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Growth faltering in 5-month old child suffering from congestive heart failure

By: Dr. Mahaboob Basha Kalluri

Consultant Pediatric Intensivist

Key Points:

Introduction:

Congenital heart disease (CHD) is the most common neonatal congenital malformation.1 CHD with large left-to-right shunts are commonly present in infancy with respiratory symptoms and poor growth. Among the various shunt lesions that present in infancy, ventricular septal defect (VSD) is the most common.2 Heart failure in children is most commonly attributable to coexistent CHD.3The cause of growth failure in CHD patient is multifactorial and likely includes a hypermetabolic state, inadequate caloric intake, swallowing dysfunction, malabsorption, gastroesophageal reflux, immaturity of the gastrointestinal tract, and genetic factors.4 Here we present a case of 5-month old child with congestive heart failure suuering from growth faltering.

Patient profile:

A 5-month old male child presented with complaint of congestive heart failure along with recurrent respiratory tract infections. He was showing growth faltering. On admission, patient’s weight was 3.2 kg, height was 57 cm, head circumference was 38 cm and mid upper arm circumference was 12 cm.

Relevant medical history:

Child had congenital heart defect. Congestive heart failure due to VSD was causing recurrent respiratory tract infections.

Relevant feeding history:

Child was on regular formula feed with energy content of 67 kcal/100 ml.

Investigations:

Chest X ray, electrocardiogram (ECG), 2D echocardiography, complete blood count (CBC), C-reactive protein (CRP) and blood cultures were ordered.

Diagnosis:

X ray showed enlarged heart. Whereas ECG showed left ventricular hypertrophy. Large muscular ventricular defect was also report in 2D echocardiography. CBC and CRP levels were normal. Blood cultures were negative.

Patient’s weight was less than that for 3rd percentiles on WHO growth chart.Child was diagnosed to be having growth faltering due to congenital heart defect and recurrent respiratory tract infections.

Management:

Child was admitted to hospital. He remained in PICU for 26 days and shifted to ward for next 4 days, making total of 30 days of hospitalization.

Nutritional management:

Aim of the nutritional management was to achieve satisfactory weight gain. He was prescribed regular formula feed with added MCT oil.

Since child was unable to gain weight with regular formula with added MCT oil, he was started initially on energy and nutrient dense formula (ENDF) with 100 ml/kg/day (100 kcal/ kg/day). Gradually, as the patient tolerated the formula, the formula amount was increased to 160 kcal/kg/day over 1-week period. The patient tolerated the formula well without any episodes of diarrhea, vomiting and flatulence. Child showed weight gain of 900 g over 30 days period making his weight 4.1 kg at the end of 30 days. His height was 58 cm, head circumference was 39 cm and mid arm circumference was 12.1 cm. At discharge, child was on 160 kcal/kg/day of ENDF.

Follow up:

At follow up after two weeks from discharge, his weight was 4.5 kg. Child showed acceptable weight gain and was thriving well with minimal respiratory tract infections. No signs of feed intolerance were reported. Therefore, ENDF was continued further.

Discussion:

CHD is the most common congenital neonatal malformation with a reported prevalence between 4 and 10 per 1000 live births. The variety of cardiac defects is very wide because of the several pathologic combinations of diuerent heart structures involved (atrias, ventricles, walls, large arteries, veins, valves).1 VSD is the most common congenital cardiac anomaly in children. An abnormal communication between the right and left ventricles and shunt formation is the main mechanism of hemodynamic compromise in VSD.5

The basis of growth failure in CHD appears to be multifactorial and may diuer in aetiology from patient to patient. It includes the underlying cardiac anomaly, haemodynamic factors, hypoxaemia, inadequate calorie, or macronutrient intake, increased energy expendi- ture relative to intake, increased inflammation, or associated comorbidities that include gut dysfunction, respiratory infections, associated genetic syndromes, and reduced growth potential.6 Growth faltering in CHD has been associated to long-term cognitive delay, including attention deficit disorders, aggressive behavior and poor social and emotional development.1

The management of newborns with CHD requires a multidisciplinary approach, in which the nutritional aspect plays an important role.1 In CHD infants with growth faltering, ENDF may promote weight gain with trend towards better growth.7

In the case presented here, we used ENDF which is more beneficial than regular formula with added MCT oil in infants who are not thriving well and suuering from chronic diseases. ENDF led to weight gain. As the child growth was satisfactory, the condition of congestive heart failure improved with decreased rate of respiratory tract infections. Use of ENDF can be considered as one of the important measures in managing CHD.

Conclusion:

It can be concluded that use of ENDF is a better option than regular formula with added MCT oil in patients with congestive heart failure who are not thriving well. ENDF can help with weight gain in cases of malnutrition, CHD and chronic respiratory problems.

References:-

  1. Mangili G, Garzoli E, Sadou Y. Feeding dysfunctions and failure to thrive in neonates with congenital heart diseases. Pediatr Med Chir. 2018 May 23;40(1)
  2. Bhatt M, Roth SJ, et al. Management of infants with large, unrepaired ventricular septal defects and respiratory infection requiring mechanical ventilation. JThorac Cardiovasc Surg. 2004 May;127(5):1466-73.
  3. Hinton RB, Ware SM. Heart failure in pediatric patients with congenital heart disease. Circ Res. 2017 Mar 17;120(6):978-994.
  4. Medou-Cooper B, Ravishankar C. Nutrition and growth in congenital heart disease: a challenge in children. Curr Opin Cardiol. 2013 Mar;28(2):122-9.
  5. Dakkak W, Bhimji SS. Ventricular Septal Defect. Last updated on: December 3, 2017. Treasure Island (FL): StatPearls Publishing. [Online]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470330/. Accessed on: 5.10.2018.
  6. Argent AC, Balachandran R, et al. Management of undernutrition and failure to thrive in children with congenital heart disease in low- and middle-income countries. Cardiol Young. 2017 Dec;27(S6):S22-S30.
  7. Clarke SE, Evans S, et al. Randomized comparison of a nutrient-dense formula with an energy-supplemented formula for infants with faltering growth. J Hum Nutr Diet. 2007 Aug;20(4):329-39.

Disclaimer:

Any personal information given herewith will be treated as confidential. We will NOT disclose any personal information about you or your patient without your consent unless we are required by law to do so. The World Health Organization (WHO)* has recommended that pregnant women and new mothers be informed of the benefits and superiority of breast-feeding, in particular, the fact that it provides the best nutrition and protection from illness for babies. Mothers should be given guidance on the preparation for and maintenance of lactation, with special emphasis on the importance of the well-balanced diet both during pregnancy and after delivery. Unnecessary introduction of partial bottle feeding or other foods and drinks should be discouraged since it will have a negative euect on breast-feeding. Similarly mothers should be warned of the diflculty of reversing a decision not to breastfeed. Before advising a mother to use an infant formula, she should be advised of the social and financial implications of her decision. For example, if a baby is exclusively bottle-fed, more than one can (500g) per week will be needed, so the family circumstances and cost should be kept in mind. Mother should be reminded that breast milk is not only the best but also the most economical food for babies. If a decision to use infant formula is taken, it is important to give instruction on correct preparation methods, emphasizing that unboiled water, unsterilized bottles or incorrect dilution can lead to illness.
*See: International Code of Marketing of Breast Milk Substitutes, adopted by the World Health Assembly in Resolution WHA 34.22, May 1981.

Important Notice:

Mothers should be explained the following advantages & nutritional superiority of breastfeeding:

  1. Immediately after delivery, breast milk is yellowish and sticky. This milk is called colostrum, which is secreted during the first week of delivery. Colostrum is more nutritious than mature milk because it contains more protein, more anti-infective properties which are of great importance for the infant’s defence against dangerous neonatal infections. It also contains higher levels of, Vitamin ‘A’
  2. Breast miIk:
    1. is, a complete and balanced food and provides all the nutrients needed by the infant (for the first six months of life)
    2. has anti-infective properties that protect the infants from infection in the early months
    3. is always available
    4. needs no utensils or water (which might, carry germs) or fuel for its preparation
  3. Breastfeeding is much cheaper than feeding infant milk substitutes as the cost of the extra food needed by the mother is negligible compared to the cost of feeding infant milk substitutes
  4. Mothers who breast-feed usually have longer periods of infertility after child birth than non-lactators

Details of management of breast feeding, as under:

  1. Breast-feeding.
    1. Immediately after delivery enables the contraction of the womb and helps the mother to regain her figure quickly
    2. is successful when the infant suckles frequently and the mother wanting to breast-feed is confident in her ability to do so
  2. In order to promote and support breast-feeding the mother’s natural desire to breast feed should always be encouraged by giving, where needed, practical advice and making sure that she has the support of her relatives
  3. Adequate care for the breast and nipples should be taken during pregnancy
  4. It is also necessary to put the infant to the breast as soon as possible after delivery
  5. Let the mother and the infant stay together after the delivery, the mother and her infant should be allowed to stay together (in hospital, this is called “rooming-in”)
  6. Give the infant colostrum as it is rich in many nutrients and anti-infective factors protecting the infants from infections during the few days of its birth
  7. The practice of discarding colostrum and giving sugar water, honey water, butter or other concoctions instead of colostrum should be very strongly discouraged
  8. Let the infants suckle on demand
  9. Every euort should be made to breast-feed the infants whenever they cry
  10. Mother should keep her body and clothes and that of the infant always neat and clean
    11. Breast-feeding is the best form of nutrition for babies and provides many benefits to babies and mothers. It is important that, in preparation for and during breast-feeding, you eat a healthy, balanced diet. Combined breast and bottle feeding in the first weeks of life may reduce the supply of your own breast-milk, and reversing the decision not to breast-feed is diflcult. Always consult your Healthcare Professional for advice about feeding your baby. The social and financial implications of using infant formula should be considered. Improper use of an infant formula or inappropriate foods or feeding methods may present a health hazard. If you use infant formula, you should follow manufacturer’s instructions for use carefully – failure to follow the instructions may make your baby ill.

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