Nigerian Journal of Cardiology

ORIGINAL ARTICLE
Year
: 2015  |  Volume : 12  |  Issue : 2  |  Page : 89--94

Nutritional profiles and selected parental factors among children with congenital heart diseases in Ibadan, Nigeria


Folusho M Balogun1, Samuel I Omokhodion2,  
1 Department of Pediatrics, University College Hospital, Ibadan, Nigeria
2 Department of Pediatrics, University College Hospital; Department of Pediatrics, College of Medicine, University of Ibadan, Ibadan, Nigeria

Correspondence Address:
Folusho M Balogun
Institute of Child Health, College of Medicine, University College Hospital Campus, Ibadan, Oyo
Nigeria

Abstract

Background: Among the many adverse sequelae of congenital heart disease (CHD), malnutrition stands out as one of the major concerns. Objective: This study was undertaken to compare the nutritional status, parental age, and mid-parental heights of children with CHD and their apparently healthy control group. Material and Methods: Electrocardiography and echocardiography were used to confirm the presence or otherwise of CHD in consecutive 100 children with CHDs and 100 age, sex, and social class matched apparently healthy control group. Nutritional parameters, parental ages, and mid-parental heights were also obtained. Associations were tested using student t test and Chi square test. Level of significance was P < 0.05. Results: There were 54 males with CHD and the age-range of the children was 1-96 months. The commonest acyanotic CHD was ventricular septal defect (49.0%) while the commonest cyanotic CHD was Fallot«SQ»s tetralogy (10%). Children with CHD compared with the control group had significantly lower mean z scores for weight for height, height for age, and weight for age. The mid upper arm circumference, triceps, and subscapular skinfold thickness were also lower than that found in the control group. Older parental age and lower mid-parental heights were found among parents of children with CHD compared with those of controls. Conclusions: Malnutrition can be quite severe in children with CHD if unattended to. Early corrective intervention is necessary to prevent short-term and long-term sequelae of malnutrition in these children. Parental malnutrition and older parental age are likely predisposing factors to CHD.



How to cite this article:
Balogun FM, Omokhodion SI. Nutritional profiles and selected parental factors among children with congenital heart diseases in Ibadan, Nigeria.Nig J Cardiol 2015;12:89-94


How to cite this URL:
Balogun FM, Omokhodion SI. Nutritional profiles and selected parental factors among children with congenital heart diseases in Ibadan, Nigeria. Nig J Cardiol [serial online] 2015 [cited 2021 Feb 27 ];12:89-94
Available from: https://www.nigjcardiol.org/text.asp?2015/12/2/89/152011


Full Text

 INTRODUCTION



Delayed corrective intervention for congenital heart diseases (CHD) is common in developing countries as a result of non-availability of funds and appropriate diagnostic and therapeutic facilities, predisposing most of the children with CHD to malnutrition and its attendant complications. [1] Malnutrition remains a major concern among children in sub-Saharan Africa and is responsible for almost 60% of deaths among under-five children aided by its interactive effects on preventable diseases. [2] When it begins in infancy, it can impair cognitive and mental development and also cause stunted final adult height. [3] These have been reported to contribute to reduced potential and productivity in adulthood. [4]

Congenital malformations have been reported with a higher frequency among offspring of parents who have malnutrition [5] and some CHD have been associated with underweight mothers. [6] Furthermore, parental ages have been associated with the incidence of CHD but the observations have been inconsistent. [7],[8],[9] Older parental ages have been associated with the occurrence of CHD and this was attributed to the significantly increasing age that men and women have their first babies. [10] This is not yet common in developing countries, therefore relationship between age of parents and incidence of CHD in these regions may be different from what have been reported from developed countries.

The present study aims to assess nutritional status of children with CHD and apparently healthy controls, compare nutritional indices of these groups of children as well as parental ages and heights.

 MATERIALS AND METHODS



The study was carried out in a tertiary health care center that provides pediatric cardiology services for children mainly from south-western Nigeria. A comparative study design was adopted and ethical approval was obtained from the University of Ibadan/University College Hospital ethical review committee. Sample size was determined using the formula for comparing two independent samples and power was set at 80%.

Study population

Children with CHD were enrolled from the pediatric cardiology clinic while the apparently healthy comparison group were recruited from the children outpatient clinic of the hospital. These were children being followed up for illnesses like malaria, upper respiratory tract infections, etc. The inclusion criteria for the CHD group were that the child should have a confirmed CHD and should be aged between one month and 12 years. Those excluded were the ones in heart failure, born preterm, having obvious chromosomal abnormalities like Down syndrome or syndromes that can affect growth like congenital rubella syndrome or having conditions that can affect nutrition like cleft lip and palate. The control group were selected if they do not have any physical signs of chronic illness like sickle cell disease and they were matched with the children with CHD by age, sex, and socioeconomic class. The matching by age was done such that the maximum disparity in the age in the first year was 3 months and in the subsequent years, 6 months was the maximum disparity.

Informed consent was taken from the parents of the participants and data was obtained using a structured questionnaire which was earlier pretested in the hospital's children outpatient clinic. Data obtained included the socio-demographic parameters of the subjects, diagnosis, or exclusion of CHD based on electrocardiographic and echocardiographic findings, nutritional history (which included breast feeding duration, weaning diets and 24 hours dietary recall), anthropometry, evidence of poor nutrition on physical examination, parental ages, heights, and mid-parental height. The participants were stratified into 5 socioeconomic classes based on a previous Nigerian study [11] in which class I is the highest socioeconomic class and V is the least.

Diagnosis of congenital heart disease

Electrocardiography (ECG) was recorded using a handheld single channel CMS 80A ECG machine (Contec Medical systems Co. Ltd. [China]) with pen calibration set at 10 mm/mv and paper speed was 25 mm/sec. Standard 12 lead ECG recordings were performed with children in supine position. The result was used to screen for possibility of a structural cardiac abnormality. Echocardiography was performed to ascertain the presence or otherwise of CHD using a Toshiba SSA-660A echocardiogram machine and a transducer with a frequency of 5 MHz. When required, chloral hydrate syrup at 30-50 mg/kg was given for sedation.

Procedure for anthropometry

The measurement of weight and length/height were performed using the techniques earlier described by Tanner et al. [12] and Owen. [13] Infants were weighed unclothed using a Waymaster infant scale (Waymaster company, Reading, England) while older children were weighed in their underpants on a bathroom scale. Both scales were checked for zero error before each measurement and also periodically with standard weights. The weights were recorded to the nearest 0.1 kg. Recumbent length (for those 1 month to 2 years) was determined using an infantiometer and height (for those 3 years and above) using a stadiometer. Occipito-frontal circumference (OFC), chest circumference (CC), and mid upper arm circumference (MUAC) were obtained using an inelastic tape with measurements recorded to the nearest 0.1 cm. OFC was measured by applying the tape round the head with the supra-orbital ridges or the most prominent frontal bulge and the most prominent part of the occiput as the landmarks. The CC was determined by applying the tape round the chest with the nipples as the landmark while MUAC was obtained by taking the arm circumference at the point midway between the distance of the acromion to the olecranon process. A Lange skinfold calliper (Beta Technology Inc. Cambridge, USA) was used to measure skinfold thickness at the triceps and subscapular regions to the nearest 1mm as described by Tanner et al. [12] The mid-parental heights were also obtained using a stadiometer as earlier described. For all the parameters, two measurements were carried out and the average calculated to ensure accuracy and avoid inter-observer errors.

Data analysis

Data was analysed using statistical package for social sciences (SPSS version 20.0, SPSS Inc; Chicago, IL, USA). Z scores for weight for height, height for age and weight for age was determined using the World Health Organisation (WHO) Anthro software and the Centre for Disease Control growth charts. Normal nutrition was defined as anthropometric values greater than, or equal to-1.99 standard deviation (SD) or Z scores and malnutrition (poor nutrition) was defined as less than or equal to-2SD or Z scores relative to the reference or median. The children with CHD were divided into two groups based on the presence or absence of cyanosis with comparison done between these groups and with the children in the control group. Means were generated for continuous variable and associations tested using student's t test while categorical variables were compared using Chi square test and where a cell had a variable less than 5, Fisher's exact test was used. Mid-parental heights and parental ages greater than the mean were categorised as higher mid-parental heights and older parental ages. Statistical level of significance was set at P < 0.05.

 RESULTS



One hundred children with CHD and a 100 age, sex, and socioeconomic class matched control group were recruited from the clinics. There were 54 males and 46 females in each group with the age range for the acyanotic CHD being 2 to 70 months, the cyanotic group 1 to 84 months and the control was 1 to 90 months. The other characteristics of the study participants are as shown in [Table 1]. The distribution of the CHD is as shown in [Table 2]. Children with acyanotic and cyanotic CHD were 83 and 17, respectively. The commonest acyanotic CHD was ventricular septal defect (45%) while the commonest cyanotic CHD was Tetralogy of Fallot (9%). Lower nutritional indices were seen among children with CHD compared with the control group especially the acyanotic group [Table 3] and [Table 4]. There was no significant difference between the nutritional indices of both acyanotic and cyanotic CHD children. Duration of breastfeeding, weaning diet, and 24-hour dietary recall were similar in both study groups. The commonest feature of malnutrition among the CHD group was fluffy hair (20%) and bony prominences (23%). Only one child had pallor and none had leg edema or skin changes. The mean maternal age, paternal age, and mid-parental height were 33 years, 37 years, and 165 cm, respectively. Comparison of the parental ages and heights is shown in [Table 5].{Table 1}{Table 2}{Table 3}{Table 4}{Table 5}

 DISCUSSION



The nutritional condition of children with CHD is very important not only as a result of its negative short- and long-term consequences, but also in its role in determining the outcomes of corrective surgical procedures. The finding of lower nutritional indices in children with CHD in the present study is similar to reports from earlier studies. [12],[14] This is important as the malnutrition is likely to persist for a long time in most of them since facilities required for corrective intervention are not readily available in the study environment. Thus, the consequences of malnutrition are a huge burden that cannot be ignored in these children and this draws attention to the urgent need of affordable pediatric cardiology centers in sub-Saharan Africa.

Considering the significantly reduced OFC among children with CHD compared with that observed in the control group, there could be impairment in the intellectual development of these children. Unfortunately, many of these children were infants who were at a critical stage of brain development and maximizing head growth in infancy and childhood is critical for the attainment of peak cognitive capacity in adult life. [15] Optimal brain growth in early life also protects against cognitive deterioration in the elderly. [16] Consideration was not given to head growth in earlier studies that looked into the nutritional status of children with CHD [14],[17],[18] but its importance cannot be overlooked.

The worse nutritional indices found among children with acyanotic CHD suggest that compromise in tissue oxygenation as a result of overperfusion of the lung tissues from shunt lesions with recurrent heart failure and lung infections may be more detrimental to growth than chronic arterial desaturation of cyanotic CHD The impact of cyanosis on nutritional indices in CHD have however been controversial as the findings have not been consistent. [19] It has been suggested that the level of anaerobic metabolism that accompanies cyanosis in CHD determines the extent of reduction in the total energy production at cellular level, hence, the nutrition. [20]

The conspicuous absence of social economic class V could be as a result of the inability to afford hospital fees since out of pocket payment is the common practice in this environment. [21] Older age of parents of children with CHD may be responsible for the heart abnormalities that these children have as older parental age have been associated with increased mutations and chromosomal aberrations in sperm cells and ova. These genetic changes could lead to birth defects in children with atrial septal defect, ventricular septal defect, pulmonary valve stenosis, and right ventricular outflow tract obstruction specifically associated with higher paternal age. [22] The children with CHD may be from polygamous family settings (which is common in sub-Saharan Africa), in which fathering of babies in older age occurs but family type was not considered in this study. This could be explored in future studies.

The lower mid-parental heights of children with CHD may point to the possibility that the parents were malnourished in childhood and it has been suggested that parental malnutrition could be a risk factor for having children with birth defects. [5],[14] Despite the matching of the socioeconomic class in the study groups, it is likely that parents of the children with CHD were exposed to poor nutrition in childhood irrespective of their present socioeconomic class which could have compromised their final adult heights, predisposing them to having children with CHD. This is possible since both childhood and adult malnutrition are common in this region of the world. [23]

The strength of this study include the homogeneity of children with CHD as those in heart failure (which has been shown to worsen malnutrition in them) [17] and other factors that could affect nutrition, like chromosomal abnormalities and congenital rubella syndrome, were excluded. Matching of the study participants was done carefully in order to ensure comparable similarities in the study groups. The adiposity, muscle bulk, and OFC were also compared which gives a more holistic assessment of nutrition and this is important in child growth. To the best of our knowledge, this is the first study in sub-Saharan Africa to consider the association of parental ages and heights with CHD among children. This was taken into account because of the peculiarity of younger parenting age, high fertility rate, [24] and the interplay of malnutrition prevalence and the incidence of congenital malformation in this region. [14]

The costly consequences of malnutrition in CHD can be prevented with the availability of affordable pediatric cardiac services which will promote prompt diagnosis and early corrective intervention. Education about the dangers of old parental age is also necessary and prevention of malnutrition at all stages of life may reduce the incidence of CHD. A larger and probably longitudinal study is required to establish firmly the possible causality between CHD and low mid-parental heights. This is a hospital-based study and may explain the absence of children from the lowest socioeconomic class. Similar study in a community setting will likely capture children across all social classes with a more representative finding. Biochemical parameters of nutritional status like serum albumin were not considered in this study. The presence of CHD may have effect on these parameters as well.

 CONCLUSIONS



There is severe malnutrition among children with CHD in this study. These children also have older fathers and lower mid-parental heights compared with the apparently healthy controls. Availability of affordable pediatric cardiology services is crucial to ensure early correction of CHD, thereby preventing malnutrition and its dire consequences. Efforts to improve the present socioeconomic situation in order to prevent malnutrition at all stages of life should be intensified. Public enlightenment is also required to raise awareness about the association of old parental age with CHD.

 ACKNOWLEDGEMENT



We wish to thank all parents and children who participated in this study.

References

1Hewitson J, Brink J, Zilla P. The challenge of pediatric cardiac services in the developing world. Semin Thorac Cardiovasc Surg 2002;14:340-5.
2Pelletier DL, Frangillo EA Jr, Schroeder DG, Habicht JP. A methodology for estimating the contribution of malnutrition to child mortality in developing countries. J Nutr 1994;124 (10 Suppl):2106-22S.
3Lloyd-Still JD, Hurwitz I, Wolff PH, Shwachman H. Intellectual development after severe malnutrition in infancy. Pediatrics 1974;54:306-11.
4Victora CG, Adair L, Fall C, Hallal PC, Martorell R, Richter L, et al. Maternal and Child undernutrition study group. Maternal and Child undernutrition: Consequences for adult health and human capital. Lancet 2008;371:340-57.
5Howson C, Christianson AM. Controlling birth defects: Reducing the hidden toll of dying and disabled children in low-income countries; 2008 p. 1-16.
6Carmichael SL, Yang W, Herring A, Abrams B, Shaw GM. Maternal food insecurity is associated with increased risk of certain birth defects. J Nutr 2007;137:2087-92.
7Tay JS, Yip WC, Joseph R. Parental age and birth order in Chinese children with congenital heart disease. J Med Genet 1982;19:441-3.
8Zhan SY, Lian ZH, Zheng DZ, Gao L. Effect of fathers′ age and birth order on occurrence of congenital heart disease. J Epidemiol Community Health 1991;45:299-301.
9Materna-Kigluk A, Wisniewska K, Badura- Stronka M, Mejnartowicz J, Wieckowska B, Balcar-Bown A, et al. Parental age as a risk factor for isolated congenital malformation in a Polish population. Paediatr Perinat Epidemiol 2009;23:29-40.
10Rychtarikova J, Gourbin C, Sipek AW. Impact of parental ages and other characteristics at child bearing on congenital anomalies: Results for the Czech Republic 2000-2007. Demogr Res 2013;28:137-76.
11Oyedeji GO. Socioeconomic and cultural background of hospitalised children in Ilesa. Nig J Paediatr 1985;12:111-7.
12Tanner JM, Whitehouse RH, Takaishi M. Standards from birth to maturity for height, weight, height velocity, weight velocity: British children. Arch Dis Child 1965;41:454-6.
13Owen GM. The assessment and recording of measurements of growth of children: Report of a small conference. Pediatrics 1973;51:461-6.
14da Silva VM, de Oliveira Lopes MV, de Araujo TL. Growth and nutritional status of children with congenital heart disease. J Cardiovasc Nurs 2007;22:390-6.
15Gale CR, O′Callaghan FJ, Brendow M, Martyn CN. Avon Longitudinal study of Parents and Children Study Team. The influence of head growth in fetal life, infancy, and childhood on Intelligence at the ages of 4 and 8 years. Pediatrics 2006;118:1486-92.
16Gale CR, Walton S, Martyn CN. Foetal and postnatal head growth and risk of cognitive decline in old age. Brain 2003;126:2273-8.
17Okoromah CA, Ekure EN, Lesi FE, Okurowo WO, Tijani BO, Okeiyi JC. Prevalence, profile and predictors of malnutrition in children with congenital heart defects: A case-control observational study. Arch Dis Child 2011;96:354-60.
18Venugopalan P, Akinbami FO, Al-Hinai KM Agarwal AK. Malnutrition in children with congenital heart defects. Saudi Med J 2001;22:964-7.
19Mehrizi A, Drash A. Growth disturbance in congenital heart disease. J Pediatr 1962;61:418-29.
20Leitch CA, Karn CA, Peppard RJ, Grayer D, Leichly EA, Ensiry GJ, et al. Increased energy expenditure in infants with cyanotic congenital heart disease. J Pediatr 1998;133:755-60.
21Ajayi IO, Jegede AS, Falade CO, Sommerfeld J. Assessing resources for implementing a community directed interventions in urban poor communities of southwestern Nigeria: A qualitative study. Infect Dis Poverty 2013;2:25.
22Green RF, Devine O, Crider KS, Olney RS, Archer N, Olshan AF. National Birth Defects Prevention study. Association of paternal age and risk for major congenital anomalies from the National Birth Defects Prevention study, 1997 to 2004. Ann Epidemiol 2010;20:241-9.
23Bain LE, Awah PK, Geraldine N, Kindong NP, Sigal Y, Bernard N, et al. Malnutrition in Sub-Saharan Africa: Burden, causes and prospects. Pan Afr Med J 2013;15:120.
24Caldwell JC, Caldwell P. The cultural context of high fertility in sub-Saharan Africa. Population Dev Rev 1987;13:409-37.