Inadequate calorie intake or absorption remains the predominant cause in most patients, especially for those who are symptomatic from congestive heart failure.114 Several investigators documented low calorie intakes in patients with CHD compared with intakes of age-matched controls.115 In their study of 22 children with CHD, Hansen and Dorup noted that the children consumed only 88% of RDAs and that most did not meet the recommendations for iron, zinc, calcium, and vitamins D, E, C, B1, and B6.116 The energy intakes correlated with weight standard deviation (SD) scores. Thommessen et al. reported poor appetite and feeding problems among children with CHD, and the problems related well with the degree of malnutrition.117 Children with feeding problems also tended to eat less than children without feeding problems. Unger et al. found that underweight children with CHD consumed only 89% of RDAs whereas the figure was 108% in those with normal weights.118 For most parents, feeding of infants and children with CHD involves difficulties, time, and anxiety. The feeding problems are related to anorexia, tachypnea, fatigue, excessive vomiting, and respiratory infections. The importance of poor intake is emphasized by studies that have shown significant improvement in growth with nutrient supplementation.118119 Rigorous fluid restriction before the advent of pow
Increased demand erful diuretics also led to calorie restriction. However, the metabolic alkalosis and hypokalemia associated with diuretic use can also lead to anorexia and may inhibit effective protein anabolism by interfering with the maintenance of adequate sodium balance. Digitalis intoxication is another recognized cause of anorexia, but the symptom can occur even as a side effect of a standard dose.
Edema of the intestinal wall and mucosal surfaces may lead to impaired nutrient absorption and lymphatic drainage. Sondheimer and Hamilton120 reported calorie losses in stools as both proteins and fats, but Menon and Poskitt114 found no significant difference between stool losses of infants with heart disease and control patients. This factor is of importance when aggressive nutritional therapy with supplemental enteral feedings is attempted in these children. Excessive vomiting caused partly by gastroesophageal reflux may reduce the net intake of food.121
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