Investigación reciente

Congenit Heart Dis. 2007 Sep;2(5):332-7

Feeding difficulty in newborns following congenital heart surgery

Kogon BE, Ramaswamy V, Todd K, Plattner C, Kirshbom PM, Kanter KR, Simsic J.
Contact: Emory University School of Medicine, Department of Cardiothoracic Surgery, Atlanta, GA, USA. Brian_kogon@emoryhealthcare.org

OBJECTIVE: Following neonatal congenital heart surgery, one of the factors impacting patient recovery is feeding difficulty. The aim of this study is to identify the risk factors.
METHODS: Patients who underwent surgery for congenital heart defects within the first 15 days of life were reviewed. Endpoints for feeding difficulty included: (1) a prolonged time to reach goal feeds; (2) a prolonged transition to oral feeds requiring tube feeds at discharge; and (3) additional procedures to facilitate feeding. Preoperative, operative, and postoperative data were examined to identify risk factors for feeding difficulty.
RESULTS: A total of 83 records were reviewed and showed the following feeding difficulties: 9 patients (10.8%) had a prolonged time to reach goal feeds, 37 (44.6%) had a prolonged time to transition to oral feeds, and 8 (9.6%) required subsequent procedures to facilitate feeding. Significant risk factors for all endpoints included an increased risk adjusted congenital heart surgery (RACHS) score and prolonged intubation. Significant risk factors for individual endpoints included return to the intensive care unit with an open chest for endpoint 1, and a single functional ventricle and the presence of a shunt for endpoint 3. The remaining factors (gestational age, weight at the time of surgery, being intubated at the time of surgery, underlying disease, utilization and time of cardiopulmonary bypass, utilization of trans-esophageal echocardiography, and surgical proximity to the aortic arch) had no significant effect on postoperative feeding.
CONCLUSIONS: Feeding difficulties are not uncommon following surgery for the correction of congenital heart defects, especially in the neonate. The most important risk factors appear to be an increased RACHS score and prolonged postoperative intubation. Hopefully, by defining the risk factors, proactive management strategies can be developed to minimize these problems following neonatal congenital heart surgery.

Indian Pediatr. 2008 Jul;45(7):541-6

Malnutrition in children with congenital heart disease (CHD) determinants and short term impact of corrective intervention

Vaidyanathan B, Nair SB, Sundaram KR, Babu UK, Shivaprakasha K, Rao SG, Kumar RK.
Contact: Department of Pediatric Cardiology, Amrita Institute of Medical Sciences and Research Center, Elamakkara P.O., Kochi, Kerala 682 026, India. baluvaidyanathan@gmail.com

OBJECTIVE: To identify determinants of malnutrition in children with congenital heart disease (CHD) and examine the short-term effects of corrective intervention.
METHODS: Patients with CHD admitted for corrective intervention were evaluated for nutritional status before and 3 months after surgery. Detailed anthropometry was performed and z-scores calculated. Malnutrition was defined as weight, height and weight/height z-score <or= -2. Determinants of malnutrition were entered into a multivariate logistic regression analysis model. RESULTS: 476 consecutive patients undergoing corrective intervention were included. There were 16 deaths (3.4%; 13 in-hospital, 3 follow-up). The 3-month follow-up data of 358 (77.8%) of remaining 460 patients were analyzed. Predictors of malnutrition at presentation are as summarized: weight z-score <or= -2 (59%): congestive heart failure (CHF), age at correction, lower birth weight and fat intake, previous hospitalizations, >or= 2 children; height z-score <or= -2 (26.3%): small for gestation, lower maternal height and fat intake, genetic syndromes; and weight/height z-score <or= -2 (55.9%): CHF, age at correction, lower birthweight and maternal weight, previous hospitalizations, religion (Hindu) and level of education of father.Comparison of z-scores on 3-month follow-up showed a significant improvement from baseline, irrespective of the cardiac diagnosis.
CONCLUSIONS: Malnutrition is common in children with CHD. Corrective intervention results in significant improvement in nutritional status on short-term follow-up.

AJR Am J Roentgenol. 2008 Oct;191(4): 1169-74

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

Sy K, Dipchand A, Atenafu E, Chait P, Bannister L, Temple M, John P, Connolly B, Amaral JG.
Contact: Department of Diagnostic Imaging, The Hospital for Sick Children, 555 University Ave., Toronto, ON, Canada M5G 1X8.

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.

J Perinatol. 2008 Sep 25

Feeding abilities in neonates with congenital heart disease: a retrospective study

Jadcherla SR, Vijayapal AS, Leuthner S.
Contact: Division of Neonatology, Pediatric Gastroenterology and Nutrition, Department of Pediatrics, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH, USA.

OBJECTIVE: An important area concerning morbidity among infants with congenital heart defects (CHD) is related to feeding problems. Our objectives were to characterize the evolution of feeding milestones related to transition to per oral feeding among infants with CHD, and to identify associated variables impacting the feeding abilities. Specifically, we differentiated the feeding characteristics in neonates with acyanotic vs cyanotic CHD.
STUDY DESIGN: Feeding progress was tracked during the first hospitalization in a retrospective chart review study involving 76 infants (29 acyanotic, 47 cyanotic CHD). The ages at which the following milestones attained were recorded: first feeds, maximum gavage feeds, first nipple feeds and maximum nipple feeds, in addition to the length of hospital stay. Effects of perinatal factors, duration of respiratory support, vasopressor and narcotic use and use of cardiopulmonary bypass on the feeding milestones were also evaluated. ANOVA, t-test, and stepwise linear regression analysis were applied as appropriate. Data stated as mean+/-s.e.m., or %; P<0.05 was considered significant.
RESULT: Prenatal and birth characteristics were similar (P=NS) between the neonates with acyanotic and cyanotic CHD. Cyanotic CHD required three times prolonged use of ventilation, narcotics and vasopressor use (all P<0.05, compared to the acyanotic group). In the acyanotic group, prolonged respiratory support correlated linearly with time to attain maximal gavage feeds and nippling (both, R(2)=0.8). In the cyanotic group, delayed initiation of gavage feeds and prolonged respiratory support both correlated linearly with time to attain maximal gavage feeds and nippling (both, R(2)=0.8). Age at first gavage feed correlated with maximum gavage feeds among neonates with cyanotic CHD, and first nipple feed correlated with maximum nipple feeds among all groups (P<0.01). Use of cardiopulmonary bypass in cyanotic CHD delayed the feeding milestones and prolonged the length of stay (both, P<0.05 vs non-bypass group); similar findings were not seen in the acyanotic group.
CONCLUSION: In contrast to neonates with acyanotic CHD, cyanotic CHD group had significant delays with (a) feeding readiness, (b) successful gastric feeding, (c) oromotor readiness and (d) successful oromotor skills. Co-morbid factors that may directly influence the delay in feeding milestones include the (a) duration of respiratory support and (b) use of cardiopulmonary bypass. Delays in achieving maximum gavage and maximum nippling may suggest foregut dysmotility and oropharyngeal dysphagia.Journal of Perinatology advance online publication, 25 September 2008; doi:10.1038/jp.2008.136.

Wei Sheng Yan Jiu. 2008 Jul;37(4):463-7

CBS gene variations and serum homocysteine level associated with congenital heart defects

Zhu W, Song X, Li M, Dao J.
Contact: Department of Nutrition and Food Hygiene, Peking University Health Science Center, Beijing 100083, China. zhuwenli@hsc.pku.edu.cn

OBJECTIVE: To study the relationship between two common CBS gene variations, tHcy level and CHDs in a nuclear family-based study.
METHODS: 234 Chinese CHDs patients and their biological parents were recruited as case groups. And another 136 normal individuals and their parents were recruited as controls. The CBS gene 844ins68 and G919A variants were analyzed by PCR and PCR-ARMS methods. The serum fasting total homocysteine (tHcy) level was detected by Fluorescence Polarization Immunoassay.
RESULTS: CBS 844ins68 variant was associated with high risk of CHDs, the odds ratios (ORs) between heterozygotes (DI) versus wild homozygotes (DD) were 14.19 (95% CI: 2.21-591.52), 4.37 (95% CI: 1.24-23.47) and 4.77 (95% CI: 1.38-25.37) in mothers, fathers and offspring respectively (P < 0.05). CBS G919A was significantly associated with low risk of CHDs. The ORs of offspring between heterozygotes (GA) and mutant homozygotes (AA) versus wild homozygotes (GG) were 0.45 (95% CI: 0.23-0.87) and 0.34 (95% CI: 0.11-1.01), P < 0.05. And the parents carrying GA and AA genotypes also was lower risk of CHDs. For both of above two variants, the significant relations occurred especially in ventricular septal defect subgroup. Genotype combination analysis showed the more risk alleles (I and G) the family members carried, the higher the offspring risk of CHDs. And the serum fasting tHcy level was not significantly different among various groups and genotypes.
CONCLUSION: CBS gene 844ins68 and G919A variations in nuclear families could be associated with CHDs risk of offspring, but not with serum fasting tHcy level.

J Heart Lung Transplant 27(5): 508-13.

Too fat or too thin? Body habitus assessment in children listed for heart transplant and impact on outcome.

Kaufman, BD, Nagle, ML, et al. (2008).
Contact: Thoracic Organ Transplant Program, Children's Hospital of Philadelphia, and Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104-4399, USA. kaufmanb@email.chop.edu.

BACKGROUND: Body habitus assessment (BHA), be it wasted or obese, is a useful marker of nutritional status and overall medical condition. Wasting and obesity pre-heart transplant adversely affects outcomes in adults. The utility of BHA as a prognostic factor in children post-transplant is unknown.

METHODS: Weight and height at listing and standard growth charts were used to determine the ideal body weight (%IBW) and percentiles for body mass index for age (BMI%) and weight-for-length (W:L%). Wasting was defined as <90%IBW and/or <or=5th percentile for BMI% or W:L%. Obesity was defined as >120%IBW and/or >or=95th percentile BMI% or W:L%. Outcomes of cohorts based on these criteria were compared.

RESULTS: From June 1990 to December 2006, 180 children, aged 5.81 +/- 6 years, were listed for transplant. Wasting occurred in 66 (37%) and obesity in 22 (12%) children, without differences between diagnoses of cardiomyopathy or congenital heart disease. %IBW was a prognostic factor for survival post-transplant on multivariate analysis: obese patients had a hazard ratio (HR) of 3.82 (95% confidence interval [CI] 1.81 to 8.06) compared with normal BHA (p < 0.001). Wasting had a survival advantage compared with normal BHA (HR 0.51, 95% CI 0.27 to 0.94, p = 0.032). There were no significant differences between cohorts in incidence of infections, first-year rejections or graft vasculopathy.

CONCLUSIONS: Abnormal BHA at listing was a prognostic factor for survival post-transplant. Obese children had increased mortality, but wasting did not adversely affect post-transplant survival in our population. Body habitus assessment may risk-stratify children at listing, potentially providing a complex target for intervention.

Pediatr Cardiol 29(2): 328-33.

Feeding difficulties and growth delay in children with hypoplastic left heart syndrome versus d-transposition of the great arteries.

Davis, D, Davis, S, et al. (2008).
Contact: Division of Pediatrics, The Children's Hospital, Cleveland Clinic, 9500 Euclid Avenue, S20, Cleveland, OH 44195, USA. davisd5@ccf.org.

The objective of this study was to identify the incidence of feeding difficulties in infants with hypoplastic left heart syndrome (HLHS) and d-transposition of the great arteries (d-TGA). Congenital heart disease is a risk factor for growth failure. The etiologies include poor caloric intake, inability to utilize calories effectively, and increased metabolic demands. The goals of our study were to (1) identify feeding difficulties in infants with HLHS and d-TGA and (2) assess their growth in the first year of life. We performed a chart review of 27 consecutive infants with HLHS and 26 with d-TGA. Descriptive statistics were generated for demographic and clinical variables within each group and are presented as means +/- standard deviations. HLHS and d-TGA groups were compared on time to achieving nutritional goals using the log rank test, on complication rate using the chi-square test, and on weight using the t-test. A significance level of 0.05 was used for all tests. Birth weight was similar for both the HLHS and d-TGA groups (3.19 +/- 0.69 vs 3.35 +/- 0.65 kg, respectively; p = 0.38). Infants with HLHS weighed less than those with d-TGA at l month (3.29 +/- 0.58 vs 3.70 +/- 0.60 kg, respectively; p = 0.021), 6 months (6.27 +/- 1.06 vs 7.31 +/- 1.02 kg, p = 0.003), and 12 months of age (8.40 +/- 1.11 vs 9.49 +/- 1.01 kg, p = 0.006). Time to achieving full caloric intake (at least 100 kcal/kg/day) for the HLHS group (24 +/- 11.9 days) was significantly longer than for the d-TGA group (12.0 +/- 11.2 days, p < 0.001). In addition, infants with HLHS had a higher incidence of feeding-related complications that those with d-TGA (48 vs 4%, respectively; p = 0.001). Compared to the d-TGA group, infants with HLHS weighed less at follow-up, took longer to reach nutritional goals, and had a much higher incidence of feeding-related complications.

Arq Bras Cardiol 89(4): 219-24.

Assessment of food intake in infants between 0 and 24 months with congenital heart disease.

Vieira, TC, Trigo, M, et al. (2007).
Contact: Hospital Auxiliar de Cotoxo, HC, FM, USP, Sao Bernardo do Campo, SP - Brazil.

BACKGROUND: Children with congenital heart disease are usually malnourished and present some degree of functional and/or structural impairment of organs. There is also deficiency in nutrient intake, due to the control of fluids required by some patients which restrains the nutrient intake of some cardiac children.

OBJECTIVE: To assess the food intake of children with congenital heart disease hospitalized in the pediatric heart unit of a "Public Teaching Hospital".

METHODS: The intake of food and nutrients was calculated based on the food consumed during three days (direct weighting method) and the calories and nutrients were calculated using the Virtual Nutri software.

RESULTS: The intake of calories per kilogram of body weight, of daily proteins, sodium and vitamin A was within the recommended levels (p < 0.05). However, the intake of daily calories, fats, fiber, potassium and iron was below the recommended levels (p < 0.05) and the intake of proteins per kilogram, carbohydrates, calcium and vitamin C was above the recommended levels (p < 0.05).

CONCLUSION: Children with congenital cardiopathy have inadequate diets, and therefore, need nutritional guidance to foster adequate dietary intake and the resulting improvement in growth and weight and height development, guaranteeing better quality of life to the patients.

J Heart Lung Transplant 26(7): 718-23.

Effect of body mass index on outcome in pediatric heart transplant patients.

Rossano, JW, Grenier, MA, et al. (2007).
Contact: Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA. jrossano@bcm.tmc.edu.

BACKGROUND: Obesity and cachexia are risk factors for adverse outcomes in adult transplant patients. However, little is known about the effects of body mass index (BMI) on outcomes in pediatric heart transplant patients.

METHODS: Patients > 2 years of age undergoing heart transplantation from 1985 to 2004 at our institution were included in this study. BMI was assessed at the time of transplant and at 1 year post-transplant. Long-term outcomes were assessed by weight group.

RESULTS: The cohort included 105 patients with a mean age at transplant of 9.6 +/- 5.3 years. The mean BMI percentile at the time of transplant was 39 +/- 34, with 22 (21%) patients underweight (< 5th percentile) and 8 (8%) patients overweight (> or = 95th percentile). Among patients surviving to 1 year (n = 92), the mean BMI percentile increased to 57 +/- 33 (p < 0.05). Overall graft survival was decreased in patients underweight at transplant, mean 6.7 years (95% confidence interval [CI] 3.6 to 9.9), vs normal weight patients, mean 10.6 years (95% CI 8.8 to 12.4) (p < 0.05). Patients overweight at transplant did not have decreased graft survival. Neither low nor high BMI at 1 year post-transplant was associated with adverse outcomes. On multivariate analysis, being underweight at transplant was an independent predictor of decreased graft survival (p = 0.03).

CONCLUSIONS: Weight gain was nearly universal post-transplant with only 4% of patients underweight at 1 year. In the small number of patients overweight at transplant, graft survival was similar to normal-weight patients. Conversely, being underweight at transplant was an independent predictor of decreased graft survival.

Pediatrics 120(5): e1157-64.

Obesity is a common comorbidity in children with congenital and acquired heart disease.

Pinto, NM, Marino, BS, et al. (2007).
Contact: Division of Cardiology, Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA 19104, USA.

OBJECTIVES: Obesity may pose additional cardiovascular risk to children with acquired and congenital heart disease. Many children with heart disease are sedentary as a result of physician-, parent-, and/or self-imposed restrictions. The aim of this study was to evaluate the impact of the epidemic of obesity on children with heart disease.

PATIENTS AND METHODS: A cross-sectional review was performed of children evaluated in 2004 at 2 cardiology outpatient clinics. Differences in the prevalence of obese (BMI > or = 95%) and overweight (BMI 85%-95%) children were compared with national data and healthy control subjects. Dictated letters were reviewed to determine whether obesity was discussed with referring practitioners.

RESULTS: Of 2921 patients assessed, 1523 had heart disease. Diagnostic subgroups included "mild" heart disease (n = 401), arrhythmia (n = 447), biventricular repair (n = 511), univentricular palliation (Fontan; n = 108), and heart transplantation (n = 56). More than 25% of the patients with heart disease were obese or overweight; the prevalence of obese and overweight children was significantly lower only in the Fontan group (15.9%). Pediatric cardiologists failed to document obesity or weight counseling in the majority of clinic letters.

CONCLUSIONS: Obesity is common in children with congenital and acquired heart disease. Pediatric cardiologists demonstrate inadequate communication regarding this problem to referring practitioners. Healthy-lifestyle counseling and routine exercise in children with heart disease may be underemphasized.

Prog Pediatr Cardiol 24(1): 59-71.

Nutrition in Pediatric Cardiomyopathy.

Miller, TL, Neri, D, et al. (2007).
Contact: Division of Pediatric Clinical Research, Department of Pediatrics, Miller School of Medicine, University of Miami, Miami, FL.

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.

Congenit Heart Dis 2(5): 332-7.

Feeding difficulty in newborns following congenital heart surgery.

Kogon, BE, Ramaswamy, V, et al. (2007).
Contact: Emory University School of Medicine, Department of Cardiothoracic Surgery, Atlanta, GA, USA. Brian_kogon@emoryhealthcare.org.

OBJECTIVE: Following neonatal congenital heart surgery, one of the factors impacting patient recovery is feeding difficulty. The aim of this study is to identify the risk factors.

METHODS: Patients who underwent surgery for congenital heart defects within the first 15 days of life were reviewed. Endpoints for feeding difficulty included: (1) a prolonged time to reach goal feeds; (2) a prolonged transition to oral feeds requiring tube feeds at discharge; and (3) additional procedures to facilitate feeding. Preoperative, operative, and postoperative data were examined to identify risk factors for feeding difficulty.

RESULTS: A total of 83 records were reviewed and showed the following feeding difficulties: 9 patients (10.8%) had a prolonged time to reach goal feeds, 37 (44.6%) had a prolonged time to transition to oral feeds, and 8 (9.6%) required subsequent procedures to facilitate feeding. Significant risk factors for all endpoints included an increased risk adjusted congenital heart surgery (RACHS) score and prolonged intubation. Significant risk factors for individual endpoints included return to the intensive care unit with an open chest for endpoint 1, and a single functional ventricle and the presence of a shunt for endpoint 3. The remaining factors (gestational age, weight at the time of surgery, being intubated at the time of surgery, underlying disease, utilization and time of cardiopulmonary bypass, utilization of trans-esophageal echocardiography, and surgical proximity to the aortic arch) had no significant effect on postoperative feeding.

CONCLUSIONS: Feeding difficulties are not uncommon following surgery for the correction of congenital heart defects, especially in the neonate. The most important risk factors appear to be an increased RACHS score and prolonged postoperative intubation. Hopefully, by defining the risk factors, proactive management strategies can be developed to minimize these problems following neonatal congenital heart surgery.

J Cardiovasc Nurs 22(5): 390-6.

Growth and nutritional status of children with congenital heart disease.

da Silva, VM, de Oliveira Lopes, MV, et al. (2007).
Contact: Nursing Department, Federal University of Ceara, Fortaleza/Ceara, Brazil.

BACKGROUND AND RESEARCH OBJECTIVE: Factors predictive of growth deficit and nutritional status in children with congenital heart disease remain unclear. The objective of this study was to characterize the growth and nutritional status of children with congenital heart disease based on anthropometric measurements and z scores.

SUBJECTS AND METHODS: One hundred and thirty-five children 1 year or younger, who had not undergone surgical correction, were evaluated. The variables studied were sex; age; type of heart disease; length, weight; z scores (length-for-age, weight-for-age, weight-for-length); abdominal, thoracic, and cephalic circumferences; triceps and subscapular skinfold thickness; and birth weight and birth length.

RESULTS AND CONCLUSIONS: The mean age of children in this study was 4.75 +/- 3.75 months and most (66.7%) were male. Mean anthropometric measurements were birth length, 48.6 +/- 2.34 cm; birth weight, 3.11 +/- 0.63 kg; cephalic circumference, 38.51 +/- 3.28 cm; thoracic circumference, 38.65 +/- 3.76 cm; abdominal circumference, 37.96 +/- 3.27 cm; triceps skinfold thickness, 3.69 +/- 1.57 mm; subscapular skinfold thickness, 3.22 +/- 1.34 mm; current length, 57.54 +/- 7.87 cm; and current weight, 4.46 +/- 1.49 kg. Variables significant for malnutrition in logistic regression models were sex, type of heart disease, birth weight, birth length, subscapular thickness, triceps thickness, and cephalic circumference. Nutritional defects were more evident in the case of the weight-for-age index. Boys had greater deterioration in the weight-for-age index, possibly indicating acute malnutrition, and girls had worse values for the height-for-age index, indicating a risk of chronic malnutrition.