1
|
Ware AL, Jones C, Kipps AK, Khadr L, Marcuccio E, Patel SS, Plummer S, Ravishankar C, Figueroa M. Feeding Variation Among Infants in Acute Care Cardiology Units. Pediatr Cardiol 2024:10.1007/s00246-024-03541-6. [PMID: 38907873 DOI: 10.1007/s00246-024-03541-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 06/04/2024] [Indexed: 06/24/2024]
Abstract
Infants with heart disease are at high risk of feeding difficulties and complications. Feeding practices amongst acute care cardiology units are not standardized. This study aims to describe feeding practices for infants at the time of discharge from a Pediatric Acute Care Cardiology Collaborative (PAC3) center and practice variation between centers. Discharge encounters for infants in the PAC3 registry between February 2019 and October 2021 were included. Nutrition type and feeding route at discharge were summarized with descriptive statistics and a modified bump plot. Center variation was assessed using funnel plots with control limits set at the 99.9% confidence interval from the group mean. A total of 15,414 encounters across 24 PAC3 centers were recorded from 8313 unique patients (median encounters 1, range 1-25). Nutrition at discharge consisted of standard formula in 8368 (54%), human milk in 6300 (41%), and elemental formula in 3230 (21%), either alone or in combination. Feeds were fortified to ≥ 24 kcal/oz in 12,359 (80%). Discharge supplemental tube feeding was present in 7353 (48%) encounters with 4643 (63%) receiving continuous feeds, 2144 (29%) bolus feeds, and 566 (8%) a combination. Funnel plots demonstrated variability in nutrition type and feeding route at discharge. Infants with heart disease commonly require high calorie nutrition and supplemental tube feedings at discharge. Feeding strategies at discharge vary widely between PAC3 centers. Collaborative approaches to identify best practices in feeding strategies are needed.
Collapse
Affiliation(s)
- Adam L Ware
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, 81 N. Mario Capecchi Dr, Salt Lake City, UT, 84113, USA.
| | - Courtney Jones
- Acute Care Therapy Services, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Alaina K Kipps
- Division of Pediatric Cardiology, Department of Pediatrics, Stanford University, Palo Alto, CA, USA
| | - Lara Khadr
- University of Michigan Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Elisa Marcuccio
- Division of Pediatric Cardiology, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Sonali S Patel
- Division of Pediatric Cardiology, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Sarah Plummer
- Division of Pediatric Cardiology, Department of Pediatrics, Case Western Reserve University, Cleveland, OH, USA
| | - Chitra Ravishankar
- Division of Cardiology, Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Mayte Figueroa
- Division of Pediatric Cardiology, Department of Pediatrics, Washington University School of Medicine, St. Louis, MS, USA
| |
Collapse
|
2
|
Jacobwitz M, Irving SY, Moriarty H, Yost J, Vossough A, Licht DJ, Lynch JM. Predictors of the inability to achieve full oral feeding in postoperative infants with CHD. Cardiol Young 2024; 34:581-587. [PMID: 37608743 DOI: 10.1017/s104795112300313x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
OBJECTIVES Poor oral feeding is a known contributor to growth challenges in neonates with complex CHD who require early surgery. Almost 60% of these infants do not achieve full oral feeding by hospital discharge. This study's objective was to identify predictors of the inability to achieve full oral feeding by discharge in neonates with complex CHD following surgical intervention with cardiopulmonary bypass. STUDY DESIGN A retrospective analysis of a prospective study of 192 full-term neonates with complex CHD was performed. A stepwise selection logistic regression model was developed to predict oral feeding status at hospital discharge. Univariate subgroup analysis was performed with groups determined based on a CHD classification system. RESULTS 58% of neonates (112/192) failed to achieve full oral feeding by hospital discharge. A logistic regression model identified duration of deep hypothermic circulatory arrest and reintubation as predictors of the inability to achieve full oral feeding. Among neonates who achieved full oral feeding by discharge (42%), only 7.5% did so after postoperative day 10. Brain maturation, brain injury, and preoperative oral feeding were not predictors of full postoperative oral feeding. CONCLUSIONS Many infants with CHD fail to achieve full oral feeding by time of hospital discharge. Longer duration of deep hypothermic circulatory arrest and increased number of intubations were predictive of poor feeding after surgery. Prolonging hospitalisation solely to achieve full oral feeding after postoperative day ten is of limited utility; earlier discharge should be promoted to avoid negative impacts on neonatal neurodevelopment as unintended consequences of lengthy hospitalisations.
Collapse
Affiliation(s)
- Marin Jacobwitz
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- M. Louise Fitzpatrick College of Nursing, Villanova University, Villanova, PA, USA
| | - Sharon Y Irving
- Critical Care Nursing, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Helene Moriarty
- M. Louise Fitzpatrick College of Nursing, Villanova University, Villanova, PA, USA
| | - Jennifer Yost
- M. Louise Fitzpatrick College of Nursing, Villanova University, Villanova, PA, USA
| | - Arastoo Vossough
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
- Division of Neuroradiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Daniel J Licht
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Jennifer M Lynch
- Division of Cardiothoracic Anesthesiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| |
Collapse
|
3
|
Tjoeng YL, Werho DK, Algaze C, Nawathe P, Benjamin S, Schumacher KR, Chan T. Development of an Equity, Diversity, and Inclusion Committee for a collaborative quality improvement network: Pediatric Cardiac Critical Care Consortium (PC 4) Equity, Diversity and Inclusion (EDI) Committee: white paper 2023. Cardiol Young 2024; 34:563-569. [PMID: 37577942 DOI: 10.1017/s1047951123002950] [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] [Indexed: 08/15/2023]
Abstract
Racial and ethnic disparities are well described in paediatric cardiac critical care outcomes. However, understanding the mechanisms behind these outcomes and implementing interventions to reduce and eliminate disparities remain a gap in the field of paediatric cardiac critical care. The Pediatric Cardiac Critical Care Consortium (PC4) established the Equity, Diversity, and Inclusion (EDI) Committee in 2020 to promote an equity lens to its aim of improving paediatric cardiac critical care quality and outcomes across North America. The PC4 EDI Committee is working to increase research, quality improvement, and programming efforts to work towards health equity. It also aims to promote health equity considerations in PC4 research. In addition to a focus on patient outcomes and research, the committee aims to increase the inclusion of Black, Indigenous, and People of Color (BIPOC) members in the PC4 collaborative. The following manuscript outlines the development, structure, and aims of the PC4 EDI Committee and describes an analysis of social determinants of health in published PC4 research.
Collapse
Affiliation(s)
- Yuen Lie Tjoeng
- Division of Critical Care Medicine and the Heart Center, Seattle Children's Hospital, Seattle, WA, USA
- University of Washington School of Medicine, University of Washington, Seattle, WA, USA
| | - David K Werho
- Division of Pediatric Cardiology, Rady Children's Hospital, University of California San Diego, San Diego, CA, USA
| | - Claudia Algaze
- Division of Pediatric Cardiology, Lucile Packard Children's Hospital, Stanford University, Palo Alto, CA, USA
| | - Pooja Nawathe
- Division of Pediatric Critical Care, Guerin Children's, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Solange Benjamin
- Division of Pediatric Cardiology, Levine Children's Hospital, Charlotte, NC, USA
| | - Kurt R Schumacher
- Division of Pediatric Cardiology, C. S. Mott Children's Hospital, University of Michigan. Ann Arbor, MI, USA
| | - Titus Chan
- Division of Critical Care Medicine and the Heart Center, Seattle Children's Hospital, Seattle, WA, USA
- University of Washington School of Medicine, University of Washington, Seattle, WA, USA
| |
Collapse
|
4
|
Davis JA, Baumgartel K, Baust T, Conley YP, Morowitz MJ, Ren D, Demirci JR. Neonatal Diet Type and Associations With Adverse Feeding Outcomes in Neonates With Critical Congenital Heart Defects. J Perinat Neonatal Nurs 2024; 38:54-64. [PMID: 38236148 PMCID: PMC10807746 DOI: 10.1097/jpn.0000000000000790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 10/30/2023] [Indexed: 01/19/2024]
Abstract
BACKGROUND Neonates with critical congenital heart defects (CCHD neonates) experience high rates of feeding intolerance, necrotizing enterocolitis (NEC), and malnutrition. The benefits of human milk and direct chest/breastfeeding are well known, but research is limited in CCHD neonates. Therefore, the purpose of this study is to examine the impact of neonatal diet and feeding modality on the incidence of feeding intolerance, NEC, and malnutrition among a cohort of CCHD neonates. METHODS A single-center retrospective study was conducted using electronic health record data of CCHD neonates admitted to a cardiac intensive care unit between April 2016 and April 2020. Regression models were fit to analyze associations between neonatal diet, feed modality, and adverse feeding outcomes. RESULTS Seventy-four CCHD neonates were included. Increased days of direct chest/breastfeeding were associated with fewer signs of gastrointestinal distress ( P = .047) and bloody stools ( P = .021). Enteral feeding days of "all human milk" were associated with higher growth trajectory ( P < .001). CONCLUSIONS Human milk and direct chest/breastfeeding may be protective against some adverse feeding outcomes for CCHD neonates. Larger, multicenter cohort studies are needed to continue investigating the effects of neonatal diet type and feeding modality on the development of adverse feeding outcomes in this unique population.
Collapse
Affiliation(s)
- Jessica A. Davis
- Division of General Academic Pediatrics, Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania (Dr Davis); UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania (Drs Davis and Morowitz); School of Nursing, University of South Florida, Tampa (Dr Baumgartel); Departments of Critical Care Medicine (Ms Baust) and Surgery (Dr Morowitz), School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; and Departments of Health Promotion and Development (Dr Conley and Demirci) and Health and Community Systems (Dr Ren), School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kelley Baumgartel
- Division of General Academic Pediatrics, Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania (Dr Davis); UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania (Drs Davis and Morowitz); School of Nursing, University of South Florida, Tampa (Dr Baumgartel); Departments of Critical Care Medicine (Ms Baust) and Surgery (Dr Morowitz), School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; and Departments of Health Promotion and Development (Dr Conley and Demirci) and Health and Community Systems (Dr Ren), School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Tracy Baust
- Division of General Academic Pediatrics, Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania (Dr Davis); UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania (Drs Davis and Morowitz); School of Nursing, University of South Florida, Tampa (Dr Baumgartel); Departments of Critical Care Medicine (Ms Baust) and Surgery (Dr Morowitz), School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; and Departments of Health Promotion and Development (Dr Conley and Demirci) and Health and Community Systems (Dr Ren), School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Yvette P. Conley
- Division of General Academic Pediatrics, Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania (Dr Davis); UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania (Drs Davis and Morowitz); School of Nursing, University of South Florida, Tampa (Dr Baumgartel); Departments of Critical Care Medicine (Ms Baust) and Surgery (Dr Morowitz), School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; and Departments of Health Promotion and Development (Dr Conley and Demirci) and Health and Community Systems (Dr Ren), School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michael J. Morowitz
- Division of General Academic Pediatrics, Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania (Dr Davis); UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania (Drs Davis and Morowitz); School of Nursing, University of South Florida, Tampa (Dr Baumgartel); Departments of Critical Care Medicine (Ms Baust) and Surgery (Dr Morowitz), School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; and Departments of Health Promotion and Development (Dr Conley and Demirci) and Health and Community Systems (Dr Ren), School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Dianxu Ren
- Division of General Academic Pediatrics, Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania (Dr Davis); UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania (Drs Davis and Morowitz); School of Nursing, University of South Florida, Tampa (Dr Baumgartel); Departments of Critical Care Medicine (Ms Baust) and Surgery (Dr Morowitz), School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; and Departments of Health Promotion and Development (Dr Conley and Demirci) and Health and Community Systems (Dr Ren), School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jill R. Demirci
- Division of General Academic Pediatrics, Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania (Dr Davis); UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania (Drs Davis and Morowitz); School of Nursing, University of South Florida, Tampa (Dr Baumgartel); Departments of Critical Care Medicine (Ms Baust) and Surgery (Dr Morowitz), School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania; and Departments of Health Promotion and Development (Dr Conley and Demirci) and Health and Community Systems (Dr Ren), School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
5
|
Maraschin FG, Adella FJ, Nagraj S. A scoping review of the post-discharge care needs of babies requiring surgery in the first year of life. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002424. [PMID: 37992047 PMCID: PMC10664918 DOI: 10.1371/journal.pgph.0002424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 11/01/2023] [Indexed: 11/24/2023]
Abstract
Congenital anomalies are among the leading causes of under-5 mortality, predominantly impacting low- and middle-income countries (LMICs). A particularly vulnerable group are babies with congenital disorders requiring surgery in their first year. Addressing this is crucial to meet SDG-3, necessitating targeted efforts. Post-discharge, these infants have various care needs provided by caregivers, yet literature on these needs is scant. Our scoping review aimed to identify the complex care needs of babies post-surgery for critical congenital cardiac conditions and non-cardiac conditions. Employing the Joanna Briggs Institute's methodological framework for scoping reviews we searched Pubmed, EMBASE, CINAHL, PsychINFO, and Web of Science databases. Search terms included i) specific congenital conditions (informed by the literature and surgeons in the field), ii) post-discharge care, and iii) newborns/infants. English papers published between 2002-2022 were included. Findings were summarised using a narrative synthesis. Searches yielded a total of 10,278 papers, with 40 meeting inclusion criteria. 80% of studies were conducted in High-Income Countries (HICs). Complex care needs were shared between cardiac and non-cardiac congenital conditions. Major themes identified included 1. Monitoring, 2. Feeding, and 3. Specific care needs. Sub-themes included monitoring (oxygen, weight, oral intake), additional supervision, general feeding, assistive feeding, condition-specific practices e.g., stoma care, and general care. The post-discharge period poses a challenge for caregivers of babies requiring surgery within the first year of life. This is particularly the case for caregivers in LMICs where access to surgical care is challenging and imposes a financial burden. Parents need to be prepared to manage feeding, monitoring, and specific care needs for their infants before hospital discharge and require subsequent support in the community. Despite the burden of congenital anomalies occurring in LMICs, most of the literature is HIC-based. More research of this nature is essential to guide families caring for their infants post-surgical care.
Collapse
Affiliation(s)
- Francesca Giulia Maraschin
- Health Systems Collaborative, Centre for Global Health Research, The Nuffield Department of Medicine, The University of Oxford, Oxford, United Kingdom
| | - Fidelis Jacklyn Adella
- Health Systems Collaborative, Centre for Global Health Research, The Nuffield Department of Medicine, The University of Oxford, Oxford, United Kingdom
| | - Shobhana Nagraj
- Health Systems Collaborative, Centre for Global Health Research, The Nuffield Department of Medicine, The University of Oxford, Oxford, United Kingdom
| |
Collapse
|
6
|
Kerstein JS, Klepper CM, Finnan EG, Mills KI. Nutrition for critically ill children with congenital heart disease. Nutr Clin Pract 2023; 38 Suppl 2:S158-S173. [PMID: 37721463 DOI: 10.1002/ncp.11046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 06/28/2023] [Accepted: 07/04/2023] [Indexed: 09/19/2023] Open
Abstract
Children with congenital heart disease often require admission to the cardiac intensive care unit at some point in their lives, either after elective surgical or catheter-based procedures or during times of acute critical illness. Meeting both the macronutrient and micronutrient needs of children in the cardiac intensive care unit requires complex decision-making when considering gastrointestinal perfusion, vasoactive support, and fluid balance goals. Although nutrition guidelines exist for critically ill children, these cannot always be extrapolated to children with congenital heart disease. Children with congenital heart disease may also suffer unique circumstances, such as chylothoraces, heart failure, and the need for mechanical circulatory support, which greatly impact nutrition delivery. Guidelines for neonates and children with heart disease continue to be developed. We provide a synthesized narrative review of current literature and considerations for nutrition evaluation and management of critically ill children with congenital heart disease.
Collapse
Affiliation(s)
- Jason S Kerstein
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusettes, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusettes, USA
| | - Corie M Klepper
- Department of Pediatrics, Harvard Medical School, Boston, Massachusettes, USA
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusettes, USA
| | - Emily G Finnan
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusettes, USA
| | - Kimberly I Mills
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusettes, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusettes, USA
| |
Collapse
|
7
|
Elgersma KM, McKechnie AC, Sommerness SA, Tanner LR, Swanson NM. Wayfinding through the "ocean of the great unknown": how lactating parents establish a direct breastfeeding relationship with an infant with critical CHD. Cardiol Young 2023; 33:2000-2011. [PMID: 36484129 DOI: 10.1017/s1047951122003808] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Lactating parents of infants hospitalised for critical congenital heart disease (CHD) face significant barriers to direct breastfeeding. While experiences of directly breastfeeding other hospitalised neonates have been described, studies including infants with critical CHD are scarce. There is no evidence-based standard of direct breastfeeding care for these infants, and substantial practice variation exists. AIM To explain how direct breastfeeding is established with an infant hospitalised for critical CHD, from lactating parents' perspectives. MATERIALS & METHODS This study is a qualitative grounded dimensional analysis of interviews with 30 lactating parents of infants with critical CHD who directly breastfed within 3 years. Infants received care from 26 United States cardiac centres; 57% had single ventricle physiology. Analysis included open, axial, and selective coding; memoing; member checking; and explanatory matrices. RESULTS Findings were represented by a conceptual model, "Wayfinding through the 'ocean of the great unknown'." The core process of Wayfinding involved a nonlinear trajectory requiring immense persistence in navigating obstacles, occurring in a context of life-and-death consequences for the infant. Wayfinding was characterised by three subprocesses: navigating the relationship with the healthcare team; protecting the direct breastfeeding relationship; and doing the long, hard work. Primary influencing conditions included relentless concern about weight gain, the infant's clinical course, and the parent's previous direct breastfeeding experience. CONCLUSIONS For parents, engaging in the Wayfinding process to establish direct breastfeeding was feasible and meaningful - though challenging. The conceptual model of Wayfinding explains how direct breastfeeding can be established and provides a framework for research and practice.
Collapse
Affiliation(s)
| | | | | | - Lynn R Tanner
- School of Nursing, University of Minnesota, Minneapolis, MN, USA
- Children's Minnesota, Minneapolis, MN, USA
| | | |
Collapse
|
8
|
Mohiuddin TA, Raol N, Tey CS, Horný M, Zhang C, Sharp WG, Chanani N, Patzer RE. Quantifying the Healthcare Burden of Pediatric Feeding Disorder after Congenital Heart Surgery. J Pediatr 2023; 261:113593. [PMID: 37399917 DOI: 10.1016/j.jpeds.2023.113593] [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] [Received: 01/10/2023] [Revised: 05/27/2023] [Accepted: 06/26/2023] [Indexed: 07/05/2023]
Abstract
OBJECTIVE To determine the healthcare costs and use burden of pediatric feeding disorder after congenital heart surgery. STUDY DESIGN A retrospective, population-based cohort study using claims data (2009-2018) was performed. Participants include patients aged 0-18 years who had undergone congenital heart surgery and were included in the insurance database ≥1 year after surgery. The main exposure variable was the presence of a pediatric feeding disorder, defined as a need for a feeding tube at discharge or diagnosis of dysphagia or feeding-related difficulty within the study timeframe. Main outcomes include overall and feeding-related medical care use, defined as readmissions and outpatient use, and feeding-related cost of care within 1 year of surgery. RESULTS A total of 10 849 pediatric patients were identified, with 3347 (30.9%) presenting with pediatric feeding disorder within 1 year of surgery. Patients with pediatric feeding disorder spent a median of 12 days (IQR, 6-33 days) in the hospital, compared with 5 days (IQR, 3-8 days) in patients without (P < .001). Rate ratios for overall readmissions, feeding-related readmissions, feeding-related outpatient use, and cost of care over the first year after surgery were significantly increased at 2.9 (95% CI, 2.5-3.4), 5.1 (95% CI, 4.6-5.7), 7.7 (95% CI, 6.5-9.1), and 2.2 (95% CI, 2.0-2.3) among patients with pediatric feeding disorder as compared with those without. CONCLUSIONS Pediatric feeding disorder after congenital heart surgery is associated with a significant healthcare burden. Multidisciplinary care for and research on this health condition is needed to identify optimal management strategies to reduce this burden and improve outcomes.
Collapse
Affiliation(s)
- Tahmina A Mohiuddin
- Medical Scholars Program, Augusta University/University of Georgia Medical Partnership, Athens, GA
| | - Nikhila Raol
- Department of Otolaryngology, Emory School of Medicine, Atlanta, GA; Department of Pediatrics, Emory School of Medicine, Atlanta, GA; Childrens Healthcare of Atlanta, Atlanta, GA; Division of Pediatric Otolaryngology, Children's Healthcare of Atlanta, Atlanta, GA.
| | - Ching S Tey
- Department of Pediatrics, Emory School of Medicine, Atlanta, GA
| | - Michal Horný
- Department of Radiology and Imaging Sciences, Emory School of Medicine, Atlanta, GA; Department of Epidemiology, Emory Rollins School of Public Health, Atlanta, GA
| | - Chao Zhang
- Department of Pediatrics, Emory School of Medicine, Atlanta, GA
| | - William G Sharp
- Department of Pediatrics, Emory School of Medicine, Atlanta, GA; Childrens Healthcare of Atlanta, Atlanta, GA; Children's Feeding Program, Children's Healthcare of Atlanta, Atlanta, GA
| | - Nikhil Chanani
- Department of Pediatrics, Emory School of Medicine, Atlanta, GA; Childrens Healthcare of Atlanta, Atlanta, GA; Sibley Heart Center, Alpharetta, GA; Division of Pediatric Cardiology, Children's Healthcare of Atlanta, Atlanta, GA
| | - Rachel E Patzer
- Department of Epidemiology, Emory Rollins School of Public Health, Atlanta, GA
| |
Collapse
|
9
|
Asfari A, Jacobs JP, Byrnes JW, Borasino S, Prodhan P, Zaccagni H, Dabal RJ, Sorabella RA, Hammel JM, Smith-Parrish M, Zhang W, Banerjee M, Schumacher KR, Tabbutt S. Norwood Operation: Immediate vs Delayed Sternal Closure. Ann Thorac Surg 2023; 115:649-654. [PMID: 35863395 DOI: 10.1016/j.athoracsur.2022.06.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 06/06/2022] [Accepted: 06/27/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND The Norwood operation is a complex neonatal surgery. There are limited data to inform the timing of sternal closure. After the Norwood operation, delayed sternal closure (DSC) is frequent. We aimed to examine the association of DSC with outcomes, with a particular interest in how sternal closure at the time of surgery compared with the timing of DSC. Our outcomes included mortality, length of ventilation, length of stay, and postoperative complications. METHODS This retrospective study included neonates who underwent a Norwood operation reported in the Pediatric Cardiac Critical Care Consortium registry from February 2019 through April 2021. Outcomes of patients with closed sternum were compared to those with sternal closure prior to postoperative day 3 (early closure) and prior to postoperative day 6 (intermediate closure). RESULTS The incidence of DSC was 74% (500 of 674). The median duration of open sternum was 4 days (interquartile range 3-5 days). Comparing patients with closed sternum to patients with early sternal closure, there was no statistical difference in mortality rate (1.1% vs 0%) and the median hospital postoperative stay (30 days vs 31 days). Compared with closed sternum, patients with intermediate sternal closure required longer mechanical ventilation (5.9 days vs 3.9 days) and fewer subsequent sternotomies (3% vs 7.5%). CONCLUSIONS For important outcomes following the Norwood operation there is no advantage to chest closure at the time of surgery if the chest can be closed prior to postoperative day 3.
Collapse
Affiliation(s)
- Ahmed Asfari
- Division of Cardiology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama.
| | - Jeffrey P Jacobs
- Department of Cardiovascular Surgery, University of Florida, Gainesville, Florida
| | - Jonathan W Byrnes
- Division of Cardiology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Santiago Borasino
- Division of Cardiology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Parthak Prodhan
- Division of Cardiology, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Hayden Zaccagni
- Division of Cardiology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert J Dabal
- Department of Cardiovascular Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert A Sorabella
- Department of Cardiovascular Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - James M Hammel
- Department of Cardiovascular Surgery, University of Nebraska, Omaha, Nebraska
| | - Melissa Smith-Parrish
- Divisions of Pediatric Critical Care Medicine and Pediatric Cardiology, Department of Pediatrics, Vanderbilt University School of Medicine and Monroe Carrell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Wenying Zhang
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | - Mousumi Banerjee
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, Michigan
| | - Kurt R Schumacher
- Division of Cardiology, Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, Michigan
| | - Sarah Tabbutt
- Division of Critical Care Medicine, Department of Pediatrics, University of California San Francisco Benioff Children's Hospitals, San Francisco, California
| |
Collapse
|
10
|
Davis JA, Glasser M, Spatz DL, Scott P, Demirci JR. First Feed Type Is Associated With Birth/Lactating Parent's Own Milk Use During NICU Stay Among Infants Who Require Surgery. Adv Neonatal Care 2022; 22:578-588. [PMID: 35421040 PMCID: PMC9556699 DOI: 10.1097/anc.0000000000000981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Early exclusive birth/lactating parent's own milk (B/LPOM) feeds have been associated with longer duration of B/LPOM use for infant feedings in healthy term and hospitalized preterm infants. This relationship has not been explored in infants undergoing neonatal surgery (surgical infants). PURPOSE To evaluate the relationship between early exclusive B/LPOM feeds and cumulative B/LPOM patterns during surgical infants' neonatal intensive care unit (NICU) hospitalization. METHODS A secondary cross-sectional analysis was performed using the electronic health record data of surgical infants admitted to a level IV NICU between January 2014 and March 2015. Multiple linear regression and Fisher's exact test were used to examine the associations between first NICU feed type and total percentage of diet composed of B/LPOM during NICU stay and continuation of any or exclusive B/LPOM feedings at NICU discharge, respectively. RESULTS The analysis included 59 infants who required surgery for gastrointestinal, cardiac, or multisystem defects or pregnancy-related complications. Receipt of B/LPOM as the first NICU feed was associated with higher percentage of B/LPOM feeds ( P < .001) throughout NICU stay, as well as continuation of any or exclusive B/LPOM feedings at NICU discharge ( P = .03). IMPLICATIONS FOR PRACTICE Early exclusive B/LPOM feeds may be an important predictor for continuation of any B/LPOM use throughout the NICU stay and at NICU discharge. Continued efforts to identify and address gaps in prenatal and postpartum lactation support for parents of surgical infants are needed. IMPLICATIONS FOR RESEARCH Powered studies are needed to corroborate these findings and to explore the potential impact of other factors on duration and exclusivity of B/LPOM use. VIDEO ABSTRACT AVAILABLE AT https://journals.lww.com/advancesinneonatalcare/Pages/videogallery.aspx .
Collapse
Affiliation(s)
- Jessica A Davis
- University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania (Ms Davis and Drs Glasser, Scott, and Demirci); and University of Pennsylvania School of Nursing, Philadelphia, and The Children's Hospital of Philadelphia (CHOP), Philadelphia, and Children's Hospital of Philadelphia's Mothers' Milk Bank, Philadelphia, Pennsylvania (Dr Spatz)
| | | | | | | | | |
Collapse
|
11
|
Bell D, Suna J, Marathe SP, Perumal G, Betts KS, Venugopal P, Alphonso N. Feeding Neonates and Infants Prior to Surgery for Congenital Heart Defects: Systematic Review and Meta-Analysis. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9121856. [PMID: 36553299 PMCID: PMC9776823 DOI: 10.3390/children9121856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 11/19/2022] [Accepted: 11/22/2022] [Indexed: 12/05/2022]
Abstract
BACKGROUND Necrotising enterocolitis (NEC) is a significant cause of mortality and morbidity in neonates requiring cardiac surgery. Feeding practices vary significantly across institutions and remain controversial. We conducted a systematic review of the literature and a meta-analysis to identify associations between feeding practices and necrotising enterocolitis. METHODS This study was carried out in accordance with the PRISMA guidelines. A literature search was performed in November 2022 using the Cochrane Central Register, Embase, and Pubmed. Two investigators then independently retrieved eligible manuscripts considered suitable for inclusion. Data extracted included gestational age, birth weight, sex, nature of congenital heart lesion, type of operation performed, time on ventilator, ICU stay, hospital stay, post-operative feeding strategy, and complications. The methodological quality was assessed using the Downs and Black score for all randomised control trials and observational studies. RESULTS The initial search yielded 92 studies. After removing duplicates, there were 85 abstracts remaining. After excluding ineligible studies, 8 studies were included for the meta-analysis. There was no significant risk of NEC associated with pre-operative feeding [OR = 1.22 (95% CI 0.77,1.92)] or umbilical artery catheter placement [OR = 0.91 (95% CI 0.44, 1.89)] and neither outcome exhibited heterogeneity [I2 = 8% and 0%, respectively]. There was a significant association between HLHS and NEC [OR = 2.56 (95% CI 1.56, 4.19)] as well as prematurity and NEC [OR 3.34 (95% CI 1.94, 5.75)] and neither outcome exhibited heterogeneity [I2 = 0% and 0%, respectively]. CONCLUSIONS There was no association between NEC and pre-operative feeding status in neonates awaiting cardiac surgery. Pre-operative feeding status was not associated with prolonged hospital stay or need for tube assisted feeding at discharge. HLHS and prematurity were associated with increased incidence of NEC.
Collapse
Affiliation(s)
- Douglas Bell
- The Prince Charles Hospital, Brisbane, QLD 4032, Australia
| | - Jessica Suna
- Queensland Paediatric Cardiac Service (QPCS), Queensland Children’s Hospital, Brisbane, QLD 4101, Australia
- School of Clinical Medicine, Children’s Health Queensland Clinical Unit, University of Queensland, Brisbane, QLD 4072, Australia
- Children’s Health Research Centre, University of Queensland, Brisbane, QLD 4101, Australia
| | - Supreet P. Marathe
- Queensland Paediatric Cardiac Service (QPCS), Queensland Children’s Hospital, Brisbane, QLD 4101, Australia
- School of Clinical Medicine, Children’s Health Queensland Clinical Unit, University of Queensland, Brisbane, QLD 4072, Australia
- Children’s Health Research Centre, University of Queensland, Brisbane, QLD 4101, Australia
| | | | - Kim S. Betts
- Children’s Health Research Centre, University of Queensland, Brisbane, QLD 4101, Australia
| | - Prem Venugopal
- Queensland Paediatric Cardiac Service (QPCS), Queensland Children’s Hospital, Brisbane, QLD 4101, Australia
- School of Clinical Medicine, Children’s Health Queensland Clinical Unit, University of Queensland, Brisbane, QLD 4072, Australia
- Children’s Health Research Centre, University of Queensland, Brisbane, QLD 4101, Australia
| | - Nelson Alphonso
- Queensland Paediatric Cardiac Service (QPCS), Queensland Children’s Hospital, Brisbane, QLD 4101, Australia
- School of Clinical Medicine, Children’s Health Queensland Clinical Unit, University of Queensland, Brisbane, QLD 4072, Australia
- Children’s Health Research Centre, University of Queensland, Brisbane, QLD 4101, Australia
- Correspondence: ; Tel.: +61-7-3068-3486
| | - QPCR Group
- QPCR Collaborators: Janelle Johnson, Tom R Karl, Children’s Health Research Centre, University of Queensland, Brisbane, QLD 4101, Australia
| |
Collapse
|
12
|
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.
Collapse
|
13
|
Levy VY, Bhombal S, Villafane J, McBride ME, Thiagarajan R, Figueroa M, Hopper A, Johnson JN, Costello JM. Introduction to the Neonatal Cardiac Care Collaborative Supplement. Pediatrics 2022; 150:189879. [PMID: 36317968 DOI: 10.1542/peds.2022-056415b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
- Victor Y Levy
- Department of Pediatrics, Texas Tech University Health Sciences Center, Lubbock, Texas.,Neonatal Heart Society.,American Academy of Pediatrics, Section of Cardiology and Cardiothoracic Surgery
| | - Shazia Bhombal
- Department of Pediatrics, Stanford University, Palo Alto, California.,Neonatal Heart Society.,American Academy of Pediatrics, Section of Neonatal and Perinatal Medicine
| | - Juan Villafane
- Department of Pediatrics, University of Cincinnati, Cincinnati Children's Hospital, Cincinnati, Ohio.,American Academy of Pediatrics, Section of Cardiology and Cardiothoracic Surgery
| | - Mary E McBride
- Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,Pediatric Cardiac Intensive Care Society
| | - Ravi Thiagarajan
- Department of Pediatrics, Harvard University, Boston Children's, Boston, Massachusetts.,American Heart Association
| | - Mayte Figueroa
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri.,American College of Cardiology
| | - Andrew Hopper
- Department of Pediatrics, Loma Linda University School of Medicine, Loma Linda, California.,American Academy of Pediatrics, Section of Neonatal and Perinatal Medicine
| | - Jonathan N Johnson
- Department of Pediatrics, Division of Pediatric Cardiology, Mayo Clinic Children's Center Rochester, Rochester, Minnesota.,American Academy of Pediatrics, Section of Cardiology and Cardiothoracic Surgery
| | - John M Costello
- Department of Pediatrics, Shawn Jenkins Children's Hospital, Medical University of South Carolina, Charleston, South Carolina.,American Heart Association
| |
Collapse
|
14
|
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.
Collapse
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
| |
Collapse
|
15
|
Horsley M, Hill GD, Kaskie S, Schnautz M, Brown J, Marcuccio E. Evaluation of an Outpatient and Telehealth Initiative to Reduce Tube Dependency in Infants with Complex Congenital Heart Disease. Pediatr Cardiol 2022; 43:1429-1437. [PMID: 35333946 DOI: 10.1007/s00246-022-02864-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 02/25/2022] [Indexed: 10/18/2022]
Abstract
Infants with congenital heart disease (CHD) often require supplemental nutrition via tube feeding, even after corrective surgical repair. The need for tube feeding can persist months after discharge home, and outpatient weaning from the tube can be a slow and difficult process. Lack of consensus exists in the literature as to the best approach to this challenge. We describe a single institution's initiative to decrease tube dependency after discharge through an intensive, telehealth-centric program for children with CHD. Of 16 children aged 1-26 months, 94% were able to be successfully tube weaned at home, with median time to tube-free of 12 days. No significant weight loss was noted during or after the wean process. Longer tube wean time was associated with older age at onset and comorbid genetic syndrome. Our telehealth-based intensive tube weaning program was successful but required a multidisciplinary team, targeted pre-participation patient evaluation, and frequent communication.
Collapse
Affiliation(s)
- Megan Horsley
- Division of Nutrition Therapy, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.
| | - Garick D Hill
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Sarah Kaskie
- Division of Speech-Language Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Maureen Schnautz
- Division of Speech-Language Pathology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - James Brown
- Department of James M Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Elisa Marcuccio
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| |
Collapse
|
16
|
Burge KY, Gunasekaran A, Makoni MM, Mir AM, Burkhart HM, Chaaban H. Clinical Characteristics and Potential Pathogenesis of Cardiac Necrotizing Enterocolitis in Neonates with Congenital Heart Disease: A Narrative Review. J Clin Med 2022; 11:3987. [PMID: 35887751 PMCID: PMC9320426 DOI: 10.3390/jcm11143987] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/07/2022] [Accepted: 07/07/2022] [Indexed: 12/10/2022] Open
Abstract
Neonates with congenital heart disease (CHD) are at an increased risk of developing necrotizing enterocolitis (NEC), an acute inflammatory intestinal injury most commonly associated with preterm infants. The rarity of this complex disease, termed cardiac NEC, has resulted in a dearth of information on its pathophysiology. However, a higher incidence in term infants, effects on more distal regions of the intestine, and potentially a differential immune response may distinguish cardiac NEC as a distinct condition from the more common preterm, classical NEC. In this review, risk factors, differentiated from those of classical NEC, are discussed according to their potential contribution to the disease process, and a general pathogenesis is postulated for cardiac NEC. Additionally, biomarkers specific to cardiac NEC, clinical outcomes, and strategies for achieving enteral feeds are discussed. Working towards an understanding of the mechanisms underlying cardiac NEC may aid in future diagnosis of the condition and provide potential therapeutic targets.
Collapse
Affiliation(s)
- Kathryn Y. Burge
- Department of Pediatrics, Division of Neonatology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA; (K.Y.B.); (A.G.); (M.M.M.)
| | - Aarthi Gunasekaran
- Department of Pediatrics, Division of Neonatology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA; (K.Y.B.); (A.G.); (M.M.M.)
| | - Marjorie M. Makoni
- Department of Pediatrics, Division of Neonatology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA; (K.Y.B.); (A.G.); (M.M.M.)
| | - Arshid M. Mir
- Department of Pediatrics, Division of Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA;
| | - Harold M. Burkhart
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA;
| | - Hala Chaaban
- Department of Pediatrics, Division of Neonatology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA; (K.Y.B.); (A.G.); (M.M.M.)
| |
Collapse
|
17
|
Reddy RK, McVadon DH, Zyblewski SC, Rajab TK, Diego E, Southgate WM, Fogg KL, Costello JM. Prematurity and Congenital Heart Disease: A Contemporary Review. Neoreviews 2022; 23:e472-e485. [PMID: 35773510 DOI: 10.1542/neo.23-7-e472] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Congenital heart disease (CHD) is the most commonly reported birth defect in newborns. Neonates with CHD are more likely to be born prematurely, and a higher proportion of preterm neonates have CHD than their term counterparts. The implications of preterm birth on the cardiac and noncardiac organ systems are vast and require special management considerations. The feasibility of surgical interventions in preterm neonates is frequently limited by patient size and delicacy of immature cardiac tissues. Thus, special care must be taken when considering the appropriate timing and type of cardiac intervention. Despite improvements in neonatal cardiac surgical outcomes, preterm and early term gestational ages and low birthweight remain important risk factors for in-hospital mortality. Understanding the risks of early delivery of neonates with prenatally diagnosed CHD may help guide perioperative management in neonates who are born preterm. In this review, we will describe the risks and benefits of early delivery, postnatal cardiac and noncardiac evaluation and management, surgical considerations, overall outcomes, and future directions regarding optimization of perinatal evaluation and management of fetuses and preterm and early term neonates with CHD.
Collapse
Affiliation(s)
- Reshma K Reddy
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Deani H McVadon
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Sinai C Zyblewski
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Taufiek K Rajab
- Division of Pediatric Cardiothoracic Surgery, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Ellen Diego
- Division of Neonatology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - W Michael Southgate
- Division of Neonatology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Kristi L Fogg
- Department of Food and Nutrition, Sodexo, Medical University of South Carolina, Charleston, SC
| | - John M Costello
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| |
Collapse
|
18
|
Assessing the Association Between Pre-operative Feeding and the Development of Oral Feeding Skills in Infants with Single Ventricle Heart Disease: An Analysis of the NPC-QIC Dataset. Pediatr Cardiol 2022; 43:1141-1155. [PMID: 35157095 DOI: 10.1007/s00246-022-02837-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 01/28/2022] [Indexed: 01/26/2023]
Abstract
Pre-operative feeding may improve long-term feeding outcomes in single ventricle patients, including weaning from supplemental tube feedings in infancy. This study examines the association between pre-operative enteral feeding and subsequent long-term feeding outcomes while also assessing the counterbalancing risk of necrotizing enterocolitis (NEC). Secondary analysis of the National Pediatric Cardiology Quality Improvement Collaborative database was performed. The association between pre-operative feeding practice and achieving all oral feeds through the first year of life was examined using a multivariable regression model. Similarly, the association between pre-operative oral feeding and NEC was also assessed. Of 944 patients with 1-year feeding outcomes available, 58% were fed preoperatively (41.3% exclusively oral) and 12.3% were not fed per institutional approach. At hospital discharge after Stage 1 palliation, 57% required a feeding tube, while 39% required a feeding tube at their first birthday. In infants who were orally fed, the odds ratio to achieving tube-free feeding at 1 year was not significantly increased (1.3, confidence interval 0.8-2.0). Of 1740 infants with pre-operative feeding and Stage 1 there was no statistically significant difference in NEC among patients who were preoperatively fed versus those that were not fed per institutional approach (p = 0.2). Pre-operative feeding of infants with single ventricle heart disease was not associated with early achievement of tube-free feeding in the first year of life. However, pre-operative oral feeding was also not associated with increased risk of NEC, suggesting that it can be safely offered among appropriate patients.
Collapse
|
19
|
Singal A, Sahu MK, Trilok Kumar G, Kumar A. Effect of energy- and/or protein-dense enteral feeding on postoperative outcomes of infant surgical patients with congenital cardiac disease: A systematic review and meta-analysis. Nutr Clin Pract 2021; 37:555-566. [PMID: 34897797 DOI: 10.1002/ncp.10799] [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] [Indexed: 11/07/2022] Open
Abstract
Infants with congenital heart disease (CHD) are malnourished because of poor dietary intakes and increased requirements. Energy requirements are higher due to increased resting energy expenditure. There are lacunae of nutrition recommendations for these infants. Therefore, this systematic review and meta-analysis was conducted to determine the effect of energy- and/or protein-dense feeds in postoperative CHD infants as compared with the standard feeding. An online literature search was performed on four databases by using different English-language keywords between 2000 and 2020. The inclusion criteria were peer reviewed journals and open access original articles on the feeding practices in infants undergoing congenital heart surgery. Exclusion criteria were editorials, commentaries, discussion papers, conference abstracts, reviews, duplicate studies, and articles on preterm infants and preoperative nutrition. A total of five studies matched the inclusion criteria. The standard mean difference (SMD) of energy intake (SMD = 13.40 kcal, P = 0.001), protein intake (SMD = 2.37 g, P = 0.001), and weight (SMD = 4.99 g, P = 0.001) was significantly higher in the intervention group. The SMD of ventilation duration (SMD = -0.18 h, P = 0.90), intensive care unit (ICU) length of stay (LOS) (SMD = -0.25 d, P = 0.70), and hospital LOS (SMD = -0.20 d, P = 0.67) were not statistically significant between the two groups. Enriched enteral nutrition for the postoperative pediatric patients with cardiac disease helps in achieving energy and protein goals and improves the overall postoperative outcomes (ie, ventilation duration, maintenance of weight, ICU LOS, and hospital LOS).
Collapse
Affiliation(s)
- Anuradha Singal
- Department of Food and Nutrition, Institute of Home Economics, University of Delhi, New Delhi, India
| | - Manoj Kumar Sahu
- Department of Cardiothoracic and Vascular Surgery, CT Centre, All India Institute of Medical Sciences, New Delhi, India
| | | | - Amit Kumar
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
20
|
Feeding infants with complex congenital heart disease: a modified Delphi survey to examine potential research and practice gaps. Cardiol Young 2021; 31:577-588. [PMID: 33303041 PMCID: PMC8058165 DOI: 10.1017/s1047951120004370] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To determine clinical consensus and non-consensus in regard to evidence-based statements about feeding infants with complex CHD, with a focus on human milk. Areas of non-consensus may indicate discrepancies between research findings and practice, with consequent variation in feeding management. MATERIALS AND METHODS A modified Delphi survey validated key feeding topics (round 1), and determined consensus on evidence-based statements (rounds 2 and 3). Patients (n=25) were an interdisciplinary group of clinical experts from across the United States of America. Descriptive analysis used SPSS Statistics (Version 26.0). Thematic analysis of qualitative data provided context for quantitative data. RESULTS Round 1 generated 5 key topics (human milk, developing oral feeding skills, clinical feeding practice, growth failure, and parental concern about feeding) and 206 evidence-based statements. The final results included 110 (53.4%) statements of consensus and 96 (46.6%) statements of non-consensus. The 10 statements of greatest consensus strongly supported human milk as the preferred nutrition for infants with complex CHD. Areas of non-consensus included the adequacy of human milk to support growth, need for fortification, safety, and feasibility of direct breastfeeding, issues related to tube feeding, and prevention and treatment of growth failure. CONCLUSIONS The results demonstrate clinical consensus about the importance of human milk, but reveal a need for best practices in managing a human milk diet for infants with complex CHD. Areas of non-consensus may lead to clinical practice variation. A sensitive approach to these topics is needed to support family caregivers in navigating feeding concerns.
Collapse
|
21
|
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.
Collapse
|
22
|
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.
Collapse
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
| |
Collapse
|
23
|
Percutaneous Endoscopic Gastrostomy Enhances Interstage Growth in Infants With Hypoplastic Left Heart Syndrome. Pediatr Crit Care Med 2021; 22:e213-e223. [PMID: 33055529 DOI: 10.1097/pcc.0000000000002596] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVES Infants with hypoplastic left heart syndrome undergoing staged palliation commonly experience chronic growth failure and malnutrition. Greater patient weight at stage 2 palliation (Glenn) is thought to be associated with improved perioperative outcomes. We aimed to compare weight for age z score and interstage growth velocity in children with and without a percutaneous endoscopic gastrostomy prior to Glenn and hypothesize that those with a percutaneous endoscopic gastrostomy experience-enhanced interstage growth and reduced malnutrition rates. DESIGN Single-center, retrospective cohort study. SETTING A total of 259-bed, quaternary, pediatric referral center. PATIENTS Infants with hypoplastic left heart syndrome from 2007 to 2016 with and without percutaneous endoscopic gastrostomy insertion after initial palliation (Norwood). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Primary outcomes were weight for age z score (at birth, Norwood, Norwood discharge, and Glenn), interstage growth velocity, and moderate-to-severe malnutrition (weight for age z score<-2) rates. Secondary outcomes were lengths of stay, mechanical ventilation rates after Glenn, and mortality. Statistical analyses included chi-square, Wilcoxon rank-sum, student's t, paired testing, and exploratory logistic regression. Of the 69 infants studied, 47 (68%) had percutaneous endoscopic gastrostomy insertion at a median of 156 (interquartile range, 115-158) days prior to Glenn. Among children with and without percutaneous endoscopic gastrostomy, we observed no differences in demographics, comorbidities, cardiothoracic surgical times, postoperative Glenn outcomes (length of stay, mechanical ventilation rate, peak 24-hr lactate, nitric oxide use, extracorporeal life support rate, or mortality), weight for age z score at birth, and weight for age z score at Norwood. At the time of percutaneous endoscopic gastrostomy insertion, weight for age z score was -2.5 ± 1.3 and subsequent growth velocity increased from 8 ± 7 to 40 ± 59 g/d (p < 0.01). From Norwood discharge to the date of Glenn, weight for age z score increased in infants with percutaneous endoscopic gastrostomy (-2.5 ± 1.1 to -1.5 ± 1.4 [p < 0.01]) with a large reduction in moderate-to-severe malnutrition rates (76-36%; p < 0.01). In general, weight for age z score at the time of Glenn was associated with reduced postoperative mortality (odds ratio, 0.3; 95% CI, 0.09-0.95; p = 0.04). CONCLUSIONS Infants undergoing palliation for hypoplastic left heart syndrome with percutaneous endoscopic gastrostomy insertion prior to Glenn had improved growth velocity and dramatically reduced rates of moderate-to-severe malnutrition rates (40% reduction). In addition, we noted weight for age z score at when Glenn was associated with improved postoperative Glenn survival. No complications from percutaneous endoscopic gastrostomy were noted. Placement of a percutaneous endoscopic gastrostomy improved weight for age z score, enhanced interstage growth, and reduced malnutrition rates for this at-risk population of malnourished children.
Collapse
|
24
|
Analysis of factors associated with prolonged post-operative course after surgical repair of aortic coarctation. Cardiol Young 2021; 31:191-198. [PMID: 33140711 DOI: 10.1017/s1047951120003637] [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
OBJECTIVE We sought to describe patient characteristics associated with prolonged post-operative length of stay in a contemporary cohort of infants who underwent isolated repair of aortic coarctation. METHODS We reviewed patients less than 1 year of age who underwent isolated repair of aortic coarctation at our institution from 2009 to 2016. Prolonged post-operative length of stay was defined as length of stay within the upper tertile for the cohort. Bivariate and multi-variable analyses were performed to determine independent risk factors for prolonged length of stay. RESULTS We reviewed 95 consecutive patients who underwent isolated repair of aortic coarctation, of whom 71 were neonates at the time of diagnosis. The median post-operative length of stay was 6.5 days. The upper tertile for post-operative length of stay was greater than 10 days; 32 patients within this tertile and 1 patient who died at 8.5 days after surgery were analysed as having prolonged post-operative length of stay. In a multi-variable analysis, pre-maturity (odds ratio: 3.5, 95% confidence interval: 1.2, 10.7), genetic anomalies (odds ratio: 4.7, 95% confidence interval: 1.2, 18), absence of pre-operative oral feeding (odds ratio: 7.4, 95% confidence interval: 2.4, 22.3), and 12-hour vasoactive-ventilation-renal score greater than 25 (odds ratio: 7.4, 95% confidence interval: 1.9, 29) were independently associated with prolonged length of stay. CONCLUSIONS In neonates and infants who underwent isolated repair of aortic coarctation, pre-maturity, genetic anomalies, lack of pre-operative oral feedings, and 12-hour vasoactive-ventilation-renal score more than 25 were independent risk factors for prolonged post-operative length of stay. Further study on the relationship between pre-operative oral feedings and post-operative length of stay should be pursued.
Collapse
|
25
|
Surgical Gastrostomy in Pediatric Patients Undergoing Cardiac Surgery. J Surg Res 2020; 259:516-522. [PMID: 33218701 DOI: 10.1016/j.jss.2020.10.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2019] [Revised: 09/24/2020] [Accepted: 10/12/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND Practices of performing gastrostomy tubes vary across institutions for patients undergoing cardiac surgery. We aim to elucidate the outcomes of gastrostomy and the duration of feeding assistance in these patients. MATERIALS AND METHODS Patients undergoing cardiac surgery (CS) at our institution from 2013 to 2017 were retrospectively reviewed using the Society of Thoracic Surgery database. A cohort of non-CS patients undergoing gastrostomy tube (g-tube) placement from 2013 to 2015 was used as control. Technical complications and postoperative feeding intolerance were analyzed. Duration of need for g-tube was also analyzed in patients undergoing CS. RESULTS The CS group had 144 patients, and the non-CS group had 677 patients. CS patients had a higher incidence of feeding intolerance (18.8% versus 5.6%, P < 0.001) and took longer to attain full feeds (median of 2 versus 1 d, P < 0.001), and this was confirmed on propensity matched analysis. In addition, technical g-tube complications were similar in the two groups. No mortality in CS was attributed to the g-tube. 58% of patients undergoing CS were able to wean from g-tube feeding by 6-12 mo after g-tube placement. CONCLUSIONS G-tube placement in patients undergoing CS by any technique is safe without increased complications. A significant portion of these patients was able to wean off supplemental enteral feeding assistance by a year after g-tube placement.
Collapse
|
26
|
Advancement of a standardised enteral feeding protocol in functional single ventricle patients following stage I palliation using cerebro-somatic near-infrared spectroscopy. Cardiol Young 2020; 30:1649-1658. [PMID: 32829739 DOI: 10.1017/s104795112000253x] [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 Infants with single ventricle following stage I palliation are at risk for poor nutrition and growth failure. We hypothesise a standardised enteral feeding protocol for these infants that will result in a more rapid attainment of nutritional goals without an increased incidence of gastrointestinal co-morbidities. MATERIALS AND METHODS Single-centre cardiac ICU, prospective case series with historical comparisons. Feeding cohort consisted of consecutive patients with a single ventricle admitted to cardiac ICU over 18 months following stage I palliation (n = 33). Data were compared with a control cohort and admitted to the cardiac ICU over 18 months before feeding protocol implementation (n = 30). Feeding protocol patients were randomised: (1) protocol with cerebro-somatic near-infrared spectroscopy feeding advancement criteria (n = 17) or (2) protocol without cerebro-somatic near-infrared spectroscopy feeding advancement criteria (n = 16). RESULTS Median time to achieve goal enteral volume was significantly higher in the control compared to feeding cohort. There were no significant differences in enteral feeds being held for feeding intolerance or necrotising enterocolitis between cohorts. Feeding cohort had significant improvements in discharge nutritional status (weight, difference admit to discharge weight, weight-for-age z score, volume, and caloric enteral nutrition) and late mortality compared to the control cohort. No infants in the feeding group with cerebro-somatic near-infrared spectroscopy developed necrotising enterocolitis versus 4/16 (25%) in the feeding cohort without cerebro-somatic near-infrared spectroscopy (p = 0.04). CONCLUSIONS A feeding protocol is a safe and effective means of initiating and advancing enteral nutrition in infants following stage I palliation and resulted in improved nutrition delivery, weight gain, and nourishment status at discharge without increased incidence of gastrointestinal co-morbidities.
Collapse
|
27
|
Perioperative nutrition in extremely preterm infants undergoing surgery for patent ductus arteriosus. CLINICAL NUTRITION EXPERIMENTAL 2020. [DOI: 10.1016/j.yclnex.2020.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
28
|
Standardized Perioperative Feeding Protocol Improves Outcomes in Patients With d-Transposition of the Great Arteries Undergoing Arterial Switch Operation. Pediatr Crit Care Med 2020; 21:e789-e794. [PMID: 32433441 DOI: 10.1097/pcc.0000000000002393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine whether the presence of a standardized feeding protocol improves outcomes in a subset of neonates undergoing cardiac surgery. DESIGN Retrospective cohort study. SETTING Cardiovascular ICU at a freestanding academic children's hospital. PATIENTS Neonates with a diagnosis of d-transposition of the great arteries undergoing arterial switch operation from January 2007 to June 2017. INTERVENTIONS Initiation of perioperative feeding protocols. MEASUREMENTS AND MAIN RESULTS Patients were evaluated before and after implementation of standardized perioperative feeding protocols in neonates with d-transposition of the great arteries undergoing arterial switch operation. Low-risk patients born after initiation of nurse-driven protocols were compared with a similar historical group. Data obtained included time to achievement of feeding goals, with primary outcome being weight gain at hospital discharge. Other measures analyzed included duration of mechanical ventilation and postoperative hospital length of stay. Overall, 33 patients in the protocol group were compared with 44 patients in the historical group. No significant baseline differences existed between the two cohorts. The protocol group achieved improved feeding outcomes in nearly all measured categories, including introduction to enteral feeds preoperatively (91% vs 59%; p < 0.01) and earlier attainment of postoperative full enteral feeds of 120 mL/kg/d (2 vs 5 d; p < 0.01). Protocol patients had significantly improved weight gain at the time of discharge (60 vs 1 g; p < 0.01), while achieving shorter postoperative length of stay (10.1 vs 12.6 d; p = 0.04). CONCLUSIONS An aggressive, but safe, perioperative feeding protocol implemented in a homogenous low-risk neonatal cardiac surgical population improves feeding outcomes, including increased weight gain, as well as decreased postoperative length of stay. Consideration for perioperative feeding protocol implementation and further study should be given.
Collapse
|
29
|
Brown KL, Pagel C, Ridout D, Wray J, Tsang VT, Anderson D, Banks V, Barron DJ, Cassidy J, Chigaru L, Davis P, Franklin R, Grieco L, Hoskote A, Hudson E, Jones A, Kakat S, Lakhani R, Lakhanpaul M, McLean A, Morris S, Rajagopal V, Rodrigues W, Sheehan K, Stoica S, Tibby S, Utley M, Witter T. Early morbidities following paediatric cardiac surgery: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08300] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Background
Over 5000 paediatric cardiac surgeries are performed in the UK each year and early survival has improved to > 98%.
Objectives
We aimed to identify the surgical morbidities that present the greatest burden for patients and health services and to develop and pilot routine monitoring and feedback.
Design and setting
Our multidisciplinary mixed-methods study took place over 52 months across five UK paediatric cardiac surgery centres.
Participants
The participants were children aged < 17 years.
Methods
We reviewed existing literature, ran three focus groups and undertook a family online discussion forum moderated by the Children’s Heart Federation. A multidisciplinary group, with patient and carer involvement, then ranked and selected nine key morbidities informed by clinical views on definitions and feasibility of routine monitoring. We validated a new, nurse-administered early warning tool for assessing preoperative and postoperative child development, called the brief developmental assessment, by testing this among 1200 children. We measured morbidity incidence in 3090 consecutive surgical admissions over 21 months and explored risk factors for morbidity. We measured the impact of morbidities on quality of life, clinical burden and costs to the NHS and families over 6 months in 666 children, 340 (51%) of whom had at least one morbidity. We developed and piloted methods suitable for routine monitoring of morbidity by centres and co-developed new patient information about morbidities with parents and user groups.
Results
Families and clinicians prioritised overlapping but also different morbidities, leading to a final list of acute neurological event, unplanned reoperation, feeding problems, renal replacement therapy, major adverse events, extracorporeal life support, necrotising enterocolitis, surgical infection and prolonged pleural effusion. The brief developmental assessment was valid in children aged between 4 months and 5 years, but not in the youngest babies or 5- to 17-year-olds. A total of 2415 (78.2%) procedures had no measured morbidity. There was a higher risk of morbidity in neonates, complex congenital heart disease, increased preoperative severity of illness and with prolonged bypass. Patients with any morbidity had a 6-month survival of 81.5% compared with 99.1% with no morbidity. Patients with any morbidity scored 5.2 points lower on their total quality of life score at 6 weeks, but this difference had narrowed by 6 months. Morbidity led to fewer days at home by 6 months and higher costs. Extracorporeal life support patients had the lowest days at home (median: 43 days out of 183 days) and highest costs (£71,051 higher than no morbidity).
Limitations
Monitoring of morbidity is more complex than mortality, and hence this requires resources and clinician buy-in.
Conclusions
Evaluation of postoperative morbidity provides important information over and above 30-day survival and should become the focus of audit and quality improvement.
Future work
National audit of morbidities has been initiated. Further research is needed to understand the implications of feeding problems and renal failure and to evaluate the brief developmental assessment.
Funding
This project was funded by the NIHR Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 30. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Katherine L Brown
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Christina Pagel
- Clinical Operational Research Unit, University College London, London, UK
| | - Deborah Ridout
- Population, Policy and Practice Programme, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Jo Wray
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Victor T Tsang
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - David Anderson
- Departments of Paediatric Intensive Care, Cardiology and Cardiac Surgery, Evelina London Children’s Hospital, London, UK
| | - Victoria Banks
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - David J Barron
- Departments of Intensive Care and Paediatric Cardiac Surgery, Birmingham Children’s Hospital, Birmingham, UK
| | - Jane Cassidy
- Departments of Intensive Care and Paediatric Cardiac Surgery, Birmingham Children’s Hospital, Birmingham, UK
| | - Linda Chigaru
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Peter Davis
- Departments of Intensive Care and Paediatric Cardiac Surgery, Bristol Royal Hospital for Children, Bristol, UK
| | - Rodney Franklin
- Paediatric Cardiology Department, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Luca Grieco
- Clinical Operational Research Unit, University College London, London, UK
| | - Aparna Hoskote
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Emma Hudson
- Department of Applied Health Research, University College London, London, UK
| | - Alison Jones
- Departments of Intensive Care and Paediatric Cardiac Surgery, Birmingham Children’s Hospital, Birmingham, UK
| | - Suzan Kakat
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Rhian Lakhani
- Departments of Paediatric Intensive Care, Cardiology and Cardiac Surgery, Evelina London Children’s Hospital, London, UK
| | - Monica Lakhanpaul
- Population, Policy and Practice Programme, UCL Great Ormond Street Institute of Child Health, London, UK
- Community Child Health, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Andrew McLean
- Department of Intensive care, Royal Hospital for Children, Glasgow, UK
| | - Steve Morris
- Department of Applied Health Research, University College London, London, UK
| | - Veena Rajagopal
- Heart and Lung Division, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Warren Rodrigues
- Department of Intensive care, Royal Hospital for Children, Glasgow, UK
| | - Karen Sheehan
- Departments of Intensive Care and Paediatric Cardiac Surgery, Bristol Royal Hospital for Children, Bristol, UK
| | - Serban Stoica
- Departments of Intensive Care and Paediatric Cardiac Surgery, Bristol Royal Hospital for Children, Bristol, UK
| | - Shane Tibby
- Departments of Paediatric Intensive Care, Cardiology and Cardiac Surgery, Evelina London Children’s Hospital, London, UK
| | - Martin Utley
- Clinical Operational Research Unit, University College London, London, UK
| | - Thomas Witter
- Departments of Paediatric Intensive Care, Cardiology and Cardiac Surgery, Evelina London Children’s Hospital, London, UK
| |
Collapse
|
30
|
Tsintoni A, Dimitriou G, Karatza AA. Nutrition of neonates with congenital heart disease: existing evidence, conflicts and concerns. J Matern Fetal Neonatal Med 2020; 33:2487-2492. [PMID: 30608033 DOI: 10.1080/14767058.2018.1548602] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Introduction: Congenital heart disease is one of the most of the groups of congenital anomalies with an incidence of about 1 per 100 live births. Almost one-third of these infants require some type of intervention, usually in the first year of life and increasingly often in the neonatal period. Innovative reparative and palliative surgical procedures and advanced medical support in the Neonatal Intensive Care Unit have significantly reduced the mortality related to congenital heart disease. Achieving survival is not the only target of clinicians for these patients. Appropriate growth, development, and improved quality of life are also very important. Growth failure is a very common problem of these children and nutritional support and management are a challenge for health care providers. Early intervention and identification of at-risk patients have the potential to decrease morbidity and mortality related to malnutrition.Aim/methods: The purpose of this article is to analyze the existing evidence and common concerns about perioperative and postdischarge nutritional management of neonates with congenital heart disease based on the special issues or complications that may arise. Furthermore, we reviewed the recent literature about current practices and proposed policies that could prevent malnutrition and improve the outcomes of neonates with congenital heart disease.Results/conclusion: A standardized institutional protocol and clear guidelines referring to feeding initiation, prompt estimation of caloric needs and provision of adequate and appropriate nutrient intake is likely to benefit these patients. Clear definitions for the nutritional approach in the setting of medical complications and close assessment of growth by pediatricians and specialized nutritionists are crucial for the long-term outlook and quality of life of these infants.
Collapse
Affiliation(s)
- Asimina Tsintoni
- Department of Pediatrics, NICU, University of Patras Medical School, Patras, Greece
| | - Gabriel Dimitriou
- Department of Pediatrics, NICU, University of Patras Medical School, Patras, Greece
| | - Ageliki A Karatza
- Department of Pediatrics, NICU, University of Patras Medical School, Patras, Greece
| |
Collapse
|
31
|
Patterns of Growth and Nutrition From Birth to 6 Months in Infants With Complex Congenital Cardiac Defects. Nurs Res 2020; 69:S57-S65. [PMID: 32569101 DOI: 10.1097/nnr.0000000000000460] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Infants with complex congenital heart defects (CCHDs) experience alterations in growth that develop following surgical intervention and persist throughout early infancy, but the roles of nutritional intake and method of feeding require further exploration as their roles are not fully explained. OBJECTIVES The purpose of this study was to characterize trends in growth and nutritional intake during the first 6 months of life in infants with CCHD. METHODS We conducted a secondary analysis of growth and nutritional data from a pilot study designed to test the feasibility of nurse-guided participatory intervention with parents of infants with CCHD. Measures included demographic data, anthropometric data at birth, hospital discharge, and 6 months of age, nutritional intake at 2 and 6 months of age from parent-completed 24-hour nutrition diaries, and assessment of oral-motor skills between 1 and 2 months of age. Descriptive statistics and correlation and group differences were examined. RESULTS Data for 28 infants were analyzed. Infants demonstrated a decrease in weight-for-age z score (WAZ) and length-for-age z score (LAZ) from birth to hospital discharge and an increase in WAZ and LAZ by 6 months of age. Many of the infants developed failure to thrive. Across the study period, one third of the infants were receiving enteral nutrition. Infants who were orally fed had better growth WAZ and LAZ at 6 months of age when compared to infants who were enterally fed. DISCUSSION Infants with CCHD exhibit growth faltering throughout early infancy. Reliance on enteral nutrition did not improve growth outcomes in these infants. Findings suggest nutritional intake may not be enough to meet the nutrient requirements to stimulate catch-up growth.
Collapse
|
32
|
Laussen PC. Sharing and learning through the Pediatric Cardiac Critical Care Consortium: Moving toward precision care. J Thorac Cardiovasc Surg 2020; 161:2195-2199. [PMID: 32680641 PMCID: PMC7286268 DOI: 10.1016/j.jtcvs.2020.05.092] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/06/2020] [Accepted: 05/08/2020] [Indexed: 10/27/2022]
Affiliation(s)
- Peter C Laussen
- Department of Critical Care Medicine, Hospital for Sick Children, Toronto, Ontario, Canada; Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada.
| |
Collapse
|
33
|
Roebuck N, Fan CS, Floh A, Harris ZL, Mazwi ML. A Comparative Analysis of Equations to Estimate Patient Energy Requirements Following Cardiopulmonary Bypass for Correction of Congenital Heart Disease. JPEN J Parenter Enteral Nutr 2020; 44:444-453. [PMID: 31209916 PMCID: PMC7078809 DOI: 10.1002/jpen.1610] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 05/09/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND No consensus exists on the optimal method to estimate resting energy expenditure (REE) in critically ill children following cardiopulmonary bypass (CPB). This study assesses the accuracy of REE estimation equations in children with congenital heart disease following CPB and tests the feasibility of using allometric scaling as an alternative energy prediction equation. METHODS A retrospective analysis of a pediatric cohort following CPB (n = 107; median age 5.2 months, median weight 5.65 kg) who underwent serial measures (median 5 measurements) of REE using indirect calorimetry for 72 hours following CPB. We estimated REE using common estimation methods (Dietary Reference Intake, Harris Benedict, Schofield, World Health Organization [WHO]) as well as novel allometric equations. We compared estimated with measured REE to determine accuracy of each equation using overall discrepancy, calculated as a time-weighted average of the absolute deviation. RESULTS All equations incorrectly estimated REE at all time points following CPB, with overestimation error predominating. WHO had the lowest discrepancy at 10.7 ± 8.4 kcal/kg/d. The allometric equation was inferior, with an overall discrepancy of 16.9 ± 10.4. There is a strong nonlinear relationship between body surface area and measured REE in this cohort, which is a key source of estimation error using linear equations. CONCLUSION In a cohort of pediatric patients with congenital heart disease following CPB, no currently utilized clinical estimation equation reliably estimated REE. Allometric scaling proved inferior in estimating REE in children following CPB. Indirect calorimetry remains the ideal method of determining REE after CPB until nonlinear methods can be derived due to overestimation using linear equations.
Collapse
Affiliation(s)
- Natalie Roebuck
- Department of PediatricsDivision of Critical Care MedicineNorthwestern University Feinberg School of MedicineAnn & Robert H. Lurie Children's Hospital of ChicagoChicagoIllinoisUSA
| | - Chun‐Po Steve Fan
- Division of CardiologyThe Labatt Family Heart CentreThe Hospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada
| | - Alejandro Floh
- Department of Critical Care MedicineThe Labatt Family Heart CentreThe Hospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada
| | - Zena Leah Harris
- Department of PediatricsDivision of Critical Care MedicineNorthwestern University Feinberg School of MedicineAnn & Robert H. Lurie Children's Hospital of ChicagoChicagoIllinoisUSA
| | - Mjaye L. Mazwi
- Department of Critical Care MedicineThe Labatt Family Heart CentreThe Hospital for Sick ChildrenUniversity of TorontoTorontoOntarioCanada
| |
Collapse
|
34
|
Is a semi-elemental diet better than a polymeric diet after congenital heart surgery? Eur J Pediatr 2020; 179:423-430. [PMID: 31781932 DOI: 10.1007/s00431-019-03505-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 10/09/2019] [Accepted: 10/10/2019] [Indexed: 10/25/2022]
Abstract
A retrospective observational study has been set up in order to compare feeding tolerance and energy delivery in children fed with a semi-elemental diet or a polymeric diet after congenital heart surgery. The study took place in the intensive care unit of a tertiary children's hospital. One hundred children were included: 56 received a semi-elemental diet and 44 received a polymeric diet. Patients were aged between 2 days and 6 years. Data from patients were obtained from medical files between February 2014 and May 2016. The feeding protocol was changed in March 2015 when a semi-elemental diet was substituted for the polymeric diet. Primary outcome was the feeding tolerance. Feeding intolerance occurs if the patient has more than two episodes of emesis or more than four liquid stools per day. Feeding tolerance in the semi-elemental and polymeric diet groups was comparable: emesis occurred in 14.3% versus 6.8% of patients, respectively (p = 0.338); diarrhea occurred in 3.6% versus 4.5% (p = 1000); post-pyloric feeding was necessary in 14% versus 9% (p = 0.542). Energy delivery was also comparable in the two groups: on postoperative day 2, the semi-elemental diet group reached 50% of the caloric target versus 52% in the polymeric diet group (p = 0.283); on day 5, 76% versus 85% (p = 0.429); and on day 10, 105% versus 125% (p = 0.397). Energy delivery was insufficient on postoperative days 2 and 5, but nutritional goals were achieved by day 10. No patient developed necrotizing enterocolitis in our population.Conclusion: the present study suggests that the feeding tolerance to a semi-elemental or a polymeric diet is similar after CHS.What is Known:•Nutrition can modify prognosis in PICU•Different types of diet have been tested in children with intestinal disorders or with congenital heart disease. None of these diets have shown to be superior in terms of feeding tolerance.What is New:•Semi elemental and polymeric diets seem to have the same feeding tolerance in PICU after cardiac surgery for congenital heart disease.
Collapse
|
35
|
Watson JD, Urban TT, Tong SS, Zenge J, Khailova L, Wischmeyer PE, Davidson JA. Immediate Post-operative Enterocyte Injury, as Determined by Increased Circulating Intestinal Fatty Acid Binding Protein, Is Associated With Subsequent Development of Necrotizing Enterocolitis After Infant Cardiothoracic Surgery. Front Pediatr 2020; 8:267. [PMID: 32537446 PMCID: PMC7267022 DOI: 10.3389/fped.2020.00267] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 04/28/2020] [Indexed: 12/13/2022] Open
Abstract
Objectives: 1 Measure serial serum intestinal fatty acid binding protein levels in infants undergoing cardiac surgery with cardiopulmonary bypass to evaluate for evidence of early post-operative enterocyte injury. 2 Determine the association between immediate post-operative circulating intestinal fatty acid binding protein levels and subsequent development of necrotizing enterocolitis. Design: Observational cohort study. Intestinal fatty acid binding protein was measured pre-operatively, at rewarming, and at 6 and 24 h post-operatively. Percent of goal enteral kilocalories on post-operative day 5 and episodes of necrotizing enterocolitis were determined. Multivariable analysis assessed for factors independently associated with clinical feeding outcomes and suspected/definite necrotizing enterocolitis. Setting: Quaternary free-standing children's hospital pediatric cardiac intensive care unit. Patients: 103 infants <120 days of age undergoing cardiothoracic surgery with cardiopulmonary bypass. Interventions: None. Results: Median pre-operative intestinal fatty acid binding protein level was 3.93 ng/ml (range 0.24-51.32). Intestinal fatty acid binding protein levels rose significantly at rewarming (6.35 ng/ml; range 0.54-56.97; p = 0.008), continued to rise slightly by 6 h (6.57 ng/ml; range 0.75-112.04; p = 0.016), then decreased by 24 h (2.79 ng/ml; range 0.03-81.74; p < 0.0001). Sixteen subjects (15.7%) developed modified Bell criteria Stage 1 necrotizing enterocolitis and 9 subjects (8.8%) developed Stage 2 necrotizing enterocolitis. Infants who developed necrotizing enterocolitis demonstrated a significantly higher distribution of intestinal fatty acid binding protein levels at both 6 h (p = 0.005) and 24 h (p = 0.005) post-operatively. On multivariable analysis, intestinal fatty acid binding protein was not associated with percentage of goal enteral kilocalories delivered on post-operative day 5. Higher intestinal fatty acid binding protein was independently associated with subsequent development of suspected/definite necrotizing enterocolitis (4% increase in odds of developing necrotizing enterocolitis for each unit increase in intestinal fatty acid binding protein; p = 0.0015). Conclusions: Intestinal fatty acid binding protein levels rise following infant cardiopulmonary bypass, indicating early post-operative enterocyte injury. Intestinal fatty acid binding protein was not associated with percent of goal enteral nutrition achieved on post-operative day 5, likely due to protocolized feeding advancement based on clinically observable factors. Higher intestinal fatty acid binding protein at 6 h post-operatively was independently associated with subsequent development of necrotizing enterocolitis and may help identify patients at risk for this important complication.
Collapse
Affiliation(s)
- John D Watson
- Department of Pediatrics, University of Colorado, Aurora, CO, United States
| | - Tracy T Urban
- Research Institute, Children's Hospital Colorado, Aurora, CO, United States
| | - Suhong S Tong
- Department of Biostatistics, Children's Hospital Colorado/University of Colorado, Aurora, CO, United States
| | - Jeanne Zenge
- Department of Pediatrics, University of Colorado, Aurora, CO, United States
| | - Ludmilla Khailova
- Department of Pediatrics, University of Colorado, Aurora, CO, United States
| | - Paul E Wischmeyer
- Duke University Department of Anesthesiology, Durham, NC, United States
| | - Jesse A Davidson
- Department of Pediatrics, University of Colorado, Aurora, CO, United States
| |
Collapse
|
36
|
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.
Collapse
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
| |
Collapse
|
37
|
Kurtz JD, Chowdhury SM, Woodard FK, Strelow JR, Zyblewski SC. Factors Associated with Delayed Transition to Oral Feeding in Infants with Single Ventricle Physiology. J Pediatr 2019; 211:134-138. [PMID: 30952511 PMCID: PMC7161424 DOI: 10.1016/j.jpeds.2019.02.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 02/20/2019] [Accepted: 02/22/2019] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To describe the duration of time to achieve exclusive oral feeding in infants with single ventricle physiology and to identify risk factors associated with prolonged gastrostomy tube dependence. STUDY DESIGN Single center, retrospective study of infants with single ventricle physiology. The primary outcome was duration of time required to achieve oral feeding. Transition periods were defined as exclusive oral feeding by Glenn palliation (early), by 1 year of age (mid), or after 1 year of age (late). RESULTS Seventy-eight infants were analyzed; 46 (59%) were discharged to home with a gastrostomy tube after the initial hospitalization. Overall, 39 infants (50%) achieved early transition, 14 (18%) mid, and 18 (23%) late. The group who achieved early transition had a higher percentage of preoperative oral feeding (P < .01), greater weight-for-age z score at initial discharge (P = .03), shorter initial intensive care unit duration (P < .01), shorter initial hospital length of stay (P < .01), and greater weight-for-age z score at Glenn admission (P = .02). No preoperative oral feeding (OR = 0.12, P = .02) and greater number of cardiac medications at initial discharge (OR = 3.8, P = .03) were associated with failure to achieve early transition. No preoperative oral feeding (OR = 0.09, P = .01) and longer initial intensive care unit duration (OR = 1.1, P = .03) were associated with failure to achieve mid transition. CONCLUSION Preoperative oral feeding may potentially be a modifiable factor to help improve early transition to oral feeding.
Collapse
|
38
|
Abstract
Dysphagia and vocal cord dysfunction are frequent complications after congenital heart surgery. Both are risk factors for aspiration, which can lead to pneumonia, progressive lung disease, and respiratory arrest. A protocol was implemented to promote early detection of aspiration in a high-risk cohort of patients. Retrospective data were collected on all patients under 120 days old who underwent the Norwood procedure, aortic arch repair, Blalock-Taussig shunt placement, or cervical cannulation for extracorporeal membrane oxygenation from 10/2012 to 05/2016 at a single institution. Patients underwent an assessment of symptoms, fiberoptic endoscopic evaluation of swallowing (FEES), and modified barium swallow (MBS) study in the postoperative period prior to initiating oral feeds. Patients with and without aspiration were compared. Of the 96 patients included in the study, one-third (33%) of patients had evidence of vocal cord dysfunction by FEES and just over half (51%) had evidence of aspiration by FEES or MBS. Most (73%) of the patients with aspiration were asymptomatic and a majority (53%) of patients with aspiration had normal vocal cord function. Aspiration is common after congenital heart surgery, and an assessment of vocal cord or swallow function in isolation may lead to underdiagnosis. A comprehensive protocol including MBS and FEES is necessary for the early detection of vocal cord dysfunction and aspiration and may prevent adverse outcomes in high-risk postoperative patients.
Collapse
|
39
|
Abstract
Malnutrition occurs when nutrient intake does not meet the needs for normal body functions and as a consequence leads to alterations of growth and development in children. Chronic illness puts children at risk for developing malnutrition. Because of children's rapid periods of growth and development, early diagnosis, prevention, and management of malnutrition are paramount. The reasons for malnutrition in children with chronic disease are multifactorial and are related to the underlying disease and non-illness-associated factors. This review addresses the causes, evaluation, and management of malnutrition in pediatric congenital heart disease, chronic kidney disease, liver disease, and cystic fibrosis.
Collapse
Affiliation(s)
- Catherine Larson-Nath
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota, USA
| | - Praveen Goday
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| |
Collapse
|
40
|
Justice L, Buckley JR, Floh A, Horsley M, Alten J, Anand V, Schwartz SM. Nutrition Considerations in the Pediatric Cardiac Intensive Care Unit Patient. World J Pediatr Congenit Heart Surg 2018; 9:333-343. [PMID: 29692230 DOI: 10.1177/2150135118765881] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Adequate caloric intake plays a vital role in the course of illness and the recovery of critically ill patients. Nutritional status and nutrient delivery during critical illness have been linked to clinical outcomes such as mortality, incidence of infection, and length of stay. However, feeding practices with critically ill pediatric patients after cardiac surgery are variable. The Pediatric Cardiac Intensive Care Society sought to provide an expert review on provision of nutrition to pediatric cardiac intensive care patients, including caloric requirements, practical considerations for providing nutrition, safety of enteral nutrition in controversial populations, feeding considerations with chylothorax, and the benefits of feeding beyond nutrition. This article addresses these areas of concern and controversy.
Collapse
Affiliation(s)
- Lindsey Justice
- 1 The Heart Institute, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | | | - Alejandro Floh
- 3 The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| | - Megan Horsley
- 1 The Heart Institute, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Jeffrey Alten
- 1 The Heart Institute, Cincinnati Children's Hospital, Cincinnati, OH, USA
| | - Vijay Anand
- 4 Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada.,5 Pediatric Cardiac Intensive Care Unit, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Steven M Schwartz
- 3 The Hospital for Sick Children and the University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
41
|
Furlong-Dillard J, Neary A, Marietta J, Jones C, Jeffers G, Gakenheimer L, Puchalski M, Eckauser A, Delgado-Corcoran C. Evaluating the Impact of a Feeding Protocol in Neonates before and after Biventricular Cardiac Surgery. Pediatr Qual Saf 2018; 3:e080. [PMID: 30229192 PMCID: PMC6132815 DOI: 10.1097/pq9.0000000000000080] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 04/02/2018] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION Feeding difficulties and malnutrition are important challenges when caring for newborns with critical congenital heart disease (CCHD) without clear available guidelines for providers. This study describes the utilization of a feeding protocol with the focus on standardization, feeding modality, and total parenteral nutrition (TPN) utilization postoperatively. METHODS Patients included neonates with CCHD undergoing complex biventricular repair using cardiopulmonary bypass. Data were collected in 2013 preintervention and from 2015 to 2017 postintervention. The feeding protocol outlined guidelines for and postoperative use of TPN. Adverse outcomes data included rates of central line-associated bloodstream infections, necrotizing enterocolitis, chylothorax, and vocal cord dysfunction. Balance outcomes measured were weight for age Z-score at discharge, number of abdominal radiographs obtained, readmission within 90 days, and central venous line utilization. RESULTS We included a total of 121 neonates: 49 in the preintervention group and 72 in the postintervention group. The protocol standardized feeding practices in CCHD neonates undergoing surgery with improved compliance from 70% early in the study period to 90% at the end of the study. Infants were fed enterally more preoperatively (86% versus 67%; P = 0.023), reached a fluid goal sooner (63 hours versus 72 hours; P = 0.035), and postoperative duration of TPN usage was significantly shorter in the postintervention period (48 hours versus 62 hours; P = 0.041) with no increase in adverse outcome events or unintended consequences. CONCLUSIONS By implementing a feeding protocol, we reduced practice variation among providers, increased the number of patients fed enterally preoperatively and reduced postoperative use of TPN without increased complications.
Collapse
Affiliation(s)
- Jamie Furlong-Dillard
- From the Division of Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Alaina Neary
- Primary Children’s Hospital, Intermountain Healthcare, Salt Lake City, Utah
| | - Jennifer Marietta
- Primary Children’s Hospital, Intermountain Healthcare, Salt Lake City, Utah
| | - Courtney Jones
- Primary Children’s Hospital, Intermountain Healthcare, Salt Lake City, Utah
| | - Grace Jeffers
- Primary Children’s Hospital, Intermountain Healthcare, Salt Lake City, Utah
| | - Lindsey Gakenheimer
- Pediatrics Residency, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Michael Puchalski
- Division of Pediatric Cardiology, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Aaron Eckauser
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah, Salt Lake City, Utah
| | - Claudia Delgado-Corcoran
- From the Division of Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| |
Collapse
|
42
|
Horsley M, Trauth A, Cooper DS. Food fight: Perhaps there is a benefit to being fat and happy. J Thorac Cardiovasc Surg 2018. [PMID: 29530570 DOI: 10.1016/j.jtcvs.2018.01.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Megan Horsley
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Amiee Trauth
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - David S Cooper
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| |
Collapse
|
43
|
Feast and Famine: Nutrition and Fluid Restriction After Infant Cardiac Surgery. Pediatr Crit Care Med 2018; 19:168-169. [PMID: 29394227 DOI: 10.1097/pcc.0000000000001418] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
44
|
Piggott KD, Liu A, Monczka J, Fakioglu H, Narasimhulu SS, Pourmoghadam K, DeCampli W. Inadequate preoperative nutrition might be associated with acute kidney injury and greater illness severity postoperatively. J Thorac Cardiovasc Surg 2017; 155:2104-2109. [PMID: 29366566 DOI: 10.1016/j.jtcvs.2017.12.080] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Revised: 12/10/2017] [Accepted: 12/16/2017] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Nutrition is vital for maintaining optimal cellular and organ function, particularly in neonates who undergo cardiac surgery. Achieving nutritional goals preoperatively can be challenging because of fluid restrictions, suboptimal oral intake, and concerns for inadequate gastrointestinal circulation. We examined preoperative caloric intake and its effects on postoperative course in neonates who underwent cardiac surgery. METHODS We retrospectively reviewed records of neonates (younger than 30 days) who underwent congenital heart surgery requiring cardiopulmonary bypass from 2008 to 2014 at Arnold Palmer Hospital for Children. Data on multiple nutritional and postoperative variables were collected. Study outcomes included hospital length of stay, duration of mechanical ventilation, and acute kidney injury (AKI). RESULTS Records of 95 neonates were reviewed. Sixty-six patients (69.5%) with a median age of 5 days did not achieve preoperative caloric goal, whereas 29 patients (30.5%) with a median age of 11 days did. Of those who achieved caloric goal, 6 (20.6%) achieved it via total parental nutrition, 9 (31.1%) with a combination of total parental nutrition and enteral feeds, and 14 (48.3%) via enteral route. There was a significant difference in peak lactate (P = .002), inotropic score (P = .02), and duration of mechanical ventilation (P = .013) between those who did and did not achieve caloric goal. In multivariable analysis we found that failure to achieve caloric goal preoperatively was independently associated with stage 2 or 3 AKI (P = .04; odds ratio, 4.48; 95% confidence interval, 1.02-19.63) and younger age at the time of surgery (P < .001; odds ratio, 0.12; 95% confidence interval, 0.04-0.33). CONCLUSIONS Failure to achieve preoperative caloric goal might contribute to development of AKI and might be associated with greater severity of illness postoperatively.
Collapse
Affiliation(s)
- Kurt D Piggott
- Pediatric Cardiac Intensive Care, Arnold Palmer Hospital for Children, Orlando, Fla; University of Central Florida College of Medicine, Orlando, Fla.
| | - Anne Liu
- University of Central Florida College of Medicine, Orlando, Fla
| | - Jessica Monczka
- Pediatric Cardiac Nutrition, Arnold Palmer Hospital for Children, Orlando, Fla
| | - Harun Fakioglu
- Pediatric Cardiac Intensive Care, Arnold Palmer Hospital for Children, Orlando, Fla; University of Central Florida College of Medicine, Orlando, Fla
| | - Sukumar Suguna Narasimhulu
- Pediatric Cardiac Intensive Care, Arnold Palmer Hospital for Children, Orlando, Fla; University of Central Florida College of Medicine, Orlando, Fla
| | - Kamal Pourmoghadam
- University of Central Florida College of Medicine, Orlando, Fla; Pediatric Cardiothoracic Surgery, Arnold Palmer Hospital for Children, Orlando, Fla
| | - William DeCampli
- University of Central Florida College of Medicine, Orlando, Fla; Pediatric Cardiothoracic Surgery, Arnold Palmer Hospital for Children, Orlando, Fla
| |
Collapse
|
45
|
Scahill CJ, Graham EM, Atz AM, Bradley SM, Kavarana MN, Zyblewski SC. Preoperative Feeding Neonates With Cardiac Disease. World J Pediatr Congenit Heart Surg 2017; 8:62-68. [PMID: 28033074 DOI: 10.1177/2150135116668833] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The potential for necrotizing enterocolitis (NEC) in neonates requiring cardiac surgery has contributed largely to wide feeding practice variations and a hesitation to initiate enteral feeding during the preoperative period, specifically those patients with hypoplastic left heart syndrome. METHODS A retrospective chart review of neonates undergoing cardiac surgery at a single institution between July 2011 and July 2013 was performed. The primary objective of this study was to determine if preoperative feeding was associated with NEC in neonates requiring cardiac surgery. Univariable and multivariable analyses were performed to evaluate the relationship between preoperative feeding and NEC. Secondary outcomes including growth failure, total ventilator days, total length of stay, and tube-assisted feeds at discharge were analyzed. RESULTS One hundred thirty consecutive neonates who required cardiac surgery were included in the analysis. Preoperative feeding occurred in 61% (n = 79). The overall prevalence of NEC was 9% (12/130), including three neonates with surgical NEC. There was no difference in the prevalence of NEC between the preoperative feeding and nil per os (NPO) groups. Preoperative NPO status was associated with longer ventilator-dependent days ( P = .01) but was not associated with worsened growth failure, longer length of stay, or increased prevalence of tube-assisted feeds at discharge. CONCLUSION In this study cohort, preoperative feeding was associated with a low prevalence of NEC. Larger prospective studies evaluating the safety and benefits of preoperative feeding in cardiac neonates are warranted.
Collapse
Affiliation(s)
- Carly J Scahill
- 1 Department of Pediatrics, The Heart Institute, Children's Hospital Colorado, Aurora, CO, USA
| | - Eric M Graham
- 2 Division of Pediatric Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Andrew M Atz
- 2 Division of Pediatric Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Scott M Bradley
- 3 Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Minoo N Kavarana
- 3 Division of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Sinai C Zyblewski
- 2 Division of Pediatric Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| |
Collapse
|