ISSN 03 02 4660         AN OFFICIAL JOURNAL OF THE PAEDIATRIC ASSOCIATION OF NIGERIA


Nigerian J Paediatrics 2017 vol 44 issue 1

Nigerian J Paediatrics 2017 vol 44 issue 1

Issue
Archives
Instructions
Submit Article
Search
Contact Us
 
 
Home
Issue
Archives
Instructions
Submit Article
Search
Contact Us
Home
Quick Navigation
Importance of micronutrient supplementation in children with congenital heart defects in Nigeria
Niger J Paediatr 2018; 45 (4):168 - 172
PERSPECTIVE
Onalo R
CC – BY
Importance of micronutrient
supplementation in children
with congenital heart defects in
Nigeria
DOI:http://dx.doi.org/10.4314/njp.v45i4.1
Accepted: 20th September 2018
Abstract : The prevalence of con-
operated congenital heart defects,
genital heart defects is increasing
especially in those on chronic diu-
Onalo R
(
)
globally. Improvements in surgi-
retic therapy. It is pertinent that the
Department of Paediatrics,
cal techniques have resulted in
need for studies on the prevalence
University of Abuja Teaching Hos-
increased life expectancy for indi-
of micronutrient deficiencies and
pital, Gwagwalada, Abuja Nigeria
viduals with heart defects. In de-
effects of micronutrient supple-
Email: richardonalo@yahoo.com
veloping countries, it is not un-
mentation in these children be em-
usual to find children with simple
phasized.
congenital heart defects present-
Therefore, the objective of this
i ng
wi t h
c o mp l i c a tio ns
paper is to highlight the impor-
(nutritional and non-nutritional)
tance of micronutrient supplemen-
due to delay in surgical correc-
tation in children with un-operated
tion.
congenital heart defects in Nigeria.
Data on nutritional deficiencies in
children with heart diseases are
Key words: micronutrients, mal-
rare, more so, those on micronu-
nutrition, children, congenital heart
trient deficiencies. Macro- and
defects, Nigeria
micronutrient deficiencies
are
common among children with un-
Introduction
fects presenting late for surgery either due to inability of
the cardiac centre to provide the immediate needed in-
Untreated congenital heart defects (CHD) either cya-
terventions or due to a delay in accessing funding for the
procedure. The delay in surgical correction of CHD
6
notic or acyanotic can impact severely on the ability of
the patient to ingest or absorb nutrients sufficient to sus-
places the individual at risk of nutritional deficiencies.
Ratanachu-EK et al showed that malnutrition occurs
7
tain well being and foster proper growth due to recur-
rent/chronic heart failure or hypoxia. The frequency of
early in this group of children with about 40% of neo-
diagnosis of CHD is increasing. The incidence has in-
1
nates being malnourished before surgery. In addition,
Thommessen et al reported a 50% prevalence of stunt-
8
creased from about 48.4 per 10,000 live births in the
1980’s to 146 per 10,000 live births in the recent
ing amongst toddlers with CHD in a study involving 40
past, probably due to better diagnosis and management,
1
children. The prevalence of malnutrition is higher in
thereby creating a significant population with need for
children with poor access to healthcare such as may oc-
proper, prompt and effective healthcare.
cur in developing countries. For instance, a hospital-
based study from Lagos, south-west Nigeria involving
Half of the children with heart defects require at least
73 children with CHD reported protein energy malnutri-
one surgical operation either in the immediate neonatal
2
tion (PEM) in 90.4%, with 61.2% having severe form of
malnutrition. PEM seldom occurs in isolation, other
5
period or later in childhood to achieve optimal life ex-
pectancy. Improvement in surgical techniques has posi-
macronutrient and micronutrient deficiencies often coex-
tively influenced the outcome of CHD. In the past,
ist with it. Information on micronutrient status in chil-
more than 50% of children with CHD died before their
dren with CHD is not readily available. It has however
first birthday, where as 85% of children with CHD now
been documented that amongst the general paediatric
population of Africa, 24% have zinc deficiency, 20%
9
survive into adulthood. The increasing survival of chil-
3
dren with CHD brings to the fore the need for nutritional
have iron deficiency and 40% are iodine deficient.
management to ensure adequate growth and develop-
ment. Adequate nutrition before surgery has been shown
Malnutrition has been implicated in two-thirds of child-
to have both immediate and long term effect on post-
hood mortality globally and this has formed the basis for
operative outcome especially in less privileged regions
aggressive nutritional management in children with
common childhood illnesses. A review by Bhutta on
10
11
of the world with poorly equipped facilities for prompt
and proper cardiac interventions.
4-6
micronutrient needs of malnourished children found
It is not unusual to find children with simple heart de-
11% of under-five mortality directly attributable to four
169
micronutrient deficiencies (vitamin A, zinc, iron and
shown to increase urinary excretion of micronutrients,
including thiamine, calcium, selenium and zinc, while
.
iodine). Despite the growing evidence of micronutrient
deficiencies in children, nutritional management is still
other medications such as angiotensin converting en-
focused mainly on PEM, with little or no emphasis on
zyme inhibitors, angiotensin receptor antagonists and
thiazides induce mainly zinciuria and hypozincemia. In
23
micronutrients.
a recent study involving 41 children with CHD in Be-
24
Nutrition and Congenital Heart Defects
nin, south-south Nigeria, serum zinc levels were lower
in children on diuretics compared to those not on diuret-
There is a causal relationship between nutrition and
ics, with some of the children having zinc levels below
CHD such that prenatal nutrition impacts on the struc-
70µg/dl. Although zinc levels were comparable to those
ture of the developing heart, while postnatal nutrition
of children without CHD, the values were generally
mostly affects the functionality of the developed heart.
lower in children with CHD, thus confirming the added
Poor intake of micronutrients is widespread and may
risk of nutritional deficiencies in children with CHD.
This finding was corroborated by a study from Egypt
25
result from several factors including poor soil nutrient
content. There is variable micronutrient soil content in
among 30 children with cyanotic congenital heart dis-
Nigeria and other parts of Africa.
12,13
In particular, there
eases that showed low levels of serum zinc and selenium
are recorded areas with low soil micronutrients content
in children with CHD as against their age-matched
within towns and villages located in south-south and
counterparts with normal hearts. In that study, it was
A recent publication
15
north-central Nigeria.
12,14
from
suggested that low serum trace elements had important
north central Nigeria has also revealed low selenium
role in the pathogenesis of myocardial damage in con-
genital cyanotic heart diseases.
25
content of tubers grown in parts of Abuja, Niger, Benue
and Kogi states. Consumers of such products are likely
to develop selenium deficiency unless food is supple-
Effects of micronutrient deficiencies on the heart
mented with micronutrients. Supplementation of food
with selenium in Keshan province of China drastically
Mild micronutrient deficiency could exacerbate existing
reduced the incidence of Keshan disease, an endemic
cardiac dysfunction while severe deficiency may cause
form of cardiomyopathy. Although, Keshan disease
16
heart failure or even cardiomyopathy. Of interest is that
have not been reported in Nigeria, 76.9% of women
the cardiac abnormalities may develop even before the
with peripartum cardiomyopathy in Kano had serum
classical clinical features of the micronutrient deficiency
selenium levels below 70µg/L, thus suggesting the likely
manifest. Several hypotheses have been proposed to
role of selenium deficiency in the aetiopathogenesis of
explain the mechanisms behind cardiac dysfunction in
peripartum cardiomyopathy. It is not clear if some of the
micronutrient deficiencies.
cases of dilated cardiomyopathy in children in Nigeria
are selenium related.
Antioxidant role: Patients with CHD are more suscepti-
ble to the effects of micronutrient deficiency because of
Beside selenium, zinc and copper contents of some
increased oxidative stress associated with the condition.
Nigerian foods have been shown to be low, though with
Zinc, copper and selenium are antioxidants and defi-
some regional variation.
17,18
A study involving children
ciency state could results in myocardial damage and
cellular apoptosis. The antioxidant role of zinc is medi-
26
from the humid-forest zone of south-east Nigeria docu-
ated through zinc-dependent superoxide dismutase,
26,27
mented 59% of children, aged 2-5years, consuming zinc
at levels below the dietary reference intake of 3-5mg/
while that of copper is through copper-dependent super-
oxide dismutase.
26,27
day. This low intake is occurring in the background of
18
Copper restriction in experimental
high dietary phytate, fibers and lignin in the staple food.
animal studies was found to be associated with increased
It is therefore not surprising that 20% of under-5 chil-
risk of myocardiocyte oxidative damage, myofibrillar
dren in Nigeria suffer from zinc deficiency. The figure
19
disarray and mitochondrial fragmentation. Decreased
is even higher in the moist savannah zone of the country
Cytochrome C oxidase activity in copper deficiency
with states in the north-central area having 36.5% of
could result to mitochondrial impairment and conse-
under-5 children with zinc deficiency.
19
Mean serum
quent cardiac dysfunction.
27
Selenium, on the other
copper and zinc levels of 2.00-2.12µmol/l and 12.6-
hand, is a constituent of the antioxidant enzyme glu-
14.9µmol/l, respectively was documented in malnour-
tathione peroxidase. Selenium deficiency has been asso-
ished under-5 children in Jos, north-central Nigeria.
20
ciated with the endemic form of cardiomyopathy com-
Other geopolitical regions have also documented micro-
monly found in regions with soil selenium deficiency in
China.
27
nutrient deficiencies. For instance, a study from south-
Selenium-deficient cardiomyopathy in humans
west Nigeria reported selenium deficiency in 18.6% of
on long-term selenium-deficient total parenteral nutri-
tion has also been described in Western countries. Se-
26
healthy controls and 71.4% of HIV infected children.
21
lenium deficiency leads to increased lipid peroxidation
Children with CHD are at increased risk of micronutri-
and, hence, increases in oxidative stress. Morphometric
ent deficiencies because of their tendency to have
analysis of cardiac specimen from selenium-deficient rat
chronic hypoxia and congestive heart failure necessitat-
revealed separation of cardiac microfibrils and Z-lines,
ing the use of antifailure drugs that may impair appetite,
mitochondrial ultrastructural changes such as fragmenta-
induce anorexia, feeding intolerance and increase nutri-
tion and loss of cristae, and increase in mitochondrial
ent excretion.
22
Loop diuretics, for instance, have been
170
volume density.
27
To corroborate the antioxidant role of
In adult volunteers
33
given zinc deficient diet, serum
micronutrients, a study in adults with acute coronary
thymulin activity and generation of T helper subset 1
syndrome have documented a correlation between serum
cell cytokines were reduced within 2-3 months of insti-
copper, zinc, iron and selenium levels with extent of
tution of such diet even before plasma zinc concentra-
myocardial damage.
28
tion began to show significant decrease. These proper-
ties account for the overwhelming role of zinc in the
Role in cardiac cytoskeleton : Iron, zinc and copper are
control of acute respiratory infections and diarrhea dis-
needed in collagen synthesis. Deficiency state has more
eases in children.
profound effect in the fetus and early infancy. Neonates
Selenium on the other hand, has stimulating effects on
with zinc deficiency show higher rates of congenital
the immune system and its deficiency may result in de-
valvular defects and increase in other congenital malfor-
fective immune function and increased susceptibility to
pathogens. Publication by Gomez et al
31
mations. In zinc-deficient rats, the activity of de-
26
as in 2001 on
oxythymidine kinase is reduced leading to decreased
studies in mice revealed the increase susceptibility of the
DNA, protein, and collagen synthesis.
26,28
This observa-
heart to coxsackie B1 and echovirus 9 viruses among
tion could explain the myocardial dysfunction and heart
rats fed on selenium deficient diet compared to the con-
failure in humans with prolonged zinc deficiency. Im-
29
trol group. Infection with viruses induces myocardial
paired collagen synthesis could alter the cytoskeletal
damage, poor contractility and eventual systolic dys-
structure of the heart causing increase in cardiac dimen-
function which with chronicity may result in dilated
sion, distortion of valvular apparatus and increased dis-
cardiomyopathy.
tensibility of blood vessels.
26,28
Defective structural
components of vascular endothelium and myocardial
Detoxification of xenobiotics : Selenium interacts with
tissues could occur even in mild copper deficiency. Ani-
cardiotoxic agents and protects the myocardium and
mals with severe copper deficiency have died of vascu-
blood vessels from their adverse effects. In a study by
Tacyildiz et al in children with anthracycline-induced
32
lar aneurysm and rupture of cardiac ventricle.
28
Lysyl
oxidase, an enzyme required for cross-linkages in con-
cardiac toxicity, selenium supplementation for several
nective tissues, utilizes copper ions in the oxidative
months was shown to decrease Prohormone Brain Natri-
deamination of peptidyl lysyl groups in tropocollagen
uretic Peptides levels and improve echocardiographic
and tropoelastin.
16,26
findings. Although the involvement of other micronutri-
ents in detoxification has not been clearly documented,
The peptidyl α -aminoadipic- δ -semialdehyde formed
studies in the future may clarify their roles in cardiopro-
readily condenses with neighbouring aldehydes to form
tection.
intra- and inter chain cross-links. This action is required
for cohesion, stability and adequate functioning of con-
nective tissues, absence of which may result in distor-
tion of cardiovascular apparatus. It is not certain if the
Conclusions
observations in animal studies occur in humans. How-
ever, in a study involving 30 elderly patients with
Micronutrient deficiencies are prevalent and do contrib-
chronic heart failure, high-dose multiple micronutrient
ute to the morbidity in children with CHD. Data on the
supplementation for 9months yielded a 5.3% increase in
magnitude of micronutrient deficiencies in children with
the left ventricular ejection fraction with a concomitant
congenital heart defects are rare in most developing
decrease in left ventricular volume,
30
suggesting that
countries including Nigeria. At the moment, micronutri-
micronutrient deficiencies may alter cardiac ventricular
ent supplementation is not regarded as part of normal
dimensions and left ventricular functions.
protocol in the management of children with congenital
heart defects. Therefore, there is need to create aware-
Protection against cytopathic viruses : Zinc is essential
ness of the prevalence of nutritional deficiencies in chil-
in cellular and humoral immune functions and its defi-
dren with CHD and probably instigate well-structured
ciency adversely affects handling of pathogenic viral
studies to document the magnitude of micronutrient de-
organisms.
26,31
Zinc is a co-factor for thymulin, a thymus
ficiencies in children with congenital heart defects and
hormone, critically important for the maturation and
determine the effects of micronutrient supplementation
functioning of T cells.
26
Zinc is involved in monocyte/
on the clinical, electrocardiographic and echocardio-
macrophage development and regulates its phagocytic
graphic parameters.
and proinflammatory cytokine production.
26
Zinc defi-
ciency affects the balance between the Th-1 and Th-2
Conflict of interest: None
cells,
26,32
thereby weakening T-cell mediated immune
Funding: None
response.
171
References
1. Lorenzo DB. Epidemiology
9. Kerac M, Douglas G, Postels
19. Maziya-Dixon B, Akinyele
and prevention of congenital
DG, Mallewa M, Jalloh AA,
IO, Oguntona EB, Nokoe S,
heart defects. In: Allen HD,
Voskuijl WP, et al .The interac-
Sanusi RA, Harris E. Nigerian
Driscoll DJ, Shaddy RE, Feltes
tionof malnutritionand neu-
food consumption and nutri-
TF (eds). Heart Diseases in
rologic disability inAfrica.
tion survey 2001-2003, Inter-
Infants, Children, and Adoles-
Semin Pediatr Neurol 2014;
national Institute of Tropical
cents 8 edition, Lippincott
th
21:42-49.
Agriculture (IITA), 2004.
Williams & Wilkins 2013, p.
10. Caballero B. Global patterns of
20. Ugwuja EI, Nwosu KO, Ugwu
577-616.
child health: the role of nutri-
NC, Okonji M. Serum zinc
2.
Marelli AJ, Mackie AS,
tion. Ann Nutri Metab 2002;
and copper levels in malnour-
Ionescu-Ittu R, Rahme E, Pi-
46. Suppl. 1: 3-7.
ished pre-school age children
lote L: Congenital heart disease
11. Bhutta ZA. Micronutrient needs
in Jos, north-central Nigeria.
in the general population:
of malnourished children. Curr
Pakistan J Nutr 2007; 6: 349-
changing prevalence and age
Opin Clin Nutr Metab 2008;
354.
distribution. Circulation 2007,
11: 309-314.
21. Anyabolu HC, Adejuyigbe
115:163-172.
12. Kolawole SE, Obueh HO. Rela-
EA, Adeodu OO. Serum mi-
3. Ruiz JMO. Congenital heart
tionship between soil contents
cronutrient status of Haart-
disease in adults: residual, se-
and plasma levels of selenium,
naïve HIV infected children in
quelae, and complications of
chromium and manganese in
south-western Nigeria: a case
cardiac defects repaired at an
healthy adult Nigerians. Afr J
controlled study. AIDS Re-
early age. Rev Esp Cardiol
Biotechnol 2013; 12: 5339-
search and Treatment 2014,
2003; 56: 73-88.
5346.
article 351043.
4. Cabreraa AG, Prodhan P,
13. Oklo AO, Sha’Ato R, Asemave
22. Roman B. Nourishing little
Bhutta AT. Nutritional chal-
K. Evaluation of selenium in
hearts: nutritional implications
lenges and outcomes after sur-
soils of Kogi state, Nigeria. J
for congenital heart defects.
gery for congenital heart dis-
Chem Biol Phy Sci 2013; 3:
Pract Gastroenterol 2011; 1:
ease. Current Opin Cardiol
966-971.
11-34.
2010; 25: 88-94.
14. Herselman JE. The concentra-
23. Reyes AJ, Olhaberry JV,
5. Okoromah CAN, Ekure EN,
tion of selected trace metals in
Leary WP, Lockett CJ, Alco-
Lesi FEA, Wahab O Okunowo
South African soils. PhD Dis-
cer L. Diuretic and zinc. S Afr
WO, Tijani BO, Okeiyi JC.
sertation, Department of Soil
Med J 1982; 62: 373-381.
Prevalence, profile and predic-
Science, University of Stellen-
24. Sadoh WE, Sadoh AE. Serum
tors of malnutrition in children
bosch, December 2007.
zinc values in children with
with congenital heart defects: a
15. Zarmai S, Eneji IS, Sha’Ato R.
congenital heart defects. Afr
case – control observational
Analysis of Selenium Content
Hlth Sci 2013; 13: 601-606.
study. Arch Dis Child 2011.
in Root and Tuber Plants in
25. Hegaz MA. The trace ele-
doi:10.1136/adc.2009.176644 .
Central Nigeria. Amer J Anal
ments in congenital heart dis-
6. Bode-Thomas F. Challenges in
Chem 2013; 4: 739-743.
eases. Egyptian Heart J 2014;
the management of congenital
16. Oster O, Prellwitz. Selenium
66:25.
heart disease in developing
and cardiovascular disease.
26. Nriagu J. Zinc deficiency in
countries. Available online at
Biol Trace Elem Res 1989; 24:
human health. Elsevier Sci-
http://www.interchopen.com/
91-103.
ence. Available at http://
books/congenital-heart-disease-
17. Udoessien EJ, Aremu CY. Min-
www.extranet .eselvier.com/…
selected-aspects/challenges-in-
eral composition of selected
/Zinc%20Deficiency%20%
the-mangement-of-congenital-
Nigerian food stuffs. J Food
20Humans.pdf
heart-disease-in-developing-
Compos Anal 1991; 4: 346-
27. Wildman REC, Medeiros DM,
countries. Accessed on 27 Oc-
353.
Jenkins J. Comparative as-
tober, 2015.
18. Gegios A, Amthor R, Maziya-
pects of cardiac ultrastructure,
7. Ratanachu-EK S, Pongdara A.
Dixon B, Egesi C, Mallowa S,
morphometry, and electrocar-
Nutritional status of pediatric
Nungo R, et al . Children con-
diography of hearts from rats
patients with congenital heart
suming cassava as a staple food
fed restricted diatary copper
disease: pre- and post-cardiac
are at risk for inadequate zinc,
and selenium. Biol Trace
surgery. J Med Assoc Thai
iron and vitamin A intake.
Elem Res 1994; 46: 51-66.
2011; 94 Suppl 3: S133-S137.
Plant Foods Hum Nutr 2010;
28. Bayır A, Kara H, Kıyıcı A,
8.
Thommessen M, Heiberg A,
65: 64-70.
Öztürk B, Akyürek F. Levels
Kase BF. Feeding problem in
of Selenium, Zinc, Copper,
children with congenital heart
and Cardiac Troponin I in
disease: the impact on energy
Serum of Patients with Acute
intake and growth outcome. Eur J
Coronary Syndrome. Biol Trace
Clin Nutr. 1992; 46: 457-464.
Elem Res 2013; 154:352 – 356.
172
29. Ghaemian A, Salehifar E,
31. Gomez RM, Berria MI, Levan-
33. Prasad AS, Rabbani P,
Jalalian R, Ghasemi F, Azizi
der OA. Host selenium status
Abbasi A, Bowersox E,
S, Masoumi S, et al . Zinc and
selectively influences suscepti-
Spivey-Fox MR. Experimen-
copper levels in severe heart
bility to experimental viral
tal zinc deficiency in humans.
failure and the effects of atrial
myocarditis. Biol Trace Elem
Ann Intern Med 1978; 89:483
fibrillation on the zinc and cop-
Res 2001; 80: 23-31.
– 90.
per Status. Biol Trace Elem Res
32. Tacyildiz N, Ozyoruk D,
2011; 143:1239 – 1246.
Kovas GO, Yaavuz G, Unal E,
30. Witte KK, Nikitin NP, Parker
Dincaslan H, et al . Selenium in
AC, von Haehling S, Volk HD,
the prevention of anthracycline
Anker SD, et al . The effect of
-induced cardiac toxicity in
micronutrient supplementation
children with cancer. J Oncol
on quality-of-life and left ven-
2012; 1; 1-6.
tricular function in elderly pa-
tients with chronic heart fail-
ure. Eur Heart J 2005; 26:
2238-2244.