ORIGINAL

Niger J Paed 2013; 40 (4): 375 –378

Sadoh WE

Atimati AO

Serum vitamin A and other

nutritional parameters in children

with congenital heart disease

DOI:http://dx.doi.org/10.4314/njp.v40i4,5

Accepted: 1st March 2013

Abstract Objective: To compare

the weight for age, the serum al-

bumin and vitamin A of children

with congenital heart disease

Fifteen (39.5 %) subjects had

bronchopneumonia while 14/38

(36.8 %) and 4/36(11.1 %) sub-

jects and controls respectively

were undernourished, p = 0.014.

The mean serum vitamin A values

in subjects 0.86 ± 0.13 mmol/l and

controls 0.87 ± 0.16 mmol/l was

not significantly different, P =

0.76. Serum albumin of subjects

and controls were 3.5 ± 0.5 and 3.6

± 0.43 respectively, p = 0.60

Conclusion: There was no signifi-

cant difference in serum vitamin A

and albumin in subjects and con-

trols. However, significantly more

children with CHD than controls

were undernourished.

(

)

Sadoh WE

Atimati AO

Department of Child Health,

University of Benin Teaching Hospital,

PMB 1111, Benin City.

E-mail: sadohehi@yahoo.com

Tel: +2348028809710

(

CHD) with those of age and sex

matched controls without CHD.

Methods: Consecutive children

diagnosed to have CHD by echo-

cardiography who were afebrile

two weeks prior were recruited.

Subjects who had bronchopneu-

monia were noted. Their weights,

haematocrit, serum albumin and

vitamin A were measured. Vari-

ables were compared between

subjects and controls. Vitamin A

was measured by high perform-

ance chromatography.

Results: Thirty eight subjects

with mean age of 3.6 ± 4.3 years

and 40 controls with mean age of

Keywords: congenital heart dis-

ease; vitamin A; serum albumin;

3

.6 ± 4.8 years were recruited.

Introduction

and Transposition of the great arteries) typically present

with cyanosis while acyanotic heart defects (e.g Ven-

tricular septal defect, Atrial septal defect, Pulmonary

stenosis) do not normally manifest with cyanosis.

Congenital heart diseases (CHD) are manifestations of

abnormal cardiovascular embryogenesis resulting in

variable degrees of circulatory dysfunction. The preva-

lence of CHD is between 3 and 10 per 1,000 live

Children with CHD have impaired growth and develop-

ment as shown in higher prevalence of underweight and

severe malnutrition compared to their controls without

1

,2

births. Congenital heart diseases is a common cause of

morbidity and mortality and poses economic challenge

to both the affected families and the Nation as the medi-

cal costs associated with its management are substantial.

This is more so in developing countries where access to

7

CHD. Other complications of CHD include, congestive

heart failure, proneness to infection, mostly pneumonia

and₇_,₈occasionally infective endocarditis amongst oth-

ers. Congenital heart disease have been associated

with recurrent episodes of pneumonia in children, it is

ranked third and is responsible for 9.2%₉of causes of

recurrent pneumonia in children in Toronto.

3

treatment is poor. Congenital heart disease account for

more than one-third of infant deaths due to congenital

anomal₄ies and approximately one-tenth of all infant

deaths. Without appropriate treatment, about half of

those born with haemodynamically significant congeni-

tal heart disease will die in infancy or early₅ childhood, a

third of them within the first month of life.

Infections, especially when severe have been associated

9

with loss of vitamin A from body stores. Helminthic

infestations, diarrhoea and respiratory infections such as

pneumo₁n₀i_,a₁₁and malnutrition are most notable in this

The aetiology of majority of CHD is multifactorial,

which include chromosomal anomalies, single-gene dis-

orders and teratogens which account for about 15% of

cases. The CHD can broadly be classified into cyanotic

heart defects (e.g Tetralogy of Fallot, Truncus arteriosus

regards.

Conversely, deficiency of vitamin A has

been associated with pr₁o₂neness to infection including

pneumonias. Reyes et al reported a 17.8% prevalence

rate of vitamin A deficiency among children less than 5

6

3

76

0

years with community acquired pneumonia in Mexico.

Children with CHD who are prone to recurrent pneumo-

nias and impaired growth and development might be at

risk of developing vitamin A and other nutritional defi-

ciencies. This study aims at comparing the vitamin A

stored in a freezer at a temperature of -4 . Once recruit-

ment was completed, retinol analysis was done₅using

1

high performance liquid chromatography method. The

analysis was done by a laboratory scientist.

(

serum retinol) status and other nutritional parameters of

Statistical analysis

children with congenital heart disease with those of age

and sex matched controls.

The data were analyzed with SPSS version 16.0. IL

Chicago. The means of continuous variable such as age,

weight, and height and serum retinol were compared

with student’s t test, multiple means were compared

with one way ANOVA. The association between non

parametric variables was tested with Pearson’s chi

square test. Statistically significant p value was taken as

<0.05.

Subjects and Materials

The study was carried out in the Paediatric Cardiology

out- patient clinic of the University of Benin Teaching,

Benin City, Nigeria. The subjects were consecutive

clinically stable children with congenital heart disease

(

CHD) attending the clinic with an inclusion criterion

that the last febrile illness was at least two weeks before

the day of recruitment. The study was conducted over

six months, from March to August 2012. Ethical ap-

proval was obtained from the University of Benin

Teaching Hospital Ethics Committee. An informed ver-

bal consent was obtained from the accompanying parent

Result

There were 38 subjects and aged between 6 weeks and

18 years while their weight ranged between 3 and 50 kg.

The controls were 41 children without CHD, aged be-

tween 6 weeks and 19 years with a weight range of 3 –

61 Kg. All the 64(81%) subjects and controls who were

old enough to receive vitamin A, had received it. Of the

38 subjects, 14(36.8 %) were undernourished while 24

(63.2 %) were well nourished. Data on weight was avail-

able for 36(90%) of the 40 controls. Only 4(11.1 %) of

the 36 controls were undernourished and 32(88.9 %)

were well nourished. The difference in the nutritional

status between the subjects and controls was statistically

significant, p = 0.014. None of the subject or control

was overweight. The other characteristics of the subjects

and controls are shown in table 1.

(

s) or caregivers. The diagnosis of the CHD was made

on clinical ground, typical findings on chest radiograph

and electrocardiogram. The diagnosis was confirmed on

echocardiography done by one of the investigators

(

WES). The controls were age and sex matched children

either attending or accompanying their parents to the

immunization clinic and patients who were being fol-

lowed up in the clinics for illnesses such as malaria,

pharyngitis and acute otitis media. In all cases, fever

would have resolved at least two weeks prior to the day

of recruitment. The controls also had echocardiography

to exclude CHD.

The subjects who also had chronic heart failure were

placed on hydrochlorthiazide and spironolactone. Capto-

pril and Digoxin were included in severe cases. It was

documented if the patient had bronchopneumonia within

two to four weeks prior to recruitment. The subjects

were being seen on a monthly clinic schedule to other

time interval as deemed appropriate. Other treatments

were offered as required. A proforma was used to collect

information on biodata, socioeconomic class (SEC) and

the presence and time since last febrile illness. The SEC

was de₃termined by the methods described by Olusanya

Table 1: Socio-demographic characteristics of study

Population

Characteristics

Subject

Control

P value

0.97

Mean Age (year)

Mean wt (kg)

Gender

3.6 ± 4.3

13.3 ± 10.8 14.4 ± 13.1 0.68

3.6 ± 4.8

Male

Female

18

20

21

20

0.73

0.72

Socioeconomic status

High

Middle

14

12

16

13

1

Low

et al. It was noted if the patient had cyanotic or

acyanotic CHD.

Most of the subjects 28(73.7 %) had acyanotic CHD

while 10(26.3 %) had cyanotic CHD. The types of CHD

in the subjects are shown in table 2. Fifteen (39.5 %) of

the subjects had bronchopneumonia within two to four

weeks prior to recruitment.

The PCV of the subjects ranged from 27 – 78%, with a

mean of 44.2 ± 13.6%. The mean PCV of the subjects

with acyanotic CHD and cyanotic CHD were 34.0 ± 4. 3

The patients’ weight was measured using a bassinet

weighing scale for infant and an appropriate weighing

scale for older children, using standard methods. The Z

scores of the weight for age were c₄omputed using the

1

WHO growth charts for children. Malnutrition was

defined thus; children with z scores < -2 SD were under-

nourished, well nourished children were those with Z

score between -2 and +2 SD and overweight children

had z scores > +2 SD.

Following aseptic procedures, 3 ml of blood was drawn

from each patient, it was spun, the serum decanted and

%

and 60.8 ± 10.7 % respectively. The difference was

statistically significant, P = 0.<0.0001 (CI = 23.09 to

0.51). The PCV of the controls was 36.5 ± 5.1%.

3

77

Table 2: Type of congenital heart disease in subjects

This finding also indicates that the studied children may

have had adequate dietary sources of vitamin A. Most

cereals available for the infants are fortified with vita-

min A and other micronutrients. Nigeria has in place

regulations to fortify₁₆cooking oils, sugar, and cereal

flour with vitamin A. The older children, who are on

adult diet, may consume palm oil which is a common

constitu₁₇ent of their diet and is known to be rich in vita-

min A.

Type of CHD

Number

%

Isolated VSD

VSD and ASD

VSD and PDA

TOF

AVSD

Isolated ASD

TA

17

1

2

7

5

44.7

2.6

5.2

18.4

13.2

5.2

2

5.2

TGA

1

2.6

Isolated PDA

1

2.6

However, the subjects who also had bronchopneumonia

had significantly lower mean retinol value compared to

subjects without pneumonia. In pneumonia, retinol val-

ues are known to be depleted. Pneumonia has been iden-

VSD = ventricular septal defect, ASD = atrial septal defect, PDA =

patent ductus arteriosus, TOF = tetralogy of Fallot, AVSD = atrio-

ventricular septal defect, TA = truncus arteriosus and TGA = transpo-

sition of great arteries.

tified as one notable disease₀_,₁₁associated with reduced

1

vitamin A in earlier studies.

In situation of recurrent

Table 3 shows the comparison of the PCV, serum albu-

min and retinol between subjects and controls. The PCV

of the controls was significantly higher than that of the

subjects with acyanotic CHD, P = 0.038 (CI = 0.14 to

pneumonia as is known to be associated with CHD with

increased pulmonary blood flow, the repeated reduction

in vitamin A may become significant. In this study,

there were few cases of recurrent pneumonia, and thus

the effect of recurrent pneumonia on vitamin A defi-

ciency could not be adequately evaluated due to the

small sample size. This association would be properly

elucidated in a study involving a larger sample size.

4

.86). There was no significant difference in the levels

of serum retinol and albumin between subjects and

controls. The mean PCV, serum albumin and retinol

values of the subjects who were under nourished, were

not significantly different from those who were well

nourished, see table 4.

In comparing the PCV of the subjects, the PCV of the

children with cyanotic CHD is expected to be higher

than those with acyanotic CHD because of the associ-

ated desaturation and polycythaemia. Thus the PCV of

subjects with acyanotic CHD were compared with the

controls, this was significantly different. It is expected

that since most of the children with CHD compared to

those without CHD were underweight, that their PCV

and other indices of nutrition would be depressed. In

this study, there was no significant difference in the,

serum retinol values between subjects and controls. This

may stem from the receipt of vitamin A supplementation

at six months of age when children present for immuni-

zation and six monthly thereafter until five years of

Table 3: Comparison of mean PCV, serum albumin and

retinol values between the subjects and controls

Characteristics

Subject

Control

P value

Mean serum vitamin A (mmol/l) 0.86 ± 0.13 0.87 ± 0.16

0.76

0.60

Mean serum albumin (mg/dl)

Mean PCV (%)

3.5 ± 0.5

34.0 ± 4.3 36.5 ± 5.1%. 0.038

3.6 ± 0.43

Table 4: Comparison of mean PCV, serum albumin and

retinol values between the malnourished and well nourished

subjects

Characteristics

Undernourished Well nourished P value

1

8

age. In this study, 81% of the studied children had re-

ceived at least the first dose of vitamin A supplementa-

tion. Thus the multiple sources of vitamin A may be

responsible for the normal levels of vitamin A seen in

the subject and controls. The small sample size may also

have contributed to the lack of significant difference in

serum retinol levels in both subjects and controls.

Serum vitamin A (mmol/l) 0.93 ± 0.20

0.84 ± 0.12

3.64 ± 0.47

45.2 ± 15.3

P = 0.14

P = 0.21

P = 0.71

Serum albumin (mg/dl)

PCV (%)

3.45 ± 0.43

42.7 ± 11.72

The difference in serum albumin between the subjects

with bronchopneumonia 3.48 ± 0.40 and those without

bronchopneumonia 3.56 ± 0.51, was not significant,

P = 0.61, (CI = -0.24 to 0.40). However, the mean serum

retinol level in subjects with bronchopneumonia 0.80 ±

The mean serum albumin value in subjects was not sig-

nificantly lo₉wer than in the controls. However in a study

0

.11 mmol/l was significantly lower than the value

obtained in those without Bronchopneumonia 0.93 ±

.19 mmol/l, P = 0.022, (CI = 0.02 to 0.24).

1

in the UK, serum albumin values in children with con-

0

genital heart disease prior to surgical intervention were

lower than normal in 64.6% of cases. It is possible that

the small sample size in this study may have led to the

non significant finding. We acknowledge that the limita-

tion of a small sample size in this study.

Discussion

The mean serum retinol level in children with CHD was

not significantly lower than in those without CHD. This

result indicates that children with CHD on the average

were not vitamin A depleted. Of note is the fact that the

mean serum retinol values in both the subjects and con-

trols were above the value for vitamin A deficiency.

Conclusion

The PCV, serum retinol and albumin values in the chil-

dren with CHD were not significantly different from the

3

78

controls without CHD. There were more malnourished

subjects than controls. However, subjects with pneumo-

nia had significantly lower retinol value than those with-

out pneumonia. Perhaps children with CHD and pneu-

monia may require vitamin A supplementation after

each episode of pneumonia. These children may require

close monitoring to prevent recurrence of pneumonia if

surgical intervention is likely to be delayed.

Authors’ contribution

WES, AOA: Designed the study, involved in data col-

lection, analysis and interpretation, wrote the draft and

approved the final manuscript.

Conflict of interest: None

Funding: None

References

8

.

Patel HT. Basic pathophysiology

In. Essential Pediatric cardiology.

Eds) Koenig P, Hijazi ZM, Zim-

merman F. McGraw-Hill Medical

publishing, London,2004; 77 - 87

Abdullah F, Owayed MD, Douglas

M, et al. Underlying causes of

16. Begin F, Greig A, Food fortifica-

tion in West Africa: Assessment of

opportunities and strategies. Pre-

pared for private-public sector

dialogue on food fortification in

West Africa. Accra, Ghana, Oct

2002. Found at foodafrica.nri.org/

nutrition/internetpapers/

1

2

.

Hoffman JIE. Congenital heart

disease: incidence and inheritance.

Pediatr. Clin. North Am. 1990; 37:

(

2

5 – 43.

Ferencz C, Rubin JD, McCarter

RJ, et al. Congenital heart disease.

Prevalence at live birth. The Balti-

more-Washington infant study. Am

J Epidemiol 1985;121:31-6

Sadoh WE, Nwaneri DU, Owobo

AC. The cost of out-patinet man-

agement of chronic heart failure in

children with congenital heart

9

.

recurrent pneumonia in children.

Arch Pediatr Adolesc Med. 2000;

AlisonGreig.doc (Accessed on

th

1

54: 190 – 194

26 January 2013)

3

4

5

.

1

0. Mitra AK, Alvarez JO, Stephensen

CB. Increased urinary retinol loss

in children with severe infections.

Lancet 1998; 351: 1033 – 1334.

1. Ejaz MS, Latif N. Stunting and

micronutrient deficiency in mal-

nourished children. J Pak Med

Assoc. 2010; 60: 543 – 547.

2. Reyes H, Villalpando S, Perez-

Cuevas R, et al. Frequency and

determinants of vitamin A defi-

ciency in children under five years

of age with pneumonia. Arch Med

Res. 2002; 33: 180 – 185.

3. Olusanya O, Okpere E, Ezimokhai

M. The importance of socioeco-

nomic class in voluntary fertility

control in a developing country W

Afri J Med 1985; 4: 205 – 212

4. WHO. Child growth standards.

Found at www.who.int/entity/

childgrowth/standards/ (Assessed

January 2011)

5. Bieri JG, Tolliver TJ, Catignan

GL. Simultaneous determination of

alpha tocopherol and retinol in

plasma or red cells by high pres-

sure liquid chromatography. Am J

Clin Nutr 1979; 31: 21 - 43

17. Zagre MN, Delpeuch F, Traissac P,

Delisle H. Red palm oil as a source

of vitamin A for mothers and chil-

dren: impact of a pilot study in

Burkina Faso. Public Health Nutr

2003; 6: 733 - 42

18. National Primary Health Care De-

velopment Agency. National Im-

munization Policy. Revised 2009.

Available at http://

disease. Nig J Clin Pract 2011; 14:

6

5 – 69

Rosano A, Botto LD, MastroI-

acovo P. Infant mortality and con-

genital anomalies from 1950 –

1

994: an international perspective.

J Epidemiol Community Health

000; 54(9): 660 – 666.

www.thephss.org/ppep/resource/

Na-

2

Children’s HeartLink. Global re-

port on paediatric cardiac disease –

to save a child: we can do more to

address global trends in paediatric

heart disease. 2005. http://www.

Childrensheartlink.org/documents/

ChildrensHeartlinkStudy.pdf Ac-

cessed August 2009.

tional_Immunization_Policy_with_

frwd_and_acknwldg.pdf Accessed

th

1

24 January 2013

19. Mitchell IM, Logan RW, Pollock

JCS, Jamieson MPG. Nutritional

status of children with congenital

heart disease. Br Heart J 1995; 73:

277 - 283

1

6

.

Botto LD, Mastroiacovo P. Epide-

miology, aetiology, and patho-

genesis of congenital heart defects.

st

Ann. 1 . Super. Sanita 1993; 29

1

(1): 105 – 114.

7

.

Okoromah CAN, Ekure NE, Lesi

FEA, et al. Prevalence, profile and

predictors of malnutrition in chil-

dren with congenital heart defects:

a case control study. Arch Dis

Child 2011; 96: 354 - 60