Anthropometric profiles of children with congenital heart disease

Background : Congenital heart disease (CHD) is often associated with malnutrition and failure to thrive in children. Children with congenital heart diseases are frequently undernourished irrespective of cardiac defect and presence or absence of cyanosis. The aim of the study is to assess the effect of CHD on growth and nutrition and to identify the areas of growth affected with reference to different anthropometric measurements. Materials and Method: A case control observational study was carried out in children aged 0-14 years old with CHD in the Department of Paediatrics at Vydehi Institute of Medical Sciences and Research Centre Bangalore. All patients underwent an anthropometric evaluation (weight, height/length, head circumference, mid-arm circumference, triceps and subscapular skin fold thickness) and standard growth charts (NCHS and WHO) were used accordingly. Results : We had total of 50 patients, 34 (68%) had acyanotic congenital malformation, while 16 (32%) had cyanotic cardiac malformation. Majority, 18 (82%) out of 22 cases above 5 years with CHD were underweight. Left to right shunt children with acyanotic malformation were tended to have acute malnutrition and stunting was more severe in children with cyanotic defects, with 100% of them affected. Majority of the children (42%) were undernourished with mid arm circumference below 13.5cms. Conclusion: A significantly higher, that is, 82% were underweight and 86% were stunted among children with congenital heart disease. In conclusion it can be stated that children with congenital heart disease have highly statistically significant growth retardation (P<0.001) by student t- test.


Introduction
Congenital cardiovascular defects, also known as congenital heart defects (CHD), are structural problems that arise from abnormal formation of the heart or major blood vessels present from birth or manifesting any time after birth or may not manifest at all. The overall incidence of congenital malformation in live birth is 0.8% [1]. CHD comprise about 30% of all congenital malformation in the new born [2].
Severe malnutrion may occur in children with congenital heart defects due to an imbalance between energy intake and consumption. Heart failure and pulmonary hypertension are the most important factors for the development of the severe malnutrition. Children with cyanotic heart disease with pulmonary hypertension are the most seriously affected requiring more aggressive nutritional therapy [3]. Cyanotic patients are affected in growth, depending upon the severity of tissue hypoxemia and degree of physiological adaptation. Weight and height are affected equally in cyanotic patients. Acyanotic lesions especially in combination with septal defect, left to right shunt will affect weight only. In short, acyanotic lesions were related to acute malnutrition whereas cyanotic lesions were related to chronic malnutrition [4].
Infants and children with CHD exhibit a range of delay in weight gain and growth. In some cases delay can be relatively mild, whereas in other cases, the failure to thrive can result in permanent physical or developmental impairment [5].
In caring for these children, it is important to develop a nutritional strategy and takes into account all of the factors at play, both physical and psychological. Therefore, there must be an effort between parents, physicians, nurses and other health care professionals to develop a plan that will be appropriate on an individual basis [6].
The aims of this study were to determine the anthropometric profiles and prevalence of undernutrition in children with CHD by using anthropometric measurement.
Those measurements are useful in early detection of CHD and assessing the prognosis of the basic cardiac defects and their complication.

Materials and Methods
Analytical study was carried out in children aged 0-14 years old with CHD who had consultation in our outpatient clinic, paediatric division in Vydehi Institute of Medical Sciences and Research Centre, Bengaluru. This study was conducted from January 2014 to December 2014.
Children who met the inclusion criteria for age, and who had no definitive or palliative treatment given, were taken up for the study.

Inclusion criteria
1. 0-14 years both male and female with congenital heart diseases (cyanotic & acyanotic) clinically detected and confirmed by investigations and 2. Patients who have not undergone any surgical intervention.
The third commonest cardiac malformation in the present study was Ventricular Septal Defect (VSD) in 9 (18%) cases. Tetralogy of Fallot (TOF) in 8 (16%) cases ranked fourth and all were male children. There were 3 (6%) cases of D-Transposition Of Great Artery (DTGA).
There were two cases of Double Outlet Right Ventricle (DORV) in 2 (4%) and there were 2 (4%) cases of Ebstein's Anomaly and there was 1 (2%) case of Pulmonary Stenosis.
Assessment of the mean observed value for weight in children with congenital cardiac malformation was 14.97 kgs significantly less than 21 kgs expected value for age and sex, NCHS standards (P=0.038) as in table 1. There was a significant mean difference between observed weight and expected weight (p=0.038).  Wellcome Trust Classification -Weight for age for children above 5 years. There was significant mean difference between observed height and expected height (P<0.001). There was a significant mean difference between observed MAC and expected MAC (p=0.001). There was a significant mean difference between observed value and expected value (p=0.001). There was a significant mean difference between observed value and expected value (p<0.001).
According to Indian Academy of Paediatrics (IAP) [8] for children less than 5 years, only 5 (17%) children with CHD had normal growth in terms of weight for age in the present study. A large majority of children (83%) with cardiac disease failed to gain weight adequately, among whom 10 (36%) had Protein energy malnutrion (PEM) grade I, 10 (36%) had grade II PEM and 2 (8%) had grade III PEM and 1 (3%) had grade IV PEM.
Growth pattern with regard to type -acyanotic and cyanotic malformations revealed that 5 (17%) had grade I malnutrition and 6 (21%) had grade II 1 (3%) had grade III and 1 (3%) had grade IV malnutrition with acyanotic malformation and; 5 (17%) had grade I PEM and 4 (14%) had grade II PEM and 1 (3%) had grade III PEM in cyanotic malformation as shown in table 2. According to Wellcome Trust classification [9], majority 18 (82%) out of 22 cases above 5 years of age with CHD were underweight (80-60%) but no one was marasmic as in According to Waterlow's classification [11] only 5 (14%) of these children had adequate height for age and sex, a large majority 43 (86%) were stunted, among whom half 25 (50%) suffered from moderate to severe stunting and only 18 (36%) suffered from marginal stunting. Stunting was more severe in children with cyanotic defects, with 100% of them affected, 7 (14%) were severely stunted while 3 (6%) were moderately stunted and 4 (8%) had marginal stunting. Majority of children in acyanotic had marginal to moderate stunting.
Head circumference was estimated in children with congenital cardiac malformation and mean was 44.6 cms which was not significant when compared to normal expected mean 46 cms value for age and sex according to WHO standards. There was no significant mean difference between observed head circumference and expected head circumference (P>0.05) as shown in table 5.
Mid-arm circumference was estimated in 27 children between the age of 1 to 5 years with congenital heart disease with mean MAC value 12.68 cms and which was highly significant (p<0.001) when compared to normal expected mean 15.28 cms value for age and sex according to WHO standards. There was significant mean difference between observed midarm circumference and expected mid-arm circumference (P<0.001) as shown in table 6.
The mean observed value for triceps skin fold thickness recorded in children with congenital cardiac malformation was 5.5 mm, significantly less than 8.12 mm (P<0.001) expected value for age and sex, WHO standards as shown in table 7.
The mean observed value for subscapular skin fold thickness recorded in children with congenital cardiac malformation was 4.51mm, significantly less than 6.17 mm (P<0.001) expected value for age and sex, WHO standards. There was significant mean difference between observed and expected subscapular skin fold thickness (P<0.001). (Table 8)
Diagnosis of type of leading cardiac defect in the present study was ASD14 (28%), followed by PDA 11 (22%), VSD 9 (18%) and TOF 8 (16% Age was found to be an inverse factor, the older one had less chance for malnutrition and was reported by Villasis Keever MA, et al in Mexico [13]. 100% children with cyanotic malformations were stunted, compared to those with acyanotic malformation. The study also showed significant growth retardation for children with cyanotic malformations, more for height, nearly 60% compared to 45% for weight. In contrast the study by Varan B, Tokel K, and Yilmaz G from Turkey, reported that cyanotic children were more malnourished for weight for age and height for age [3]. A study by Tambic-Bukovac L, Malcic I in Croatia [14], showed statistically significant growth retardation in 222 children with cardiac disease as compared to 50 in the control group, by values of body weight and height (p<0.001).
Weight retardation was more marked than retardation in body height (p<0.001). Growth retardation was more significant in the cyanotic children than in those with acyanotic heart disease (p<0.001).
Among the children with left to right intracardiac shunt, growth retardation was found to increase proportionally with size of the shunt and was most significant in patients with large left to right shunt (QP/QS>1.80) (p>0.01) [14].
Dietary assessment in present study revealed that poor feeding practices involving late introduction of weaning foods, with poor quality of weaning foods, early discontinuation of breast feeding and introduction of diluted milk feeds was observed with deficit calorie intake when compared to recommended dietary allowance (RDA) for age.
Poor feeding practices are observed in the low socioeconomic population. In this study only 20 (40%) had income above Rupees 1000 per person.
Commonest symptoms were recurrent upper respiratory infections with breathlessness in 58% of patient followed by cyanosis in 24% of patients, cyanotic spells in 10% and congestive cardiac failure in 8%.
Thus growth is affected in children with congenital heart disease, being highly statistically significant when compared to expected values, in terms of weight height, mid-arm circumference and skin fold thickness for age and sex, 50 th centile, NCHS and WHO standards (p<0.001). Around 90% of children were malnourished, indicating that children with CHD significantly suffered from growth failure. Failure to gain weight was seen in those with acyanotic malformation while stunting was seen with cyanotic CHD.
Mid-arm circumference and skinfold thickness were also reduced significantly (p<0.001) in present study. Head circumference between children with acyanotic and cyanotic defect showed no difference.
Severity of the cardiac lesions and malnutrition put children with CHD at risk for increased morbidity and mortality. Hence, strategies for intervening in the monitoring of growth, a more intensive nutritional rehabilitation, and early corrective surgery should be done to optimise the outcome.
Some limitations in our study should be considered. Firstly, this study was conducted in hospitalized patients and hence the results in this study are not a true representative of the general population. Secondly, possible risk factors such as number of family members, mid-parental height, were not analysed in this study.
Thirdly, our exclusion criteria may have caused selection bias, leading to underestimation of the true prevalence of malnutrition as some excluded cases may have had more severe malnutrition.

Conclusion
Congenital heart disease in children constitutes an organic cause for failure to thrive. The child needs increase calorie intake for increased cardiac work, sympathetic over activity, recurrent respiratory infections, and hypoxia, in addition, congestive cardiac failure causes difficulty in feeding with poor intake and malabsorption.
Hence growth failure is inevitable in symptomatic children with congenital heart disease, which was noted among nearly 90% of the cases with regard to weight, height, mid-arm circumference and skin fold thickness, compared to 50 th centile of NCHS and WHO standards being highly statistically significant (P<0.001) by student t-test.
The two main groups of structural heart defects, acyanotic and cyanotic heart disease show a distinct pattern of growth failure. Children with acyanotic malformations such as ASD, VSD, PDA, PS etc. manifested with characteristic symptoms of poor feeding, fatigue, dyspnoea, tended to gain less weight and to be leaner than those with cyanotic defects such as TOF, DORV, D-TGA, who have decreased oxygen carrying capacity which affects the growing ends of the epiphyseal plates of long bones affecting growth and hence severely stunted in height.
Mid arm circumference and triceps and subscapular skin fold thickness were also affected significantly in present study. PEM and growth retardation are probably the most wide spread, health and nutritional problems in developing countries. In India, 43% under-fives are underweight and 48% stunted [15] in comparison a significantly higher 82% underweight and 86% stunted among children with congenital heart disease [16].
The difference of 40% contributed by cardiac defect as cause for growth failure is significant. In conclusion it can be stated that children with congenital heart disease have highly statistically significant growth retardation (P<0.001) by student t-test.
Children with CHD are at risk for increased morbidity and mortality. Strategies for growth monitoring, nutritional rehabilitation, and early surgery should be done in these children.
Funding: Nil, Conflict of interest: Nil Permission from IRB: Yes