Doğumsal kalp hastalığı ve büyüme geriliği arasındaki ilişkinin araştırılması
Investigation of relationship between growth retardation and congenital heart disease
Yazar: BUMİN NURİ DÜNDAR
Danışman: PROF. DR. ADNAN AKÇORAL
Dokuz Eylül Üniversitesi / Tıp Fakültesi / Çocuk Sağlığı ve Hastalıkları Ana Bilim Dalı
Derece: Tıpta Uzmanlık, 1998
Konu: Çocuk Sağlığı ve Hastalıkları = Child Health and Diseases
Dizin: Büyüme bozuklukları = Growth disorders ; Kalp defektleri-konjenital = Heart defects-congenital

Özet:
ABSTRACT Investigation of the Relationship Between Gro\vth Retardation and Congenital Hcart Disease Dr.Bumin Nuri Dündar Growth retardation is a well recognised complication of congenital heart disease(CHD). Several possible explanations for this complication have been suggested; insufficient intake of nutritients, increased energy recpıirement, hypoxia, cardiac drugs, frequent respiratory infections and malabsorption. Recentiy, investigators have been demonstrated that nutritional and endocrine factors have a complex relationship in the growth of children and endocrine status is effected by the nutritional factors. We evaluated 80 patient with CHD,[ mean age 4.06 ± 3.38 (0.07-12), 29 (36%) cyanotic (13 tetralogy of fallot, 16 complex cyanotic ) and 51 ( 64%) acyanotic (33 left to right shunt, 18 obstructive type )] to estimate growth of patients in relation to nutritional and endocrine factors. Body weight and height, triceps skinfold (TSF) and mid arm circumference (MAÇ) measurements were made in ali patients and standart deviation scores (SDS) were calculated. Also, three days dietaıy history was analysed and, ratios of calorie and protein intake/expected values were calculated. in addition, frequency of lower respiratory infection throughout öne year and mother's educational status were recorded. Cyanotic and acyanotic patients were classifıed as moderate and severe according to severity of disease. Ali patients were classified according to nutritional state; nutritionally sufBcient and nutritionally insufBcient using height for age and weight for height ratios,and also TSF and MAÇ values for each patient. in addition; nutritionally insufBcient patients were seperated into three groups according to Waterlow's classifîcation (wasted, stunded and wasted +stunded ).Bood samples were obtained during catheter-angiography and complete blood count, seram electrolytes, liver function tests, oxygen saturations (for cyanotic patients), serum zinc levels, thyroid function tests,Insulin-like growth factor 1(IGF-I) and IGF-I binding protein 3 (IGFBP3) levels were measured. A control group of 20 well-nourished children in the similar age were formed in order to compare the values of IGF-I and IGFBP-3 between control and study groups. Cyanotic and acyanotic patients showed marked retardation in both weight and height, but there was no signifîcant difference between weight and height among two groups (p>0.05). in two groups, there were not significant differences between weight and length within each group (weight SDS -1.46 ±0.85 and-1.11 ± 1.39, p>0.05; height SDS -1.16 ± 1.29 and -1.05 ± 1.21, respectively; p>0.05). Complex cyanotic patients were more severely retarded in weight (weight SDS -1.69 ± 0.71, height SDS -1.14 ± 1.04,p<0.05) and obstractive type patients had the least retardation in both weight and height (weight SDS -0.41 ± 0.99, height SDS -0.75 ± 0.89).According to nutritional classifîcation of 80 cyanotic and acyanotic patients; 43 (%54) of patients were nutritionally insufficient. The ratio nutritionally insufficient patients was high in cyanotic group ( 72.5% in cyanotic and 43.2% in acyanotic, p<0.001). However, we could not determine any difference in intake of calorie and protein between two groups (p>0.05). When we evaluated IXthe patients according to the severity of disease, a high ratio of nutritionally insufficient children were determined in severe disease groups compared with moderate disease groups in TOF, complex cyanotic and left to right shunt groups (p<0.05). But, Intake of calori and protein ratio between moderate and severe disease groups was not different. However, we determined that nutritionally insufficient patients were taking much less calorie and protein compared with the nutritionally sufficient patients, (calorie; 78.6% ± 14.1 and 94.3% ± 11.7, p<0.05 ve protein; 86.8% ± 11.8 and 98.8% ±9.2, respectively, p<0.05).Also,there was a positive correlation between intake of calorie and protein and both weight and height. We found low serum zinc concentration in nutritionally insufficient group ( 83.3 ± 26.1 and 98 ± 22.5, p<0.05). IGF-I and IGFBP-3 values were lower in nutritionally insufficient group than in both nutritionally sufficient and control groups. (IGF-I; 50.4 ± 22.8, 91.6 ± 33 and 107 ± 19.7; p<0.005 and IGFBP-3;1530 ± 874, 3133 ± 1055 and 3312 ± 409; p<0.005, respectively) There was a positive correlation between IGF-I with IGFBP3 and weight (r=0.647,p=0.0001 and r=0.679,p=0.0001,respectively), and length (0r=0.384,p=0.0004 and r=0.518,p=0.0001),TSF( r=0.340,p=0.002 and r=0.415,p=0.0001, respectively), MAC( r=0.502,p=0.0001 and r=0.506,p=0.001, respectively) and intake of calorie ratio ( r=0.478,p=0.0001 and r=0.398, p=0.0002, respectively), and oxygen saturation for cyanotic patients ( r=0.36,p=0.048 and r=0.42,p=023, respectively) We also determined a positive correlation between IGF-I and intake of protein ratio ( r=0.359,p=0.001 ), but this was not true for IGFBP-3. When we considered IGF-I levels, nutritionally sufficient cyanotic patients, had significantly low levels to compared with the control group ( 85.5 ± 30.2 and 107 ± 19.7; p<0.05, respectively ). When we classified nutritionally insufficient patients according to Waterlow's classification, a high ratio of wasted and wasted + stunded patients were determined in cyanotic (47.6%) and acyanotic ( 50 %) groups, respectively.The lowest concentrations of IGF-I and IGFBP-3 were found in wasted + stunded patients.There was a significant difference in IGFBP-3 levels (p<0.005) but not in IGF-I among the three malnutrition types. In conclusion, we found that insufficent intake of nutritients (especialy in intake of calori), and increased energy requirement (especialy in severe disease and cyanotic patients) lead to growth failure in CHD.There is a strong relationship between IGF-I with IGFBP-3 levels and growth failure in CHD. Hypoxia is another important factor that effect the growth of cyanotic patients and, probably effect IGF-I and IGFBP-3 levels. In addition, we determined a relation in between IGFBP-3 levels and malnutrition types in CHD. Key Words: Congenital Heart Disease, Growth Retardation, Nutritionally insufficient, IGF-I, IGFBP-3.

Abstract:
ABSTRACT Investigation of the Relationship Between Gro\vth Retardation and Congenital Hcart Disease Dr.Bumin Nuri Dündar Growth retardation is a well recognised complication of congenital heart disease(CHD). Several possible explanations for this complication have been suggested; insufficient intake of nutritients, increased energy recpıirement, hypoxia, cardiac drugs, frequent respiratory infections and malabsorption. Recentiy, investigators have been demonstrated that nutritional and endocrine factors have a complex relationship in the growth of children and endocrine status is effected by the nutritional factors. We evaluated 80 patient with CHD,[ mean age 4.06 ± 3.38 (0.07-12), 29 (36%) cyanotic (13 tetralogy of fallot, 16 complex cyanotic ) and 51 ( 64%) acyanotic (33 left to right shunt, 18 obstructive type )] to estimate growth of patients in relation to nutritional and endocrine factors. Body weight and height, triceps skinfold (TSF) and mid arm circumference (MAÇ) measurements were made in ali patients and standart deviation scores (SDS) were calculated. Also, three days dietaıy history was analysed and, ratios of calorie and protein intake/expected values were calculated. in addition, frequency of lower respiratory infection throughout öne year and mother's educational status were recorded. Cyanotic and acyanotic patients were classifıed as moderate and severe according to severity of disease. Ali patients were classified according to nutritional state; nutritionally sufBcient and nutritionally insufBcient using height for age and weight for height ratios,and also TSF and MAÇ values for each patient. in addition; nutritionally insufBcient patients were seperated into three groups according to Waterlow's classifîcation (wasted, stunded and wasted +stunded ).Bood samples were obtained during catheter-angiography and complete blood count, seram electrolytes, liver function tests, oxygen saturations (for cyanotic patients), serum zinc levels, thyroid function tests,Insulin-like growth factor 1(IGF-I) and IGF-I binding protein 3 (IGFBP3) levels were measured. A control group of 20 well-nourished children in the similar age were formed in order to compare the values of IGF-I and IGFBP-3 between control and study groups. Cyanotic and acyanotic patients showed marked retardation in both weight and height, but there was no signifîcant difference between weight and height among two groups (p>0.05). in two groups, there were not significant differences between weight and length within each group (weight SDS -1.46 ±0.85 and-1.11 ± 1.39, p>0.05; height SDS -1.16 ± 1.29 and -1.05 ± 1.21, respectively; p>0.05). Complex cyanotic patients were more severely retarded in weight (weight SDS -1.69 ± 0.71, height SDS -1.14 ± 1.04,p<0.05) and obstractive type patients had the least retardation in both weight and height (weight SDS -0.41 ± 0.99, height SDS -0.75 ± 0.89).According to nutritional classifîcation of 80 cyanotic and acyanotic patients; 43 (%54) of patients were nutritionally insufficient. The ratio nutritionally insufficient patients was high in cyanotic group ( 72.5% in cyanotic and 43.2% in acyanotic, p<0.001). However, we could not determine any difference in intake of calorie and protein between two groups (p>0.05). When we evaluated IXthe patients according to the severity of disease, a high ratio of nutritionally insufficient children were determined in severe disease groups compared with moderate disease groups in TOF, complex cyanotic and left to right shunt groups (p<0.05). But, Intake of calori and protein ratio between moderate and severe disease groups was not different. However, we determined that nutritionally insufficient patients were taking much less calorie and protein compared with the nutritionally sufficient patients, (calorie; 78.6% ± 14.1 and 94.3% ± 11.7, p<0.05 ve protein; 86.8% ± 11.8 and 98.8% ±9.2, respectively, p<0.05).Also,there was a positive correlation between intake of calorie and protein and both weight and height. We found low serum zinc concentration in nutritionally insufficient group ( 83.3 ± 26.1 and 98 ± 22.5, p<0.05). IGF-I and IGFBP-3 values were lower in nutritionally insufficient group than in both nutritionally sufficient and control groups. (IGF-I; 50.4 ± 22.8, 91.6 ± 33 and 107 ± 19.7; p<0.005 and IGFBP-3;1530 ± 874, 3133 ± 1055 and 3312 ± 409; p<0.005, respectively) There was a positive correlation between IGF-I with IGFBP3 and weight (r=0.647,p=0.0001 and r=0.679,p=0.0001,respectively), and length (0r=0.384,p=0.0004 and r=0.518,p=0.0001),TSF( r=0.340,p=0.002 and r=0.415,p=0.0001, respectively), MAC( r=0.502,p=0.0001 and r=0.506,p=0.001, respectively) and intake of calorie ratio ( r=0.478,p=0.0001 and r=0.398, p=0.0002, respectively), and oxygen saturation for cyanotic patients ( r=0.36,p=0.048 and r=0.42,p=023, respectively) We also determined a positive correlation between IGF-I and intake of protein ratio ( r=0.359,p=0.001 ), but this was not true for IGFBP-3. When we considered IGF-I levels, nutritionally sufficient cyanotic patients, had significantly low levels to compared with the control group ( 85.5 ± 30.2 and 107 ± 19.7; p<0.05, respectively ). When we classified nutritionally insufficient patients according to Waterlow's classification, a high ratio of wasted and wasted + stunded patients were determined in cyanotic (47.6%) and acyanotic ( 50 %) groups, respectively.The lowest concentrations of IGF-I and IGFBP-3 were found in wasted + stunded patients.There was a significant difference in IGFBP-3 levels (p<0.005) but not in IGF-I among the three malnutrition types. In conclusion, we found that insufficent intake of nutritients (especialy in intake of calori), and increased energy requirement (especialy in severe disease and cyanotic patients) lead to growth failure in CHD.There is a strong relationship between IGF-I with IGFBP-3 levels and growth failure in CHD. Hypoxia is another important factor that effect the growth of cyanotic patients and, probably effect IGF-I and IGFBP-3 levels. In addition, we determined a relation in between IGFBP-3 levels and malnutrition types in CHD. Key Words: Congenital Heart Disease, Growth Retardation, Nutritionally insufficient, IGF-I, IGFBP-3.