Prevalence of Malnutrition in Children with Congenital Heart Disease: A Systematic Review and Meta-Analysis

Preoperative Feeding Fortification Among Infants with Congenital Heart Disease is Associated with Higher Growth Velocity in the First 30 Days Post-repair and Lower BMI Percentile for Age at 10 Years: A Retrospective Cohort Study

It remains unclear how preoperative nutrition fortification impacts postoperative growth trajectories and nutritional status among infants with congenital heart disease. A single center retrospective cohort study was performed to evaluate measures of growth among patients who underwent cardiac repair at 0-18 months of age for atrial septal defect, ventricular septal defect, atrioventricular septal defect, or tetralogy of Fallot. Cohorts were analyzed at 0-30 and 31-60 days post-repair as well as at 2, 5, and 10 years of age. Records of 24 patients who received fortified nutrition and 60 patients who received unfortified nutrition preoperatively were reviewed. Those with fortified nutrition had higher growth velocities in the first 30 days post-repair compared to those with unfortified nutrition: 28.4 (23.8-83.3) grams per day versus 16.7 (7.1-21.4) grams per day, p = 0.004. Weight percentile for age was higher in the unfortified group at 2, 5, and 10 years of age (p = 0.02, p = 0.045, and p = 0.01). Body mass index (BMI) percentile for age was higher in the unfortified group at 5 and 10 years of age (p = 0.045 and p = 0.02) with a trend toward higher prevalence of either overweight or obesity compared to the fortified group (p = 0.13). reoperative nutrition fortification among infants with congenital heart disease is associated with higher growth velocity in the first 30 days post-repair and lower BMI percentile for age at 10 years. Further studies are needed to evaluate the association between preoperative nutrition fortification and postoperative outcomes, nutritional status, and prevalence of obesity in adolescence and adulthood.

Preoperative nutritional status and serum insulin-like growth factor of children with cyanotic and acyanotic congenital heart disease

BACKGROUND

Malnutrition is common among children with congenital heart disease (CHD). We compared the anthropometric indices, serum insulin-like growth factor (IGF), and IGF acid-labile subunit (IGFALS) of children with cyanotic and acyanotic CHD before corrective surgery.

METHODS

This 82-patient case-control study included 1- to 24-month-old CHD patients referred for corrective surgery. (41 with tetralogy of Fallot [TOF] and 41 with ventricular septal defect [VSD] or atrial septal defect [ASD]). Anthropometric indices represented as Z-scores were used to determine nutritional status. Serum IGF-1 and IGFALS levels were measured.

RESULTS

The median [quartile] age of the acyanotic group was 8 [7,11] months which was lower than the cyanotic group (11 [8,14.5] months). The prevalence of underweight (weight for age Z [WAZ] < -2), wasting (weight for length Z [WLZ] < -2), and thinness (body mass index Z [BMIZ] < -2) was significantly higher in children with acyanotic than cyanotic children with. WAZ, WLZ, and BMIZ were significantly lower in acyanotic children than cyanotic children with CHD (-2.5 ± 1.2 vs -1.0 ± 1.2, p < 0.001 for WAZ, -2.5 ± 1.5 vs -0.8 ± 1.4, p < 0.001 for WLZ, and -2.5 ± 1.5 vs -0.8 ± 1.4, p < 0.001 for BMIZ), but length for age Z was not different between the two groups (-1.2 ± 1.0 vs -0.8 ± 1.1, p = 0.31). A comparison of preoperative serum albumin, IGF-1, and IGFALS showed no differences.

CONCLUSIONS

In CHD children without corrective surgery, moderate to severe underweight and wasting were more common in acyanotic CHD (VSD and ASD) than in cyanotic CHD (TOF), but the higher prevalence of malnutrition was not associated with lower IGF-1 and IGFALS levels.

Predicting acute lung injury in infants with congenital heart disease after cardiopulmonary bypass by gut microbiota

Background

Acute lung injury (ALI) is a serious and common complication that occurs in children with congenital heart disease after cardiopulmonary bypass (CPB) surgery, leading to higher mortality rates and poorer prognosis. Currently, there is no reliable predictive strategy for CPB-associated lung injury (CPB-ALI) in infants. Certain characteristics of the gut microbiota could potentially serve as biomarkers for predicting the development of CPB-ALI.

Methods

We conducted 16S rRNA sequencing to analyze the characteristics of the intestinal microbiota in healthy controls and infants with CHD admitted to the hospital. The CHD infants were divided into CPB-ALI and non-ALI (CPB-NALI) groups based on postoperative outcomes. Bacterial functional pathway prediction analysis was performed using PIRCUSt2, and the gut microbiota composition associated with immune status was determined with heatmap. Random forest regression models and ROC curves were utilized to predict the occurrence of CPB-ALI.

Results

Our study revealed significantly different microbiota compositions among three groups (CON, CPB-ALI, and CPB-NALI). The microbiota diversity was low in the CPB-ALI group with high pathogen abundance and significant decrease in Bacteroides, while the opposite was observed in the CPB-NALI group. The microbiota dysbiosis index was high in the CPB-ALI group, with its dominant microbiota significantly associated with multiple metabolic pathways. Additionally, CPB-ALI patients showed high levels of inflammatory cytokines IL-8 and HMGB1 in their serum, with high expression of IL-8 being associated with Enterobacteriaceae. Further correlation analysis showed that the differences in gut bacterial taxonomy were related to the occurrence of ALI, length of stay in the cardiac care unit, and ventilation time. It is noteworthy that Escherichia Shigella performed best in distinguishing CPB-ALI patients from non-ALI patients.

Conclusions

Our study suggests that postoperative ALI patients have distinct gut microbiota upon admission compared to non-ALI patients after surgery. Dysbiosis of the gut microbiota may potentially impact the progression of ALI through metabolic pathways, quorum sensing, and the levels of inflammatory factors expressed in the serum. Escherichia Shigella represents a potential predictive factor for the occurrence of ALI in CHD infants after surgery. Acute lung injury, congenital heart disease, cardiopulmonary bypass surgery, gut microbiota, biomarker.

The effect of nutritional risk management program on the growth and development of infants and toddlers with congenital heart disease after discharge

Objective

To evaluate the effect of nutritional risk management program on the growth and development of infants and toddlers with congenital heart disease (CHD) after discharge.

Methods

Infants and toddlers with CHD discharged from a children's specialized hospital in southeast China were selected as the research subjects. The subjects were divided into the intervention group and the control group. The intervention group underwent a nutritional risk management program combined with traditional follow-up after discharge, whereas the control group received traditional follow-up after discharge. The primary outcome measure were the height-for-age Z-score (HAZ), weight-for-age Z-score (WAZ), and weight-for-height Z-score (WHZ) at different time point and the percentage of growth and development curves were also recorded and analyzed.

Results

There were no statistically significant differences in general characteristics between the two groups. However, in the intervention group, the percentages of HAZ < -2, WAZ < -2, and WHZ < -2 were lower than those in the control group at 3rd and 6th months after discharge (P < 0.05). The percentage of growth and development curves (3%-97%) was higher than that in the control group (P < 0.05). The readmission rate within 6 months after discharge in the intervention group was lower than that in the control group (P < 0.05).

Conclusion

Implementing nutritional risk management program for infants and toddlers with CHD after discharge can help improve postoperative malnutrition, promote growth and development and achieve catch-up growth as soon as possible.

A Systematic Review of Clinical Practice Guidelines on the Management of Malnutrition in Children with Congenital Heart Disease

Congenital heart disease (CHD) is one of the most common inborn disorders, with a prevalence of 0.8-1.2%. Affected children are often malnourished due to increased dietary requirements. This may lead to severe long-term complications. Several authoritative organizations have published guidelines addressing nutritional intervention in children with CHD. We aimed to systematically assess the consistency of recommendations, the methodological quality of these guidelines, and the quality of evidence supporting each recommendation. PubMed, Embase, the Cochrane Database, World Health Organization Global Index Medicus, and 16 scientific societies' websites were searched for the period until September 2023. The guideline quality was assessed using the AGREE II tool. After screening 765 records, only 2 guidelines published in 2013 and 2022 met our inclusion criteria. The main reason for exclusion was the absence of any system for rating the evidence. The main issues concerned the lack of implementation advice or tools and the lack of criteria to measure the application of guideline recommendations. The included guidelines were of good quality and within specific recommendations, both publications were largely in agreement, and the score for the overall assessment was high (83%). There is a pressing need for comprehensive, multi-threaded guidelines incorporating implementation strategies and methods for the performance assessment of children with malnutrition and CHD.

Risk factors of malnutrition in children with congenital heart disease: a meta-analysis

Background

The associated factors of malnutrition in children with congenital heart disease (CHD) must be evaluated to provide evidence for the treatment and care of such children.

Methods

Two investigators searched the PubMed database until 25 June 2023 for literature about the associated factors of malnutrition in children with CHD. A meta-analysis of associated factors of malnutrition was performed by RevMan 5.3 software.

Results

Thirteen studies involving 8,031 children with CHD were included. Pulmonary hypertension (OR = 3.81, 95% CI: 2.46-4.12), low birth weight (OR = 2.69, 95% CI: 1.25-5.77) and parents' height (OR = 2.15, 95% CI: 1.89-2.92) were the associated factors of growth retardation (all P < 0.05). Pulmonary hypertension (OR = 3.77, 95% CI: 3.13-4.24), low birth weight (OR = 3.04, 95% CI: 2.61-4.18) and pneumonia (OR = 2.35, 95% CI: 2.08-2.83) were the associated factors of low body weight of children with CHD (all P < 0.05).

Conclusions

Medical staff should fully understand the risk factors, strengthen nutritional support and enhance nursing care for children with CHD to reduce malnutrition.

Preoperative Malnutrition Increases Risk of In-Hospital Mortality, Major Infection, and Longer Intensive Care Unit Stay After Ventricular Septal Defect Closure

BACKGROUND

High energy requirements and poor feeding can lead to growth failure in patients with ventricular septal defect (VSD), but effects of preoperative malnutrition on surgical outcomes are poorly understood, especially in low-resource settings.

METHODS AND RESULTS

We analyzed a cohort of children <5 years of age undergoing VSD closure at 60 global centers participating in the International Quality Improvement Collaborative for Congenital Heart Disease, 2015 to 2020. We calculated adjusted odds ratios (ORs) for in-hospital death and major infection and adjusted coefficients for duration of intensive care unit stay for 4 measures of malnutrition: severe wasting (weight-for-height Z score, <-3), moderate wasting (-3

CONCLUSIONS

Malnutrition was associated with mortality, infection, and longer intensive care unit stay in a global cohort of children undergoing VSD closure.

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Key Words

• congenital heart disease
• global health
• malnutrition
• mortality
• ventricular septal defect

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MESH Headings

• Humans
• Heart Septal Defects, Ventricular/surgery
• Heart Septal Defects, Ventricular/mortality
• Heart Septal Defects, Ventricular/complications
• Male
• Female
• Infant
• Hospital Mortality
• Child, Preschool
• Length of Stay/statistics & numerical data
• Malnutrition/mortality
• Malnutrition/epidemiology
• Malnutrition/diagnosis
• Risk Factors
• Cardiac Surgical Procedures/adverse effects
• Intensive Care Units/statistics & numerical data
• Nutritional Status
• Postoperative Complications/epidemiology
• Postoperative Complications/mortality
• Retrospective Studies
• Risk Assessment
• Time Factors

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Grants

• P30 DK040561 NIDDK NIH HHS
• National Institutes of Health

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Affiliation(s)

Rachel E. Wittenberg Harvard Medical SchoolBostonMAUSA
Kimberlee Gauvreau Harvard Medical SchoolBostonMAUSA Boston Children’s HospitalBostonMAUSA
Christopher P. Duggan Harvard Medical SchoolBostonMAUSA Boston Children’s HospitalBostonMAUSA
Xinwei Du Shanghai Children’s Medical CenterShanghaiChina
Do Giang Nhi Dong 1Ho Chi Minh CityVietnam
Kishore Jayanthi Star HospitalHyderabadIndia
Nestor Sandoval Fundación Cardioinfantil y LaCardioBogotáColombia
Sivakumar Sivalingam Institut Jantung NegaraKuala LumpurMalaysia
Xiaolei Zhao TEDA International Cardiovascular HospitalTianjinChina
Kathy J. Jenkins Harvard Medical SchoolBostonMAUSA Boston Children’s HospitalBostonMAUSA

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Situs Ambiguus Is Associated With Adverse Clinical Outcomes in Children With Primary Ciliary Dyskinesia

BACKGROUND

Primary ciliary dyskinesia (PCD) is a rare disorder of motile cilia associated with situs abnormalities. At least 12% of patients with PCD have situs ambiguus (SA), including organ laterality defects falling outside normal arrangement (situs solitus [SS]) or mirror image inversion (situs inversus totalis [SIT]).

RESEARCH QUESTION

Do patients with PCD and SA achieve worse clinical outcomes compared with those with SS or SIT?

STUDY DESIGN AND METHODS

This cross-sectional, multicenter study evaluated participants aged 21 years or younger with PCD. Participants were classified as having SA, including heterotaxy, or not having SA (SS or SIT). Markers of disease severity were compared between situs groups, adjusting for age at enrollment and severe CCDC39 or CCDC40 genotype, using generalized linear models and logistic and Poisson regression.

RESULTS

In 397 participants with PCD (mean age, 8.4 years; range, 0.1-21), 42 patients were classified as having SA, including 16 patients (38%) with complex cardiovascular malformations or atrial isomerism, 13 patients (31%) with simple CVM, and 13 patients (31%) without cardiovascular malformations. Of these, 15 patients (36%) underwent cardiac surgery, 24 patients (57%) showed an anatomic spleen abnormality, and seven patients (17%) showed both. The remaining 355 participants did not have SA, including 152 with SIT and 203 with SS. Overall, 70 participants (17%) harbored the severe CCDC39 or CCDC40 genotype. Compared with participants without SA, those with SA showed lower median BMI z scores (P = .03), lower FVC z scores (P = .01), and more hospitalizations and IV antibiotic courses for acute respiratory infections during the 5 years before enrollment (P < .01). Participants with cardiovascular malformations requiring surgery or with anatomic spleen abnormalities showed lower median BMI z scores and more hospitalizations and IV therapies for respiratory illnesses compared with participants without SA.

INTERPRETATION

Children with PCD and SA achieve worse nutritional and pulmonary outcomes with more hospitalizations for acute respiratory illnesses than those with SS or SIT combined. Poor nutrition and increased hospitalizations for respiratory infections in participants with SA and PCD are associated with cardiovascular malformations requiring cardiac surgery, splenic anomalies, or both.

TRIAL REGISTRY

ClinicalTrials.gov; Nos.: NCT02389049 and NCT00323167; URL: www.

CLINICALTRIALS

gov.

Associated factors of undernutrition in children with congenital heart disease: a cross-sectional study

Objective

To evaluate the prevalence and associated factors of undernutrition among children with congenital heart disease (CHD) who have not undergone surgeries in China.

Methods

This cross-sectional study included 734 CHD children along with their parents. The outcome of interest was undernutrition, including underweight, wasting, and stunting, defined as Z-scores (i.e., weight-for-age, weight-for-height, and height-for-age) ≤-2, according to the World Health Organization (WHO) growth standard. Exposures of interest, containing demographics, obstetric factors, maternal dietary factors, parents' life behaviors and habits, birth-related factors, cardiac-related factors, and preoperative factors, were analyzed using a multivariate logistic regression model to test their associations with undernutrition in CHD children.

Results

Overall, 36.1%, 29.7%, and 21.3% of cases were underweight, wasted, and stunted, respectively. Multivariate logistic regression indicated that underweight was associated with demographic factors (including parents' occupational status, family income, and maternal body mass index pre-pregnancy), low birth weight (OR = 4.60, 2.76-7.70), pulmonary hypertension (OR = 4.46, 3.09-6.43), and pneumonia (OR = 1.88, 1.28-2.76). Artificially-fed children were 2.34 (1.36-4.01) times more likely to be underweight. Occupied mothers (OR = 0.62, 0.44-0.88) and fathers (OR = 0.49, 0.26-0.92) served as protective factors, while mothers having gestational complications (OR = 1.56, 1.11-2.18) and exposed to noisy environment (OR = 1.64, 1.11-2.42) during this pregnancy, and pulmonary hypertension (OR = 3.21, 2.30-4.49) increased the chance of wasting in offspring. The odds of being stunted were greater in families with >2 children (OR = 1.88, 1.13-3.14), placental abruption during this pregnancy (OR = 25.15, 2.55-247.89), preterm births (OR = 1.84, 1.02-3.31), low birth weight (OR = 3.78, 2.16-6.62), pulmonary hypertension (OR = 2.35, 1.56-3.53) and pneumonia (OR = 1.93, 1.28-2.90). In subgroup analyses, the associations differed between patients with different feeding patterns (breastfeeding vs. non-breastfeeding), CHD classifications (cyanotic vs. acyanotic), and prematurity (preterm vs. non-preterm).

Conclusion

Undernutrition is common in preoperative CHD children. Familial demographics, maternal factors (including having gestational complications and exposure to noisy environment during pregnancy), and patient-related factors (encompassing preterm births, low birth weight, pulmonary hypertension, pneumonia, and feeding pattern) were found to contribute to undernutrition in CHD cases. However, associated factors among the three subgroups of distinct feeding patterns, CHD categorization, and prematurity exhibited varied outcomes, suggesting the necessity for targeted interventions.

Undernutrition in young children with congenital heart disease undergoing cardiac surgery in a low-income environment

BACKGROUND

Malnutrition (undernutrition) in children with congenital disease (CHD) is a notable concern, with preoperative and persistent growth failure post-cardiac surgery contributing to poorer outcomes. Poor growth in children with CHD in low-income environments is exacerbated by feeding difficulties, poverty, delayed diagnosis, and late corrective surgery. This study describes and compares the growth of young children with CHD undergoing cardiac surgery in central South Africa from before to 6-months after cardiac surgery.

METHODS

Children 30 months and younger, with their mothers, were included in this prospective observational descriptive study. Weight- height-, and head circumference-for-age z-scores were used to identify children who were underweight, stunted and microcephalic. Z-scores for growth indices were compared from baseline to 3-months and 6-months post-cardiac surgery. Changes in growth over time were calculated using a 95% confidence interval on the difference between means. Linear regression was used to determine the association between growth and development, health-related quality of life and parenting stress respectively.

RESULTS

Forty mother-child pairs were included at baseline. Most children (n = 30) had moderate disease severity, with eight children having cyanotic defects. A quarter of the children had Down syndrome (DS). Twenty-eight children underwent corrective cardiac surgery at a median age of 7.4 months. Most children (n = 27) were underweight before cardiac surgery [mean z-score - 2.5 (±1.5)], and many (n = 18) were stunted [mean z-score - 2.2 (±2.5)]. A quarter (n = 10) of the children had feeding difficulties. By 6-months post-cardiac surgery there were significant improvements in weight (p = 0.04) and head circumference (p = 0.02), but complete catch-up growth had not yet occurred. Malnutrition (undernutrition) was strongly associated (p = 0.04) with poorer motor development [Mean Bayley-III motor score 79.5 (±17.5)] before cardiac surgery. Growth in children with cyanotic and acyanotic defects, and those with and without DS were comparable.

CONCLUSION

Malnutrition (undernutrition) is common in children with CHD in central South Africa, a low-income environment, both before and after cardiac surgery, and is associated with poor motor development before cardiac surgery. A diagnosis of CHD warrants regular growth monitoring and assessment of feeding ability. Early referral for nutritional support and speech therapy will improve growth outcomes.

Improving nutritional status of children using artificial intelligence-based mobile application postsurgery: randomised controlled trial

Background

Malnutrition is a common problem in children postsurgery especially in low-middle-income countries. Health-based mobile apps play an important role for better nutritional status.

Methods

This is a two-arm randomised controlled trial, which was conducted at a tertiary care hospital, Rawalpindi. The study duration was 6 months from February 2021 to July 2021. The sample size with power of 80% and significance level of 5% was calculated to be 88. The intervention group was given a diet-related mobile app, and the usual care group was handed a pamphlet with diet instructions on discharge.

Findings

The mean weight of all participants was 15 (SD 5.7) kg at the time of discharge. However, at the end of the 8th week, the mean weight of the participants in the usual care group was 16.5 (SD 7.2) kg and that of the intervention group was 17.1 (SD 5) kg. The average calorie consumed by the usual care group was 972 (SD 252) kcal and 1000.75 (SD 210) kcal by the intervention group after 8 weeks of discharge. The average protein consumed by the usual care group was 34.3 (SD 12.5) g and 39 (SD 6.4) g by the intervention group after 8 weeks of discharge.

Interpretation

This study showed strength for the future of scalable modern technology for self-nutrition monitoring. There was a slight increase in the weight and nutritional intake of both groups.

Trial registration number

NCT04782635.

Nutrition for critically ill children with congenital heart disease

Children with congenital heart disease often require admission to the cardiac intensive care unit at some point in their lives, either after elective surgical or catheter-based procedures or during times of acute critical illness. Meeting both the macronutrient and micronutrient needs of children in the cardiac intensive care unit requires complex decision-making when considering gastrointestinal perfusion, vasoactive support, and fluid balance goals. Although nutrition guidelines exist for critically ill children, these cannot always be extrapolated to children with congenital heart disease. Children with congenital heart disease may also suffer unique circumstances, such as chylothoraces, heart failure, and the need for mechanical circulatory support, which greatly impact nutrition delivery. Guidelines for neonates and children with heart disease continue to be developed. We provide a synthesized narrative review of current literature and considerations for nutrition evaluation and management of critically ill children with congenital heart disease.

A scoping review: urinary markers of metabolic maturation in infants with CHD and the relationship to growth

BACKGROUND

Growth failure in infants born with CHD is a persistent problem, even in those provided with adequate nutrition.

OBJECTIVE

To summarise the published data describing the change in urinary metabolites during metabolic maturation in infants with CHD and identify pathways amenable to therapeutic intervention.

DESIGN

Scoping review.

ELIGIBILITY CRITERIA

Studies using qualitative or quantitative methods to describe urinary metabolites pre- and post-cardiac surgery and the relationship with growth in infants with CHD.

SOURCES OF EVIDENCE

NICE Healthcare Databases website was used as a tool for multiple searches.

RESULTS

347 records were identified, of which 37 were duplicates. Following the removal of duplicate records, 310 record abstracts and titles were screened for inclusion. The full texts of eight articles were reviewed for eligibility, of which only two related to infants with CHD. The studies included in the scoping review described urinary metabolites in 42 infants. A content analysis identified two overarching themes of metabolic variation predictive of neurodevelopmental abnormalities associated with anaerobic metabolism and metabolic signature associated with the impact on gut microbiota, inflammation, energy, and lipid digestion.

CONCLUSION

The results of this scoping review suggest that there are considerable gaps in our knowledge relating to metabolic maturation of infants with CHD, especially with respect to growth. Surgery is a key early life feature for CHD infants and has an impact on the developing biochemical phenotype with implications for metabolic pathways involved in immunomodulation, energy, gut microbial, and lipid metabolism. These early life fingerprints may predict those individuals at risk for neurodevelopmental abnormalities.

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.

Improving long-term care and outcomes of congenital heart disease: fulfilling the promise of a healthy life

Advances in the prevention, diagnosis, and treatment for congenital heart disease (CHD), the most common birth defect in China, have drastically improved survival for individuals with the disease. However, China's current health system is not well prepared to manage the growing population of people with CHD and their complex medical needs, which range from early detection of the condition and intervention for physical, neurodevelopmental, and psychosocial impairment, to long-term management of major complications and chronic health problems. Health disparities caused by long-standing regional differences in access to care pose challenges when major complications such as pulmonary hypertension arise, and when individuals with complex CHD become pregnant and give birth. Currently, no data sources track neonates, children, adolescents, and adults with CHD in China and delineate their clinical characteristics and use of health resources. This scarcity of data should warrant attention from the Chinese Government and relevant specialists in the field. In the third paper of the Series on CHD in China, we summarise key literature and current data to identify knowledge gaps and call for concerted efforts by the government, hospitals, clinicians, industries, and charitable organisations to develop an actionable, lifelong framework of congenital cardiac care that is accessible and affordable for all individuals with CHD. TRANSLATION: For the Chinese translation of the abstract see Supplementary Materials section.

Nutritional Management of Patients with Fontan Circulation: A Potential for Improved Outcomes from Birth to Adulthood

Fontan circulation (FC) is a surgically achieved palliation state offered to patients affected by a wide variety of congenital heart defects (CHDs) that are grouped under the name of univentricular heart. The procedure includes three different surgical stages. Malnutrition is a matter of concern in any phase of life for these children, often leading to longer hospital stays, higher mortality rates, and a higher risk of adverse neurodevelopmental and growth outcomes. Notwithstanding the relevance of proper nutrition for this subset of patients, specific guidelines on the matter are lacking. In this review, we aim to analyze the role of an adequate form of nutritional support in patients with FC throughout the different stages of their lives, in order to provide a practical approach to appropriate nutritional management. Firstly, the burden of faltering growth in patients with univentricular heart is analyzed, focusing on the pathogenesis of malnutrition, its detection and evaluation. Secondly, we summarize the nutritional issues of each life phase of a Fontan patient from birth to adulthood. Finally, we highlight the challenges of nutritional management in patients with failing Fontan.