Malnutrition is still a common problem in pediatric practice in India(1). But at present in India, we may not be correct in assuming that all the cases of malnutrition are due to lack of availability of proper diet due to poor socio-economic background. Even though it is an important problem to be addressed by our society, we should not loose sight of the fact that in some cases the malnutrition could be secondary to some medical disease or these diseases may be a contributing factor, one of them being congenital heart disease. It is important to keep this in mind as at present most of the congenital heart diseases can be corrected if diagnosed early and timely intervention is provided. This will result in normalization of their malnourishment early due to decreased caloric requirement, better absorption, reduction in lower respiratory tract infections, etc. Some of the cases of malnutrition may have an underlying heart disease which may be solely responsible or more commonly contribute to malnutrition(2, 3).

Patients with increased pulmonary blood flow and pulmonary hypertension are more prone to develop malnutrition and growth retardation. Associated hypoxia in patient with cyanosis and pulmonary hypertension further increases the problem. Inadequate diet, repeated infection, worm infestation, etc being the other issues. The article written by Vaidyanathan, et al.(4) in this issue of Indian Pediatrics very aptly emphasizes the need to understand that till the underlying heart disease is corrected, no amount of hyperalimentation is going to improve malnutrition.

In the process of trying to do the same, one may miss the correct time for corrective intervention of the defect. In the present era of expertise in the fields of pediatric cardiac surgery, intensive care, anesthesia and cardiology, the weight alone is no criteria to reject an infant for corrective intervention. However one has to realize that the baby needs careful assessment whether the heart disease is actually responsible or contributing to the malnutrition or not. Some of the babies may have associated heart disease which may not really be the cause of malnutrition and taking the risk to intervene a baby with inadequate weight may be futile in such a situation.

It is interesting to note that in the article by Vaidyanathan, et al.(4) in this issue, degree of desaturation and the cardiac diagnosis in no way affected the nutritional status of the patients which is contrary to the earlier reports(2,5). However they do find a correlation with congestive heart failure as reported by several authors(2,6). They have demonstrated an adverse impact of delayed corrective intervention for the growth potential, which is quiet logical. In this article a very important factor of properly timing the corrective intervention has been highlighted. This is extremely important to emphasize that in children with congenital heart disease and congestive heart failure it is useless to attempt aggressive calorie supplementation and wait for adequate weight for corrective intervention. The best approach is to give calorie supplements, appropriate management of congestive heart failure and timely referral for corrective intervention. In the present era, age and weight are no bar for corrective intervention. Timely corrective intervention remains the most important factor for good long term results.

Competing interests: None stated