in CHD patients (22.7%) compared to 15.5% in healthy subjects (P=.015). SBP percentiles were higher in overweight compared to normal-weight patients (P < .001). The prevalence of SBP readings ≥ the 95th percentile was greater in overweight than in normal weight CHD patients (29.5% versus 7.7%, P < .001) and also in the overweight healthy controls compared to those of normal weight (12.2% versus 0.7%, P < .001).

CONCLUSIONS

The proportion of obesity is high in children treated for CHD and it is associated with elevated SBP levels. The risk of long-term complications needs to be reduced by means of prevention and treatment of obesity in this vulnerable population.

A Translational Model of Incomplete Catch-Up Growth: Early-Life Hypoxia and the Effect of Physical Activity

Advances in therapies have led to prolonged survival from many previously lethal health threats in children, notably among prematurely born babies and those with congenital heart disease. Evidence for catch‐up growth is common in these children, but in many cases the adult phenotype is never achieved. A translational animal model is required in which specific tissues can be studied over a reasonable time interval. We investigated the impact of postnatal hypoxia (HY) (12%O₂ (HY12) or 10% O₂ (HY10)) on growth in rats relative to animals raised in room air. Subgroups had access to running wheels following the HY period. Growth was fully compensated in adult HY12 rats but not HY10 rats. The results of this study indicate that neonatal hypoxia can be a useful model for the elucidation of mechanisms that mediate successful catch‐up growth following neonatal insults and identify the critical factors that prevent successful catch‐up growth.

The Care of Children With Congenital Heart Disease in Their Primary Medical Home

Congenital heart disease (CHD) is the most common birth anomaly. With advances in repair and palliation of these complex lesions, more and more patients are surviving and are discharged from the hospital to return to their families. Patients with CHD have complex health care needs that often must be provided for or coordinated for by the primary care provider (PCP) and medical home. This policy statement aims to provide the PCP with general guidelines for the care of the child with congenital heart defects and outlines anticipated problems, serving as a repository of current knowledge in a practical, readily accessible format. A timeline approach is used, emphasizing the role of the PCP and medical home in the management of patients with CHD in their various life stages.

Increased arterial stiffness in children with congenital heart disease

Objective Central systolic blood pressure (SBP) is a measure of arterial stiffness and strongly associated with atherosclerosis and end-organ damage. It is a stronger predictor of cardiovascular events and all-cause mortality than peripheral SBP. In particular, for children with congenital heart disease, a higher central SBP might impose a greater threat of cardiac damage. The aim of the study was to analyse and compare central SBP in children with congenital heart disease and in healthy counterparts. Patients and methods Central SBP was measured using an oscillometric method in 417 children (38.9% girls, 13.0 ± 3.2 years) with various congenital heart diseases between July 2014 and February 2017. The test results were compared with a recent healthy reference cohort of 1466 children (49.5% girls, 12.9 ± 2.5 years). Results After correction for several covariates in a general linear model, central SBP of children with congenital heart disease was significantly increased (congenital heart disease: 102.1 ± 10.2 vs. healthy reference cohort: 100.4 ± 8.6, p < .001). The analysis of congenital heart disease subgroups revealed higher central SBP in children with left heart obstructions (mean difference: 3.6 mmHg, p < .001), transpositions of the great arteries after arterial switch (mean difference: 2.2 mmHg, p = .017) and univentricular hearts after total cavopulmonary connection (mean difference: 2.1 mmHg, p = .015) compared with the reference. Conclusion Children with congenital heart disease have significantly higher central SBP compared with healthy peers, predisposing them to premature heart failure. Screening and long-term observations of central SBP in children with congenital heart disease seems warranted in order to evaluate the need for treatment.

Serum C-reactive protein levels and body mass index in children and adolescents with CHD

BACKGROUND

The prevalence of overweight in children with CHD is about 26.9%. Increase in adipose tissue is related to the secretion of proinflammatory markers such as C-reactive protein. Assuming that children with CHD are exposed to other inherent risk factors for heart disease, our objective was to evaluate the correlation between levels of C-reactive protein and body mass index in children and adolescents with CHD.

METHODS

A cross-sectional study with 377 children and adolescents with CHD in a clinical setting of a reference hospital was carried out. C-reactive protein data were collected after 12 hours of fasting. Nutritional status was classified according to body mass index. The patients were divided into three groups: cyanotic, acyanotic, and minimal heart defects (controls).

RESULTS

The mean age was 9.9±4.2 years, and 53.6% of the sample included males. The cyanotic group represented 22.3%, acyanotic 42.2%, and minimal defects 35.5% of the sample. The average body mass index percentile was 57.23±32.06. The median values of C-reactive protein were as follows: cyanotic 0.340, acyanotic with clinical repercussion 0.203, and minimal defects 0.128. There was a significant difference between the minimal defects and the cyanotic groups (p=0.023). There was a significant correlation between C-reactive protein and body mass index percentile (r=0.293, p<0.01). C-reactive protein levels were higher in girls (p=0.034). There were no significant correlations between C-reactive protein and age or birth weight.

CONCLUSION

The correlation between body mass index percentile and C-reactive protein was confirmed in this population. The prevention of overweight is paramount to avoid overlapping modifiable risk factors to those already inherent to the CHD.

[Cardiac rehabilitation for children and adults with congenital heart disease]

Advances in heart surgery over the past 30 years have significantly improved the prognosis of congenital heart diseases (CHD). Therefore, the epidemiology of CHD has changed dramatically with a shift of mortality from pediatrics to adulthood and an increased prevalence of complex CHD. Today, caregivers and patients focus their interests to new perspectives: improving the quality of life, practicing sports, improving psychosocial care. Cardiac rehabilitation is completely integrated in these new therapeutic strategies. The starting point is the cardiopulmonary exercise test (CPET), with the measurement of oxygen uptake, or "VO2". CPET is now recommended in the follow-up of the adults with CHD. Maximum oxygen uptake correlates to the quality of life of children and adults with CHD. The principles of the rehabilitation in patients with heart failure may usually be applied to CHD patients. Some studies in complex CHD showed improvement of VO2 and quality of life after rehabilitation, without any adverse events. However few physicians have the experience in rehabilitation among CHD patients, especially children. Randomized trials on cardiac rehabilitation in adult and pediatric CHD patients are essential to increase the level of evidence and lead to specific guidelines in this population.

Congenital heart disease and the prevalence of underweight and obesity from age 1 to 15 years: data on a nationwide sample of children

OBJECTIVE

We examined the prevalence of underweight and obesity in children with congenital heart disease (CHD) compared with the general population.

METHODS

Using the Danish National Patient Registry, we identified individuals born and diagnosed with CHD in Denmark during 1996-2012 who were alive at 1 year of age. A unique personal identifier enabled identification of CHD subjects, as well as birth year and sex-matched (1:10) general population controls. The Children's Database has recorded height and weight measured by clinical providers at preventive health checks offered to all children in Denmark. Data recording were made mandatory in 2011. Obesity was defined as body mass index (BMI) above the 95thpercentile and underweight as BMI below the fifth percentile for age and sex. We determined the prevalence of underweight and obesity at study subjects' first height and weight recording. For those underweight at age 1 year, prevalence of underweight and obesity at later recordings was assessed.

RESULTS

We identified 9194 children with CHD of which 2679 (29%) had at least one recording of height and weight. The control cohort demonstrated a similar portion of anthropometric data: 30 047 (31%) of 96 585 controls. The prevalence of underweight and obesity at CHD study subjects' first height and weight recording was 9.7% (95% CI 8.7 to 11) and 4.1% (95% CI 3.4 to 4.9), respectively. Among individuals with CHD who were underweight at age 1 year (n=78), 51 (65%) had additional BMI recordings between ages 2 and 5 years with a subsequently diminished prevalence of underweight of 27% (95% CI 20 to 35) and none were obese.

CONCLUSION

The CHD population had an increased prevalence of underweight compared with the general population. Data indicated potential for BMI normalisation among those initially underweight at age 1 year. The prevalence of obesity in children with CHD was comparable with that of the general population.

Validity of Commercial Activity Trackers in Children With Congenital Heart Disease

BACKGROUND

Increasing physical activity levels is a high priority to optimize long-term health in children with congenital heart disease (CHD). Commercial activity trackers have been validated in adults and are increasingly used to measure and promote physical activity in pediatric populations, but they have not been validated in children.

METHODS

In 30 children with CHD aged 10-18 years, we assessed the validity of physical activity form the wrist-based Fitbit Charge HR (Fitbit, San Francisco, CA) against hip-based ActiGraph (ActiGraph LLC, Pensacola, FL) accelerometers under free living conditions for 7 days. We assessed the association between devices using intraclass correlation coefficients (ICCs) and Bland-Altman plots. Receiver operating curves were used to identify Fitbit step cut points.

RESULTS

There was a strong association between the 2 devices for daily steps across 138 analyzed person-days (ICC = 0.855; P < 0.001), but poorer agreement for time spent in physical activity intensities (ICCs < 0.7). Daily Fitbit steps of ≥ 12,500 identified meeting physical activity guidelines defined as ≥ 60 minutes of moderate-to-vigorous physical activity per day. Fitbit devices recorded more steps than accelerometers (-2242 steps per day, 95% limits of agreement of -7738 to 3253). Between-device differences were greater in boys vs girls. Fitbit devices were worn for longer than accelerometers (-36 minutes per day, 95% limits of agreement, -334 to 261), but overall differences in wear time explained little of the variance in step differences (7%, P = 0.048).

CONCLUSIONS

Commercial activity trackers provide opportunities to remotely monitor physical activity in children with CHD, but absolute values might differ from accelerometers. These findings are important because of the increasing emphasis on physical activity promotion and monitoring in children with cardiovascular risk factors.

Overweight and obesity in children and adolescents with Down syndrome-prevalence, determinants, consequences, and interventions: A literature review

BACKGROUND

Children with Down syndrome (DS) are more likely to be overweight or obese than the general population of youth without DS.

AIMS

To review the prevalence of overweight and obesity and their determinants in youth with DS. The health consequences and the effectiveness of interventions were also examined.

METHODS AND PROCEDURES

A search using MEDLINE, Embase, Web of Science, Scopus, CINAHL, PsycINFO, SPORTDiscus, LILACS, and COCHRANE was conducted. From a total of 4280 studies, we included 45 original research articles published between 1988 and 2015.

OUTCOMES AND RESULTS

The combined prevalence of overweight and obesity varied between studies from 23% to 70%. Youth with DS had higher rates of overweight and obesity than youths without DS. Likely determinants of obesity included increased leptin, decreased resting energy expenditure, comorbidities, unfavorable diet, and low physical activity levels. Obesity was positively associated with obstructive sleep apnea, dyslipidemia, hyperinsulinemia, and gait disorder. Interventions for obesity prevention and control were primarily based on exercise-based programs, and were insufficient to achieve weight or fat loss.

CONCLUSIONS AND IMPLICATIONS

Population-based research is needed to identify risk factors and support multi-factorial strategies for reducing overweight and obesity in children and adolescents with DS.

Rehabilitation during congenital heart disease in pediatric patients

Cardiac rehabilitation is an important part of daily routine for cardiac disorder patients in adults. However, pediatric rehabilitation is an emerging field, and is totally different and new field in case of pediatric patients. The main reason of variability is the Pediatric patients differ from adult patients in several ways. The main difference is they are dependent on their parents for meeting their needs, including for transportation and following of rehabilitation initiatives. Furthermore, rehabilitation initiatives are often connected to large urban university hospitals and unavailable to children whose parents cannot bring them for exercise training on a regular basis. The present review article is focused on these aspects of rehabilitation during congenital heart disease.

Association Between DSCR1 Variations and Congenital Heart Disease Susceptibility

Background

The objective of this study was aimed to detect the association of Down syndrome critical region 1 (DSCR1) gene polymorphisms (rs149048873 and rs143081213) and congenital heart disease (CHD) susceptibility.

Material/Methods

This case-control study included 102 CHD patients and 113 healthy controls. Cases and controls were matched in age and gender. Genotypes of DSCR1 gene polymorphisms were detected by TaqMan method in cases and controls. Hardy-Weinberg equilibrium (HWE) examination was performed by PLINK 1.0 software. Chi square test was utilized to assess the distribution of the genotypes and the alleles. Relative risk of CHD was presented by odds ratios (ORs) with 95% confidence intervals (CIs). All of the calculations were implemented using SPSS 18.0.

Results

Variant genotype distribution of rs149048873 and rs143081213 mutations were higher in cases than in controls, but the differences were not statistically obvious (P>0.05). Additionally, frequencies of mutant allele of the two polymorphisms were also significantly different in case and control groups (P>0.05).

Conclusions

No significant associations existed between DSCR1 gene rs149048873 and rs143081213 polymorphisms and CHD susceptibility.

Increased Body Mass Index Is Associated with Congestive Heart Failure and Mortality in Adult Fontan Patients

OBJECTIVE

Obesity affects adults with congenital heart disease (CHD). The effect of an increased body mass index (BMI) with respect to morbidity and mortality has not been evaluated in adults with complex CHD. Our objective was to evaluate the effects of increased BMI on heart failure and mortality in univentricular patients who had undergone Fontan palliation.

METHODS

A query of Fontan patients' first appointments at the Washington University Center for Adults with CHD between 2007 and 2014 yielded 79 patients. BMI status as normal (<25 kg/m(2) ), overweight (≥25, <30 kg/m(2) ), and obese (≥30 kg/m(2) ) was established at the patient's first appointment. We analyzed demographics, diuretic requirements, New York Heart Association (NYHA) class, and laboratory values using Student's two-sample t-test and Fisher's exact test. Mortality was assessed via survival curves, and hazard ratios were compiled with proportional hazard modeling.

RESULTS

The recent average BMI was significantly greater in patients with NYHA classes II-IV (29.3 ± 9 kg/m(2) ) compared with asymptomatic patients (24.8 ± 5.1 kg/m(2) , P = .006). Additionally, the average BMI of patients with a high diuretic requirement (≥40 mg/day IV furosemide equivalent) was obese, at 32.15 ± 9.1 kg/m(2) , compared with 25.91 ± 7.3 kg/m(2) for those on no or lower doses of diuretics (P = .009). Eighteen of the 79 patients met an endpoint of death, hospice placement, or cardiac transplant by the study conclusion. Kaplan-Meier analysis from time of first appointment until recent follow-up revealed a significant association between time to combined endpoint and BMI class. Cox proportional hazard modeling with age adjustment yielded a hazard ratio of 3.2 (95% CI 1.096-9.379) for obesity upon first presentation to an adult CHD clinic.

CONCLUSIONS

In patients with univentricular hearts and Fontan palliation, obesity is associated with symptomatic heart failure and mortality.