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Mitteregger E, Dirks T, Theiler M, Kretschmar O, Latal B. The implementation of EMI-Heart, a family-tailored early motor intervention in infants with complex congenital heart disease, in practice: a feasibility RCT. Pilot Feasibility Stud 2024; 10:105. [PMID: 39095881 DOI: 10.1186/s40814-024-01532-1] [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: 09/30/2023] [Accepted: 07/15/2024] [Indexed: 08/04/2024] Open
Abstract
BACKGROUND Children with congenital heart disease (CHD) who undergo open-heart surgery are at risk of developmental impairment, including motor delay, which contributes to parental concerns. Additionally, parents experience prolonged stress associated with their child's disease. There is a lack of early motor interventions in infants with CHD accounting for parental burdens. We developed a family-tailored early motor intervention (EMI-Heart), aiming to promote motor development in infants with CHD and family well-being. The primary aim was to evaluate the feasibility of the study design and the intervention. The secondary aim was to evaluate differences between the intervention and the control group in motor outcomes and family well-being at baseline (3-5 months), post-treatment (6-8 months), and at follow-up (12 months). METHOD In this single-centre feasibility randomized control trial (RCT), infants with CHD after open-heart surgery without genetic or major neurological comorbidities were randomly allocated to EMI-Heart or the control group (standard of care). EMI-Heart's key elements promote postural functional activities and encourage parental sensitivity to infants' motor and behaviour cues. Infants assigned to EMI-Heart received nine sessions of early motor intervention at home, in the hospital, and online for a duration of 3 months by a paediatric physiotherapist. We performed descriptive statistics for feasibility and secondary outcomes. RESULTS The recruitment rate was 59% (10/17), all participating families completed the study (10/10), and the intervention duration was 3.9 months (± 0.54), including nine intervention sessions per family. Median acceptability to parents was 3.9 (1 = not agree-4 = totally agree, Likert scale). The paediatric physiotherapist considered the intervention as feasible. The comparison of motor outcomes did not show differences between groups. However, we detected improved reliable change scores in family well-being outcomes for families of the intervention group compared to the controls. CONCLUSIONS Our research indicates that EMI-Heart is a feasible intervention for infants with CHD after open-heart surgery. The intervention was highly acceptable both to parents and to the paediatric physiotherapist. Online treatment sessions offer a valuable alternative to home and hospital visits. This feasibility RCT provides a foundation for a future full trial. TRIAL REGISTRATION ClinicalTrials.gov, NCTT04666857. Registered 23.11.2020.
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Affiliation(s)
- Elena Mitteregger
- Child Development Center, University Children's Hospital Zurich, Steinwiesstrasse 75, Zurich, CH-8032, Switzerland.
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland.
- University of Zurich, Zurich, Switzerland.
| | - Tineke Dirks
- Lecturer Emerita, Paediatric, Physiotherapy, Groningen, Netherlands
| | - Manuela Theiler
- Swiss Parents' Association for Children with Heart Disease (Elternvereinigung für das Herzkranke Kind), Aarau, Switzerland
| | - Oliver Kretschmar
- University of Zurich, Zurich, Switzerland
- Department of Pediatric Cardiology, University Children's Hospital Zurich, Zurich, Switzerland
| | - Beatrice Latal
- Child Development Center, University Children's Hospital Zurich, Steinwiesstrasse 75, Zurich, CH-8032, Switzerland
- Children's Research Center, University Children's Hospital Zurich, Zurich, Switzerland
- University of Zurich, Zurich, Switzerland
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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..
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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
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Abstract
BACKGROUND Feeding difficulty is common in infants with CHD. OBJECTIVE The purpose of this study was to describe the feeding skills and behaviours of infants with CHD at 6-12 months of age and explore relationships between feeding, gastrointestinal distress, and gastroesophageal reflux. METHODS Parents of 30 infants with CHD completed online surveys when their infant was 6, 8, 10, and 12 months old. Surveys included parent-report measures of feeding skills (Child Oral and Motor Proficiency Scale), feeding behaviours (Pediatric Eating Assessment Tool), symptoms of gastrointestinal distress (Infant Gastrointestinal Symptoms Questionnaire), and gastroesophageal reflux (Infant Gastroesophageal Reflux Questionnaire-Revised). RESULTS We found that 95, 32, 67, and 30% of infants were delayed in their feeding skill development at 6, 8, 10, and 12 months, respectively. Symptoms of problematic feeding behaviours were similarly high, with 90, 62, 29, and 38% of infants meeting criteria for problematic feeding at 6, 8, 10, and 12 months, respectively. Feeding skills and behaviours were related but unique contributors. Feeding behaviours were related to both gastrointestinal distress and gastroesophageal reflux, but feeding skills were rarely related to either. CONCLUSIONS Delayed acquisition of feeding skills and problematic feeding were common in infants with CHD. Infants with more gastrointestinal and gastroesophageal reflux symptoms had more symptoms of problematic feeding behaviours. CLINICAL IMPLICATIONS Comprehensive assessment, targeted interventions, and early involvement of feeding specialists are important to support feeding in infants with CHD through at least the first year of life.
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Affiliation(s)
- Britt F Pados
- School of Nursing, Boston College, Chestnut Hill, MA, USA
- Infant Feeding Care, Wellesley, MA, USA
| | - Tondi M Harrison
- College of Nursing, The Ohio State University, Columbus, OH, USA
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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.
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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
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Kataria-Hale J, Gollins L, Bonagurio K, Blanco C, Hair AB. Nutrition for Infants with Congenital Heart Disease. Clin Perinatol 2023; 50:699-713. [PMID: 37536773 DOI: 10.1016/j.clp.2023.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Perioperative malnutrition in infants with congenital heart disease can lead to significant postnatal growth failure and poor short- and long-term outcomes. A standardized approach to nutrition is needed for the neonatal congenital heart disease population, taking into consideration the type of cardiac lesion, the preoperative and postoperative period, and prematurity. Early enteral feeding is beneficial and should be paired with parenteral nutrition to meet the fluid and nutrient needs of the infant.
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Affiliation(s)
- Jasmeet Kataria-Hale
- Department of Pediatrics, Division of Neonatology, Mission Hospital, 509 Biltmore Avenue, Asheville, NC 28801, USA
| | - Laura Gollins
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin Street, MC: A5590, Houston, TX 77030, USA
| | - Krista Bonagurio
- University of Texas Health Science Center, San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA
| | - Cynthia Blanco
- University of Texas Health Science Center, San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA
| | - Amy B Hair
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin Street, MC: A5590, Houston, TX 77030, USA.
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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.
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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.
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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.
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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
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Desai H, Jones CE, Fogel JL, Negrin KA, Slater NL, Morris K, Doody LR, Engstler K, Torzone A, Smith J, Butler SC. Assessment and management of feeding difficulties for infants with complex CHD. Cardiol Young 2022; 33:1-10. [PMID: 36562257 DOI: 10.1017/s1047951122004024] [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] [Indexed: 12/24/2022]
Abstract
Early surgical intervention in infants with complex CHD results in significant disruptions to their respiratory, gastrointestinal, and nervous systems, which are all instrumental to the development of safe and efficient oral feeding skills. Standardised assessments or treatment protocols are not currently available for this unique population, requiring the clinician to rely on knowledge based on neonatal literature. Clinicians need to be skilled at evaluating and analysing these systems to develop an appropriate treatment plan to improve oral feeding skill and safety, while considering post-operative recovery in the infant with complex CHD. Supporting the family to re-establish their parental role during the hospitalisation and upon discharge is critical to reducing parental stress and oral feeding success.
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Affiliation(s)
- Hema Desai
- Department of Rehabilitation Services, Children's Hospital of Orange County, Orange, CA, USA
| | - Courtney E Jones
- Acute Care Therapy Services, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Jennifer L Fogel
- Department of Pediatric Rehabilitation, Advocate Children's Hospital, Oak Lawn, IL, USA
| | - Karli A Negrin
- Department of Therapy and Rehabilitative Services, Nemours Children's Health, Wilmington, DE, USA
| | - Nancy L Slater
- Physical Medicine and Rehabilitation Services, Children's Minnesota, Minneapolis, MN, USA
| | - Kimberly Morris
- Department of Speech-Language Pathology, Rady Children's Hospital San Diego, San Diego, CA, USA
| | - Lisa R Doody
- Pediatric Rehabilitation and Development, Advocate Children's Hospital, Oak Lawn, IL, USA
| | - Katherine Engstler
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, MA, USA
| | - Andrea Torzone
- Heart Center, Cardiac Intensive Care Unit, Children's Medical Center Dallas, Dallas, TX, USA
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Risk Factors for Tube Feeding at Discharge in Infants Undergoing Neonatal Surgery for Congenital Heart Disease: A Systematic Review. Pediatr Cardiol 2022; 44:769-794. [PMID: 36404346 DOI: 10.1007/s00246-022-03049-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 11/07/2022] [Indexed: 11/22/2022]
Abstract
Approximately 30-50% of infants undergoing neonatal surgery for congenital heart disease (CHD) cannot meet oral feeding goals by discharge and require feeding tube support at home. Feeding tubes are associated with increased readmission rates and consequent hospital, payer, and family costs, and are a burden for family caregivers. Identification of modifiable risk factors for oral feeding problems could support targeted care for at-risk infants. Therefore, the aim of this systematic review is to determine risk factors for tube feeding at discharge in infants undergoing neonatal surgery for CHD. Following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, a search was conducted using MEDLINE, CINAHL, and Cochrane Database of Systematic Reviews. Studies published before 2010 were excluded. The search resulted in 607 records, of which 18 were included. Studies were primarily retrospective cohort designs and results were often inconsistent. Study quality was assessed using the Joanna Briggs Critical Appraisal Tools. As a group, the studies exhibited substantial risk for bias. Based on the findings, infants who struggle with feeding preoperatively, experience increased nil per os duration and/or low oral feeding volume postoperatively, experience increased duration of mechanical ventilation, or have vocal cord dysfunction may be at risk for tube feeding at hospital discharge. Factors warranting further examination include cardiac physiology (e.g., aortic arch obstruction) and the relationship between neurodevelopment and oral feeding. Clinicians should use caution in assuming risk for an individual and prioritize early implementation of interventions that facilitate oral feeding development.
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Mills KI, Kim JH, Fogg K, Goldshtrom N, Graham EM, Kataria-Hale J, Osborne SW, Figueroa M. Nutritional Considerations for the Neonate With Congenital Heart Disease. Pediatrics 2022; 150:189883. [PMID: 36317972 DOI: 10.1542/peds.2022-056415g] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 02/25/2023] Open
Abstract
The importance of nutrition in managing critically ill infants with congenital heart disease (CHD) is foundational to optimizing short- and long-term health outcomes. Growth failure and malnutrition are common in infants with CHD. The etiology of growth failure in this population is often multifactorial and may be related to altered metabolic demands, compromised blood flow to the intestine leading to nutrient malabsorption, cellular hypoxia, inadequate energy intake, and poor oral-motor skills. A dearth of high-quality studies and gaps in previously published guidelines have led to wide variability in nutrition practices that are locally driven. This review provides recommendations from the nutrition subgroup of the Neonatal Cardiac Care Collaborative for best evidence-based practices in the provision of nutritional support in infants with CHD. The review of evidence and recommendations focused on 6 predefined areas of clinical care for a target population of infants <6 months with CHD admitted to the ICU or inpatient ward. These areas include energy needs, nutrient requirements, enteral nutrition, feeding practice, parenteral nutrition, and outcomes. Future progress will be directed at quality improvement efforts to optimize perioperative nutrition management with an increasing emphasis on individualized care based on nutritional status, cardiorespiratory physiology, state of illness, and other vulnerabilities.
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Affiliation(s)
- Kimberly I Mills
- Division of Cardiovascular Critical Care, Department of Cardiology, Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts.,Contributed equally as co-first authors
| | - Jae H Kim
- Division of Neonatology, Perinatal Institute, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, College of Medicine, Cincinnati, Ohio.,Contributed equally as co-first authors
| | - Kristi Fogg
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Nimrod Goldshtrom
- Division of Neonatology, Department of Pediatrics, Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, New York
| | - Eric M Graham
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Jasmeet Kataria-Hale
- Division of Neonatology, Department of Pediatrics, Mission Children's Hospital, Asheville, North Carolina
| | - Scott W Osborne
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Mayte Figueroa
- Division of Cardiology and Critical Care, Department of Pediatrics, St Louis Children's Hospital, Washington University School of Medicine, St Louis, Missouri
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Non-Pharmacological and Non-Surgical Feeding Interventions for Hospitalized Infants with Pediatric Feeding Disorder: A Scoping Review. Dysphagia 2022; 38:818-836. [PMID: 36044080 DOI: 10.1007/s00455-022-10504-7] [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: 07/26/2021] [Accepted: 07/25/2022] [Indexed: 11/27/2022]
Abstract
Infants born prematurely or with complex medical conditions often require treatment to facilitate safe and efficient feeding. Practice is based on evidence, so frontline clinicians look to the literature to make informed clinical decisions. The aim of this scoping review was to map and describe the literature base for infant feeding and swallowing interventions and to identify areas for further research. Four electronic databases were searched from the sources' inceptions through April 2020 using a search strategy designed by a health sciences research librarian. Thirteen grey literature sources were searched and forward and backward citation chasing was performed. Inclusion criteria were English-language studies reporting non-pharmacological and non-surgical interventions for hospitalized infants. Exclusion criteria included interventions exclusively for infants with cleft lip or palate or for infants being fed exclusively though enteral feeding. Data were extracted using a form created a priori and data were reported descriptively. We reviewed 6654 abstracts: 725 were chosen for full-text review and 136 met inclusion. Most studies explored interventions for infants born prematurely (n = 128). Studies were stratified by intervention domain: bridging (n = 91) and feeding/swallowing (n = 45); intervention approach: direct (n = 72), indirect (n = 31), or combination (n = 33); and outcome: feeding performance (n = 125), physiologic stability (n = 40), and swallowing physiology (n = 12). The body of research in infant feeding has grown; however, a need remains for research focused on populations of infants with various medical complexities and for frequently used interventions that lack supporting evidence.
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Oral feeding dysfunction in post-operative infants with CHDs: a scoping review. Cardiol Young 2022; 33:570-578. [PMID: 35450551 PMCID: PMC9652479 DOI: 10.1017/s1047951122001299] [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] [Indexed: 11/05/2022]
Abstract
Post-operative oral feeding difficulties in neonates and infants with CHD is common. While pre-operative oral feeding may be normal, oral feeding challenges manifest in the post-operative period without a clearly defined aetiology. The objective of this scoping review was to examine post-operative oral feeding in full-term neonates and infants with a CHD. Electronic databases query (1 January 1975-31 May 2021), hand-search of the reference lists of included studies, contact with experts, and review of relevant conferences were performed to identify quantitative studies evaluating post-operative oral feeding in full-term neonates and infants with a CHD. Associations with additional quantitative variables in these studies were also examined. Twenty-five studies met inclusion criteria. Eighty per cent were cohort studies that utilised retrospective chart review from a single institution. The primary variable of interest in all studies was oral feeding status upon discharge from neonatal hospitalisation. The most common risk factors evaluated with poor feeding at time of discharge were birth weight (36% of included studies), gestational age (44%), duration of post-operative intubation (48%), cardiac diagnosis (40%), and presence of genetic syndrome or chromosomal anomaly (36%). The most common health-related outcomes evaluated were length of hospital stay (40%) and length of ICU stay (16%). Only the health-related outcomes of length of hospital stay and length of ICU stay were consistently significantly associated with poor post-operative oral feeding across studies in this review. A clear aetiology of poor post-operative oral feeding remains unknown.
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13
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Feeding outcomes in post-discharge feeding clinic for infants following cardiac surgery. Cardiol Young 2022; 32:628-635. [PMID: 34304751 DOI: 10.1017/s1047951121002833] [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] [Indexed: 11/07/2022]
Abstract
INTRODUCTION The aim of this study was to describe the development and assess the usefulness of a feeding clinic to help infants with CHD tolerate the highest level of oral feeding while achieving growth velocity and supporting neurodevelopment. MATERIALS AND METHODS This retrospective, cohort study assessed feeding outcomes for infants who underwent cardiac surgery at <30 days of age with cardiopulmonary bypass between February 2016 and April 2020. Diagnoses, age at surgery, hospitalisation variables, and feeding outcomes were compared between two cohorts, pre- and post-implementation of a specialised feeding clinic using Exact Wilcoxon signed-rank test, chi-squared, or Fisher's exact test. The association between time to full oral feed and risk factors was assessed using univariable and multivariable Cox regression model. RESULTS Post-clinic infants (n = 116) surgery was performed at a median of 6 days of life (interquartile range: 4, 8) with median hospital length of stay of 19 days (interquartile range: 16, 26). Infants' median age at first clinic visit was at 30 days old (interquartile range: 24, 40) and took median 10 days (interquartile range: 7, 12) after hospital discharge to first clinic visit. In the post-clinic cohort, the median time to 100% oral feeding was 47 days (interquartile range: 27, 96) compared to the 60 days (interquartile range: 20, 84) in the pre-clinic cohort (n = 22), but the difference was not statistically significant. DISCUSSION The cardiac feeding clinic was utilised by our neonatal surgery population and feasible in coordination with cardiology follow-up visits. Future assessment of cardiac feeding clinic impact should include additional measures of feeding and neurodevelopmental success.
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Pettigrew J, Tzannes G, Swift L, Docking K, Osland K, Cheng AT. Surgically Acquired Vocal Cord Palsy in Infants and Children with Congenital Heart Disease (CHD): Description of Feeding Outcomes. Dysphagia 2022; 37:1288-1304. [PMID: 34981253 DOI: 10.1007/s00455-021-10390-5] [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: 11/17/2020] [Accepted: 11/22/2021] [Indexed: 11/28/2022]
Abstract
Impaired swallowing in infants can impact upon the ability to feed orally, often resulting in dependency on supplementary feeding. Such difficulties can lead to an increased burden of care and associated costs. The primary aim of this study was to investigate the impact of vocal cord palsy (VCP), acquired intraoperatively during cardiac surgery, on the feeding outcomes of infants at a tertiary metropolitan children's hospital. An additional aim was to obtain preliminary information on the impact of feeding difficulties in this group on the quality of life of parents and families. A review of 48 patients who had been referred to the speech pathology service was undertaken. Participants presented with heterogeneous cardiac diagnoses, and had an initial Videofluoroscopic Swallow Study (VFSS) at a median corrected age of 3.6 weeks. Sixty percent of participants presented with silent aspiration on VFSS. Thirty percent of participants required supplementary tube feeding more than 6 months post-surgery. Six percent of participants with poor feeding progress and persistent aspiration required further surgical intervention to support nutrition. Findings revealed no significant relationship between participant factors and the presence of feeding difficulties, however, infants with concomitant genetic and syndromic conditions were found to be most at-risk for long-term feeding difficulties. Analysis of informal parent questionnaire responses indicated parents experienced stress and anxiety after their child's discharge. This was noted in regard to their child's feeding, which impacts quality of life across a number of domains. Findings of this study highlight the importance of communicating the potential feeding difficulties to parents of at-risk infants prior to cardiac surgery. This study further highlighted the importance of routine post-operative otorhinolaryngology examinations following high-risk surgeries, as well as speech pathology management for all infants and children identified with VCP. Post-operative input from appropriately trained Speech Pathologists is vital in assisting parents to support and mitigate their child's difficulties through the provision of early intervention for feeding difficulties.
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Affiliation(s)
- Jane Pettigrew
- Speech Pathology Department, The Sydney Children's Hospital Network, Westmead Campus, Cnr Hawkesbury Road and Hainsworth St, Westmead, NSW, 2145, Australia.
| | - Gloria Tzannes
- Speech Pathology Department, The Sydney Children's Hospital Network, Westmead Campus, Cnr Hawkesbury Road and Hainsworth St, Westmead, NSW, 2145, Australia
| | - Laura Swift
- Speech Pathology Department, The Sydney Children's Hospital Network, Westmead Campus, Cnr Hawkesbury Road and Hainsworth St, Westmead, NSW, 2145, Australia
| | - Kimberley Docking
- NeuroKids Communication Research Laboratory, Faculty Medicine and Health, Sydney School of Health Sciences, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Kate Osland
- Speech Pathology Department, The Sydney Children's Hospital Network, Westmead Campus, Cnr Hawkesbury Road and Hainsworth St, Westmead, NSW, 2145, Australia
| | - Alan T Cheng
- ENT Department, The Children's Hospital at Westmead, The Sydney Children's Hospital Network, Westmead Campus, Cnr Hawkesbury Road and Hainsworth St, Westmead, NSW, 2145, Australia
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Liu B, Wang M, Dong J, Wang H, Tian Z. Evaluation of Critical Factors of Postoperative Arrhythmia and Preventive Measures of Deep Venous Thrombosis. JOURNAL OF ONCOLOGY 2021; 2021:6103092. [PMID: 34868315 PMCID: PMC8635950 DOI: 10.1155/2021/6103092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 10/08/2021] [Indexed: 11/18/2022]
Abstract
The study focused on the risk factors of postoperative arrhythmia and lung infection and the preventive effects of targeted low-molecular-weight heparin (LMWH) on the occurrence of deep venous thrombosis (DVT) in patients with esophageal/cardia cancer. In this article, 82 patients who were pathologically diagnosed with esophageal/cardia cancer and underwent surgical treatment were selected as the research subjects. According to the different preoperative treatment methods, the patients were divided into the control group (without anticoagulant drugs before the operation, 44 cases) and the anticoagulation group (anticoagulant drugs were administered before the operation, 38 cases), and they were compared for basic clinical indicators and disease history. Logistic regression analysis was performed to analyze the risk factors of adverse events, and the Wells and Autar scale scores were calculated. Different groups were compared for the operation time, blood loss, and postoperative drainage volume during the operation. D-dimer was detected on the first 1, 3, 5, and 7 days after the operation, and the lower extremity venous color Doppler ultrasound was performed on the 1st and 7th days after the operation. The results showed that age ≥65 years, abnormal preoperative ECG, preoperative coronary heart disease (CHD), preoperative chronic obstructive pulmonary disease (COPD), operative time ≥4 h, and preoperative blood sodium <4.04.0 mmol/L were all risk factors for postoperative arrhythmia. Age, preoperative diabetes mellitus, preoperative COPD, length of hospital stay, and FEV1 were all risk factors for postoperative lung infections. In the control group and anticoagulation group, 11 cases (13.41%) and 5 cases (16.10%) had lower extremity DVT, respectively. The incidence of lower extremity DVT was lower in the anticoagulation group than in the control group (P < 0.01). It suggested that age, preoperative disease history, hospital stay, and operation time were risk factors for postoperative adverse events in patients with esophageal/cardia cancer. The targeted anticoagulant LMWH has a significant preventive effect on the occurrence of lower extremity DVT in patients with esophageal/cardia cancer, providing an effective reference for the prognosis and prevention of esophageal/cardia cancer.
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Affiliation(s)
- Boheng Liu
- Department of Thoracic Surgery, The Fourth Hospital of Hebei Medical University, No. 169 Tianshan Street, Economic and Technological Development District, Shijiazhuang 050035, Hebei, China
| | - Mingbo Wang
- Department of Thoracic Surgery, The Fourth Hospital of Hebei Medical University, No. 169 Tianshan Street, Economic and Technological Development District, Shijiazhuang 050035, Hebei, China
| | - Jiawei Dong
- Department of Thoracic Surgery, The Fourth Hospital of Hebei Medical University, No. 169 Tianshan Street, Economic and Technological Development District, Shijiazhuang 050035, Hebei, China
| | - Hao Wang
- Department of Thoracic Surgery, The Fourth Hospital of Hebei Medical University, No. 169 Tianshan Street, Economic and Technological Development District, Shijiazhuang 050035, Hebei, China
| | - Ziqiang Tian
- Department of Thoracic Surgery, The Fourth Hospital of Hebei Medical University, No. 169 Tianshan Street, Economic and Technological Development District, Shijiazhuang 050035, Hebei, China
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Mahdi EM, Tran NN, Ourshalimian S, Sanborn S, Alquiros MT, Squillaro A, Lascano D, Herrington C, Kelley-Quon LI. Factors Impacting Long-Term Gastrostomy Tube Dependence in Infants with Congenital Heart Disease. J Surg Res 2021; 270:455-462. [PMID: 34800791 DOI: 10.1016/j.jss.2021.09.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 09/09/2021] [Accepted: 09/21/2021] [Indexed: 01/15/2023]
Abstract
BACKGROUND Infants with congenital heart disease (CHD) often experience oral feeding intolerance requiring gastrostomy (GT). Complications related to GT use are common. The study aim was to identify factors associated with continued GT use at one-year. METHODS A retrospective cohort study was performed at a tertiary children's hospital using the Society of Thoracic Surgeons database and patients' electronic medical record. Infants <1-year with CHD who underwent cardiac and GT surgery between January 2014-October 2019 were identified. Patient demographics, preoperative feeding, clinical variables, and GT use at one-year was evaluated. A separate cohort discharged with a nasogastric tube (NGT) was identified for longitudinal comparisons. RESULTS Of 137 infants who received a GT, 115 (84%) continued using their GT at one-year. Factors associated with continued GT use included lower median percent of goal oral feeding before GT placement (0% IQR 0-6.5 versus 3.7% IQR 0-31), prolonged hospitalization after GT placement (36% versus 14%, P-value = 0.048), and failure to take oral feeds at discharge (69% versus 27%, P-value <0.001). There was no difference in demographics or clinical comorbidities between groups. Clinic/emergency room visits for GT complications were common (72%). Eight infants discharged with a NGT did not require GT placement. CONCLUSIONS Patients with CHD tolerating minimal oral nutrition before GT placement, prolonged hospitalization after GT, and difficulty with oral feeds at discharge were more likely to use their GT at 1-year. Outpatient NGT feeding is feasible for select infants with CHD. Efforts to optimize care for this complex, device-dependent population are warranted to minimize risks and facilitate family engagement for long-term care.
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Affiliation(s)
- Elaa M Mahdi
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Nhu N Tran
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Shadassa Ourshalimian
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Stephanie Sanborn
- Department of Clinical Nutrition and Lactation Services, Children's Hospital Los Angeles, Los Angeles, California
| | - Maria Theresa Alquiros
- Division of Cardiac Surgery, Children's Hospital Los Angeles, Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Anthony Squillaro
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Danny Lascano
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Cynthia Herrington
- Division of Cardiac Surgery, Children's Hospital Los Angeles, Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA; Department of Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California; Department of Population and Public Health Sciences, University of Southern California, Los Angeles, California.
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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]
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Cassidy AR, Butler SC, Briend J, Calderon J, Casey F, Crosby LE, Fogel J, Gauthier N, Raimondi C, Marino BS, Sood E, Butcher JL. Neurodevelopmental and psychosocial interventions for individuals with CHD: a research agenda and recommendations from the Cardiac Neurodevelopmental Outcome Collaborative. Cardiol Young 2021; 31:888-899. [PMID: 34082844 PMCID: PMC8429097 DOI: 10.1017/s1047951121002158] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
In 2018, the Neurodevelopmental and Psychosocial Interventions Working Group of the Cardiac Neurodevelopmental Outcome Collaborative convened through support from an R13 grant from the National Heart, Lung, and Blood Institute to survey the state of neurodevelopmental and psychosocial intervention research in CHD and to propose a slate of critical questions and investigations required to improve outcomes for this growing population of survivors and their families. Prior research, although limited, suggests that individualised developmental care interventions delivered early in life are beneficial for improving a range of outcomes including feeding, motor and cognitive development, and physiological regulation. Interventions to address self-regulatory, cognitive, and social-emotional challenges have shown promise in other medical populations, yet their applicability and effectiveness for use in individuals with CHD have not been examined. To move this field of research forward, we must strive to better understand the impact of neurodevelopmental and psychosocial intervention within the CHD population including adapting existing interventions for individuals with CHD. We must examine the ways in which dedicated cardiac neurodevelopmental follow-up programmes bolster resilience and support children and families through the myriad transitions inherent to the experience of living with CHD. And, we must ensure that interventions are person-/family-centred, inclusive of individuals from diverse cultural backgrounds as well as those with genetic/medical comorbidities, and proactive in their efforts to include individuals who are at highest risk but who may be traditionally less likely to participate in intervention trials.
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Affiliation(s)
- Adam R. Cassidy
- Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Samantha C. Butler
- Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Johanna Calderon
- Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Frank Casey
- Paediatric Cardiology Belfast Trust, Royal Belfast Hospital for Sick Children, Belfast, Northern Ireland
| | - Lori E. Crosby
- Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | | | - Naomi Gauthier
- Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Bradley S. Marino
- Department of Pediatric Cardiology, Cleveland Clinic Children’s Hospital, Cleveland, Ohio, USA
| | - Erica Sood
- Nemours Cardiac Center & Nemours Center for Healthcare Delivery Science, Alfred I. duPont Hospital for Children, Wilmington, Delaware, USA; Department of Pediatrics, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Abstract
BACKGROUND Feeding difficulty is a known complication of congenital heart surgery. Despite this, there is a relative sparsity in the available data regarding risk factors, incidence, associated symptoms, and outcomes. METHODS In this retrospective chart review, patients aged 0-18 years who underwent congenital heart surgery at a single institution between January and December, 2017 were reviewed. Patients with feeding difficulties before surgery, multiple surgeries, and potentially abnormal recurrent laryngeal nerve anatomy were excluded. Data collected included patient demographics, feeding outcomes, post-operative symptoms, flexible nasolaryngoscopy findings, and rates of readmission within a 1-year follow-up period. Multivariable regression analyses were performed to evaluate the risk of an alternative feeding plan at discharge and length of stay. RESULTS Three-hundred and twenty-six patients met the inclusion criteria for this study. Seventy-two (22.09%) were discharged with a feeding tube and 70 (97.22%) of this subgroup were younger than 12 months at the time of surgery. Variables that increased the risk of being discharged with a feeding tube included patient age, The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery score, procedure group, aspiration, and reflux. Speech-language pathology was the most frequently utilised consulting service for patients discharged with feeding tubes (90.28%) while other services were not frequently consulted. The median length of stay was increased from 4 to 10 days for patients who required an enteral feeding tube at discharge. DISCUSSION Multidisciplinary management protocol and interventions should be developed and standardised to improve feeding outcomes following congenital heart surgery.
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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.
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Martini S, Beghetti I, Annunziata M, Aceti A, Galletti S, Ragni L, Donti A, Corvaglia L. Enteral Nutrition in Term Infants with Congenital Heart Disease: Knowledge Gaps and Future Directions to Improve Clinical Practice. Nutrients 2021; 13:nu13030932. [PMID: 33805775 PMCID: PMC8002077 DOI: 10.3390/nu13030932] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 03/09/2021] [Indexed: 12/18/2022] Open
Abstract
Optimal nutrition is essential to improve short- and long-term outcomes in newborns with congenital heart disease (CHD). Nevertheless, several issues on nutritional management and concerns about the potential risk of complications related to enteral feeding exist. This narrative review aims to summarize and discuss the available literature on enteral feeding in term infants with CHD. A wide variability in feeding management exists worldwide. Emerging approaches to improve nutritional status and outcomes in infants with CHD include: implementation of a standardized enteral feeding protocol, both preoperative and postoperative, clearly defining time of initiation and advancement of enteral feeds, reasons to withhold, and definitions of feeding intolerance; early minimal enteral feeding; enteral feeding in stable term infants on hemodynamic support; evaluation of enteral feeding in term infants with umbilical arterial catheters and during prostaglandin infusion; assessment and support of oro-motor skills; and promotion and support of breastfeeding and provision of mother's own milk or donor milk when mother's own milk is not available. As evidence from term infants is scarce, available observations and recommendations partially rely on studies in preterm infants. Thus, well-designed studies assessing standardized clinically relevant outcomes are needed to provide robust evidence and shared recommendations and practices.
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Affiliation(s)
- Silvia Martini
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (S.M.); (I.B.); (M.A.); (S.G.); (L.C.)
| | - Isadora Beghetti
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (S.M.); (I.B.); (M.A.); (S.G.); (L.C.)
| | - Mariarosaria Annunziata
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (S.M.); (I.B.); (M.A.); (S.G.); (L.C.)
| | - Arianna Aceti
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (S.M.); (I.B.); (M.A.); (S.G.); (L.C.)
- Neonatal Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
- Correspondence: ; Tel./Fax: +39-051-342754
| | - Silvia Galletti
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (S.M.); (I.B.); (M.A.); (S.G.); (L.C.)
- Neonatal Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Luca Ragni
- Pediatric Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (L.R.); (A.D.)
| | - Andrea Donti
- Pediatric Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (L.R.); (A.D.)
| | - Luigi Corvaglia
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (S.M.); (I.B.); (M.A.); (S.G.); (L.C.)
- Neonatal Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
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The Relationship Between Preoperative Feeding Exposures and Postoperative Outcomes in Infants With Congenital Heart Disease. Pediatr Crit Care Med 2021; 22:e91-e98. [PMID: 33009358 DOI: 10.1097/pcc.0000000000002540] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate the association of preoperative risk factors and postoperative outcomes in infants with complex congenital heart disease. DESIGN Single-center retrospective cohort study. SETTING Neonatal ICU and cardiovascular ICU. PATIENTS Infants of all gestational ages, born at Texas Children's Hospital between 2010 and 2016, with complex congenital heart disease requiring intervention prior to discharge. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 399 patients were enrolled in the study. Preoperative risk factors included feeding, type of feeding, feeding route, and cardiac lesion. Postoperative outcomes included necrotizing enterocolitis, hospital length of stay, and days to full feeds. The occurrence rate of postoperative necrotizing enterocolitis (all stages) was 8%. Preoperative feeding, type of feeding, feeding route, and cardiac lesion were not associated with higher odds of postoperative necrotizing enterocolitis. Cardiac lesions with ductal-dependent systemic blood flow were associated with a hospital length of stay of 19.6 days longer than those with ductal-dependent pulmonary blood flow (p < 0.001) and 2.9 days longer to reach full feeds than those with ductal-dependent pulmonary blood flow (p < 0.001), after controlling for prematurity. Nasogastric feeding route preoperatively was associated with a length of stay of 29.8 days longer than those fed by mouth (p < 0.001) and 2.4 days longer to achieve full feeds (p < 0.001), after controlling for prematurity and cardiac lesion. Preoperative diet itself was not associated with significant change in length of stay or days to reach full feeds. CONCLUSIONS Although cardiac lesions with ductal-dependent systemic blood flow are considered high risk and may increase length of stay and days to achieve full feeds, they are not associated with a higher risk of postoperative necrotizing enterocolitis. Nasogastric route is not associated with a significantly higher risk of necrotizing enterocolitis, but longer length of stay and days to reach full feeds. These findings challenge our perioperative management strategies in caring for these infants, as they may incur more hospital costs and resources without significant medical benefit.
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Morton K, Darlington ASE, Marino LV. Protocol for a multicentre longitudinal mixed-methods study: feeding and survivorship outcomes in previously healthy young paediatric Intensive care survivors (the PIES Study). BMJ Open 2020; 10:e041234. [PMID: 33273049 PMCID: PMC7716671 DOI: 10.1136/bmjopen-2020-041234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION An admission to paediatric intensive care unit (PICU) is associated with multiple physical and environmental stressors, often involving many negative and painful oral experiences. Evidence from children with complex medical conditions suggests that feeding difficulties post-PICU stay are common, causing significant parental anxiety. Adult intensive care unit (ICU) survivor studies suggest feeding issues lasting up to 3 months post-discharge from ICU. There is, however, a paucity of evidence regarding feeding outcomes for previously healthy children following a PICU admission and whether painful oral experiences during an admission contribute to feeding difficulties post-discharge, negatively impacting on parental/caregiver anxiety. METHODS AND ANALYSIS This longitudinal mixed-methods study will explore the impact of feeding difficulties, identifying any clinical risk factors during the first 6 months of PICU discharge in previously healthy young children (≤4 years). Parents/caregivers of children will be asked to complete questionnaires relating to: feeding difficulties, parental/caregiver stress, and child and parental/caregivers' feeding behaviours at the point of PICU discharge, 1, 3 and 6 months post-discharge. Parents/caregivers will be invited to participate in qualitative semistructured interviews at 3 and 6 months post-PICU discharge exploring parental/caregiver experiences of feeding their child after PICU. Statistical analysis of the survey data will consist of descriptive and inferential statistics, plus qualitative analysis of any free text comments using thematic analysis. ETHICS AND DISSEMINATION This study will provide an insight and increase our understanding of the prevalence of feeding difficulties in previously healthy children admitted to PICU and parental/caregiver experiences. Multiple methods will be used to ensure that the findings are effectively disseminated to service users, clinicians, policy and academic audiences. The study has full ethical approval from the National Health Service Research Ethics Committee (Ref: 20/YH/0160) and full governance clearance.
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Affiliation(s)
- Kathryn Morton
- Paediatric Intensive Care Unit, Southampton Children's Hospital, Southampton, UK
- School of Health Sciences, University of Southampton, Southampton, UK
| | | | - L V Marino
- NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Department of Dietetics and Speech and Language Therapy, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Comparison of growth and feeding method in infants with and without genetic abnormalities after neonatal cardiac surgery. Cardiol Young 2020; 30:1826-1832. [PMID: 32972475 DOI: 10.1017/s1047951120002887] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Congenital heart disease (CHD) is multifactorial in origin, resulting from an interaction between environmental and genetic factors. Multifactorial growth delay is common in infants with CHD. The impact of a genetic abnormality and CHD on the growth of an infant is lacking in the literature. The aim of this study is to compare the growth and method of feeding following neonatal cardiac surgery in infants with normal versus abnormal genetic testing. METHODS A retrospective chart review of neonates who underwent a Risk Adjustment in Congenital Heart Surgery IV-VI procedure between 1 January, 2006 and 22 September, 2016 was performed at our institution. Weight, length, head circumference measurements, and feeding method were collected at birth, time of neonatal surgery, and monthly up to 6 months of age. RESULTS A total of 53 infants met inclusion criteria, of which 22 had abnormal genetic testing. Approximately 90% of infants were discharged following neonatal cardiac surgery with supplemental tube feeds. At each monthly follow-up visit, more infants were exclusively fed orally: 80% of infants with normal genetics at 5 months post-operative follow-up versus 60% of infants with abnormal genetic testing, although statistically insignificant. Growth was not different among the two groups. CONCLUSIONS Infants with critical CHD with or without genetic abnormalities are at risk for growth delays and many need supplemental tube feeds post-operatively and throughout follow-up. Infants with genetic abnormalities are slower to achieve oral feeds and more likely to require tube feedings. It is important to have a systematic protocol for managing these high-risk infants.
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Neurodevelopmental evaluation strategies for children with congenital heart disease aged birth through 5 years: recommendations from the cardiac neurodevelopmental outcome collaborative. Cardiol Young 2020; 30:1609-1622. [PMID: 33143781 DOI: 10.1017/s1047951120003534] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This paper provides specific guidelines for the neurodevelopmental evaluation of children aged birth through 5 years with complex congenital heart disease. There is wide recognition that children with congenital heart disease are at high risk for neurodevelopmental impairments that are first apparent in infancy and often persist as children mature. Impairments among children with complex congenital heart disease cross developmental domains and affect multiple functional abilities. The guidelines provided are derived from the substantial body of research generated over the past 30 years describing the characteristic developmental profiles and the long-term trajectories of children surviving with complex congenital heart conditions. The content and the timing of the guidelines are consistent with the 2012 American Heart Association and the American Academy of Pediatrics scientific statement documenting the need for ongoing developmental monitoring and assessment from infancy through adolescence. The specific guidelines offered in this article were developed by a multidisciplinary clinical research team affiliated with the Cardiac Neurodevelopmental Outcome Collaborative, a not-for-profit organisation established to determine and implement best neurodevelopmental practices for children with congenital heart disease. The guidelines are designed for use in clinical and research applications and offer an abbreviated core protocol and an extended version that expands the scope of the evaluation. The guidelines emphasise the value of early risk identification, use of evidence-based assessment instruments, consideration of family and cultural preferences, and the importance of providing multidimensional community-based services to remediate risk.
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Shahi N, Phillips R, Meier M, Shirek G, Goldsmith A, Soden JS, Kaufman J, Moulton S. Gastrostomy Button Placement in Infants With Cyanotic Versus Acyanotic Congenital Heart Disease. J Surg Res 2020; 259:407-413. [PMID: 33616074 DOI: 10.1016/j.jss.2020.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 09/01/2020] [Accepted: 09/22/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Infants with congenital heart disease (CHD) may exhibit increased metabolic demands, and many will undergo placement of a gastrostomy to achieve adequate nutritional intake. There is a paucity of data, however, comparing the operative risks and overall complications of gastrostomy placement in cyanotic versus acyanotic infants with CHD. We hypothesized that patients with cyanotic CHD would have a higher rate of gastrostomy-associated complications than infants with acyanotic CHD. METHODS We retrospectively reviewed patients who underwent gastrostomy button placement after cardiac surgery for CHD between 2013 and 2018. Patients were stratified into cyanotic CHD and acyanotic CHD cohorts. Patient data were extracted from the Society of Thoracic Surgeons database and merged with clinical data related to gastrostomy placement and complications from chart review. Unadjusted analyses were used to find covariates associated with cyanotic CHD and acyanotic CHD, using a t-test or Wilcoxon rank-sum test for continuous data, depending on normalcy, and χ2 or Fisher's exact tests for categorical data depending on the distribution. RESULTS There were 257 infants with CHD who underwent gastrostomy placement during the study period, of which 86 had cyanotic CHD. There were no significant differences in baseline weight or preoperative albumin levels between the two groups. Patients with cyanotic CHD had a lower incidence of comorbid syndromes (P = 0.0001), higher Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery scores (P < 0.0001), and higher postoperative mortality rate (P = 0.0189). There was a higher rate of granulation tissue formation in patients with acyanotic CHD (48.5% versus 22.1%, P < 0.0001). There were no differences in other gastrostomy button-related complications, including leakage, wound infection, or dislodgement. CONCLUSIONS Patients with acyanotic CHD demonstrated a higher incidence of granulation tissue. We found no difference in gastrostomy-specific complication rates between the two groups, with the notable exception of granulation tissue formation. Based on this study, the diagnosis of cyanotic CHD does not increase the risk of gastrostomy-related complications.
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Affiliation(s)
- Niti Shahi
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, Colorado; Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado.
| | - Ryan Phillips
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, Colorado; Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Maxene Meier
- The Center for Research in Outcomes for Children's Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Gabrielle Shirek
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, Colorado
| | - Adam Goldsmith
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, Colorado
| | - Jason S Soden
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, Colorado; Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Hospital Colorado, Aurora, Colorado
| | - Jon Kaufman
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, Colorado; Department of Pediatric Cardiology, Children's Hospital Colorado, Aurora, Colorado
| | - Steven Moulton
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, Colorado; Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
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Tilyard R, Reilly C, Gallegos D, Syrmis M, Frederiksen N, Press C. Temporary feeding tube dependency in pediatric patients: A retrospective analysis of risk factors and preventative practices. Clin Nutr ESPEN 2020; 40:320-326. [PMID: 33183557 DOI: 10.1016/j.clnesp.2020.08.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 08/07/2020] [Accepted: 08/21/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Prolonged temporary tube feeding places pediatric patients at risk of tube dependency. This chart audit aimed to identify current temporary tube feeding practice within an Australian tertiary hospital, risk factors of prolonged temporary tube feeding, and the likelihood of high risk patients receiving tube dependency preventative practices. METHODS A retrospective chart audit was conducted of the medical records of 187 pediatric inpatients who had temporary feeding tubes placed in an Australian tertiary hospital between November 2014 and March 2017. Information was collected on patient demographics and tube feeding practices. The Kaplan Meier estimate, Cox regression and logistic regression were used to determine the median time until feeding tube removal, predictors of prolonged temporary tube feeding, and the relationship between these predictors and utilization of preventative practices. RESULTS The Kaplan Meier estimate of median tube feeding duration was 6.43 months (95% CI: 5.17-7.90). Predictors of prolonged tube feeding were prematurity (p = 0.003), feeding difficulties requiring speech pathology referral (p = 0.002), and referral for long-term feeding tubes (p = 0.002). There was a low prevalence of preventative clinical practices including documentation of tube exit plans (5.3%, n = 10) and referral for long-term feeding tubes (27.3%, n = 51). Exhibiting risk factors for prolonged tube feeding did not increase the likelihood of receiving preventative clinical practices. CONCLUSIONS The prolonged duration of temporary tube feeding within this sample highlights the need for improved utilization of tube dependency preventative practices within high risk groups.
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Affiliation(s)
- Regina Tilyard
- School of Nutrition and Exercise Sciences, Queensland University of Technology, Victoria Park Road, Kelvin Grove, Brisbane, Queensland 4059, Australia.
| | - Claire Reilly
- Department of Dietetics and Food Services, Queensland Children's Hospital, 501 Stanley Street, South Brisbane, Brisbane, Queensland 4101, Australia; Centre for Children's Health Research, Institute of Health and Biomedical Innovation. Graham Street, South Brisbane, Queensland 4101, Australia
| | - Danielle Gallegos
- School of Nutrition and Exercise Sciences, Queensland University of Technology, Victoria Park Road, Kelvin Grove, Brisbane, Queensland 4059, Australia; Centre for Children's Health Research, Institute of Health and Biomedical Innovation. Graham Street, South Brisbane, Queensland 4101, Australia
| | - Maryanne Syrmis
- Department of Dietetics and Food Services, Queensland Children's Hospital, 501 Stanley Street, South Brisbane, Brisbane, Queensland 4101, Australia
| | - Nadine Frederiksen
- Department of Dietetics and Food Services, Queensland Children's Hospital, 501 Stanley Street, South Brisbane, Brisbane, Queensland 4101, Australia
| | - Clare Press
- School of Human Movement and Nutrition Sciences, University of Queensland. St Lucia, Brisbane, Queensland 4072, Australia
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Shahi N, Phillips R, Meier M, Shirek G, Goldsmith A, Soden JS, Kaufman J, Moulton S. The Nissen Unwrapped: Predictors and Outcomes of Nissen Fundoplication in Congenital Heart Disease. J Surg Res 2020; 256:251-257. [PMID: 32712438 DOI: 10.1016/j.jss.2020.06.021] [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: 02/28/2020] [Revised: 06/04/2020] [Accepted: 06/16/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Infants with congenital heart disease (CHD) often require the placement of a gastrostomy button to ensure proper nutrition. Some also require a Nissen fundoplication (NF) to further improve nutrition capabilities in the setting of reflux, however, the clinical and diagnostic imaging characteristics that support NF are variable. The aims of this study were as follows: (1) identify the factors associated with NF in patients with CHD and (2) determine the incidence of NF complications in patients with CHD. METHODS All patients with CHD who underwent cardiac repair and subsequent creation of a gastrostomy at a single institution between 6/1/2013 and 9/1/2018 were included. We then identified which patients underwent NF. RESULTS Two-hundred fifty-seven CHD patients who had a gastrostomy button placed after CHD repair, with 17% undergoing a simultaneous NF or an NF at a later time. The presence of acyanotic heart disease, neurologic comorbidities, and vocal cord dysfunction was not univariately associated with a higher likelihood of NF. On multivariable model, only prematurity was significantly associated with NF (P = 0.022). Abnormal findings on imaging studies (upper gastrointestinal series, gastric emptying studies, motility studies, upper endoscopies, swallow studies, and pH probe studies) were not associated with an NF (all P's > 0.05). The overall complication rate was 23%. CONCLUSIONS Prematurity was the only factor associated with an NF. Surprisingly, cyanotic heart disease, neurologic comorbidities, age at first cardiac surgery, and vocal cord dysfunction were not associated with an NF. We identified an area for quality improvement at our institution given the lack of standardized work-up for the NF in this high-risk population.
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Affiliation(s)
- Niti Shahi
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, Colorado; University of Colorado School of Medicine, Aurora, Colorado.
| | - Ryan Phillips
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, Colorado; University of Colorado School of Medicine, Aurora, Colorado
| | - Maxene Meier
- The Center for Research in Outcomes for Children's Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Gabrielle Shirek
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, Colorado
| | - Adam Goldsmith
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, Colorado
| | - Jason S Soden
- Department of Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Hospital Colorado, Aurora, Colorado
| | - Jon Kaufman
- Department of Pediatric Cardiology, Children's Hospital Colorado, Aurora, Colorado
| | - Steven Moulton
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, Colorado; University of Colorado School of Medicine, Aurora, Colorado
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Azuma D, Maron JL. Individualizing Oral Feeding Assessment and Therapies in the Newborn . RESEARCH AND REPORTS IN NEONATOLOGY 2020. [DOI: 10.2147/rrn.s223472] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Arch intervention following stage 1 palliation in hypoplastic left heart syndrome is associated with slower feed advancement: a report from the National Pediatric Quality Cardiology Improvement Collaborative. Cardiol Young 2020; 30:396-401. [PMID: 32008590 DOI: 10.1017/s1047951120000177] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Infants undergoing stage 1 palliation for hypoplastic left heart syndrome may have post-operative feeding difficulties. Although the cause of feeding difficulties in these patients is multi-factorial, residual arch obstruction may affect gut perfusion, contributing to feeding intolerance. We hypothesised that undergoing arch reintervention following stage 1 palliation would be associated with post-operative feeding difficulties. METHODS This was a retrospective cohort study. We analysed data from the National Pediatric Cardiology Quality Improvement Collaborative, which maintains a multicentre registry for infants with hypoplastic left heart syndrome discharged home following stage 1 palliation. Patients who underwent arch reintervention (percutaneous or surgical) prior to discharge following stage 1 palliation were compared with those who underwent non-aortic arch interventions after stage 1 palliation and those who underwent no intervention. Median post-operative days to full enteral feeds and weight for age z-scores were compared. Predictors of post-operative days to full feeds were identified. RESULTS Among patients who underwent arch reintervention, post-operative days to full enteral feeds were greater than for those who underwent non-aortic arch interventions (25 versus 16, p = 0.003) or no intervention (median days 25 versus 12, p < 0.001). Arch intervention, multiple interventions, gestational age, and the presence of a gastrointestinal anomaly were predictors of days to full feeds. CONCLUSIONS Repeat arch intervention is associated with a longer time to achieve full enteral feeding in patients with hypoplastic left heart syndrome after stage 1 palliation. Further investigation of this association is needed to understand the role of arch obstruction in feeding problems in these patients.
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Maynard TM, Zohn IE, Moody SA, LaMantia AS. Suckling, Feeding, and Swallowing: Behaviors, Circuits, and Targets for Neurodevelopmental Pathology. Annu Rev Neurosci 2020; 43:315-336. [PMID: 32101484 DOI: 10.1146/annurev-neuro-100419-100636] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
All mammals must suckle and swallow at birth, and subsequently chew and swallow solid foods, for optimal growth and health. These initially innate behaviors depend critically upon coordinated development of the mouth, tongue, pharynx, and larynx as well as the cranial nerves that control these structures. Disrupted suckling, feeding, and swallowing from birth onward-perinatal dysphagia-is often associated with several neurodevelopmental disorders that subsequently alter complex behaviors. Apparently, a broad range of neurodevelopmental pathologic mechanisms also target oropharyngeal and cranial nerve differentiation. These aberrant mechanisms, including altered patterning, progenitor specification, and neurite growth, prefigure dysphagia and may then compromise circuits for additional behavioral capacities. Thus, perinatal dysphagia may be an early indicator of disrupted genetic and developmental programs that compromise neural circuits and yield a broad range of behavioral deficits in neurodevelopmental disorders.
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Affiliation(s)
- Thomas M Maynard
- Fralin Biomedical Research Institute at Virginia Tech Carilion, Roanoke, Virginia 24016, USA;
| | - Irene E Zohn
- Department of Pediatrics, George Washington University School of Medicine and Health Sciences, Washington, DC 20037, USA.,Center for Genetic Medicine Research, Children's National Health System, Washington, DC 20037, USA
| | - Sally A Moody
- Department of Anatomy and Cell Biology, George Washington University School of Medicine and Health Sciences, Washington, DC 20037, USA
| | - Anthony-S LaMantia
- Fralin Biomedical Research Institute at Virginia Tech Carilion, Roanoke, Virginia 24016, USA; .,Department of Biological Sciences, Virginia Tech, Blacksburg, Virginia 24061, USA
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McSweeney ME, Meleedy-Rey P, Kerr J, Chan Yuen J, Fournier G, Norris K, Larson K, Rosen R. A Quality Improvement Initiative to Reduce Gastrostomy Tube Placement in Aspirating Patients. Pediatrics 2020; 145:peds.2019-0325. [PMID: 31996405 PMCID: PMC6993527 DOI: 10.1542/peds.2019-0325] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/15/2019] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES Oropharyngeal dysphagia and aspiration may occur in infants and children. Currently, there is wide practice variation regarding when to feed children orally or place more permanent gastrostomy tube placement. Through implementation of an evidence-based guideline (EBG), we aimed to standardize the approach to these patients and reduce the rates of gastrostomy tube placement. METHODS Between January 2014 and December 2018, we designed and implemented a quality improvement intervention creating an EBG to be used by gastroenterologists evaluating patients ≤2 years of age with respiratory symptoms who were found to aspirate on videofluoroscopic swallow study (VFSS). Our primary aim was to encourage oral feeding and decrease the use of gastrostomy tube placement by 10% within 1 year of EBG initiation; balancing measures included total hospital readmissions or emergency department (ED) visits within 6 months of the abnormal VFSS. RESULTS A total of 1668 patients (27.2%) were found to have aspiration or penetration noted on an initial VFSS during our initiative. Mean gastrostomy tube placement in these patients was 10.9% at the start of our EBG implementation and fell to 5.2% approximately 1 year after EBG initiation; this improvement was sustained throughout the next 3 years. Our balancing measures of ED visits and hospital readmissions also did not change during this time period. CONCLUSIONS Through implementation of this EBG, we reduced gastrostomy tube placement by 50% in patients presenting with oropharyngeal dysphagia and aspiration, without increasing subsequent hospital admissions or ED visits.
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Affiliation(s)
- Maireade E. McSweeney
- Aerodigestive Center and Motility and Functional Gastrointestinal Disorders Center, Division of Gastroenterology, Hepatology and Nutrition
| | | | | | | | - Gregory Fournier
- Aerodigestive Center and Motility and Functional Gastrointestinal Disorders Center, Division of Gastroenterology, Hepatology and Nutrition
| | - Kerri Norris
- Finance, Boston Children’s Hospital, Boston, Massachusetts
| | - Kara Larson
- Aerodigestive Center and Motility and Functional Gastrointestinal Disorders Center, Division of Gastroenterology, Hepatology and Nutrition
| | - Rachel Rosen
- Aerodigestive Center and Motility and Functional Gastrointestinal Disorders Center, Division of Gastroenterology, Hepatology and Nutrition
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Gakenheimer-Smith L, Glotzbach K, Ou Z, Presson AP, Puchalski M, Jones C, Lambert L, Delgado-Corcoran C, Eckhauser A, Miller T. The Impact of Neurobehavior on Feeding Outcomes in Neonates with Congenital Heart Disease. J Pediatr 2019; 214:71-78.e2. [PMID: 31402138 PMCID: PMC6815703 DOI: 10.1016/j.jpeds.2019.06.047] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/22/2019] [Accepted: 06/21/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To evaluate the association between neonatal neurobehavioral state and oral feeding outcomes following congenital heart disease (CHD) surgery. STUDY DESIGN This single center retrospective cohort study described neonates undergoing cardiac surgery evaluated perioperatively with the Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS). We compared NNNS attention scores, which evaluates neonates' ability to orient and fixate on stimuli, with the feeding outcomes percentage of feeds taken orally at discharge and time to reach full oral feeds using regression analyses. Models were constructed for both preoperative and postoperative NNNS evaluations. RESULTS Between August 2015 and October 2017, 124 neonates underwent 89 preoperative and 97 postoperative NNNS evaluations. In multivariable Cox regression, higher preoperative NNNS attention scores were associated with a shorter time to achieve full oral feeds (hazard ratio 1.4; 95% CI 1.0‒2.0; P = .047). This relationship was not seen for post-operative NNNS attention scores or percentage of oral feeds at discharge. Depending on the model, younger age at surgery, increased ventilator days, increased length of stay, and single or 2-ventricle anatomy with aortic arch obstruction were associated with lower percentage of oral feeds at discharge and/or delay in full oral feeds. CONCLUSIONS Higher neonatal attention before cardiac surgery is associated with improved feeding outcomes. Prospective assessment of neonatal neurobehavioral state may be a novel approach to predict and target interventions to improve feeding outcomes in CHD. Future studies should examine the impact of intrinsic neurodevelopmental delay vs environmental adaptation on the neurobehavioral state of neonates with CHD.
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Affiliation(s)
| | - Kristi Glotzbach
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Zhining Ou
- Department of Pediatrics, University of Utah, Salt Lake City, UT; Division of Epidemiology, University of Utah, Salt Lake City, UT; Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Angela P Presson
- Department of Pediatrics, University of Utah, Salt Lake City, UT; Division of Epidemiology, University of Utah, Salt Lake City, UT
| | - Michael Puchalski
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | | | - Linda Lambert
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Claudia Delgado-Corcoran
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, UT
| | - Aaron Eckhauser
- Division of Pediatric Cardiothoracic Surgery, Department of Surgery, University of Utah, Salt Lake City, UT
| | - Thomas Miller
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, UT
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Abstract
INTRODUCTION Infants with CHD often experience growth failure. Ensuring optimal growth before surgery is associated with improved outcomes and has emerged as a significant cause of parental stress. Parents have reported a perceived lack of accessible feeding information for infants with CHD. To address this gap, the aim of this study was to develop feeding information to better support parents. MATERIALS AND METHODS A search for existing material on six electronic databases and an internet search for unpublished (grey) literature on feeding information for infants with CHD were carried out. Following the development of feeding information, semi-structured interview(s) with parents/health-care professionals were completed, focusing on whether the information was easy to understand, relevant, provided sufficient information around feeding/feeding difficulties, and whether there were any information gaps. Iterative changes were made to the information following each interview. The process was completed until thematic saturation was achieved. RESULTS A total of 23 unique articles were identified of which 5 studies were included. From the grey literature, four web pages were reviewed. A total of 22 parents and 25 health-care professionals were interviewed. All parents/health-care professionals felt that the feeding information developed provided sufficient information; however, many wanted information on how to introduce complementary food, particularly if weaning was delayed. CONCLUSIONS This study describes the development of feeding information for infants with CHD. From parent interviews, gaps identified focused on the introduction of complementary foods and uncertainty regarding the feeding journey beyond surgery.
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Li L, Li K, An C, Fan J, Guo C, Liang S, Guo Y, Xia H, Chen X, Zhu Y, Hu C, Si W, Liang H, Cui Y. Identification of risk factors affecting catch-up growth after infant congenital heart disease surgery: rationale and design of a multicentre prospective cohort study in China. BMJ Open 2019; 9:e030084. [PMID: 31434778 PMCID: PMC6707667 DOI: 10.1136/bmjopen-2019-030084] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 07/09/2019] [Accepted: 07/12/2019] [Indexed: 01/25/2023] Open
Abstract
INTRODUCTION Successful surgical treatment of congenital heart disease improves neonates' long-term survival and leads to catch-up growth, which however does not occur in part of the patient population for largely undetermined reasons. METHODS AND ANALYSIS A multicentre, prospective cohort study is being conducted in four paediatric medical institutions in China to collect detailed nutritional, anthropometric and clinical data at perioperative phases and during a 1-year period of follow-up after surgery. The study is expected to recruit approximately 5000 patients by the year of 2023 when the cohort is fully established. The primary endpoint of this study is the occurrence of postoperative catch-up growth, which will be determined in both absolute and relative terms (ie, reduced anthropometric deficits from the reference measures and improved z-scores that have passed the -2 SD cut-offs). Multivariable regression analyses will be performed to identify factors that are statistically significantly associated with the absence of postoperative catch-up growth. ETHICS AND DISSEMINATION The protocol of this study has been approved by the individual ethics committees of the participating centres (Guangzhou Women and Children's Medical Centre (2008071601), the Children's Hospital of Zhejiang University School of Medicine (2018-IRB-094), Gansu Provincial Maternity and Child-Care Hospital (2019-IRB-01) and Zhengzhou Cardiovascular Hospital (2019012001)). Written informed consent from parents will be obtained before study entry. Findings of this study will be disseminated through publications in international peer-reviewed journals and will be presented in academic conferences.
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Affiliation(s)
- Lijuan Li
- CICU, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Kuanrong Li
- Institute of Paediatrics, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Caixia An
- CICU, Gansu Provincial Maternity and Child-Care Hospital, Lanzhou, China
| | - Jiajie Fan
- CICU, The Children's Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Changying Guo
- CICU, Zhengzhou Cardiovascular Hospital, Zhengzhou, China
| | - Suixin Liang
- CICU, Shenzhen Children's Hospital, Shenzhen, China
| | - Yue Guo
- CICU, Gansu Provincial Maternity and Child-Care Hospital, Lanzhou, China
| | - Huimin Xia
- Guangdong Key Laboratory of Structural Birth Defects, Guangzhou, China
| | - Xinxin Chen
- CICU, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Yanna Zhu
- Department of Maternal and Child Health, Sun Yat-sen University School of Public Health, Guangzhou, China
| | - Chunmei Hu
- CICU, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
| | - Wenyue Si
- Institute of Paediatrics, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Huiying Liang
- Institute of Paediatrics, Guangzhou Women and Children's Medical Center, Guangzhou, China
| | - Yanqin Cui
- CICU, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, China
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Morton K, Marino L, Pappachan J, Darlington A. Feeding difficulties in young paediatric intensive care survivors: A scoping review. Clin Nutr ESPEN 2019; 30:1-9. [DOI: 10.1016/j.clnesp.2019.01.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 01/07/2019] [Accepted: 01/31/2019] [Indexed: 11/30/2022]
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Abstract
Children with CHD often experience difficulty with oral feeding, which contributes to growth faltering in this population. Few studies have explored symptoms of problematic feeding in children with CHD using valid and reliable measures of oral feeding. The purpose of this study was to describe symptoms of problematic feeding in children with CHD compared to healthy children without medical conditions, taking into account variables that may contribute to symptoms of problematic feeding. Oral feeding was measured by the Pediatric Eating Assessment Tool, a parent report assessment of feeding with evidence of validity and reliability. This secondary analysis used data collected from web-based surveys completed by parents of 1093 children between 6 months and 7 years of age who were eating solid foods by mouth. General linear models were used to evaluate the differences between 94 children with CHD and 999 children without medical conditions based on the Pediatric Eating Assessment Tool total score and four subscale scores. Covariates tested in the models included breathing tube duration, type of CHD, gastroesophageal reflux, genetic disorder, difficulty with breast- or bottle-feeding during infancy, cardiac surgery, and current child age. Children with CHD had significantly more symptoms of problematic feeding than healthy children on the Pediatric Eating Assessment Tool total score, more physiologic symptoms, problematic mealtime behaviours, selective/restrictive eating, and oral processing dysfunction (p <0.001 for all), when taking into account relevant covariates. Additional research is needed in children with CHD to improve risk assessment and develop interventions to optimise feeding and growth.
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Shine AM, Finn DG, Allen N, McMahon CJ. Transition from tube feeding to oral feeding: experience in a tertiary care paediatric cardiology unit. Ir J Med Sci 2018; 188:201-208. [DOI: 10.1007/s11845-018-1812-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 04/07/2018] [Indexed: 10/17/2022]
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Christian BJ. Translational Research - Challenging Children and Their Families Throughout the World: Integrating Chronic Conditions Into Everyday Life. J Pediatr Nurs 2017; 35:155-159. [PMID: 28602511 DOI: 10.1016/j.pedn.2017.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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