Myocardial dysfunction in malnourished children

The importance of Naples prognostic score in predicting long-term mortality in heart failure patients

BACKGROUND

Heart failure (HF) remains a significant health problem despite advances in diagnosis and treatment options. Malnutrition and increased inflammation predict poor disease prognosis. The parameters of the Naples prognostic score (NPS) include albumin, total cholesterol, neutrophil-lymphocyte ratio (NLR), and lymphocyte-monocyte ratio (LMR). We aimed to assess the potential of NPS as a predictor of long-term mortality in patients with HF.

METHODS

A total of 1728 patients with HF who applied to our center between 2018 and 2022 were included in this study. The NPS was computed and the patients were divided into three groups according to their NPS values as follows: NPS = 0 (Group 1), NPS = 1-2 (Group 2), and NPS = 3-4 (Group 3). We also evaluated the association between NPS value and HF mortality.

RESULTS

The patients were followed for a mean follow-up duration of 30 months. The mortality rate was 8.3% (145 patients). We carried out Model-1 and -2 Cox regression analyses to identify long-term mortality determinants. Model-2 was constructed by adding NPS to Model-1. NPS was significantly associated with HF mortality (Hazard Ratio: 2.194, 95% Confidence Interval: 1.176-4.091, p = 0.014). According to the Kaplan-Meier plot and log-rank analyses, there was a statistically significant difference in the long-term mortality of patients with HF and their NPS values for the entire cohort.

CONCLUSION

Based on our findings, NPS showed promise as an independent predictor of long-term mortality in individuals with HF.

Patterns of malnutrition in infants and children with congenital heart diseases, an experience of a large tertiary hospital

Background: Congenital heart disease (CHD) is the most prevalent congenital abnormality in children. Infants and children with CHD are at a higher risk of malnutrition. Aim: The purpose of this research was to investigate the frequency of anthropometric malnutrition, for example, underweight, wasting, and stunting, among infants and children with CHD attending the emergency room of a large tertiary hospital. Methods: Between January 2022 and August 2022, a cross-sectional study was carried out on 96 infants and children presenting with heart failure at Children's Hospital Cairo University. All enrolled participants had anthropometric and biochemical nutritional assessments. Anthropometric z-scores were calculated for each infant or child using WHO reference ranges. Biochemical and nutritional assessments were carried out through screening for iron deficiency anemia and electrolyte imbalances. Results: Ninety-six infants and children were enrolled in our study, with males representing 54.8%. Seventy percent of the patients were anthropometrically malnourished, with underweight being the most prevalent (59.4%). Some children had more than one type of malnutrition. Electrolyte imbalance was a major biochemical malnutrition indicator, with hypophosphatemia present in 39.6% of the enrolled children. Conclusion: Malnutrition poses a significant health problem in infants and children with CHDs. To improve outcomes, it is essential to integrate systematic measures for identifying and managing malnutrition into the care of these patients. Both anthropometric and biochemical malnutrition should be routinely screened in all clinical settings to ensure comprehensive management and support.

Efficacy of dopamine, epinephrine and blood transfusion for treatment of fluid refractory shock in children with severe acute malnutrition or severe underweight and cholera or other dehydrating diarrhoeas: protocol for a randomised controlled clinical trial

INTRODUCTION

Diarrhoea is one of the leading causes of under-5 childhood mortality and accounts for 8% of 5.4 million global under-5 deaths. In severely malnourished children, diarrhoea progresses to shock, where the risk of mortality is even higher. At icddr,b Dhaka Hospital, the fatality rate is as high as 69% in children with severe malnutrition and fluid refractory septic shock. To date, no study has evaluated systematically the effects of inotrope or vasopressor or blood transfusion in children with dehydrating diarrhoea (eg, in cholera) and severe acute malnutrition (SAM) or severe underweight who are in shock and unresponsive to WHO-recommended fluid therapy. To reduce the mortality of severely malnourished children presenting with diarrhoea and fluid refractory shock, we aim to compare the efficacy of blood transfusion, dopamine and epinephrine in fluid refractory shock in children who do not respond to WHO-recommended fluid resuscitation.

METHODS AND ANALYSIS

In this randomised, three-arm, controlled, non-masked clinical trial in children 1-59 months old with SAM or severe underweight and fluid refractory shock, we will compare the efficacy of dopamine or epinephrine administration versus blood transfusion in children who failed to respond to WHO-recommended fluid resuscitation. The primary outcome variable is the case fatality rate. The effect of the intervention will be assessed by performing an intention-to-treat analysis. Recruitment and data collection began in July 2021 and are now ongoing. Results are expected by May 2023.

ETHICS AND DISSEMINATION

This study has been approved by the icddr,b Institutional Review Board. We adhere to the 'Declaration of Helsinki' (2000), guidelines for Good Clinical Practice. Before enrolment, we collect signed informed consent from the parents or caregivers of the children. We will publish the results in a peer-reviewed journal and will arrange a dissemination seminar.

TRIAL REGISTRATION NUMBER

NCT04750070.

Prevalence of Cardiac Dysfunction in Malawian Children With Severe Febrile Illness

OBJECTIVES

To investigate the prevalence of left ventricular systolic dysfunction (LVSD) in Malawian children with severe febrile illness and to explore associations between LVSD and mortality and lactate levels.

DESIGN

Prospective observational study.

SETTING

Pediatric ward of a tertiary government referral hospital in Malawi.

PATIENTS

Children between 60 days and 10 years old with severe febrile illness (fever with at least one sign of impaired perfusion plus altered mentation or respiratory distress) were enrolled at admission from October 2017 to February 2018.

INTERVENTIONS

Focused cardiac ultrasound (FoCUS) was performed, and serum lactate was measured for each child at enrollment, with repeat FoCUS the following day. LV systolic function was later categorized as normal, reduced, severely reduced, or hyperdynamic by two pediatric cardiologists blinded to clinical course and outcomes.

MEASUREMENTS AND MAIN RESULTS

Fifty-four children were enrolled. LVSD was present in 14 children (25.9%; 95% CI, 15.4-40.3%), of whom three had severely reduced function. Thirty patients (60%) had a lactate greater than 2.5 mmol/L, of which 20 (40%) were markedly elevated (>5 mmol/L). Ten children died during admission (18.5%). Of children who survived, 22.7% had decreased LV systolic function versus 40% of those who died. Dysfunction was not associated with mortality or elevated lactate.

CONCLUSIONS

Cardiac dysfunction may be present in one in four Malawian children with severe febrile illness, and mortality in these patients is especially high. Larger studies are needed to further clarify the role cardiac dysfunction plays in mortality and integrate practical bedside assessments for decision support around individualized resuscitation strategies.

Evaluation of the left ventricular systolic strain in hypocalcemic infants with two-dimensional speckle tracking echocardiography

INTRODUCTION

Speckle tracking echocardiography (STE) is a new emerging method for evaluation of the cardiac systolic performance. We characterized left ventricular (LV) systolic functions of hypocalcemic infants, and assessed the effects of calcium and vitamin D supplementations on LV systolic functions using two-dimensional STE.

PATIENTS AND METHODS

A prospective controlled study was conducted in Mansoura University Children's Hospital, Egypt from 2015 to 2018 including 88 hypocalcemic infants (patient group) and 30 healthy controls. We subdivided the patient group into vitamin D deficiency group (n = 32) and normal vitamin D group (n = 56). All infants were investigated for serum phosphorus, alkaline phosphatase and 25-hydroxy vitamin D levels. Both patients and controls were initially evaluated for LV systolic functions using two-dimensional STE. After correction of hypocalcemia and vitamin D deficiency, reevaluation of LV systolic functions was done for the patient group.

RESULTS

LV systolic strains were lower in the patient group than controls (p < .001). After recovery of hypocalcemia of the patients, we reported significant improvement of strains and significant reductions of the end-diastolic and end-systolic volumes of the left ventricle (p < .001). Global longitudinal and circumferential strains were lower in patients with vitamin D deficiency than patients with normal vitamin D levels (p < .001). The LV systolic strain improved after correction of vitamin D deficiency and hypocalcemia (p < .001).

CONCLUSION

Two-dimensional STE could detect and follow up early LV systolic dysfunction in infants with hypocalcemia and vitamin D deficiency.

The impact of malnutrition on short-term morbidity and mortality in ambulatory patients with heart failure

BACKGROUND

Malnutrition is common in patients with chronic heart failure (CHF) and is associated with adverse outcomes, but it is uncertain how malnutrition should best be evaluated.

OBJECTIVES

This prospective cohort study aims to compare the short-term prognostic value of 9 commonly used malnutrition tools in patients with CHF.

METHODS

We assessed, simultaneously, 3 simple tools [Controlling Nutritional Status (CONUT) score, Geriatric Nutritional Risk Index, and Prognostic Nutritional Index], 3 multidimensional tools [Malnutrition Universal Screening Tool, Mini Nutritional Assessment-Short Form (MNA-SF), Subjective Global Assessment], and 3 laboratory tests (serum cholesterol, albumin, and total lymphocyte count) in consecutive patients with CHF attending a routine follow-up. The primary end point was all-cause mortality; the secondary end point was the combination of all-cause hospitalization and all-cause mortality.

RESULTS

In total, 467 patients [67% male, median age 76 y (range: 21-98 y), median N-terminal pro-B-type natriuretic peptide (NT-proBNP) 1156 ng/L] were enrolled. During a median follow-up of 554 d, 82 (18%) patients died and 201 (43%) patients either had a nonelective hospitalization or died. In models corrected for age, hemoglobin (Hb), renal function, New York Heart Association (NYHA) class, NTproBNP, BMI, and comorbidities, all malnutrition tools, except total lymphocyte count and serum cholesterol, were independently associated with worse morbidity and mortality. A base model for predicting mortality, including age, NYHA class, log [NT-proBNP], Hb, renal function, and comorbidities, had a C-statistic of 0.757. CONUT (C-statistic = 0.777), among simple tools; MNA-SF (C-statistic = 0.776), among multidimensional tools; and albumin (C-statistic = 0.773), among biochemical tests, increased model performance most compared with the base model. Patients with serum albumin <30 g/L had a 6-fold increase in mortality compared with patients with albumin ≥35 g/L.

CONCLUSIONS

Malnutrition is strongly associated with adverse outcomes in patients with CHF. Measuring serum albumin provides comparable prognostic information to simple or multidimensional malnutrition tools.

Myocardial injury in patients with sickle cell anaemia and myocardial ischaemia in Calabar, Nigeria

Background In children with sickle cell anaemia (SCA), ischaemic electrocardiogram (ECG) changes occur during both vaso-occlusive crises (VOC) and the steady state. Myocardial ischaemia evidenced by an ischaemic pattern on ECG may lead to myocardial injury which is evidenced by elevated serum cardiac troponin T (cTnT). Occasionally, the myocardial injury is fatal. Aim To determine the relationship between raised serum cTnT levels and an ischaemic ECG pattern in children with SCA. Methods This was a dual study design comprising a prospective cohort study of a group of children with SCA observed during VOC and 6 weeks later during follow-up steady state, and a case-control study of SCA children and apparently healthy children. The subjects were 34 SCA children aged 5-17 years and 34 age- and sex-matched apparently healthy controls with haemoglobin genotype AA attending University of Calabar Teaching Hospital. VOC was diagnosed by clinical examination and a history of bone pain. During VOC and follow-up steady state, an ECG was performed and blood taken for serum cTnT estimation. In the apparently healthy children, only serum cTnT was estimated. Serum cTnT was analysed by electrochemiluminescence immune-assay. Ischaemic ECG was assessed using the World Heart Federation criteria. Results Twenty-eight (82.4%) SCA children had elevated serum cTnT during VOC and it was elevated in only six (17.6%) of them during the steady state. An ischaemic ECG was observed in 25 (73.5%) and 20 (58.8%) of them during VOC and the steady state, respectively. Ischaemic ECG identified SCA children with elevated cTnT during VOC (sensitivity 75%, specificity 33.3%) and the follow-up steady state (sensitivity 50%, specificity 39.3%). Measures of agreement between ECG and cTnT in detecting myocardial injury were poor during VOC (κ 0.07, p = 0.68) and the follow-up steady state (κ - 0.06, p = 0.63). Conclusions Most SCA children have an ischaemic ECG with elevated serum cTnT, especially during VOC, which suggests ischaemic-induced cardiac injury. However, elevated serum cTnT can occur without an ischaemic ECG and vice versa. Performing only electrocardiography or cTnT to detect ischaemia-induced cardiac injury may be misleading. Therefore, when there is a high index of suspicion, both tests should be undertaken, especially during VOC, to ensure prompt, effective treatment. Abbreviations AHC, apparently healthy children; AUC, area under the ROC curve; BMI, body mass index; cTnT, cardiac troponin T; ECG, electrocardiogram; EDTA, ethylene diamine tetra-acetic acid; GFR, glomerular filtration rate; HbS, haemoglobin S; HLA, human leucocyte antigen; LVH, left ventricular hypertrophy; ROC, receiver operating characteristic; SCA, sickle cell anaemia; UCTH, University of Calabar Teaching Hospital; URL, upper reference limit; USFDA, United States Food and Drug Administration; USNIH, United States National Institutes of Health; VOC, vaso-occlusive painful crisis; WHF, World Heart Federation.

Cardiac changes in children hospitalized with severe acute malnutrition: A prospective study at tertiary care center of northern India

Severe acute malnutrition (SAM) may affect cardiac structure and function. Cardiac changes in sick children with SAM have received little attention in the literature. Children aged 6–60 months with SAM were cases, and age and sex matched children were controls. Cardiac biomarker levels were measured by the quantitative the Enzyme- linked immunosorbent assay (ELISA) method, and echocardiography was used to assess cardiac changes in all children. The study included 76 children in each group. Children with SAM had less left ventricular mass and increased myocardial performance index as compared with controls (p < 0.0001). Cardiac biomarker levels were increased in children with SAM (p < 0.0001). Cardiac changes and biomarker levels were comparable in children with edema and children without edema except creatine kinase-MB (p = 0.01).

Assessment of left ventricular systolic and diastolic functions in severely malnourished children

Background

Malnourished children endure many changes in body composition and lose heart and skeletal muscle mass. Diastolic dysfunction is one of the major causes of heart failure with preserved ejection fraction.

Aim

To assess left ventricular systolic and diastolic functions in children with severe acute malnutrition using tissue Doppler imaging technique and to evaluate the effect of nutritional rehabilitation.

Patients and Methods

A follow-up case-control study conducted on 60 severely malnourished children (WHZ < -3SD) and 120 age and sex-matched healthy children as a control group. Tissue Doppler imaging (TDI) was done for all included malnourished children at admission and for control to measure left ventricular systolic and diastolic functions. Nutritional rehabilitation was done according to WHO protocol and tissue doppler was repeated after rehabilitation when (WHZ > -2SD) to detect any changes in systolic or diastolic functions.

Results

Systolic function was normal in malnourished children and control. Grade I diastolic dysfunction was detected in 40% and grade II in 30% of severely malnourished children in comparison to 100% normal diastolic function in control group. No correlations between diastolic dysfunction and either anthropometric measurements, electrolyte disturbances or Hb% in malnourished children before nutritional rehabilitation. Mortality from sepsis with associated ventricular dysfunction grade II documented in 3.3% of malnourished children. After nutritional rehabilitation diastolic function improved significantly as 65.6% of children attained normal diastolic function, 31% grade1 and 3.4% grade II. Positive correlations between diastolic function and WAZ, HAZ, WHZ and MUAC after rehabilitation.

Conclusion

Severe acute malnutrition affects diastolic function in children which is reversible in most of these cases with rehabilitation. TDI is an easy and practical method for detection and follow-up of ventricular function in malnourished children.

Cardiac evaluation in children with malnutrition

AIM

The main purpose of this study was to identify myocardial changes in malnourished children.

MATERIAL AND METHODS

This prospective study included 47 patients with malnutrition and 44 healthy controls. The subjects who had malnutrition were classified according to the method of Gomez and Waterlow. Electrocardiographic and echocardiographic examinations, 24-h Holter monitoring, and biochemical assessments were performed in all subjects.

RESULTS

The malnutrition group included 20 (42.5%) males, and the control group included 19 (43.1%) males (p<0.05). There was no difference between the malnutrition and control groups with regard to mean age (69.4±57.3 months and 68.9±48.2 months, respectively, p=0.5). Although the left ventricular mass was lower in the patient group compared with the control group, the left ventricular mass index was not different (42.3±24.5 g, 53.4±23.9 g, p=0.049 and 60.7±13.3 g/m2, 61.9±12.1 g/m2, p=0.67, respectively). The left ventricular ejection fraction and fractional shortening were lower in the patient group compared with the control group (66.2±5.3%, 69.2±4.07%, p=0.04 and 35.4±4.2%, 37.9±3.4%, p=0.03, respectively). The myocardial performance index was higher in the patient group (0.45±0.09, 0.36±0.05, respectively, p=0.001). The deterioration of cardiac functions was associated with the severity and duration of malnutrition. Troponin concentrations were not elevated in any patients. The corrected QT dispersion was significantly higher in patients with malnutrition (47.9±16.8, 32.9±10.6, respectively, p=0.001). Complex ventricular arrhythmias were not noted in any patients.

CONCLUSION

The malnourished children in this study exhibited impairment in the functions of cardiac contraction including mainly systolic functions and in cardiac conduction system. Cardiac morbidity and mortality can be prevented by early detection and treatment of malnutrition in these patients.

Evaluation of Baseline Cardiac Function by Echocardiography and its Association With Nutritional Status in Pediatric Cancer Patients at The Indus Hospital in Karachi, Pakistan

INTRODUCTION

Evidence on conducting baseline echocardiogram before starting chemotherapy in pediatric cancer patients is limited from developing countries where malnutrition and infections are common and which may result in cardiac dysfunction.

MATERIALS AND METHODS

A prospective, observational study was conducted from October 2016 to May 2017 at The Indus Hospital, Karachi, Pakistan, among children 1 to 16 years of age suffering from cancer. Echocardiography was performed before starting chemotherapy. Associations between body mass index and cardiac abnormalities were studied.

RESULTS

A total of 384 children met the inclusion criteria. The median (interquartile range) age was 8.0 (5.0 to 12.0) years and 62.0% (n=238) were male individuals. Twenty-two of 384 (5.7%) children had systolic dysfunction. Four of 22 had moderate-systolic and one of 22 had mild systolic dysfunction, for whom the therapy was altered, and they were treated without anthracyclines. Four of these 5 patients died, and only 1 of 5 survived through high-risk protocol. Seventeen of 22 children had low-normal systolic dysfunction. We found no evidence of an association between body mass index for age and abnormal left ventricular ejection fraction and abnormal fractional shortening (P-trend=0.587; 0.487, respectively). No associations were found of weight-for-age and height-for-age with these outcomes.

CONCLUSIONS

In developing countries, echocardiograms should be expeditiously performed and technology made more accessible to rule out cardiac dysfunction and avoid delay in chemotherapy. Malnutrition was not associated with cardiac dysfunction.

Study of NT-proBNP and Hs-Troponin I biomarkers for early detection of children's heart function of proteinenergy malnutrition

The Protein Energy Malnutrition (PEM) is the condition of a lack of carbohydrate and protein stores in the body that trigger chronic failure nutrient intake and body maintenance function caused to impact the heart functions. The NT-pro-BNP and Hs- Troponin I proteins were found as the indicator of cardiac dysfunction. The sixty subjects of PEM, analyzed by standard of Indonesia Healt Ministry as well as nutritional status. The blood electrolytes examined by laboratory assay and the levels of Hs-Troponin 1 and NT-Pro-BNP were analyzed by Immune-Chromatography method. Assessing of the ventricular mass with the seeing the peak of the diastolic flow rate of left ventricular that estimated by the curve of the receiver operating characteristic and the area under the curve (P<0.05). The result has shown that the PEM decreased in the left ventricular mass for impaired heart function and systolic disorder. The Hs- Troponin I (90.9%) has better sensitivity than NT-pro-BNP (85.5%) if the merger of those markers possesses the lowest sensitivity (81.8%). These proteins have good biomarkers in heart function, mainly in cases where PEM is present.

Cardiac changes in moderately malnourished children and their correlations with anthropometric and electrolyte changes

OBJECTIVE

To evaluate electrocardiographic and echocardiographic changes in moderately malnourished children and to correlate them with both anthropometric and electrolyte changes.

PATIENTS AND METHOD

Sixty moderately malnourished children were taken as patient group, and 60 healthy children of matched age and sex were taken as control group. Weight, height, body mass index (BMI), serum albumin, and electrolytes were measured for all children. Electrocardiographic evaluation for calculated QT (QTc) and QT dispersion (QTd) was performed. Left ventricular (LV) function was also evaluated using conventional echocardiography, tissue Doppler, and strain methods. Left ventricular mass index (LVMI) was also calculated.

RESULTS

Weight, BMI, serum levels of albumin, total calcium, and ionized calcium were significantly lower, while QTc and QTd were significantly prolonged in malnourished children (P = .001 for all). There was significant reduction in LV fraction shortening (FS), LV E'/A', LV strain (S), LV myocardial performance index (MPI), LV global systolic strain (GLSS), and LVMI (P = .001 for all) in malnourished children. There was significant correlation between BMI and all cardiac variables. Moreover, there was significant positive correlation between serum albumin level and LV E'/A' (P = .02), LV GLSS (P = .03), and LVMI (P = .03).Total and ionized calcium level were significantly correlated with QTc, QTd, and LVMI (P < .05 for all). BMI was the most powerful predictor of these electrocardiographic and echocardiographic changes.

CONCLUSION

Cardiac changes were present in moderately malnourished children as documented by electrocardiographic and echocardiographic changes, and these changes are in strong association with BMI and for a lesser extent with electrolyte changes especially serum calcium.

Myocardial and haemodynamic responses to two fluid regimens in African children with severe malnutrition and hypovolaemic shock (AFRIM study)

BACKGROUND

Fluid therapy in severely malnourished children is hypothesized to be deleterious owing to compromised cardiac function. We evaluated World Health Organization (WHO) fluid resuscitation guidelines for hypovolaemic shock using myocardial and haemodynamic function and safety endpoints.

METHODS

A prospective observational study of two sequential fluid management strategies was conducted at two East African hospitals. Eligible participants were severely malnourished children, aged 6-60 months, with hypovolaemic shock secondary to gastroenteritis. Group 1 received up to two boluses of 15 ml/kg/h of Ringer's lactate (RL) prior to rehydration as per WHO guidelines. Group 2 received rehydration only (10 ml/kg/h of RL) up to a maximum of 5 h. Comprehensive clinical, haemodynamic and echocardiographic data were collected from admission to day 28.

RESULTS

Twenty children were enrolled (11 in group 1 and 9 in group 2), including 15 children (75%) with kwashiorkor, 8 (40%) with elevated brain natriuretic peptide >300 pg/ml, and 9 (45%) with markedly elevated median systemic vascular resistance index (SVRI) >1600 dscm-5/m2 indicative of severe hypovolaemia. Echocardiographic evidence of fluid-responsiveness (FR) was heterogeneous in group 1, with both increased and decreased stroke volume and myocardial fractional shortening. In group 2, these variables were more homogenous and typical of FR. Median SVRI marginally decreased post fluid administration (both groups) but remained high at 24 h. Mortality at 48 h and to day 28, respectively, was 36% (4 deaths) and 81.8% (9 deaths) in group 1 and 44% (4 deaths) and 55.6% (5 deaths) in group 2. We observed no pulmonary oedema or congestive cardiac failure on or during admission; most deaths were unrelated to fluid interventions or echocardiographic findings of response to fluids.

CONCLUSION

Baseline and cardiac response to fluid resuscitation do not indicate an effect of compromised cardiac function on response to fluid loading or that fluid overload is common in severely malnourished children with hypovolaemic shock. Endocrine response to shock and persistently high SVRI post fluid-therapy resuscitation may indicate a need for further research investigating enhanced fluid volumes to adequately correct volume deficit. The adverse outcomes are concerning, but appear to be unrelated to immediate fluid management.

A pediatric echocardiographic Z-score nomogram for a developing country: Indian pediatric echocardiography study - The Z-score

Background:

Almost all presently available pediatric echocardiography Z-score nomograms are based on Western data. They may not be a suitable reference standard for assessing the sizes of cardiac structures of children from developing countries.

Objective:

This study's objective was to collect normative data of 21 commonly measured cardiovascular structures using M-mode and two-dimensional echocardiography in Indian children aged between 4 and 15 years and to derive Z-score nomograms for each.

Subjects and Methods:

The study was conducted at two centers in India - Ajmer, Rajasthan, and Mohali, Punjab. We studied a community-based sample involving healthy school going children. After excluding children with cardiovascular abnormalities on the screening echocardiogram, 746 children were included in the final analysis. Echocardiographic assessment was performed using a Philips iE33 system.

Results and Analysis:

For each parameter measured, seven models were evaluated to assess the relationship of that parameter with the body surface area and the one with the best fit was used to plot the Z-score chart for that parameter. Z score charts were thus derived.

Conclusions:

The Z-score nomograms derived by this study may be better alternatives to the Western nomograms for use in India and other developing countries for preprocedural decision making in the pediatric population. However, they will require validation in large-scale studies before they can become clinically applicable.

Dilated Cardiomyopathy Induced by Chronic Starvation and Selenium Deficiency

Protein energy malnutrition (PEM) has been rarely documented as a cause of cardiovascular abnormalities, including dilated cardiomyopathy. Selenium is responsible for antioxidant defense mechanisms in cardiomyocytes, and its deficiency in the setting of PEM and disease related malnutrition (DRM) may lead to exacerbation of the dilated cardiomyopathy. We report a rare case of a fourteen-year-old boy who presented with symptoms of congestive heart failure due to DRM and PEM (secondary to chronic starvation) along with severe selenium deficiency. An initial echocardiogram showed severely depressed systolic function consistent with dilated cardiomyopathy. Aggressive nutritional support and replacement of selenium and congestive heart failure medications that included diuretics and ACE inhibitors with the addition of carvedilol led to normalization of the cardiac function within four weeks. He continues to have significant weight gain and is currently completely asymptomatic from a cardiovascular standpoint.

Double-Blind Randomized Clinical Trial Comparing Dopamine and Epinephrine in Pediatric Fluid-Refractory Hypotensive Septic Shock

OBJECTIVE

We compared efficacy of dopamine and epinephrine as first-line vasoactive therapy in achieving resolution of shock in fluid-refractory hypotensive cold septic shock.

DESIGN

Double-blind, pilot, randomized controlled study.

SETTING

Pediatric emergency and ICU of a tertiary care teaching hospital.

PATIENTS

Consecutive children 3 months to 12 years old, with fluid-refractory hypotensive septic shock, were enrolled between July 2013 and December 2014.

INTERVENTION

Enrolled children were randomized to receive either dopamine (in incremental doses, 10 to 15 to 20 μg/kg/min) or epinephrine (0.1 to 0.2 to 0.3 μg/kg/min) till end points of resolution of shock were achieved. After reaching maximum doses of test drugs, open-label vasoactive was started as per discretion of treating team. Primary outcome was resolution of shock within first hour of resuscitation. The study was registered (CTRI/2014/02/004393) and was approved by institute ethics committee.

MEASUREMENTS AND MAIN RESULTS

We enrolled 29 children in epinephrine group and 31 in dopamine group. Resolution of shock within first hour was achieved in greater proportion of children receiving epinephrine (n = 12; 41%) than dopamine (n = 4; 13%) (odds ratio, 4.8; 95% CI, 1.3-17.2; p = 0.019); the trend persisted even at 6 hours (48.3% vs 29%; p = 0.184). Children in epinephrine group had lower Sequential Organ Function Assessment score on day 3 (8 vs 12; p = 0.05) and more organ failure-free days (24 vs 20 d; p = 0.022). No significant difference in adverse events (16.1% vs 13.8%; p = 0.80) and mortality (58.1% vs 48.3%; p = 0.605) was observed between the two groups.

CONCLUSION

Epinephrine is more effective than dopamine in achieving resolution of fluid-refractory hypotensive cold shock within the first hour of resuscitation and improving organ functions.

Higher protein intake increases cardiac function parameters in healthy children: metabolic programming by infant nutrition-secondary analysis from a clinical trial

BACKGROUND

Protein intake may modulate cardiac structure and function in pathological conditions, but there is a lack of knowledge on potential effects in healthy infants.

METHODS

Secondary analysis of an ongoing randomized clinical trial comparing two groups of infants receiving a higher (HP) or lower (LP) protein content formula in the first year of life, and compared with an observational group of breastfed (BF) infants. Growth and dietary intake were assessed periodically from birth to 2 y. Insulin-like growth factor 1 (IGF-1) axis parameters were analyzed at 6 mo in a blood sample. At 2 y, cardiac mass and function were assessed by echocardiography.

RESULTS

HP infants (n = 50) showed a higher BMI z-score at 2 y compared with LP (n = 47) or BF (n = 44). Cardiac function parameters were increased in the HP group compared with the LP and were directly related to the protein intake during the first 6 mo of life. Moreover, there was an increase in free IGF-1 in the HP group at 6 mo.

CONCLUSION

A moderate increase in protein supply during the first year of life is associated with higher cardiac function parameters at 2 y. IGF-1 axis modifications may, at least in part, underlie these effects.

Effects of Malnutrition on Left Ventricular Mass in a North-Malagasy Children Population

Background

Malnutrition among children population of less developed countries is a major health problem. Inadequate food intake and infectious diseases are combined to increase further the prevalence. Malnourishment brings to muscle cells loss with development of cardiac complications, like arrhythmias, cardiomyopathy and sudden death. In developed countries, malnutrition has generally a different etiology, like chronic diseases. The aim of our study was to investigate the correlation between malnutrition and left ventricular mass in an African children population.

Methods

313 children were studied, in the region of Antsiranana, Madagascar, with age ranging from 4 to 16 years old (mean 7,8 ± 3 years). A clinical and echocardiographic evaluation was performed with annotation of anthropometric and left ventricle parameters. Malnutrition was defined as a body mass index (BMI) value age- and sex-specific of 16, 17 and 18,5 at the age of 18, or under the 15^th percentile. Left ventricle mass was indexed by height^2.7 (LVMI).

Results

We identified a very high prevalence of children malnutrition: 124 children, according to BMI values, and 100 children under the 15^th percentile. LVMI values have shown to be increased in proportion to BMI percentiles ranging from 29,8 ± 10,8 g/m^2.7 in the malnutrition group to 45 ± 15,1 g/m^2.7 in >95^th percentile group. LVMI values in children < 15^th BMI percentile were significantly lower compared to normal nutritional status (29,8 ± 10,8 g/m^2,7 vs. 32,9 ± 12,1 g/m^2,7, p = 0.02). Also with BMI values evaluation, malnourished children showed statistically lower values of LVMI (29,3 ± 10,1 g/m^2,7 vs. 33,6 ± 12,5 g/m^2,7, p = 0.001).

Conclusion

In African children population, the malnourishment status is correlated with cardiac muscle mass decrease, which appears to be reduced in proportion to the decrease in body size.

Early Programming by Protein Intake: The Effect of Protein on Adiposity Development and the Growth and Functionality of Vital Organs

This article reviews the role of protein intake on metabolic programming early in life. The observations that breastfeeding in infancy reduces the risk of being overweight and obese later in life and the differences in the protein content between formula milk and human milk have generated the early protein hypothesis. The present review focuses on a mechanistic approach to programmed adiposity and the growth and development of other organs by protein intake in infancy, which may be mediated by branched-chain amino acids, insulin, and insulin-like growth factor 1 via the mammalian target of rapamycin. Observational studies and clinical trials have shown that lowering the protein content in infant and follow-on formulas may reduce the risk of becoming obese later in life. The recent body of evidence is currently being translated into new policies. Therefore, the evolution of European regulatory laws and recommendations by expert panels on the protein content of infant and follow-on formulas are also reviewed. Research gaps, such as the critical window for programming adiposity by protein intake, testing formulas with modified amino acids, and the long-term consequences of differences in protein intake on organ functionality among well-nourished infants, have been identified.

Cardiac Dysfunction in a Porcine Model of Pediatric Malnutrition

BACKGROUND

Half a million children die annually of severe acute malnutrition and cardiac dysfunction may contribute to the mortality. However, cardiac function remains poorly examined in cases of severe acute malnutrition.

OBJECTIVE

To determine malnutrition-induced echocardiographic disturbances and longitudinal changes in plasma pro-atrial natriuretic peptide and cardiac troponin-T in a pediatric porcine model.

METHODS AND RESULTS

Five-week old piglets (Duroc-x-Danish Landrace-x-Yorkshire) were fed a nutritionally inadequate maize-flour diet to induce malnutrition (MAIZE, n = 12) or a reference diet (AGE-REF, n = 12) for 7 weeks. Outcomes were compared to a weight-matched reference group (WEIGHT-REF, n = 8). Pro-atrial natriuretic peptide and cardiac troponin-T were measured weekly. Plasma pro-atrial natriuretic peptide decreased in both MAIZE and AGE-REF during the first 3 weeks but increased markedly in MAIZE relative to AGE-REF during week 5-7 (p ≤ 0.001). There was overall no difference in plasma cardiac troponin-T between groups. However, further analysis revealed that release of cardiac troponin-T in plasma was more frequent in AGE-REF compared with MAIZE (OR: 4.8; 95%CI: 1.2-19.7; p = 0.03). However, when release occurred, cardiac troponin-T concentration was 6.9-fold higher (95%CI: 3.0-15.9; p < 0.001) in MAIZE compared to AGE-REF. At week 7, the mean body weight in MAIZE was lower than AGE-REF (8.3 vs 32.4 kg, p < 0.001), whereas heart-weight relative to body-weight was similar across the three groups. The myocardial performance index was 86% higher in MAIZE vs AGE-REF (p < 0.001) and 27% higher in MAIZE vs WEIGHT-REF (p = 0.025).

CONCLUSIONS

Malnutrition associates with cardiac dysfunction in a pediatric porcine model by increased myocardial performance index and pro-atrial natriuretic peptide and it associates with cardiac injury by elevated cardiac troponin-T. Clinical studies are needed to see if the same applies for children suffering from malnutrition.

Severe Sepsis in Severely Malnourished Young Bangladeshi Children with Pneumonia: A Retrospective Case Control Study

BACKGROUND

In developing countries, there is no published report on predicting factors of severe sepsis in severely acute malnourished (SAM) children having pneumonia and impact of fluid resuscitation in such children. Thus, we aimed to identify predicting factors for severe sepsis and assess the outcome of fluid resuscitation of such children.

METHODS

In this retrospective case-control study SAM children aged 0-59 months, admitted to the Intensive Care Unit (ICU) of the Dhaka Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh from April 2011 through July 2012 with history of cough or difficult breathing and radiologic pneumonia, who were assessed for severe sepsis at admission constituted the study population. We compared the pneumonic SAM children with severe sepsis (cases = 50) with those without severe sepsis (controls = 354). Severe sepsis was defined with objective clinical criteria and managed with fluid resuscitation, in addition to antibiotic and other supportive therapy, following the standard hospital guideline, which is very similar to the WHO guideline.

RESULTS

The case-fatality-rate was significantly higher among the cases than the controls (40% vs. 4%; p<0.001). In logistic regression analysis after adjusting for potential confounders, lack of BCG vaccination, drowsiness, abdominal distension, acute kidney injury, and metabolic acidosis at admission remained as independent predicting factors for severe sepsis in pneumonic SAM children (p<0.05 for all comparisons).

CONCLUSION AND SIGNIFICANCE

We noted a much higher case fatality among under-five SAM children with pneumonia and severe sepsis who required fluid resuscitation in addition to standard antibiotic and other supportive therapy compared to those without severe sepsis. Independent risk factors and outcome of the management of severe sepsis in our study children highlight the importance for defining optimal fluid resuscitation therapy aiming at reducing the case fatality in such children.

Malnutrition and Cachexia in Heart Failure

Heart failure is a growing public health concern. Advanced heart failure is frequently associated with severe muscle wasting, termed cardiac cachexia This process is driven by systemic inflammation and tumor necrosis factor in a manner common to other forms of disease-related wasting seen with cancer or human immunodeficiency virus. A variable degree of malnutrition is often superimposed from poor nutrient intake. Cardiac cachexia significantly decreases quality of life and survival in patients with heart failure. This review outlines the evaluation of nutrition status in heart failure, explores the pathophysiology of cardiac cachexia, and discusses therapeutic interventions targeting wasting in these patients.

Severe acute malnutrition and infection

Severe acute malnutrition (SAM) is associated with increased severity of common infectious diseases, and death amongst children with SAM is almost always as a result of infection. The diagnosis and management of infection are often different in malnourished versus well-nourished children. The objectives of this brief are to outline the evidence underpinning important practical questions relating to the management of infectious diseases in children with SAM and to highlight research gaps. Overall, the evidence base for many aspects covered in this brief is very poor. The brief addresses antimicrobials; antipyretics; tuberculosis; HIV; malaria; pneumonia; diarrhoea; sepsis; measles; urinary tract infection; nosocomial Infections; soil transmitted helminths; skin infections and pharmacology in the context of SAM. The brief is structured into sets of clinical questions, which we hope will maximise the relevance to contemporary practice.

The immune system in children with malnutrition--a systematic review

BACKGROUND

Malnourished children have increased risk of dying, with most deaths caused by infectious diseases. One mechanism behind this may be impaired immune function. However, this immune deficiency of malnutrition has not previously been systematically reviewed.

OBJECTIVES

To review the scientific literature about immune function in children with malnutrition.

METHODS

A systematic literature search was done in PubMed, and additional articles identified in reference lists and by correspondence with experts in the field. The inclusion criteria were studies investigating immune parameters in children aged 1-60 months, in relation to malnutrition, defined as wasting, underweight, stunting, or oedematous malnutrition.

RESULTS

The literature search yielded 3402 articles, of which 245 met the inclusion criteria. Most were published between 1970 and 1990, and only 33 after 2003. Malnutrition is associated with impaired gut-barrier function, reduced exocrine secretion of protective substances, and low levels of plasma complement. Lymphatic tissue, particularly the thymus, undergoes atrophy, and delayed-type hypersensitivity responses are reduced. Levels of antibodies produced after vaccination are reduced in severely malnourished children, but intact in moderate malnutrition. Cytokine patterns are skewed towards a Th2-response. Other immune parameters seem intact or elevated: leukocyte and lymphocyte counts are unaffected, and levels of immunoglobulins, particularly immunoglobulin A, are high. The acute phase response appears intact, and sometimes present in the absence of clinical infection. Limitations to the studies include their observational and often cross-sectional design and frequent confounding by infections in the children studied.

CONCLUSION

The immunological alterations associated with malnutrition in children may contribute to increased mortality. However, the underlying mechanisms are still inadequately understood, as well as why different types of malnutrition are associated with different immunological alterations. Better designed prospective studies are needed, based on current understanding of immunology and with state-of-the-art methods.