What Determines Nutritional Recovery in Malnourished Children After Correction of Congenital Heart Defects?

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Children After Correction of Congenital Heart Defects?

WHAT’S KNOWN ON THIS SUBJECT: Malnutrition is common in children with CHD. Corrective intervention results in

normalization of growth parameters on follow-up.

WHAT THIS STUDY ADDS: Approximately one quarter of children with CHD continue to have persistent malnutrition even after corrective intervention. Persistent malnutrition on follow-up is predicted by the nutritional status at the time of correction, birth weight, and parental anthropometry.

abstract

BACKGROUND:Malnutrition is common in children with congenital heart disease (CHD), especially in developing countries.

OBJECTIVE:To examine the impact of corrective intervention on the nutritional status of children with CHD and identify factors associated with suboptimal recovery.

METHODS:Consecutive patients with CHD in a tertiary center in South India were evaluated for nutritional status before and 2 years after corrective intervention. Anthropometry was performed at presenta-tion and every 6 months for 2 years, andz scores were compared. Malnutrition was deﬁned as a weight-for-age, height-for-age, and weight/heightz score⬍⫺2. Determinants of malnutrition were en-tered into a multivariate logistic regression analysis model.

RESULTS:Of 476 patients undergoing corrective intervention (surgical: 344; catheter-based: 132)z scores of less than⫺2 for weight for age, height for age, and weight/height were recorded in 59%, 26.3%, and 55.9% of patients, respectively, at presentation. On follow-up (425 patients [92.5% of survivors; 20.63⫾13.1 months of age]),zscores for weight for age and weight/height improved signiﬁcantly from the baseline (weight:⫺1.42⫾ 1.03 vs⫺2.19⫾1.16;P⬍.001; weight/height:⫺1.15⫾1.25 vs⫺2.09

⫾1.3;P⬍.001). Height-for-agezscores were not signiﬁcantly differ-ent. Malnutrition persisted in 116 (27.3%) patients on follow-up and was associated with a birth weight ofⱕ2.5 kg, nutritional status at presentation, and height of parents and not with type of cardiac lesion, dietary intake, or socioeconomic factors.

CONCLUSIONS:This study from South India demonstrates severe mal-nutrition in over half of the patients with CHD and is not always re-versed by corrective surgery or intervention. Persistent malnutrition after corrective intervention is predicted by nutritional status at pre-sentation, birth weight, and parental anthropometry.Pediatrics2009; 124:e294–e299

CONTRIBUTORS:Balu Vaidyanathan, DM,a_Reshma

Radhakrishnan, MPH,a_{Deepa Aravindakshan Sarala, MSW,}a

Karimassery Ramaiyar Sundaram, PhD,b_{and Raman Krishna}

Kumar, DM, FACCa

Departments ofa_{Pediatric Cardiology and}b_{Biostatistics, Amrita} Institute of Medical Sciences and Research Center, Elamakkara, Kochi, Kerala, India

KEY WORDS

congenital heart disease, malnutrition, corrective intervention

ABBREVIATIONS

CHD— congenital heart disease CHF— congestive heart failure

CDC—Centers for Disease Control and Prevention

www.pediatrics.org/cgi/doi/10.1542/peds.2009-0141

doi:10.1542/peds.2009-0141

Accepted for publication Mar 16, 2009

Address correspondence to Balu Vaidyanathan, DM, Amrita Institute of Medical Sciences and Research Center, Department of Pediatric Cardiology, Amrita Lane, Elamakkara PO, Kochi, Kerala, India. E-mail: baluvaidyanathan@gmail.com

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

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Malnutrition is a common cause of morbidity in children with congenital heart disease (CHD).1–6 _{Studies from}

developed countries have documented normalization of somatic growth when corrective surgery for CHD is per-formed early.7–12 _{In developing}

coun-tries, because of resource limitations, corrective interventions for CHD are performed late, leading to a vicious cy-cle of congestive heart failure (CHF) and respiratory infections.13,14_This

re-sults in a high prevalence of preopera-tive malnutrition in patients with CHD.15_{The implications of}

preopera-tive malnutrition for future somatic growth are unknown, and the role of different ethnic, socioeconomic, and cultural factors on the nutritional sta-tus of patients with CHD have not been reported.

We previously reported that preopera-tive malnutrition and respiratory in-fection do not impact immediate out-comes after surgery for infants with large ventricular septal defects.15,16

However, on 5-year follow-up, a signiﬁ-cant proportion of these patients con-tinued to have suboptimal growth compared with the normal popula-tion.17_{In a previous study, we reported}

a very high prevalence of malnutrition (⬎50%) in a cohort of 476 patients un-dergoing corrective intervention for a variety of defects and identiﬁed the predictors of malnutrition at the time of intervention.18 _{This study analyzes}

the impact of correction intervention on the nutritional status on 2-year follow-up of the survivors of the same cohort of patients and also attempts to

identify factors associated with subop-timal recovery of nutritional status.

PATIENTS AND METHODS

This was a prospective study con-ducted in a tertiary referral hospital in Southern India. All children ⱕ5 years of age undergoing surgical or catheter-based corrective interven-tion at our center from June 2005 to June 2006 were included. Patients undergoing palliative procedures were excluded.

A comprehensive evaluation of deter-minants of malnutrition was per-formed at admission for corrective intervention. These included demo-graphic, birth-related, cardiac, socio-economic, and cultural factors as well as feeding practices (Table 1). Socio-economic status was graded by using the modiﬁed Kuppuswamy scale.19_All

patients underwent an anthropomet-ric evaluation at presentation;zscores for weight for age, height for age, and weight/height were calculated by us-ing Centers for Disease Control and Prevention (CDC) 2000 reference val-ues.20_{The weight and height of}

par-ents were recorded and midparental height was estimated. Follow-up evaluations were scheduled at 3 months and then at 6-month inter-vals for a period of 2 years after cor-rective intervention. Follow-up evalu-ations included assessment of growth, dietary intake, and cardiac evaluation for any signiﬁcant resid-ual abnormalities. At follow-up, a di-etician provided nutritional counsel-ing and advice on optimizcounsel-ing the

dietary intake in all patients. Malnu-trition was deﬁned aszscores of less than ⫺2 for weight (low weight for age), height (low height for age), and weight/height (low weight for height).21

Comparison of 2-year follow-up data with baseline values was performed by using the pairedttest. To test the sta-tistical signiﬁcance of the association between malnutrition on follow-up and risk variables, univariate analysis was performed by applying the␹2_test

(dis-crete variables) and independent sam-ples ttest (continuous variables). All variables significant at the 10% level (90% confidence) were included in the stepwise multivariate logistic regres-sion analysis. Odds ratios with 95% confidence intervals and P values were computed for the statistically significant variables by using stan-dard formulae.

This study was approved by the review board of the institution and the fund-ing agency.

RESULTS

Four hundred seventy-six consecutive patients undergoing corrective inter-vention for CHD were included. Mean age at presentation was 15.2 ⫾ 16.2 months. There were 296 (62.2%) in-fants (ⱕ1 year of age) and 45 (9.5%) neonates, and 233 (48.9%) patients were boys. The most common cardiac diagnosis was left-right shunts (64.3%). A total of 344 (72.3%) patients underwent surgery, and the remaining patients received catheter-based in-terventions. A total of 194 (40.8%)

pa-TABLE 1 Determinants of Malnutrition in CHD Studied at Presentation and on Follow-up

Demographic factors Age, gender, birth weight, order of birth, and weight for gestational age (categorized as AGA, SGA, or LGA)

Cardiac and clinical factors Cardiac diagnosis and physiology; presence of congestive heart failure, pulmonary hypertension; oxygen saturation; previous hospitalizations; and presence of associated genetic syndromes

Socioeconomic factors Details of family: nuclear/joint, number of family members and children; religion, consanguinity; age and level of education of parents; occupation of father; employment status of mother; and monthly income

Growth potential Weight and height of parents and midparental height

Dietary factors Intake of calories, protein, carbohydrate, fat (expressed as percentage of RDA), breastfeeding, age at weaning, type of weaning foods, and adequacy of weaning

AGA indicates appropriate for gestational age; SGA, small for gestational age; LGA, large for gestational age; RDA, recommended daily allowance.

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tients had CHF. Thirty (6.3%) patients had associated genetic syndromes. Ta-ble 2 lists the cardiac diagnoses of pa-tients included in the study, and Table 3 details the interventions performed.

There were 16 deaths (3.35%; 13 in-hospital, 3 on follow-up). Fifty-nine per-cent (weight for age), 26.3% (height for age), and 55.9% (weight/height) of pa-tients had z scores of less than or equal to ⫺2 at presentation. Predic-tors of malnutrition at presentation in-cluded CHF, age at correction, lower birth weight and fat intake, previous hospitalizations,ⱖ2 children (weightz

score less than⫺2); small for gesta-tion, lower maternal height, fat intake, and genetic syndromes (heightzscore less than⫺2); CHF, age at correction, lower birth weight and maternal weight, previous hospitalizations, reli-gion (Hindu), and level of education of the father (weight/heightzscore less than⫺2). Gender, cardiac diagnosis, oxygen saturation, and dietary and so-cioeconomic factors did not inﬂuence the nutritional status.

Of the 460 survivors, the follow-up data were available for 425 (92.5%) tients. The remaining 35 (7.5%) pa-tients were lost to follow-up. The base-line data were similar in patients with

and without follow-up. The mean follow-up duration was 20.63 ⫾ 13.1 months, and the mean age at follow-up was 35.76 ⫾ 21.6 months. Forty-four

quired cardiac medications.

One hundred sixteen (27.3%) patients had a weight-for-age z score of less than⫺2 on follow-up. A height-for-age

zscore of less than⫺2 was observed in 123 (28.9%) patients, whereas 104 (24.5%) patients had a weight/heightz

score of less than⫺2.

Comparison of z scores on follow-up with baseline values showed signiﬁ-cant improvement for weight-for-age and weight/height scores; for the height-for-age z score there was a trend toward increase, which was not statistically signiﬁcant. These results are summarized in Fig 1.

On univariate analysis, a weight z

score of less than⫺2 at surgery, age at surgery, lower birth weight, pres-ence of preoperative CHF and pulmo-nary artery hypertension (moderate-severe), consanguinity, level of education of the parents, and parental anthropometry predicted a weight-for-agezscore of less than⫺2 on follow-up. For the height-for-agezscore, age at surgery, birth weight, a height z

FIGURE 1

Comparison ofzscores at presentation for corrective intervention (baseline) and 2-year follow-up (425 patients).

Cardiac Diagnosis n(%)

Patent ductus arteriosus 118 (24.8) Ventricular septal defect 112 (23.5) Tetralogy of fallot 63 (13.2) Atrial septal defect 58 (12.2) D-transposition of great arteries 39 (8.2) Total anomalous pulmonary

venous connection

33 (6.9)

Pulmonic stenosis 15 (3.2)

Coarctation of aorta 12 (2.5) Atrioventricular septal defect 11 (2.3) Anomalous left coronary from

pulmonary artery

5 (1.1)

Aortopulmonary window 3 (0.6)

Truncus arteriosus 3 (0.6)

Aortic stenosis 2 (0.4)

Coronary arteriovenous ﬁstula 1 (0.2) Congenital mitral regurgitation 1 (0.2)

(N⫽476)

Corrective Cardiac Intervention n(%)

Patent ductus arteriosus closure 119 (25.00) Transcatheter closure 103 (21.64) Surgical division 16 (3.36) Ventricular septal defect closure 120 (23.32) Tetralogy of fallot repair 61 (12.82) Atrial septal defect closure 58 (12.18)

Transcatheter 9 (1.89)

Surgical 49 (10.29)

Transposition of great arteries 39 (8.19) Arterial switch operation 28 (5.88) Sennings operation 11 (2.31)

TAPVC repair 33 (6.93)

Balloon pulmonary valvuloplasty 14 (2.94) Coarctation of aorta 11 (2.31)

Surgical repair 7 (1.47)

Balloon dilatation 4 (0.84) Complete AV canal defect repair 7 (1.47)

ALCAPA repair 5 (1.05)

Aortopulmonary window repair 3 (0.63) Truncus arteriosus repair 2 (0.42) Balloon aortic valvuloplasty 1 (0.21) Supravalvar aortic stenosis repair 1 (0.21) Coronary ﬁstula coil closure 1 (0.21) Cleft mitral valve repair 1 (0.21)

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score of less than ⫺2 at surgery, height of parents, presence of preop-erative CHF, and dietary intake of calo-ries after surgery emerged as signiﬁ-cant predictors. A weight/height z

score of less than⫺2 on follow-up was predicted by lower birth weight, a weight/heightzscore of less than⫺2 at surgery, presence of consanguinity, weight of parents, height of father, ed-ucation status of father, and lower socioeconomic status (modiﬁed Kup-puswamy score).

The results of multivariate logistic re-gression analysis of predictors of mal-nutrition on follow-up are summarized in Table 4.

The trends in the recovery of nutri-tional status after corrective interven-tion are summarized in Fig 2. The max-imum recovery for weight and weight/ height occurred in the ﬁrst year after corrective intervention, whereas for height there was not much variation. The catch-up growth for weight and weight/height was apparent from the time of the ﬁrst follow-up (3 months).

DISCUSSION

This study reports a very high preva-lence of malnutrition at presentation

(more than half of patients had low weight for age and one quarter had low height for age) in a large cohort of patients with various CHD undergoing correction (surgical and catheter based). The prevalence is more than twice that reported for this region.22

However, there was signiﬁcant catch-up growth on follow-catch-up (Fig 1), sug-gesting that correction of the cardiac anomaly favorably inﬂuences nutri-tional status.

In a previous report, we identiﬁed hemodyanamic factors (presence of

CHF), older age at corrective interven-tion, and lower growth potential (lower birth weight, small for gesta-tion, lower parental anthropometry, and associated genetic syndrome) as signiﬁcant predictors of malnutrition in the same cohort of patients at the time of corrective intervention.18_This

study describes the impact of correc-tive intervention on the nutritional sta-tus of the survivors at 2-year follow-up and analyzed the factors associated with suboptimal nutritional recovery. One of the features of the follow-up was that an active surveillance of the dietary intake was attempted and de-tailed dietary counseling was provided by a professional dietician for all pa-tients on every follow-up visit. We ob-served that about a quarter of the patients continued to signiﬁcant mal-nutrition despite the correction of the heart disease and optimization of di-etary intake.

On multivariate analysis, a zscore of less than⫺2 at the time of corrective intervention, lower birth weight (⬍2.5 kg), and lower parental height were the only factors associated with signif-icant malnutrition on follow-up (Table 4). Age of⬍6 months at surgery was associated with a heightzscore of less than ⫺2 on follow-up, possibly

be-FIGURE 2

Trends inzscores before and after corrective intervention (zscores are on the x-axis, and duration of follow-up is on the y-axis).

TABLE 4 Multivariate Logistic Regression Analysis of Predictors of Weight, Height, and Weight/ HeightzScore Less Than or Equal to⫺2 on Follow-up

Variable Odds Ratio (95% CI) P

Weightzscore less than⫺2

Weight at surgeryzscore less than⫺2 7.63 (3.78–15.38) ⬍.001

Birth weightⱕ2.5 kg 2.74 (1.39–54) .04

Height of mother⬍150 cm 2.97 (1.25–7.03) .013

Heightzscore less than⫺2

Heightzscore at surgery less than⫺2 2.91 (1.76–4.82) ⬍.001

Birth weight⬍2.5 kg 1.89 (1.04–3.44) .036

Height of motherⱕ150 cm 2.93 (1.26–6.80) .012

Age at surgery

⬍6 mo 3.30 (1.84–5.92) ⬍.001

6–12 mo 2.20 (1.10–4.42) .03

Weight/heightzscore less than⫺2

Weight/heightzscore at surgery less than⫺2 2.62 (1.56–4.41) ⬍.001

Birth weightⱕ2.5 kg 3.41 (1.79–6.51) ⬍.001

Height of father

⬍160 cm 3.55 (1.62–7.80) .002

160–170 cm 2.48 (1.17–5.26) .018

Consanguinity 3.73 (1.38–10.13) .01

CI indicates conﬁdence interval.

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CHD, which could have impacted the nutritional status more severely at presentation. The only modiﬁable fac-tors for persistent malnutrition is lowerzscores at surgery (severe pre-operative malnutrition), whereas all the other factors point toward a lower growth potential (lower birth weight, shorter parents). A similar observa-tion was reported in our previous study in a cohort of 100 infants with ventricular septal defect and severe malnutrition.17

The temporal trends in the recovery of the nutritional status after correc-tive intervention (see Fig 2) suggest that the maximum catch-up growth occurs in the ﬁrst year after correc-tion of the CHD (weight and weight/ height). The obvious change was ap-parent from even 3 months after corrective intervention. This is a re-ﬂection of the correction of the he-modyanamic derangements (CHF) leading to lessening of the cardiac cachexia and promotion of a more anabolic state. After 1 year, the growth curves start to plateau and this may mean that malnutrition at-tributed to the direct effects of CHD is overcome by then and the other factors affecting growth (constitu-tional, dietary, etc) come into play from there onward.

mended by the World Health Organiza-tion.20 _{Although separate reference}

standards do exist for Indian chil-dren,23 _{previous studies from India}

have reported the reproducibility of the National Center for Health Statis-tics CDC 2000 reference standards in the Indian setting.24

The results of this study could have sig-nificant implications for physicians caring for children with heart disease in developing countries. Correction of CHD results in significant catch-up growth on follow-up. Significant preop-erative malnutrition was perhaps the only modifiable predictor of subopti-mal nutritional recovery on follow-up in this study. This emphasizes the need to refer patients with hemodynami-cally significant CHD for early correc-tive intervention before significant malnutrition sets in. The study under-lines the importance of identifying pa-tients with reduced growth potential (lower birth weight) before interven-tion, because these patients continue to have significant malnutrition even after correction of CHD. It is apparent that the lower anthropometric status in these patients on follow-up may be a reflection of a truly reduced genetic growth potential and the family needs to be counseled accordingly.

with clinically identiﬁable genetic syn-dromes. The speciﬁcs of individual ge-netic syndromes have not been ascer-tained here because of the absence of a cytogenetic facility at our institution when the study was conducted. We have excluded patients undergoing palliative interventions, and it is possi-ble that these patients have more com-plex forms of CHD and more severe malnutrition.

CONCLUSIONS

Signiﬁcant malnutrition is common in patients with CHD and is reversible in the majority once corrective interven-tion is performed. Persistent malnutri-tion after corrective intervenmalnutri-tion is predicted by nutritional status at pre-sentation, birth weight, and parental anthropometry.

ACKNOWLEDGMENTS

This study was supported by a re-search grant provided by the Kerala State Council for Science, Technol-ogy, and Environment (government of Kerala).

We thank Ms Priya Francis, our staff dietician, for providing assistance with dietary assessment and counseling for the study patients on follow-up.

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DOI: 10.1542/peds.2009-0141 originally published online July 5, 2009;

2009;124;e294

Pediatrics

Karimassery Ramaiyar Sundaram and Raman Krishna Kumar

Balu Vaidyanathan, Reshma Radhakrishnan, Deepa Aravindakshan Sarala,

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What Determines Nutritional Recovery in Malnourished Children After Correction of Congenital Heart Defects?

Children After Correction of Congenital Heart Defects?

abstract

DOI: 10.1542/peds.2009-0141 originally published online July 5, 2009;

2009;124;e294

Pediatrics

Karimassery Ramaiyar Sundaram and Raman Krishna Kumar

Balu Vaidyanathan, Reshma Radhakrishnan, Deepa Aravindakshan Sarala,

DOI: 10.1542/peds.2009-0141 originally published online July 5, 2009;

2009;124;e294

Pediatrics

Karimassery Ramaiyar Sundaram and Raman Krishna Kumar

Balu Vaidyanathan, Reshma Radhakrishnan, Deepa Aravindakshan Sarala,

Correction of Congenital Heart Defects?

What Determines Nutritional Recovery in Malnourished Children After

http://pediatrics.aappublications.org/content/124/2/e294

located on the World Wide Web at:

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