Pediatrics International (2011) 53, 345–349 doi: 10.1111/j.1442-200X.2010.03230.

Original Article ped_3230 345..349

Evaluation of growth and neurodevelopment in children with

congenital heart disease

Selda Polat,1 Cetin Okuyaz,2 Olgu Hallıoğlu,3 Ertan Mert4 and Khatuna Makharoblidze5
1
Department of Pediatrics, 2Department of Pediatric Neurology, 3Department of Pediatric Cardiology, 4Department of
Family Medicine, and 5Department of Pediatrics, Mersin University Faculty of Medicine, Mersin, Turkey

Abstract Background: Children with congenital heart disease are under risk of delayed growth and development. We evaluated
physical growth parameters and neurodevelopment in these patients in comparison with normal children and examined
the effect of hemodynamic status.
Methods: Patients with congenital heart disease (n = 76) and healthy children (n = 51) aged 1–72 months applied to
Mersin University Hospital, Mersin, Turkey were included. Patients with heart failure and those requiring intervention
or surgery were classified as hemodynamically impaired (HI group, n = 30), and the others, hemodynamically normal
(HN group, n = 46). Growth parameters including weight, height, body mass index (BMI), mid-arm circumference
(MAC), and triceps skin fold thickness (TSF) were measured and standard deviations (SD) were determined. Functional
development was assessed by Denver Developmental Screening Test-II (DDST II).
Results: MAC and BMI values of the group with impaired hemodynamic status were significantly lower than the
hemodynamically normal and control groups (MAC P < 0.05 and BMI P < 0.01). In the DDST II, the group with
hemodynamic abnormality had more failures in gross motor and fine motor skills than HN group and controls (gross
motor P = 0.011, P < 0.001 and fine motor P = 0.028, P = 0.001, respectively) and more failures in language development
than the control group (P = 0.001).
Conclusion: The results showed the importance of hemodynamic status in growth and neurodevelopment of children
with congenital heart disease. Besides routine growth parameters, more detailed examinations such as BMI, MAC, TSF,
and developmental screening tests appear useful in identifying children with cardiac disease who are under risk for
delayed growth and development.

Key words congenital heart disease, developmental screening, growth.

Introduction like hypoplastic left heart, transposition of great arteries and

Among the most common birth defects, congenital heart disease
with the prevelance of 0.5–0.8% and having abnormal hemody-
namic nearly at the rate of 1/3, requires surgical intervention in
infancy.1,2 With prolongation of the lifespan due to advances in
pediatric cardiology and cardiovascular surgery, growth and
developmental problems have become more noticeable in these
patients.3,4 Cyanosis, heart failure, recurrent infections, frequent
hospitalization, feeding difficulties and surgical interventions are
the factors negatively influencing growth and development.5
Usually the differences in growth patterns of patients with
congenital heart disease were compared to pre- and postsurgical
periods, the difficulties in determining the true timing of opera-
tions for optimal growth of patients were discussed very fre-
quently and most of the studies were related to certain diagnosis
Correspondence: Selda Polat, MD, Department of Pediatrics, Mersin
University Faculty of Medicine, 33079 Zeytinlibahce/Mersin, Turkey.
Email: seldapolat2003@hotmail.com
Received 23 October 2009; revised 13 July 2010; accepted 27 July
2010.
ECT.6–8 There are also some studies, investigating the long-term
neurological and cognitive developmental outcomes of children
with congenital heart disease;3,9–12; nevertheless, these earlier
studies have focused on children with specific types of congenital
heart disease, rather than population as a whole.
The aim of this study was to evaluate the growth and neurode-
velopment of infants and children with congenital heart disease
as well as to investigate the influence of hemodynamic status on
growth or development within the detailed aspects.
Methods
Subjects
Seventy-six children with congenital heart disease between 1 and
72 months who had been diagnosed in the Pediatric Cardiology
Outpatient Clinic of Mersin University Hospital between August
2007 and January 2008 were included. During this period,
4536 patients were examined in this clinic and the ones who
definitely had congenital heart disease were the subjects. Twenty-
two patients with a history of hypoxic birth, prematurity,

© 2011 The Authors

Pediatrics International © 2011 Japan Pediatric Society
346 S Polat et al.
hypoglycemia, epilepsy, a neurological disease or a genetic syn-
drome were omitted from the study. The control group consisted
of 52 healthy children who were diagnosed with innocent
murmurs or followed up in the well-child clinic. Body weight,
height, and mid-arm circumference (MAC) were measured by
standard anthropometric techniques and left arm triceps skinfold
thickness (TSF) measurements were made with standard Lange
calipers by the same specialist. Standard deviation scores were
calculated for all measurements. Data for weight and height were
evaluated using Tanner standard tables.13,14 MAC and TSF values
were evaluated using Frisancho’s standard tables.15 Body mass
index values were calculated (weight/height2). Prenatal, natal,
and postnatal characteristics and neurodevelopmental risk factors
were recorded from the patient files. The study was approved by
the local ethics committee.
Patients with congenital heart disease were grouped as
normal hemodynamic status and impaired hemodynamic status.
Impaired hemodynamic status was defined in two groups: the
ones who need medical treatment, and the ones having any sur-
gical operation or an invasive intervention. After having the
informed consent from the first degree relatives of the patients,
Denver Developmental Screening Test II (DDST II) adapted for
Turkish children16,17 was given to the patients by the same
pediatrician who has had proper certification. DDST II is the
adapted and re-standardized version of the widely used DDST
for children aged 0–72 months and screens children’s perfor-
mance in four developmental domains: personal-social, fine
motor-adaptive, language, and gross motor with respect to the
age-matched population. Failure to perform a developmental
item is recognized as ‘delay’ if it occurs in a task accomplished
by 90% of peers, and as ‘caution’ if the item is accomplished
by 75–90% of peers. DDST II results were expressed as
‘normal’ in patients who completed all the items for their age or
scored no delay or only one caution; as ‘questionable’ if there
was one delay and/or two or more cautions, as ‘abnormal’ if
there were two or more delays, and as ‘un-testable’ based on
the number of refusals that would be cautions or delays if the
items were failed.18
Composite scores were also calculated by assigning one
failure point to each ‘caution’ and two failure points to each
delay in every four domains and these points were summed.
Thus the higher the score, the more delayed the child was
considered.18
Table 1 Diagnoses of the patients
Diagnoses
Ventricular septal defect (one operated)
Patent ductus arteriosus (one operated)
Ventricular septal defect and patent ductus arteriosus
Atrial septal defect
Cyanotic congenital heart disease (two operated)
Coarctation of the aorta (one operated)
Mitral stenosis
Cyanotic congenital heart diseases: Fallot tetralogy (2), univentricular heart (2), transposition of great arteries (two of them are operated) (3),
double outlet right ventricle (2).
HI group, hemodynamically impaired patients’ group; HN group, hemodynamically normal patients’ group.
© 2011 The Authors
Pediatrics International © 2011 Japan Pediatric Society
Statistics
Numerical data of the patients were shown as mean 1 standard
deviation (SD). Data were evaluated by a SPSS 11.0 computer
statistics program. Following descriptive statistics, c2 test was
employed for comparison of percentages according to gender and
DDST II results. One way analysis of variance (ANOVA) and
Tukey tests were applied for multiple comparisons between
patient groups (HN group and HI group) and the control group.
Chi-square test was used for P-value of gender, and one way
ANOVA test was used for the other parameters. Tukey test was
used for P-values. P < 0.05 was accepted as significant.
Results
The congenital heart disease group was consisted of 33 girls
(43.4%) and 43 boys (56.6%) and the control group was con-
sisted of 29 girls (56.9%) and 22 boys (43.1%). The diagnoses of
congenital heart disease patients with respect to hemodynamic
status were shown in Table 1. There was no significant difference
in the age and gender distributions between patient and control
groups (P > 0.05).
MAC SD and BMI values of the patients in HI group were
significantly lower than the patients in the HN group and control
group (for MAC SD P < 0.05 and for BMI P < 0.01), and
additionally the height SD and TSF SD values of the same group
were significantly lower than the control group (P < 0.05, P <
0.01, respectively). There was no difference in weight SD values,
among the three groups (P > 0.05). All growth parameters of the
group with normal hemodynamic were similar to the controls
(Table 2).
Eleven patients had abnormal test results on DDST II: nine of
them were in HI group and two were in HN group (P < 0.001).
DDST II results of HN group were similar to the normal controls
(Table 3).
The sum of the numerical scores of the DDST II results were
0.78 1 1.4 in HN group, 2.28 1 2.3 in HI group and 0.37 1 0.7 in
the control group. When compared, the numerical DDST II
scores of HI group were higher than the HN group (P < 0.001)
and the control group (P < 0.001), indicating low success rates of
the HI group (Table 4).
Considering the numeral sum of failure points of every
domain in DDST II, the HI group was significantly higher in fine
motor and gross motor domains when compared to the HN group
HN group (n = 46) HI group (n = 30)
27 (58.7%) 10 (33.3%)
12 (26.1%) 3 (10%)
4 (8.7%) 2 (6.7%)
3 (6.5%) 2 (6.7%)
– 9 (30%)
– 3 (10%)
– 1 (3.3%)
 Congenital heart disease 347

Table 2 Age, gender, and growth parameters of the patient and control groups

HN group (n = 46) HI group (n = 30) Control group (n = 51) P

Gender (M/F) 24/22 19/11 22/29 NS
Age (month) 17.9 1 18.2(1–72) 25.3 1 19.4(1–71) 25.3 1 20.6(2–74) NS
Weight SD -0.03 1 1.58 -1.03 1 2.57 0.28 1 2.94 NS
Height SD 0.24 1 1.91 -0.65 1 2.84 0.61 1 2.03 P < 0.05
BMI 16.8 1 1.9 15.6 1 2.4 17.01 1 1.9 P < 0.01
MAC SD -0.34 1 2.15 -2.09 1 4.16 -0.08 1 2.55 P < 0.05
TSF SD -0.79 1 1.25 -1.49 1 0.90 -0.24 1 1.19 P < 0.01
BMI, body mass index; HI group, hemodynamically impaired patients’ group; HN group, hemodynamically normal patients’ group; MAC, mid
arm circumference; NS, not significant; SD, standard deviation; TSF, triceps skinfold thickness.

(P = 0.028 and P = 0.011, respectively) and the control group
(P = 0.001 and P < 0.001, respectively). Moreover, in the
language domain, the sum of failure points of the HI group was
higher than the control group (P = 0.001).
Discussion
As growth and neurodevelopment of children in the first years
of life usually predicts adulthood wellbeing, screening growth
and neurodevelopmental status of the patients with congenital
heart disease during infancy and childhood are important. In
our study, the MAC SD and BMI of HI group were lower than
HN and control group. In additiona, TSF SD and height SD of
the same group was lower than the control group. There was no
difference between HN and the control group. Growth retarda-
tion is one of the most common problems among children with
congenital heart disease and stability of the cardiac hemody-
namic has favorable effect on growth parameters.18,19 In a study
conducted with 300 patients with congenital heart disease, it
was found that the level of malnutrition was worse in the group
with cardiac defects disrupting the hemodynamic status,20 simi-
larly growth parameters of the HI patients in our study were
found to be low.
Among the studies conducted with the congenital heart
disease patients, the types of the classification of hemodynamic
status of the patients and the evaluated growth parameters are
varied.3,5,20–22 There are not many studies evaluating the detailed
growth parameters like ours. Da Silva et al. carried out a study
with infants having congenital heart disease and claimed that
nutritional disturbances were directly related to subscapuler skin-
fold thickness, TSF and cephalic circumferences of the patients,
and that hemodynamic status was effective on these parameters.5
Besides routine anthropometric measurements, the factors pre-
dictive of malnutrition could be performed while evaluating the
growth of patients with congenital heart disease. Although
weight measurements of our patients with unstable hemody-
namic were not different, the factors predictive of malnutrition
were lower than the HN and control groups. These kinds of data
may be valuable for detecting malnutrition in early critical ages.
As growth and neurodevelopment are closely related, both should
be taken into consideration when a child’s progress examined.3
The children who have failure to thrive in the first years of life, at
least 30% of them will have many developmental and psycho-
logical problems in later life,23 therefore the patients with con-
genital heart disease are more susceptible to the direct or indirect

Table 3 Denver-II test results of the patient and control groups

HN group HI group Control group P (Chi-square)

Normal 39 (84.8%) 16 (53.3%) 49 (96.1%)
Abnormal 2 (4.3%) 9 (30%) – <0.0001
Questionable 5 (10.9%) 4 (13.3%) 2 (3.9%)
Untestable – 1 (3.3%) –
Total (n = 127) 46 30 51
Pearson’s c2 test was performed.
HI group, hemodynamically impaired patients’ group; HN group, hemodynamically normal patients’ group.

Table 4 Success rates of patients in the four domains of DENVER-II test

Normal results HN group HI group Control group P

(n = 46) (n = 30) (n = 51)
Total test (%) 97.1 1 4.6 91.6 1 8.1 98.4 1 2.9 P < 0.001
Personal-social (%) 99.6 1 2.9 99.4 1 3.2 100 1 0.0 NS
Fine motor (%) 95.9 1 9.2 88.7 1 16.7 96.7 1 10.3 P < 0.05
Language (%) 94.8 1 11.2 96.0 1 16.5 98.7 1 4.9 P < 0.01
Gross motor (%) 97.8 1 7.1 88.9 1 16.1 97.9 1 6.6 P < 0.001
HI group, hemodynamically impaired patients’ group; HN group, hemodynamically normal patients’ group; NS, not significant.

© 2011 The Authors

Pediatrics International © 2011 Japan Pediatric Society
348 S Polat et al.
effects of malnutrition. To detect the growth retardation before
becoming clinically apparent will allow us to build up effective
preventive measures.
Children with congenital heart disease may experience
delays in developmental milestones and cognitive impairment,3
periodical developmental screening of the congenital heart
disease patients is critical.24 Weinberg et al. in their study of 64
children with congenital heart disease obtained abnormal,
untestable or questionable results in the Denver-II test
in 35 patients (54%), all with hemodynamic abnormality.18
Our results are similar: abnormal DDST II results were
observed in 57% of the group with hemodynamic abnormality.
The majority of patients with normal hemodynamic
showed normal test results: 86% in the former study and
84.8% in our study. Chen et al. also showed gross motor retar-
dation in DDST II of children with congenital heart disease.3
Despite this, 73.7% of their patients were asymptomatic and
only 2.6% of patients had had moderate or severe heart symp-
toms in their study, and most of them were significantly slow in
gross motor development domain.3 Thirty percent of the
patients had shown symptoms of unstable hemodynamic in our
study and abnormal results were seen in gross motor domain as
expected.
Fine motor development of patients with abnormal
hemodynamic were also delayed in our study. In a study con-
ducted with 64 patients with congenital heart disease, the group
with unstable hemodynamic showed fine motor development
delay.17 Gross and fine motor abilities have been shown
to be particularly affected in children with congenital heart
disease.17,24,25
Forty percent of our patients with abnormal hemodynamic
showed delay in language domain. The rates of language delay
were higher. Retardation in this area is considered as a more
powerful sign of present or future mental developmental abnor-
mality compared to motor domains.
Our study demonstrates that during the follow-up
of congenital heart disease patients especially with hemody-
namic impairment, the evaluation of TSF, MAC and
BMI values may be useful for detecting latent growth
problems. Furthermore, evaluating the neurodevelopmental
status of the patients periodically, informing the parents about
existing risks, planning education and schooling are likely to
prevent or lessen developmental delays and improve the child’s
achievement.
Long-term follow-up including detailed growth parameters
and screening with developmental testing may help to assist
optimal social and academic adjustment of these patients and
programmes that involve medical professionals, speech, dieti-
cians, physical therapists and social workers should be estab-
lished to provide support to community members with congenital
heart diseases.
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© 2011 The Authors
Pediatrics International © 2011 Japan Pediatric Society