European Journal of Cardiovascular Medicine

Congenital heart disease (CHD) represents the most prevalent congenital anomaly worldwide, accounting for approximately 28% of all major birth defects. It affects nearly 0.8% of live births globally, with an estimated incidence of 2.5 to 5 per 1000 live births in India. While advances in diagnostic and therapeutic approaches have improved survival rates, children with CHD remain vulnerable to a range of complications, particularly malnutrition and anemia, which significantly influence their clinical outcomes and quality of life.

Malnutrition in children with CHD arises from a multifactorial interplay involving increased metabolic demand, inadequate caloric intake, feeding difficulties, chronic hypoxemia, and delayed surgical correction. These children often experience failure to thrive, muscle wasting, and compromised immunity. A previous study estimated that approximately 59% of children with CHD were underweight, independent of the type or severity of the defect. Poor nutritional status contributes to increased morbidity, prolonged hospitalization, poor wound healing, and reduced neurodevelopmental outcomes.

Anemia, a frequently overlooked but critical comorbidity in CHD, can further impair oxygen delivery in already compromised cardiac physiology. The causes are often multifactorial, including iron deficiency, chronic illness, and increased erythropoietic demand in cyanotic CHD. Untreated anemia not only worsens hypoxia but also increases the risk of perioperative complications.

Despite its clinical relevance, routine screening for malnutrition and anemia in CHD patients is often inadequate. Therefore, this study was conducted to evaluate the prevalence and pattern of malnutrition and anemia among children with CHD aged 1–12 years in a tertiary care setting and to compare findings across cyanotic and acyanotic subtypes.

Study Design and Setting

This was a hospital-based, cross-sectional observational study conducted over a period of two years at the Institute of Child Health, Niloufer Hospital, Osmania Medical College, Hyderabad, Telangana, a tertiary care referral center for pediatric cardiac cases.

Study Population

Children aged 1 to 12 years diagnosed with congenital heart disease (CHD) and presenting either to the outpatient department or admitted for surgical or non-surgical management were included. Only preoperative cases were enrolled.

Inclusion Criteria

Children aged 1–12 years with a confirmed diagnosis of CHD (both cyanotic and acyanotic types)

• Preoperative status
• Informed consent obtained from parents or legal guardians

Exclusion Criteria

• Children with chromosomal abnormalities, genetic syndromes, or other congenital anomalies
• Postoperative CHD patients
• Acquired heart diseases
• Refusal of consent

Sample Size

A total of 154 children were enrolled using purposive sampling and included consecutively as per eligibility criteria.

Data Collection

Demographic details, clinical history, feeding practices, and dietary intake were recorded using a structured proforma. Anthropometric assessments included weight, height/length, body mass index (BMI), and mid-upper arm circumference (MUAC), and were plotted on WHO/IAP growth charts for age-appropriate interpretation.

Assessment of Nutritional Status

Weight-for-Age (W/A), Height-for-Age (H/A), Weight-for-Height (W/H), and BMI were interpreted using WHO MGRS (0–5 years) and Revised IAP 2015 (5–18 years) growth charts.

MUAC was measured for children aged 6–59 months to assess acute malnutrition.

Assessment of Anemia

• Hematological parameters included:
• Hemoglobin levels (interpreted using WHO age-specific cut-offs)

Red cell indices: Mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), and mean corpuscular hemoglobin concentration (MCHC)

Red cell distribution width (RDW)

Reticulocyte count

Peripheral smear

Serum ferritin levels (interpreted per WHO guidelines)

Ethical Considerations

The study was conducted after obtaining approval from the Institutional Ethics Committee of Niloufer Hospital. Informed consent was obtained from parents or guardians of all participants.

Statistical Analysis

Data were entered into Microsoft Excel and analyzed using SPSS version 20.0. Descriptive statistics were used to summarize categorical variables as frequencies and percentages. Chi-square test was applied to determine statistical associations, and a p-value < 0.05 was considered statistically significant.

A total of 154 children aged between 1 to 12 years with congenital heart disease (CHD) were included in the study. Among them, 69.5% (n = 107) were in the age group of 1–5 years, and 30.5% (n = 47) were in the 5–12 years group. The gender distribution was equal, with 50% (n = 77) males and 50% (n = 77) females, yielding a male-to-female ratio of 1:1 (Table 1).

Table 1: Demographic Characteristics of Study Population (n = 154)

The majority of the children (93.5%) had acyanotic congenital heart disease (ACHD), while only 6.5% had cyanotic congenital heart disease (CCHD). Among ACHD cases, atrial septal defect (ASD) and ventricular septal defect (VSD) were the predominant types (Table 2).

Table 2: Distribution According to Type of Congenital Heart Disease

Anthropometric evaluation revealed that 44.2% of the children were underweight according to weight-for-age (W/A) criteria, with 31.2% being severely underweight and 13.0% classified as underweight. In terms of height-for-age (H/A), 48.7% of children were found to be stunted, including 33.8% severely stunted and 14.9% moderately stunted (Table 3).

Table 3: Nutritional Status Based on Weight-for-Age (W/A) and Height-for-Age (H/A)

Clinical signs of anemia and malnutrition were prevalent among the study participants. Pallor was noted in 52.6% of children, vitamin D deficiency in 35.7%, and vitamin B complex deficiency in 13.6%. Other features such as vitamin A deficiency, bipedal edema, and hair changes were less frequently observed (Table 4).

Table 4: Clinical Features Indicative of Anemia and Malnutrition

Assessment of body mass index (BMI) revealed that 21.43% of the children were underweight/thin, while the remaining 78.57% fell within the normal BMI range. None of the children were classified as overweight or obese based on age-appropriate WHO and IAP growth charts (Table 5).

Table 5: Body Mass Index (BMI) Classification

This cross-sectional study was conducted to evaluate the nutritional status and prevalence of anemia among children aged 1–12 years with congenital heart disease (CHD) admitted to a tertiary care hospital. Our findings highlight a significant burden of malnutrition and hematological deficits among this vulnerable population, with higher prevalence observed in those with acyanotic CHD.

In our study, 44.2% of children were underweight and 48.7% were stunted. These findings are consistent with previous studies by Vaidyanathan et al. and Okoromah et al., which reported malnutrition prevalence rates ranging from 40% to 90% in children with CHD, particularly among those with delayed corrective surgery and heart failure. The high rates of undernutrition in our cohort can be attributed to increased metabolic demands, feeding difficulties, recurrent infections, and chronic hypoxia associated with CHD.

Interestingly, we found that acyanotic CHD was more prevalent (93.5%) than cyanotic CHD (6.5%) in our population, with ASD and VSD being the most common defects. While it is often assumed that cyanotic CHD leads to more severe nutritional compromise due to hypoxia, our findings suggest that acyanotic CHD patients—who may live longer without early intervention—are also at substantial risk of chronic undernutrition.

Anemia was also highly prevalent, with pallor present in 52.6% of the children. Vitamin deficiencies were common, particularly vitamin D deficiency (35.7%), which aligns with previous literature linking CHD to impaired absorption and limited outdoor activity. Hematological evaluation showed signs of iron deficiency and red cell index abnormalities, emphasizing the need for early nutritional and medical intervention.

The majority of children belonged to lower middle and upper lower socioeconomic strata, reflecting the impact of poverty, poor dietary diversity, and limited access to early medical care. Furthermore, early initiation of complementary feeding and exclusive breastfeeding practices were suboptimal in a considerable proportion of participants, which likely contributed to the poor nutritional outcomes.

This study highlights the significant burden of malnutrition and anemia among children aged 1–12 years with congenital heart disease, particularly in those with acyanotic lesions. Nearly half of the participants were underweight or stunted, and clinical features of anemia were highly prevalent. Socioeconomic factors, delayed intervention, and inadequate nutritional practices contribute to these adverse outcomes. Early identification and comprehensive management of nutritional deficits, including dietary counseling and micronutrient supplementation, are essential. Routine growth monitoring and hematological screening should be integrated into CHD management protocols to improve surgical outcomes and long-term health. Multidisciplinary care is crucial to ensure optimal growth and development in this high-risk group.

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