2 9 8
EVALUATI ON OF THE GROW TH PERCENTI LES OF CHI LDREN W I TH
CONGENI TAL HEART DI SEASE
1Viv iane Mar t ins da Silv a2 Mar cos Venícios de Oliv eir a Lopes3 Thelm a Leit e de Ar auj o3
Silva VM, Lopes MVO, Ar auj o TL. Evaluat ion of t he gr ow t h per cent iles of childr en w it h congenit al hear t disease. Rev Lat ino- am Enfer m agem 2 0 0 7 m ar ço- abr il; 1 5 ( 2 ) : 2 9 8 - 3 0 3 .
The pur pose of t his st udy w as t o evaluat e t he cor r elat ion bet w een ant hr opom et r ic m easur es of childr en
w it h congenit al hear t disease w it h per cent iles t hat r epr esent t heir gr ow t h indicat or s. Ant hr opom et r ic evaluat ions
of 135 hospit alized childr en w it h congenit al hear t disease w er e per for m ed in a hospit al specialized in car diac
diseases in For t aleza, CE, Br azil. For t he gr ow t h evaluat ion, per cent iles of height by age, w eight by height and
w eight by age w er e calculat ed. Childr en’s av er age age w as 4. 74 m ont hs ( + 3. 78) and 66. 7% of t he childr en
w er e m ale. Th e m ed ian s of t h e t h r ee p er cen t iles p r esen t ed v alu es b elow p er cen t ile 1 0 , in d icat in g a h ig h
pr opor t ion of values consider ed of r isk. The subscapular t hickness pr esent ed posit ive cor r elat ion w it h t he t hr ee
per cent iles. The v alues of per cent iles st udied indicat ed gr ow t h delay .
DESCRI PTORS: Hear t defect s, congenit al; Ant hr opom et r y ; Cont inuit y of pat ient car e
EVALUACI ÓN DE LOS PERCENTI LES DE CRECI MI ENTO EN NI ÑOS CON
CARDI OPATÍ AS CONGÉNI TAS
El p r op ósit o d el p r esen t e est u d io f u e ev alu ar la cor r elación en t r e las m ed id as an t r op om ét r icas d e
n iñ os con car d iop at ías con g én it as con los p er cen t iles q u e r ep r esen t an los in d icad or es d e cr ecim ien t o. Se
r ealizar on 1 3 5 ev alu acion es an t r opom ét r icas de n iñ os con car diopat ías con gén it as in t er n ados en u n h ospit al
especializado en enfer m edades car díacas de la ciudad de For t aleza / Cear á. Par a evaluar el cr ecim ient o fuer on
calculados los per cent iles de t alla por edad, peso por t alla y peso por edad. La m edia de edad de los niños fue
de 4, 74 m eses ( + 3, 78) , siendo que 66, 7% de los niños er an del sex o m asculino. Las m edianas de los t r es
p er cen t iles p r esen t ar on v alor es p or d eb aj o d el p er cen t il 1 0 , lo q u e in d ica u n a g r an p r op or ción d e v alor es
dent r o del gr upo consider ado de r iesgo. El pliegue subescapular est uv o cor r elacionado de for m a posit iv a con
los t r es per cent iles. Los v alor es de los per cent iles est udiados indicar on r et r aso en el cr ecim ient o.
DESCRI PTORES: car diopat ías congénit as; ant r opom et r ía; cont inuidad en la at ención al pacient e
AVALI AÇÃO DOS PERCEN TI S DE CRESCI MEN TO DE CRI AN ÇAS COM
CARDI OPATI AS CONGÊNI TAS
O pr opósit o do pr esent e est udo foi av aliar a cor r elação ent r e as m edidas ant r opom ét r icas de cr ianças
com car d iop at ias con g ên it as com os p er cen t is q u e r ep r esen t am seu s in d icad or es d e cr escim en t o. For am
r ealizadas 1 3 5 av aliações an t r opom ét r icas de cr ian ças com car diopat ias con gên it as, int er nadas num h ospit al
especializado em doen ças car díacas da cidade de For t aleza / Cear á. Par a av aliação do cr escim en t o, f or am
calculados os per cent is de alt ur a por idade, peso por alt ur a e peso por idade. A m édia de idade das cr ianças foi
d e 4 , 7 4 m eses ( + 3 , 7 8 ) e 6 6 , 7 % d as cr ian ças er am d o sex o m ascu lin o. As m ed ian as d os t r ês p er cen t is
apr esent ar am v alor es abaix o do per cent il 10, indicando gr ande pr opor ção de v alor es na faix a consider ada de
r isco. A pr ega su bescapu lar est ev e cor r elacion ada de f or m a posit iv a com os t r ês per cen t is. Os v alor es dos
per cen t is est u dados in dicar am at r aso de cr escim en t o.
DESCRI TORES: car diopat ias con gên it as; an t r opom et r ia; con t in u idade da assist ên cia ao pacien t e
1 St udy funded by CNPQ - Pr ocess num ber 50639/ 03- 5; 2 RN, Nur sing graduat e st udent , e- m ail: vivianem ar t insdasilva@hot m ail.com ; 3 RN, PhD, Pr ofessor,
e- m ail: m ar [email protected], t helm aarauj [email protected] .br. Federal Univer sit y of Cear á
Rev Lat ino- am Enfer m agem 2007 m ar ço- abr il; 15( 2) : 298- 303 w w w . eer p. usp. br / r lae
Art igo Original
I NTRODUCTI ON
A
n t h r o p o m e t r i c m e a su r e s a r e i m p o r t a n t healt h indicat ors t o assess children’s growt h. For Brazil,in growt h assessm ent based on weight / lengt h, weight /
age and age/ lengt h per cent iles, v alues abov e 10 ar e
considered norm al, while children wit h percent ile values
bet ween 3 and 10 are considered as t he risk range for
g r ow t h d ef icit( 1 ). I n ch ild r en w it h con g en it al h ear t
d i se a se , t h e h e m o d y n a m i c ch a n g e s t h e y p r e se n t
p r o v o k e n u t r i t i o n al al t er at i o n s, g r o w t h d ef i ci t an d
com plicat ions r elat ed t o post - sur gical sur v iv al( 2).
I n t h i s co n t ex t , ad eq u at e n u r si n g car e t o
children w it h congenit al heart disease is needed before,
dur ing and aft er sur ger y. Special em phasis is put on
nur sing care in t he first par t of t r eat m ent , dir ect ed at
t h e ear ly det ect ion of decom pen sat ion sign s an d at
t h e m ain t en an ce of op t im al con d it ion s f or su r g er y.
The nursing process applied t o children w it h congenit al
h ear t d isease su p p or t s t h e id en t if icat ion of n u r sin g
diagnoses, t he est ablishm ent of goals and a car e plan
t o so l v e t h e su r v e y e d p r o b l e m s, a s w e l l a s t h e
im plem ent at ion and assessm ent of t he car e plan( 3).
Possib le n u r sin g d iag n oses in ch ild r en w it h
con gen it al h ear t disease h ospit alized at clin ical an d
su r g i ca l u n i t s i n cl u d e : Al t e r e d n u t r i t i o n , Ri sk f o r
infect ion, I neffect iv e air w ay clear ance, I m pair ed gas
ex change, Hy per t her m ia, Acut e pain, Alt er ed gr ow t h
and developm ent , Sleep pat t er n dist ur bance, Risk for
const ipat ion and I m pair ed sk in int egr it y( 3- 4).
The nur sing diagnoses r elat ed t o nut r it ion and
g r ow t h an d d ev el op m en t r em ar k ab l y p r esen t h i g h
p r o p o r t i o n s a n d i m p o r t a n t cl i n i ca l a n d st a t i st i ca l
a s s o c i a t i o n s . M o r e o v e r, t h e i n v e s t i g a t i o n o f
co l l ab o r at i v e p r o b l em s t h ese ch i l d r en p r esen t h as
dem onst r at ed a st r ong st at ist ical r elat ion bet w een t he
p ot en t ial com p licat ion : Pn eu m on ia an d t h e n u r sin g
diagnosis Alt er ed gr ow t h and dev elopm ent( 4).
I n ad d it ion , m an y ch ild r en w it h con g en it al
heart disease present nut rit ional difficult ies during t he
f ir st y ear of lif e, w it h v om it in g as on e of t h e m ost
com m on pr oblem s( 5 ).
Th i s l e a d s t o i n c r e a s e d m o r b i d i t y a n d
m o r t a l i t y r a t e s w h e n h e a r t t r a n sp l a n t a t i o n s a r e
r ealized in ch ild r en w it h con g en it al h ear t d isease,
b e c a u s e o f t h e i r p o o r n u t r i t i o n a l s t a t e a n d t h e
consequent final dam age t o t he or gan( 6).
Thus, ant hr opom et r ic m easur es ar e im por t ant
healt h st at us indicat ors w hen assessing t he nut rit ional
st at e, gr ow t h and dev elopm ent of t hese childr en, as
t hey help t o diagnose nut rit ional alt erat ions, t o assess
i n d i v i d u a l m o r p h o l o g i c a l c h a r a c t e r i s t i c s a n d t o
det er m ine t he prognosis of baseline defect s and t heir
com p licat ion s. I n Br azil, com m on ly u sed in d icat or s
in clu de t h e calcu lat ion of len gt h / age, w eigh t / len gt h
an d w eig h t / ag e p er cen t iles, b esid es h ead , t h or acic
and abdom inal per im et er and subscapular and t r iceps
fold m easu r es( 1 ).
Alt hough t hey exer t a global influence in t he
t r eat m en t of ch ildr en w it h con gen it al h ear t disease,
t he exact relat ion bet w een gr ow t h and food difficult ies
is not v er y clear y et( 2). I t should be added t hat few
st u dies assess t h e r elat ion bet w een an t h r opom et r ic
m easu r es an d g r ow t h in d icat or s in t h is p op u lat ion .
Mor eov er, t h e h ospit alizat ion pr ocess is r epor t ed as
a n a g g r a v a t i n g f a c t o r o f c h i l d d e v e l o p m e n t( 7 ).
Ther efor e, t his st udy aim ed t o assess t he cor r elat ion
bet w een t he ant hr opom et r ic m easur es of childr en w it h
c o n g e n i t a l h e a r t d i s e a s e a n d t h e p e r c e n t i l e s
r epr esent ing t he gr ow t h indicat or s. Mor e specifically,
w e at t em p t ed t o d escr i b e t h ei r g r ow t h i n d i cat or s,
a n t h r o p o m et r i c d a t a a n d d i f f er en ces a cco r d i n g t o
gender and t y pe of hear t disease.
MATERI AL AND METHODS
I n t his cr oss- sect ional st udy, w e car r ied out
135 serial ant hropom et ric assessm ent s of children w it h
congenit al hear t disease hospit alized at an inst it ut ion
sp ecialized in h ear t d iseases in For t aleza / Cear á,
Br a z i l . Th i s i s a ce n su s o f ch i l d r e n h o sp i t a l i z e d
bet w een June and Decem ber 2004, w it h t he follow ing
in clu sion cr it er ia: ag e u p t o 1 2 m on t h s; con f ir m ed
m e d i ca l d i a g n o si s o f a cy a n o t i c o r cy a n o t i c h e a r t
disease; and not hav ing been subm it t ed t o definit iv e
or palliat iv e h ear t su r gical cor r ect ion . Th e f ollow in g
ex clusion cr it er ia w er e defined: child’s ex it fr om t he
st udy unit because of dischar ge or t r ansfer ence, and
f o l l o w - u p o f t h e c h i l d b y a p e r s o n i n c a p a b l e o f
pr ov iding t he necessar y dat a. The st udy per iod w as
delim it ed based on t he aut hor s’ av ailabilit y for dat a
collect ion .
Dat a w er e collect ed t h r ou gh a st an dar dized
p r o t o c o l t h a t c o n s i d e r e d , b e s i d e s g e n d e r, a g e
( m ont hs) , t y pe of hear t disease ( 0 - acy anot ic, 1 –
cy an ot ic) , b ir t h w eig h t ( k g ) an d b ir t h len g t h ( cm ) ,
an t h r opom et r ic m easu r es an d gr ow t h in dicat or s.
For t h e ch ild ’s an t h r op om et r ic assessm en t ,
3 0 0
per im et er ( cm ) , t h or acic per im et er ( cm ) , abdom in al
p er im et er ( cm ) , t r icep s f old ( m m ) an d su b scap u lar
f o l d ( m m ) m e a s u r e s . I n o r d e r t o m i n i m i z e t h e
v er ificat ion bias, t r iple m easur es w er e per for m ed for
each of t h ese v ar iab les, calcu lat in g t h e r esp ect iv e
av er age. Th e f ollow in g m easu r in g in st r u m en t s w er e
u se d : Fi l i zo l a® BP b a b y sca l e s w i t h a m a x i m u m
c a p a c i t y o f 1 5 k g a n d d i v i s i o n s o f 5 g , S a n n y®
adipom et er w it h a m easur em ent scale gr aded in t ens
of m illim et ers, non t ight enable m easur em ent t ape w it h
a m i l l i m et er scal e an d a sci en t i f i c an t h r o p o m et er.
Ant hr opom et r ic m easur em ent t echniques for childr en
bet w een zer o and 23 m ont hs w er e adopt ed for w eight
a n d l e n g t h m e a s u r e m e n t s( 1 ). Pe r i m e t e r a n d
su b cu t a n e o u s f o l d m e a su r e s f o l l o w e d p r o ce d u r e s
descr ibed in specialized lit er at ur e( 1- 8).
To assess gr ow t h, w e calculat ed t he lengt h/
age, w eight / lengt h and w eight / height per cent iles, in
a c c o r d a n c e w i t h Wo r l d H e a l t h O r g a n i z a t i o n
r ecom m en dat ion s, based on a st an dar dized v er sion
of t he gr ow t h r efer ence cur ves by t he Nat ional Cent er
f or Healt h St at ist ics ( NCHS) , issu ed in 1 9 7 7( 8 ). Th e
r ecom m en ded cu t - of f poin t t o assess gr ow t h def icit
is t he per cent ile 3 , adopt ed in t his r esear ch. Values
locat ed bet w een 3 and 10 w er e consider ed as a r isk
r an ge( 1 ).
Dat a w er e an aly zed in SPSS v er sion 1 3 . 0©.
Nut St at© soft w ar e w as used t o calculat e per cent iles.
For descr ipt iv e analy sis, w e consider ed absolut e and
per cen t age f r equ en cies. To com par e t h e per cen t iles
w it h g en d er an d t y p e of h ear t d isease, d at a w er e
ordered in post s for t he post erior calculat ion of m eans,
c o n s i d e r i n g t h a t p e r c e n t i l e s t e n d t o p r e s e n t
a sy m m e t r i ca l d i st r i b u t i o n s, w h i ch d i f f i cu l t d i r e ct
c o m p a r i s o n s o f t h e i r m e a n s . Fo r t h e n u m e r i c a l
var iables, cent ral t endency, disper sion and separat ion
line m easures w ere present ed. Spearm an’s correlat ion
coefficient ( Rho) w as used t o analy ze cor r elat ions.
Th e p r oj ect w as su b m it t ed t o t h e Boar d of
t h e in st it u t ion in or der t o au t h or ize dat a collect ion ,
and t o it s Et hics Com m it t ee, w it h a view t o com plying
w it h r esolut ion 196/ 96 on r esear ch inv olv ing hum an
bein gs, issu ed by t h e Nat ion al Et h ics Cou n cil of t h e
Br azilian Healt h Min ist r y, an d w as appr ov ed( 9 ). Dat a
w e r e co l l e ct e d a f t e r p a r t i ci p a n t s h a d b e e n f u l l y
i n f o r m e d a b o u t t h e s e c r e c y o f i n f o r m a t i o n a n d
ident it ies, and aft er t he parent s / r esponsibles for t he
ch ild r en h ad sig n ed t h e f r ee an d in f or m ed con sen t
t er m .
RESULTS
The childr en’s aver age age w as 4.74 m ont hs
( SD ± 3.78) , w it h 25% up t o one m ont h and 75% up
t o eight m ont hs old. How ever, t he highest fr equency
o ccu r r ed i n t h e ag e r an g e o f u p t o t h r ee m o n t h s
( 4 6 . 7 % ) . Fr om t h e w h ole gr ou p, 6 6 . 7 % w er e m ale
childr en, cor r esponding t o t w o boys for one gir l. This
pr opor t ion can be h igh er an d ev en r each f ou r boy s
for on e gir l if w e con sider t h e ex t r em e en ds of t h e
confidence int er v als, w her e t he low est per cent age of
fem ale childr en is 20% , and t he highest for boys 80% .
Am ong t he ident ified m edical diagnoses, t he
m o s t f r e q u e n t c o n g e n i t a l d i a g n o s e s w e r e :
I n t er v en t r icu lar com m u n icat ion ( 5 3 . 3 % ) , I n t er at r ial
com m u n icat ion ( 4 2 . 2 % ) , Per sist en ce of t h e ar t er ial
channel ( 2 6 . 7 % ) , Coar ct at ion of t he aor t a ( 1 7 . 8 % ) ,
Te t r a l o g y o f Fa l l o t ( 1 3 . 3 % ) , Pu l m o n a r y st e n o si s
( 1 3 . 3 % ) a n d To t a l a n o m a l o u s p u l m o n a r y v e n o u s
dr ain age ( 1 1 . 1 % ) .
Tab le1 – An t h r op om et r ic ch ar act er ist ics of ch ild r en
w it h congenit al heart disease hospit alized at Fort aleza
Hospit al - CE
s e l b a i r a
V Mean SP Percentiles
5
2 50 75
) s h t n o m ( e g
A 4,75 3,75 1 4 8
) m c ( h t g n e
L 57,54 7,87 50,5 57 64,4 ) g K ( h t g i e
W 4,46 1,49 3,34 4,03 5,9 ) g k ( h t g i e w h t r i
B 3,11 0,63 2,63 3,13 3,35 ) m c ( h t g n e l h t r i
B 48,6 2,34 47 49 50
) m c ( r e t e m i r e P l a n i m o d b
A 37,96 3,27 35,2 38,3 40,5 ) m c ( r e t e m i r e P c i c a r o h
T 38,65 3,76 35,6 39,8 42,1 ) m c ( r e t e m i r e P d a e
H 38,51 3,28 36,3 38,3 41,3 ) m m ( d l o F s p e c i r
T 3,69 1,57 2,2 3,8 4,4 ) m m ( d l o F r a l u p a c s b u
S 3,22 1,34 2,3 3,4 4,2 P
L
A 10,89 17,64 0,48 4,06 13,72
P L
W 17,3 24,1 2,79 5,91 22,96 P
A
W 7,29 16,64 0,12 0,72 5,21
SD – St andar d dev iat ion, ALP – Age/ Lengt h Per cent ile; WLP – Weight / Lengt h Per cent ile; WAP – Weight / Age Per cent ile
The m ean bir t h lengt h w as 48.6 cm . ( SD ± 2.34
cm ) , and t he m ean bir t h w eight 3.11 kg ( SD ± 0.63
k g ) . A l t h o u g h t h e m e a n c u r r e n t l e n g t h c a n b e
consider ed adequat e for t he sam ple’s m ean age ( 57
cm , SD ± 7.87) , t he m ean cur r ent w eight is r em ar kably
low ( 4.46 kg, SD ± 1.49) , in view of a m ean w eight
gain of on ly on e k g f or a m ean age of alm ost f iv e
m ont hs. The m eans of t he t hr ee assessed par am et er s
w e r e m u t u a l l y v e r y c l o s e , w i t h a v a l u e o f
ap p r ox im at ely 3 8 . 5 1 cm an d a st an d ar d d ev iat ion
b e t w e e n 3 . 2 a n d 3 . 8 . Th e m e a n v a l u e s o f t h e
cu t an eou s f old s w er e also m u t u ally v er y close, i. e.
Evaluat ion of t he gr ow t h per cent iles...
Silva VM, Lopes MVO, Ar auj o TL.
t hat of t he t r iceps cor r esponded t o 3. 69 m m ( SD ±
1 . 5 7 ) an d t h e su b scap u lar f old t o 3 . 2 2 m m ( SD ±
1.34) ( Table 1) .
Table 2 – An aly sis of dif f er en ces in m ean valu es of
ant hr opom et r ic per cent iles in childr en w it h congenit al
hear t disease hospit alized at For t aleza Hospit al – CE,
accor ding t o gender and t y pe of hear t disease
s e l i t n e c r e
P Gender Meanofposts Heart e s a e s i
d Meanofposts
P L
A Female 48,69 Acyanotic 70,17 e
l a
M 77,66 Cyanotic 65,52
P L
W Female 66,64 Acyanotic 59,78 e
l a
M 56,73 Cyanotic 59,14
P A
W Female 54,23 Acyanotic 68,76 e
l a
M 74,88 Cyanotic 67,13
ALP – Age/ Lengt h Per cent ile; WLP – Weight / Lengt h Per cent ile; WAP – Weight / Age Per cent ile
I t is r em ar kable t hat t he m edian of t he t hr ee
per cent iles is below t he per cent ile 10. This indicat es
a lar ge pr opor t ion of values w it hin t he r isk r ange. I n
t he Age/ Lengt h per cent ile, t he r esult s of alm ost half
of t he assessm ent s ar e consider ed low gr ow t h signs
( 46.7% ) . This per cent age r ises t o 71.1% of t he t ot al
i f w e ad d t h o se ch i l d r en i n t h e r i sk r an g e w i t h a
m edian close t o t he percent ile 4. Dat a are sim ilar for
t h e Weigh t / Len gt h per cen t ile, f or w h ich 3 5 . 6 % w as
below t he per cent ile 3 and t he accum ulat ed t ot al of
values below t he per cent ile 10 w as 70.4% . The w or st
indicat or w as t he Weight / Age per cent ile, w it h 71. 9%
o f t h e v a l u e s b e l o w t h e p e r c e n t i l e 3 , a n d a n
accum ulat ed per cent age of 82.2% of t he assessm ent s
b elow t h e p er cen t ile 1 0 an d t h e m ed ian b elow t h e
per cent ile 1 ( Table 1) . Par t icular ly t he Age/ Lengt h and
Weigh t / Age per cen t iles display a h igh er m ean valu e
of post s f or t h e m ale gen der. How ev er, t h e t y pe of
hear t disease show ed slight differ ences accor ding t o
gender ( Table 2 ) .
Tab le 3 – Cor r elat ion ( ñ ) b et w een p er cen t iles an d
ant hr opom et r ic m easur es of childr en w it h congenit al
hear t diseases hospit alized in For t aleza Hospit al – CE
s e r u s a e m c i r t e m o p o r h t n
A ALP WLP WAP
r e t e m i r e P l a n i m o d b
A 0,027 -0,010 -0,148 r e t e m i r e P c i c a r o h
T -0,031 -0,212 -0,280
r e t e m i r e P d a e
H -0,060 -0,372 -0,345 d l o F s p e c i r
T 0,188 -0,083 0,119
d l o F r a l u p a c s b u
S 0,230 0,202 0,321
ALP – Age/ Lengt h Per cent ile; WLP – Weight / Lengt h Per cent ile; WAP – Weight / Age Per cent ile.; ñ – Spear m an’s Cor r elat ion Coefficient
I n t he non- par am et r ical cor r elat ion analy sis,
w e o b se r v e d a p o si t i v e co r r e l a t i o n b e t w e e n t h e
subscapular fold and t he t hr ee per cent iles. The best
cor r elat ion occu r r ed w it h t h e Weigh t / Age per cen t ile
( R = 0 . 3 2 1 ) . Th i s p e r c e n t i l e a l s o r e v e a l e d t h e
st r on gest cor r elat ion w it h alm ost all an t h r opom et r ic
m easu r es, ex cept f or t h e t r iceps f old. Th e n egat iv e
cor r elat ion b et w een t h e p er cen t iles an d p er im et er s
show s t hat t he gr ow t h indicat or s ar e not dev eloping
sat isf act or ily in lin e w it h t h e ch ild ’s st r u ct u r es an d
or gans. Hence, w hile t he head, t hor acic and abdom inal
p er im et er s in cr ease t h r ou g h t h e g r ow t h of in t er n al
or gan s, t h e r elat ion s bet w een t h e gr ow t h in dicat or s
w or sen ( See Table 3) .
DI SCUSSI ON
I n an epidem iological st u dy of ch ildr en an d
adolescen t s w it h con gen it al h ear t def ect s, t h e m ost
fr equ en t ly fou n d age r an ges w er e t h e n eon at al an d
br east feeding per iods, cor r esponding t o 71.5% of t he
t ot al num ber of par t icipant s w it h defect s( 10). An earlier
st udy of infant s w it h congenit al heart disease ident ified
a p r of ile sim ilar t o t h is st u d y in t er m s of ag e an d
g en d er( 4 ). D esp i t e t h e g r ea t er p r o p o r t i o n o f m a l e
ch ild r en in ou r st u d y, t h e p r ev alen ce of con g en it al
hear t diseases differ s for t he var ious t ypes of defect s
t hat ar e diagnosed. Som e of t hese defect s can ev en
show higher pr opor t ions in fem ale childr en( 10).
Am ong t he com m only used child assessm ent
m e a su r e s, w e i g h t a n d l e n g t h d i sp l a y t h e h i g h e st
g r ow t h sp eed , m ain ly f r om b ir t h u n t il t h e f ir st t w o
y e a r s o f l i f e . H o w e v e r, t h e d e c o m p e n s a t i o n o f
con gen it al h ear t diseases can decr ease or in t er r u pt
t his gr ow t h speed. I t is em phasized t hat , aft er bir t h,
children w it h congenit al heart disease present profiles
sim ilar t o t h ose f ou n d in t h is st u d y, in w h ich b ir t h
w eight and lengt h v alues ar e close t o or ev en w it hin
t he nor m alit y r ange and t he childr en generally obt ain
high Apgar scor es( 11).
Wh en con sid er in g t h e p er im et er m easu r es
isolat edly, t heir m eans are w it hin t he norm alit y range.
More specifically, t he head perim et er direct ly assesses
h ead gr ow t h an d in dir ect ly br ain dev elopm en t( 1 ). I n
full- t er m new bor ns, it am ount s t o 32- 35 cm , but can
be low er due t o overr iding sut ur es. I t s gr ow t h is higher
in t he fir st m ont hs of life: it cor r esponds t o t w o cm
p e r m o n t h i n t h e f i r s t t e r m a n d d e c r e a s e s i n
su b seq u en t m o n t h s( 8 ). W h en ca l cu l a t i n g t h e h ea d
perim et er for a child of five m ont hs, t he result is close
t o t he m ean r esult found in t he st udy sam ple. A sim ilar
3 0 2
A t b i r t h , t h e t h o r a c i c p e r i m e t e r i s
a p p r o x i m a t e l y t w o c m s m a l l e r t h a n t h e h e a d
p e r i m e t e r, g e t s e q u a l a t a b o u t s i x m o n t h s a n d
b e c o m e s l a r g e r a s f r o m t h e f i r s t y e a r o f l i f e
onw ar ds( 8). At bir t h, t he abdom inal per im et er is about
2- 3 cm sm aller t han t he head per im et er. The pr opor t ion
of it s grow t h speed is sim ilar t o t he t horacic perim et er.
I n t his st udy, m ut ually sim ilar values w er e found for
t he t hr ee per im et er s, possibly due t o t he pr esence of
t h o r a ci c d e f o r m i t i e s a n d a n e x p a n d e d a b d o m i n a l
cont our in childr en w it h congenit al hear t diseases.
Th e m easu r es u n der goin g t h e gr eat est loss
in childr en w it h congenit al hear t diseases ar e cur r ent
l en g t h an d w ei g h t . A f i f t een - cen t i m et er g r o w t h i s
ex pect ed in t h e f ir st sem est er an d y et an ot h er t en
cen t im et er s in t h e secon d. Th e ch ild gr ow s abou t 3
cm dur ing t he fir st m ont h and bet w een 1 and 2 cm in
subsequent m ont hs( 12). What w eight is concerned, unt il
t he t hird m ont h of life, t he child’s w eight is assessed
b y t h e w eig h t g ain in g r am s p er d ay, at a r at io of
bet w een 25 and 30 g/ day. As fr om t he second t er m ,
t h e d aily g ain p r og r essiv ely d ecr eases an d r each es
10 g/ day in t he last t hr ee m ont hs( 13). The m ean w eight
an d len g t h v alu es sh ow ed a d ecr ease in ex p ect ed
values for t he m ean age of five m ont hs in t he assessed
childr en w it h congenit al hear t diseases.
I t should be highlighted that the anthropom etric
m easures alone have no m eaning t o assess children’s
growt h. Thus, t hey need t o be associat ed wit h gender,
a g e o r o t h er a n t h r o p o m et r i c v a r i a b l es a n d t h e
construction of indicators. As to the weight/ length ratio,
literature appoints that, in children with congenital heart
diseases, it decreases rapidly in adverse situations, m ainly
in case of cy an ot ic h ear t d iseases( 1 , 1 1 ), a f act t h at
co r r o b o r at es o u r f i n d i n g s. Mo r eo v er, t h e assessed
children’s weight/ age and length/ age ratios were close to
the lower cut-off points. We also perceived difficulties in
t h ese ch i l d r en t o p er f o r m p sy ch o m o t o r a ct i v i t i es
characteristic of the studied age range.
How ev er, it h as n ot b een clar if ied y et h ow
t he t ype of heart disease influences t he child’s grow t h.
A p r ev iou s st u d y( 1 4 ) d id n ot f in d an y d if f er en ce in
an t h r opom et r ic in dicat or s am on g gr ou ps of ch ildr en
w it h cy anot ic and acy anot ic hear t disease. I t should
be clar ified t hat w e did not find such a differ ence in
t his st udy eit her.
S o m e o f t h e f i n d i n g s i n o u r s t u d y a r e
cor r obor at ed by an ot h er r esear ch am on g Au st r alian
ch ildr en , w h ich fou n d t h at alm ost all ch ildr en u n der
st udy ( 98% ) pr esent ed a low er w eight / age r at io t han
t h e t h ir d cen t ile an d 4 1 % a low er len g t h / ag e r at io
t h a n t h i s cu t - o f f p o i n t( 1 5 ). Fu r t h e r m o r e , a n o t h e r
r esear ch indicat ed t hat childr en w it h congenit al hear t
disease t en d t o obt ain a w or se w eigh t / len gt h r at io,
especially at t he age of six t o t w elve m ont hs( 9).
I n parallel, a st udy of Belgian childr en show ed
an in cr ease in t h e f r eq u en cy an d sev er it y of acu t e
and chr onic m alnut r it ion aft er bir t h, w hich w as m or e
in t en se in ch ild r en w it h m u lt ip le d ef ect s ( p = 0 . 0 3 ) .
Ch r on ic m aln u t r it ion w as f ou n d m or e f r eq u en t ly in
childr en w it h hear t failur e, cyanosis or a com binat ion
of bot h ( p= 0.01) . The pr evalence of m alnut r it ion w as
in f lu en ced n eit h er by gen der n or by t h e r eason f or
h osp it alizat ion . How ev er, it s con seq u en ces f or t h e
childr en’s gr ow t h could be per ceived( 11). I n t his st udy,
on t h e ot h er h an d , d i f f er en ces b et w een m al e an d
fem ale children w ere ident ified for t he age/ lengt h and
w eigh t / age per cen t iles.
Unfor t unat ely, w e did not find any st udies t hat
cor r elat ed per im et er s and cut aneous folds w it h gr ow t h
percent iles, as used in t his st udy. One im port ant point
t hat should be highlight ed, how ev er, is t he negat iv e
cor r elat ion bet w een t he head and t hor acic per im et er s
on t he one hand and t he w eight / lengt h and w eight /
age per cent iles on t he ot her, show ing t he t endency t o
d ev elop in t er n al or g an s, p ar t icu lar ly t h e b r ain an d
hear t st r uct ur es, as w ell as t he w eak pr ogr ession in
g r ow t h in d icat or s, m ain ly t h ose r elat ed t o w eig h t .
Alt hough t he folds dem onst r at ed a posit ive cor r elat ion,
m ainly t he subscapular one, t heir influence on grow t h
indicat or s r ev eals t o be w eak .
Th i s st u d y sh o w s so m e l i m i t a t i o n s, w h i ch
should be t aken int o account in it s applicat ion. I n t he
first place, t he use of percent iles t o analyze children’s
gr ow t h and developm ent , alt hough com m on in Br azil,
m ak es it d if f icu lt t o com p ar e r esear ch r esu lt s w it h
int er nat ional dat a, w hich com m only use t he Z scor es.
Mor eov er, it should be em phasized t hat t he dat a w e
pr esent ed w er e not com par ed w it h a cont r ol gr oup of
childr en w it hout hear t diseases, m ak ing it im possible
t o assess t he efficacy of using percent iles in pract ice.
The fact t hat t his st udy w as dev eloped w it h childr en
f r om an econ om i cal l y p oor er r eg i on i n Br azi l m ay
have influenced t he low rat ios w e ident ified. Moreover,
t h e m u l t i p l e h e m o d y n a m i c ch a n g e s p r o v o k e d b y
d if f er en t h ear t d ef ect s ar e a f act or t h at sh ou ld b e
t a k e n i n t o a c c o u n t w h e n a n a l y z i n g t h e l a c k o f
differ en ces am on g t h e st u died per cen t iles.
I t sh ou ld be h igh ligh t ed t h at , w h at n u r sin g
p r act i ce i s co n cer n ed , i n Br azi l , f ew st u d i es h av e
Evaluat ion of t he gr ow t h per cent iles...
Silva VM, Lopes MVO, Ar auj o TL.
look ed at car e d eliv er y t o ch ild r en w it h con g en it al
hear t diseases. Br azilian nur ses need m or e accur at e
in f or m at ion t o assess t h e pr ogr ession an d st age of
t he hear t pr oblem , w it h a v iew t o ident ify ing hum an
r esponses and fact or s r elat ed t o nut r it ion and gr ow t h
an d dev elopm en t in t h is popu lat ion . Th is ar ea lack s
st udies t hat allow for a m or e t hor ough descr ipt ion of
t h e se r e sp o n se s a n d , m a i n l y, r e se a r ch i n v o l v i n g
int ervent ions t hat are specifically direct ed at im proving
t hese childr en’s nut r it ional indicat or s.
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