Undernutrition Burdens Young Children With Congenital Heart Disease in Pakistan

Nearly half of young children with congenital heart disease in northwestern Pakistan are undernourished, and the deficits are most severe during infancy, according to a multicenter study that offers some of the most detailed regional evidence yet on how cardiac defects and malnutrition collide in a resource-constrained setting. The research, published in Frontiers in Nutrition, examined 197 children under five years of age with echocardiographically confirmed congenital heart disease (CHD) across three tertiary hospitals in Bannu District, Khyber Pakhtunkhwa, and found that 44.2 percent were underweight, 40.1 percent were stunted, and 35.5 percent suffered from wasting. These figures substantially exceed national population averages for Pakistan, where the Health and Demographic Survey reports 38 percent stunting, 23 percent underweight, and 7 percent wasting among children generally.

Congenital heart disease refers to structural abnormalities of the heart or the great vessels present at birth, encompassing more than 25 recognized types. Septal defects, which include atrial septal defect (ASD), ventricular septal defect (VSD), and atrioventricular septal defect (AVSD), account for roughly 40 percent of cases. CHD is the most common congenital anomaly worldwide, affecting approximately 1.5 million newborns annually, and in Pakistan it caused 9.4 infant deaths per 1,000 live births between 2010 and 2017, ranking seventh among causes of infant mortality. Children with CHD face a markedly elevated risk of undernutrition because the pathophysiology of the disease works directly against growth: elevated metabolic demands, feeding intolerance, impaired nutrient absorption, fluid restrictions, heart failure, and chronic hypoxia-induced polycythemia collectively impair growth, weaken myocardial and respiratory muscle function, compromise immunity, and increase susceptibility to infection.

The study was conducted from December 2024 to May 2025 at Khalifa Gul Nawaz Teaching Hospital, District Headquarter Teaching Hospital, and Women and Children Teaching Hospital, all affiliated with the Medical Teaching Institution Bannu. Participants were children aged 6 to 59 months with CHD confirmed by echocardiography, recruited consecutively from pediatric and cardiology departments. The sample size was calculated using the standard formula for estimating a single population proportion, based on an estimated CHD prevalence of 4.3 percent, a 95 percent confidence level, and a 3 percent margin of error, yielding a target of 196 children after accounting for a 10 percent non-response rate; 197 respondents were ultimately included. Children with co-occurring major congenital anomalies, chromosomal or monogenic disorders such as Down syndrome, or chronic conditions known to independently impair growth, such as chronic kidney disease or celiac disease, were excluded to isolate the cardiac and nutritional burden.

Data collection was carried out by pediatric residents and cardiology fellows trained by the principal investigator on standardized anthropometric measurement techniques, structured questionnaire administration, and ethical protocols for working with CHD children. All measurements were performed by trained medical doctors under direct supervision, and caregivers provided written informed consent before any data collection. Age was confirmed from vaccination cards or national identity documents, and sociodemographic and feeding practice data were collected in Pashto or Urdu using validated, pretested questionnaires. CHD cases were classified by a pediatric cardiologist based on echocardiographic findings into anatomical subtypes, including ASD, VSD, patent ductus arteriosus (PDA), tetralogy of Fallot (TOF), and transposition of the great arteries (TGA), and further stratified as cyanotic or acyanotic.

Anthropometric assessment followed WHO-recommended protocols using calibrated equipment, with digital weighing scales accurate to 0.1 kilograms and infant length boards or standing stadiometers accurate to 0.1 centimeters. Measurements were recorded twice and averaged. Length was measured for children under two years and height for those two years or older. Nutritional status was classified using the WHO 2006 Child Growth Standards: stunting defined as height-for-age Z-score below negative two, wasting as weight-for-height Z-score below negative two, and underweight as weight-for-age Z-score below negative two. Z-scores were calculated with WHO Anthro software, and statistical analysis was performed with IBM SPSS Statistics version 22.0. Multivariable logistic regression identified independent associations, reported as adjusted odds ratios with 95 percent confidence intervals, with model fit assessed by the Hosmer–Lemeshow test and multicollinearity screened using variance inflation factors below five.

The cohort was male-predominant at 58.9 percent, predominantly rural-dwelling at 80.7 percent, and had a mean age of 23.1 months. Most children were born in healthcare facilities, fathers were primarily engaged in manual labor or agriculture, and mothers were overwhelmingly homemakers. Parental educational attainment was low, with 68.5 percent of fathers and 82.7 percent of mothers having completed no formal schooling or only primary education. Ventricular septal defect was the most prevalent lesion at 34.5 percent, followed by patent ductus arteriosus at 23.4 percent, atrial septal defect at 21.3 percent, tetralogy of Fallot at 14.2 percent, transposition of the great arteries at 5.1 percent, and coarctation of the aorta at 1.5 percent. At the time of assessment, 68 percent were receiving cardiac-specific pharmacotherapy such as diuretics, beta-blockers, or digoxin, and 20.3 percent had undergone prior corrective or palliative surgery or catheter-based intervention.

Z-score analysis revealed mean values notably below the reference median for height-for-age (negative 1.82), weight-for-age (negative 1.84), and weight-for-height (negative 1.09), indicating moderate-to-severe undernutrition across the cohort. The youngest age group, 6 to 11 months, exhibited the most severe deficits, with mean weight-for-age Z-scores of negative 2.46 and height-for-age Z-scores of negative 2.08, both falling below the negative two threshold, while older children aged 25 to 59 months showed relatively better, though still suboptimal, growth parameters. Boys demonstrated worse stunting, whereas girls showed slightly higher wasting on raw Z-scores. These findings indicate a substantial concurrent burden of both chronic undernutrition, reflected in stunting, and acute undernutrition, reflected in underweight and wasting, among children with CHD in the region.

Multivariable logistic regression identified several independent factors. Male children had significantly higher odds of wasting than female children, with an adjusted odds ratio of 2.10 and a 95 percent confidence interval of 1.10 to 3.98. Children from households with a monthly income of at least 40,000 Pakistani rupees had significantly lower odds of wasting (adjusted odds ratio 0.45, confidence interval 0.24 to 0.84) and underweight (adjusted odds ratio 0.52, confidence interval 0.29 to 0.94), indicating a protective effect of higher household income. Children whose fathers were government employees also had significantly lower odds of being underweight (adjusted odds ratio 0.30, confidence interval 0.09 to 0.98). No sociodemographic or clinical variable was significantly associated with stunting after adjustment, although some variables, including atrial septal defect, patent ductus arteriosus, tetralogy of Fallot, and higher household income, demonstrated trends toward association that did not reach statistical significance.

The authors note that the absence of statistical significance for stunting does not necessarily indicate the absence of a clinically meaningful association. Possible explanations include limited sample size, insufficient variability in relevant exposures, heterogeneity in CHD severity, unmeasured clinical confounding, measurement-related factors, and the cross-sectional nature of the study. The researchers also acknowledge that recruitment from tertiary care hospitals may have resulted in a sample that differs from the broader population of CHD children, and that higher socioeconomic groups are underrepresented because they preferentially utilize private healthcare facilities. However, they argue that this sampling bias inadvertently captures the population most susceptible to malnutrition-related morbidity. Variables such as heart failure class, pulmonary hypertension, oxygen saturation, feeding difficulties, timing of surgical intervention, and recurrent infections were not included in the analysis and may have influenced the findings.

The study’s regional specificity strengthens its value for policy. In Khyber Pakhtunkhwa, the regional distribution of CHD prevalence indicates the highest rates in the Peshawar division at 36.98 percent, followed by Malakand at 28.84 percent, Mardan at 16.71 percent, Kohat at 6.1 percent, Bannu at 4.3 percent, Hazara at 3.5 percent, and Dera Ismail Khan at 3.5 percent. A tertiary hospital in Karachi reported that approximately 60,000 infants are born annually with congenital malformations, among whom 60 percent experience early-stage mortality. Research in Faisalabad found that atrial septal defect was the most observed cardiac defect at 41.5 percent of cases, followed by tetralogy of Fallot at 21 percent, ventricular septal defect at 14 percent, and patent ductus arteriosus at 8 percent. The Bannu cohort’s lesion distribution differs from these regional patterns, with ventricular septal defect leading, suggesting geographic variation in the spectrum of CHD across Pakistan.

Comparative evidence from other low- and middle-income countries places the Bannu findings in a broader context. A previous study in Indonesia reported that 49 percent of children with CHD were underweight, 47.8 percent were stunted, and 31.4 percent were wasted, figures closely mirroring the Bannu cohort. The prevalence of stunting in Bannu, at 40.1 percent, exceeds rates reported in high-income countries of 21 to 24 percent and is close to findings from Uganda at 45 percent, affirming the disproportionate impact of CHD on linear growth in low- and middle-income settings. Underweight at 44.2 percent further indicates a concurrent acute and chronic energy deficit, aggravated by CHD-associated feeding challenges such as dysphagia, fatigue during feeding, and gastroesophageal reflux, as well as an increased infection burden. According to the World Health Organization, approximately 15 to 64 percent of children suffering from CHD experience undernutrition, and hospital-based investigations in developing nations consistently indicate high incidences of malnutrition among these children.

The mechanisms linking CHD to undernutrition are well documented. Hemodynamic instability, reduced nutritional intake resulting from feeding fatigue, impaired food absorption, fluid restriction, heart failure, polycythemia caused by persistent hypoxia, and increased metabolic requirements due to the pathophysiology of CHD all contribute. The cardiac and respiratory muscles are impacted, entailing atrophy of muscle mass, which results in impaired myocardial and respiratory functions. Immunological competence and reparative capacity are also influenced, increasing susceptibility to infections. Pulmonary hypertension has been associated with roughly 1.9-fold higher odds of malnutrition, and congestive heart failure impedes growth via chronic hypoxia, reduced perfusion, gut congestion, and nutrient malabsorption. These factors suggest insufficient nutrient intake and chronic exposure to infections, along with substandard care practices during the crucial early stages of life.

The authors emphasize that early diagnosis alone is inadequate in the context of this concurrent epidemic of cardiac and nutritional vulnerability. An effective response requires integrated clinical measures, including routine anthropometric screening at initial contact for CHD, family-centered feeding counseling, and systematic linkage of cardiac services with community growth monitoring and social support. They recommend expanding the implementation of antenatal echocardiography for early detection, subsidizing CHD medications and therapeutic foods within public health systems, according priority to nutritional rehabilitation for rural and male infants, and empowering caregivers through context-appropriate feeding education and growth monitoring. The associations between household income, paternal government employment, and nutritional outcomes not only mirror material benefits but also heightened health literacy, care coordination, and treatment compliance, which consistently correlate with improved outcomes in pediatric CHD, although potential mechanisms such as health literacy and treatment adherence were not directly assessed in the current study.

The multicenter design, encompassing three public hospitals catering to diverse service areas within Bannu District, enhances internal validity and local representativeness. All anthropometric measurements were standardized in accordance with WHO Growth Standards, and multivariable modeling was rigorously adjusted for factors such as age, sex, locality, income, and maternal education. The demographic and healthcare characteristics of Bannu are generally representative of similar low- and middle-income regions, though the single-district setting restricts national generalizability. The authors conclude that children with CHD have high rates of undernutrition, including wasting and stunting, with several associated factors, and that timely referrals for nutritional support are of great significance in preventing nutritional deterioration. They call for population-based studies and the incorporation of standardized clinical measures such as severity, heart failure status, oxygen saturation, pulmonary hypertension, and feeding difficulties to provide representative findings and improve generalizability. Addressing these intersecting biological and social determinants, they argue, is crucial for enhancing the survival, growth, and long-term developmental outcomes of children with CHD in resource-limited settings.

Subject of Research: Addressing the burden and associated factors of undernutrition in under-five children with congenital heart disease in Pakistan: evidence from a multicenter cross-sectional study

Article Title: Addressing the burden and associated factors of undernutrition in under-five children with congenital heart disease in Pakistan: evidence from a multicenter cross-sectional study

Article References: Addressing the burden and associated factors of undernutrition in under-five children with congenital heart disease in Pakistan: evidence from a multicenter cross-sectional study. (n.d.). https://doi.org/10.3389/fnut.2026.1953133

Image Credits: AI Generated

DOI: 10.3389/fnut.2026.1953133

Keywords: Addressing, burden, associated, factors, undernutrition, under-five, children, congenital, heart, disease, Pakistan, evidence