An Analysis of Growth Failure in Children

with Congenital Heart Disease

ORIGINAL PAPER

Noble K, Forsey J, Wilson D
University Hospital of Wales, Cardiff

Aims
Growth failure in children with congenital heart disease (CHD) is well recognised. The primary
aim of this study was to compare two groups of patients (cyanotic v non-cyanotic) at diagnosis,
at the time of corrective surgery and at long term follow up to assess weight gain as compared
to the general population and each other. ong-term follow up data were reviewed to esta!lish if
catch-up growth occurred post surgical intervention and whether catch-up growth potential is
influenced !y the severity of preoperative growth failure.

Background
"hile growth failure in CHD is often descri!ed the e#act aetiology remains unclear. $t is li%ely to
!e multifactorial with proposed mechanisms including reduced calorie inta%e, mala!sorption,
increased energy e#penditure, relative hypo#ia and possi!le endocrine adaptations. $t has !een
suggested that if growth failure is severe preoperatively there may !e a limit on su!se&uent
catch up growth.
'
(dvances in cardiothoracic surgical techni&ues have ena!led earlier surgical intervention with
improved primary surgical outcomes. This has reduced the duration for which these children are
e#posed to poor growth velocity. )everal studies have suggested that pre-operative weight gain
is an important factor for predicting associated surgical mor!idity.
*,+
Hirose et al have suggested
that reduced weight gain in infants with CHD !etween +-, months of age is the most important
factor for future developmental delay.
-

Methods
Two patient groups were identified. patients with perimem!ranous ventricular septal defects
(/01)D) and patients with Tetralogy of 2allot (T32). (ll patients were under the care of the
paediatric cardiology team at the 4niversity Hospital of "ales. $nclusion criteria for this study
were patients with T32 without associated syndromes and patients with an isolated /01)D
re&uiring surgical intervention with at least five years of follow up. 3nce the patient groups were
identified from the cardiac data!ase (Cardio!ase
5
) a retrospective analysis of patient notes and
the data!ase were performed detailing weight at diagnosis, time of surgery and at five year
follow-up. /atients with comple# CHD, associated syndromes, and evidence of $4G6 were
e#cluded from the study. 6esults for !oth patient groups were e#pressed as standard deviations
from the normal (7 scores) and compared to normal data o!tained from the 8ritish '99: growth
reference data set.
,
Catch up growth was defined as the difference !etween pre-operative 7
score and , year follow up 7 score. ( 7 score of ; or < * signifies a measurement less or more
than * standard deviations from the mean, respectively. )tatistical analysis was performed
using )/)) statistical analysis pac%age.
This study was underta%en as a medical student senior clinical pro=ect and was assessing a
clinical service. The wor% did not therefore re&uire separate ethics committee approval.

Results
Growth data from *+ children with /01)D and '> children with T32 were included in this study.
8oth groups had height and weight data reviewed as documented at the time of inpatient
admission or outpatient review.
$n the /01)D group, weight data were recorded in *+?*+ patients, !ut height in only -?*+
patients. )tatistical analysis for height for this patient group was therefore not possi!le and
these were e#cluded. Time of diagnosis was at !irth '*?*+ and at a mean of @ months (range
'.*-*:) for ''?*+. 3f those diagnosed after the neonatal period ,,A (@?'') were referred for
failure to thrive. 0ean weight e#pressed as 7 scores at diagnosis, surgical intervention and
follow up were -'.99 (*
nd
centile), -*.+* ('
st
centile) and :.'+ (,,
th
centile). This clearly
demonstrates a deterioration in weight from the time of diagnosis to the time of surgical
correction.

Table 1 Comparative 7 score readings for growth parameters in patients with perimem!ranous
1)D (/01)D) and Tetralogy of 2allot (T32), at diagnosis, immediately prior to surgical
correction and after , years Bsee endC


1alues e#pressed as 7 scores (9,A C$)
D indicates statistical significance compared to normal population and to the su!=ectEs status at ,
years.
B C indicates num!ers of patients in whom the parameter was recorded. inear regression
modelF Catch-up "eightG :.-:9 H :.I9@("eight7s#)

There were '> su!=ects in the T32 group. 2ive were diagnosed either antenatally or at !irth.
The mean age of diagnosis for the '+ su!=ects diagnosed outside this period was '' wee%s
(range '.,-+@). 0ean weight 7 scores at diagnosis, intervention and follow-up were -'.I' (-
th
centile), -'.+: (*
nd
centile) and :.++ (+:
th
centile). 0ean height 7 scores at diagnosis,
intervention and follow-up were -'.9* (+
rd
centile), -'.9@ (*nd centile) and -:.,' (+:
th
centile),
respectively. The T32 group showed no ongoing deterioration in either height or weight from the
time of diagnosis to surgical correction. "ithin the T32 group there was a su!group of -
patients who underwent temporary palliation with a modified 8laloc%-Taussig shunt (08T)).
"ithin this su!group two patients demonstrated increased weight velocity post 08T) however
the remaining two patients continued to have poor weight gain. (ll four patients demonstrated
an increase in their height velocity following the palliative procedure.
$n !oth the /01)D and T32 groups there was a statistically significant difference in weight
from the normal population at !oth diagnosis and time of intervention, and the T32 group
showed a significant reduction in height at diagnosis and intervention compared to the normal
population. 8y the time of , year follow up all parameters returned to the normal range with no
statistical difference from the normal population.
4sing /earsons correlation co-efficient the degree of catch-up growth in !oth height and weight
was demonstrated not to correlate with the age at surgical intervention for either group. There
was a positive correlation !etween severity of growth failure in /01)D prior to intervention and
su!se&uent catch-up growth.

igure 1
The severity of growth failure (weight) in the 1)D su!=ects showed positive linear correlation
with their su!se&uent catch-up growth (using a 9,A confidence level) Bsee endC.


)everity of weight loss at time of surgery in T32 patients did not correlate. however there was a
positive relationship with height at surgery and catch up height at , years.

igure !
$n the T32 group the severity of height loss at the time of surgery was found to have a
statistically significant linear correlation with the su!se&uent degree of su!se&uent catch-up
height. there was no similar correlation with weight, however Bsee endC.


"onclusion
Growth failure has !een demonstrated in !oth su!=ect groups. "hile data regarding height
stunting in the /01)D group are not availa!le it is clear that the T32 group suffer !oth stunting
and wasting. $nterestingly the /01)D group show a relative fall in 7 score !etween diagnosis
and treatment despite dietetic intervention. 8oth groups attained normal heights and weights at
five year follow up suggesting that surgical intervention was fully corrective and that intervention
was underta%en at an early enough age.
(ll clinicians are aware of the potential for growth failure in patients with left-to-right shunt,
however the ris% of faltering growth in patients with T32 is not widely appreciated. This study
demonstrates the need for greater awareness amongst clinicians involved in the care of
children with T32 that growth failure can !e a ma=or concern. "hilst there is e#cellent care in
other aspects of T32 management these data clearly demonstrate that closer monitoring of
growth is re&uired and early intervention with nutritional supplementation is needed. "hilst
traditional parameters for surgical correction are well understood (weight, o#ygen saturation and
anatomical su!strates) perhaps growth velocity and overall nutritional status should !e given
e&ual standing as an indication for surgical referral of these patients.
The deterioration in growth in the /01)D following diagnosis and prior to surgery is of concern.
Despite the %nowledge that failure to thrive occurs in these patients we are still not managing
this aspect of the condition optimally. Greater awareness and earlier referral for specialist
dietetic advice to optimise calorie inta%e may !e indicated if we are to !est manage these
children prior to surgery. $ndeed if poor growth is demonstrated in these children despite optimal
nutritional support this should !e an indication for earlier surgical intervention.

Re#erences
'. /eterson 6J and "et7el GT. Growth failure in congenital heart diseaseF where are we nowK
Curr Opin Cardiol *::-.1$(*)F>'-+
*. 0itchell $ 0 et al. Lutritional status of children with congenital hear disease. Br Heart J
'99,.%&(+)F*II->+
+. u C M et al. 8ody weight related ioni7ed hypomagnesemia in paediatric patients undergoing
cardiopulmonary !ypass for surgical repair of congenital cardiac defects. J Clin Anesth
*::+.1'(+)F'>9-9+
-. Hirose M, $chida 2, 3shima M. Developmental status of young infants with congenital heart
disease. aediatr int *::I.($(-)F-@>-I'
,. 0edical 6esearch Council. !"#$ro%th. *::*-:I