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ORIGINAL ARTICLE Growth Restriction in Infants and Young Children with Congenital Heart Disease Claire L. Costello, MND, BSc,* Marcelee Gellatly, BSpPath,† Jane Daniel, BAppSc (SP),† Robert N. Justo, MBBS, FRACP,‡ and Kelly Weir, MSpPath§¶** Departments of *Nutrition & Dietetics and †Speech Pathology, ‡Queensland Paediatric Cardiac Service, Mater Children’s Hospital, §Speech Pathology Department, Royal Children’s Hospital, ¶Discipline of Paediatrics & Child Health, **Queensland Children’s Medical Research Institute, The University of Queensland, Herston, Queensland, Australia ABSTRACT
Objective. The purpose of this study was to determine the prevalence of growth restriction in infants and young children with congenital heart disease (CHD) and investigate the relationship between poor growth, feeding difficulties, cardiac classification, and nutrition intervention on outcomes. Design. This is a prospective observational cohort study of infants and young children with CHD aged 0–3 years admitted to hospital for cardiac surgery. Anthropometry, growth history, cardiac classification, cardiac diagnosis, feeding difficulty, and nutrition intervention data were collected for 78 participants. Results. Many participants demonstrated growth restriction as evidenced by a z-score ≤−2 for population growth parameters including weight/age z-score (n = 18, 23%), height/age z-score (n = 16, 21%), and weight/height z-score (n = 12, 18%). Increased hospital length of stay was associated with factors including faltering growth preadmission (P = .009), tube feeding required preadmission (P = .002), diagnosis of cyanotic CHD (P = .015), and presence of a feeding difficulty (P = .015). Conclusions. Growth restriction remains an ongoing problem in children with CHD. Faltering growth preadmission and lower growth parameters were associated with an increased hospital length of stay. Nutritional screening from diagnosis may detect growth faltering, improve access to early nutrition intervention, and improve patient outcomes. Key Words. Congenital Heart Disease/Defects; Infant/Child; Growth; Nutrition; Feeding Difficulty; Dysphagia
Introduction
T
he incidence of moderate to severe forms of congenital heart disease (CHD) occurs in approximately 7.6 cases per 1000 live births in Australia.1 Poor weight gain and growth restriction are a common feature in infants and children with CHD with rates of growth restriction (less than third percentile on growth charts or 2 standard deviations [SDs] below the mean for both weight and height) ranging from 27% to 60%.2–6 The frequency and severity of growth restriction tend be more apparent in children with cyanotic CHD compared with acyanotic CHD.2,7 Despite major advances in surgical techniques and improved timing of corrective cardiac surgery, © 2014 Wiley Periodicals, Inc.
recent studies indicate malnutrition persists in this population6,8–11 although limited data exist in the Australian pediatric CHD population. The etiology of growth restriction in this population is multifactorial. Known contributing factors significantly associated with growth restriction include fluid restriction, hemodynamic impairment, inadequate caloric intake, and hypermetabolism.12–15 Many studies have demonstrated increased metabolic rate in infants and children with CHD; however, this tends to decrease and normalize within 24 hours postcorrective cardiac surgery.16–19 Other factors likely to impact on growth in this population include fatigue during feeding and frequent respiratory infections.13,16,20 Congenit Heart Dis. 2014;••:••–••
2 Malnutrition at time of surgery may increase the risk of postoperative morbidity, increase hospital length of stay (LOS), and delay recovery.5,9,10,21–23 Early nutrition intervention and improved nutritional status have the potential to reduce cardiac impact on growth and feeding, reduce hospital LOS, and/or improve surgical outcomes.10,24–26 Continuous 24-hour enteral feeding has been shown to be a safe and effective method to achieve increased nutrient intake and improve nutritional status in patients with CHD and poor growth but tends to be used mainly in an acute hospital setting.10,12,15 High energy feeding with fortified formula can improve energy intake and weight gain, and decrease hospital LOS postcardiac surgery in infants with CHD.27 It is suggested that the ideal time to implement effective nutrition intervention is between initial diagnosis and surgery.9 However, limited research is available detailing the use of nutrition intervention prior to admission for cardiac surgery in the CHD population. Knowledge about the extent of growth restriction, cardiac classification/diagnoses, feeding difficulty, and nutrition intervention presurgery in children with CHD in an Australian context would be beneficial to streamline appropriate clinical interventions. This study aimed to 1. Determine the prevalence of growth restriction and/or faltering growth in children with CHD admitted to hospital for cardiac surgery at the Queensland Paediatric Cardiac Service (QPCS); 2. Determine the relationship between cardiac classification (cyanotic vs. acyanotic) and/or specific cardiac diagnosis and growth; 3. Determine the proportion of participants receiving some form of nutrition intervention preadmission for cardiac surgery, the type of nutrition intervention, and any relationship to growth parameters; and 4. Determine whether growth restriction (and growth parameters), nutrition intervention, and/or presence of feeding difficulties is related to hospital LOS. We hypothesized that children with CHD would have a higher prevalence of growth restriction and or/faltering growth compared with the normal population, that children with cyanotic CHD would have greater growth restriction than those with acyanotic CHD, that a significant number of participants would not be receiving appropriate nutrition intervention prior to hospiCongenit Heart Dis. 2014;••:••–••
Costello et al. tal admission for cardiac surgery, that children with a feeding difficulty would have lower growth parameters, and that children with growth restriction or lower growth parameters would have a longer hospital LOS. Methods
Participants This prospective observational cohort study of infants and young children with CHD was undertaken initially at The Prince Charles Hospital (TPCH) and then at the Mater Children’s Hospital (MCH) in Brisbane where the QPCS has been relocated. The recruitment and data collection period spanned 15 months, between September 2007 and December 2008 (including a break of 4 months due to the merge/relocation of services). The research project was approved by the Ethics Committee at TPCH and MCH sites, and written informed parental consent was obtained for each participant. All infants and children aged 0–3 years, with a diagnosis of CHD and admitted for cardiac surgery, were eligible for inclusion. Children with other comorbidities and medical diagnoses including preterm birth (
ORIGINAL ARTICLE Growth Restriction in Infants and Young Children with Congenital Heart Disease Claire L. Costello, MND, BSc,* Marcelee Gellatly, BSpPath,† Jane Daniel, BAppSc (SP),† Robert N. Justo, MBBS, FRACP,‡ and Kelly Weir, MSpPath§¶** Departments of *Nutrition & Dietetics and †Speech Pathology, ‡Queensland Paediatric Cardiac Service, Mater Children’s Hospital, §Speech Pathology Department, Royal Children’s Hospital, ¶Discipline of Paediatrics & Child Health, **Queensland Children’s Medical Research Institute, The University of Queensland, Herston, Queensland, Australia ABSTRACT
Objective. The purpose of this study was to determine the prevalence of growth restriction in infants and young children with congenital heart disease (CHD) and investigate the relationship between poor growth, feeding difficulties, cardiac classification, and nutrition intervention on outcomes. Design. This is a prospective observational cohort study of infants and young children with CHD aged 0–3 years admitted to hospital for cardiac surgery. Anthropometry, growth history, cardiac classification, cardiac diagnosis, feeding difficulty, and nutrition intervention data were collected for 78 participants. Results. Many participants demonstrated growth restriction as evidenced by a z-score ≤−2 for population growth parameters including weight/age z-score (n = 18, 23%), height/age z-score (n = 16, 21%), and weight/height z-score (n = 12, 18%). Increased hospital length of stay was associated with factors including faltering growth preadmission (P = .009), tube feeding required preadmission (P = .002), diagnosis of cyanotic CHD (P = .015), and presence of a feeding difficulty (P = .015). Conclusions. Growth restriction remains an ongoing problem in children with CHD. Faltering growth preadmission and lower growth parameters were associated with an increased hospital length of stay. Nutritional screening from diagnosis may detect growth faltering, improve access to early nutrition intervention, and improve patient outcomes. Key Words. Congenital Heart Disease/Defects; Infant/Child; Growth; Nutrition; Feeding Difficulty; Dysphagia
Introduction
T
he incidence of moderate to severe forms of congenital heart disease (CHD) occurs in approximately 7.6 cases per 1000 live births in Australia.1 Poor weight gain and growth restriction are a common feature in infants and children with CHD with rates of growth restriction (less than third percentile on growth charts or 2 standard deviations [SDs] below the mean for both weight and height) ranging from 27% to 60%.2–6 The frequency and severity of growth restriction tend be more apparent in children with cyanotic CHD compared with acyanotic CHD.2,7 Despite major advances in surgical techniques and improved timing of corrective cardiac surgery, © 2014 Wiley Periodicals, Inc.
recent studies indicate malnutrition persists in this population6,8–11 although limited data exist in the Australian pediatric CHD population. The etiology of growth restriction in this population is multifactorial. Known contributing factors significantly associated with growth restriction include fluid restriction, hemodynamic impairment, inadequate caloric intake, and hypermetabolism.12–15 Many studies have demonstrated increased metabolic rate in infants and children with CHD; however, this tends to decrease and normalize within 24 hours postcorrective cardiac surgery.16–19 Other factors likely to impact on growth in this population include fatigue during feeding and frequent respiratory infections.13,16,20 Congenit Heart Dis. 2014;••:••–••
2 Malnutrition at time of surgery may increase the risk of postoperative morbidity, increase hospital length of stay (LOS), and delay recovery.5,9,10,21–23 Early nutrition intervention and improved nutritional status have the potential to reduce cardiac impact on growth and feeding, reduce hospital LOS, and/or improve surgical outcomes.10,24–26 Continuous 24-hour enteral feeding has been shown to be a safe and effective method to achieve increased nutrient intake and improve nutritional status in patients with CHD and poor growth but tends to be used mainly in an acute hospital setting.10,12,15 High energy feeding with fortified formula can improve energy intake and weight gain, and decrease hospital LOS postcardiac surgery in infants with CHD.27 It is suggested that the ideal time to implement effective nutrition intervention is between initial diagnosis and surgery.9 However, limited research is available detailing the use of nutrition intervention prior to admission for cardiac surgery in the CHD population. Knowledge about the extent of growth restriction, cardiac classification/diagnoses, feeding difficulty, and nutrition intervention presurgery in children with CHD in an Australian context would be beneficial to streamline appropriate clinical interventions. This study aimed to 1. Determine the prevalence of growth restriction and/or faltering growth in children with CHD admitted to hospital for cardiac surgery at the Queensland Paediatric Cardiac Service (QPCS); 2. Determine the relationship between cardiac classification (cyanotic vs. acyanotic) and/or specific cardiac diagnosis and growth; 3. Determine the proportion of participants receiving some form of nutrition intervention preadmission for cardiac surgery, the type of nutrition intervention, and any relationship to growth parameters; and 4. Determine whether growth restriction (and growth parameters), nutrition intervention, and/or presence of feeding difficulties is related to hospital LOS. We hypothesized that children with CHD would have a higher prevalence of growth restriction and or/faltering growth compared with the normal population, that children with cyanotic CHD would have greater growth restriction than those with acyanotic CHD, that a significant number of participants would not be receiving appropriate nutrition intervention prior to hospiCongenit Heart Dis. 2014;••:••–••
Costello et al. tal admission for cardiac surgery, that children with a feeding difficulty would have lower growth parameters, and that children with growth restriction or lower growth parameters would have a longer hospital LOS. Methods
Participants This prospective observational cohort study of infants and young children with CHD was undertaken initially at The Prince Charles Hospital (TPCH) and then at the Mater Children’s Hospital (MCH) in Brisbane where the QPCS has been relocated. The recruitment and data collection period spanned 15 months, between September 2007 and December 2008 (including a break of 4 months due to the merge/relocation of services). The research project was approved by the Ethics Committee at TPCH and MCH sites, and written informed parental consent was obtained for each participant. All infants and children aged 0–3 years, with a diagnosis of CHD and admitted for cardiac surgery, were eligible for inclusion. Children with other comorbidities and medical diagnoses including preterm birth (
