It is well known that undernutrition is common in cardiac patients and related with increased morbidity and mortality. In developing countries like Ethiopia where surgical intervention for cardiac disease like congenital heart disease and/or rheumatic heart disease is scarce or unavailable at all, the magnitude of undernutrition is expected to be high.
This study reports a high burden of undernutrition and growth failure in children with cardiac diseases. The overall prevalence of undernutrition was 65.7%, with 31.2% of cases having severe acute undernutrition. Stunting which is an indicator of chronic undernutrition was found to be 39.7% and with 14.5% of cases had severe stunting. As noted above, this study reported a very high prevalence of undernutrition in children with cardiac disease as compared to the country national estimate of undernutrition in Ethiopia(14). Other studies also showed children with cardiac disease are higher risk of undernutrition compared to those without cardiac disease(10).
Similar to our finding, a study done in turkey by Varun etal reported higher prevalence of acute undernutrition (65%) and chronic undernutrition (42%)(7). Okoromah and colleagues reported a prevalence of undernutrition (90.4%), severe undernutrition (61.2%) and chronic undernutrition indicated by stunting (28.8%) in children with congenital heart disease visiting a tertiary teaching hospital Lagos, Nigeria. Though they reported lower prevalence of stunting, the overall prevalence of undernutrition and severe acute undernutrition is much higher than those seen in our study(6). Another study in India done by Vaidyanathan and colleagues, shows higher prevalence of acute undernutrition (55.9%) evidenced by weight for height(15). This suggests the presence of heterogeneity from country-to-country accounting for the difference in determinant of undernutrition among children with cardiac disease.
Based on the multivariable analysis we have found that the likelihoods of undernutrition were significantly higher among children with NYHA/Modified ROSS class III and IV heart failure, cardiac chamber enlargement and pulmonary hypertension. This is in line with various studies that reported children with advanced congestive heart failure and/or pulmonary hypertension were more likely to be malnourished(9, 10, 16). An explanation might be the fact that children with heart failure and pulmonary hypertension could have poor oral intake and also congestion of bowel and liver attributing to early satiety. In addition to this, heart failure causes a cascade of sympathetic activation and leading the patient to a hypermetabolic state with higher caloric demand(17).
This study has certain limitations. First, this a hospital-based study and there is high probability of patients are referred to us with advanced heart failure resulting in high burden of undernutrition Thus, our patients are not likely to be representative of the full extent of the disease prevalence at the community level. Second, the small proportion of children with cardiac disease in our study may bias the associations, in that we may have failed to detect significant associations based on proportions, which may have existed. However, this study provides new insights into the burden of undernutrition and its associated factors among children with cardiac disease in our hospital and encourages for a more comprehensive population-based analysis.
Conclusion and Recommendation: Undernutrition is a very common morbidity among children with cardiac disease. Advanced congestive heart failure, presence of pulmonary hypertension and cardiac chamber enlargement were associated with undernutrition. We recommend routine nutritional counseling and nutritional rehabilitation as standard practice for all children with cardiac disease. In addition to this we recommend every effort to be made for early and definitive corrective measures to be performed including surgery.