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 [3, 13, 14].
This study detected 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 whereas the prevalence of underweight was found to be 54.5%. As noted above, this study detected a high burden of undernutrition in children with cardiac disease as compared to the country national estimate of undernutrition in Ethiopia . Other studies also showed children with cardiac disease are higher risk of undernutrition compared to those without cardiac disease [5, 9]. Children with cardiac disease have several reasons to have undernutrition. This includes higher metabolic demand, inadequate intake, associated comorbidities like recurrent respiratory infection, gut dysfunction and associated chromosomal and genetic syndromes .
Similar to our finding, a study done in Turkey by Varun etal reported higher prevalence of acute undernutrition (65%) and chronic undernutrition (42%) . 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 . Another study in India done by Vaidyanathan and colleagues, shows higher prevalence of acute undernutrition (55.9%) evidenced by weight for height deficit . This suggests the presence of heterogeneity from country-to-country accounting for the difference in determinant of undernutrition among children with cardiac disease.
This study found a higher prevalence of wasting, underweight but a lower prevalence of stunting compared to a study done at Mulago referral hospital, Uganda (31.5% wasted, 42.5% underweight and 45.4% stunted) and Cameron et al. study which reported a prevalence of acute undernutrition (33%) and chronic undernutrition (64%). In our study we included both congenital heart disease and acquired heart disease patients in contrast to the studies in the above setting where they included only children with congenital heart disease. This is could be the reason why our study has a higher prevalence of undernutrition in addition to the differences in socioeconomic characteristics and health service delivery system of these countries [16, 17].
NYHA/Modified ROSS class III and IV heart failure, cardiac chamber enlargement, and pulmonary hypertension were associated with undernutrition in our study. 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 [8, 9, 18]. This association may be explained by congestion of bowel and liver leading to early satiety. In addition, heart failure activates the sympathetic nervous system, leading to decreased appetite and increased caloric demand .
This study has several limitations. First, many patients in this study were referred to us with advanced disease, which may have led us to overestimate the true prevalence of undernutrition among children with cardiac disease. Second, we were unable to include other variables known to affect nutrition, including prematurity, genetic disorders, and previous dietary interventions. Third, our study was not powered to identify determinants of undernutrition among children with different categories of cardiac disease. 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.