Language Disorders in Children with Chronic Cardiac Illness

Introduction

heart disorders (CHDs) are structural issues caused by faulty heart or major blood artery development. It is the most prevalent of all congenital lesions and the most prevalent form of pediatric heart diseases patient  may exhibit abnormal brain development^[2]. This may then result in developmental delays, such as a decline in cognitive function and/or specific neuropsy-chological deficits ^{[3, 4]}.

Children with CHD are more likely to experience language and speech issues in their preschool years^{[5, 6]}.

Most studies found that children with CHD had overall IQ values that were below average ^{[7, 8]}.

In those children with CHD, the neuro-developmental abnormalities altering brain development can occur due to multiple factors^[5].

Prenatally, decreased umbilical vein oxygen content and altered cerebral hemodynamic flow result in decreased oxygen supply to the brain^[9,10]. Reduced cerebral growth results from these changes, especially during the last trimester of pregnancy when energy demands increase^[11].

In addition to the pre-existing changes in brain growth and maturation, there are other postnatal influences. For instance, postnatal hypoxia^{[12, 13]} and decreased cerebral blood flow^[14].

Methods

Subjects and Study Design:

The present study was carried out at Minia University hospital (ENT department, Phoniatrics unit), and included 50 children aged between 2 to 7 years and 5 months. They were 24  males (48%) and 26 females (52%) and classified into 2 groups: The (study group) included 25 children who diagnosed with chronic cardiac diseases and the (control group) included 25 children without cardiac diseases. This study was approved by the ethics comm-ittee in the faculty of medicine, Minia university hospital, and consents were obtained from subjects.

Exclusion criteria:

• Presence of any acute illness.
• Previous language therapy.
• Previously diagnosed neurological or psychiatric disorder.

Methods:

All children were assessed according to the language assessment protocol in the Phon-iatrics Unit, Minia University Hospital.

I- Preliminary Diagnostic Procedures:

1. Parents' interview and history including complaint, personal data, personal history, searching for etiological factors during pregnancy, natal, neonatal, and postnatal periods, developmental milestones and illness of early childhood.
2. Examination including neurological and otorhinolaryngology examination to exclude any neurological deficit.
3. Subjective auditory perceptual assessment "APA" of language for preliminary evaluation of receptive and expressive language abilities.

II-Clinical Diagnostic Aids:

1. Audiological evaluation: included middle ear assessment through immitan-cemetry (Tympanometry and Acoustic Reflex threshold recording) and hearing assessment. According to the age of child, hearing assessment was performed through one of the following methods:

• Free field audiometry and Behavioral Observational Audiomety (BOA).
• Pure tone audiometry (Conditioned play or conventional audiometry).
• Auditory Brainstem Response "ABR".

2. Psychometric evaluation:

By Intelligence Quotient "IQ" using Stan-ford Binet Intelligence test 5^th edition  ^[15].

3. Language test: by Arabic Preschool Language Scale-4 "APLS-4" ^[16].

Results

As regard demographic data, Non- statistical significant differences were obtained between the study and the control group as regard the age, sex, parent consanguinity and similar condition in family (P≥0.05). Whereas, a statistically significant difference was obtained between the two groups as regard prenatal problems (Table 1).

There was statistically significant differ-ence between the study and control groups regarding time of the first cry, with a statistically significant difference between

the two groups regarding cyanosis at birth (P< 0.001).

As regard type of feeding, children with cardiac diseases showed significant increase in the frequency of mixed feeding in comparison to children in the control group who showed significant increase in the frequency of breast feeding (Table 2).

There was a statistically significant difference between the study and control groups as regarding the IQ grades (P< 0.001), with a mean of (93.8±5.8) in the control group and (82±9.7) in the cardiac disease group (Table 3).

Also, a statistically significant difference was obtained between the two groups regarding the standard scores of receptive, expressive and total languages (Table 3).

And there were non-statistical significant differences on comparison between the two lines of treatment regarding IQ and language outcomes (Table 4).

By correlation, there were positive significant correlations between IQ and standard scores of receptive, expressive and total language scores, positive significant correlations between SS of receptive and SS of expressive and total language and positive significant correlation between SS of expressive and SS of total language (Table 5).

There was negative significant correlation between parent consanguinity and standard scores of receptive and total language scores, negative significant correlation between delayed onset of walking and IQ, standard scores of receptive, expressive and total languages. Also, there was negative significant correlation between delayed age of first word utterance and IQ, standard scores of receptive, expressive and total languages (Table 5).

Discussion

In terms of prenatal issues, a statistically significant difference between the children with cardiac illnesses and controls was found. Eight out of twenty-five mothers of children with cardiac conditions experi-enced these issues, which included preeclampsia (five), anemia (one), first-trimester hemorrhage (one), and steroid use during pregnancy (one).

Preeclampsia and maternal anemia have the potential to disrupt the placenta, which increases the risk of fetal hypoxia and congenital abnormalities, such CHD. Additionally, prenatal steroid use might result in congenital abnormalities and disrupted fetal growth.

This was in agreement with Yilgwan, Pam^[17] who proposed that Preeclamptic mothers may increase the risk of CHD in their infants. And in agreement with Kalisch-Smith, Ved ^[18] who assumed that maternal anemia may raise the chance of CHD development..

Regarding the timing of the first cry and the presence of cyanosis at birth, there was a statistically significant difference between the study and control groups. This is due to the cyanotic nature of various heart disorders, as mentioned by Humayun and Atiq ^[19] that cyanotic congenital heart disorders are to blame for roughly 25% of cardiac abnormalities.

And as explained by Grifka ^[20] children with cyanotic CHD may develop cyanosis for one of two reasons: either there is insufficient blood flow to the lungs, or a sizable volume of deoxygenated  blood is pumped to the body (systemic circulation) and a sizable amount of oxygenated blood is pushed back to the lungs (together with some blue blood).

In terms of feeding style, children with heart conditions had a much higher frequency of mixed breast-and-formula feedings than children in the control group, who had a significantly higher frequency of breast-feeding. This can be explained by the fact that adding bottle formula feeding to some meals makes feeding simpler and requires less effort because children with cardiac disorders may face feeding difficulties and early exhaustion owing to shortness of breath. 

This is in agreement with Jones, Desai ^[21] who stated that due to medical conditions, delayed transition to oral feeding, oral feeding rejection, developmental delays, and the effects of the stressful intensive care unit (ICU) environment, children with CHD typically encounter oral feeding difficulties.

With a mean IQ score of (93.8±5.8) in the control group and (82±9.7) in the cardiac illness group, there was a statistically significant difference between the study and control groups with regard to the IQ grades (P< 0.001). This could be as a result of hypoxia's harmful effects on the brain and cognition, lengthy hospital stays, and medical and surgical difficulties.

This came in agreement with^[7] who suggested that the greatest risk variables for neurodevelopmental deficits in children with CHD were low birth weight, lengthy stays in the NICU, post-operative clinically confirmed seizures, and low socioeco-nomic status.

This also, was in agreement with several studies that indicated lower overall IQ scores for children with CHD were in the low average range ^{[7, 8]}.

Additionally, a statistically significant difference was found between the two groups in terms of the receptive, expressive, and total language standard scores. This is because children with heart conditions have lower IQs, hospitalization causes environmental deprivation, and hypoxia affects neurodevelopment.

This was in agreement with Hövels-Gürich, Bauer^[6] and Liamlahi and Latal ^[5] who demonstrated a greater frequency of linguistic problems in preschool-aged children with CHD. Also agreed with recent investigations by Karmacharya, Gagoski ^[22] and Sommariva, Zilli ^[3] who suggested that children with CHD may experience severe impairments in the brain networks responsible for language processing.

This, however, went against some neuro-psychological research by Cassidy, Ilardi ^[23] and Sarrechia, Miatton^[24] who sugge-sted that language was a pretty well-preserved cognitive capacity in children with CHDs.

Regarding IQ and language outcomes, there were non-statistically significant differences between the conservative and surgical treatment modalities. This might be a result of recent advancements in surgical techniques that produce better results, have less side effects, and need shorter hospital stays.

This was contrary to the claim made by Mussatto, Hoffmann^[4] and Sommariva, Zilli^[3] that infants who have undergone heart surgery are more likely to have early language difficulties..

By correlation, there were positive significant correlations between IQ and standard scores of receptive, expressive and total language scores. This is due to the strong correlation between IQ and language development. This goes with Chomsky ^[25] who discovered a substantial correlation between language development and IQ throughout all levels.

There was negative significant correlation between parent consanguinity and standard scores of receptive and total language scores. This might be due to genetic factors and socioeconomic variables.

This came in agreement with Sunderajan and Kanhere^[26] revealed that consanguinity is a statistically significant risk factor for language delay. This might be of a genetic etiology as suggested by Andres, Hafeez ^[27] who examined the association between consanguinity and SLI.

There was negative significant correlation between delayed walking and IQ, standard scores of receptive, expressive and total languages. The child's limited environm-ental exploration due to poorer motor development may slow down language development.

This was in agreement with Viholainen, Ahonen ^[28] who claimed that there is a strong likelihood that language and motor development are interrelated, and that an early delay in language development may be tied to an early delay in motor development.