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Jangid V, Yadav DK, Bhatt DD. Weight gain in infants with congenital heart disease; breastfeeding alone versus supplemental spoon-feeding of expressed breast milk: an open-label, pilot, randomised control trial. Cardiol Young 2024:1-6. [PMID: 38577777 DOI: 10.1017/s1047951124000635] [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: 04/06/2024]
Abstract
OBJECTIVES Infants with congenital heart disease and increased pulmonary blood flow frequently suffer from feeding difficulties and growth failure. Providing expressed breast milk by spoon has been hypothesised to decrease energy expenditure in these infants as compared to breastfeeding. This study assessed the effect of supplemental feeding of expressed breast milk on weight gain in infants with unoperated congenital heart disease. METHOD This was a prospective open-label randomised control trial. In total, 50 infants with post tricuspid left to right shunt were enrolled in the study. In the intervention group, apart from breastfeeding, a minimum predetermined volume of expressed breast milk was targeted to be given by spoon. 30-50 kcal/kg/day was given by expressed breast milk by spoon-feeding. In the control group, the infants were given at least 8 feeds per 24 hours by direct breastfeeding. Both groups were followed up for 1 month and assessed for weight gain. RESULT Despite a high rate of protocol breach in both groups (30% overall), infants in the intervention group had better weight gain at one-month follow-up compared to those in the control group, 780 ± 300 versus 530 ± 250 gm (p = 0.01). CONCLUSION In infants with left to right shunts, supplemental feeding of expressed breast milk by spoon along with breastfeeding resulted in significantly higher average weight gain at 30 days compared to the control group who received breastfeeding alone. Future studies with larger sample sizes and longer follow-ups need to be done to confirm the findings of this study.
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Affiliation(s)
- Varsha Jangid
- Department of Pediatrics, ABVIMS and Dr RML Hospital, New Delhi, DL, India
| | - Dinesh Kumar Yadav
- Department of Pediatrics, ABVIMS and Dr RML Hospital, New Delhi, DL, India
| | - Dheeraj Deo Bhatt
- Department of Pediatrics, ABVIMS and Dr RML Hospital, New Delhi, DL, India
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Murray SE, Zimmerman D, Patel SS. Preoperative Feeding Fortification Among Infants with Congenital Heart Disease is Associated with Higher Growth Velocity in the First 30 Days Post-repair and Lower BMI Percentile for Age at 10 Years: A Retrospective Cohort Study. Pediatr Cardiol 2024:10.1007/s00246-024-03433-9. [PMID: 38451285 DOI: 10.1007/s00246-024-03433-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 01/25/2024] [Indexed: 03/08/2024]
Abstract
It remains unclear how preoperative nutrition fortification impacts postoperative growth trajectories and nutritional status among infants with congenital heart disease. A single center retrospective cohort study was performed to evaluate measures of growth among patients who underwent cardiac repair at 0-18 months of age for atrial septal defect, ventricular septal defect, atrioventricular septal defect, or tetralogy of Fallot. Cohorts were analyzed at 0-30 and 31-60 days post-repair as well as at 2, 5, and 10 years of age. Records of 24 patients who received fortified nutrition and 60 patients who received unfortified nutrition preoperatively were reviewed. Those with fortified nutrition had higher growth velocities in the first 30 days post-repair compared to those with unfortified nutrition: 28.4 (23.8-83.3) grams per day versus 16.7 (7.1-21.4) grams per day, p = 0.004. Weight percentile for age was higher in the unfortified group at 2, 5, and 10 years of age (p = 0.02, p = 0.045, and p = 0.01). Body mass index (BMI) percentile for age was higher in the unfortified group at 5 and 10 years of age (p = 0.045 and p = 0.02) with a trend toward higher prevalence of either overweight or obesity compared to the fortified group (p = 0.13). reoperative nutrition fortification among infants with congenital heart disease is associated with higher growth velocity in the first 30 days post-repair and lower BMI percentile for age at 10 years. Further studies are needed to evaluate the association between preoperative nutrition fortification and postoperative outcomes, nutritional status, and prevalence of obesity in adolescence and adulthood.
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Affiliation(s)
- Shannon E Murray
- Department of Pediatric Cardiology, University of Colorado, Aurora, CO, USA
| | - Dayna Zimmerman
- Department of Pediatric Cardiology, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Sonali S Patel
- Department of Pediatric Cardiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, USA.
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3
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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.
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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
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4
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Lisanti AJ, Vittner DJ, Peterson J, Van Bergen AH, Miller TA, Gordon EE, Negrin KA, Desai H, Willette S, Jones MB, Caprarola SD, Jones AJ, Helman SM, Smith J, Anton CM, Bear LM, Malik L, Russell SK, Mieczkowski DJ, Hamilton BO, McCoy M, Feldman Y, Steltzer M, Savoca ML, Spatz DL, Butler SC. Developmental care pathway for hospitalised infants with CHD: on behalf of the Cardiac Newborn Neuroprotective Network, a Special Interest Group of the Cardiac Neurodevelopmental Outcome Collaborative. Cardiol Young 2023; 33:2521-2538. [PMID: 36994672 PMCID: PMC10544686 DOI: 10.1017/s1047951123000525] [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: 03/31/2023]
Abstract
Infants and children born with CHD are at significant risk for neurodevelopmental delays and abnormalities. Individualised developmental care is widely recognised as best practice to support early neurodevelopment for medically fragile infants born premature or requiring surgical intervention after birth. However, wide variability in clinical practice is consistently demonstrated in units caring for infants with CHD. The Cardiac Newborn Neuroprotective Network, a Special Interest Group of the Cardiac Neurodevelopmental Outcome Collaborative, formed a working group of experts to create an evidence-based developmental care pathway to guide clinical practice in hospital settings caring for infants with CHD. The clinical pathway, "Developmental Care Pathway for Hospitalized Infants with Congenital Heart Disease," includes recommendations for standardised developmental assessment, parent mental health screening, and the implementation of a daily developmental care bundle, which incorporates individualised assessments and interventions tailored to meet the needs of this unique infant population and their families. Hospitals caring for infants with CHD are encouraged to adopt this developmental care pathway and track metrics and outcomes using a quality improvement framework.
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Affiliation(s)
- Amy J. Lisanti
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA, Research Institute, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Dorothy J. Vittner
- Egan School of Nursing and Health Studies, Fairfield University Fairfield, CT, USA, Connecticut Children’s, Hartford, CT, USA
| | | | - Andrew H. Van Bergen
- Advocate Children’s Heart Institute, Advocate Children’s Hospital, Oak Lawn, IL, USA
| | - Thomas A. Miller
- Department of Pediatrics, Maine Medical Center, Portland, ME, USA
| | - Erin E. Gordon
- DO, Inpatient Cardiac Neurodevelopment Program, Division of Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Karli A Negrin
- Department of Therapeutic and Rehabilitative Services, Nemours Children Hospital, Wilmington, Delaware, USA
| | - Hema Desai
- Rehabilitation Services, CHOC Children’s Hospital, Orange, CA, USA
| | - Suzie Willette
- Department of Speech-Language Pathology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
| | - Melissa B Jones
- Cardiac Critical Care, Children’s National Hospital, Washington DC USA
| | - Sherrill D. Caprarola
- Heart Institute, Children’s Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Anna J. Jones
- Office of Advanced Practice Providers, UT Southwestern Medical Center, Dallas, TX, USA, Heart Center, Children’s Health, Dallas, TX, USA
| | - Stephanie M. Helman
- Department of Acute and Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, PA, USA
| | - Jodi Smith
- Parent Representative, The Mended Hearts, Inc., Program Director, Richmond, VA, USA
| | - Corinne M. Anton
- Department of Psychology and Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, USA, Department of Cardiology, Children’s Health, Dallas, Texas, USA
| | - Laurel M. Bear
- Department of Pediatrics, Medical College of Wisconsin, Children’s Wisconsin, Milwaukee, WI, USA
| | - Lauren Malik
- Department of Acute Care Therapy Services, Primary Children’s Hospital, Salt Lake City, UT, USA
| | - Sarah K. Russell
- Department of Therapeutic and Rehabilitative Services, Nemours Children Hospital, Wilmington, DE, USA
| | - Dana J. Mieczkowski
- Department of Therapeutic and Rehabilitative Services, Nemours Children Hospital, Wilmington, DE, USA
| | - Bridy O. Hamilton
- Department of Therapeutic and Rehabilitative Services, Nemours Children Hospital, Wilmington, Delaware, USA
| | - Meghan McCoy
- Pediatric and Congenital Heart Center, Duke University Hospital, Durham, NC, USA
| | - Yvette Feldman
- Nursing & Patient Care Center of Excellence, St. Luke’s Health System, Boise, ID, USA
| | - Michelle Steltzer
- Single Ventricle Center of Excellence, Ann & Robert H. Lurie Children’s Hospital, Chicago, IL, USA
| | - Melanie L Savoca
- Department of Clinical Nutrition, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Diane L. Spatz
- Department of Family & Community Health, University of Pennsylvania School of Nursing, The Center for Pediatric Nursing Research and Evidence Based Practice, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Samantha C. Butler
- Department of Psychiatry (Psychology), Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
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5
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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.
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Affiliation(s)
| | | | | | - Lynn R Tanner
- School of Nursing, University of Minnesota, Minneapolis, MN, USA
- Children's Minnesota, Minneapolis, MN, USA
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6
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Kjeldsen CP, Emery L, Simsic J, He Z, Stark AR, Neel ML, Maitre NL. Contingent Mother's Voice Intervention Targeting Feeding in Hospitalized Infants with Critical Congenital Heart Defects. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1642. [PMID: 37892305 PMCID: PMC10605591 DOI: 10.3390/children10101642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 09/28/2023] [Accepted: 09/29/2023] [Indexed: 10/29/2023]
Abstract
Infants with critical congenital heart defects (CCHD) are at high risk for feeding challenges and neurodevelopmental delays; however, few interventions promoting the neurodevelopmental progression of feeding have been studied with this population. Contingent mother's voice has been successfully used as positive reinforcement for non-nutritive suck (NNS) in studies with preterm infants, leading to improved weight gain and more rapid cessation of tube feedings; however, this type of intervention has not been studied in infants with CCHD. This study aimed to determine whether an NNS-training protocol using the mother's voice as positive reinforcement and validated in preterm infants could improve oral feeding outcomes in hospitalized infants with CCHD undergoing cardiac surgical procedures. Infants were randomized to receive the contingent mother's voice intervention before or after cardiac surgery, with a control comparison group receiving passive exposure to the mother's voice after surgery. There were no significant differences in discharge weight, PO intake, length of stay, time to full feeds, or feeding status at 1-month post-discharge between infants who received contingent mother's voice compared to those who did not. There were significant differences in PO intake and time to full feeds following surgery based on infants' pre-enrollment PO status and severity of illness. At 1-month post-discharge, parents of infants in the intervention group expressed a higher rate of positive feelings and fewer concerns regarding their infant's feeding compared to parents of infants in the control group. While the current protocol of 5 sessions was not associated with improved feeding outcomes in infants with CCHD, it empowered parents to contribute to their infant's care and demonstrated the feasibility of using the mother's voice as positive reinforcement for infants with CCHD. Further study of timing, intensity, and duration of interventions leveraging the mother's voice in this population is needed. ClinicalTrials.gov Identifier: NCT03035552.
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Affiliation(s)
- Caitlin P. Kjeldsen
- Department of Speech and Hearing Science, The Ohio State University, Columbus, OH 43210, USA;
- School of Medicine and Children’s Healthcare of Atlanta, Emory University, Atlanta, GA 30306, USA
| | - Lelia Emery
- Nationwide Children’s Hospital, Columbus, OH 43205, USA
| | - Janet Simsic
- Nationwide Children’s Hospital, Columbus, OH 43205, USA
| | - Zhulin He
- School of Medicine and Children’s Healthcare of Atlanta, Emory University, Atlanta, GA 30306, USA
| | - Ann R. Stark
- Beth Israel Deaconess Medical Center, Department of Neonatology, Boston, MA 02215, USA
| | - Mary Lauren Neel
- School of Medicine and Children’s Healthcare of Atlanta, Emory University, Atlanta, GA 30306, USA
| | - Nathalie L. Maitre
- School of Medicine and Children’s Healthcare of Atlanta, Emory University, Atlanta, GA 30306, USA
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Elgersma KM, Wolfson J, Fulkerson JA, Georgieff MK, Looman WS, Spatz DL, Shah KM, Uzark K, McKechnie AC. Human Milk Feeding and Direct Breastfeeding Improve Outcomes for Infants With Single Ventricle Congenital Heart Disease: Propensity Score-Matched Analysis of the NPC-QIC Registry. J Am Heart Assoc 2023; 12:e030756. [PMID: 37642030 PMCID: PMC10547322 DOI: 10.1161/jaha.123.030756] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 07/28/2023] [Indexed: 08/31/2023]
Abstract
Background Infants with single ventricle congenital heart disease undergo 3 staged surgeries/interventions, with risk for morbidity and mortality. We estimated the effect of human milk (HM) and direct breastfeeding on outcomes including necrotizing enterocolitis, infection-related complications, length of stay, and mortality. Methods and Results We analyzed the National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC) registry (2016-2021), examining HM/breastfeeding groups during stage 1 and stage 2 palliations. We calculated propensity scores for feeding exposures, then fitted Poisson and logistic regression models to compare outcomes between propensity-matched cohorts. Participants included 2491 infants (68 sites). Estimates for all outcomes were better in HM/breastfeeding groups. Infants fed exclusive HM before stage 1 palliation (S1P) had lower odds of preoperative necrotizing enterocolitis (odds ratio [OR], 0.37 [95% CI, 0.17-0.84]; P=0.017) and shorter S1P length of stay (rate ratio [RR], 0.87 [95% CI, 0.78-0.98]; P=0.027). During the S1P hospitalization, infants with high HM had lower odds of postoperative necrotizing enterocolitis (OR, 0.28 [95% CI, 0.15-0.50]; P<0.001) and sepsis (OR, 0.29 [95% CI, 0.13-0.65]; P=0.003), and shorter S1P length of stay (RR, 0.75 [95% CI, 0.66-0.86]; P<0.001). At stage 2 palliation, infants with any HM (RR, 0.82 [95% CI, 0.69-0.97]; P=0.018) and any breastfeeding (RR, 0.71 [95% CI, 0.57-0.89]; P=0.003) experienced shorter length of stay. Conclusions Infants with single ventricle congenital heart disease in high-HM and breastfeeding groups experienced multiple significantly better outcomes. Given our findings of improved health, strategies to increase the rates of HM/breastfeeding in these patients should be implemented. Future research should replicate these findings with granular feeding data and in broader congenital heart disease populations, and should examine mechanisms (eg, HM components, microbiome) by which HM/breastfeeding benefits these infants.
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Affiliation(s)
| | - Julian Wolfson
- Division of BiostatisticsUniversity of Minnesota School of Public HealthMinneapolisMNUSA
| | - Jayne A. Fulkerson
- University of Minnesota School of NursingMinneapolisMNUSA
- Division of EpidemiologyUniversity of Minnesota School of Public HealthMinneapolisMNUSA
| | - Michael K. Georgieff
- Department of PediatricsUniversity of Minnesota Medical SchoolMinneapolisMNUSA
- M Health Fairview University of Minnesota Masonic Children’s HospitalMinneapolisMNUSA
| | | | - Diane L. Spatz
- University of Pennsylvania School of NursingPhiladelphiaPAUSA
- Children’s Hospital of PhiladelphiaPhiladelphiaPAUSA
| | - Kavisha M. Shah
- Department of PediatricsUniversity of Minnesota Medical SchoolMinneapolisMNUSA
- M Health Fairview University of Minnesota Masonic Children’s HospitalMinneapolisMNUSA
| | - Karen Uzark
- Division of Cardiac SurgeryUniversity of Michigan Medical SchoolAnn ArborMIUSA
- C. S. Mott Children’s HospitalAnn ArborMIUSA
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8
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Elgersma KM, Wolfson J, Fulkerson JA, Georgieff MK, Looman WS, Spatz DL, Shah KM, Uzark K, McKechnie AC. Human milk feeding and direct breastfeeding improve outcomes for infants with single ventricle congenital heart disease: Propensity score matched analysis of the NPC-QIC registry. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.04.26.23289126. [PMID: 37162951 PMCID: PMC10168482 DOI: 10.1101/2023.04.26.23289126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
Background Infants with single ventricle (SV) congenital heart disease (CHD) undergo three staged surgeries/interventions, with risk for morbidity and mortality. We estimated the effect of human milk (HM) and direct breastfeeding (BF) on outcomes including necrotizing enterocolitis (NEC), infection-related complications, length of stay (LOS), and mortality. Methods We analyzed the National Pediatric Cardiology Quality Improvement Collaborative registry (2016-2021), examining HM/BF groups during stage 1 (S1P) and stage 2 (S2P) palliations. We calculated propensity scores for feeding exposures, then fitted Poisson and logistic regression models to compare outcomes between propensity-matched cohorts. Results Participants included 2491 infants (68 sites). Estimates for all outcomes were better in HM/BF groups. Infants fed exclusive HM before S1P had lower odds of preoperative NEC (OR=0.37, 95% CI=0.17-0.84, p=0.017) and shorter S1P LOS (RR=0.87, 0.78-0.98, p=0.027). During the S1P hospitalization, infants with high HM had lower odds of postoperative NEC (OR=0.28, 0.15-0.50, p<0.001) and sepsis (0.29, 0.13-0.65, p=0.003), and shorter S1P LOS (RR=0.75, 0.66-0.86, p<0.001). At S2P, infants with any HM (0.82, 0.69-0.97, p=0.018) and any BF (0.71, 0.57-0.89, p=0.003) experienced shorter LOS. Conclusions Infants with SV CHD in high HM and BF groups experienced multiple significantly better outcomes. Given our findings of improved health, strategies to increase the rates of HM/BF in these patients should be implemented. Future research should replicate these findings with granular feeding data and in broader CHD populations, and should examine mechanisms (eg, HM components; microbiome) by which HM/BF benefits these infants. Clinical Perspective What is new?: This is the first large, multisite study examining the impact of human milk and breastfeeding on outcomes for infants with single ventricle congenital heart disease.All outcome estimates were better in high human milk and breastfeeding groups, with significantly lower odds of necrotizing enterocolitis, sepsis, and infection-related complications; and significantly shorter length of stay at both the neonatal stage 1 palliation and the subsequent stage 2 palliation.All estimates of all-cause mortality were substantially lower in human milk and breastfeeding groups, with clinically important estimates of 75%-100% lower odds of mortality in direct breastfeeding groups.What are the clinical implications?: There is a critical need for improved, condition-specific lactation support to address the low prevalence of human milk and breastfeeding for infants with single ventricle congenital heart disease.Increasing the dose and duration of human milk and direct breastfeeding has strong potential to substantially improve the health outcomes of these vulnerable infants.
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Affiliation(s)
| | - Julian Wolfson
- University of Minnesota School of Public Health, Division of Biostatistics
| | - Jayne A. Fulkerson
- University of Minnesota School of Nursing
- University of Minnesota School of Public Health, Division of Epidemiology
| | - Michael K. Georgieff
- University of Minnesota Medical School, Department of Pediatrics
- M Health Fairview University of Minnesota Masonic Children’s Hospital
| | | | - Diane L. Spatz
- University of Pennsylvania School of Nursing
- Children’s Hospital of Philadelphia
| | - Kavisha M. Shah
- University of Minnesota Medical School, Department of Pediatrics
- M Health Fairview University of Minnesota Masonic Children’s Hospital
| | - Karen Uzark
- University of Michigan Medical School, Division of Cardiac Surgery
- C. S. Mott Children's Hospital
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9
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Desai H, Jones CE, Fogel JL, Negrin KA, Slater NL, Morris K, Doody LR, Engstler K, Torzone A, Smith J, Butler SC. Assessment and management of feeding difficulties for infants with complex CHD. Cardiol Young 2022; 33:1-10. [PMID: 36562257 DOI: 10.1017/s1047951122004024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Early surgical intervention in infants with complex CHD results in significant disruptions to their respiratory, gastrointestinal, and nervous systems, which are all instrumental to the development of safe and efficient oral feeding skills. Standardised assessments or treatment protocols are not currently available for this unique population, requiring the clinician to rely on knowledge based on neonatal literature. Clinicians need to be skilled at evaluating and analysing these systems to develop an appropriate treatment plan to improve oral feeding skill and safety, while considering post-operative recovery in the infant with complex CHD. Supporting the family to re-establish their parental role during the hospitalisation and upon discharge is critical to reducing parental stress and oral feeding success.
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Affiliation(s)
- Hema Desai
- Department of Rehabilitation Services, Children's Hospital of Orange County, Orange, CA, USA
| | - Courtney E Jones
- Acute Care Therapy Services, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Jennifer L Fogel
- Department of Pediatric Rehabilitation, Advocate Children's Hospital, Oak Lawn, IL, USA
| | - Karli A Negrin
- Department of Therapy and Rehabilitative Services, Nemours Children's Health, Wilmington, DE, USA
| | - Nancy L Slater
- Physical Medicine and Rehabilitation Services, Children's Minnesota, Minneapolis, MN, USA
| | - Kimberly Morris
- Department of Speech-Language Pathology, Rady Children's Hospital San Diego, San Diego, CA, USA
| | - Lisa R Doody
- Pediatric Rehabilitation and Development, Advocate Children's Hospital, Oak Lawn, IL, USA
| | - Katherine Engstler
- Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital, Boston, MA, USA
| | - Andrea Torzone
- Heart Center, Cardiac Intensive Care Unit, Children's Medical Center Dallas, Dallas, TX, USA
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10
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Risk Factors for Tube Feeding at Discharge in Infants Undergoing Neonatal Surgery for Congenital Heart Disease: A Systematic Review. Pediatr Cardiol 2022; 44:769-794. [PMID: 36404346 DOI: 10.1007/s00246-022-03049-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 11/07/2022] [Indexed: 11/22/2022]
Abstract
Approximately 30-50% of infants undergoing neonatal surgery for congenital heart disease (CHD) cannot meet oral feeding goals by discharge and require feeding tube support at home. Feeding tubes are associated with increased readmission rates and consequent hospital, payer, and family costs, and are a burden for family caregivers. Identification of modifiable risk factors for oral feeding problems could support targeted care for at-risk infants. Therefore, the aim of this systematic review is to determine risk factors for tube feeding at discharge in infants undergoing neonatal surgery for CHD. Following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, a search was conducted using MEDLINE, CINAHL, and Cochrane Database of Systematic Reviews. Studies published before 2010 were excluded. The search resulted in 607 records, of which 18 were included. Studies were primarily retrospective cohort designs and results were often inconsistent. Study quality was assessed using the Joanna Briggs Critical Appraisal Tools. As a group, the studies exhibited substantial risk for bias. Based on the findings, infants who struggle with feeding preoperatively, experience increased nil per os duration and/or low oral feeding volume postoperatively, experience increased duration of mechanical ventilation, or have vocal cord dysfunction may be at risk for tube feeding at hospital discharge. Factors warranting further examination include cardiac physiology (e.g., aortic arch obstruction) and the relationship between neurodevelopment and oral feeding. Clinicians should use caution in assuming risk for an individual and prioritize early implementation of interventions that facilitate oral feeding development.
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11
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Elgersma KM, McKechnie AC, Schorr EN, Shah KM, Trebilcock AL, Ramel SE, Ambrose MB, Swanson NM, Sommerness SA, Spatz DL. The Impact of Human Milk on Outcomes for Infants with Congenital Heart Disease: A Systematic Review. Breastfeed Med 2022; 17:393-411. [PMID: 35167760 DOI: 10.1089/bfm.2021.0334] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background: Infants with congenital heart disease (CHD) are at risk for feeding-related morbidity and mortality, with growth failure and oral feeding problems associated with poor outcomes. The benefits of human milk (HM) for preterm infants have been well documented, but evidence on HM for infants with CHD has recently begun to emerge. Objectives: Our primary aim was to examine the impact of HM feeding on outcomes for infants with CHD. Methods: Following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines, a search was conducted using MEDLINE, CINAHL, and Cochrane Database of Systematic Reviews. The quality of each study was assessed using the Joanna Briggs Critical Appraisal Tools. A total of 16 studies were included. Results: There was evidence that an exclusive HM diet reduces the risk of necrotizing enterocolitis (NEC) for infants with CHD. Evidence with a higher risk for bias indicated that a well-managed HM diet may be associated with improved growth, shorter length of stay, and improved postoperative feeding and nutritional outcomes. Chylothorax outcomes were similar between modified HM and medium-chain triglyceride formula. The studies had significant limitations related to power, lack of control for covariates, and inconsistent delineation of feeding groups. Conclusions: Based on the reduced risk for NEC and given the conclusive benefits in other vulnerable populations, we recommend that clinicians and institutions prioritize programs to support HM feeding for infants with CHD. Large high-quality studies are needed to validate these results. Future work should clarify best practices in managing an HM diet to support optimal growth and development for these infants.
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Affiliation(s)
| | | | - Erica N Schorr
- University of Minnesota School of Nursing, Minneapolis, Minnesota, USA
| | - Kavisha M Shah
- University of Minnesota School of Nursing, Minneapolis, Minnesota, USA.,Department of Pediatrics, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA
| | - Anna L Trebilcock
- University of Minnesota School of Nursing, Minneapolis, Minnesota, USA
| | - Sara E Ramel
- University of Minnesota School of Nursing, Minneapolis, Minnesota, USA.,Department of Pediatrics, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA
| | - Matthew B Ambrose
- University of Minnesota School of Nursing, Minneapolis, Minnesota, USA.,Department of Pediatrics, M Health Fairview University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota, USA
| | - Nellie Munn Swanson
- University of Minnesota School of Nursing, Minneapolis, Minnesota, USA.,Department of Nursing, Children's Minnesota, Minneapolis, Minnesota, USA
| | | | - Diane L Spatz
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA.,Center for Nursing Research & Evidence Based Practice, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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12
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Pedi-R-MAPP: The development of a nutritional awareness tool for use in remote paediatric consultations using a modified Delphi consensus. Clin Nutr 2022; 41:661-672. [PMID: 35149245 DOI: 10.1016/j.clnu.2022.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND & AIMS The Remote Malnutrition Application (R-MAPP) was developed during the COVID-19 pandemic to provide support for health care professionals (HCPs) working in the community to complete remote nutritional assessments, and provide practical guidance for nutritional care. The aim of this study was to modify the R-MAPP into a version suitable for children, Pediatric Remote Malnutrition Application (Pedi-R-MAPP), and provide a structured approach to completing a nutrition focused assessment as part of a technology enabled care service (TECS) consultation. METHODS A ten-step process was completed: 1) permission to modify adult R-MAPP, 2) literature search to inform the Pedi-R-MAPP content, 3) Pedi-R-MAPP draft, 4) international survey of HCP practice using TECS, 5) nutrition experts invited to participate in a modified Delphi process, 6) first stakeholder meeting to agree purpose/draft of the tool, 7) round-one online survey, 8) statements with consensus removed from survey, 9) round-two online survey for statements with no consensus and 10) second stakeholder meeting with finalisation of the Pedi-R-MAPP nutrition awareness tool. RESULTS The international survey completed by 463 HCPs, 55% paediatricians, 38% dietitians, 7% nurses/others. When HCPs were asked to look back over the last 12 months, dietitians (n = 110) reported that 5.7 ± 10.6 out of every 10 appointments were completed in person; compared to paediatricians (n = 182) who reported 7.5 ± 7.0 out of every 10 appointments to be in person (p < 0.0001), with the remainder completed as TECS consultations. Overall, 74 articles were identified and used to develop the Pedi-R-MAPP which included colour-coded advice using a traffic light system; green, amber, red and purple. Eighteen participants agreed to participate in the Delphi consensus and completed both rounds of the modified Delphi survey. Agreement was reached at the first meeting on the purpose and draft sections of the proposed tool. In round-one of the online survey, 86% (n = 89/104) of statements reached consensus, whereas in round-two 12.5% (n = 13/104) of statements reached no consensus. At the second expert meeting, contested statements were discussed until agreement was reached and the Pedi-R-MAPP could be finalised. CONCLUSION The Pedi-R-MAPP nutrition awareness tool was developed using a modified Delphi consensus. This tool aims to support the technological transformation fast-tracked by the COVID-19 pandemic by providing a structured approach to completing a remote nutrition focused assessment, as well as identifying the frequency of follow up along with those children who may require in-person assessment.
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