Rheumatic heart disease in children of developing countries is the commonest

acquired heart disease. Malnutrition is associated with rheumatic fever that preceding
rheumatic heart disease. Chronic malnutrition that indicated with low height for age is
associated with rheumatic fever (1). Low intake of several foods such as eggs, milk,
and meats observed in subjects with rheumatic fever (2). Rheumatic subjects found to
have lower intake of eggs than in non-rheumatic control subjects (1). The
phospholipids and palmitamide that contained in those stuffs are considered have
roles in supressing hyper-responsiveness of the susceptible subject and rheumatic
process maturation (3). Other study found that serum albumin and iron stores are
lower in rheumatic subjects (1).
Malnutrition in pediatric heart failure is related to an imbalance between energy
intake and energy expenditure, caused by multifactorials such as hypermetabolism,
decreased intake, increased nutrient losses, inefficient utilization of nutrients, and
malabsorption. Children with heart failure often present with decreased appetite,
increased muscle wasting, increased protein breakdown, and reduced muscle
regeneration due to the chronic imbalance of autonomic sympathetic and
parasympathetic activities. Insufficient utilization of nutrients and intestinal
malabsorption also present due to chronic hypoxia and gut edema from venous
congestion (4).
Growth failure is a problem in children with heart failure and can be an important
predictor factor of disease outcome and severity. The prevalence of wasting (z score
of weight for height <–2) in pediatric heart failure was reported as 86%. Therefore,
nutrition assessment is important to provide appropriate intake of energy, protein, and
micronutrients (4). Condition such as tachypnea, tachycardia, fatigue, nausea, and
vomiting that caused children may not be able to meet nutrition requirements through
oral intake should be considered for nutrition support such as enteral or parenteral
nutrition (5). Clinical outcomes and quality of life of pediatric heart failure can be
improved with nutrition interventions (4). On contrary, malnutrition in pediatric heart
failure were associated with death. In children with heart failure, a year mortality in
malnourished patient was found to be 56% (6).
Macronutrient requirements such as protein and fat should be estimated based on
increased metabolic needs of children with heart failure. Micronutrients such as
vitamin D and calcium also have important roles due to patient with heart failure may
be at risk for developing metabolic bone disease. Other trace elements such as zinc
and selenium as enzymatic antioxidants that protect cell membranes from free radical
also required. Maintenance fluid requirements are often limited in patient with heart
failure, therefore feeds need to be modified. Hypercaloric feeds and oral supplement
may be required in patient with fluid restriction and hypermetabolism (4). Sodium
balance also needs to be ideally adjusted to assist in managing fluid balance because
high sodium concentration causes fluid retention (7).

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associated with acute rheumatic fever: a hospital-based case control study in
Bangladesh. Pediatr Perinat Epidemiol. 1997;11:322–32
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Microbiol Rev. 2000;13:470–511
4. Lewis KD, Conway J, Cunningham C, Larsen BMK. Optimizing nutrition in
pediatric heart failure: the crisis is over and now it's time to feed. Nutr Clin Pract.
2018;33(3):397-403
5. Benzecry SG, Leite HP, Oliveira FC, et al. Interdisciplinary approach improves
nutritional status of children with heart diseases. Nutrition. 2008;24(7):669-74
6. Gebremariam S, Moges T. Pediatric heart failure, lagging, and sagging of care in
low income settings: A Hospital Based Review of Cases in Ethiopia. Cardiol Res
Pract. 2016;2016:1-7
7. Sica DA. Sodium and water retention in heart failure and diuretic therapy: basic
mechanisms. Cleve Clin J Med. 2006;73(2):2-7