Caloric intake during the perioperative period and growth failure in infants with congenital heart disease

Impact of calorie intake and weight gain after Norwood procedure on the outcome of stage II palliation

BACKGROUND

This study aimed to assess the impact of caloric intake and weight-for-age-Z-score after the Norwood procedure on the outcome of bidirectional cavopulmonary shunt.

METHODS

A total of 153 neonates who underwent the Norwood procedure between 2012 and 2020 were surveyed. Postoperative daily caloric intake and weight-for-age-Z-score up to five months were calculated, and their impact on outcome after bidirectional cavopulmonary shunt was analysed.

RESULTS

Median age and weight at the Norwood procedure were 9 days and 3.2 kg, respectively. Modified Blalock-Taussig shunt was used in 95 patients and right ventricle to pulmonary artery conduit in 58. Postoperatively, total caloric intake gradually increased, whereas weight-for-age-Z-score constantly decreased. Early and inter-stage mortality before stage II correlated with low caloric intake. Older age (p = 0.023) at Norwood, lower weight (p < 0.001) at Norwood, and longer intubation (p = 0.004) were correlated with low weight-for-age-Z-score (< -3.0) at 2 months of age. Patients with weight-for-age-Z-score < -3.0 at 2 months of age had lower survival after stage II compared to those with weight-for-age-Z-score of -3.0 or more (85.3 versus 92.9% at 3 years after stage II, p = 0.017). There was no difference between inter-stage weight gain and survival after bidirectional cavopulmonary shunt between the shunt types.

CONCLUSION

Weight-for-age-Z-score decreased continuously throughout the first 5 months after the Norwood procedure. Age and weight at Norwood and intubation time were associated with weight gain. Inter-stage low weight gain (Z-score < -3) was a risk for survival after stage II.

Impact of Type of Enteral Feeds on Early Postoperative Outcomes After Congenital Heart Surgery in Neonates and Young Infants: A Single Center Experience in a Limited Resource Environment

Background: Breast milk is known to prevent infections and is recommended for enteral feeding of infants after congenital heart surgery (CHS). During the Covid-19 pandemic, expressed breast milk (EBM) was not always available; hence, feeding after CHS was maintained with EBM or infant formula (IF) or both; we evaluated the impact of enteral feed type on early postoperative outcomes after CHS. Methods: In a prospective observational study, consecutive neonates and infants <4 months undergoing CHS were divided into EBM, IF, or EBM+IF groups; incidences of postoperative infections, ventilation duration, intensive care unit (ICU) stay, and mortality were studied. Results: Among 270 patients; 90 (33.3%) received EBM, 89 (32.9%) received IF, and 91 (33.7%) received EBM+IF. IF group had more neonates (78.7%[IF] vs 42.2%[EBM] and 52.7%[EBM+IF], P < 0.001) and greater surgical complexity. Postoperative infections were 9 (10.0%) in EBM; 23 (25.8%) in IF; and 14 (15.4%) in EBM+IF (P = .016). IF group (OR 2.58 [1.05-6.38], P = .040), absence of preoperative feeding (OR 6.97 [1.06-45.97], P = .040), and increase in cardiopulmonary bypass time (OR 1.005 [1.001-1.010], P = .027) were associated with postoperative infection. Ventilation duration in hours was 26 (18-47.5) in EBM; 47 (28-54.5) in IF; and 40 (17.5-67) in EBM+IF (P = .004). ICU stay in days was 4 (3-7) in EBM; 6 (5-9) in IF; and 5 (3-9) in EBM+IF (P = .001). Mortality did not differ (P = .556). Conclusion: IF group had a greater proportion of neonates with higher surgical complexity. Patients who received EBM after CHS had fewer postoperative infections and better postoperative outcomes compared to those receiving IF or EBM+IF.

Nutritional Management of Patients with Fontan Circulation: A Potential for Improved Outcomes from Birth to Adulthood

Fontan circulation (FC) is a surgically achieved palliation state offered to patients affected by a wide variety of congenital heart defects (CHDs) that are grouped under the name of univentricular heart. The procedure includes three different surgical stages. Malnutrition is a matter of concern in any phase of life for these children, often leading to longer hospital stays, higher mortality rates, and a higher risk of adverse neurodevelopmental and growth outcomes. Notwithstanding the relevance of proper nutrition for this subset of patients, specific guidelines on the matter are lacking. In this review, we aim to analyze the role of an adequate form of nutritional support in patients with FC throughout the different stages of their lives, in order to provide a practical approach to appropriate nutritional management. Firstly, the burden of faltering growth in patients with univentricular heart is analyzed, focusing on the pathogenesis of malnutrition, its detection and evaluation. Secondly, we summarize the nutritional issues of each life phase of a Fontan patient from birth to adulthood. Finally, we highlight the challenges of nutritional management in patients with failing Fontan.

What is the postoperative nutrition intake in children with congenital heart disease? A single-center analysis in China

BACKGROUND

It is common that inadequate nutritional intake happens in patients with congenital heart disease (CHD), which can adversely affect the prognosis of patients. However, the details and reasons are not clear enough so far. Therefore, the primary aim of this study was to investigate the current nutritional requirements and energy intake on days 1-7 in the cardiac intensive care unit after surgery. Our secondary aim was to investigate potential factors that hinder nutritional supply and to compare the resting energy expenditure (REE) based on two methods, the Fick method and the Schofield equation.

METHODS

Using retrospective analysis, we collected data from postoperative children with CHD at a children's hospital in Shanghai, China. We used the Fick method to calculate the REE, and compare the results with the actual enteral nutrition intake. Meanwhile, we recorded the initiation time of enteral nutrition, feeding intolerance, unfinished milk volume, etc. Then the correlation between the results of the Fick method and the equation method was calculated.

RESULTS

A total of 49 patients were included, with a median age of 22 months (IQR 4.9, 57.3), and a median Aristotle basic complexity score of 8 (IQR 6.0, 9.8). The time interval for surgical intervention within 7 days after operation was 4 (IQR 2.5, 6). No statistical difference in REE on postoperative days 1-7. The average enteral nutrition energy provided 64.6 (33.6, 79.6)% of the REE, which showed a significant decrease on postoperative day 4, and then reached its lowest on postoperative day 5. The protein supply was 0.7 ± 0.3 kcal/kg/d. In addition, the REE calculated by the Fick method was moderately correlated with that estimated by the equation (r = 0.467, P = 0.001).

CONCLUSIONS

The energy and protein supply in the acute postoperative period in children with CHD is inadequate. Fluid restriction and fasting may be the main causes. In addition, there is a moderate correlation between the REE calculated by the Fick method and that estimated by the equation.

Telehealth education improves parental care ability and postoperative nutritional status of infants after CHD surgery: A prospective randomized controlled study

Objective

This study aimed to explore the effect of telehealth education on improving the parental care ability and postoperative nutritional status of infants after congenital heart disease surgery.

Methods

A prospective randomized controlled study was conducted at a provincial maternal and child hospital in southeastern China. A total of 84 infants were enrolled in the study, with 42 infants in the intervention group and 42 infants in the control group.

Results

Body weight, albumin, prealbumin, and hemoglobin of infants in the intervention group were significantly higher than those in the control group one month after discharge (P<0.05). The STRONGkids score of infants in the intervention group was significantly higher than that of those in the control group one month after discharge (P<0.05). The Family Caregiver Task Inventory score of infants in the intervention group was significantly lower than that of those in the control group one month after discharge (P<0.05).

Conclusion

Performing telehealth education about home feeding and care guidance for parents of infants after congenital heart disease surgery can greatly improve parental care ability so that infants get better feeding and care, which can effectively improve the postoperative nutritional status of the infants.

Effect of energy- and/or protein-dense enteral feeding on postoperative outcomes of infant surgical patients with congenital cardiac disease: A systematic review and meta-analysis

Infants with congenital heart disease (CHD) are malnourished because of poor dietary intakes and increased requirements. Energy requirements are higher due to increased resting energy expenditure. There are lacunae of nutrition recommendations for these infants. Therefore, this systematic review and meta-analysis was conducted to determine the effect of energy- and/or protein-dense feeds in postoperative CHD infants as compared with the standard feeding. An online literature search was performed on four databases by using different English-language keywords between 2000 and 2020. The inclusion criteria were peer reviewed journals and open access original articles on the feeding practices in infants undergoing congenital heart surgery. Exclusion criteria were editorials, commentaries, discussion papers, conference abstracts, reviews, duplicate studies, and articles on preterm infants and preoperative nutrition. A total of five studies matched the inclusion criteria. The standard mean difference (SMD) of energy intake (SMD = 13.40 kcal, P = 0.001), protein intake (SMD = 2.37 g, P = 0.001), and weight (SMD = 4.99 g, P = 0.001) was significantly higher in the intervention group. The SMD of ventilation duration (SMD = -0.18 h, P = 0.90), intensive care unit (ICU) length of stay (LOS) (SMD = -0.25 d, P = 0.70), and hospital LOS (SMD = -0.20 d, P = 0.67) were not statistically significant between the two groups. Enriched enteral nutrition for the postoperative pediatric patients with cardiac disease helps in achieving energy and protein goals and improves the overall postoperative outcomes (ie, ventilation duration, maintenance of weight, ICU LOS, and hospital LOS).

Energy- and protein-enriched formula improves weight gain in infants with malnutrition due to cardiac and non-cardiac etiologies

Background

We aimed to assess safety, tolerability, and improvement in weight gain with an energy‐ and protein‐enriched formula (EPEF) in infants with poor growth.

Methods

Infants aged 1–8 months with poor growth received EPEF for 16 weeks. Our primary objective was improvement in weight as measured by change in weight‐for‐age z‐score (WAZ) and weight gain velocity (grams per day) ≥ median for age. Secondary objectives included improvement in other anthropometric z‐scores, formula tolerance, and safety.

Results

Twenty‐six patients with poor growth due to congenital heart disease (n = 15), other organic causes (n = 9), and nonorganic causes (n = 2) completed the study per protocol. Mean daily energy intake was 123 ± 32 kilocalories per kilogram of body weight, with >90% of energy coming from EPEF. Weight gain velocity exceeded the median for 83% (20 of 24) and 67% (16 of 24) of infants at ≥1 time point and for the overall study period, respectively. Mean ± SD WAZ improved from −2.92 ± 1.04 at baseline to −2.01 ± 1.12 at 16 weeks (P = 0.0001). Z‐scores for weight‐for‐length and head circumference (P = 0.0001) and for length‐for‐age (P = 0.003) improved significantly at 16 weeks. Compared with baseline, stool consistency was different at 2, 4, and 16 weeks (P < 0.05). There were no significant differences in vomiting, fussiness, or daily number of stools while there was a decrease or no change in spit‐up, flatulence, crying, or gassiness.

Conclusion

EPEF is safe, well tolerated, and improves weight gain in infants with poor growth.

Performance of remote health education via WeChat to improve the pre-operative nutritional status of infants with non-restrictive ventricular septal defects: A prospective randomised controlled study

AIM

This study aimed to explore the effect of performing remote health education via WeChat to improve the pre-operative nutritional status of non-restrictive ventricular septal defects (VSD).

METHODS

A prospective randomised controlled study was conducted in a provincial maternity and child hospital in China. Participants were randomised regarding education to the intervention group (WeChat) and the control group (leaflets). The nutritional status and complications of the patients were compared after intervening for 1 month.

RESULTS

Nutrient status comparison at 1 month after intervention showed that the body weight, head circumference, haemoglobin, albumin and pre-albumin of the WeChat group were significantly higher than those of the leaflet group (P < 0.05). The STRONGkids score of the WeChat group was significantly lower than that of the leaflet group (P < 0.05). The incidence of feeding intolerance and respiratory tract infection in the WeChat group was significantly lower than that found in the leaflet group (P < 0.05). There was no significant difference in the incidence of liver insufficiency and jaundice between the two groups (P > 0.05).

CONCLUSION

Providing pre-operative feeding and care guidance for parents of infants with non-restrictive VSD, via remote health education through WeChat, can effectively improve nutritional status and reduce the risk of malnutrition and feeding complications.

Risk factors of malnutrition in Chinese children with congenital heart defect

Background

The study aimed to investigate the risk factors of malnutrition in children with congenital heart defect (CHD) in China.

Methods

This cohort study was performed at the biggest pediatric heart center in China; 3252 patients with CHD who underwent cardiac surgeries in 2013 were included. Anthropometric measurements included weight for age Z score (WAZ), weight for height Z score (WHZ), and height for age Z score (HAZ). The patients were classified as normal nutritional status and malnutrition, based on a cut-off Z score of <− 2. Factors associated with malnutrition were determined using logistic regression analysis.

Results

The prevalence of preoperative WAZ < -2 (underweight), HAZ < -2 (stunting), and WHZ < -2 (wasting) was 23.3, 23.3, and 14.3%, respectively. The multivariable analysis of preoperative malnutrition showed that hospitalization, age at surgery, risk adjustment for congenital heart surgery-1 > 3, mechanical ventilation, pulmonary hypertension, and acyanotic heart disease were associated with underweight. Parents’ height, single ventricle, and cyanotic heart disease were associated with stunting. Hospitalization and pulmonary hypertension were associated with wasting. After surgery, the patients presented a significant improvement in growth within the first year in all three parameters and grew to the normal range of WAZ (− 0.3 ± 0.9, P < 0.001), HAZ (0.2 ± 0.8, P = 0.001), and WHZ (0.03 ± 0.6, P < 0.001) at 2 years after surgery. The prevalence of underweight, stunted, and wasting declined to 3.2, 2.7, and 1.9% 3 years after surgery. Malnutrition after surgery was associated with cardiac residual cardiac abnormalities (OR = 35.3, p < 0.0001), high Ross classification of heart function (OR = 27.1, p < 0.0001), and long-term taking oral diuretics (OR = 20.5, P = 0.001).

Conclusions

Malnutrition is still a problem in children with CHD in China, especially before the surgery. There is need to strengthen the nutrition support for children with CHD before surgery. Hemodynamic factors were found to be the risk factors associated with malnutrition after operation.

[Clinical effect of feeding with calorie-enriched formula in children with ventricular septal defect and severe pneumonia]

OBJECTIVE

To study the effect of different energy feeding patterns on the nutritional status, clinical course, and outcome of children with congenital heart disease (CHD) and severe pneumonia.

METHODS

A total of 43 malnourished infants, aged <6 months, who were diagnosed with ventricular septal defect and severe pneumonia and underwent surgical operation from January 1 to December 30, 2017 were enrolled. They were randomly divided into an observation group with 21 infants and a control group with 22 infants. The infants in the observation group were given calorie-enriched formula milk powder (100 kcal/100 mL) after surgery, and those in the control group were given formula milk powder with normal calories (67 kcal/100 mL). The two groups were observed for 3 months to record physical measurements, laboratory markers and nutritional risk screening results. Nutritional status was evaluated for all infants. The two groups were compared in terms of prognosis and adverse events.

RESULTS

There were no significant differences between the two groups in physical measurements, laboratory markers, nutritional assessment and nutritional risk screening results on admission (P>0.05). At discharge and 1 and 3 months after surgery, the control group had significantly higher degree of malnutrition and level of nutritional risk than the observation group (P<0.05). The analysis of variance with repeated measures showed significant differences in body weight, upper arm circumference, weight-for-age Z-score, height-for-age Z-score, weight-for-height Z-score, and albumin level at different time points and between different groups, and there was an interaction between group factors and time factors (P<0.05). Compared with the control group, the observation group had a significantly lower average daily intake of fluid, a significantly higher average daily intake of energy, and a significantly lower incidence rate of insufficient feeding during hospitalization (P<0.05). Compared with the control group, the observation group had significantly shorter length of hospital stay, duration of mechanical ventilation, and duration of postoperative pyrexia, as well as significantly lower hospital costs (P<0.05). No significant adverse reactions were observed in either group.

CONCLUSIONS

An appropriate increase in postoperative energy supply for children with CHD can improve the status of malnutrition and clinical outcome.

Nutritional support in the recovery phase of critically ill children

PURPOSE OF REVIEW

The metabolic stress response of a critically ill child evolves over time and thus it seems reasonable that nutritional requirements change during their course of illness as well. This review proposes strategies and considerations for nutritional support during the recovery phase to gain optimal (catch-up) growth with preservation of lean body mass.

RECENT FINDINGS

Critical illness impairs nutritional status, muscle mass and function, and neurocognition, but early and high intakes of artificial nutrition during the acute phase cannot resolve this. Although (parenteral) nutrient restriction during the acute phase appears to be beneficial, persistent nutrient restriction, when the metabolic stress response resolves, has short-term and long-term detrimental consequences. Requirements increase markedly during the recovery phase to enable recovery and catch-up growth. Such large amounts of intake demand for alternate approach, especially when intestinal problems constitute a barrier for full enteral feeding. As part of the nutritional recovery, mobilization and exercise are essential to achieve catch-up growth with an optimal body composition.

SUMMARY

During the recovery phase of paediatric critical illness (catch-up) growth and muscle recovery require nutritional intakes at least two times the resting energy expenditure.

Meeting nutritional needs of infants under 3 months of life within the first week after cardiovascular surgery

BACKGROUND

After heart surgery requiring cardiopulmonary bypass, neonates have a profound metabolic response to stress. If adequate nutritional support is not provided this leads to loss of lean mass and deterioration of vital organs. The objective of this study was to describe the nutritional status and nutritional support achieved in infants younger than 3 months of life undergo in cardiovascular surgery.

METHODS

A prospective, descriptive study was conducted in a Pediatric Cardiovascular intensive therapy at tertiary care center. All patients younger than 3 months of life admitted to the cardiovascular unit undergoing heart surgery between April 2013 and May2014 were included. We proposed to achieve 67 kcal/kg/day as one of the nutritional intervention goals. The children were evaluated on admission and at 3 and 7 days post-surgery.

RESULTS

Seventy-four patients were evaluated. Total parenteral nutrition could be implemented in all patients that were entered into the protocol requiring parenteral nutrition. Mean volume administered over this period was 50 mL/kg/day (range, 25 to 80 mL/kg/day). Evaluation on admission, at 72 hours, and one week postoperatively showed that 70%, 69%, and 62.7% of the patients, respectively, were not able to achieve the 67 kcal/kg/day proposed as one of the nutritional intervention goals. It was found that at the three study time points enteral and parental caloric intake could cover 100% of the metabolic resting energy expenditure (REE) estimated using the Schofield and WHO equations with no significant differences between the two.

CONCLUSIONS

Although the calorie intake proposed by our intervention was not achieved, it did cover 100% of the REE calculated by the equations.

Understanding the Impact of Fluid Restriction on Growth Outcomes in Infants Following Cardiac Surgery

OBJECTIVE

Fluid restriction is reported to be a barrier in providing adequate nutrition following cardiac surgery. The specific aim of this study was to evaluate the adequacy of nutritional intake during the postoperative period using anthropometrics by comparing preoperative weight status, as measured by weight-for-age z scores, to weight status at discharge home.

DESIGN

Prospective cohort study.

SETTING

Cardiac ICU at Miami Children's Hospital.

PATIENTS

Infants from birth to 12 months old who were scheduled for cardiac surgery at Miami Children's Hospital between December 2013 and September 2014 were followed during the postoperative stay.

INTERVENTIONS

Observational study.

MEASUREMENTS AND MAIN RESULTS

Preoperative and discharge weight-for-age z scores were analyzed. The Risk Adjustment for Congenital Heart Surgery 1 categories were obtained to account for the individual complexity of each case. In patients who had preoperative and discharge weights available (n = 40), the mean preoperative weight-for-age z score was -1.3 ± 1.43 and the mean weight-for-age z score at hospital discharge was -1.89 ± 1.35 with a mean difference of 0.58 ± 0.5 (p < 0.001). A higher Risk Adjustment for Congenital Heart Surgery 1 category was correlated with a greater decrease in weight-for-age z scores (r = -0.597; p = 0.002).

CONCLUSIONS

Nutritional status during the postoperative period was found inadequate through the use of objective anthropometric measures and by comparing them with normal growth curves. Increase in surgical risk categories predicted a greater decrease in weight-for-age z scores. The development of future protocols for nutritional intervention should consider surgical risk categories.

Management of undernutrition and failure to thrive in children with congenital heart disease in low- and middle-income countries

Poor growth with underweight for age, decreased length/height for age, and underweight-for-height are all relatively common in children with CHD. The underlying causes of this failure to thrive may be multifactorial, including innate growth potential, severity of cardiac disease, increased energy requirements, decreased nutritional intake, malabsorption, and poor utilisation of absorbed nutrition. These factors are particularly common and severe in low- and middle-income countries. Although nutrition should be carefully assessed in all patients, failure of growth is not a contraindication to surgical repair, and patients should receive surgical repair where indicated as soon as possible. Close attention should be paid to nutritional support - primarily enteral feeding, with particular use of breast milk in infancy - in the perioperative period and in the paediatric ICU. This nutritional support requires specific attention and allocation of resources, including appropriately skilled personnel. Thereafter, it is essential to monitor growth and development and to identify causes for failure to catch-up or grow appropriately.

A cross-sectional audit of the prevalence of stunting in children attending a regional paediatric cardiology service

CHD is associated with poor growth, delayed motor and language skills development, and increased length of hospital stay; 28.2% of infants were stunted, with z-scores<-2. The severity of surgery score was not associated with an increased length of stay, suggesting that a low weight-for-age z-score at the time of surgery may impact on length of stay.

Nutrition Support for Children Undergoing Congenital Heart Surgeries: A Narrative Review

Energy imbalance in infants and children with congenital heart disease (CHD) is common and influenced by age, underlying cardiac diagnoses, and presence or absence of congestive heart failure. During the surgical hospitalization period, these children are prone to nutritional deterioration due to stress of surgery, anesthetic/perfusion techniques, and postoperative care. Poor nutrition is associated with increased perioperative morbidity and mortality. This review aims to examine various aspects of nutrition in critically ill children with CHD, including (1) energy expenditure, (2) perioperative factors that contribute to energy metabolism, (3) bedside practices that are potentially able to optimize nutrient delivery, and (4) medium- to long-term impact of energy balance on clinical outcomes. We propose a nutrition algorithm to optimize nutrition of these children in the perioperative period where improvements in nutrition status will likely impact surgical outcomes.

Working group reports: evaluation of the evidence to support practice guidelines for nutritional care of preterm infants-the Pre-B Project

The "Evaluation of the Evidence to Support Practice Guidelines for the Nutritional Care of Preterm Infants: The Pre-B Project" is the first phase in a process to present the current state of knowledge and to support the development of evidence-informed guidance for the nutritional care of preterm and high-risk newborn infants. The future systematic reviews that will ultimately provide the underpinning for guideline development will be conducted by the Academy of Nutrition and Dietetics' Evidence Analysis Library (EAL). To accomplish the objectives of this first phase, the Pre-B Project organizers established 4 working groups (WGs) to address the following themes: 1) nutrient specifications for preterm infants, 2) clinical and practical issues in enteral feeding of preterm infants, 3) gastrointestinal and surgical issues, and 4) current standards of infant feeding. Each WG was asked to 1) develop a series of topics relevant to their respective themes, 2) identify questions for which there is sufficient evidence to support a systematic review process conducted by the EAL, and 3) develop a research agenda to address priority gaps in our understanding of the role of nutrition in health and development of preterm/neonatal intensive care unit infants. This article is a summary of the reports from the 4 Pre-B WGs.

Total Energy Expenditure of Infants with Congenital Heart Disease Who Have Undergone Surgical Intervention

Growth failure is often observed in infants with congenital heart disease (CHD); it is unclear, however, whether growth failure is due to increased total energy expenditure (TEE). An observational study of infants with CHD and surgical intervention within the first 30 days of life and healthy infants of similar age was undertaken. TEE was measured using the doubly labeled water method in 3-month-old infants (n = 15 CHD, 12 healthy) and 12-month-old infants (n = 11 CHD, 12 healthy). Multiple linear regression models were fit to examine the association between health status (CHD vs. healthy) and TEE. The accuracy of equations for calculating TEE was also determined. TEE for CHD infants was not significantly different from healthy infants at 3 and 12 months; TEE in CHD infants was 36.4 kcal/day higher (95 % CI -46.3, 119.2; p = 0.37) and 31.7 kcal/day higher, (95 % CI -71.5, 134.8; p = 0.53) at 3 and 12 months, respectively, compared to healthy infants. The 2002 Dietary Reference Intake (DRI) equation and the 1989 Recommended Dietary Allowance equation over-estimated measured TEE to a lesser extent than CHD specific equations; the 2002 DRI yielded the smallest mean difference between calculated versus measured TEE (difference 79 kcal/day). During the first year of life, TEE of infants with CHD and interventional surgery within the first month of life was not different than age-matched healthy infants. When calculating TEE of ≤12-month-old infants with CHD who have undergone surgical intervention, the 2002 DRI equation may be used as a starting point for estimating initial clinical energy intake goals.

Randomized Clinical Trial of Preoperative Feeding to Evaluate Intestinal Barrier Function in Neonates Requiring Cardiac Surgery

OBJECTIVES

To evaluate intestinal barrier function in neonates undergoing cardiac surgery using lactulose/mannitol (L/M) ratio measurements, and to determine correlations with early breast milk feeding.

STUDY DESIGN

This was a single-center, prospective, randomized pilot study of 27 term-born neonates (≥ 37 weeks gestation) requiring cardiac surgery who were randomized to 1 of 2 preoperative feeding groups: nil per os (NPO) or trophic (10 mL/kg/day) breast milk feeds. At 3 time points (preoperative [preop], postoperative [postop] day 7, and postop day 14), subjects were administered an oral L/M solution, after which urine L/M ratios were measured using gas chromatography, with higher ratios indicative of increased intestinal permeability. Trends over time in the mean urine L/M ratios for each group were estimated using a general linear mixed model.

RESULTS

There were no adverse events related to preoperative trophic feeding. In the NPO group (n = 13), the mean urine L/M ratio was 0.06 at preop, 0.12 at postop day 7, and 0.17 at postop day 14. In the trophic breast milk feeds group (n = 14), the mean urine L/M ratio was 0.09 at preop, 0.19 at postop day 7, and 0.15 at postop day 14. In both groups, L/M ratios were significantly higher at postop day 7 and postop day 14 compared with preop (P < .05).

CONCLUSION

Neonates have increased intestinal permeability after cardiac surgery extending to at least postop day 14. This pilot study was not powered to detect differences in benefit or adverse events comparing the NPO and trophic breast milk feeds groups. Further studies to identify mechanisms of intestinal injury and therapeutic interventions are warranted.

TRIAL REGISTRATION

Registered with ClinicalTrials.gov: NCT01475357.

Home Nasogastric Feeds: Feeding Status and Growth Outcomes in a Pediatric Population

BACKGROUND

Home enteral nutrition (HEN) is a safe method for providing nutrition to children with chronic diseases. Advantages of HEN include shorter hospitalizations, lower cost, and decreased risk of malnutrition-associated complications. Follow-up after hospital discharge on HEN is limited. The purpose of this study was to look at children discharged on nasogastric (NG) feeds to assess follow-up feeding status and impact on growth.

METHODS

A retrospective chart review was conducted of pediatric patients discharged from Mount Sinai Medical Center on NG feeds between January 2010 and March 2013.

RESULTS

A total of 87 patients were included. Average age was 1.2 years. The most common diagnoses were congenital heart disease (47%), metabolic disease (17%), neurologic impairment (10%), liver disease (9%), prematurity (8%), and inflammatory bowel disease (6%). At most recent follow-up, 44 (50.6%) were on full oral feeds, 8 (9.2%) were still on NG feeds, 9 (10.3%) had a gastrostomy tube placed, 9 (10.3%) were deceased, and 17 (19.5%) had transferred care or were lost to follow-up. Average time to discontinuation of NG feeds was 4.8 months. Change in body mass index from hospital discharge to follow-up visit 6 to 12 weeks after discharge was statistically significant, from a mean (SD) of 13.78 (2.82) to 14.58 (2.1) (P = .02). Change in weight z score was significant for neurologic impairment (-1.35 to -0.04; P = .03). Height z score change was significant for prematurity (-3.84 to -3.34; P = .02). There was no significant change in height or weight z scores for the other diagnoses.

CONCLUSIONS

NG feeds can help to improve short-term growth after hospital discharge in children with chronic illnesses.

Longitudinal assessment of growth in hypoplastic left heart syndrome: results from the single ventricle reconstruction trial

BACKGROUND

We sought to characterize growth between birth and age 3 years in infants with hypoplastic left heart syndrome who underwent the Norwood procedure.

METHODS AND RESULTS

We performed a secondary analysis using the Single Ventricle Reconstruction Trial database after excluding patients <37 weeks gestation (N=498). We determined length-for-age z score (LAZ) and weight-for-age z score (WAZ) at birth and age 3 years and change in WAZ over 4 clinically relevant time periods. We identified correlates of change in WAZ and LAZ using multivariable linear regression with bootstrapping. Mean WAZ and LAZ were below average relative to the general population at birth (P<0.001, P=0.05, respectively) and age 3 years (P<0.001 each). The largest decrease in WAZ occurred between birth and Norwood discharge; the greatest gain occurred between stage II and 14 months. At age 3 years, WAZ and LAZ were <-2 in 6% and 18%, respectively. Factors associated with change in WAZ differed among time periods. Shunt type was associated with change in WAZ only in the Norwood discharge to stage II period; subjects with a Blalock-Taussig shunt had a greater decline in WAZ than those with a right ventricle-pulmonary artery shunt (P=0.002).

CONCLUSIONS

WAZ changed over time and the predictors of change in WAZ varied among time periods. By age 3 years, subjects remained small and three times as many children were short as were underweight (>2 SD below normal). Failure to find consistent risk factors supports the strategy of tailoring nutritional therapies to patient- and stage-specific targets.

CLINICAL TRIAL REGISTRATION URL

http://clinicaltrials.gov/. Unique identifier: NCT00115934.