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Bertrandt RA, Gist K, Hasson D, Zang H, Reichle G, Krawczeski C, Winlaw D, Bailly D, Goldstein S, Selewski D, Alten J. Cardiac Surgery-Associated Acute Kidney Injury in Neonates Undergoing the Norwood Operation: Retrospective Analysis of the Multicenter Neonatal and Pediatric Heart and Renal Outcomes Network Dataset, 2015-2018. Pediatr Crit Care Med 2024; 25:e246-e257. [PMID: 38483198 DOI: 10.1097/pcc.0000000000003498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
OBJECTIVES Cardiac surgery-associated acute kidney injury (CS-AKI) is associated with adverse outcomes. Single-center studies suggest that the prevalence of CS-AKI is high after the Norwood procedure, or stage 1 palliation (S1P), but multicenter data are lacking. DESIGN A secondary analysis of the Neonatal and Pediatric Heart and Renal Outcomes Network (NEPHRON) multicenter cohort who underwent S1P. Using neonatal modification of Kidney Disease Improving Global Outcomes (KDIGO) criteria, perioperative associations between CS-AKI with morbidity and mortality were examined. Sensitivity analysis, with the exclusion of prophylactic peritoneal dialysis (PD) patients, was performed. SETTING Twenty-two hospitals participating in the Pediatric Cardiac Critical Care Consortium (PC 4 ) and contributing to NEPHRON. PATIENTS Three hundred forty-seven neonates (< 30 d old) with S1P managed between September 2015 and January 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 347 patients, CS-AKI occurred in 231 (67%). The maximum stages were as follows: stage 1, in 141 of 347 (41%); stage 2, in 51 of 347 (15%); and stage 3, in 39 of 347 (11%). Severe CS-AKI (stages 2 and 3) peaked on the first postoperative day. In multivariable analysis, preoperative feeding was associated with lower odds of CS-AKI (odds ratio [OR] 0.48; 95% CI, 0.27-0.86), whereas prophylactic PD was associated with greater odds of severe CS-AKI (OR 3.67 [95% CI, 1.88-7.19]). We failed to identify an association between prophylactic PD and increased creatinine (OR 1.85 [95% CI, 0.82-4.14]) but cannot exclude the possibility of a four-fold increase in odds. Hospital mortality was 5.5% ( n = 19). After adjusting for risk covariates and center effect, severe CS-AKI was associated with greater odds of hospital mortality (OR 3.67 [95% CI, 1.11-12.16]). We failed to find associations between severe CS-AKI and respiratory support or length of stay. The sensitivity analysis using PD failed to show associations between severe CS-AKI and outcome. CONCLUSIONS KDIGO-defined CS-AKI occurred frequently and early postoperatively in this 2015-2018 multicenter PC 4 /NEPHRON cohort of neonates after S1P. We failed to identify associations between resource utilization and CS-AKI, but there was an association between severe CS-AKI and greater odds of mortality in this high-risk cohort. Improving the precision for defining clinically relevant neonatal CS-AKI remains a priority.
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Affiliation(s)
- Rebecca A Bertrandt
- Division of Critical Care, Department of Pediatrics, Herma Heart Institute, Children's Wisconsin, Medical College of Wisconsin, Milwaukee, WI
| | - Katja Gist
- Division of Pediatric Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Denise Hasson
- Division of Pediatric Critical Care Medicine, New York University Langone Health, New York University Grossman School of Medicine, New York, NY
| | - Huaiyu Zang
- Division of Pediatric Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Garrett Reichle
- Department of Pediatrics, Division of Cardiology, C. S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI
| | - Catherine Krawczeski
- Department of Pediatrics, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, OH
| | - David Winlaw
- Department of Pediatrics, Lurie Children's Hospital of Chicago, Chicago, IL
| | - David Bailly
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Primary Children's Hospital, Salt Lake City, UT
| | - Stuart Goldstein
- Division of Pediatric Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - David Selewski
- Division of Nephrology, Department of Pediatrics, Medical University of South Carolina, Charleston, SC
| | - Jeffrey Alten
- Division of Pediatric Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
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Pappas LB, Erickson LA, Ricketts AM, Moehlmann ML, Hahn AM, Daniel JM. Pre-operative enteral feeding in single-ventricle CHD patients and necrotising enterocolitis risk. Cardiol Young 2024; 34:364-369. [PMID: 37434452 DOI: 10.1017/s1047951123001580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Abstract
INTRODUCTION Enteral feeding prior to cardiac surgery has benefits in pre-operative and post-operative patient statuses. In 2020, to increase pre-operative feeding for single-ventricle patients prior to stage 1 palliation, an enteral feeding algorithm was created. The aim of this study is to monitor the impact of our practice change with the primary outcome of necrotising enterocolitis incidence from birth to 2 weeks following surgical intervention. METHODS This is a single-site, retrospective cohort study including patients from 1 March, 2018 to 1 July, 2022. Variables assessed include demographics, age at cardiac surgery, primary cardiac diagnosis, necrotising enterocolitis pre-operative and 2 weeks post-operative cardiac surgery, feeding route, feeding type, volume of trophic enteral feeds, and near-infrared spectroscopy. RESULTS Following implementation of a pre-operative enteral feeding algorithm, the rate of neonates fed prior to surgery increased (39.5-75%, p = .001). The feedings included a mean volume of 28.24 ± 11.16 ml/kg/day, 83% fed breastmilk only, 44.4% tube fed, and 55.5% of infants had all oral feedings. Comparing enterally fed neonates and those not enterally fed, the necrotising enterocolitis incidence from birth to 2 weeks post-op was not significantly increased (p = 0.926). CONCLUSION As a result of implementing our feeding algorithm, the frequency of infants fed prior to stage I Norwood or Hybrid surgeries increased to 75%, and there was no significant change in the incidence of necrotising enterocolitis. This study confirmed that pre-operative enteral feeds are safe and are not associated with increased incidence of necrotising enterocolitis.
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Affiliation(s)
- Lucy B Pappas
- Department of Nutrition and Division of Neonatology, Children's Mercy Hospital, Kansas City, MO, USA
| | - Lori A Erickson
- Remote Health Solutions and Strategic Planning, Children's Mercy Hospital, Kansas City, MO, USA
| | - Amy M Ricketts
- Remote Health Solutions and Strategic Planning, Children's Mercy Hospital, Kansas City, MO, USA
| | - Matthew L Moehlmann
- Division of Pediatric Cardiology, Children's Mercy Hospital, Kansas City, MO, USA
| | - Aaron M Hahn
- Division of Pediatric Cardiology, Children's Mercy Hospital, Kansas City, MO, USA
| | - John M Daniel
- Division of Neonatology, Children's Mercy Hospital, Kansas City, MO, USA
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Deitch AM, Moynihan K, Przybylski R, Gauvreau K, Braudis NJ, Farr B, Modi B, Mills KI, Nathan M, Levy PT. Risk Factors for Adverse Outcomes in Term Infants with CHD and Definitive Necrotising Enterocolitis. Cardiol Young 2024; 34:92-100. [PMID: 37226515 DOI: 10.1017/s104795112300121x] [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: 05/26/2023]
Abstract
OBJECTIVES To define the incidence of definitive necrotising enterocolitis in term infants with CHD and identify risk factors for morbidity/mortality. METHODS We performed a 20-year (2000-2020) single-institution retrospective cohort study of term infants with CHD admitted to the Boston Children's Hospital cardiac ICU with necrotising enterocolitis (Bell's stage ≥ II). The primary outcome was a composite of in-hospital mortality and post-necrotising enterocolitis morbidity (need for extracorporeal membrane oxygenation, multisystem organ failure based on the paediatric sequential organ failure assessment score, and/or need for acute gastrointestinal intervention). Predictors included patient characteristics, cardiac diagnosis/interventions, feeding regimen, and severity measures. RESULTS Of 3933 term infants with CHD, 2.1% (n = 82) developed necrotising enterocolitis, with 67% diagnosed post-cardiac intervention. Thirty (37%) met criteria for the primary outcome. In-hospital mortality occurred in 14 infants (17%), of which nine (11%) deaths were attributable to necrotising enterocolitis. Independent predictors of the primary outcome included moderate to severe systolic ventricular dysfunction (odds ratio 13.4,confidence intervals 1.13-159) and central line infections pre-necrotising enterocolitis diagnosis (odds ratio 17.7, confidence intervals 3.21-97.0) and mechanical ventilation post-necrotising enterocolitis diagnosis (odds ratio 13.5, confidence intervals 3.34-54.4). Single ventricle, ductal dependency, and feeding related factors were not independently associated with the primary outcome. CONCLUSIONS The incidence of necrotising enterocolitis was 2.1% in term infants with CHD. Adverse outcomes occurred in greater than 30% of patients. Presence of systolic dysfunction and central line infections prior to diagnosis and need for mechanical ventilation after diagnosis of necrotising enterocolitis can inform risk triage and prognostic counseling for families.
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Affiliation(s)
- Anna M Deitch
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Cardiology, Lucile Packard Children's Hospital, Stanford, CA, USA
| | - Katie Moynihan
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert Przybylski
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nancy J Braudis
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Bethany Farr
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Biren Modi
- Department of Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kimberly I Mills
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Philip T Levy
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
- Division of Newborn Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
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Abstract
BACKGROUND Feeding difficulty is common in infants with CHD. OBJECTIVE The purpose of this study was to describe the feeding skills and behaviours of infants with CHD at 6-12 months of age and explore relationships between feeding, gastrointestinal distress, and gastroesophageal reflux. METHODS Parents of 30 infants with CHD completed online surveys when their infant was 6, 8, 10, and 12 months old. Surveys included parent-report measures of feeding skills (Child Oral and Motor Proficiency Scale), feeding behaviours (Pediatric Eating Assessment Tool), symptoms of gastrointestinal distress (Infant Gastrointestinal Symptoms Questionnaire), and gastroesophageal reflux (Infant Gastroesophageal Reflux Questionnaire-Revised). RESULTS We found that 95, 32, 67, and 30% of infants were delayed in their feeding skill development at 6, 8, 10, and 12 months, respectively. Symptoms of problematic feeding behaviours were similarly high, with 90, 62, 29, and 38% of infants meeting criteria for problematic feeding at 6, 8, 10, and 12 months, respectively. Feeding skills and behaviours were related but unique contributors. Feeding behaviours were related to both gastrointestinal distress and gastroesophageal reflux, but feeding skills were rarely related to either. CONCLUSIONS Delayed acquisition of feeding skills and problematic feeding were common in infants with CHD. Infants with more gastrointestinal and gastroesophageal reflux symptoms had more symptoms of problematic feeding behaviours. CLINICAL IMPLICATIONS Comprehensive assessment, targeted interventions, and early involvement of feeding specialists are important to support feeding in infants with CHD through at least the first year of life.
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Affiliation(s)
- Britt F Pados
- School of Nursing, Boston College, Chestnut Hill, MA, USA
- Infant Feeding Care, Wellesley, MA, USA
| | - Tondi M Harrison
- College of Nursing, The Ohio State University, Columbus, OH, USA
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Kataria-Hale J, Gollins L, Bonagurio K, Blanco C, Hair AB. Nutrition for Infants with Congenital Heart Disease. Clin Perinatol 2023; 50:699-713. [PMID: 37536773 DOI: 10.1016/j.clp.2023.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Perioperative malnutrition in infants with congenital heart disease can lead to significant postnatal growth failure and poor short- and long-term outcomes. A standardized approach to nutrition is needed for the neonatal congenital heart disease population, taking into consideration the type of cardiac lesion, the preoperative and postoperative period, and prematurity. Early enteral feeding is beneficial and should be paired with parenteral nutrition to meet the fluid and nutrient needs of the infant.
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Affiliation(s)
- Jasmeet Kataria-Hale
- Department of Pediatrics, Division of Neonatology, Mission Hospital, 509 Biltmore Avenue, Asheville, NC 28801, USA
| | - Laura Gollins
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin Street, MC: A5590, Houston, TX 77030, USA
| | - Krista Bonagurio
- University of Texas Health Science Center, San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA
| | - Cynthia Blanco
- University of Texas Health Science Center, San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA
| | - Amy B Hair
- Department of Pediatrics, Division of Neonatology, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin Street, MC: A5590, Houston, TX 77030, USA.
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Zhang QL, Zhou SJ, Chen XH, Cao H, Chen Q. Creating the optimal preoperative nutritional status for neonates undergoing cardiac surgery by implementing a preoperative nutritional support plan. J Paediatr Child Health 2023; 59:901-905. [PMID: 37057648 DOI: 10.1111/jpc.16414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 03/21/2023] [Accepted: 04/06/2023] [Indexed: 04/15/2023]
Abstract
AIM The purpose of this study was to explore the effect of a preoperative nutritional support programme on improving preoperative nutritional status and promoting postoperative recovery in neonates undergoing cardiac surgery. METHODS The clinical data of neonates undergoing cardiac surgery who received preoperative nutritional support therapy in our hospital from March 2021 to December 2021 were collected, and the clinical data of neonates undergoing cardiac surgery who did not receive preoperative nutritional support therapy in our hospital from February 2020 to February 2021 were selected as the control. The nutritional status and postoperative recovery of the two groups were compared. RESULTS A total of 30 neonates who received nutritional support before cardiac surgery were included in this study. A total of 28 neonates who did not receive nutritional support before cardiac surgery were included in the control group. There were no significant differences in general information or the nutritional status at birth between the two groups. The duration of nutritional support in the intervention group was 16.8 ± 7.1 days. Before the operation, the intervention group was significantly better than the control group in terms of body weight, albumin, prealbumin and haemoglobin, which indicated that the nutritional status of the intervention group was better than that of the control group. The intensive care time, ventilator time and hospital stay time in the intervention group were significantly lower than those in the control group. CONCLUSION Nutritional support plans after birth for neonates with severe congenital heart disease can effectively improve the nutritional status of patients before surgery and accelerate the speed of postoperative recovery.
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Affiliation(s)
- Qi-Liang Zhang
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Si-Jia Zhou
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Xiu-Hua Chen
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Hua Cao
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
| | - Qiang Chen
- Department of Cardiac Surgery, Fujian Children's Hospital (Fujian Branch of Shanghai Children's Medical Center), College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China
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Penk J, Cagle W, Holloway A, Connolly J, Miles A, Bhakta R, Jain P, Davis SP, Riley C, Roddy DJ. Multicenter Evaluation of Pre-operative Feeding in Infants with Ductal Dependent Circulation. Pediatr Cardiol 2023:10.1007/s00246-023-03182-1. [PMID: 37209186 DOI: 10.1007/s00246-023-03182-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/12/2023] [Indexed: 05/22/2023]
Abstract
Enteral feeds are often withheld from neonates with ductal dependent cardiac lesions who are receiving prostaglandins. This is despite positive benefits of enteral feeding. We describe a multicenter cohort of these neonates who were fed pre-operatively. We also give a granular description of vital sign measurements and other risk factors prior to feeding. A retrospective chart review was performed at seven centers. Inclusion criteria were full-term neonates under one month of age with ductal dependent lesions receiving prostaglandins. These neonates were fed for at least 24 h during the pre-operative period. Premature neonates were excluded. Using the inclusion criteria, 127 neonates were identified. While being fed, 20.5% of the neonates were intubated, 10.2% were on inotropes, and 55.9% had an umbilical arterial catheter in place. Median oxygen saturations in the six hours prior to feeding were 92.5% in patients with cyanotic lesions, median diastolic blood pressure was 38 mmHg and median somatic NIRS were 66.5%. The median peak daily feeding volume reached was 29 ml/kg/day (IQ range 15.5-96.8 ml/kg/day). One patient developed suspected necrotizing enterocolitis (NEC) in this cohort. Only one adverse event occurred, which was an aspiration thought to be related to feeding, but did not result in intubation or cessation of feeds. NEC was rare among neonates with ductal dependent lesions while receiving enteral nutrition pre-operatively. Umbilical arterial catheters were in place in the majority of these patients. Hemodynamic measures demonstrated a high median oxygen saturation prior to initiation of feeds.
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Affiliation(s)
- Jamie Penk
- Department of Pediatrics, Lurie Children's Hospital, Chicago, IL, USA.
| | - Will Cagle
- Department of Pediatrics, Children's Hospital of Georgia, Augusta, GA, USA
| | - Adrian Holloway
- Department of Pediatrics, Children's Hospital University of Maryland Medical Center, Baltimore, MD, USA
| | - Julie Connolly
- Department of Pediatrics, Advocate Children's Hospital, Oak Lawn, IL, USA
| | - Alison Miles
- Department of Anesthesia and Critical Care, John Hopkins All Children's Hospital, Baltimore, MD, USA
| | - Rupal Bhakta
- Department of Pediatrics, Arkansas Children's, Little Rock, AR, USA
| | - Parag Jain
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | | | - Christine Riley
- Department of Pediatrics, Children's National Medical Center, Washington, DC, USA
| | - Dantin Jeramy Roddy
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
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Zaleski KL, Valencia E, Matte GS, Kaza AK, Nasr VG. How We Would Treat Our Own Hypoplastic Left Heart Syndrome Neonate for Stage 1 Surgery. J Cardiothorac Vasc Anesth 2023; 37:504-512. [PMID: 36717315 DOI: 10.1053/j.jvca.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/26/2022] [Accepted: 01/02/2023] [Indexed: 01/09/2023]
Affiliation(s)
- Katherine L Zaleski
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Eleonore Valencia
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Gregory S Matte
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Aditya K Kaza
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Viviane G Nasr
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Harvard Medical School, Boston, MA.
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Alkhushi N. The management of newborns with critical congenital heart diseases prior to transport to a cardiac center. THE CARDIOTHORACIC SURGEON 2023. [DOI: 10.1186/s43057-022-00090-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
AbstractCritical congenital heart diseases (CCHD) are important causes of mortality and morbidity in the newborn period. Even after diagnosis, their management could be seriously compromised by the unplanned delivery in hospitals with limited expertise and resources. The newborn may spend days or week before transport putting a significant burden on the neonatal team to manage such challenging diseases. In this review, the management principles of each individual pathology are discussed in the setting before transport to cardiac centers. Understanding these principles will help the treating teams evaluate and manage those complex conditions. The review avoids the advanced discussion on the management of CCHDs not applicable to the pre-transport setup. It highlights the critical elements in the maintenance of normal hemodynamics specific to each pathology and their variation.
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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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Blanco CL, Hair A, Justice LB, Roddy D, Bonagurio K, Williams PK, Machado D, Marino BS, Chi A, Takao C, Gordon EE, Ashrafi A, Cacho N, Pruetz JD, Costello JM, Cooper DS. A Randomized Trial of an Exclusive Human Milk Diet in Neonates with Single Ventricle Physiology. J Pediatr 2022; 256:105-112.e4. [PMID: 36528055 DOI: 10.1016/j.jpeds.2022.11.043] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 11/10/2022] [Accepted: 11/18/2022] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To determine whether weight gain velocity (g/kg/day) 30 days after the initiation of feeds after cardiac surgery and other clinical outcomes improve in infants with single ventricle physiology fed an exclusive human milk diet compared with a mixed human and bovine diet. STUDY DESIGN In this multicenter, randomized, single blinded, controlled trial, term neonates 7 days of age or younger with single ventricle physiology and anticipated cardiac surgical palliation within 30 days of birth were enrolled at 10 US centers. Both groups received human milk if fed preoperatively. During the 30 days after feeds were started postoperatively, infants in the intervention group received human milk fortified once enteral intake reached 60 mL/kg/day with a human milk-based fortifier designed for term neonates. The control group received standard fortification with formula once enteral intake reached 100 mL/kg/day. Perioperative feeding and parenteral nutrition study algorithms were followed. RESULTS We enrolled 107 neonates (exclusive human milk = 55, control = 52). Baseline demographics and characteristics were similar between the groups. The median weight gain velocity at study completion was higher in exclusive human milk vs control group (12 g/day [IQR, 5-18 g/day] vs 8 g/day [IQR, 0.4-14 g/day], respectively; P = .03). Other growth measures were similar between groups. Necrotizing enterocolitis of all Bell stages was higher in the control group (15.4 % vs 3.6%, respectively; P = .04). The incidence of other major morbidities, surgical complications, length of hospital stay, and hospital mortality were similar between the groups. CONCLUSIONS Neonates with single ventricle physiology have improved short-term growth and decreased risk of NEC when receiving an exclusive human milk diet after stage 1 surgical palliation. TRIAL REGISTRATION This trial is registered with ClinicalTrials.gov (www. CLINICALTRIALS gov, Trial ID: NCT02860702).
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Affiliation(s)
- Cynthia L Blanco
- Division of Neonatology, Department of Pediatrics, University of Texas Health Science Center and University Health, San Antonio, TX.
| | - Amy Hair
- Division of Neonatology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Lindsey B Justice
- Department of Cardiology, The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Dantin Roddy
- Division of Pediatric Critical Care, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, TX
| | - Krista Bonagurio
- Division of Neonatology, Department of Pediatrics, University of Texas Health Science Center and University Health, San Antonio, TX
| | - Patricia K Williams
- Division of Neonatal Perinatal Medicine, Department of Pediatrics, Oklahoma Children's Hospital, University of Oklahoma Health Sciences Center, Oklahoma City, OK
| | - Desiree Machado
- Pediatric Cardiac ICU, Congenital Heart Center, Shands Hospital University of Florida, Gainesville, FL
| | - Bradley S Marino
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Department of Pediatric Cardiology, Cleveland Clinic Children's, Cleveland, OH
| | - Annie Chi
- Division of Neonatology, Cook Children's Medical Center, Fort Worth, TX
| | - Cheryl Takao
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Los Angeles, University of Southern California, Los Angeles, CA
| | - Erin E Gordon
- Division of Critical Care, Department of Pediatrics, University of Texas Southwestern. Dallas, TX
| | - Amir Ashrafi
- Department of Pediatrics, Children's Hospital of Orange County, Orange, CA
| | - Nicole Cacho
- Division of Neonatology, Congenital Heart Center, Department of Pediatrics, Shands Hospital University of Florida, Gainesville, FL
| | - Jay D Pruetz
- Division of Cardiology, Department of Pediatrics, Children's Hospital of Los Angeles, University of Southern California, Los Angeles, CA
| | - John M Costello
- Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Pediatric Cardiology, Department of Pediatrics, Shawn Jenkins Children's Hospital, Medical University of South Carolina, Charleston, SC
| | - David S Cooper
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
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Increased interstage morbidity and mortality following stage 1 palliation in patients with genetic abnormalities. Cardiol Young 2022; 32:1999-2004. [PMID: 35137681 DOI: 10.1017/s1047951122000166] [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: 12/16/2022]
Abstract
BACKGROUND Hypoplastic left heart syndrome and single ventricle variants with aortic hypoplasia are commonly classified as severe forms of CHD. We hypothesised patients with these severe defects and reported genetic abnormalities have increased morbidity and mortality during the interstage period. METHODS AND RESULTS This was a retrospective review of the National Pediatric Cardiology Quality Improvement Collaborative Phase I registry. Three patient groups were identified: major syndromes, other genetic abnormalities, and no reported genetic abnormality. Tukey post hoc test was applied for pairwise group comparisons of length of stay, death, and combined outcome of death, not a candidate for stage 2 palliation, and heart transplant. Participating centres received a survey to establish genetic testing and reporting practices. Of the 2182 patients, 110 (5%) had major genetic syndromes, 126 (6%) had other genetic abnormalities, and 1946 (89%) had no genetic abnormality. Those with major genetic syndromes weighed less at birth and stage 1 palliation. Patients with no reported genetic abnormalities reached full oral feeds sooner and discharged earlier. The combined outcome of death, not a candidate for stage 2 palliation, and heart transplant was more common in those with major syndromes. Survey response was low (n = 23, 38%) with only 14 (61%) routinely performing and reporting genetic testing. CONCLUSIONS Patients with genetic abnormalities experienced greater morbidity and mortality during the interstage period than those with no reported genetic abnormalities. Genetic testing and reporting practices vary significantly between participating centres.
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Brief F, Guimber D, Baudelet JB, Houeijeh A, Piéchaud JF, Richard A, Vaksmann G, Godart F, Domanski O. Prevalence and Associated Factors of Long-term Growth Failure in Infants with Congenital Heart Disease Who Underwent Cardiac Surgery Before the Age of One. Pediatr Cardiol 2022; 43:1681-1687. [PMID: 35661240 DOI: 10.1007/s00246-022-02933-w] [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: 11/15/2021] [Accepted: 05/06/2022] [Indexed: 11/29/2022]
Abstract
Long-term growth failure can have negative impact on health (by increasing morbidity and mortality) and on neurodevelopmental outcomes. Its prevalence among children with congenital heart disease (CHD) is not well described. The aim of our study was to evaluate the prevalence of growth failure in a population of infants with CHD away from cardiac surgery and identify associated factors. We conducted a retrospective and multicentric study that included infants from the North of France who underwent cardiac surgery before the age of one, between January 2013 and December 2017. 331 infants were included among which 48% had a prenatal diagnosis, 15% had a genetic syndrome, and 15% were premature infants. Mean birth weight was 3 ± 0.6 kg. At surgery, 35% presented feeding difficulties (need for enriched formula and/or feeding tube) and 14% had growth failure (defined by Z-score weight for age < -2SD). 6-12 months after surgery, 16% still presented growth failure. Several associated factors were identified: prenatal diagnosis, genetic syndrome association, birth weight ≤ 3 kg, complex CHD (≥ 2 significative lesions, or double outlet right ventricle or single ventricle physiology), surgery after 30 days, and need for diuretic drug before surgery and/or still needed 1 month after surgery. Growth failure persists between 6 and 12 months after surgery in 16% of infants with CHD. More studies are needed to link growth failure and neurodevelopment, which is the new challenge for this aging population.
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Affiliation(s)
- Floriane Brief
- Department of Pediatric and Congenital Heart Diseases, CHU Lille, 59000, Lille, France.
| | - Dominique Guimber
- Reference Center for Congenital and Malformative Esophageal Diseases (CRACMO), Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics Jeanne de Flandre, CHU Lille, 59000, Lille, France
| | - Jean-Benoit Baudelet
- Department of Pediatric and Congenital Heart Diseases, CHU Lille, 59000, Lille, France
| | - Ali Houeijeh
- Department of Pediatric and Congenital Heart Diseases, CHU Lille, 59000, Lille, France
| | | | - Adélaïde Richard
- Department of Pediatric Cardiology, Hôpital Privé de La Louvière, Lille, France
| | - Guy Vaksmann
- Department of Pediatric Cardiology, Hôpital Privé de La Louvière, Lille, France
| | - François Godart
- Department of Pediatric and Congenital Heart Diseases, CHU Lille, 59000, Lille, France
| | - Olivia Domanski
- Department of Pediatric and Congenital Heart Diseases, CHU Lille, 59000, Lille, France.
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14
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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.
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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
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15
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Mills KI, Kim JH, Fogg K, Goldshtrom N, Graham EM, Kataria-Hale J, Osborne SW, Figueroa M. Nutritional Considerations for the Neonate With Congenital Heart Disease. Pediatrics 2022; 150:189883. [PMID: 36317972 DOI: 10.1542/peds.2022-056415g] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 02/25/2023] Open
Abstract
The importance of nutrition in managing critically ill infants with congenital heart disease (CHD) is foundational to optimizing short- and long-term health outcomes. Growth failure and malnutrition are common in infants with CHD. The etiology of growth failure in this population is often multifactorial and may be related to altered metabolic demands, compromised blood flow to the intestine leading to nutrient malabsorption, cellular hypoxia, inadequate energy intake, and poor oral-motor skills. A dearth of high-quality studies and gaps in previously published guidelines have led to wide variability in nutrition practices that are locally driven. This review provides recommendations from the nutrition subgroup of the Neonatal Cardiac Care Collaborative for best evidence-based practices in the provision of nutritional support in infants with CHD. The review of evidence and recommendations focused on 6 predefined areas of clinical care for a target population of infants <6 months with CHD admitted to the ICU or inpatient ward. These areas include energy needs, nutrient requirements, enteral nutrition, feeding practice, parenteral nutrition, and outcomes. Future progress will be directed at quality improvement efforts to optimize perioperative nutrition management with an increasing emphasis on individualized care based on nutritional status, cardiorespiratory physiology, state of illness, and other vulnerabilities.
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Affiliation(s)
- Kimberly I Mills
- Division of Cardiovascular Critical Care, Department of Cardiology, Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts.,Contributed equally as co-first authors
| | - Jae H Kim
- Division of Neonatology, Perinatal Institute, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, College of Medicine, Cincinnati, Ohio.,Contributed equally as co-first authors
| | - Kristi Fogg
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Nimrod Goldshtrom
- Division of Neonatology, Department of Pediatrics, Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, New York
| | - Eric M Graham
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Jasmeet Kataria-Hale
- Division of Neonatology, Department of Pediatrics, Mission Children's Hospital, Asheville, North Carolina
| | - Scott W Osborne
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Mayte Figueroa
- Division of Cardiology and Critical Care, Department of Pediatrics, St Louis Children's Hospital, Washington University School of Medicine, St Louis, Missouri
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16
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Seliga-Siwecka J, Płotko A, Wójcik-Sep A, Bokiniec R, Latka-Grot J, Żuk M, Furmańczyk K, Zieliński W, Chrzanowska M. Effect of standardized vs. local preoperative enteral feeding practice on the incidence of NEC in infants with duct dependent lesions: Protocol for a randomized control trial. Front Cardiovasc Med 2022; 9:893764. [PMID: 36158805 PMCID: PMC9492877 DOI: 10.3389/fcvm.2022.893764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 07/18/2022] [Indexed: 11/15/2022] Open
Abstract
Background Infants with duct dependent heart lesions often require invasive procedures during the neonatal or early infancy period. These patients remain a challenge for pediatric cardiologists, neonatologists, and intensive care unit personnel. A relevant portion of these infant suffer from respiratory, cardiac failure and may develop NEC, which leads to inadequate growth and nutrition, causing delayed or complicated cardiac surgery. Methods This randomized control trial will recruit term infants diagnosed with a duct dependant lesion within the first 72 h of life. After obtaining written parental consent patients will be randomized to either the physician led enteral feeding or protocol-based feeding group. The intervention will continue up to 28 days of life or day of cardiosurgical treatment, whichever comes first. The primary outcomes include NEC and death related to NEC. Secondary outcomes include among others, number of interrupted feedings, growth velocity, daily protein and caloric intake, days to reach full enteral feeding and on mechanical ventilation. Discussion Our study will be the first randomized control trial to evaluate if standard (as in healthy newborns) initiation and advancement of enteral feeding is safe, improves short term outcomes and does not increase the risk of NEC. If the studied feeding regime proves to be intact, swift implementation and advancement of enteral nutrition may become a recommendation. Trial registration The study protocol has been approved by the local ethical board. It is registered at ClinicalTrials.gov NCT05117164.
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Affiliation(s)
- Joanna Seliga-Siwecka
- Department of Neonatology and Neonatal Intensive Care, Medical University of Warsaw, Warsaw, Poland
- *Correspondence: Joanna Seliga-Siwecka
| | - Ariel Płotko
- Department of Neonatology and Neonatal Intensive Care, Medical University of Warsaw, Warsaw, Poland
| | - Agata Wójcik-Sep
- Department of Neonatology and Neonatal Intensive Care, Medical University of Warsaw, Warsaw, Poland
| | - Renata Bokiniec
- Department of Neonatology and Neonatal Intensive Care, Medical University of Warsaw, Warsaw, Poland
| | - Julita Latka-Grot
- Department of Neonatology, Children's Health Memorial Institute, Warsaw, Poland
| | - Małgorzata Żuk
- Cardiology Clinic, Children's Health Memorial Institute, Warsaw, Poland
| | - Konrad Furmańczyk
- Department of Applied Mathematics, Institute of Information Technology, Warsaw University of Life Sciences, Warsaw, Poland
- Department of Prevention of Environmental Hazards, Allergology and Immunology, Medical University of Warsaw, Warsaw, Poland
| | - Wojciech Zieliński
- Department of Prevention of Environmental Hazards, Allergology and Immunology, Medical University of Warsaw, Warsaw, Poland
- Department of Statistics and Econometrics, Institute of Economics and Finance, Warsaw University of Life Sciences, Warsaw, Poland
| | - Mariola Chrzanowska
- Department of Prevention of Environmental Hazards, Allergology and Immunology, Medical University of Warsaw, Warsaw, Poland
- Department of Statistics and Econometrics, Institute of Economics and Finance, Warsaw University of Life Sciences, Warsaw, Poland
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17
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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.
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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.)
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18
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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.
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19
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Salvatori G, De Rose DU, Massolo AC, Patel N, Capolupo I, Giliberti P, Evangelisti M, Parisi P, Toscano A, Dotta A, Di Nardo G. Current Strategies to Optimize Nutrition and Growth in Newborns and Infants with Congenital Heart Disease: A Narrative Review. J Clin Med 2022; 11:jcm11071841. [PMID: 35407451 PMCID: PMC8999967 DOI: 10.3390/jcm11071841] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 03/22/2022] [Accepted: 03/24/2022] [Indexed: 11/24/2022] Open
Abstract
(1) Objective: This review aims to identify the clinical and practical barriers to optimizing nutrition in newborn infants with congenital heart disease (CHD) and to describe updated evidence-based recommendations for clinical and nutritional management of these patients in a narrative review. (2) Research Methods and Procedures: We conducted a search of the relevant literature published from 2000 to December 2021. (3) Results: CHD patients undergo several nutritional challenges related to the underlying cardiac disease anomaly, the potential increased risk of NEC, and delayed enteral feeding, resulting in inadequate energy intake and sub-optimal growth, increased morbidity and mortality. (4) Conclusions: To optimize nutrition and growth in newborn infants with CHD, standardized protocols should be implemented. Regular nutritional and growth assessment with a multi-disciplinary team is essential. We propose a decisional algorithm that may represent a potentially useful tool to guide clinicians to optimize growth and nutrition.
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Affiliation(s)
- Guglielmo Salvatori
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus-Newborn-Infant, “Bambino Gesù” Children’s Hospital, IRCCS, 00165 Rome, Italy; (D.U.D.R.); (A.C.M.); (I.C.); (P.G.); (A.D.)
- Human Milk Bank, Medical and Surgical Department of Fetus-Newborn-Infant, “Bambino Gesù” Children’s Hospital, IRCCS, 00165 Rome, Italy
- Correspondence: ; Tel.: +39-06-6859-2427; Fax: +39-06-6859-3916
| | - Domenico Umberto De Rose
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus-Newborn-Infant, “Bambino Gesù” Children’s Hospital, IRCCS, 00165 Rome, Italy; (D.U.D.R.); (A.C.M.); (I.C.); (P.G.); (A.D.)
- PhD Course in Microbiology, Immunology, Infectious Diseases, and Transplants (MIMIT), Faculty of Medicine and Surgery, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | - Anna Claudia Massolo
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus-Newborn-Infant, “Bambino Gesù” Children’s Hospital, IRCCS, 00165 Rome, Italy; (D.U.D.R.); (A.C.M.); (I.C.); (P.G.); (A.D.)
- Human Milk Bank, Medical and Surgical Department of Fetus-Newborn-Infant, “Bambino Gesù” Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Neil Patel
- Department of Neonatology, Royal Hospital for Children, Glasgow G51 4TF, UK;
| | - Irma Capolupo
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus-Newborn-Infant, “Bambino Gesù” Children’s Hospital, IRCCS, 00165 Rome, Italy; (D.U.D.R.); (A.C.M.); (I.C.); (P.G.); (A.D.)
- Human Milk Bank, Medical and Surgical Department of Fetus-Newborn-Infant, “Bambino Gesù” Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Paola Giliberti
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus-Newborn-Infant, “Bambino Gesù” Children’s Hospital, IRCCS, 00165 Rome, Italy; (D.U.D.R.); (A.C.M.); (I.C.); (P.G.); (A.D.)
- Human Milk Bank, Medical and Surgical Department of Fetus-Newborn-Infant, “Bambino Gesù” Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Melania Evangelisti
- NESMOS Department, Chair of Pediatrics, Faculty of Medicine and Psychology, Sapienza University of Rome, Sant’Andrea University Hospital, 00189 Rome, Italy; (M.E.); (P.P.); (G.D.N.)
| | - Pasquale Parisi
- NESMOS Department, Chair of Pediatrics, Faculty of Medicine and Psychology, Sapienza University of Rome, Sant’Andrea University Hospital, 00189 Rome, Italy; (M.E.); (P.P.); (G.D.N.)
| | - Alessandra Toscano
- Perinatal Cardiology Unit, Medical and Surgical Department of Fetus-Newborn-Infant, “Bambino Gesù” Children’s Hospital, IRCCS, 00165 Rome, Italy;
| | - Andrea Dotta
- Neonatal Intensive Care Unit, Medical and Surgical Department of Fetus-Newborn-Infant, “Bambino Gesù” Children’s Hospital, IRCCS, 00165 Rome, Italy; (D.U.D.R.); (A.C.M.); (I.C.); (P.G.); (A.D.)
- Human Milk Bank, Medical and Surgical Department of Fetus-Newborn-Infant, “Bambino Gesù” Children’s Hospital, IRCCS, 00165 Rome, Italy
| | - Giovanni Di Nardo
- NESMOS Department, Chair of Pediatrics, Faculty of Medicine and Psychology, Sapienza University of Rome, Sant’Andrea University Hospital, 00189 Rome, Italy; (M.E.); (P.P.); (G.D.N.)
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20
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Shine AM, Foyle L, Gentles E, Ward F, McMahon CJ. Growth and Nutritional Intake of Infants with Univentricular Circulation. J Pediatr 2021; 237:79-86.e2. [PMID: 34171362 DOI: 10.1016/j.jpeds.2021.06.037] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 06/15/2021] [Accepted: 06/17/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES To evaluate the nutritional status and early nutritional intake of infants with univentricular congenital heart disease. STUDY DESIGN The included infants underwent a Norwood procedure or hybrid intervention (stage 1) within the first 6 weeks of life, between January 2014 and January 2019, at Children's Health Ireland at Crumlin. Demographic, anthropometric, nutritional intake, and morbidity data were collected. RESULTS Data were collected on 90 infants and 1886 neonatal admission days. There was a significant drop in mean weight-for-age z-score (WAZ) between measurements at birth, -0.01 and on discharge post stage 1 surgery -1.45 (P < .01). On hospital discharge (median hospital stay, 25 days) 32% of infants had a WAZ <-2 and 11% had a WAZ <-3. Pre-stage 1, 26% received trophic feeds and 39% received parenteral nutrition. Basal metabolic requirements and target caloric intake (120 kcal/kg) were met on 56% and 13% of admission days, respectively. Infants referred to a dietitian had a shorter time to any form of nutrition support, enteral feeds, and target caloric intake (P < .001, P = .016, and P = .048, respectively). At stage 3 (Fontan) surgery, 15% of infants were classified as stunted (length-for-age z-score [LAZ] <-2). CONCLUSIONS The greatest decline in nutritional status occurs in the neonatal period, followed by significant growth stunting by the time of the Fontan procedure. Early involvement of dietitians is critical in the care of this nutritionally fragile group. With the currently low rate of preoperative nutritional support, there may be opportunities to improve intake at this critical stage.
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Affiliation(s)
- Anne Marie Shine
- Department of Clinical Nutrition and Dietetics, Children's Health Ireland at Crumlin, Dublin, Ireland.
| | - Leah Foyle
- Department of Clinical Nutrition and Dietetics, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Emma Gentles
- Department of Clinical Nutrition and Dietetics, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Fiona Ward
- Department of Clinical Nutrition and Dietetics, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Colin J McMahon
- Department of Paediatric Cardiology and Cardiothoracic Surgery, Children's Health Ireland at Crumlin, Dublin, Ireland
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21
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Lisanti AJ, Savoca M, Gaynor JW, Mascarenhas MR, Ravishankar C, Sullivan E, Pieciak K, Costarino A, Chen J, Kennedy A, Olsen R, Min J, Mondal A, Huang J, Irving SY. Standardized Feeding Approach Mitigates Weight Loss in Infants with Congenital Heart Disease. J Pediatr 2021; 231:124-130.e1. [PMID: 33359473 PMCID: PMC8005454 DOI: 10.1016/j.jpeds.2020.12.047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 12/11/2020] [Accepted: 12/16/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To evaluate the effect of a standardized feeding approach using a clinical nutrition pathway on weight-for-age Z score (WAZ) over hospital length of stay (HLOS) for infants with congenital heart disease (CHD). STUDY DESIGN A 10-year retrospective cohort study examined eligible infants who underwent neonatal cardiac surgery between July 2009 and December 2018 (n = 987). Eligibility criteria included infants born at least 37 weeks of gestation and a minimum birth weight of 2 kg who underwent cardiac surgery for CHD within the first 30 days of life. Using the best linear unbiased predictions from a linear mixed effects model, WAZ change over HLOS was estimated before and after January 2013, when the standardized feeding approach was initiated. The best linear unbiased predictions model included adjustment for patient characteristics including sex, race, HLOS, and class of cardiac defect. RESULTS The change in WAZ over HLOS was significantly higher from 2013 to 2018 than from 2009 to 2012 (β = 0.16; SE = 0.02; P < .001), after controlling for sex, race, HLOS, and CHD category, indicating that infants experienced a decreased WAZ loss over HLOS after the standardized feeding approach was initiated. Additionally, differences were found in WAZ loss over HLOS between infants with single ventricle CHD (β = 0.26; SE = 0.04; P < .001) and 2 ventricle CHD (β = 0.04; SE = 0.02; P = .04). CONCLUSIONS These data suggest that an organized, focused approach for nutrition therapy using a standardized pathway improves weight change outcomes before hospital discharge for infants with single and 2 ventricle CHD who require neonatal cardiac surgery.
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Affiliation(s)
- Amy Jo Lisanti
- Children’s Hospital of Philadelphia, Nursing and Clinical Care Services,University of Pennsylvania School of Nursing,Corresponding author: Address: 3401 Civic Center Blvd, Philadelphia, PA 19104, Phone: 610-368-4788 Fax: 267-426-7385
| | - Melanie Savoca
- Children’s Hospital of Philadelphia, Nursing and Clinical Care Services
| | - J. William Gaynor
- Children’s Hospital of Philadelphia, Division of Pediatric Cardiothoracic Surgery,University of Pennsylvania Perelman School of Medicine
| | - Maria R Mascarenhas
- University of Pennsylvania Perelman School of Medicine,Children’s Hospital of Philadelphia, Division of Gastroenterology, Hepatology and Nutrition
| | - Chitra Ravishankar
- University of Pennsylvania Perelman School of Medicine,Children’s Hospital of Philadelphia, Division of Cardiology
| | - Erin Sullivan
- Children’s Hospital of Philadelphia, Nursing and Clinical Care Services
| | - Karyn Pieciak
- Children’s Hospital of Philadelphia, Nursing and Clinical Care Services
| | - Andrew Costarino
- University of Pennsylvania Perelman School of Medicine,Children’s Hospital of Philadelphia, Division of Cardiac Critical Care Medicine
| | - Jodi Chen
- University of Pennsylvania Perelman School of Medicine,Children’s Hospital of Philadelphia, Division of Cardiac Critical Care Medicine
| | - Andrea Kennedy
- Children’s Hospital of Philadelphia, Center for Healthcare and Quality Analytics
| | - Robert Olsen
- Children’s Hospital of Philadelphia, Center for Healthcare and Quality Analytics
| | - Jungwon Min
- Children’s Hospital of Philadelphia, Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit
| | - Antara Mondal
- Children’s Hospital of Philadelphia, Department of Biomedical and Health Informatics, Data Science and Biostatistics Unit
| | - Jing Huang
- Children’s Hospital of Philadelphia Research Institute,University of Pennsylvania Perelman School of Medicine, Department of Biostatistics, Epidemiology, and Informatics
| | - Sharon Y. Irving
- Children’s Hospital of Philadelphia, Nursing and Clinical Care Services,University of Pennsylvania School of Nursing
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22
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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.
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Abstract
Congenital heart disease (CHD) is the most common birth defect for infants born in the United States, with approximately 36,000 affected infants born annually. While mortality rates for children with CHD have significantly declined, there is a growing population of individuals with CHD living into adulthood prompting the need to optimise long-term development and quality of life. For infants with CHD, pre- and post-surgery, there is an increased risk of developmental challenges and feeding difficulties. Feeding challenges carry profound implications for the quality of life for individuals with CHD and their families as they impact short- and long-term neurodevelopment related to growth and nutrition, sensory regulation, and social-emotional bonding with parents and other caregivers. Oral feeding challenges in children with CHD are often the result of medical complications, delayed transition to oral feeding, reduced stamina, oral feeding refusal, developmental delay, and consequences of the overwhelming intensive care unit (ICU) environment. This article aims to characterise the disruptions in feeding development for infants with CHD and describe neurodevelopmental factors that may contribute to short- and long-term oral feeding difficulties.
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24
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Martini S, Beghetti I, Annunziata M, Aceti A, Galletti S, Ragni L, Donti A, Corvaglia L. Enteral Nutrition in Term Infants with Congenital Heart Disease: Knowledge Gaps and Future Directions to Improve Clinical Practice. Nutrients 2021; 13:nu13030932. [PMID: 33805775 PMCID: PMC8002077 DOI: 10.3390/nu13030932] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 03/09/2021] [Indexed: 12/18/2022] Open
Abstract
Optimal nutrition is essential to improve short- and long-term outcomes in newborns with congenital heart disease (CHD). Nevertheless, several issues on nutritional management and concerns about the potential risk of complications related to enteral feeding exist. This narrative review aims to summarize and discuss the available literature on enteral feeding in term infants with CHD. A wide variability in feeding management exists worldwide. Emerging approaches to improve nutritional status and outcomes in infants with CHD include: implementation of a standardized enteral feeding protocol, both preoperative and postoperative, clearly defining time of initiation and advancement of enteral feeds, reasons to withhold, and definitions of feeding intolerance; early minimal enteral feeding; enteral feeding in stable term infants on hemodynamic support; evaluation of enteral feeding in term infants with umbilical arterial catheters and during prostaglandin infusion; assessment and support of oro-motor skills; and promotion and support of breastfeeding and provision of mother's own milk or donor milk when mother's own milk is not available. As evidence from term infants is scarce, available observations and recommendations partially rely on studies in preterm infants. Thus, well-designed studies assessing standardized clinically relevant outcomes are needed to provide robust evidence and shared recommendations and practices.
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Affiliation(s)
- Silvia Martini
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (S.M.); (I.B.); (M.A.); (S.G.); (L.C.)
| | - Isadora Beghetti
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (S.M.); (I.B.); (M.A.); (S.G.); (L.C.)
| | - Mariarosaria Annunziata
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (S.M.); (I.B.); (M.A.); (S.G.); (L.C.)
| | - Arianna Aceti
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (S.M.); (I.B.); (M.A.); (S.G.); (L.C.)
- Neonatal Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
- Correspondence: ; Tel./Fax: +39-051-342754
| | - Silvia Galletti
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (S.M.); (I.B.); (M.A.); (S.G.); (L.C.)
- Neonatal Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Luca Ragni
- Pediatric Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (L.R.); (A.D.)
| | - Andrea Donti
- Pediatric Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (L.R.); (A.D.)
| | - Luigi Corvaglia
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (S.M.); (I.B.); (M.A.); (S.G.); (L.C.)
- Neonatal Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
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25
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A preoperative standardized feeding protocol improves human milk use in infants with complex congenital heart disease. J Perinatol 2021; 41:590-597. [PMID: 33547410 DOI: 10.1038/s41372-021-00928-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 11/06/2020] [Accepted: 01/15/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To evaluate the hypothesis that implementation of a preoperative standardized feeding protocol increases human milk use in infants with complex congenital heart disease (CHD). STUDY DESIGN Single-center, quasi-experimental study of infants with complex CHD. A cohort of 546 infants pre protocol was compared to 55 patients post protocol. Feeding regimen and peri-operative outcomes information were collected. RESULT Human milk use increased significantly (58.4% versus 100%, p < 0.01) and there was no formula use post protocol (18.7% versus 0%, p < 0.01). Preoperative necrotizing enterocolitis occurred in 18/546 (3.3%) infants pre protocol versus 1/55 (1.8%) post protocol, p = 1.00. Days to full feeds and length of hospital stay in both cohorts were not significantly different. CONCLUSION Successful implementation of a preoperative standardized feeding protocol can increase human milk and decrease formula use in infants with complex CHD without significant adverse outcomes. A larger study is needed to evaluate the association of human milk use with peri-operative outcomes.
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26
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Kelleher ST, McMahon CJ, James A. Necrotizing Enterocolitis in Children with Congenital Heart Disease: A Literature Review. Pediatr Cardiol 2021; 42:1688-1699. [PMID: 34510235 PMCID: PMC8557173 DOI: 10.1007/s00246-021-02691-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 07/23/2021] [Indexed: 12/29/2022]
Abstract
Infants with congenital heart disease (CHD) are at an increased risk of developing necrotising enterocolitis (NEC), a serious inflammatory intestinal condition classically associated with prematurity. CHD not only increases the risk of NEC in preterm infants but is one of the most commonly implicated risk factors in term infants. Existing knowledge on the topic is limited largely to retrospective studies. This review acts to consolidate existing knowledge on the topic in terms of disease incidence, pathophysiology, risk factors, outcomes and the complex relationship between NEC and enteral feeds. Potential preventative strategies, novel biomarkers for NEC in this population, and the role of the intestinal microbiome are all explored. Numerous challenges exist in the study of this complex multifactorial disease which arise from the heterogeneity of the affected population and its relative scarcity. Nevertheless, its high related morbidity and mortality warrant renewed interest in identifying those infants most at risk and implementing strategies to reduce the incidence of NEC in infants with CHD.
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Affiliation(s)
- Sean T. Kelleher
- Department of Paediatric Cardiology, Children’s Health Ireland at Crumlin, Dublin 12, Ireland
| | - Colin J. McMahon
- Department of Paediatric Cardiology, Children’s Health Ireland at Crumlin, Dublin 12, Ireland
| | - Adam James
- Department of Paediatric Cardiology, Children's Health Ireland at Crumlin, Dublin 12, Ireland.
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27
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The Relationship Between Preoperative Feeding Exposures and Postoperative Outcomes in Infants With Congenital Heart Disease. Pediatr Crit Care Med 2021; 22:e91-e98. [PMID: 33009358 DOI: 10.1097/pcc.0000000000002540] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To evaluate the association of preoperative risk factors and postoperative outcomes in infants with complex congenital heart disease. DESIGN Single-center retrospective cohort study. SETTING Neonatal ICU and cardiovascular ICU. PATIENTS Infants of all gestational ages, born at Texas Children's Hospital between 2010 and 2016, with complex congenital heart disease requiring intervention prior to discharge. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 399 patients were enrolled in the study. Preoperative risk factors included feeding, type of feeding, feeding route, and cardiac lesion. Postoperative outcomes included necrotizing enterocolitis, hospital length of stay, and days to full feeds. The occurrence rate of postoperative necrotizing enterocolitis (all stages) was 8%. Preoperative feeding, type of feeding, feeding route, and cardiac lesion were not associated with higher odds of postoperative necrotizing enterocolitis. Cardiac lesions with ductal-dependent systemic blood flow were associated with a hospital length of stay of 19.6 days longer than those with ductal-dependent pulmonary blood flow (p < 0.001) and 2.9 days longer to reach full feeds than those with ductal-dependent pulmonary blood flow (p < 0.001), after controlling for prematurity. Nasogastric feeding route preoperatively was associated with a length of stay of 29.8 days longer than those fed by mouth (p < 0.001) and 2.4 days longer to achieve full feeds (p < 0.001), after controlling for prematurity and cardiac lesion. Preoperative diet itself was not associated with significant change in length of stay or days to reach full feeds. CONCLUSIONS Although cardiac lesions with ductal-dependent systemic blood flow are considered high risk and may increase length of stay and days to achieve full feeds, they are not associated with a higher risk of postoperative necrotizing enterocolitis. Nasogastric route is not associated with a significantly higher risk of necrotizing enterocolitis, but longer length of stay and days to reach full feeds. These findings challenge our perioperative management strategies in caring for these infants, as they may incur more hospital costs and resources without significant medical benefit.
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28
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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.
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29
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Eveleens R, Joosten K, de Koning B, Hulst J, Verbruggen S. Definitions, predictors and outcomes of feeding intolerance in critically ill children: A systematic review. Clin Nutr 2020; 39:685-693. [DOI: 10.1016/j.clnu.2019.03.026] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 02/20/2019] [Accepted: 03/17/2019] [Indexed: 01/18/2023]
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30
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Cognata A, Kataria-Hale J, Griffiths P, Maskatia S, Rios D, O’Donnell A, Roddy DJ, Mehollin-Ray A, Hagan J, Placencia J, Hair A. Human Milk Use in the Preoperative Period Is Associated with a Lower Risk for Necrotizing Enterocolitis in Neonates with Complex Congenital Heart Disease. J Pediatr 2019; 215:11-16.e2. [PMID: 31561958 PMCID: PMC7294855 DOI: 10.1016/j.jpeds.2019.08.009] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 07/31/2019] [Accepted: 08/06/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate the hypothesis that feeding volumes exceeding 100 mL/kg/d and exposure to cow's milk formula preoperatively increase the risk for preoperative necrotizing enterocolitis (NEC) in infants with complex congenital heart disease. STUDY DESIGN All infants, of any gestational age, with an isolated cardiac lesion at high risk for NEC (ductal-dependent lesions, transposition of the great arteries, truncus arteriosus, and aorto-pulmonary window) admitted to Texas Children's Hospital from 2010 to 2016 were included. NEC was defined based on the modified Bell criteria. Feeding regimen information and relevant covariates were collected. Logistic regression was used to evaluate the association of feeding regimen and other potential risk factors with NEC. RESULTS In this single-center, retrospective cohort of 546 infants, 3.3% developed Bell stage I-III NEC preoperatively. An exclusive unfortified human milk diet was associated with a significantly lower risk of preoperative NEC (OR 0.17, 95% CI 0.04-0.84, P = .03) in a multivariable regression model controlling for cardiac lesion, race, feeding volume, birth weight small for gestational age, inotrope use presurgery/pre-NEC, and prematurity. Feeding volumes exceeding 100 mL/kg/d were associated with a significantly greater risk of preoperative NEC (OR 3.05, 95% CI 1.19-7.90, P = .02). CONCLUSIONS The findings suggest that an unfortified exclusive human milk diet may reduce the risk of preoperative NEC in infants with complex congenital heart disease.
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Affiliation(s)
- Acacia Cognata
- Department of Pediatrics, Texas Children’s Hospital, Houston, TX,,Section of Neonatology, Texas Children’s Hospital, Houston, TX,,Baylor College of Medicine, Texas Children’s Hospital, Houston, TX
| | - Jasmeet Kataria-Hale
- Department of Pediatrics, Texas Children’s Hospital, Houston, TX,,Section of Neonatology, Texas Children’s Hospital, Houston, TX,,Baylor College of Medicine, Texas Children’s Hospital, Houston, TX
| | - Pamela Griffiths
- Department of Pediatrics, Texas Children’s Hospital, Houston, TX,,Pediatrix Medical Group, Phoenix, AZ
| | - Shiraz Maskatia
- Department of Pediatrics, Texas Children’s Hospital, Houston, TX,,Division of Cardiology, Stanford University School of Medicine, Palo Alto, CA
| | - Danielle Rios
- Department of Pediatrics, Texas Children’s Hospital, Houston, TX,,Section of Neonatology, Texas Children’s Hospital, Houston, TX,,Baylor College of Medicine, Texas Children’s Hospital, Houston, TX
| | - Andrea O’Donnell
- Department of Pediatrics, Texas Children’s Hospital, Houston, TX,,Section of Neonatology, Texas Children’s Hospital, Houston, TX,,Baylor College of Medicine, Texas Children’s Hospital, Houston, TX
| | - Dantin J. Roddy
- Department of Pediatrics, Texas Children’s Hospital, Houston, TX,,Section of Cardiology, Texas Children’s Hospital, Houston, TX,,Baylor College of Medicine, Texas Children’s Hospital, Houston, TX
| | - Amy Mehollin-Ray
- Department of Radiology, Texas Children’s Hospital, Houston, TX,,Baylor College of Medicine, Texas Children’s Hospital, Houston, TX
| | - Joseph Hagan
- Department of Pediatrics, Texas Children’s Hospital, Houston, TX,,Section of Neonatology, Texas Children’s Hospital, Houston, TX,,Baylor College of Medicine, Texas Children’s Hospital, Houston, TX
| | - Jennifer Placencia
- Department of Pediatrics, Texas Children’s Hospital, Houston, TX,,Section of Neonatology, Texas Children’s Hospital, Houston, TX,,Baylor College of Medicine, Texas Children’s Hospital, Houston, TX
| | - Amy Hair
- Department of Pediatrics, Texas Children’s Hospital, Houston, TX,,Section of Neonatology, Texas Children’s Hospital, Houston, TX,,Baylor College of Medicine, Texas Children’s Hospital, Houston, TX
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31
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Kataria-Hale J, Osborne SW, Hair A, Hagan J, Pammi M. Preoperative Feeds in Ductal-Dependent Cardiac Disease: A Systematic Review and Meta-analysis. Hosp Pediatr 2019; 9:998-1006. [PMID: 31744846 DOI: 10.1542/hpeds.2019-0111] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
CONTEXT Our aim for this review is to determine if preoperative feeds in neonates with ductal-dependent congenital heart disease are harmful or beneficial. OBJECTIVES To summarize current evidence for preoperative feeding in neonates with ductal-dependent congenital heart disease. DATA SOURCES We used the following databases: Medline, Embase, and Cochrane Central Register of Controlled Trials. STUDY SELECTION We included observational studies in which the following outcomes were addressed: necrotizing enterocolitis (NEC), hospital length of stay (LOS), time to achieve full postoperative enteral feeding, and feeding intolerance. DATA EXTRACTION Two reviewers independently screened each study for eligibility and extracted data. Methodologic quality was assessed by using a standardized item bank, and certainty of evidence for each outcome was assessed by using Grading of Recommendations Assessment, Development and Evaluation criteria. RESULTS Five retrospective cohort studies were eligible for inclusion, for which risk of bias was significant. When comparing neonates who received preoperative feeds with those who did not, there was no significant difference in NEC (pooled odds ratio = 1.09 [95% confidence interval 0.06-21.00; P = .95]; 3 studies, 6807 participants, very low certainty evidence), hospital LOS (mean of 14 days for those not fed versus 9.9 days for those fed preoperatively; P < .01; 1 study, 57 participants, very low certainty evidence), or feeding intolerance (odds ratio = 2.014 [95% confidence interval 0.079-51.703; P = .67]; 1 study, 56 participants, very low certainty evidence). No data were available for the outcome time to achieve full postoperative enteral feeding. All studies were observational and had small sample sizes. CONCLUSIONS There is insufficient evidence to suggest that preoperative enteral feeds in patients with ductal-dependent cardiac lesions adversely influence the rate of NEC, LOS, or feeding intolerance.
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Affiliation(s)
- Jasmeet Kataria-Hale
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Scott Webb Osborne
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Amy Hair
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Joseph Hagan
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Mohan Pammi
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
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32
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Latham GJ. Highlights of Current Research in Congenital Heart Disease: Presenting Abstracts From the 2019 Congenital Cardiac Anesthesia Society (CCAS) Annual Meeting. Semin Cardiothorac Vasc Anesth 2019; 23:349-351. [PMID: 31390945 DOI: 10.1177/1089253219867696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Gregory J Latham
- Seattle Children's Hospital, University of Washington, Seattle, WA, USA
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33
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Human Milk and Infants With Congenital Heart Disease: A Summary of Current Literature Supporting the Provision of Human Milk and Breastfeeding. Adv Neonatal Care 2019; 19:212-218. [PMID: 30694819 DOI: 10.1097/anc.0000000000000582] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Human milk is a life-saving medical intervention. Infants with congenital heart disease are at an increased risk for necrotizing enterocolitis, chylothorax, feeding difficulties, and growth failure. In the absence of evidence-based care, their mothers are also at risk for low milk supply and/or poor breastfeeding outcomes. PURPOSE Summarize the role of human milk and clinical outcomes for infants with congenital heart disease (CHD). Summarize methods of ideal breastfeeding support. METHODS/SEARCH STRATEGY PubMed, Cochrane Library, and CINAHL were the databases used. The terms used for the search related to CHD and necrotizing enterocolitis were "human milk" and "necrotizing enterocolitis" and "congenital heart disease." This resulted in a total of 17 publications for review. FINDINGS Infants receiving exclusive human milk diet are at a lower risk for necrotizing enterocolitis and will have improved weight gain. Infants with chylothorax who receive skimmed human milk have higher weight-for-age scores than formula-fed infants. Maternal breastfeeding education correlates with decreased risk of poor breastfeeding outcomes. IMPLICATIONS FOR PRACTICE Human milk is the ideal source of nutrition for infants with CHD and should be encouraged by the care team. Evidence-based lactation education and care must be provided to mothers and families prenatally and continue throughout the infant's hospitalization. If a mother's goal is to directly breastfeed, this should be facilitated during the infant's hospital stay. IMPLICATIONS FOR RESEARCH Evaluate the role between human milk and the incidence of necrotizing enterocolitis, feeding difficulties, and clinical outcomes in the population of infants with CHD.
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Vavolizza RD, Grabski DF, Levin DE, Gander JW. Gastrostomy tubes appear to be safe following pediatric orthotopic heart transplant. Pediatr Transplant 2019; 23:e13374. [PMID: 30786108 DOI: 10.1111/petr.13374] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 12/07/2018] [Accepted: 01/13/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Gastrostomy tube (GT) placement is a common pediatric surgical procedure typically indicated for oral aversion. This may develop in patients with congenital heart disease (CHD) who require an orthotopic heart transplant (OHT). The safety profile of GT placement in OHT patients who are immunosuppressed is unknown. Given the potential increased risk of wound site complications on a patient receiving immunosuppression, we sought to determine the safety profile of GT placement in pediatric patients with OHT. MATERIALS AND METHODS We performed a retrospective case series of all pediatric OHT recipients who subsequently underwent GT placement from January 1, 2009, to August 1, 2018, at the University of Virginia Children's Hospital. Major GT complications of wound breakdown, wound infection, peristomal GT leakage, ileus, or persistent emesis, and minor GT complication including the presence of granulation tissue are reported. RESULTS Six patients who had a pediatric OHT subsequently underwent GT placement over the study period. There were no major 30-day or 90-day GT complications. One patient had excessive granulation tissue at their GT site. There were no accounts of acute kidney injury, urinary tract infection, sepsis, or pneumonia. CONCLUSION Gastrostomy tube (GT) placement appears to be safe in pediatric OHT patients who are on immunosuppressive medications and unable to feed orally. This is the first study documenting the safety profile of GTs in pediatric OHT patients and may aid clinicians to make decisions regarding this intervention.
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Affiliation(s)
- Rick D Vavolizza
- University of Virginia School of Medicine, Charlottesville, Virginia
| | - David F Grabski
- Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Daniel E Levin
- Division of Pediatric Surgery, Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Jeffrey W Gander
- Division of Pediatric Surgery, Department of Surgery, University of Virginia School of Medicine, Charlottesville, Virginia
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The association between feeding protocol compliance and weight gain following high-risk neonatal cardiac surgery. Cardiol Young 2019; 29:594-601. [PMID: 31133078 DOI: 10.1017/s1047951119000222] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Children with congenital heart disease are at high risk for malnutrition. Standardisation of feeding protocols has shown promise in decreasing some of this risk. With little standardisation between institutions' feeding protocols and no understanding of protocol adherence, it is important to analyse the efficacy of individual aspects of the protocols. METHODS Adherence to and deviation from a feeding protocol in high-risk congenital heart disease patients between December 2015 and March 2017 were analysed. Associations between adherence to and deviation from the protocol and clinical outcomes were also assessed. The primary outcome was change in weight-for-age z score between time intervals. RESULTS Increased adherence to and decreased deviation from individual instructions of a feeding protocol improves patients change in weight-for-age z score between birth and hospital discharge (p = 0.031). Secondary outcomes such as markers of clinical severity and nutritional delivery were not statistically different between groups with high or low adherence or deviation rates. CONCLUSIONS High-risk feeding protocol adherence and fewer deviations are associated with weight gain independent of their influence on nutritional delivery and caloric intake. Future studies assessing the efficacy of feeding protocols should include the measures of adherence and deviations that are not merely limited to caloric delivery and illness severity.
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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.
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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
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Nutrition Management: Parenteral and Enteral Nutrition and Oral Intake. CONGENIT HEART DIS 2019. [DOI: 10.1007/978-3-319-78423-6_7] [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: 10/27/2022]
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Nascimento J, Santos IMMD, Silva LJD. CARE GIVEN TO NEWBORNS FED BY GASTRIC TUBE: CONCEPTS AND PRACTICES. TEXTO & CONTEXTO ENFERMAGEM 2019. [DOI: 10.1590/1980-265x-tce-2017-0242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
ABSTRACT Objective: to describe the conduct related to feeding care through gastric tube in neonates hospitalized in the Neonatal Intensive Care Unit, from scientific articles published in the last five years. Method: an integrative literature review was developed in the databases: MEDLINE, LILACS, SciELO, CINAHL and BDENF. The search for the studies was carried out in August 2016, in English, Spanish and Portuguese. Results: 33 articles were analyzed. The level of evidence was classified as level IV (30%), level VI (27%), level II (15%), level III (18%), level I, V and VII with 3% each. The analytical categories were: Gastric tubes, their materials and their use in the Neonatal Intensive Care Unit, Nursing care for enteral nutrition through gastric tube in the Neonatal Intensive Care Unit, From the tube the oral route. The time to reach total enteral nutrition is lower, as is the decrease in length of hospital stay. The largest losses of milk fat are during gastroclysis at the expense of gavage. The relationship of food tolerance to dietary dosage form and volumes is not yet conclusive. Nursing stands out: in favor of the bond with the family, in the physical examination and evaluation, in the positioning, in the non-nutritive suction during the diet, in the oral stimulus, in the observation and conduct regarding the gastric residue. Conclusion: due to the heterogeneity of the data, more randomized and qualitative clinical trials are required to better support the conduct and improvement of nursing care.
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Gephart SM, Moore EF, Fry E. Standardized Feeding Protocols to Reduce Risk of Necrotizing Enterocolitis in Fragile Infants Born Premature or with Congenital Heart Disease: Implementation Science Needed. Crit Care Nurs Clin North Am 2018; 30:457-466. [PMID: 30447806 DOI: 10.1016/j.cnc.2018.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Although a unit-adopted standardized feeding protocol (SFP) for neonates is standard of care, implementation strategies for SFPs vary across neonatal and pediatric intensive care. Besides improving growth and reducing feeding interruptions, SFPs reduce risk for necrotizing enterocolitis in infants with heart disease or born premature. The purpose of this article is to bridge the gap between recommended and actual care using SFPs.
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Affiliation(s)
- Sheila M Gephart
- Community and Health Systems Science, College of Nursing, The University of Arizona, PO Box 210203, Tucson, AZ 85721, USA.
| | - Emily F Moore
- Regional cardiology program, Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA 98105, USA
| | - Emory Fry
- Cognitive Medical Systems, 9444 Waples Street, Suite 300, San Diego, CA 92121, USA
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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.
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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
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41
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Shine AM, Finn DG, Allen N, McMahon CJ. Transition from tube feeding to oral feeding: experience in a tertiary care paediatric cardiology unit. Ir J Med Sci 2018; 188:201-208. [DOI: 10.1007/s11845-018-1812-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 04/07/2018] [Indexed: 10/17/2022]
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Necrotizing Enterocolitis in Infants with Hypoplastic Left Heart Syndrome Following Stage 1 Palliation or Heart Transplant. Pediatr Cardiol 2018; 39:774-785. [PMID: 29392349 DOI: 10.1007/s00246-018-1820-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Accepted: 01/20/2018] [Indexed: 10/18/2022]
Abstract
Previous studies of necrotizing enterocolitis (NEC) among infants with hypoplastic left heart syndrome (HLHS) were conducted in single centers or had small sample sizes. This study aimed to determine the mortality rate and the risk factors for NEC among infants with HLHS who were discharged over a 10-year period (2004-2013) from 41 Pediatric Health Information System affiliated children's hospitals. Either stage 1 palliation and/or heart transplant were completed prior to patient's death or hospital discharge. We compared the characteristics of infants with HLHS who did not develop NEC and those who developed medical or surgical NEC and of patients who had medical vs. surgical NEC. The primary outcome was mortality over time and by birth weight category (low birth weight [LBW], birth weight < 2500 vs. ≥ 2500 g). Multivariable analyses were performed to identify the risk factors for developing NEC and for mortality among infants with HLHS. The study evaluated 5720 infants with HLHS including 349 patients (6.1%) with medical or surgical NEC. Fifty-two patients (0.9%) required laparotomy or percutaneous abdominal drainage. On univariable analysis, the overall mortality rate for infants who developed NEC was significantly higher than infants who did not develop NEC (23.5 vs. 13.9%, P < 0.001). On multivariable analysis, neither medical nor surgical NEC was a significant predictor of mortality in the study population. LBW infants were at higher risk for mortality in both the univariable and the multivariable models. Nevertheless, LBW did not significantly predispose infants with HLHS to develop NEC. Our results provide a national benchmark incidence of NEC, its risk factors, and outcomes among a large cohort of infants with HLHS and establish that NEC is not a significant risk factor for mortality in this population.
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43
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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.
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44
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Preoperative malnutrition is associated with increased mortality and adverse outcomes after paediatric cardiac surgery. Cardiol Young 2017; 27. [PMID: 28625194 PMCID: PMC5908464 DOI: 10.1017/s1047951117001068] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Malnutrition is common in children with CHD and is likely to place them at an increased risk for adverse surgical outcomes. We sought to evaluate the impact of preoperative malnutrition on outcomes after paediatric cardiac surgery. METHODS We conducted a retrospective analysis of patients from age 0 to 5 years undergoing cardiac surgery at Seattle Children's Hospital from 2006 to 2015. We used regression modelling to examine the impact of malnutrition on surgical outcomes. RESULTS We found a non-linear relationship between low height-for-age and weight-for-age z-scores and mortality after surgery. In the range of z-score ⩽-2, each additional unit decrease in height-for-age or weight-for-age z-score was associated with a 2.9 or 2.1% increased risk for mortality, respectively. Each unit decrease in height-for-age z-score was associated with a 1.2% increased risk for cardiac arrest, 1.1% increased risk for infection, and an average of 1.7 additional hours of mechanical ventilation, 6 hours longer ICU stay, and 13 hours longer hospital stay. Each unit decrease in weight-for-age z-score was associated with a 0.7% increased risk for cardiac arrest, 0.8% increased risk for infection, and an average of 1.9 additional hours of mechanical ventilation and 5.3 additional hours of ICU stay. CONCLUSIONS This study is unique in demonstrating a significant association between malnutrition and 30-day mortality and other adverse outcomes after paediatric cardiac surgery in a mixed population of CHD patients. By evaluating nutritional status as a continuous variable, we were able to clearly distinguish the point at which malnutrition begins to affect mortality.
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45
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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.
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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
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Slicker J, Sables-Baus S, Lambert LM, Peterson LE, Woodard FK, Ocampo EC. Perioperative Feeding Approaches in Single Ventricle Infants: A Survey of 46 Centers. CONGENIT HEART DIS 2016; 11:707-715. [DOI: 10.1111/chd.12390] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/27/2016] [Indexed: 11/27/2022]
Affiliation(s)
| | - Sharon Sables-Baus
- University of Colorado, College of Nursing; Children's Hospital Colorado; Aurora Colo USA
| | | | | | - Frances K. Woodard
- Medical University of South Carolina Children's Hospital; Charleston SC USA
| | - Elena C. Ocampo
- Baylor College of Medicine; Texas Children's Hospital; Houston Tex USA
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Results of a Feeding Protocol in Patients Undergoing the Hybrid Procedure. Pediatr Cardiol 2016; 37:852-9. [PMID: 26921065 DOI: 10.1007/s00246-016-1359-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Accepted: 02/13/2016] [Indexed: 12/13/2022]
Abstract
Neonates with single-ventricle physiology are at increased risk of developing gastrointestinal morbidities. Feeding protocols in this patient population have been shown to decrease feeding complications after the Norwood procedure, but no data exist to determine the effectiveness of a feeding protocol in patients undergoing the hybrid procedure. Goal of this study was to examine the impact of a standardized feeding protocol on the incidence of overall postoperative gastrointestinal morbidity after the hybrid procedure. Retrospective chart review was performed on neonates undergoing the hybrid procedure. Neonates were divided into two groups, pre-feeding protocol (pre-FP), which encompassed the years 2002-2008, and post-feeding protocol (post-FP), which encompassed the years 2011-2014. Preoperative, operative, and postoperative data were collected. T test or Fisher's exact test was used for analysis. p < 0.05 was considered significant. Seventy-three neonates were in the pre-FP and 52 neonates were in the post-FP. There were no significant differences between the pre-FP and the post-FP in cardiac diagnosis (62 HLHS, 11 other vs. 39 HLHS, 13 other, respectively). Pre-FP underwent hybrid procedure later than the post-FP (9.1 ± 5.8 vs. 5.7 ± 3.4 days, respectively, p < 0.01) and achieved full enteral feeds earlier than the post-FP (3.2 + 2.9 vs. 7.8 + 3.9 days, respectively, p < 0.01). The incidence of necrotizing enterocolitis was higher in the pre-FP versus post-FP [11.0 % (8/65) vs. 5.8 % (3/49), respectively, p = 0.36]. Though not significant, the incidence of necrotizing enterocolitis decreased by almost 50 % after initiating a feeding protocol in patients undergoing the hybrid procedure. This is consistent with previous studies showing beneficial results of a feeding protocol in this complex patient population.
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48
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Karpen HE. Nutrition in the Cardiac Newborns: Evidence-based Nutrition Guidelines for Cardiac Newborns. Clin Perinatol 2016; 43:131-45. [PMID: 26876126 DOI: 10.1016/j.clp.2015.11.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Both protein and energy malnutrition are common in neonates and infants with congenital heart disease (CHD). Neonates with CHD are at increased risk of developing necrotizing enterocolitis (NEC), particularly the preterm population. Mortality in patients with CHD and NEC is higher than for either disease process alone. Standardized feeding protocols may affect both incidence of NEC and growth failure in infants with CHD. The roles of human milk and probiotics have not yet been explored in this patient population.
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Affiliation(s)
- Heidi E Karpen
- Department of Pediatrics, Emory University School of Medicine, 2015 Uppergate Drive Northeast, Atlanta, GA 30322, USA.
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49
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Donnellan A, Justice L. Preoperative Stabilization of Infants With Hypoplastic Left Heart Syndrome Before Stage I Palliation. Crit Care Nurse 2016; 36:52-9. [DOI: 10.4037/ccn2016461] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Hypoplastic left heart syndrome is a severe form of congenital heart disease that results in single-ventricle physiology. Although surgical palliation in infants with this syndrome is widely agreed on in practice, variation occurs in both surgical and medical management. Perinatal factors that affect preoperative management include the subtype of the syndrome and the patient’s birth weight, gestational age, and genetic abnormalities. The general aspects of perioperative stabilization and management are monitoring, use of vasoactive infusions, ventilatory support, and nutrition. Management strategies for balancing single-ventricle physiology are aimed at addressing the 3 major causes of desaturation: diminished pulmonary blood flow, low mixed venous oxygen saturation, and pulmonary venous desaturation.
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Affiliation(s)
- Amy Donnellan
- Amy Donnellan is a nurse practitioner in the cardiac intensive care unit, the Heart Institute, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Lindsey Justice
- Lindsey Justice is a nurse practitioner in the cardiac intensive care unit, the Heart Institute, Cincinnati Children’s Hospital Medical Center
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50
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Jenkins E. Feeding Protocols for Neonates With Hypoplastic Left Heart Syndrome. AACN Adv Crit Care 2015. [DOI: 10.4037/nci.0000000000000096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Optimizing nutrition in neonates with hypoplastic left heart syndrome is essential, given the high rate of growth failure in this population. Infants with hypoplastic left heart syndrome are predisposed to nutritional deficiency as a result of their increased metabolic demand; however, early enteral feeding also increases the risk of serious gastrointestinal morbidity and mortality caused by poor intestinal perfusion. Consequently, providers have difficulty deciding when and how to safely feed these patients. A review of the literature found that implementation of a structured enteral feeding protocol may decrease the risk of gastrointestinal complications while also minimizing dependence on parenteral nutrition and decreasing length of hospital stay. As these studies were limited, further research is warranted to establish a best practice feeding protocol to decrease risk and optimize nutrition in this fragile population.
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Affiliation(s)
- Erin Jenkins
- Erin Jenkins is Pediatric Acute Care Nurse Practitioner, 250 Hartford St, #4, San Francisco, CA 94114
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