1
|
Wong J, Loomba R, Allen KY, Chan T, Coolidge N, Del Grippo E, Horsley M, Slater N, Spader-Cloud M, Steltzer M, Marcuccio E. Structured Tube Weaning Using the Hunger Provocation Method in Infants with Single Ventricle Heart Defects: A Multicenter Study. Pediatr Cardiol 2024:10.1007/s00246-024-03558-x. [PMID: 38913163 DOI: 10.1007/s00246-024-03558-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 06/18/2024] [Indexed: 06/25/2024]
Abstract
Despite improvement in hemodynamics, children with single ventricle heart disease remain on feeding tubes long after stage 2 palliation (S2P). Use of a hunger provocation method in a multidisciplinary team setting has been successful at weaning these children from feeding tubes. The objective of this study is to describe patient characteristics and outcomes in the single ventricle population who underwent a formal tube weaning process using a standardized hunger provocation method. Single ventricle patients after S2P from six centers were included. Patient data collected included baseline demographics, swallow evaluation results, and feeding characteristics such as percent oral intake at the start of tube wean. Tube wean data included tube weaning process and duration, interruptions to the tube wean, adverse events, and weights before, during, and after the tube wean. 94% (60 of 64) of patients achieved oral independence. The median time to tube wean was 12.5 days. 62% of patients had transient weight loss during the tube wean. 61% of the cohort was taking less than 10% goal volumes by mouth with 90% of those patients successfully tube weaned. All patients with history of aspiration were successfully tube weaned. 75% of successfully weaned patients were above baseline weight at 1-month post-tube wean. The most common cause of tube wean interruption was contraction of a viral illness. Use of a standardized tube weaning process via hunger provocation method is both feasible and safe in the single ventricle population, resulting in successful feeding tube removal in a timely manner with minimal adverse effects.
Collapse
Affiliation(s)
- Joshua Wong
- Division of Pediatric Cardiology, Advocate Children's Hospital, Chicago, IL, USA.
| | - Rohit Loomba
- Division of Pediatric Cardiology, Advocate Children's Hospital, Chicago, IL, USA
| | - Kiona Y Allen
- Division of Cardiac Critical Care, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Titus Chan
- Division of Pediatric Cardiac Critical Care and the Heart Center, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, WA, USA
| | - Nicole Coolidge
- Pediatric Cardiology, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Erica Del Grippo
- Division of Pediatric Cardiology, Nemours Children's Hospital, Delaware, Wilmington, DE, USA
| | - Megan Horsley
- Division of Nutrition Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Nancy Slater
- Division of Physical Medicine and Rehabilitation Services, Children's Minnesota, Minneapolis, MN, USA
| | | | - Michelle Steltzer
- Pediatric Cardiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Elisa Marcuccio
- Heart Institute, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| |
Collapse
|
2
|
Kaskie S, Horsley M, Marcuccio E. Experiences in Tube Weaning Children with Congenital Heart Disease and Oral Feeding Aversion. Pediatr Cardiol 2024:10.1007/s00246-024-03515-8. [PMID: 38744695 DOI: 10.1007/s00246-024-03515-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 04/29/2024] [Indexed: 05/16/2024]
Abstract
Infants and children with congenital heart disease (CHD) often require supplemental nutrition via tube feeding before and after surgery. Tube feeding may be required due to poor weight gain, inadequate oral-motor skills, and/or reduced endurance for oral feeding. Our team has described a successful approach to weaning this population (Horsley et al. (2022) Pediatr Cardiol 43:1429-1437). A subgroup of tube-fed patients with CHD who demonstrate oral feeding aversion (OA) presents unique challenges to the tube weaning process. We discuss our team's experience with tube weaning orally averse children with CHD. Of 36 patients enrolled in the Cincinnati Children's Heart Institute Cardiology Feeding Tube Wean Clinic, 11 (31%) were determined to have oral feeding aversion (OA) by a speech-language pathologist (SLP). Descriptive data comparing the OA group to the non-averse group was gathered prior to and during the wean. Both groups had the ability to tube wean successfully, although the OA group had lower median oral intake (9 vs 24%) and higher age at start of the wean (9 vs 4 months). Those with OA also had a longer median duration of wean in days (17 vs 12 days) and higher likelihood of return to tube feeds within six-month post-wean (22 vs 0%). Additionally, the OA group had a higher percentage of genetic syndromes (36 vs 16%), although this was not found to be statistically significant in this study. Children with OA present with unique challenges for tube weaning. The results of this study show that weaning children with CHD and OA is possible with a multidisciplinary team who is knowledgeable about this population.
Collapse
Affiliation(s)
- Sarah Kaskie
- Division of Speech-Language Pathology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA.
| | - Megan Horsley
- Division of Nutrition Therapy, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Elisa Marcuccio
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| |
Collapse
|
3
|
Viswanathan S, F Ong KJ, Kakavand B. Prevalence and Risk Factors for Tube-Feeding at Discharge in Infants following Early Congenital Heart Disease Surgery: A Single-Center Cohort Study. Am J Perinatol 2024; 41:e2832-e2841. [PMID: 37848045 DOI: 10.1055/s-0043-1775976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
OBJECTIVE Oral feeding difficulty is common in infants after congenital heart disease (CHD) surgical repair and is associated with prolonged hospital stay and increased risk for tube-feeding at discharge (TF). The current understanding of the enteropathogenesis of oral feeding difficulty in infants requiring CHD surgery is limited. To determine the prevalence and risk factors for TF following CHD surgery in early infancy. STUDY DESIGN This was a 6-year single-center retrospective cohort study (2016-2021) of infants under 6 months who had CHD surgery. Infants required TF were compared with infants who reached independent oral feeding (IOF). RESULTS Of the final sample of 128 infants, 24 (18.8%) infants required TF at discharge. The risk factors for TF in univariate analysis include low birth weight, low 5-minute Apgar score, admitted at birth, risk adjustment in congenital heart surgery categories IV to VI, presence of genetic diagnosis, use of Prostin, higher pre- and postsurgery respiratory support, lower weight at surgery, lower presurgery oral feeding, higher presurgery milk calory, delayed postsurgery enteral and oral feeding, higher pre- and postsurgery gastroesophageal reflux disease (GERD), need for swallow study, abnormal brain magnetic resonance imaging (p < 0.05). In the multivariate analysis, only admitted at birth, higher presurgery milk calories, and GERD were significant risk factors for TF. TF had significantly longer hospital stay (72 vs. 17 days) and lower weight gain at discharge (z-score: -3.59 vs. -1.94) compared with IOF (p < 0.05). CONCLUSION The prevalence of TF at discharge in our study is comparable to previous studies. Infants with CHD admitted at birth, received higher presurgery milk calories, and clinical GERD are significant risk factors for TF. Mitigating the effects of identified risk factors for TF will have significant impact on the quality of life for these infants and their families and may reduce health care cost. KEY POINTS · Oral feeding difficulty in infants after congenital heart disease surgical repair is common.. · Such infants require prolonged hospital stay and higher risk for tube-feeding at discharge.. · Identifying modifiable risk factors associated with tube-feeding can enhance clinical outcomes..
Collapse
Affiliation(s)
- Sreekanth Viswanathan
- Division of Neonatology, Department of Pediatrics, Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando, Florida
| | - Kaitlyn Jade F Ong
- Division of Neonatology, Department of Pediatrics, Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando, Florida
| | - Bahram Kakavand
- Department of Pediatrics, Division of Pediatric Cardiology, Nemours Children's Hospital, University of Central Florida College of Medicine, Orlando, Florida
| |
Collapse
|
4
|
Haughey BS, Dean P, Spaeder MC, Smith CJ, Conaway M, White SC. Gastrostomy tube placement in congenital cardiac surgery: a multi-institutional database study. Cardiol Young 2023; 33:1672-1677. [PMID: 36184837 DOI: 10.1017/s1047951122003079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Neonates and infants who undergo congenital cardiac surgery frequently have difficulty with feeding. The factors that predispose these patients to require a gastrostomy tube have not been well defined. We aimed to report the incidence and describe hospital outcomes and characteristics in neonates and infants undergoing congenital cardiac surgery who required gastrostomy tube placement. MATERIALS AND METHOD A retrospective review was performed on patients undergoing congenital cardiac surgery between October 2015 and December 2020. Patients were identified by International Classification of Diseases 10th Revision codes, utilising the performance improvement database Vizient® Clinical Data Base, and stratified by age at admission: neonates (<1 month) and infants (1-12 months). Outcomes were compared and comparative analysis performed between admissions with and without gastrostomy tube placement. RESULTS There were 11,793 admissions, 3519 (29.8%) neonates and 8274 (70.2%) infants. We found an increased incidence of gastrostomy tube placement in neonates as compared to infants following congenital cardiac surgery (23.1% versus 6%, p = <0.001). Outcomes in neonates and infants were similar with increased length of stay and cost in those requiring a gastrostomy tube. Gastrostomy tube placement was noted to be more likely in neonates and infants with upper airway anomalies, congenital abnormalities, hospital infections, and genetic abnormalities. DISCUSSION Age at hospitalisation for congenital cardiac surgery is a definable risk factor for gastrostomy tube requirement. Additional factors contribute to gastrostomy tube placement and should be used when counselling families regarding the potential requirement of a gastrostomy tube.
Collapse
Affiliation(s)
- Brena S Haughey
- Department of Pediatrics (Cardiology), University of Virginia, Charlottesville, VA, USA
| | - Peter Dean
- Department of Pediatrics (Cardiology), University of Virginia, Charlottesville, VA, USA
| | - Michael C Spaeder
- Department of Pediatrics (Critical Care), University of Virginia, Charlottesville, VA, USA
| | - Clyde J Smith
- Department of Pediatrics (Cardiology), University of Virginia, Charlottesville, VA, USA
- Department of Pediatrics (Critical Care), University of Virginia, Charlottesville, VA, USA
| | - Mark Conaway
- Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA
| | - Shelby C White
- Department of Pediatrics (Cardiology), University of Virginia, Charlottesville, VA, USA
| |
Collapse
|
5
|
Avasarala V, Aitharaju V, Encisco EM, Rymeski B, Ponsky TA, Huntington JT. Enteral access and reflux management in neonates with severe univentricular congenital heart disease: literature review and proposed algorithm. Eur J Pediatr 2023; 182:3375-3383. [PMID: 37191690 DOI: 10.1007/s00431-023-04992-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 04/14/2023] [Accepted: 04/18/2023] [Indexed: 05/17/2023]
Abstract
Neonates with severe congenital heart disease undergoing surgical repair may face various complications, including failure to thrive. Feeding tube placement and fundoplication are often performed to combat poor growth in neonates. With the variety of feeding tubes available and controversy surrounding when fundoplication is appropriate, there is no current protocol to determine which intervention is necessary for this patient population. We aim to provide an evidence-based feeding algorithm for this patient population. Initial searches for relevant publications yielded 696 publications; after review of these studies and inclusion of additional studies through external searches, a total of 38 studies were included for qualitative synthesis. Many of the studies utilized did not directly compare the different feeding modalities. Of the 38 studies included, five studies were randomized control trials, three studies were literature reviews, one study was an online survey, and the remaining twenty-nine studies were observational. There is no current evidence to suggest that this specific patient population should be treated differently regarding enteral feeding. We propose an algorithm to assist optimal feeding for neonates with congenital heart disease. Conclusion: Nutrition remains a vital component of the care of neonates with congenital heart disease; determining the optimal feeding strategy for these patients can be approached like other neonates.
Collapse
Affiliation(s)
- Vardhan Avasarala
- Department of Surgery, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Varun Aitharaju
- Department of Surgery, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Ellen M Encisco
- Department of Pediatric Surgery, Akron Children's Hospital, 215 West Bowery Street, Level 6, Akron, OH, 44308, USA
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Beth Rymeski
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Todd A Ponsky
- Department of Surgery, Northeast Ohio Medical University, Rootstown, OH, USA
- Department of Pediatric Surgery, Akron Children's Hospital, 215 West Bowery Street, Level 6, Akron, OH, 44308, USA
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Justin T Huntington
- Department of Pediatric Surgery, Akron Children's Hospital, 215 West Bowery Street, Level 6, Akron, OH, 44308, USA.
| |
Collapse
|
6
|
Sunthankar SD, Zhao J, Wei WQ, Hill GD, Parra DA, Kohl K, McCoy A, Jayaram NM, Godown J. Machine Learning to Predict Interstage Mortality Following Single Ventricle Palliation: A NPC-QIC Database Analysis. Pediatr Cardiol 2023; 44:1242-1250. [PMID: 36820914 PMCID: PMC10627450 DOI: 10.1007/s00246-023-03130-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Accepted: 02/10/2023] [Indexed: 02/24/2023]
Abstract
There is high risk of mortality between stage I and stage II palliation of single ventricle heart disease. This study aimed to leverage advanced machine learning algorithms to optimize risk-prediction models and identify features most predictive of interstage mortality. This study utilized retrospective data from the National Pediatric Cardiology Quality Improvement Collaborative and included all patients who underwent stage I palliation and survived to hospital discharge (2008-2019). Multiple machine learning models were evaluated, including logistic regression, random forest, gradient boosting trees, extreme gradient boost trees, and light gradient boosting machines. A total of 3267 patients were included with 208 (6.4%) interstage deaths. Machine learning models were trained on 180 clinical features. Digoxin use at discharge was the most influential factor resulting in a lower risk of interstage mortality (p < 0.0001). Stage I surgery with Blalock-Taussig-Thomas shunt portended higher risk than Sano conduit (7.8% vs 4.4%, p = 0.0002). Non-modifiable risk factors identified with increased risk of interstage mortality included female sex, lower gestational age, and lower birth weight. Post-operative risk factors included the requirement of unplanned catheterization and more severe atrioventricular valve insufficiency at discharge. Light gradient boosting machines demonstrated the best performance with an area under the receiver operative characteristic curve of 0.642. Advanced machine learning algorithms highlight a number of modifiable and non-modifiable risk factors for interstage mortality following stage I palliation. However, model performance remains modest, suggesting the presence of unmeasured confounders that contribute to interstage risk.
Collapse
Affiliation(s)
- Sudeep D Sunthankar
- Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, 37232, USA.
- Thomas P. Graham Jr Division of Pediatric Cardiology, Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt, 2220 Children's Way, Suite 5230, Nashville, TN, 37232, USA.
| | - Juan Zhao
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wei-Qi Wei
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Garick D Hill
- Division of Pediatric Cardiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David A Parra
- Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Karen Kohl
- Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| | - Allison McCoy
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Natalie M Jayaram
- Division of Pediatric Cardiology, Children's Mercy Hospital, Kansas City, MO, USA
| | - Justin Godown
- Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN, 37232, USA
| |
Collapse
|
7
|
Milligan C, Mills KI, Ge S, Michalowski A, Braudis N, Mansfield L, Nathan M, Sleeper LA, Teele SA. Cardiovascular intensive care unit variables inform need for feeding tube utilization in infants with hypoplastic left heart syndrome. J Thorac Cardiovasc Surg 2023; 165:1248-1256. [PMID: 35691711 DOI: 10.1016/j.jtcvs.2022.04.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 03/24/2022] [Accepted: 04/28/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Feeding strategies in infants with hypoplastic left heart syndrome (HLHS) following stage 1 palliation (S1P) include feeding tube utilization (FTU). Timely identification of infants who will fail oral feeding could mitigate morbidity in this vulnerable population. We aimed to develop a novel clinical risk prediction score for FTU. METHODS This was a retrospective study of infants with HLHS admitted to the Boston Children's Hospital cardiovascular intensive care unit for S1P from 2009 to 2019. Infants discharged with feeding tubes were compared with those on full oral feeds. Variables from early (birth to surgery), mid (postsurgery to cardiovascular intensive care unit transfer), and late (inpatient transfer to discharge) hospitalization were analyzed in univariate and multivariable models. RESULTS Of 180 infants, 66 (36.7%) discharged with a feeding tube. In univariate analyses, presence of a genetic disorder (early variable, odds ratio, 3.25; P = .014) and nearly all mid and late variables were associated with FTU. In the mid multivariable model, abnormal head imaging, ventilation duration, and vocal cord dysfunction were independent predictors of FTU (c-statistic 0.87). Addition of late variables minimally improved the model (c-statistic 0.91). A risk score (the HV2 score) for FTU was developed based on the mid multivariable model with high specificity (93%). CONCLUSIONS Abnormal head imaging, duration of ventilation, and presence of vocal cord dysfunction were associated with FTU in infants with HLHS following S1P. The predictive HV2 risk score supports routine perioperative head imaging and vocal cord evaluation. Future application of the HV2 score may improve nutritional morbidity and hospital length of stay in this population.
Collapse
Affiliation(s)
- Caitlin Milligan
- Department of Cardiology, Boston Children's Hospital, Boston, Mass.
| | - Kimberly I Mills
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Shirley Ge
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Anna Michalowski
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Nancy Braudis
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Laura Mansfield
- Department of Cardiology, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass
| | - Lynn A Sleeper
- Department of Cardiology, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Sarah A Teele
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| |
Collapse
|
8
|
Payne E, Garden F, d'Udekem Y, Weintraub R, McCallum Z, Wightman H, Zentner D, Cordina R, Wilson TG, Ayer J. Prolonged Enteral Tube Feeding in Infants With a Functional Single Ventricle Is Associated With Adverse Outcomes After Fontan Completion. J Pediatr 2023:S0022-3476(23)00042-2. [PMID: 36708874 DOI: 10.1016/j.jpeds.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 01/13/2023] [Accepted: 01/22/2023] [Indexed: 01/26/2023]
Abstract
OBJECTIVES To define the baseline characteristics of long-term tube-fed single ventricle patients, investigate associations between long-term enteral tube feeding and growth, and determine associations with long-term outcomes after Fontan procedure. STUDY DESIGN We performed a retrospective cohort study of patients in the Australia and New Zealand Fontan Registry undergoing treatment at the Royal Children's Hospital, the Children's Hospital at Westmead, Royal Melbourne Hospital, and Royal Prince Alfred Hospital from 1981-2018. Patients were defined as tube-fed (TF) or non-tube-fed (NTF) based on enteral tube feeding at age 90 days. Feeding groups were compared regarding BMI trajectory, BMI at last follow-up, and long-term incidence of severe Fontan failure. RESULTS Of 390 patients (56(14%) TF, 334(86%) NTF), TF was associated with right ventricular dominance, hypoplastic left heart syndrome, Norwood procedure, increased procedures prior to Fontan, extracardiac conduit Fontan, Fontan fenestration, and atrioventricular valve repair/replacement. TF patients were less likely to be in the higher compared with lowest 0-6 month BMI trajectory (P<0.01,P=0.03), had lower 6month weight-for-age z-scores (P<0.01) and length-for-age z-scores (P=0.01). TF were less likely to be overweight/obese at pediatric follow-up (HR=0.31,95%CI:0.12-0.80;P=0.02) and more likely to be underweight at adult follow-up ((HR=16.51; 5%CI:2.70-101.10;P<0.01).TF compared with NTF was associated with increased risk of severe Fontan failure (HR=4.13;95%CI=1.65,10.31;P<0.01). CONCLUSIONS Prolonged infant enteral tube feeding is an independent marker of poor growth and adverse clinical outcomes extending long-term post-Fontan procedure.
Collapse
Affiliation(s)
- Emma Payne
- The University of Sydney, Sydney, AUSTRALIA; The University of Melbourne, Melbourne, AUSTRALIA
| | - Frances Garden
- The University of New South, Sydney, AUSTRALIA; The Ingham Institute of Applied Medical Research, Sydney, AUSTRALIA
| | | | - Robert Weintraub
- The University of Melbourne, Melbourne, AUSTRALIA; The Royal Children's Hospital, Melbourne, AUSTRALIA; The Murdoch Children's Research Institute, Melbourne, AUSTRALIA
| | - Zoe McCallum
- The Royal Children's Hospital, Melbourne, AUSTRALIA
| | | | - Dominica Zentner
- The University of Melbourne, Melbourne, AUSTRALIA; The Royal Melbourne Hospital, Melbourne, AUSTRALIA
| | - Rachael Cordina
- The University of Sydney, Sydney, AUSTRALIA; The Royal Prince Alfred Hospital, Sydney, AUSTRALIA
| | - Thomas G Wilson
- The University of Melbourne, Melbourne, AUSTRALIA; The Royal Children's Hospital, Melbourne, AUSTRALIA
| | - Julian Ayer
- The University of Sydney, Sydney, AUSTRALIA; The Heart Centre for Children, The Sydney Children's Hospital Network, Sydney, AUSTRALIA.
| |
Collapse
|
9
|
Puriani D, Allenidekania A, Afiyanti Y. The Experience of Uncertainty in Mothers Caring for Children at Home after Palliative Heart Surgery. Indian J Palliat Care 2023; 29:46-50. [PMID: 36846277 PMCID: PMC9944655 DOI: 10.25259/ijpc_453_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 10/05/2022] [Indexed: 01/22/2023] Open
Abstract
Objectives Palliative heart surgery is a compelling option for some children with congenital heart disease for which corrective heart surgery is not yet possible due to its complexity. As primary caregivers, mothers have the challenge of providing optimal care to their children at home post-surgery. This study aims to explore the experiences of mothers who are caring for children recovering from palliative heart surgery at home. The research applied descriptive, qualitative and phenomenology design. Material and Methods This study was conducted in Jakarta. The participants were 15 mothers of palliative heart surgery patients from seven provinces in Indonesia; Jakarta, Aceh, Bali, North Sumatra, West Java, Central Java and Banten. Data were collected using semi-structured interviews through the WhatsApp video call application and analysed using the Colaizzi method. Results Mothers often felt uncertain about how to provide the best care and felt that their needs for hospital services to assist them went unmet. Conclusions: This study has implications for the development of nursing services related to discharge planning for palliative heart surgery patients.
Collapse
Affiliation(s)
- Dewi Puriani
- Department of Paediatric Nursing, Faculty of Nursing, Universitas Indonesia, Depok, Indonesia
| | | | - Yati Afiyanti
- Department of Paediatric Nursing, Faculty of Nursing, Universitas Indonesia, Depok, Indonesia
| |
Collapse
|
10
|
Matthews CR, Hartman D, Farrell AG, Colgate CL, Gray BW, Zborek K, Herrmann JL. Impact of Home Monitoring Program and Early Gastrostomy Tube on Interstage Outcomes following Stage 1 Norwood Palliation. Pediatr Cardiol 2023; 44:124-131. [PMID: 35727331 DOI: 10.1007/s00246-022-02947-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 05/31/2022] [Indexed: 01/24/2023]
Abstract
Nutritional management and home monitoring programs (HMPs) may be beneficial for improving interstage morbidity and mortality following stage I Norwood palliation (S1P) for hypoplastic left heart syndrome (HLHS). We recognized an increasing trend towards early feeding gastrostomy tube (GT) placement prior to discharge in our institution, and we aimed to investigate the effect of HMPs and GTs on interstage mortality and growth parameters. Single-institutional review at a tertiary referral center between 2008 and 2018. Individual patient charts were reviewed in the electronic medical record. Those listed for transplant or hybrid procedures were excluded. Baseline demographics, operative details, and interstage outcomes were analyzed in GT and non-GT patients (nGT). Our HMP was instituted in 2009, and patients were analyzed by era: I (early, 2008-2012), II (intermediate, 2013-2016), and III (recent, 2017-2018). 79 patients were included in the study: 29 nGTs and 50 GTs. GTs had higher number of preoperative risk factors more S1P complications, longer ventilation times, longer lengths of stay, and shorter times to readmission. There were no differences in interstage mortality or overall mortality between groups. There was one readmission for a GT-related issue with no periprocedural complications in the group. Weight gain doubled after GT placement in the interstage period while waiting periods for placement decreased across Eras. HMPs and early GTs, especially for patients with high-risk features, provide a dependable mode of nutritional support to optimize somatic growth following S1P.
Collapse
Affiliation(s)
- Caleb R Matthews
- Section of Pediatric Cardiothoracic Surgery, Department of Surgery, Indiana School of Medicine, 545 Barnhill Drive, Emerson 215, Indianapolis, IN, 46202, USA
| | - Dana Hartman
- Section of Pediatric Cardiology, Department of Surgery, Indiana School of Medicine, Indianapolis, IN, USA
- Riley Children's Health at IU Health, Indianapolis, IN, USA
| | - Anne G Farrell
- Section of Pediatric Cardiology, Department of Surgery, Indiana School of Medicine, Indianapolis, IN, USA
- Riley Children's Health at IU Health, Indianapolis, IN, USA
| | - Cameron L Colgate
- Center for Outcomes Research in Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Brian W Gray
- Division of Pediatric Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
- Riley Children's Health at IU Health, Indianapolis, IN, USA
| | - Kirsten Zborek
- Section of Pediatric Cardiothoracic Surgery, Department of Surgery, Indiana School of Medicine, 545 Barnhill Drive, Emerson 215, Indianapolis, IN, 46202, USA
- Riley Children's Health at IU Health, Indianapolis, IN, USA
| | - Jeremy L Herrmann
- Section of Pediatric Cardiothoracic Surgery, Department of Surgery, Indiana School of Medicine, 545 Barnhill Drive, Emerson 215, Indianapolis, IN, 46202, USA.
- Riley Children's Health at IU Health, Indianapolis, IN, USA.
| |
Collapse
|
11
|
Horsley M, Hill GD, Kaskie S, Schnautz M, Brown J, Marcuccio E. Evaluation of an Outpatient and Telehealth Initiative to Reduce Tube Dependency in Infants with Complex Congenital Heart Disease. Pediatr Cardiol 2022; 43:1429-1437. [PMID: 35333946 DOI: 10.1007/s00246-022-02864-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 02/25/2022] [Indexed: 10/18/2022]
Abstract
Infants with congenital heart disease (CHD) often require supplemental nutrition via tube feeding, even after corrective surgical repair. The need for tube feeding can persist months after discharge home, and outpatient weaning from the tube can be a slow and difficult process. Lack of consensus exists in the literature as to the best approach to this challenge. We describe a single institution's initiative to decrease tube dependency after discharge through an intensive, telehealth-centric program for children with CHD. Of 16 children aged 1-26 months, 94% were able to be successfully tube weaned at home, with median time to tube-free of 12 days. No significant weight loss was noted during or after the wean process. Longer tube wean time was associated with older age at onset and comorbid genetic syndrome. Our telehealth-based intensive tube weaning program was successful but required a multidisciplinary team, targeted pre-participation patient evaluation, and frequent communication.
Collapse
Affiliation(s)
- Megan Horsley
- Division of Nutrition Therapy, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.
| | - Garick D Hill
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Sarah Kaskie
- Division of Speech-Language Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Maureen Schnautz
- Division of Speech-Language Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - James Brown
- Department of James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Elisa Marcuccio
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| |
Collapse
|
12
|
Goldstein SA, Watkins KJ, Lowery RE, Yu S, Knight RM, Drayton AK, Sayers L, Gaies M. Oral Aversion in Infants With Congenital Heart Disease: A Single-Center Retrospective Cohort Study. Pediatr Crit Care Med 2022; 23:e171-e179. [PMID: 34991136 DOI: 10.1097/pcc.0000000000002879] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Neonates undergoing cardiac surgery are at risk for oral aversion (OA). OA is not well described outside of the index hospitalization and impacts patients and families. We evaluated the prevalence of OA at 1 year old after neonatal cardiopulmonary bypass (CPB) surgery. DESIGN Retrospective cohort study. SETTING Single quaternary care hospital. SUBJECTS Our cohort included 157 neonates who underwent CPB surgery from 2014 to 2017 and had follow-up data available at 1 year old. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Three feeding experts reviewed the medical record to define children with OA; 30% of charts were evaluated in triplicate for validation. Neonates with and without OA were compared in univariate analysis, and risk factors for OA were explored in a limited multivariable analysis. OA was present at 1 year in 37 patients (23.6%) and other feeding difficulties were present in an additional 29 patients (18.5%). Thirty-eight patients (24.2%) had a feeding tube, including 12 (7.6%) with a gastrostomy tube. Factors associated with OA at 1 year included total ICU days, duration of mechanical ventilation, total number of nil per os days, and number of postoperative days (PODs) until oral feeding initiation (all p < 0.0001). Number of POD until oral feeding initiation remained independently associated with OA at 1 year in multivariable analysis (adjusted odds ratio, 1.08; 95% CI, 1.04-1.12; p < 0.0001). Infants with any oral intake at discharge had lower odds of OA at 1 year (0.21; 95% CI, 0.08-0.5; p = 0.0003). At hospital discharge, 132 patients (84.1%) were taking some oral feeds, and 128 patients (81.5%) received tube feeding. CONCLUSIONS OA and other feeding difficulties are common at 1 year old in neonates undergoing CPB surgery. Delayed exposure to oral intake may be a modifiable risk factor for OA and efforts to improve early oral feeding could lead to better functional outcomes.
Collapse
Affiliation(s)
- Stephanie A Goldstein
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Primary Children's Hospital, Salt Lake City, UT
| | - Kimberly J Watkins
- The Children's Heart Clinic, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN
| | - Ray E Lowery
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, MI
| | - Sunkyung Yu
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, MI
| | - Rachel M Knight
- Department of Pediatric Feeding Disorders, University of Nebraska Medical Center, Munroe-Meyer Institute, Omaha, NE
| | - Amy K Drayton
- Department of Pediatric Feeding Disorders, University of Nebraska Medical Center, Munroe-Meyer Institute, Omaha, NE
| | | | - Michael Gaies
- Division of Pediatric Cardiology, Department of Pediatrics, University of Michigan, C.S. Mott Children's Hospital, Ann Arbor, MI
| |
Collapse
|
13
|
Slater N, Spader M, Fridgen J, Horsley M, Davis M, Griffin KH. Weaning from a feeding tube in children with congenital heart disease: A review of the literature. PROGRESS IN PEDIATRIC CARDIOLOGY 2021. [DOI: 10.1016/j.ppedcard.2021.101406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
|
14
|
Abstract
Cardiac critical care has become an increasingly complex subspecialty, involving multiple subspecialists to support patients with congenital heart disease. This requires understanding of their physiology and the impact of medical interventions. The purpose of this article is to provide a concise review of the current strategies utilized by cardiac intensivists to optimize outcomes for this vulnerable patient population, with the goal of broadening the knowledge of other members of the multi-disciplinary team.
Collapse
|
15
|
Abstract
Congenital heart disease (CHD) is the most common birth defect for infants born in the United States, with approximately 36,000 affected infants born annually. While mortality rates for children with CHD have significantly declined, there is a growing population of individuals with CHD living into adulthood prompting the need to optimise long-term development and quality of life. For infants with CHD, pre- and post-surgery, there is an increased risk of developmental challenges and feeding difficulties. Feeding challenges carry profound implications for the quality of life for individuals with CHD and their families as they impact short- and long-term neurodevelopment related to growth and nutrition, sensory regulation, and social-emotional bonding with parents and other caregivers. Oral feeding challenges in children with CHD are often the result of medical complications, delayed transition to oral feeding, reduced stamina, oral feeding refusal, developmental delay, and consequences of the overwhelming intensive care unit (ICU) environment. This article aims to characterise the disruptions in feeding development for infants with CHD and describe neurodevelopmental factors that may contribute to short- and long-term oral feeding difficulties.
Collapse
|
16
|
A Multi-Interventional Nutrition Program for Newborns with Congenital Heart Disease. J Pediatr 2021; 228:66-73.e2. [PMID: 32827527 DOI: 10.1016/j.jpeds.2020.08.039] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 07/21/2020] [Accepted: 08/14/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To evaluate how outcomes changed in newborns undergoing surgery for congenital heart disease after implementation of a standardized preoperative and postoperative nutrition program. STUDY DESIGN We performed a single-center cohort study of newborns who underwent cardiac surgery between September 2008 and July 2015. We evaluated growth and feeding outcomes in the 2 years of preprogram time (phase 0), in the 2 years after initiation of a postoperative feeding algorithm (phase 1), and in the 2 years following introduction of a preoperative feeding program (phase 2) using traditional statistics and quality improvement methods. RESULTS The study included 570 newborns with congenital heart disease. Weight-for-age z-score change from birth to hospital discharge significantly improved from phase 0 (-1.02 [IQR, -1.45 to -0.63]) to phase 1 (-0.83 [IQR, -1.25 to -0.54]; P = .006), with this improvement maintained in phase 2 (-0.89 [IQR, -1.30 to -0.56]; P = .017 across phases). Gastrostomy tube use decreased significantly (25% in phase 0 vs 12% and 14% in phases 1 and 2; P < .001) and preoperative enteral feeding increased significantly (47% and 46% in phases 0 and 1 vs 76% in phase 2; P < .001) without increases in necrotizing enterocolitis, hospital stay, or mortality. CONCLUSIONS Introduction of a multi-interventional nutrition program was associated with improved weight gain, fewer gastrostomy tubes at hospital discharge, and increased preoperative enteral feeding without increases in necrotizing enterocolitis, hospital stay, or mortality.
Collapse
|
17
|
Yasukawa T, Hoashi T, Kitano M, Shimada M, Imai K, Kurosaki K, Ichikawa H. Interstage management of pulmonary blood flow after the Norwood procedure with right ventricle-to-pulmonary artery conduit. Eur J Cardiothorac Surg 2020; 58:551-558. [PMID: 32187360 DOI: 10.1093/ejcts/ezaa062] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 01/03/2020] [Accepted: 01/31/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Our goal was to assess the efficacy of managing pulmonary blood flow from the Norwood procedure with a right ventricle-to-pulmonary artery (RV-PA) conduit until stage 2 palliation (S2P). METHODS Among 48 consecutive patients undergoing the Norwood procedure between 2008 and 2018, 40 (83.3%) patients who survived to discharge were included in this study. The primary diagnosis was hypoplastic left heart syndrome in 28 (70%) patients and hypoplastic left heart syndrome variant in 12 (30%) patients. All patients received bilateral pulmonary artery banding. The median age and weight at the time of the Norwood procedure were 41 (25th-75th percentiles: 27-89) days and 3.2 (2.7-3.9) kg, respectively. In keeping with institutional strategy, S2P was undertaken when body weight exceeded 5.0 kg, and normal gross motor development was confirmed. RESULTS The RV-PA conduit was clipped in 28 (70%) patients during the perioperative period of the Norwood procedure, then partial unclipping was performed in 8 (20%) patients and full unclipping was performed in 20 (50%) patients. Before S2P, the median pulmonary-to-systemic blood flow ratio was 1.0 (0.7-1.3). The median age and weight at the time of S2P were 10.7 (9.0-12.9) months and 6.3 (5.5-7.1) kg, respectively. The survival rate 5 years after Norwood discharge was 85.3%. Pre-S2P pulmonary-to-systemic blood flow ratio was linearly correlated with greater interstage changes in systemic atrioventricular valve regurgitation (R2 = 0.223, P = 0.004). CONCLUSIONS Interstage management of pulmonary blood flow by RV-PA conduit clipping and gradual unclipping provided good interstage outcomes. The median pulmonary-to-systemic blood flow ratio could be controlled to 1.0 at pre-S2P catheter examination.
Collapse
Affiliation(s)
- Takashi Yasukawa
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Takaya Hoashi
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Masataka Kitano
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Masatoshi Shimada
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kenta Imai
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kenichi Kurosaki
- Department of Pediatric Cardiology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Hajime Ichikawa
- Department of Pediatric Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| |
Collapse
|
18
|
Alphonso N, Angelini A, Barron DJ, Bellsham-Revell H, Blom NA, Brown K, Davis D, Duncan D, Fedrigo M, Galletti L, Hehir D, Herberg U, Jacobs JP, Januszewska K, Karl TR, Malec E, Maruszewski B, Montgomerie J, Pizzaro C, Schranz D, Shillingford AJ, Simpson JM. Guidelines for the management of neonates and infants with hypoplastic left heart syndrome: The European Association for Cardio-Thoracic Surgery (EACTS) and the Association for European Paediatric and Congenital Cardiology (AEPC) Hypoplastic Left Heart Syndrome Guidelines Task Force. Eur J Cardiothorac Surg 2020; 58:416-499. [DOI: 10.1093/ejcts/ezaa188] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Nelson Alphonso
- Queensland Pediatric Cardiac Service, Queensland Children’s Hospital, University of Queensland, Brisbane, QLD, Australia
| | - Annalisa Angelini
- Department of Cardiac, Thoracic Vascular Sciences and Public health, University of Padua Medical School, Padua, Italy
| | - David J Barron
- Department of Cardiovascular Surgery, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | | | - Nico A Blom
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Katherine Brown
- Paediatric Intensive Care, Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Deborah Davis
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, PA, USA
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
| | - Daniel Duncan
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
| | - Marny Fedrigo
- Department of Cardiac, Thoracic Vascular Sciences and Public Health, University of Padua Medical School, Padua, Italy
| | - Lorenzo Galletti
- Unit of Pediatric Cardiac Surgery, Bambino Gesù Children's Hospital, Rome, Italy
| | - David Hehir
- Division of Cardiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ulrike Herberg
- Department of Pediatric Cardiology, University Hospital Bonn, Bonn, Germany
| | | | - Katarzyna Januszewska
- Division of Pediatric Cardiac Surgery, University Hospital Muenster, Westphalian-Wilhelm’s-University, Muenster, Germany
| | | | - Edward Malec
- Division of Pediatric Cardiac Surgery, University Hospital Muenster, Westphalian-Wilhelm’s-University, Muenster, Germany
| | - Bohdan Maruszewski
- Department for Pediatric Cardiothoracic Surgery, Children's Memorial Health Institute, Warsaw, Poland
| | - James Montgomerie
- Department of Anesthesia, Birmingham Children’s Hospital, Birmingham, UK
| | - Christian Pizzaro
- Nemours Cardiac Center, A.I. Du Pont Hospital for Children, Wilmington, DE, USA
- Department of Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Dietmar Schranz
- Pediatric Heart Center, Justus-Liebig University, Giessen, Germany
| | - Amanda J Shillingford
- Division of Cardiology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | | | | |
Collapse
|
19
|
Casar Berazaluce AM, Gibbons AT, Hanke RE, Ponsky TA, Harmon CM. It Is a Wrap! Or Is It?: The Role of Fundoplication in Infant Feeding Intolerance. J Laparoendosc Adv Surg Tech A 2019; 29:1315-1319. [PMID: 31264917 DOI: 10.1089/lap.2019.0076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Purpose: Fundoplication is one of the most common procedures performed by pediatric surgeons, frequently for gastroesophageal reflux with feeding intolerance. No consensus exists in its management, with multiple institutions opting for medical therapy over surgical intervention. Methods: A case-based survey was administered at a national pediatric surgery conference. Clinical vignettes described former-premature infants with reflux and feeding intolerance with or without failure to thrive (FTT), neurological impairment, complex cardiopathy, and respiratory symptoms. Odds ratios (ORs) for fundoplication were calculated from participants' responses. Results: Surgeons elected to perform fundoplication in 14%-74% of cases. The OR for performing fundoplication in the presence of FTT was 1.84 (confidence interval [CI] 1.34-2.54, P = .0002) overall, achieving significance in subgroup analysis for cardiopathy (OR 3.56, CI 1.88-6.71, P = .0001) and neurological impairment (OR 1.79, CI 1.04-3.07, P = .04), but not in the absence of these comorbidities (OR 1.05, CI 0.61-1.83, P = .86). The OR for fundoplication in the presence of neurological impairment was 1.97 (CI 1.34-2.90, P = .0005) and that for cardiopathy was 1.70 (CI 1.20-2.40, P = .003), independent of FTT status. In subgroup analysis, the greatest predictors for fundoplication were neurological impairment with FTT (OR 2.63, CI 1.55-4.48, P = .0004) and complex cardiopathy with FTT and cough/syncope (OR 7.14, CI 4.05-12.58, P < .0001). Presence of cardiopathy without FTT had the overall lowest odds of fundoplication (OR 0.40, CI 0.21-0.78, P = .006). Conclusion: Surgeons tend to perform fundoplication in the presence of FTT and other comorbidities, particularly when these are concurrent. Respiratory symptoms are a strong predictor for fundoplication in patients with complex cardiopathies.
Collapse
Affiliation(s)
- Alejandra M Casar Berazaluce
- Department of Surgical Services, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Alexander T Gibbons
- Department of Surgery, Division of Pediatric Surgery, Akron Children's Hospital, Akron, Ohio
| | - Rachel E Hanke
- Department of Surgical Services, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Todd A Ponsky
- Department of Surgical Services, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,Department of Surgery, Division of Pediatric Surgery, Akron Children's Hospital, Akron, Ohio
| | - Carroll M Harmon
- Department of Surgery, Division of Pediatric Surgery, Kaleida Health, John R. Oishei Children's Hospital, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York
| |
Collapse
|
20
|
White BR, Zhang C, Presson AP, Friddle K, DiGeronimo R. Prevalence and outcomes for assisted home feeding in medically complex neonates. J Pediatr Surg 2019; 54:465-470. [PMID: 29937107 DOI: 10.1016/j.jpedsurg.2018.05.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 04/30/2018] [Accepted: 05/27/2018] [Indexed: 10/14/2022]
Abstract
OBJECTIVE To describe the prevalence and outcome of assisted home feeding (AHF) in medically complex neonatal intensive care unit (NICU) patients, and to identify variables associated with AHF in this population. STUDY DESIGN 1223 infants who survived to discharge from 2013 to 2015 were identified in our single-center, retrospective cohort study at a large tertiary referral NICU. Demographic and selected disease-specific variables were compared between infants discharged on full oral feeding (PO) versus AHF. RESULT 404 (33%) infants were discharged on AHF (NG = 201, GT = 186, NJ = 17). AHF neonates were born at an earlier gestational age, lower birth weight, had longer hospital admission, greater post-menstrual age at discharge, and had more associated co-morbidities compared to the PO group. CONCLUSION AHF was a frequently used and safe intervention in our large cohort of infants. LEVEL OF EVIDENCE Treatment Study Level III.
Collapse
Affiliation(s)
- Benjamin R White
- Department of Pediatrics, University of Utah, School of Medicine; Division of Neonatology, University of Utah, School of Medicine.
| | - Chong Zhang
- Department of Internal Medicine, Division of Epidemiology, University of Utah, School of Medicine
| | - Angela P Presson
- Department of Pediatrics, University of Utah, School of Medicine; Department of Internal Medicine, Division of Epidemiology, University of Utah, School of Medicine
| | - Kim Friddle
- University of Utah, College of Nursing, Salt Lake City, UT
| | - Robert DiGeronimo
- Department of Pediatrics, Division of Neonatology, University of Washington, Seattle, WA
| |
Collapse
|
21
|
Prodhan P, Tang X, Gossett J, Beam B, Simsic J, Ghanayem N, ElHassan NO. Gastrostomy tube placement among infants with hypoplastic left heart syndrome undergoing stage 1 palliation. CONGENIT HEART DIS 2018; 13:519-527. [PMID: 29756326 DOI: 10.1111/chd.12610] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 02/23/2018] [Accepted: 03/16/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Different feeding strategies have been suggested to improve growth and survival of infants with hypoplastic left heart syndrome following stage 1 palliation. The study objective was to assess hospital mortality following stage 1 palliation among infants with hypoplastic left heart syndrome who had two feeding modalities, gastrostomy tube vs no gastrostomy tube. DESIGN Retrospective study design. SETTING Multicenter pediatric heath information system database. PATIENT About 4287 patients with hypoplastic left heart syndrome who underwent stage 1 Norwood procedure from 2004 through 2013. Infants who had gastrostomy tube with or without fundoplication procedure were identified and their clinical characteristics were compared. INTERVENTION None. OUTCOMES MEASURES The primary outcome was discharge hospital mortality following stage 1 palliation. RESULTS About 1214 patients who underwent stage 1 palliation had gastrostomy tube placement prior to hospital discharge. About 881 only had this procedure, while 333 patients also underwent fundoplication. Infants who had a gastrostomy tube placement vs no gastrostomy procedure had longer hospital stay, but significantly lower hospital mortality (5% vs 19%, P < .001). Hospital mortality was lower in infants who had only gastrostomy vs gastrostomy with fundoplication procedure (4% vs 8%, P = .004). In the multivariable analysis, gastrostomy procedure was associated with a higher likelihood of survival to hospital discharge (HR: 0.06, CI [0.04, 0.1]), whereas additional fundoplication procedure increased the risk of mortality (HR: 2.77, CI [1.52, 5.04]). CONCLUSIONS The gastrostomy procedure did not place infants with hypoplastic left heart syndrome at higher risk of mortality. These infants should be considered for gastrostomy tube placement if they had persistent difficulty in oral feeding following stage 1 palliation.
Collapse
Affiliation(s)
- Parthak Prodhan
- Pediatric Cardiology/Pediatric Critical Care, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas, USA
| | - Xinyu Tang
- Biostatistics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas, USA
| | - Jeffrey Gossett
- Biostatistics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas, USA
| | - Brandon Beam
- Bioinformatics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas, USA
| | - Janet Simsic
- Pediatric Cardiology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Nancy Ghanayem
- Cardiac Critical Care, Department of Pediatrics, Medical College of Wisconsin/Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Nahed O ElHassan
- Neonatology, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas, USA
| |
Collapse
|
22
|
Nieves JA, Rudd NA, Dobrolet N. Home surveillance monitoring for high risk congenital heart newborns: Improving outcomes after single ventricle palliation - why, how & results. PROGRESS IN PEDIATRIC CARDIOLOGY 2018. [DOI: 10.1016/j.ppedcard.2018.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
|
23
|
Piggott KD, Babb J, Yong S, Fakioglu H, Blanco C, DeCampli W, Pourmoghadam K. Risk Factors for Gastrostomy Tube Placement in Single Ventricle Patients Following The Norwood Procedure. Semin Thorac Cardiovasc Surg 2018; 30:443-447. [DOI: 10.1053/j.semtcvs.2018.02.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2018] [Indexed: 11/11/2022]
|
24
|
Nieves JA, Uzark K, Rudd NA, Strawn J, Schmelzer A, Dobrolet N. Interstage Home Monitoring After Newborn First-Stage Palliation for Hypoplastic Left Heart Syndrome: Family Education Strategies. Crit Care Nurse 2017; 37:72-88. [PMID: 28365652 DOI: 10.4037/ccn2017763] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Children born with hypoplastic left heart syndrome are at high risk for serious morbidity, growth failure, and mortality during the interstage period, which is the time from discharge home after first-stage hypoplastic left heart syndrome palliation until the second-stage surgical intervention. The single-ventricle circulatory physiology is complex, fragile, and potentially unstable. Multicenter initiatives have been successfully implemented to improve outcomes and optimize growth and survival during the interstage period. A crucial focus of care is the comprehensive family training in the use of home surveillance monitoring of oxygen saturation, enteral intake, weight, and the early recognition of "red flag" symptoms indicating potential cardiopulmonary or nutritional decompensation. Beginning with admission to the intensive care unit of the newborn with hypoplastic left heart syndrome, nurses provide critical care and education to prepare the family for interstage home care. This article presents detailed nursing guidelines for educating families on the home care of their medically fragile infant with single-ventricle circulation.
Collapse
Affiliation(s)
- Jo Ann Nieves
- Jo Ann Nieves is a pediatric nurse practitioner in the neonatal high-risk cardiac surgery clinic and the adult congenital heart disease program at the Nicklaus Children's Hospital Heart Program, Miami, Florida. .,Karen Uzark is a pediatric nurse practitioner in the congenital heart center and the cardiac neurodevelopmental follow-up clinic. She is assistant director of the Michigan Congenital Heart Outcomes Research and Discovery program, Mott's Children's Hospital, University of Michigan, Ann Arbor, Michigan. .,Nancy A. Rudd is a cardiology nurse practitioner for the Herma Heart Center at Children's Hospital of Wisconsin, Milwaukee, with a dual clinical role within the interstage home monitoring and the adult congenital heart disease program. .,Jennifer Strawn is a nurse clinician in pediatric cardiology at Children's Hospital & Medical Center, Omaha, Nebraska. She was a member of the pilot team for National Pediatric Cardiology Quality Improvement Collaborative and continues to serve as a key contact and data coordinator. .,Anne Schmelzer is the nurse coordinator for the neurocardiac developmental program and a cardiology nurse in the high-risk cardiac surgery clinic at Nicklaus Children's Hospital Heart Program, Miami, Florida. .,Nancy Dobrolet is director of the high-risk cardiac surgery clinic and codirector of the neurocardiac developmental clinic at the Nicklaus Children's Hospital Heart Program, Miami Children's Health System.
| | - Karen Uzark
- Jo Ann Nieves is a pediatric nurse practitioner in the neonatal high-risk cardiac surgery clinic and the adult congenital heart disease program at the Nicklaus Children's Hospital Heart Program, Miami, Florida.,Karen Uzark is a pediatric nurse practitioner in the congenital heart center and the cardiac neurodevelopmental follow-up clinic. She is assistant director of the Michigan Congenital Heart Outcomes Research and Discovery program, Mott's Children's Hospital, University of Michigan, Ann Arbor, Michigan.,Nancy A. Rudd is a cardiology nurse practitioner for the Herma Heart Center at Children's Hospital of Wisconsin, Milwaukee, with a dual clinical role within the interstage home monitoring and the adult congenital heart disease program.,Jennifer Strawn is a nurse clinician in pediatric cardiology at Children's Hospital & Medical Center, Omaha, Nebraska. She was a member of the pilot team for National Pediatric Cardiology Quality Improvement Collaborative and continues to serve as a key contact and data coordinator.,Anne Schmelzer is the nurse coordinator for the neurocardiac developmental program and a cardiology nurse in the high-risk cardiac surgery clinic at Nicklaus Children's Hospital Heart Program, Miami, Florida.,Nancy Dobrolet is director of the high-risk cardiac surgery clinic and codirector of the neurocardiac developmental clinic at the Nicklaus Children's Hospital Heart Program, Miami Children's Health System
| | - Nancy A Rudd
- Jo Ann Nieves is a pediatric nurse practitioner in the neonatal high-risk cardiac surgery clinic and the adult congenital heart disease program at the Nicklaus Children's Hospital Heart Program, Miami, Florida.,Karen Uzark is a pediatric nurse practitioner in the congenital heart center and the cardiac neurodevelopmental follow-up clinic. She is assistant director of the Michigan Congenital Heart Outcomes Research and Discovery program, Mott's Children's Hospital, University of Michigan, Ann Arbor, Michigan.,Nancy A. Rudd is a cardiology nurse practitioner for the Herma Heart Center at Children's Hospital of Wisconsin, Milwaukee, with a dual clinical role within the interstage home monitoring and the adult congenital heart disease program.,Jennifer Strawn is a nurse clinician in pediatric cardiology at Children's Hospital & Medical Center, Omaha, Nebraska. She was a member of the pilot team for National Pediatric Cardiology Quality Improvement Collaborative and continues to serve as a key contact and data coordinator.,Anne Schmelzer is the nurse coordinator for the neurocardiac developmental program and a cardiology nurse in the high-risk cardiac surgery clinic at Nicklaus Children's Hospital Heart Program, Miami, Florida.,Nancy Dobrolet is director of the high-risk cardiac surgery clinic and codirector of the neurocardiac developmental clinic at the Nicklaus Children's Hospital Heart Program, Miami Children's Health System
| | - Jennifer Strawn
- Jo Ann Nieves is a pediatric nurse practitioner in the neonatal high-risk cardiac surgery clinic and the adult congenital heart disease program at the Nicklaus Children's Hospital Heart Program, Miami, Florida.,Karen Uzark is a pediatric nurse practitioner in the congenital heart center and the cardiac neurodevelopmental follow-up clinic. She is assistant director of the Michigan Congenital Heart Outcomes Research and Discovery program, Mott's Children's Hospital, University of Michigan, Ann Arbor, Michigan.,Nancy A. Rudd is a cardiology nurse practitioner for the Herma Heart Center at Children's Hospital of Wisconsin, Milwaukee, with a dual clinical role within the interstage home monitoring and the adult congenital heart disease program.,Jennifer Strawn is a nurse clinician in pediatric cardiology at Children's Hospital & Medical Center, Omaha, Nebraska. She was a member of the pilot team for National Pediatric Cardiology Quality Improvement Collaborative and continues to serve as a key contact and data coordinator.,Anne Schmelzer is the nurse coordinator for the neurocardiac developmental program and a cardiology nurse in the high-risk cardiac surgery clinic at Nicklaus Children's Hospital Heart Program, Miami, Florida.,Nancy Dobrolet is director of the high-risk cardiac surgery clinic and codirector of the neurocardiac developmental clinic at the Nicklaus Children's Hospital Heart Program, Miami Children's Health System
| | - Anne Schmelzer
- Jo Ann Nieves is a pediatric nurse practitioner in the neonatal high-risk cardiac surgery clinic and the adult congenital heart disease program at the Nicklaus Children's Hospital Heart Program, Miami, Florida.,Karen Uzark is a pediatric nurse practitioner in the congenital heart center and the cardiac neurodevelopmental follow-up clinic. She is assistant director of the Michigan Congenital Heart Outcomes Research and Discovery program, Mott's Children's Hospital, University of Michigan, Ann Arbor, Michigan.,Nancy A. Rudd is a cardiology nurse practitioner for the Herma Heart Center at Children's Hospital of Wisconsin, Milwaukee, with a dual clinical role within the interstage home monitoring and the adult congenital heart disease program.,Jennifer Strawn is a nurse clinician in pediatric cardiology at Children's Hospital & Medical Center, Omaha, Nebraska. She was a member of the pilot team for National Pediatric Cardiology Quality Improvement Collaborative and continues to serve as a key contact and data coordinator.,Anne Schmelzer is the nurse coordinator for the neurocardiac developmental program and a cardiology nurse in the high-risk cardiac surgery clinic at Nicklaus Children's Hospital Heart Program, Miami, Florida.,Nancy Dobrolet is director of the high-risk cardiac surgery clinic and codirector of the neurocardiac developmental clinic at the Nicklaus Children's Hospital Heart Program, Miami Children's Health System
| | - Nancy Dobrolet
- Jo Ann Nieves is a pediatric nurse practitioner in the neonatal high-risk cardiac surgery clinic and the adult congenital heart disease program at the Nicklaus Children's Hospital Heart Program, Miami, Florida.,Karen Uzark is a pediatric nurse practitioner in the congenital heart center and the cardiac neurodevelopmental follow-up clinic. She is assistant director of the Michigan Congenital Heart Outcomes Research and Discovery program, Mott's Children's Hospital, University of Michigan, Ann Arbor, Michigan.,Nancy A. Rudd is a cardiology nurse practitioner for the Herma Heart Center at Children's Hospital of Wisconsin, Milwaukee, with a dual clinical role within the interstage home monitoring and the adult congenital heart disease program.,Jennifer Strawn is a nurse clinician in pediatric cardiology at Children's Hospital & Medical Center, Omaha, Nebraska. She was a member of the pilot team for National Pediatric Cardiology Quality Improvement Collaborative and continues to serve as a key contact and data coordinator.,Anne Schmelzer is the nurse coordinator for the neurocardiac developmental program and a cardiology nurse in the high-risk cardiac surgery clinic at Nicklaus Children's Hospital Heart Program, Miami, Florida.,Nancy Dobrolet is director of the high-risk cardiac surgery clinic and codirector of the neurocardiac developmental clinic at the Nicklaus Children's Hospital Heart Program, Miami Children's Health System
| |
Collapse
|
25
|
Abstract
UNLABELLED Aim The aims of this study were to examine the prevalence and potential correlates of feeding difficulties in infants who underwent cardiac surgery in the neonatal period and to investigate resource utilisation by infants with feeding difficulties. METHODS All neonates who underwent their first cardiac surgery at the Heart Centre for Children, The Children's Hospital at Westmead, between January and December, 2009 were included. Demographic, preoperative, intraoperative, and postoperative data were collected via electronic medical records. For the purpose of this study, feeding difficulty was defined as the requirement for ongoing tube feeding at the time of discharge home or transfer to another hospital. RESULTS Out of a total of 79 neonates, 24 (30%) were discharged home or transferred to another hospital with a feeding tube. Feeding difficulties were associated with the presence of a genetic syndrome (p<0.0001), assisted feeding preoperatively (odds ratio (OR)=4.4, p=0.03), and having a palliative procedure before biventricular repair (OR=5.1, p=0.02). Infants with feeding difficulties had significantly more reviews by speech pathologists (M=5.9, SD=7.9), dieticians (M=5.9, SD=5.4), and cardiac clinical nurse consultants (M=1.2, SD=1.4) compared with those without feeding difficulties. CONCLUSIONS This study identified factors that can be used in the early recognition of infant feeding difficulties, to help guide the direction of limited health resources, as well as being focal points for future research and clinical practice improvement.
Collapse
|
26
|
Identification of Risk Factors for Poor Feeding in Infants with Congenital Heart Disease and a Novel Approach to Improve Oral Feeding. J Pediatr Nurs 2017; 35:149-154. [PMID: 28169036 PMCID: PMC5522347 DOI: 10.1016/j.pedn.2017.01.009] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 01/18/2017] [Accepted: 01/20/2017] [Indexed: 12/21/2022]
Abstract
Many infants with complex congenital heart disease (CHD) do not develop the skills to feed orally and are discharged home on gastrostomy tube or nasogastric feeds. We aimed to identify risk factors for failure to achieve full oral feeding and evaluate the efficacy of oral motor intervention for increasing the rate of discharge on full oral feeds by performing a prospective study in the neonatal and cardiac intensive care units of a tertiary children's hospital. 23 neonates born at ≥37weeks gestation and diagnosed with single-ventricle physiology requiring a surgical shunt were prospectively enrolled and received oral motor intervention therapy. 40 historical controls were identified. Mean length of stay was 53.7days for the control group and 40.9days for the study group (p=0.668). 13/23 patients who received oral motor intervention therapy (56.5%) and 18/40 (45.0%) controls were on full oral feeds at discharge, a difference of 11.5% (95% CI -13.9% to 37.0%, p=0.378). Diagnosis of hypoplastic left heart syndrome, longer intubation and duration of withholding enteral feeds, and presence of gastroesophageal reflux disease were predictors of poor oral feeding on univariate analysis. Although we did not detect a statistically significant impact of oral motor intervention, we found clinically meaningful differences in hospital length of stay and feeding tube requirement. Further research should be undertaken to evaluate methods for improving oral feeding in these at-risk infants.
Collapse
|
27
|
Kvello M, Åvitsland TL, Knatten CK, Pripp AH, Aabakken L, Emblem R, Bjørnland K. Trends in the use of gastrostomies at a tertiary paediatric referral centre. Scand J Gastroenterol 2016; 51:625-32. [PMID: 26679498 DOI: 10.3109/00365521.2015.1123288] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The aims of this study were to describe the population of paediatric patients undergoing gastrostomy placement at a Norwegian tertiary referral centre and to investigate trends over time in patient characteristics and operative technique. MATERIALS AND METHODS Patients <15 years of age getting a primary gastrostomy from 1994 to 2012 were included in this retrospective observational study. Patient data were collected from medical records and the National Registry. RESULTS Six-hundred forty-nine patients with a median age of 1.2 years [gestational week 30-14.9 years] were included. Neurological disorders (ND) was the most common underlying group of diagnosis (n = 311, 48%), followed by cardiac disease 104 (16%), congenital anomalies 85 (13%), respiratory disease 43 (7%), malignancy 29 (5%), and others 77 (12%). At follow-up, 162 (25%) patients were dead. A percutaneous endoscopic technique (PEG) was used in 401 (62%) patients, open surgery (OPEN) in 201 (31%) and laparoscopy (LAP) in 47 (7%). The number of gastrostomies per year more than doubled during the period (p < 0.001). More patients with cardiac disease and congenital anomalies were given a gastrostomy during the last years (all p < 0.05), whereas the number of patients with ND remained stable. Furthermore, there has been a decrease in median age and an increase in the number of PEG and LAP (p < 0.05). CONCLUSION The number of gastrostomy insertions has increased from 1994 to 2012. NDs is the most common underlying diagnosis in patients receiving a gastrostomy, PEG is the most common technique and patient characteristics have changed during the study period.
Collapse
Affiliation(s)
- Morten Kvello
- a Institute of Clinical Medicine, University of Oslo , Oslo , Norway ;,b Department of Gastrointestinal and Paediatric Surgery , Oslo University Hospital, Rikshospitalet , Norway
| | - Tone Lise Åvitsland
- a Institute of Clinical Medicine, University of Oslo , Oslo , Norway ;,b Department of Gastrointestinal and Paediatric Surgery , Oslo University Hospital, Rikshospitalet , Norway
| | - Charlotte Kristensen Knatten
- a Institute of Clinical Medicine, University of Oslo , Oslo , Norway ;,b Department of Gastrointestinal and Paediatric Surgery , Oslo University Hospital, Rikshospitalet , Norway
| | - Are Hugo Pripp
- c Oslo Centre of Biostatistics and Epidemiology, Oslo University Hospital , Oslo , Norway
| | - Lars Aabakken
- a Institute of Clinical Medicine, University of Oslo , Oslo , Norway ;,d Department of Gastroenterology , Oslo University Hospital, Rikshospitalet , Norway
| | - Ragnhild Emblem
- a Institute of Clinical Medicine, University of Oslo , Oslo , Norway ;,b Department of Gastrointestinal and Paediatric Surgery , Oslo University Hospital, Rikshospitalet , Norway
| | - Kristin Bjørnland
- a Institute of Clinical Medicine, University of Oslo , Oslo , Norway ;,b Department of Gastrointestinal and Paediatric Surgery , Oslo University Hospital, Rikshospitalet , Norway
| |
Collapse
|
28
|
Abstract
OBJECTIVES The objectives of this review are to discuss the challenges of delivering adequate nutrition to children with congenital heart disease, including pre- and postoperative factors and the role of enteral and parenteral nutrition, as well as the evidence supporting current practices. DATA SOURCE MEDLINE and PubMed. CONCLUSION Providing adequate nutritional support is paramount for critically ill infants with congenital heart disease, a population at particular risk for malnutrition. Improved nutritional support has been associated with increased survival and reduction in overall morbidity. Further gains can be achieved by creating a clinical culture that emphasizes optimal perioperative nutritional support. Additional research is required to identify the specific nutrient composition, optimal mode, and timing of delivery to maximize clinical benefit.
Collapse
|
29
|
Slicker J, Sables-Baus S, Lambert LM, Peterson LE, Woodard FK, Ocampo EC. Perioperative Feeding Approaches in Single Ventricle Infants: A Survey of 46 Centers. CONGENIT HEART DIS 2016; 11:707-715. [DOI: 10.1111/chd.12390] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/27/2016] [Indexed: 11/27/2022]
Affiliation(s)
| | - Sharon Sables-Baus
- University of Colorado, College of Nursing; Children's Hospital Colorado; Aurora Colo USA
| | | | | | - Frances K. Woodard
- Medical University of South Carolina Children's Hospital; Charleston SC USA
| | - Elena C. Ocampo
- Baylor College of Medicine; Texas Children's Hospital; Houston Tex USA
| | | |
Collapse
|
30
|
Burch PT, Spigarelli MG, Lambert LM, Loftus PD, Sherwin CM, Linakis MW, Sheng X, LuAnn Minich L, Williams RV. Use of Oxandrolone to Promote Growth in Neonates following Surgery for Complex Congenital Heart Disease: An Open-Label Pilot Trial. CONGENIT HEART DIS 2016; 11:693-699. [PMID: 27257953 DOI: 10.1111/chd.12376] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/19/2016] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Malnutrition and poor weight gain, common in neonates following repair of complex congenital heart disease (CHD), are associated with increased morbidity and mortality. Oxandrolone, an anabolic steroid, improves weight gain in older children at high-risk for growth failure. We sought to determine feasibility, safety, and efficacy of oxandrolone therapy in neonates following surgery for complex CHD. DESIGN Neonates with RACHS-1 score >3 were eligible to receive open-label oxandrolone for 28 days in this prospective pilot trial. There were 3 cohorts of 5 subjects receiving oxandrolone therapy under 3 specified dosage and preparation protocols: 0.1 mg/kg/day aqueous solution, 0.2 mg/kg/day aqueous solution, and 0.1 mg/kg/day preparation in medium chain triglyceride (MCT) oil. Age- and diagnosis-matched neonates who underwent surgery, but received no oxandrolone, served as a control cohort. Anthropometric measurements, physical examination for virilization, safety labs, and adverse events were monitored. RESULTS Of 25 eligible patients, 15 consented (60%, 13/15 with Norwood procedure). There was no evidence of virilization, no changes in safety labs, and no serious adverse events related to oxandrolone among subjects receiving therapy. No subject met criteria for termination of study drug. There was a significant difference in change in weight-for-age z-score among the four cohorts, with subjects receiving 0.1 mg/kg/day in MCT oil having the lowest decline during the study period (-1.8 ± 0.5 for controls, -1.7 ± 0.4 for 0.1 mg/kg/day aqueous, -1.0 ± 0.4 for 0.2 mg/kg/day aqueous, and -0.6 ± 0.7 for 0.1 mg/kg/day MCT oil, P = .012). CONCLUSIONS Oxandrolone therapy at the doses studied appears safe in neonates after surgery for complex CHD. The decline in weight-for-age z-score was lowest in those receiving the MCT oil preparation suggesting better bioavailability of this preparation and a potential growth benefit with oxandrolone therapy. Further investigation is needed to define optimal dosing and assess efficacy.
Collapse
Affiliation(s)
- Phillip T Burch
- Divisions of Cardiothoracic Surgery, University of Utah and Primary Children's Hospital, Salt Lake City, UT, USA
| | - Michael G Spigarelli
- Adolescent Medicine, University of Utah and Primary Children's Hospital, Salt Lake City, UT, USA.,Pediatric Clinical Pharmacology, University of Utah and Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Linda M Lambert
- Divisions of Cardiothoracic Surgery, University of Utah and Primary Children's Hospital, Salt Lake City, UT, USA
| | - Patrick D Loftus
- Divisions of Cardiothoracic Surgery, University of Utah and Primary Children's Hospital, Salt Lake City, UT, USA
| | - Catherine M Sherwin
- Pediatric Clinical Pharmacology, University of Utah and Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Matthew W Linakis
- Pediatric Clinical Pharmacology, University of Utah and Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Xiaoming Sheng
- Department of Pediatrics, University of Utah and Primary Children's Hospital, Salt Lake City, UT, USA
| | - L LuAnn Minich
- Pediatric Cardiology, University of Utah and Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Richard V Williams
- Pediatric Cardiology, University of Utah and Primary Children's Hospital, Salt Lake City, Utah, USA
| |
Collapse
|
31
|
Crowe S, Ridout DA, Knowles R, Tregay J, Wray J, Barron DJ, Cunningham D, Parslow RC, Utley M, Franklin R, Bull C, Brown KL. Death and Emergency Readmission of Infants Discharged After Interventions for Congenital Heart Disease: A National Study of 7643 Infants to Inform Service Improvement. J Am Heart Assoc 2016; 5:JAHA.116.003369. [PMID: 27207967 PMCID: PMC4889202 DOI: 10.1161/jaha.116.003369] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Improvements in hospital‐based care have reduced early mortality in congenital heart disease. Later adverse outcomes may be reducible by focusing on care at or after discharge. We aimed to identify risk factors for such events within 1 year of discharge after intervention in infancy and, separately, to identify subgroups that might benefit from different forms of intervention. Methods and Results Cardiac procedures performed in infants between 2005 and 2010 in England and Wales from the UK National Congenital Heart Disease Audit were linked to intensive care records. Among 7976 infants, 333 (4.2%) died before discharge. Of 7643 infants discharged alive, 246 (3.2%) died outside the hospital or after an unplanned readmission to intensive care (risk factors were age, weight‐for‐age, cardiac procedure, cardiac diagnosis, congenital anomaly, preprocedural clinical deterioration, prematurity, ethnicity, and duration of initial admission; c‐statistic 0.78 [0.75–0.82]). Of the 7643, 514 (6.7%) died outside the hospital or had an unplanned intensive care readmission (same risk factors but with neurodevelopmental condition and acquired cardiac diagnosis and without preprocedural deterioration; c‐statistic 0.78 [0.75–0.80]). Classification and regression tree analysis were used to identify 6 subgroups stratified by the level (3–24%) and nature of risk for death outside the hospital or unplanned intensive care readmission based on neurodevelopmental condition, cardiac diagnosis, congenital anomaly, and duration of initial admission. An additional 115 patients died after planned intensive care admission (typically following elective surgery). Conclusions Adverse outcomes in the year after discharge are of similar magnitude to in‐hospital mortality, warrant service improvements, and are not confined to diagnostic groups currently targeted with enhanced monitoring.
Collapse
Affiliation(s)
- Sonya Crowe
- Clinical Operational Research Unit, University College London, London, UK
| | - Deborah A Ridout
- Population, Policy and Practice Programme, UCL Institute of Child Health, London, UK
| | - Rachel Knowles
- Population, Policy and Practice Programme, UCL Institute of Child Health, London, UK
| | - Jenifer Tregay
- Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Jo Wray
- Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - David J Barron
- Birmingham Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - David Cunningham
- NICOR: National Institute for Cardiovascular Outcomes Research, UCL, London, UK
| | | | - Martin Utley
- Clinical Operational Research Unit, University College London, London, UK
| | - Rodney Franklin
- Royal Brompton and Harefield Hospitals NHS Trust, London, UK
| | - Catherine Bull
- Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | | |
Collapse
|
32
|
Brown KL, Wray J, Knowles RL, Crowe S, Tregay J, Ridout D, Barron DJ, Cunningham D, Parslow R, Franklin R, Barnes N, Hull S, Bull C. Infant deaths in the UK community following successful cardiac surgery: building the evidence base for optimal surveillance, a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04190] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundWhile early outcomes of paediatric cardiac surgery have improved, less attention has been given to later outcomes including post-discharge mortality and emergency readmissions.ObjectivesOur objectives were to use a mixed-methods approach to build an evidenced-based guideline for postdischarge management of infants undergoing interventions for congenital heart disease (CHD).MethodsSystematic reviews of the literature – databases used: MEDLINE (1980 to 1 February 2013), EMBASE (1980 to 1 February 2013), Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1981 to 1 February 2013), The Cochrane Library (1999 to 1 February 2013), Web of Knowledge (1980 to 1 February 2013) and PsycINFO (1980 to 1 February 2013). Analysis of audit data from the National Congenital Heart Disease Audit and Paediatric Intensive Care Audit Network databases pertaining to records of infants undergoing interventions for CHD between 1 January 2005 and 31 December 2010. Qualitative analyses of online discussion posted by 73 parents, interviews with 10 helpline staff based at user groups, interviews with 20 families whose infant either died after discharge or was readmitted urgently to intensive care, and interviews with 25 professionals from tertiary care and 13 professionals from primary and secondary care. Iterative multidisciplinary review and discussion of evidence incorporating the views of parents on suggestions for improvement.ResultsDespite a wide search strategy, the studies identified for inclusion in reviews related only to patients with complex CHD, for whom adverse outcome was linked to non-white ethnicity, lower socioeconomic status, comorbidity, age, complexity and feeding difficulties. There was evidence to suggest that home monitoring programmes (HMPs) are beneficial. Of 7976 included infants, 333 (4.2%) died postoperatively, leaving 7634 infants, of whom 246 (3.2%) experienced outcome 1 (postdischarge death) and 514 (6.7%) experienced outcome 2 (postdischarge death plus emergency intensive care readmissions). Multiple logistic regression models for risk of outcomes 1 and 2 had areas under the receiver operator curve of 0.78 [95% confidence interval (CI) 0.75 to 0.82] and 0.78 (95% CI 0.75 to 0.80), respectively. Six patient groups were identified using classification and regression tree analysis to stratify by outcome 2 (range 3–24%), which were defined in terms of neurodevelopmental conditions, high-risk cardiac diagnosis (hypoplastic left heart, single ventricle or pulmonary atresia), congenital anomalies and length of stay (LOS) > 1 month. Deficiencies and national variability were noted for predischarge training and information, the process of discharge to non-specialist services including documentation, paediatric cardiology follow-up including HMP, psychosocial support post discharge and the processes for accessing help when an infant becomes unwell.ConclusionsNational standardisation may improve discharge documents, training and guidance on ‘what is normal’ and ‘signs and symptoms to look for’, including how to respond. Infants with high-risk cardiac diagnoses, neurodevelopmental conditions or LOS > 1 month may benefit from discharge via their local hospital. HMP is suggested for infants with hypoplastic left heart, single ventricle or pulmonary atresia. Discussion of postdischarge deaths for infant CHD should occur at a network-based multidisciplinary meeting. Audit is required of outcomes for this stage of the patient journey.Future workFurther research may determine the optimal protocol for HMPs, evaluate the use of traffic light tools for monitoring infants post discharge and develop the analytical steps and processes required for audit of postdischarge metrics.Study registrationThis study is registered as PROSPERO CRD42013003483 and CRD42013003484.FundingThe National Institute for Health Research Health Services and Delivery Research programme. The National Congenital Heart Diseases Audit (NCHDA) and Paediatric Intensive Care Audit Network (PICANet) are funded by the National Clinical Audit and Patient Outcomes Programme, administered by the Healthcare Quality Improvement Partnership (HQIP). PICAnet is also funded by Welsh Health Specialised Services Committee; NHS Lothian/National Service Division NHS Scotland, the Royal Belfast Hospital for Sick Children, National Office of Clinical Audit Ireland, and HCA International. The study was supported by the National Institute for Health Research Biomedical Research Centre at Great Ormond Street Hospital for Children NHS Foundation Trust and University College London. Sonya Crowe was supported by the Health Foundation, an independent charity working to continuously improve the quality of health care in the UK.
Collapse
Affiliation(s)
- Katherine L Brown
- Cardiac Unit, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Jo Wray
- Cardiac Unit, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Rachel L Knowles
- Population Policy and Practice Programme, University College London Institute of Child Health, London, UK
| | - Sonya Crowe
- Clinical Operational Research Unit, University College London, London, UK
| | - Jenifer Tregay
- Cardiac Unit, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Deborah Ridout
- Population Policy and Practice Programme, University College London Institute of Child Health, London, UK
| | - David J Barron
- Cardiac Surgery Department, Birmingham Children’s Hospital NHS Foundation Trust, Birmingham, UK
| | - David Cunningham
- National Institute for Cardiovascular Outcomes Research, University College London, London, UK
| | - Roger Parslow
- Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Rodney Franklin
- Paediatric Cardiac Unit, Royal Brompton and Harefield Hospitals NHS Trust, London, UK
| | - Nick Barnes
- Department of Paediatrics, Northampton General Hospital NHS Trust, Northampton, UK
| | - Sally Hull
- Primary Care Department, Queen Mary University of London, London, UK
| | - Catherine Bull
- Cardiac Unit, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| |
Collapse
|
33
|
Alternative strategies in newborns and infants with major co-morbidities to improve congenital heart surgery outcomes at an emerging programme. Cardiol Young 2016; 26:485-92. [PMID: 26032881 DOI: 10.1017/s1047951115000463] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Debilitating patient-related non-cardiac co-morbidity cumulatively increases risk for congenital heart surgery. At our emerging programme, flexible surgical strategies were used in high-risk neonates and infants generally considered in-operable, in an attempt to make them surgical candidates and achieve excellent outcomes. MATERIALS AND METHODS Between April, 2010 and November, 2013, all referred neonates (142) and infants (300) (average scores: RACHS 2.8 and STAT 3.0) underwent 442 primary cardiac operations: patients with bi-ventricular lesions underwent standard (n=294) or alternative (n=19) repair/staging strategies, such as pulmonary artery banding(s), ductal stenting, right outflow patching, etc. Patients with uni-ventricular hearts followed standard (n=96) or alternative hybrid (n=34) staging. The impact of major pre-operative risk factors (37%), standard or alternative surgical strategy, prematurity (50%), gestational age, low birth weight, genetic syndromes (23%), and major non-cardiac co-morbidity requiring same admission surgery (27%) was analysed on the need for extracorporeal membrane oxygenation, mortality, length of intubation, as well as ICU and hospital length of stays. RESULTS The need for extracorporeal membrane oxygenation (8%) and hospital survival (94%) varied significantly between surgical strategy groups (p=0.0083 and 0.028, respectively). In high-risk patients, alternative bi- and uni-ventricular strategies minimised mortality, but were associated with prolonged intubation and ICU stay. Major pre-operative risk factors and lower weight at surgery significantly correlated with prolonged intubation, hospital length of stay, and mortality. DISCUSSION In our emerging programme, flexible surgical strategies were offered to 53/442 high-risk neonates and infants with complex CHDs and significant non-cardiac co-morbidity, in order to buffer risk and achieve patient survival, although at the cost of increased resource utilisation.
Collapse
|
34
|
Ugonabo N, Hirsch-Romano JC, Uzark K. The role of home monitoring in interstage management of infants following the Norwood procedure. World J Pediatr Congenit Heart Surg 2015; 6:266-73. [PMID: 25870346 DOI: 10.1177/2150135114563771] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although outcomes for infants with complex single ventricle heart defects have steadily improved in recent decades, there is still a significant risk for mortality and morbidity during the interstage period between stage 1 Norwood hospitalization discharge and stage 2 palliation. Home monitoring programs, which involve parental surveillance of daily weight and oxygen saturations during the interstage period, have been shown to significantly improve survival rates. This article describes the potential risk factors or causes of interstage mortality and reviews the role of home monitoring in early detection and potential prevention of adverse outcomes.
Collapse
Affiliation(s)
- Nkem Ugonabo
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jennifer C Hirsch-Romano
- Department of Cardiac Surgery, University of Michigan Mott Children's Hospital, Ann Arbor, MI, USA
| | - Karen Uzark
- Department of Cardiac Surgery, University of Michigan Mott Children's Hospital, Ann Arbor, MI, USA
| |
Collapse
|
35
|
Unexpected deaths and unplanned re-admissions in infants discharged home after cardiac surgery: a systematic review of potential risk factors. Cardiol Young 2015; 25:839-52. [PMID: 25547262 DOI: 10.1017/s1047951114002492] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Babies with CHDs are a particularly vulnerable population with significant mortality in their 1st year. Although most deaths occur in the hospital within the early postoperative period, around one-fifth of postoperative deaths in the 1st year of life may occur after hospital discharge in infants who have undergone apparently successful cardiac surgery. Aim To systematically review the published literature and identify risk factors for adverse outcomes, specifically deaths and unplanned re-admissions, following hospital discharge after infant surgery for life-threatening CHDs. METHODS A systematic search was conducted in MEDLINE, EMBASE, CINAHL, Cochrane Library, Web of Knowledge, and PsycINFO electronic databases, supplemented by manual searching of conference abstracts. RESULTS A total of 15 studies were eligible for inclusion. Almost exclusively, studies were conducted in single US centres and focussed on children with complex single ventricle diagnoses. A wide range of risk factors were evaluated, and those more frequently identified as having a significant association with higher mortality or unplanned re-admission risk were non-Caucasian ethnicity, lower socio-economic status, co-morbid conditions, age at surgery, operative complexity and procedure type, and post-operative feeding difficulties. CONCLUSIONS Studies investigating risk factors for adverse outcomes post-discharge following diverse congenital heart operations in infants are lacking. Further research is needed to systematically identify higher risk groups, and to develop interventions targeted at supporting the most vulnerable infants within an integrated primary and secondary care pathway.
Collapse
|
36
|
El-Sayed Ahmed MM, Alfares FA, Hynes CF, Ramakrishnan K, Louis C, Dou C, Costello JP, Zurakowski D, Jonas RA, Nath DS. Timing of Gastrostomy Tube Feeding in Three-stage Palliation of Single-ventricle Physiology. CONGENIT HEART DIS 2015; 11:34-8. [DOI: 10.1111/chd.12272] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/17/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Magdy M. El-Sayed Ahmed
- Division of Cardiovascular Surgery; Children's National Health System; Washington DC USA
- Department of Surgery; Zagazig University Faculty of Medicine; Zagazig Egypt
| | - Fahad A. Alfares
- Division of Cardiovascular Surgery; Children's National Health System; Washington DC USA
| | - Conor F. Hynes
- Division of Cardiovascular Surgery; Children's National Health System; Washington DC USA
| | - Karthik Ramakrishnan
- Division of Cardiovascular Surgery; Children's National Health System; Washington DC USA
| | - Clouden Louis
- Division of Cardiovascular Surgery; Children's National Health System; Washington DC USA
| | - Cookie Dou
- Division of Cardiovascular Surgery; Children's National Health System; Washington DC USA
| | - John P. Costello
- Division of Cardiovascular Surgery; Children's National Health System; Washington DC USA
| | - David Zurakowski
- Departments of Anesthesia and Surgery; Boston Children's Hospital; Harvard Medical School; Boston Mass USA
| | - Richard A. Jonas
- Division of Cardiovascular Surgery; Children's National Health System; Washington DC USA
| | - Dilip S. Nath
- Division of Cardiovascular Surgery; Children's National Health System; Washington DC USA
| |
Collapse
|
37
|
Malkar MB, Jadcherla S. Neuromotor mechanisms of pharyngoesophageal motility in dysphagic infants with congenital heart disease. Pediatr Res 2014; 76:190-6. [PMID: 24819378 PMCID: PMC4104136 DOI: 10.1038/pr.2014.68] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2013] [Accepted: 02/07/2014] [Indexed: 01/02/2023]
Abstract
BACKGROUND Aero-digestive morbidities are common in congenital heart disease infants, and the mechanisms are unclear. We hypothesized that adaptive pharyngoesophageal motility reflexes are different in surgical congenital heart disease infants (S-CHD) vs. nonsurgical congenital heart disease infants (CHD) and healthy controls. METHODS Abrupt pharyngeal provocation was performed with graded water infusions using purpose-built micromanometry. The data from 12 S-CHD were compared with data from 10 CHD and 12 controls. One hundred and ninety-seven water stimulations were examined for the frequency, latency, duration, and magnitude of pharyngo-upper esophageal sphincter contractile response (PUCR), pharyngeal reflexive swallow (PRS), esophageal body peristalsis, and lower esophageal sphincter (LES) relaxation characteristics. Mixed statistical models were applied. RESULTS Frequency distribution (%) of PUCR: PRS: none in S-CHD vs. CHD vs. controls, respectively, were 36:46:17 vs. 9:80:11 vs. 15:61:24 (P < 0.05). Response latency to the final esophageal body waveform (P = 0.01) and the response duration of esophageal body peristalsis (P = 0.04) were prolonged in S-CHD vs. controls but were similar to CHD (P = 0.22). Pharyngeal infusion-induced LES relaxation characteristics were similar in all three groups. CONCLUSION Abnormality in the recruitment of PUCR or PRS reflexes and esophageal body peristalsis in S-CHD implicate dysregulation in vagal cholinergic excitatory neuromotor responses.
Collapse
Affiliation(s)
- Manish B. Malkar
- Section of Neonatology, The Neonatal and Infant Feeding Disorders Program, Nationwide Children’s Hospital, Columbus, Ohio, USA,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Sudarshan Jadcherla
- Section of Neonatology, The Neonatal and Infant Feeding Disorders Program, Nationwide Children’s Hospital, Columbus, Ohio, USA,Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio, USA,Section of Pediatric Gastroenterology and Nutrition, Center for Perinatal Research, The Research Institute at Nationwide Children’s Hospital, Columbus, Ohio, USA
| |
Collapse
|
38
|
Cross RR, Harahsheh AS, McCarter R, Martin GR. Identified mortality risk factors associated with presentation, initial hospitalisation, and interstage period for the Norwood operation in a multi-centre registry: a report from the national pediatric cardiology-quality improvement collaborative. Cardiol Young 2014; 24:253-62. [PMID: 23388401 PMCID: PMC4457366 DOI: 10.1017/s1047951113000127] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Despite improvements in care following Stage 1 palliation, interstage mortality remains substantial. The National Pediatric Cardiology-Quality Improvement Collaborative captures clinical process and outcome data on infants discharged into the interstage period after Stage 1. We sought to identify risk factors for interstage mortality using these data. MATERIALS AND METHODS Patients who reached Stage 2 palliation or died in the interstage were included. The analysis was considered exploratory and hypothesis generating. Kaplan-Meier survival analysis was used to screen for univariate predictors, and Cox multiple regression modelling was used to identify potential independent risk factors. RESULTS Data on 247 patients who met the criteria between June, 2008 and June, 2011 were collected from 33 surgical centres. There were 23 interstage mortalities (9%). The identified independent risk factors of interstage mortality with associated relative risk were: hypoplastic left heart syndrome with aortic stenosis and mitral atresia (relative risk = 13), anti-seizure medications at discharge (relative risk = 12.5), earlier gestational age (relative risk = 11.1), nasogastric or nasojejunal feeding (relative risk = 5.5), unscheduled readmissions (relative risk = 5.3), hypoplastic left heart syndrome with aortic atresia and mitral stenosis (relative risk = 5.2), fewer clinic visits with primary cardiologist identified (relative risk = 3.1), and fewer post-operative vasoactive medications (relative risk = 2.2). CONCLUSION Interstage mortality remains substantial, and there are multiple potential risk factors. Future efforts should focus on further exploration of each risk factor, with potential integration of the factors into surveillance schemes and clinical practice strategies.
Collapse
Affiliation(s)
- Russell R Cross
- 1 Department of Pediatrics, Division of Cardiology, Children's National Medical Center and the George Washington University School of Medicine, Washington, DC, United States of America
| | - Ashraf S Harahsheh
- 1 Department of Pediatrics, Division of Cardiology, Children's National Medical Center and the George Washington University School of Medicine, Washington, DC, United States of America
| | - Robert McCarter
- 2 Division of Biostatistics & Research Methodology, Children's National Medical Center and the George Washington University School of Medicine, Washington, DC, United States of America
| | - Gerard R Martin
- 1 Department of Pediatrics, Division of Cardiology, Children's National Medical Center and the George Washington University School of Medicine, Washington, DC, United States of America
| |
Collapse
|
39
|
Hill GD, Hehir DA, Bartz PJ, Rudd NA, Frommelt MA, Slicker J, Tanem J, Frontier K, Xiang Q, Wang T, Tweddell JS, Ghanayem NS. Effect of feeding modality on interstage growth after stage I palliation: a report from the National Pediatric Cardiology Quality Improvement Collaborative. J Thorac Cardiovasc Surg 2014; 148:1534-9. [PMID: 24607373 DOI: 10.1016/j.jtcvs.2014.02.025] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Revised: 12/30/2013] [Accepted: 02/03/2014] [Indexed: 12/14/2022]
Abstract
OBJECTIVES Achieving adequate growth after stage 1 palliation for children with single-ventricle heart defects often requires supplemental nutrition through enteral tubes. Significant practice variability exists between centers in the choice of feeding tube. The impact of feeding modality on the growth of patients with a single ventricle after stage 1 palliation was examined using the multiinstitutional National Pediatric Cardiology Quality Improvement Collaborative data registry. METHODS Characteristics of patients were compared by feeding modality, defined as oral only, nasogastric tube only, oral and nasogastric tube, gastrostomy tube only, and oral and gastrostomy tube. The impact of feeding modality on change in weight for age z-score during the interstage period, from stage 1 palliation discharge to stage 2 palliation, was evaluated by multivariable linear regression, adjusting for important patient characteristics and postoperative morbidities. RESULTS In this cohort of 465 patients, all groups demonstrated improved weight for age z-score during the interstage period with a mean increase of 0.3±0.8. In multivariable analysis, feeding modality was not associated with differences in the change in weight for age z-score during the interstage period (P=.72). Risk factors for poor growth were a diagnosis of hypoplastic left heart syndrome (P=.003), vocal cord injury (P=.007), and lower target caloric goal at discharge (P=.001). CONCLUSIONS In this large multicenter cohort, interstage growth improved for all groups and did not differ by feeding modality. With appropriate caloric goals and interstage monitoring, adequate growth may be achieved regardless of feeding modality and therefore local comfort and complication risk should dictate feeding modality.
Collapse
Affiliation(s)
- Garick D Hill
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis.
| | - David A Hehir
- Division of Critical Care, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - Peter J Bartz
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis; Division of Adult Cardiovascular Medicine, Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, Wis
| | - Nancy A Rudd
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - Michele A Frommelt
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - Julie Slicker
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - Jena Tanem
- Division of Cardiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - Katherine Frontier
- Division of Speech and Audiology, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| | - Qun Xiang
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wis
| | - Tao Wang
- Division of Biostatistics, Medical College of Wisconsin, Milwaukee, Wis
| | - James S Tweddell
- Division of Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wis
| | - Nancy S Ghanayem
- Division of Critical Care, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wis
| |
Collapse
|
40
|
Di Maria MV, Glatz AC, Ravishankar C, Quartermain MD, Rush CH, Nance M, William Gaynor J, Goldberg DJ. Supplemental tube feeding does not mitigate weight loss in infants with shunt-dependent single-ventricle physiology. Pediatr Cardiol 2013; 34:1350-6. [PMID: 23423308 DOI: 10.1007/s00246-013-0648-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Accepted: 01/24/2013] [Indexed: 10/27/2022]
Abstract
Infants with shunt-dependent single-ventricle (SV) physiology are at risk for poor weight gain before superior cavopulmonary connection (SCPC). Lower weight-for-age z-score is a risk factor for prolonged length of stay (LOS) after SCPC. We sought to characterize infant growth and feeding and determine the effect of method of feeding on outcomes. Chart review of infants with shunt-dependent SV physiology born between October 2007 and September 2010 was performed. The cohort was divided into three groups based on feeding method at discharge after initial palliation; 53 in the oral feeding (PO) group, 56 in the nasogastric (NG) tube group, and 26 in the gastrostomy tube (GT) group. Birth weight z-score did not differ among groups (p = 0.39), but infants fed by NG or GT were smaller than PO-fed infants at hospital discharge (p = 0.0001), a difference that persisted through SCPC (p < 0.0001). Predictors of need for GT included Norwood procedure (p = 0.008) and longer LOS after initial palliation (p < 0.001). Interstage mortality and age at SCPC did not differ among groups. Risk factors for longer LOS at SCPC included longer LOS and need for supplemental feeds at discharge from initial palliation as well as lower weight at SCPC. Poor growth is common among infants with shunt-dependent SV physiology. Infants who require GT have lower weight-for-age z-scores at hospital discharge and remain smaller at SCPC than those fed PO. Although GT after initial palliation is associated with longer LOS after SCPC, it is not associated with an increase in interstage morbidity or mortality.
Collapse
Affiliation(s)
- Michael V Di Maria
- The Cardiac Center, The Children's Hospital of Philadelphia, 34th Street and Civic Center Blvd., Philadelphia, PA 19104, USA.
| | | | | | | | | | | | | | | |
Collapse
|
41
|
Song J, Kang IS, Huh J, Lee OJ, Kim G, Jun TG, Yang JH. Interstage mortality for functional single ventricle with heterotaxy syndrome: a retrospective study of the clinical experience of a single tertiary center. J Cardiothorac Surg 2013; 8:93. [PMID: 23591028 PMCID: PMC3652744 DOI: 10.1186/1749-8090-8-93] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Accepted: 04/15/2013] [Indexed: 01/08/2023] Open
Abstract
Background In spite of improved survival after palliation for single ventricle, interstage mortality for a single ventricle with heterotaxy syndrome is unknown. The purpose of this study was to quantify interstage mortality and influence mortality risk factors. Methods From November 1994 until February 2012, all patients that had a functional single ventricle and heterotaxy syndrome who underwent palliative operations at our center were included. Patients with hypoplastic left heart syndrome and operative mortality cases were excluded. The factors that influenced interstage mortality were determined by multivariate Cox analysis. Results There were 16 patients with interstage mortality (41.0%), much higher than the non-heterotaxy group (vs. 11.3%, P = 0.001, OR = 5.478). The major presumptive causes of death were infection or sepsis (37.5%) and unknown sudden death (31.3%). When we compared the survival group and the mortality group with heterotaxy syndrome, Blalock-Taussig shunt as a 1st palliation is most common for both groups but there were more for the mortality group (81.2% vs. 52.2%), and there were more with bidirectional cavo-pulmonary shunt as a 1st palliation in the survival group (10 patients vs. 2 patients). The existence of pulmonary vein stenosis at initial diagnosis was more common for the mortality group. In multivariate Cox analysis, however, the duration of hospitalization at palliation, the duration of intensive care unit stay after palliation and the existence of pulmonary vein stenosis at diagnosis were significant risk factors. Conclusion Interstage mortality for a functional single ventricle with heterotaxy syndrome is significantly higher than for non-heterotaxy syndrome. Therefore more attention should be given to the prevention of interstage mortality in these patients with risk factors.
Collapse
Affiliation(s)
- Jinyoung Song
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, South Korea
| | | | | | | | | | | | | |
Collapse
|
42
|
|