Growth and Nutritional Status of Children With Congenital Heart Disease

Neonatal anthropometry of malformed newborns: A large South American population-based study

BACKGROUND

Population-based anthropometric evaluation of malformed newborns is scarce.

OBJECTIVES

To evaluate malformed newborns' foetal growth using the ICD 10 malformations' classification.

METHODS

A study including 33,769 newborns (14,857 malformed and 18,912 nonmalformed), selected from 678,840 births from nine South American countries, period 2010-2018, was conducted. Prevalence of severe small and small for gestational age was calculated for malformed and nonmalformed newborns classified by preterm birth categories. Prevalence and relative risk (RR) with its 95% confidence interval (CI) were calculated. The associations between anthropometric phenotypes and congenital malformations were evaluated with generalized linear models.

RESULTS

Prevalence of preterm and term severe small and small for gestational age newborns was higher in malformed than that in nonmalformed neonates. For grouped ICD 10 malformations categories, the RR for severe small for gestational age was 2.88 (95% CI 2.51, 3.30) and 2.10 (95% CI 1.92, 2.30) for small for gestational age. For at-term and preterm malformed newborns, the RR for severe small for gestational age was 2.21 (95% CI 1.87, 2.61) and 3.21 (95% CI 2.52, 4.10), respectively; for small for gestational age, the RR was 2.31 (95% CI 2.11, 2.53) for at-term newborns and 2.58 (95% CI 2.16, 3.08) for preterm ones.

CONCLUSIONS

Prevalence and relative risk of severe small and small for gestational age vary according to the group of malformations and gestational age; they increase in congenital malformations of the nervous, respiratory and digestive systems, and in chromosomal abnormalities and are lower for malformations of eye, ear, face and neck and cleft lip and palate. Foetal growth considered together with malformed newborns' gestational age would allow for inferring different risks of morbidity and mortality.

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.

Short-Term Nutritional Support for Infants With Unrestricted Ventricular Septal Defects to Promote Postoperative Recovery

OBJECTIVE

This study is aimed to explore the effect of short-term nutritional support for infants with unrestricted ventricular septal defects on improving preoperative nutritional status and promoting postoperative recovery.

METHODS

The clinical data of 35 infants with unrestricted ventricular septal defects who were treated with 2 weeks of nutritional support in our hospital from December 2020 to March 2021 were analyzed retrospectively. The clinical data of 38 infants with unrestricted ventricular septal defects who were treated in our hospital from May 2020 to October 2020 were selected as controls.

RESULTS

The preoperative body weight, preoperative albumin, preoperative prealbumin, and preoperative hemoglobin in the intervention group were significantly higher than those in the control group (P < 0.05). The postoperative ventilator time, intensive care time, and discharge time in the intervention group were significantly shorter than those in the control group (P < 0.05).

CONCLUSION

Performing 2 weeks of nutritional support for infants with unrestricted ventricular septal defects can improve their preoperative nutritional status and promote postoperative recovery.

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.

Performance of remote health education via WeChat to improve the pre-operative nutritional status of infants with non-restrictive ventricular septal defects: A prospective randomised controlled study

AIM

This study aimed to explore the effect of performing remote health education via WeChat to improve the pre-operative nutritional status of non-restrictive ventricular septal defects (VSD).

METHODS

A prospective randomised controlled study was conducted in a provincial maternity and child hospital in China. Participants were randomised regarding education to the intervention group (WeChat) and the control group (leaflets). The nutritional status and complications of the patients were compared after intervening for 1 month.

RESULTS

Nutrient status comparison at 1 month after intervention showed that the body weight, head circumference, haemoglobin, albumin and pre-albumin of the WeChat group were significantly higher than those of the leaflet group (P < 0.05). The STRONGkids score of the WeChat group was significantly lower than that of the leaflet group (P < 0.05). The incidence of feeding intolerance and respiratory tract infection in the WeChat group was significantly lower than that found in the leaflet group (P < 0.05). There was no significant difference in the incidence of liver insufficiency and jaundice between the two groups (P > 0.05).

CONCLUSION

Providing pre-operative feeding and care guidance for parents of infants with non-restrictive VSD, via remote health education through WeChat, can effectively improve nutritional status and reduce the risk of malnutrition and feeding complications.

Cardiac point of care ultrasound in resource limited settings to manage children with congenital and acquired heart disease

BACKGROUND

In resource limited settings, children with cardiac disease present late, have poor outcomes and access to paediatric cardiology programmes is limited. Cardiac point of care ultrasound was introduced at several Médecins Sans Frontières sites to facilitate cardiopulmonary assessment. We describe the spectrum of disease, case management and outcomes of cases reviewed over the Telemedicine platform.

METHODS

Previously ultrasound naïve, remotely placed clinical teams received ultrasound training on focussed image acquisition. The Médecins Sans Frontières Telemedicine platform was utilised for remote case and imaging review to diagnose congenital and acquired heart disease and guide management supported by a remotely situated paediatric cardiologist.

RESULTS

Two-hundred thirty-three cases were reviewed between 2016 and 2018. Of 191 who underwent focussed cardiac ultrasound, diagnoses included atrial and ventricular septal defects 11%, atrioventricular septal defects 7%, Tetralogy of Fallot 9%, cardiomyopathy/myocarditis 8%, rheumatic heart disease 8%, isolated pericardiac effusion 6%, complex congenital heart disease 4% and multiple other diagnoses in 15%. In 17%, there was no identifiable abnormality while 15% had inadequate imaging to make a diagnosis. Cardiologist involvement led to management changes in 75% of cases with a diagnosis. Mortality in the entire group was disproportionately higher among neonates (38%, 11/29) and infants (20%, 16/81). There was good agreement on independent review of selected cases between two independent paediatric cardiologists.

CONCLUSION

Cardiac point of care ultrasound performed by remote clinical teams facilitated diagnosis and influenced management in cases reviewed over a Telemedicine platform. This is a feasible method to support clinical care in resource limited settings.

Perioperative nutritional prehabilitation in malnourished children with congenital heart disease: A randomized controlled trial

OBJECTIVE

The poor preoperative nutritional state of children with congenital heart disease (CHD) is often exacerbated postoperatively. The aim of this study was to evaluate the effect of perioperative 1- versus 2-wk nutritional prehabilitation programs on growth and surgical outcomes in malnourished children with CHD.

METHODS

Forty malnourished infants scheduled for elective CHD surgery were randomized to receive either 1 or 2 wk of a nutritional prehabilitation program. Pre- and postoperative anthropometric parameters and feeding characteristics, feeding tolerance, duration of mechanical ventilation, intensive care unit (ICU) length of stay (LOS) and total hospital LOS were documented.

RESULTS

The 2-wk prehabilitation group showed higher weight-for-age z-score and body mass index than the 1-wk group both preoperatively postnutritional, and postoperatively with significantly higher weight gain postoperatively. The 2-wk prehabilitation group had a shorter duration of postoperative mechanical ventilation, ICU LOS, and total hospital LOS.

CONCLUSION

The 2-wk prehabilitation program was associated with better anthropometric measurements, shorter ICU LOS postoperatively, and shorter duration of hospitalization and mechanical ventilation. The preoperative nutritional status of children with CHD had a negative effect on ICU LOS and duration of mechanical ventilation.

Gluten Sensitivity among Egyptian Infants with Congenital Heart Disease

BACKGROUND

Gastrointestinal symptoms are a common feature in infants with congenital heart disease.

AIM

This study was designed to evaluate age-dependent serum levels of antigliadin antibodies among malnourished Egyptian infants with congenital heart disease (CHD) and gastrointestinal symptoms.

SUBJECTS AND METHODS

This case-control study conducted on 60 infants with established congenital heart disease. They were subdivided into cyanotic and acyanotic groups, and each group includes 30 patients compared with thirty apparently healthy infants of matched age, sex, and social class. Serum antigliadin antibodies levels were measured using ELISA.

RESULTS

The mean age of introduction of cereals in the diet and appearance of gastrointestinal symptoms were six months. On comparison with controls, patients showed highly significant higher serum levels of antigliadin antibodies (P < 0.000). On analysing risk factors using odds ratio, the age at onset of GIT symptoms, diarrhoea, abdominal pain, and distension had been found to be significantly associated with high serum antigliadin antibodies among malnourished CHD infants with a prediction of 95%.

CONCLUSION

Serum IgA, IgM, and IgG class antibodies to gliadin play a significant role in the pathogenesis of malnutrition in infants with CHD. Gluten containing foods should never be introduced before the end of the six months.

Impact of malnutrition on pediatric risk of mortality score and outcome in Pediatric Intensive Care Unit

OBJECTIVES

This study was done to determine the effect of malnutrition on mortality in Pediatric Intensive Care Unit (PICU) and on the pediatric risk of mortality (PRISM) scoring.

SUBJECTS AND METHODS

This was a prospective study done over 1 year. There were total 400 patients (1 month 14 years), who were divided into cases with weight for age <3(rd) centile and controls with ≥3(rd) centile of WHO charts. Cases were subdivided into mild/moderate (61-80% of expected weight for age) and severe malnutrition (<60%).

RESULTS

Out of total, 38.5% patients were underweight, and malnutrition was more in infancy, 61/104, i.e. 58.5% (P - 0.003). There was no significant difference in vitals at admission. Cases needed prolonged mechanical ventilation (P - 0.0063) and hospital stay (P - 0.0332) compared to controls. Mean and median PRISM scores were comparable in both the groups, but mortality was significantly higher in severely malnourished (P value 0.027).

CONCLUSION

Severe malnutrition is independently associated with higher mortality even with similar PRISM score. There is need to give an additional score to children with weight for age <60% of expected.

Malnutrition in Hospitalized Pediatric Patients: Assessment, Prevalence, and Association to Adverse Outcomes

Malnutrition is a frequent finding in pediatric health care settings in the form of undernutrition or excess body weight. Its increasing prevalence and impact on overall health status, which is reflected in the adverse outcomes, renders imperative the application of commonly accepted and evidence-based practices and tools by health care providers. Nutrition risk screening on admission and nutrition status evaluation are key points during clinical management of hospitalized pediatric patients, in order to prevent health deterioration that can lead to serious complications and growth consequences. In addition, anthropometric data based on commonly accepted universal growth standards can give accurate results for nutrition status. Both nutrition risk screening and nutrition status assessment are techniques that should be routinely implemented, based on commonly accepted growth standards and methodology, and linked to clinical outcomes. The aim of the present review was to address the issue of hospital malnutrition in pediatric settings in terms of prevalence, outline nutrition status evaluation and nutrition screening process using different criteria and available tools, and present its relationship with outcome measures. Key teaching points • Malnutrition-underweight or excess body weight-is a frequent imbalance in pediatric settings that affects physical growth and results in undesirable clinical outcomes. • Anthropometry interpretation through growth charts and nutrition screening are cornerstones for the assessment of malnutrition.To date no commonly accepted anthropometric criteria or nutrition screening tools are used in hospitalized pediatric patients. • Commonly accepted nutrition status and screening processes based on the World Health Organization's growth standards can contribute to the overall hospital nutrition care of pediatric patients.

Predictors of High Serum Casein Antibody Levels among Malnourished Infants and Young Children with Congenital Heart Disease

BACKGROUND

Factors predictive of growth retardation and malnutrition in patients with congenital heart disease remain unclear.

OBJECTIVES

This study aimed to measure antibody response to bovine casein through assessing serum casein antibody levels in malnourished patients three year or younger with CHD, and to determine its relationship to gastrointestinal symptoms, anthropometric measures, and laboratory data.

SUBJECTS AND METHODS

This cross sectional case control study was conducted in sixty patients with CHD aged 4 to 72 months. They were subdivided into thirty patients with cyanotic and thirty patients with acyanotic CHD compared with thirty apparently healthy children.

RESULTS

On comparison with controls, patients showed highly significant lower anthropometric measures, calcium, iron, hemoglobin levels, and higher serum levels of casein antibody, total iron binding capacity, and alkaline phoshatase activity (P<0.000). Serum levels of casein antibody showed significantly positive correlations with serum total iron binding capacity and alkaline phosphatase activities and negatively correlated with the age at onset of symptoms, anthropometric measures, serum calcium, and iron levels.

CONCLUSION

Serum casein antibody levels play a significant role in the pathogenesis of malnutrition. Encouragement of breast feeding and avoidance of early cow's milk consumption could prevent the development of antibody response to bovine casein.

Bone quality and nutritional status in children with congenital heart defects

The aim of this study was to evaluate bone quality and nutritional status in children with congenital heart defects (CHDs) using quantitative ultrasound. A cross-sectional study was designed. A population-based sample of 75 children with CHD (age: 0--6yr) from the Department of Pediatric Cardiology at the National Cardiology Institute "Ignacio Chávez" was compared with 106 healthy children during 2009. Weight and height were determined in both groups; bone status was measured at the radius and tibia as speed of sound (SOS). Nutritional status was defined according to the Waterloo and Gómez index. Chi-square test, Student's t-test, and analysis of variance were used to determine the statistical differences. A linear regression analysis adjusted by age, weight, height, type of CHD, and birth weight was made. Both groups were similar in sex distribution, prematurity, and birth weight. Acyanotic cardiopathy with increased pulmonary flow was the most frequent (61.3%). Prevalence of malnutrition was higher in CHD group compared with healthy children (p<0.001), and radius SOS was lower in children with CHD compared with healthy children (3484±180 vs 3575±159m/s, respectively; 95% confidence interval: 39.8--143; p=0.001). A positive correlation was found between CHD and reduced SOS in the adjusted linear regression model, r²=0.455 (p<0.001). Children with CHD have lower SOS radius values compared with healthy children, suggesting reduced bone quality regardless of the nutritional status.

Evaluation of growth and neurodevelopment in children with congenital heart disease

BACKGROUND

Children with congenital heart disease are under risk of delayed growth and development. We evaluated physical growth parameters and neurodevelopment in these patients in comparison with normal children and examined the effect of hemodynamic status.

METHODS

Patients with congenital heart disease (n= 76) and healthy children (n= 51) aged 1-72 months applied to Mersin University Hospital, Mersin, Turkey were included. Patients with heart failure and those requiring intervention or surgery were classified as hemodynamically impaired (HI group, n= 30), and the others, hemodynamically normal (HN group, n= 46). Growth parameters including weight, height, body mass index (BMI), mid-arm circumference (MAC), and triceps skin fold thickness (TSF) were measured and standard deviations (SD) were determined. Functional development was assessed by Denver Developmental Screening Test-II (DDST II).

RESULTS

MAC and BMI values of the group with impaired hemodynamic status were significantly lower than the hemodynamically normal and control groups (MAC P < 0.05 and BMI P < 0.01). In the DDST II, the group with hemodynamic abnormality had more failures in gross motor and fine motor skills than HN group and controls (gross motor P= 0.011, P < 0.001 and fine motor P= 0.028, P= 0.001, respectively) and more failures in language development than the control group (P= 0.001).

CONCLUSION

The results showed the importance of hemodynamic status in growth and neurodevelopment of children with congenital heart disease. Besides routine growth parameters, more detailed examinations such as BMI, MAC, TSF, and developmental screening tests appear useful in identifying children with cardiac disease who are under risk for delayed growth and development.

Oropharyngeal aspiration and silent aspiration in children

BACKGROUND

Limited information exists about the nature of and factors associated with oropharyngeal aspiration (OPA) and silent aspiration (SA) in children. A prospective study was undertaken to determine the factors associated with fluoroscopically identified OPA and SA.

METHODS

Three hundred children presenting with feeding difficulties underwent a videofluoroscopic swallow study (VFSS) for evaluation of swallowing. Swallowing performance on each food and fluid consistency was rated using the penetration-aspiration scale, and children were classified into the following groups: OPA, SA, overt aspiration (OA), and no aspiration (NA).

RESULTS

OPA occurred in 34% of children; of these, 81% had SA. SA was significantly associated with neurologic impairment (OR, 4.65; 95% CI, 2.26-9.54), developmental delay (OR, 4.62; 95% CI, 2.28-9.35), aspiration lung disease (OR, 3.22; 95% CI, 1.29-8.05), and enteral feeding (OR, 2.03; 95% CI, 1.04-3.62). Similar results were found for OPA. Children with SA were more likely to have neurologic disease (OR, 4.1; 95% CI, 1.1-15.8) than those with OA. Age or gender differences, gastroesophageal reflux disease, recurrent respiratory tract infections, and asthma were no more likely to occur in children with OPA, SA, or OA.

CONCLUSIONS

SA is very common in children with feeding difficulties and is most likely to occur in children with a neurologic problem. Limited medical diagnoses distinguished between aspirators (OPA, SA) and those with NA. VFSS should be performed in children with feeding difficulties and diagnoses of neurologic impairment, cerebral palsy, aspiration lung disease, and/or enteral feeding because of the increased likelihood of SA.

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.

Neuropsychomotor development before and after open-heart surgery in infants

There are few Brazilian studies on neuropsychomotor follow-up after open-heart surgery with circulatory bypass in infants. Twenthy infants had neurodevelopmental outcomes (neurological exam and Denver II test) assessed before open-heart surgery, after intensive care unit discharge and 3-6 months after hospital discharge. Heart lesions consisted of septal defects in 11 cases (55%). The mean circulatory bypass time was 67 ± 23.6 minutes. Fifteen infants had altered neurological examination and also neurodevelopment delay before surgery. After 6 months it was observed normalization in 6 infants. When Denver II test indexes were analysed, it was observed an improvement in all domains except personal-social. Although those infants were in risk of new neurological findings, an early improvement on neuropsychomotor indexes were seen.