A preoperative standardized feeding protocol improves human milk use in infants with complex congenital heart disease

Human milk, breastfeeding, and early neurodevelopmental outcomes for infants with critical CHD

Human milk improves neurodevelopment for preterm infants, but relationships between human milk and neurodevelopment for infants with critical CHD are unknown. We aimed to (1) explore associations between human milk/direct breastfeeding and neurodevelopment at 1-year and 2-year follow-up and (2) describe patterns of human milk (maternal, donor) and commercial formula during hospitalisation in the first year of life.This retrospective cohort study included infants who underwent surgery for CHD < 6 months old. The primary outcome was neurodevelopment via Bayley Scales of Infant Development-IV. Analysis included adjusted linear regression for associations between exclusive human milk while inpatient during the first 6 months or any direct breastfeeding while inpatient during the first year of life and 1-year Bayley-IV scores. Models were adjusted for race, insurance type, genetic diagnosis, and length of stay.Of 98 eligible infants, 40% followed up at 1 year; 27% at 2 years. There were differences in follow-up related to demographics (race, ethnicity) and social determinants of health (insurance type, distance from clinic). In adjusted models, infants who directly breastfed had 13.18 points higher cognition (95% CI: 0.84-25.53, p = 0.037); 14.04 points higher language (2.55-25.53, p = 0.018); and 15.80 points higher motor scores (3.27-28.34, p = 0.015) at 1-year follow-up. Infants fed exclusive human milk had 12.64 points higher cognition scores (-0.53-25.82, p = 0.059).Future investigation into nutrition and neurodevelopment in the context of critical CHD is warranted. As neurodevelopmental follow-up becomes standard of care in this population, efforts are needed to mitigate disparities in access to this care.

Neonatal Diet Type and Associations With Adverse Feeding Outcomes in Neonates With Critical Congenital Heart Defects

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.

Predictors of Human Milk Feeding and Direct Breastfeeding for Infants with Single Ventricle Congenital Heart Disease: Machine Learning Analysis of the National Pediatric Cardiology Quality Improvement Collaborative Registry

OBJECTIVE

To identify factors that support or limit human milk (HM) feeding and direct breastfeeding (BF) for infants with single ventricle congenital heart disease at neonatal stage 1 palliation (S1P) discharge and at stage 2 palliation (S2P) (∼4-6 months old).

STUDY DESIGN

Analysis of the National Pediatric Cardiology Quality Improvement Collaborative (NPC-QIC) registry (2016-2021; 67 sites). Primary outcomes were any HM, exclusive HM, and any direct BF at S1P discharge and at S2P. The main analysis involved multiple phases of elastic net logistic regression on imputed data to identify important predictors.

RESULTS

For 1944 infants, the strongest predictor domain areas included preoperative feeding, demographics/social determinants of health, feeding route, clinical course, and site. Significant findings included: preoperative BF was associated with any HM at S1P discharge (OR = 2.02, 95% CI = 1.74-3.44) and any BF at S2P (OR = 2.29, 95% CI = 1.38-3.80); private/self-insurance was associated with any HM at S1P discharge (OR = 1.91, 95% CI = 1.58-2.47); and Black/African-American infants had lower odds of any HM at S1P discharge (OR = 0.54, 95% CI = 0.38-0.65) and at S2P (0.57, 0.30-0.86). Adjusted odds of HM/BF practices varied among NPC-QIC sites.

CONCLUSIONS

Preoperative feeding practices predict later HM and BF for infants with single ventricle congenital heart disease; therefore, family-centered interventions focused on HM/BF during the S1P preoperative time are needed. These interventions should include evidence-based strategies to address implicit bias and seek to minimize disparities related to social determinants of health. Future research is needed to identify supportive practices common to high-performing NPC-QIC sites.

Translation, cross-cultural adaptation, content validation, and clinical feasibility of the nutritional pathway for infants with congenital heart disease before surgery

OBJECTIVE

The aim of this study is to translate and validate the Nutritional Pathway for Infants with Congenital Heart Disease before Surgery British nutritional protocol into Brazilian Portuguese and test its clinical feasibility for specialized clinicians in Brazilian hospitals.

METHOD

The translation and validation process followed strict methodological standards over the following steps: 1) initial translation; 2) synthesis; 3) back-translation; 4) expert committee content validation, and pre-test clinical feasibility with 30 health professionals. Data were collected through the Research Electronic Data Capture software data system, and then extracted and analyzed through statistical analysis software.

RESULTS

The culturally adapted version was considered equivalent to the original. In the first round, 82% agreement was achieved, and after consensus, there was 100% agreement among the experts. Regarding the ease of use of the protocol in clinical practice, the instrument obtained a minimum agreement rate of 93.4% and a 0.92 content validity index.

CONCLUSIONS

The results indicate that the instrument adapted to Brazilian Portuguese has high content validity, and high reliability among the experts, suggesting a high level of accuracy of the instrument and cultural adaptation for Brazilian culture and medical systems. It was easily understandable by health professionals, as well as simple to apply in clinical practice. The Nutritional protocol for preoperative infants with congenital heart disease can reproduce the outcomes found in the pilot of this instrument carried out in the United Kingdom, which may promote better pre-surgical nutritional status for infants with congenital heart disease in Brazil.

Nutrition for Infants with Congenital Heart Disease

Perioperative malnutrition in infants with congenital heart disease can lead to significant postnatal growth failure and poor short- and long-term outcomes. A standardized approach to nutrition is needed for the neonatal congenital heart disease population, taking into consideration the type of cardiac lesion, the preoperative and postoperative period, and prematurity. Early enteral feeding is beneficial and should be paired with parenteral nutrition to meet the fluid and nutrient needs of the infant.

Patterns of Breastfeeding and Human Milk Feeding in Infants with Single-Ventricle Congenital Heart Disease: A Population Study of the National Pediatric Cardiology Quality Improvement Collaborative Registry

Introduction: Infants with single-ventricle (SV) congenital heart disease (CHD) undergo staged surgical and/or catheter-based palliation and commonly experience feeding challenges and poor growth. Little is known about human milk (HM) feeding or direct breastfeeding (BF) in this population. Aim: To determine (1) HM and BF prevalence for infants with SV CHD, and (2) whether BF at neonatal stage 1 palliation (S1P) discharge is associated with any HM at stage 2 palliation (S2P; ∼4-6 months old). Materials and Methods: Analysis of the National Pediatric Cardiology Quality Improvement Collaborative registry (2016-2021) using (1) descriptive statistics for prevalence, and (2) logistic regression adjusted for multiple variables (e.g., prematurity, insurance, length of stay) to examine early BF/later HM feeding. Results: Participants included 2,491 infants from 68 sites. HM prevalence ranged from 49.3% any/41.5% exclusive before S1P to 37.1% any/7.0% exclusive at S2P. Direct BF ranged from 16.1% any/7.9% exclusive before S1P to 9.2% any/3.2% exclusive at S2P discharge. Prevalence varied among sites; for example, 0-100% any HM before S1P. Infants BF at S1P discharge had greater odds of any HM (odds ratio = 4.11, 95% confidence interval [CI] = 2.79-6.07, p < 0.001) and exclusive HM (1.85, 95% CI 1.03-3.30, p = 0.039) at S2P. Conclusions: The prevalence of HM and BF for infants with SV CHD was low and declined over time. Direct BF at S1P discharge was associated with increased odds of any HM at S2P. Wide variation suggests that site-specific practices impact feeding outcomes. HM and BF prevalence are suboptimal in this population, and identification of supportive institutional practices is needed.

Relationship Between Human Milk Feeding Patterns and Growth in the First Year of Life in Infants with Congenital Heart Defects

The purpose of this study was to determine the relationship between patterning of human milk feeding and growth of infants with congenital heart defects in the first year of life. Inclusion criteria for this prospective cohort study included infants 0-21 days, who had undergone or had planned neonatal corrective or palliative surgery prior to hospital discharge, and whose mothers planned to feed human milk. Data on anthropometric measures (weight, length, head circumference) and infant milk type (human milk, formula, other) were collected at nine time points (0.5, 1, 2, 3, 4, 6, 8, 10, 12 months). Anthropometric data were converted to weight-for-age, length-for-age, head circumference-for-age, and weight-for-length Z-scores using World Health Organization growth reference data. Cluster analysis identified three milk type feeding patterns in the first year: Infants fed human milk only with no formula supplementation, infants fed human milk who then transitioned to a mix of human milk and formula, and infants who fed human milk and transitioned to formula only. General linear models assessed the effect of milk type feeding patterns on growth parameters over time. No effect of milk type pattern × time was found on longitudinal changes in weight-for-age (p for interaction = 0.228), length-for-age (p for interaction = 0.173), weight-for-length (p for interaction = 0.507), or head circumference-for-age (p for interaction = 0.311) Z-scores. In this cohort study, human milk alone or combined with infant formula supported age-appropriate growth in infants with congenital heart defects in the first year.

First Feed Type Is Associated With Birth/Lactating Parent's Own Milk Use During NICU Stay Among Infants Who Require Surgery

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 .

Antenatal Milk Expression as a Lactation Support Intervention for Parents of Infants With Severe Birth Defects: A Case Series

BACKGROUND

A diet high in parent's own milk (parental milk) is a lifesaving intervention for critically ill infants. Lactating parents whose infants are born with birth defects that require surgical repair (surgical infants) shortly after birth often struggle to initiate and maintain a milk supply that meets their infant's nutritional needs. Antenatal milk expression has been identified as a safe, feasible, and potentially effective strategy that promotes parents' direct chest/breastfeeding or milk expression (lactation) confidence and helps parents attain their lactation goals. Two cases are presented to illustrate the potential for using antenatal milk expression as a lactation support intervention for parents of surgical infants.

CASE PRESENTATION

Cases were drawn from a pilot study exploring the feasibility of implementing antenatal milk expression among pregnant parents of surgical infants. Participants were healthy women recruited after 30 weeks of gestation who received a fetal diagnosis of a complex congenital heart defect. Despite variability in clinical course and length of stay, parental milk was provided for the duration of each infant's hospitalization. Participant perceptions of antenatal milk expression varied.

CONCLUSION

More research is needed to evaluate the feasibility, efficacy, and parent or provider perceptions of antenatal milk expression as a lactation support intervention for parents of surgical infants.

Clinical Characteristics and Potential Pathogenesis of Cardiac Necrotizing Enterocolitis in Neonates with Congenital Heart Disease: A Narrative Review

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.

Prematurity and Congenital Heart Disease: A Contemporary Review

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.

Prevalence and patterns of gestational parent's own milk feeds among infants with major congenital surgical anomalies in the NICU

OBJECTIVE

To describe the prevalence and patterns of gestational parent's own milk (GPOM) feedings among infants undergoing major surgery during their neonatal intensive care unit (NICU) admission.

STUDY DESIGN

We analyzed de-identified electronic medical records of all infants admitted to a regional NICU 2014-2015 who underwent surgery for a gastrointestinal, cardiac, or other major organ system defect(s).

RESULTS

Of 79 infants, 85% received any GPOM during the NICU hospitalization. The median proportion of GPOM feeds was 66%. There was a trend toward decreassing proportions of GPOM with progressive months in NICU. The rate of any and exclusive GPOM feeds at NICU discharge was 49% and 29%, respectively. Infants who had a GI anomaly were more likely than infants with a cardiac anomaly to be discharged from NICU receiving GPOM.

CONCLUSION

Barriers to the exclusive and continued provision of GPOM in this population require further study and intervention.