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.
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.
Child had congenital heart defect. Congestive heart failure due to VSD was causing recurrent respiratory tract infections.
Child was on regular formula feed with energy content of 67 kcal/100 ml.
Chest X ray, electrocardiogram (ECG), 2D echocardiography, complete blood count (CBC), C-reactive protein (CRP) and blood cultures were ordered.
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.
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.
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.
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.
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.
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.