Growth, nutrition and energy expenditure in pediatric heart failure

Long-term kidney outcomes in pediatric continuous-flow ventricular assist device patients

BACKGROUND

Continuous-flow ventricular assist devices (CF-VADs) are used increasingly in pediatric end-stage heart failure (ESHF) patients. Alongside common risk factors like oxidant injury from hemolysis, non-pulsatile flow constitutes a unique circulatory stress on kidneys. Post-implantation recovery after acute kidney injury (AKI) is commonly reported, but long-term kidney outcomes or factors implicated in the evolution of chronic kidney disease (CKD) with prolonged CF-VAD support are unknown.

METHODS

We studied ESHF patients supported > 90 days on CF-VAD from 2008 to 2018. The primary outcome was CKD (per Kidney Disease Improving Global Outcomes (KDIGO) criteria). Secondary outcomes included AKI incidence post-implantation and CKD evolution in the 6-12 months of CF-VAD support.

RESULTS

We enrolled 134 patients; 84/134 (63%) were male, median age was 13 [IQR 9.9, 15.9] years, 72/134 (54%) had preexisting CKD at implantation, and 85/134 (63%) had AKI. At 3 months, of the 91/134 (68%) still on a CF-VAD, 34/91 (37%) never had CKD, 13/91 (14%) developed de novo CKD, while CKD persisted or worsened in 49% (44/91). Etiology of heart failure, extracorporeal membrane oxygenation use, duration of CF-VAD, AKI history, and kidney replacement therapy were not associated with different CKD outcomes. Mortality was higher in those with AKI or preexisting CKD.

CONCLUSIONS

In the first multicenter study to focus on kidney outcomes for pediatric long-term CF-VAD patients, preimplantation CKD and peri-implantation AKI were common. Both de novo CKD and worsening CKD can happen on prolonged CF-VAD support. Proactive kidney function monitoring and targeted follow-up are important to optimize outcomes.

Elimination of 15N-thymidine after oral administration in human infants

BACKGROUND

We have developed a new clinical research approach for the quantification of cellular proliferation in human infants to address unanswered questions about tissue renewal and regeneration. The approach consists of oral 15N-thymidine administration to label cells in S-phase, followed by Multi-isotope Imaging Mass Spectrometry for detection of the incorporated label in cell nuclei. To establish the approach, we performed an observational study to examine uptake and elimination of 15N-thymidine. We compared at-home label administration with in-hospital administration in infants with tetralogy of Fallot, a form of congenital heart disease, and infants with heart failure.

METHODS

We examined urine samples from 18 infants who received 15N-thymidine (50 mg/kg body weight) by mouth for five consecutive days. We used Isotope Ratio Mass Spectrometry to determine enrichment of 15N relative to 14N (%) in urine.

RESULTS/FINDINGS

15N-thymidine dose administration produced periodic rises of 15N enrichment in urine. Infants with tetralogy of Fallot had a 3.2-fold increase and infants with heart failure had a 4.3-fold increase in mean peak 15N enrichment over baseline. The mean 15N enrichment was not statistically different between the two patient populations (p = 0.103). The time to peak 15N enrichment in tetralogy of Fallot infants was 6.3 ± 1 hr and in infants with heart failure 7.5 ± 2 hr (mean ± SEM). The duration of significant 15N enrichment after a dose was 18.5 ± 1.7 hr in tetralogy of Fallot and in heart failure 18.2 ± 1.8 hr (mean ± SEM). The time to peak enrichment and duration of enrichment were also not statistically different (p = 0.617 and p = 0.887).

CONCLUSIONS

The presented results support two conclusions of significance for future applications: (1) Demonstration that 15N-thymidine label administration at home is equivalent to in-hospital administration. (2) Two different types of heart disease show no differences in 15N-thymidine absorption and elimination. This enables the comparative analysis of cellular proliferation between different types of heart disease.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Factors Associated with Congenital Heart Disease in Severely Malnourished Children under Five and Their Outcomes at an Urban Hospital, Bangladesh

Congenital heart disease (CHD) is one of the most common types of birth defect with a high morbidity and mortality, particularly in severely malnourished children under five. In this study, we aim to identify the predicting factors for CHD and their outcomes. 694 malnourished children under five years of age admitted between April 2015 and December 2017 constituted the study population. Of them, 64 were cases of CHD, and by comparison 630 were without CHD. CHD was diagnosed clinically and confirmed by echocardiogram. 64% of the cases had a single defect. Cases were more likely to be present with diarrhea, cough, respiratory distress, cyanosis, hypoxemia, hypoglycemia and hypernatremia on admission. The cases also had a high proportion of severe sepsis, bacteremia, heart failure, respiratory failure and death, compared to those without CHD. Cough (95% CI = 1.09–18.92), respiratory distress (95% CI = 1.46–5.39) and hypoxemia (95% CI = 1.59–6.86) were found to be the independent predictors for CHD after regression analysis, and their early identification might be helpful to lessen ramifications, including mortality, in such populations, especially in resource-limited settings.

Pediatric urgent heart transplantation with age or weight mismatched donors: Reducing waiting time by enlarging donor criteria

BACKGROUND

Despite considerable progress in heart transplantation, pediatric waiting list mortality is still high, and often patients do not have enough time to wait. We hypothesized that extending the donor criteria regarding age and weight mismatch does not significantly affect the early follow-up.

METHODS

We retrospectively analyzed our pediatric heart transplantation patients operated on from 2014 to 2020 for high (>3.0) or low (<0.6) donor-recipient weight ratio (DRWR) or chronological age mismatches (donor organ >5 years older than recipient age). This patient cohort constituted "mismatched heart transplantations" (mHTX). We compared mHTX preoperative status, postoperative course, 1-year survival, and early clinical follow-up to standard pediatric heart transplantations (sHTX).

RESULTS

We performed 20 pediatric heart transplantations-10 mHTX and 10 sHTX. The minimum DRWR was 0.44, the maximum was 5.60, and the maximum age mismatch was 42.6 years. Median days in the intensive care unit (p = .436) and time-to-first-rejection episode (p = .925) were comparable. Nine patients in each group were alive after 1 year, two patients were operated within 1 year of follow-up. One mHTX patient developed cardiac allograft vasculopathy after 15 months and died 648 days after transplantation (p = .237). All other patients were alive at the end of follow-up and in good clinical conditions (median follow-up for mHTX was 732.5 days, 1149.5 days for sHTX).

CONCLUSION

Postoperative course and early follow-up after mHTX were comparable to sHTX. In urgent clinical situations, extended donor criteria may be considered an additional option for pediatric heart transplantation.

Relations of blood lead levels to echocardiographic left ventricular structure and function in preschool children

Lead (Pb) has been proved to exert adverse effect on human cardiovascular system. However, the cardiotoxicity of Pb on children is still unclear. The aim of this study was to evaluate left ventricular (LV) structure and function, by using echocardiographic indices, in order to elucidate the effect of Pb on low-grade inflammation related to left ventricle in healthy preschool children. We recruited a total of 486 preschool children, 310 from Guiyu (e-waste-exposed area) and 176 from Haojiang (reference area). Blood Pb levels, complete blood counts, and LV parameters were evaluated. Associations between blood Pb levels and LV parameters and peripheral leukocyte counts were analyzed using linear regression models. The median blood level of Pb and the counts of white blood cells (WBCs), monocytes, and neutrophils were higher in exposed group. In addition, the exposed group showed smaller left ventricle (including interventricular septum, LV posterior wall, and LV mass index) and impaired LV systolic function (including LV fractional shortening and LV ejection fraction) regardless gender. After adjustment for confounding factors, elevated blood Pb levels were significantly associated with higher counts of WBCs and neutrophils, and lower levels of LV parameters. Furthermore, counts of WBCs, monocytes, and neutrophils were negatively correlated with LV parameters. Taken together, smaller left ventricle and impaired systolic function were found in e-waste-exposed children and associated with chronic low-grade inflammation and elevated blood Pb levels. It indicates that the heart health of e-waste-exposed children is at risk due to the long-term environmental chemical insults.

Risk factors of malnutrition in Chinese children with congenital heart defect

Background

The study aimed to investigate the risk factors of malnutrition in children with congenital heart defect (CHD) in China.

Methods

This cohort study was performed at the biggest pediatric heart center in China; 3252 patients with CHD who underwent cardiac surgeries in 2013 were included. Anthropometric measurements included weight for age Z score (WAZ), weight for height Z score (WHZ), and height for age Z score (HAZ). The patients were classified as normal nutritional status and malnutrition, based on a cut-off Z score of <− 2. Factors associated with malnutrition were determined using logistic regression analysis.

Results

The prevalence of preoperative WAZ < -2 (underweight), HAZ < -2 (stunting), and WHZ < -2 (wasting) was 23.3, 23.3, and 14.3%, respectively. The multivariable analysis of preoperative malnutrition showed that hospitalization, age at surgery, risk adjustment for congenital heart surgery-1 > 3, mechanical ventilation, pulmonary hypertension, and acyanotic heart disease were associated with underweight. Parents’ height, single ventricle, and cyanotic heart disease were associated with stunting. Hospitalization and pulmonary hypertension were associated with wasting. After surgery, the patients presented a significant improvement in growth within the first year in all three parameters and grew to the normal range of WAZ (− 0.3 ± 0.9, P < 0.001), HAZ (0.2 ± 0.8, P = 0.001), and WHZ (0.03 ± 0.6, P < 0.001) at 2 years after surgery. The prevalence of underweight, stunted, and wasting declined to 3.2, 2.7, and 1.9% 3 years after surgery. Malnutrition after surgery was associated with cardiac residual cardiac abnormalities (OR = 35.3, p < 0.0001), high Ross classification of heart function (OR = 27.1, p < 0.0001), and long-term taking oral diuretics (OR = 20.5, P = 0.001).

Conclusions

Malnutrition is still a problem in children with CHD in China, especially before the surgery. There is need to strengthen the nutrition support for children with CHD before surgery. Hemodynamic factors were found to be the risk factors associated with malnutrition after operation.

Alternative methods for virtual heart transplant-Size matching for pediatric heart transplantation with and without donor medical images available

BACKGROUND

Listed pediatric heart transplant patients have the highest solid-organ waitlist mortality rate. The donor-recipient body weight (DRBW) ratio is the clinical standard for allograft size matching but may unnecessarily limit a patient's donor pool. To overcome DRBW ratio limitations, two methods of performing virtual heart transplant fit assessments were developed that account for patient-specific nuances. Method 1 uses an allograft total cardiac volume (TCV) prediction model informed by patient data wherein a matched allograft 3-D reconstruction is selected from a virtual library for assessment. Method 2 uses donor images for a direct virtual transplant assessment.

METHODS

Assessments were performed in medical image reconstruction software. The allograft model was developed using allometric/isometric scaling assumptions and cross-validation.

RESULTS

The final predictive model included gender, height, and weight. The 25th-, 50th-, and 75th-percentiles for TCV percentage errors were -13% (over-prediction), -1%, and 8% (under-prediction), respectively. Two examples illustrating the potential of virtual assessments are presented.

CONCLUSION

Transplant centers can apply these methods to perform their virtual assessments using existing technology. These techniques have potential to improve organ allocation. With additional experience and refinement, virtual transplants may become standard of care for determining suitability of donor organ size for an identified recipient.

Energy Intake and Expenditure in Children With Heart Failure

OBJECTIVES

Up to one third of children with heart failure exhibit growth failure. Limited data exists reporting energy requirements in this population. A study was designed to characterize the energy intake and total daily energy expenditure of children with heart failure using the doubly labeled water method.

DESIGN

Prospective study using doubly labeled water to measure total daily energy expenditure in children with heart failure. Doubly labeled water was administered orally and daily urine samples collected for 10 days. Total daily energy expenditure was compared with historic data from age- and gender-matched healthy population. Anthropometrics and 3-day calorie count were also done.

SETTING

The Cardiovascular Intensive Care Unit and Cardiology ward at Texas Children's Hospital.

PATIENTS

Children with new presentation of heart failure as defined by an ejection fraction less than 35% and requiring inotrope(s) at the time of enrollment.

MEASUREMENTS AND MAIN RESULTS

A total of five children with heart failure were enrolled from 2015 to 2016. All children showed weight-for-length less than mean-for-age. All had depressed myocardial function at enrollment, and all but one demonstrated improvement in ejection fraction at follow-up. Three had energy intake that met or surpassed their total daily energy expenditure, with total daily energy expenditure that measured below historic controls. One infant, despite supplementation, had an energy intake substantially below that of measured total daily energy expenditure and required cardiac transplantation.

CONCLUSIONS

Growth failure in heart failure is likely multifactorial and may be related to suboptimal energy intake secondary to exercise intolerance, malabsorption, and/or end-organ dysfunction due to impaired cardiac output. Doubly labeled water is a feasible method to assess total daily energy expenditure in children with heart failure.

Can energy intake alter clinical and hospital outcomes in PICU?

BACKGROUND & AIMS

Energy is essential for the treatment and recovery of children admitted to Pediatric Intensive Care Units (PICU). There are significant immediate and long-term health consequences of both under- and over-feeding in this population. Energy requirements of critically ill children vary depending on age, nutritional status, sepsis, fever, pharmacotherapy, and duration and stage of critical illness. This study aimed to determine the incidence of over- and under-feeding and to compare hospital outcomes between these feeding categories. Secondary outcomes were collected to describe the association between feeding categories and biochemistries (serum lactate, triglycerides, C-reactive protein).

METHODS

An ethics approved retrospective study of children admitted to PICU was performed. All intubated patients admitted to PICU (2008-2013) were included, except those in which an IC test was not feasible. Data collection included demographics, the primary outcome variable reported as under feeding (<90%MREE), appropriate (MREE ±10%) or overfeeding (>110% MREE) determined through comparison of measured resting energy expenditure (MREE) using indirect calorimetry (IC) to actual energy intake based on predicted basal metabolic rate (PBMR) and clinical outcomes mechanical ventilation and PICU length of stay (LOS). Data were analysed with descriptive methods, ANOVA and linear regression models.

RESULTS

A total of 139 patients aged 10 (range 0.03-204) months were included. Sixty (43%) were female and 77 (55%) were admitted after a surgical procedure. A total of 210 IC tests were conducted showing a statistically significant difference between MREE measurements and PBMR (p = 0.019). Of the 210 measurements, only 26 measures (12.4%) demonstrated appropriate feeding, while 72 (34.3) were underfed and 112 (53.3%) were overfed. Children who were overfed had significantly longer PICU LOS (median 45.5, IQR 47.8 days) compared to those children in the appropriately fed (median 21.0, IQR 54.5 days), and underfed groups (median 16.5, IQR 21.3 days). There was a mean difference between the over and under feeding category and ventilation days after adjusting for age and PRISM score (p = 0.026), suggesting decreased mechanical ventilation days for underfed. Children who were underfed had significantly higher CRP (median 75.5, IQR 152.8 mg/L) compared to those children in the appropriately fed (median 57.8, IQR 90.9 mg/L) and overfed groups (median 22.4, IQR 56.2 mg/L).

CONCLUSIONS

This retrospective study confirms that estimations of energy expenditure in critically ill children are inaccurate leading to unintended under and overfeeding. Importantly under feeding seems to be associated with fewer mechanical ventilation days and PICU LOS. Further research is required to elucidate the role of optimal nutrition in altering clinical variables in this population.

Nutrition Support for Children Undergoing Congenital Heart Surgeries: A Narrative Review

Energy imbalance in infants and children with congenital heart disease (CHD) is common and influenced by age, underlying cardiac diagnoses, and presence or absence of congestive heart failure. During the surgical hospitalization period, these children are prone to nutritional deterioration due to stress of surgery, anesthetic/perfusion techniques, and postoperative care. Poor nutrition is associated with increased perioperative morbidity and mortality. This review aims to examine various aspects of nutrition in critically ill children with CHD, including (1) energy expenditure, (2) perioperative factors that contribute to energy metabolism, (3) bedside practices that are potentially able to optimize nutrient delivery, and (4) medium- to long-term impact of energy balance on clinical outcomes. We propose a nutrition algorithm to optimize nutrition of these children in the perioperative period where improvements in nutrition status will likely impact surgical outcomes.

"I was so worried about every drop of milk" - feeding problems at home are a significant concern for parents after major heart surgery in infancy

Increasing numbers of operations in small infants with complex congenital heart disease are being carried out in the UK year on year, with more surviving the initial operation. However, even after successful surgery some of these infants remain fragile when they are discharged home. The aim of the study was to elicit parents' experiences of caring for a child with complex needs after major congenital heart surgery. We conducted a qualitative study involving semi-structured interviews with parents of 20 children (aged <1-5 months at hospital discharge), who had undergone open heart surgery and subsequently died or been readmitted unexpectedly to intensive care following their initial discharge home. Feeding difficulties following discharge from the specialist surgical centre emerged as one of the most significant parental concerns spontaneously raised in interviews. For some parents the impact of feeding difficulties overshadowed any other cardiac concerns. Key themes centred around feeding management (particularly the practical challenges of feeding their baby), the emotional impact of feeding for parents and the support parents received or needed after discharge with respect to feeding. Caring for a child with congenital heart disease following surgery is demanding, with feeding difficulties being one of the most significant parent stressors. Local health professionals can be a good source of support for parents provided that they are well informed about the needs of a cardiac baby and have realistic expectations of weight gain. Specialist surgical centres should consider addressing issues of parental stress around feeding and weight gain prior to hospital discharge. © 2016 Blackwell Publishing Ltd.

Nutritional status of congenital heart disease (CHD) patients: Burden and determinant of malnutrition at university of Nigeria teaching hospital Ituku - Ozalla, Enugu

Background and Objectives:

Children with congenital heart disease (CHD) are prone to malnutrition. This can have a significant effect on the outcome of surgery. Our objective was to determine the burden and determinant of malnutrition in children with several types of congenital heart disease (CHD).

Methods:

This is a descriptive cross sectional study of children attending the outpatient clinic of UNTH, Ituku – Ozalla, Enugu State, over a six year period from March 2007 to April 2014. Data analysis was done with Statistical Package for Social Sciences (SPSS) version 19 (Chicago IL).

Results:

Forty thousand one hundred and twenty three (40,123) children attended the outpatient clinic during the study period. Of these, 50 had congenital heart disease, from which 46 were found to have various degree of malnutrition, giving a prevalence of 92% among children with congenital disease and 0.11% in the general population. Malnutrition showed significant correlation between age in years, age appropriate dietary adequacy and pulmonary hypertension. (r= 0.22, p = 0.01; r = 0.20, p = 0.02; r = 0.15, p = 0.01).

Conclusion:

Children with CHD develop severe malnutrition and growth failure. The significant contributing factors are mean age at presentation and age appropriate dietary adequacy.

General approach to velocardiofacial anomalies: a pediatric case presenting with Fallot tetralogy

Velocardiofacial syndrome (VCFS), also known as “Shprintzen syndrome” or “22q11.2 deletion syndrome” is an autosomal dominant genetic disorder with a wide range of phenotypical findings. It is majorly characterized by cleft palate, dysmorphic face, conotruncal cardiac anomalies, growth retardation, neurologic disorders and learning disabilities. Our case was the first child of her family and she had a cleft palate, dysmorphic face, tetralogy of Fallot (TOF), growth retardation and a mild neuromotor developmental delay. It is important to recognize this syndrome and inform the family about the probable future health problems of their babies as early as possible. Genetic counselling is crucial for the subsequent pregnancies. Therefore, we wanted to review the literature about the differential diagnosis and genetics of velocardiofacial anomalies.

Current management of pediatric dilated cardiomyopathy

PURPOSE OF REVIEW

American and European guidelines for treatment of adult heart failure have been recently revised. This review will reconcile those guidelines to recent studies and experience in the treatment of pediatric dilated cardiomyopathy.

RECENT FINDINGS

Therapy for pediatric dilated cardiomyopathy includes establishing a diagnosis for diagnostic-specific therapies as well as preventive strategies for anthracycline toxicity and muscular dystrophy. Pediatric studies demonstrate safety and efficacy for use of angiotensin-converting enzyme inhibition and beta-blockers in dilated cardiomyopathy. Cardiac resynchronization and mitral annuloplasty represent potential nonpharmacologic therapies. Implantable defibrillator therapy may be of less import in children as compared with adults. Ventricular assist devices (VADs) are now available for all ages, which can improve survival and potentially can lead to recovery.

SUMMARY

The robust development of new therapies for adult heart failure has been successfully applied to children with dilated cardiomyopathy. Therapies for severe, intractable heart failure have been more widely utilized than therapies for mild-to-moderate heart failure.

Content validation of the infant malnutrition and feeding checklist for congenital heart disease: a tool to identify risk of malnutrition and feeding difficulties in infants with congenital heart disease

Infants with congenital heart disease (CHD) have a high prevalence of feeding difficulties and malnutrition. Early intervention decreases morbidity and long-term developmental deficits. The purpose of this study was to develop and establish the content validity of a screening checklist to identify infants with CHD at risk of feeding difficulties or inadequate nutritional intake for timely referral to a feeding specialist or dietitian. The Delphi method was used, and expert participants reached consensus on 24 risk indicators. This study is the first step in establishing the validity and reliability of a screening tool for early intervention of feeding difficulties and inadequate nutritional intake in infants with CHD.

[Assessment of nutritional status in esophageal atresia]

OBJECTIVE

The aim of the study was to find out whether patients who underwent esophageal atresia (EA) surgery suffered from nutritional problems, to compare the nutritional status of these patients with a control group, and to determine if there is a relationship between the type of atresia and the nutritional condition.

MATERIAL AND METHODS

We selected 25 patients out of a total of 32 who underwent EA surgery in our hospital from 2000 to 2006. A retrospective was conducted study based on the information obtained from the medical histories. A case-control study was also carried out by selecting a control group from a randomized population.

RESULTS

The analyses performed showed that the mean weight and height Z-score was always negative, but not below -2 SD. There was a significant decrease in the weight Z-score between 3 and 9 months and in the weight/size Z-score between 3 and 24 months. Significant differences in weight and size Z-score were found between cases and controls, but not in skin-fold thickness. Independently of the type of atresia and the presence or not of congenital heart defects, no significant differences were found.

CONCLUSIONS

There are significant differences in the weight and height Z-score between cases and controls. We stress the need to be aware of the nutritional status in order to prevent changes that could lead to a further deterioration of the patient.

Study on bone age in pediatric patients with congenital heart disease and its relation with cyanosis and pulmonary artery pressure

The aim of this study is to evaluate the growth failure in children with Congenital Heart Diseases (CHD) associated with the Pulmonary Hypertension (PH) and cyanosis. Growth parameters including weight, height and head circumference of 120 cases with congenital heart defects aged 6 months to 14 years were compared with standard growth curves (50th percentile) between November 2007 and November, 2008. Of all, sixty five (54.1%) were male and 55 (45.8%) were female. The patients were classified into four groups based on the presence or absence of PH and cyanosis. The gap between chronological age and bone age (BA) for all subjects was determined. Growth disturbance in weight, height and head circumference was detected in 80 (66.7%), 79 (65.8%) and 41 (34.2%) of the patients, respectively. Bone age delay was seen in fifty five percent of the cases. Generally, delay in all parameters was more seen in acyanotic patients with pulmonary hypertension. In subjects with cyanosis whether in addition to PH or not, bone age was significantly retarded. Etiology of growth failure in children with CHD is multifactorial. Further studies are required to assess the role of different factors in this field.

Rationale and design of a trial of angiotensin-converting enzyme inhibition in infants with single ventricle

BACKGROUND

Angiotensin converting enzyme (ACE) inhibitors are known to improve clinical outcome and ventricular function in adults with heart failure. Infants with single-ventricle physiology show abnormalities in ventricular function as well as poor growth. The ability of an ACE inhibitor to preserve ventricular function and improve growth in these infants is unknown.

METHODS

The Pediatric Heart Network designed a randomized, double-blind trial to compare outcomes in infants with single-ventricle physiology receiving enalapril or placebo. Neonates < or =45 days old were eligible. The primary outcome is weight-for-age Z-score at 14 months of age. Secondary outcomes include other measures of somatic growth, laboratory and functional measures of heart failure, developmental indices, measures of ventricular size and function, and the relationship of the renin-angiotensin-aldosterone system genotype to the response to enalapril. The incidence and spectrum of adverse events will also be compared between treatment groups.

RESULTS

A total of 1,245 neonates were screened and 533 (43%) were eligible. The consent rate was 43%; 230 subjects were enrolled. Parental reluctance to participate was the primary reason for non-consent in 79% of the eligible nonconsenting patients. Randomized patients were older, more likely to be male, and more likely to have hypoplastic left heart syndrome than the eligible patients who did not enroll.

CONCLUSIONS

The results of this randomized trial will make an important contribution to the management of infants with single-ventricle physiology by determining whether initiation of ACE inhibition therapy in the neonatal period improves growth, clinical outcome, and ventricular function.

Safety and effectiveness of radiologic percutaneous gastrostomy and gastro jejunostomy in children with cardiac disease

OBJECTIVE

The purpose of our study was to evaluate the safety and effectiveness of radiologic percutaneous gastrostomy and gastrojejunostomy for providing nutritional support in children with cardiac disease.

MATERIALS AND METHODS

Retrospective chart review of 58 children with cardiac disease who underwent radiologic percutaneous gastrostomy from November 2001 to June 2005 was conducted. Patient data were collected until January 2007. The patients' weights were collected at the time of insertion and 6, 12, 18, and 24 months after insertion, and weight-for-age z-scores were calculated.

RESULTS

The mean weight-for-age z-score increased from -2.79 at the time of radiologic percutaneous gastrostomy insertion to -2.33 (p = 0.05) at 6 months after insertion, -1.89 (p = 0.001) at 12 months, -1.65 (p = 0.0002) at 18 months, and -1.40 (p = 0.0004) at 24 months. Repeated measures regression analysis showed a significant increase in weight-for-age z-score over time (p < 0.0001), with an estimated mean increase in weight-for-age z-score of 0.055 per month. No mortality was associated with the insertion or usage of radiologic percutaneous gastrostomy. Major complications included intestinal perforation (3.4%) and aspiration pneumonia (12.1%).

CONCLUSION

Radiologic percutaneous gastrostomy is a safe method for providing long-term nutritional support in children with cardiac disease and is effective for improving growth and nutrition in this group of patients.

Nutrition in Pediatric Cardiomyopathy

Pediatric cardiomyopathies are heterogeneous groups of serious disorders of the heart muscle and are responsible for significant morbidity and mortality among children who have the disease. While enormous improvements have been made in the treatment and survival of children with congenital heart disease, parallel strides have not been made in the outcomes for cardiomyopathies. Thus, ancillary therapies, such as nutrition and nutritional interventions, that may not cure but may potentially improve cardiac function and quality of life, are imperative to consider in children with all types of cardiomyopathy. Growth failure is one of the most significant clinical problems of children with cardiomyopathy with nearly one-third of children with this disorder manifesting some degree of growth failure during the course of their illness. Optimal intake of macronutrients can help improve cardiac function. In addition, several specific nutrients have been shown to correct myocardial abnormalities that often occur with cardiomyopathy and heart failure. In particular, antioxidants that can protect against free radical damage that often occurs in heart failure and nutrients that augment myocardial energy production are important therapies that have been explored more in adults with cardiomyopathy than in the pediatric population. Future research directions should pay particular attention to the effect of overall nutrition and specific nutritional therapies on clinical outcomes and quality of life in children with pediatric cardiomyopathy.

Indications for Heart Transplantation in Pediatric Heart Disease

Background— Since the initial utilization of heart transplantation as therapy for end-stage pediatric heart disease, improvements have occurred in outcomes with heart transplantation and surgical therapies for congenital heart disease along with the application of medical therapies to pediatric heart failure that have improved outcomes in adults. These events justify a reevaluation of the indications for heart transplantation in congenital heart disease and other causes of pediatric heart failure.

Methods and Results— A working group was commissioned to review accumulated experience with pediatric heart transplantation and its use in patients with unrepaired and/or previously repaired or palliated congenital heart disease (children and adults), in patients with pediatric cardiomyopathies, and in pediatric patients with prior heart transplantation. Evidence-based guidelines for the indications for heart transplantation or retransplantation for these conditions were developed.

Conclusions— This evaluation has led to the development and refinement of indications for heart transplantation for patients with congenital heart disease and pediatric cardiomyopathies in addition to indications for pediatric heart retransplantation.