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Lisanti AJ, Vittner DJ, Peterson J, Van Bergen AH, Miller TA, Gordon EE, Negrin KA, Desai H, Willette S, Jones MB, Caprarola SD, Jones AJ, Helman SM, Smith J, Anton CM, Bear LM, Malik L, Russell SK, Mieczkowski DJ, Hamilton BO, McCoy M, Feldman Y, Steltzer M, Savoca ML, Spatz DL, Butler SC. Developmental care pathway for hospitalised infants with CHD: on behalf of the Cardiac Newborn Neuroprotective Network, a Special Interest Group of the Cardiac Neurodevelopmental Outcome Collaborative. Cardiol Young 2023; 33:2521-2538. [PMID: 36994672 PMCID: PMC10544686 DOI: 10.1017/s1047951123000525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
Infants and children born with CHD are at significant risk for neurodevelopmental delays and abnormalities. Individualised developmental care is widely recognised as best practice to support early neurodevelopment for medically fragile infants born premature or requiring surgical intervention after birth. However, wide variability in clinical practice is consistently demonstrated in units caring for infants with CHD. The Cardiac Newborn Neuroprotective Network, a Special Interest Group of the Cardiac Neurodevelopmental Outcome Collaborative, formed a working group of experts to create an evidence-based developmental care pathway to guide clinical practice in hospital settings caring for infants with CHD. The clinical pathway, "Developmental Care Pathway for Hospitalized Infants with Congenital Heart Disease," includes recommendations for standardised developmental assessment, parent mental health screening, and the implementation of a daily developmental care bundle, which incorporates individualised assessments and interventions tailored to meet the needs of this unique infant population and their families. Hospitals caring for infants with CHD are encouraged to adopt this developmental care pathway and track metrics and outcomes using a quality improvement framework.
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Affiliation(s)
- Amy J. Lisanti
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, PA, USA, Research Institute, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Dorothy J. Vittner
- Egan School of Nursing and Health Studies, Fairfield University Fairfield, CT, USA, Connecticut Children’s, Hartford, CT, USA
| | | | - Andrew H. Van Bergen
- Advocate Children’s Heart Institute, Advocate Children’s Hospital, Oak Lawn, IL, USA
| | - Thomas A. Miller
- Department of Pediatrics, Maine Medical Center, Portland, ME, USA
| | - Erin E. Gordon
- DO, Inpatient Cardiac Neurodevelopment Program, Division of Critical Care Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Karli A Negrin
- Department of Therapeutic and Rehabilitative Services, Nemours Children Hospital, Wilmington, Delaware, USA
| | - Hema Desai
- Rehabilitation Services, CHOC Children’s Hospital, Orange, CA, USA
| | - Suzie Willette
- Department of Speech-Language Pathology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
| | - Melissa B Jones
- Cardiac Critical Care, Children’s National Hospital, Washington DC USA
| | - Sherrill D. Caprarola
- Heart Institute, Children’s Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Anna J. Jones
- Office of Advanced Practice Providers, UT Southwestern Medical Center, Dallas, TX, USA, Heart Center, Children’s Health, Dallas, TX, USA
| | - Stephanie M. Helman
- Department of Acute and Tertiary Care, University of Pittsburgh School of Nursing, Pittsburgh, PA, USA
| | - Jodi Smith
- Parent Representative, The Mended Hearts, Inc., Program Director, Richmond, VA, USA
| | - Corinne M. Anton
- Department of Psychology and Psychiatry, University of Texas Southwestern Medical Center, Dallas, Texas, USA, Department of Cardiology, Children’s Health, Dallas, Texas, USA
| | - Laurel M. Bear
- Department of Pediatrics, Medical College of Wisconsin, Children’s Wisconsin, Milwaukee, WI, USA
| | - Lauren Malik
- Department of Acute Care Therapy Services, Primary Children’s Hospital, Salt Lake City, UT, USA
| | - Sarah K. Russell
- Department of Therapeutic and Rehabilitative Services, Nemours Children Hospital, Wilmington, DE, USA
| | - Dana J. Mieczkowski
- Department of Therapeutic and Rehabilitative Services, Nemours Children Hospital, Wilmington, DE, USA
| | - Bridy O. Hamilton
- Department of Therapeutic and Rehabilitative Services, Nemours Children Hospital, Wilmington, Delaware, USA
| | - Meghan McCoy
- Pediatric and Congenital Heart Center, Duke University Hospital, Durham, NC, USA
| | - Yvette Feldman
- Nursing & Patient Care Center of Excellence, St. Luke’s Health System, Boise, ID, USA
| | - Michelle Steltzer
- Single Ventricle Center of Excellence, Ann & Robert H. Lurie Children’s Hospital, Chicago, IL, USA
| | - Melanie L Savoca
- Department of Clinical Nutrition, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Diane L. Spatz
- Department of Family & Community Health, University of Pennsylvania School of Nursing, The Center for Pediatric Nursing Research and Evidence Based Practice, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Samantha C. Butler
- Department of Psychiatry (Psychology), Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
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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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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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Abstract
Optimal nutrition support in critically ill children is associated with improved outcomes and decreased mortality. Nutrition provision often competes with other care priorities in critically ill patients. The 2017 Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient supplement clinician knowledge and inform best practices for nutrition therapy in this vulnerable patient population.
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Brown AM, Fisher E, Forbes ML. Bolus vs Continuous Nasogastric Feeds in Mechanically Ventilated Pediatric Patients: A Pilot Study. JPEN J Parenter Enteral Nutr 2018; 43:750-758. [PMID: 30570162 DOI: 10.1002/jpen.1495] [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] [Received: 08/01/2018] [Accepted: 11/27/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND Malnutrition increases the risk of mortality and morbidity in the pediatric intensive care unit (PICU). Barriers to adequate delivery of enteral nutrition (EN) include hemodynamic instability, feeding interruptions and intolerance, and lack of standardized feeding protocols. The most recent guidelines on nutrition support for the critically ill child describe a paucity of evidence around the best method to deliver EN. There is an untested clinical assumption that bolus gastric feeding (B-GF) in intubated patients is associated with aspiration events, lung injury, and associated morbidity compared with continuous gastric feeding (C-GF). This study compared the effectiveness and safety of C-GF vs B-GF in intubated pediatric patients. METHODS We enrolled randomized patients aged 1 month-12 years who were intubated within 24 hours and received EN starting within 48 hours of admission to a C-GF or B-GF group. Goal-directed EN volume and caloric density were increased every 3 and 12 hours, respectively, to target. Feeding interruptions and intolerance events were recorded. RESULTS Twenty-five subjects were enrolled (B-GF = 11; C-GF = 14). At 24 hours, B-GF was associated with higher energy and protein delivery (P < 0.007) and was associated with faster time to goal volume (median B-GF = 15 hours; C-GF = 29.5 hours). No aspiration events resulting in additional lung injury were noted for either group (P = 0.866). CONCLUSIONS B-GF was associated with superior delivery of EN with a comparable safety profile to C-GF. Further study is needed to compare both EN methods in other PICU populations.
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Affiliation(s)
- Ann-Marie Brown
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA.,Pediatric Intensive Care Unit, Akron Children's Hospital, Akron, Ohio, USA
| | - Elaine Fisher
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA.,School of Nursing, College of Health Professions, The University of Akron, Akron, Ohio, USA
| | - Michael L Forbes
- Pediatric Intensive Care Unit, Akron Children's Hospital, Akron, Ohio, USA
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Tume LN, Valla FV. A review of feeding intolerance in critically ill children. Eur J Pediatr 2018; 177:1675-1683. [PMID: 30116972 DOI: 10.1007/s00431-018-3229-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 08/09/2018] [Accepted: 08/10/2018] [Indexed: 01/01/2023]
Abstract
Ensuring optimal nutrition is vital in critically ill children and enteral feeding is the main route of delivery in intensive care. Feeding intolerance is the most commonly cited reason amongst pediatric intensive care unit healthcare professionals for stopping or withholding enteral nutrition, yet the definition for this remains inconsistent, nebulous, and entirely arbitrary. Not only does this pose problems clinically, but research in this field frequently uses feeding intolerance as an endpoint and the heterogeneity in this definition makes the comparison of studies difficult and meta-analysis impossible. We reviewed the use of, and definitions of, the term feed intolerance in pediatric intensive care research papers in the last 20 years. Gastric residual volume remains the most common factor used to define feed intolerance, despite the lack of evidence for this. Healthcare professionals would benefit from further education to improve their awareness of the limitations of the markers to define feeding intolerance, and the international PICU community needs to agree a consistent definition of this phenomenon to improve consistency in both practice and research.Conclusion: This paper will provide a narrative review of the definitions of, evidence for, and markers of feeding intolerance in critically ill children. What is Known?: • Feeding intolerance is a commonly cited reason amongst pediatric intensive care unit healthcare professionals for stopping or withholding enteral nutrition. • There is no agreed definition for feeding intolerance in critically ill children. What is New?: • This paper provides an up to date review of the definitions of, evidence for, and markers of feeding intolerance in critically ill children. • Despite no evidence, gastric residual volume continues to drive clinical bedside decisions about enteral feeding and feeding tolerance.
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Affiliation(s)
- Lyvonne N Tume
- Faculty of Health and Applied Sciences, The University of the West of England, Glenside Campus, Blackberry Hill, Stapleton, Bristol, BS16 1DD, UK. .,Pediatric Intensive Care Unit, Bristol Children's Hospital, Upper Maudlin Street, Bristol, UK.
| | - Frédéric V Valla
- Pediatric Intensive Care Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 59 Bd Pinel, 69500, Lyon-Bron, France
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Baǧci S, Keleş E, Girgin F, Yıldızdaş DR, Horoz ÖÖ, Yalındağ N, Tanyıldız M, Bayrakçi B, Kalkan G, Akyıldız BN, Köker A, Köroğlu T, Anıl AB, Zengin N, Dinleyici EÇ, Kıral E, Dursun O, Yavuz ST, Bartmann P, Müller A. Early initiated feeding versus early reached target enteral nutrition in critically ill children: An observational study in paediatric intensive care units in Turkey. J Paediatr Child Health 2018; 54:480-486. [PMID: 29278447 DOI: 10.1111/jpc.13810] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 09/25/2017] [Accepted: 10/03/2017] [Indexed: 01/12/2023]
Abstract
AIM Although early enteral nutrition (EN) is strongly associated with lower mortality in critically ill children, there is no consensus on the definition of early EN. The aim of this study was to evaluate our current practice supplying EN and to identify factors that affect both the initiation of feeding within 24 h after paediatric intensive care unit (PICU) admission and the adequate supply of EN in the first 48 h after PICU admission in critically ill children. METHODS We conducted a prospective, multicentre, observational study in nine PICUs in Turkey. Any kind of tube feeding commenced within 24 h of PICU admission was considered early initiated feeding (EIF). Patients who received more than 25% of the estimated energy requirement via enteral feeding within 48 h of PICU admission were considered to have early reached target EN (ERTEN). RESULTS Feeding was initiated in 47.4% of patients within 24 h after PICU admission. In many patients, initiation of feeding seems to have been delayed without an evidence-based reason. ERTEN was achieved in 43 (45.3%) of 95 patients. Patients with EIF were significantly more likely to reach ERTEN. ERTEN was an independent significant predictor of mortality (P < 0.001), along with reached target enteral caloric intake on day 2 associated with decreased mortality. CONCLUSIONS There is a substantial variability among clinicians' perceptions regarding indications for delay to initiate enteral feeding in critically ill children, especially after the first 6 h of PICU admission. ERTEN, but not EIF, is associated with a significantly lower mortality rate in critically ill children.
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Affiliation(s)
- Soyhan Baǧci
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, University of Bonn, Bonn, Germany
| | - Elif Keleş
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Gazi, Ankara, Turkey
| | - Feyza Girgin
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Marmara, Istanbul, Turkey
| | - Dinçer R Yıldızdaş
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Cukurova, Adana, Turkey
| | - Özden Ö Horoz
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Cukurova, Adana, Turkey
| | - Nilüfer Yalındağ
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Marmara, Istanbul, Turkey
| | - Murat Tanyıldız
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Hacettepe, Ankara, Turkey
| | - Benan Bayrakçi
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Hacettepe, Ankara, Turkey
| | - Gökhan Kalkan
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Gazi, Ankara, Turkey
| | - Başak N Akyıldız
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Erciyes, Kayseri, Turkey
| | - Alper Köker
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Dokuz Eylül, Izmir, Turkey
| | - Tolga Köroğlu
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Dokuz Eylül, Izmir, Turkey
| | - Ayşe B Anıl
- Pediatric Intensive Care Unit, Department of Pediatrics, Izmir Tepecik Hospital, Izmir, Turkey.,Pediatric Intensive Care Unit, Department of Pediatrics, University of Izmir Katip Celebi, Izmir, Turkey
| | - Neslihan Zengin
- Pediatric Intensive Care Unit, Department of Pediatrics, Izmir Tepecik Hospital, Izmir, Turkey
| | - Ener Ç Dinleyici
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Osmangazi, Eskisehir, Turkey
| | - Eylem Kıral
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Osmangazi, Eskisehir, Turkey
| | - Oğuz Dursun
- Pediatric Intensive Care Unit, Department of Pediatrics, University of Akdeniz, Antalya, Turkey
| | | | - Peter Bartmann
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, University of Bonn, Bonn, Germany
| | - Andreas Müller
- Department of Neonatology and Pediatric Intensive Care, Children's Hospital, University of Bonn, University of Bonn, Bonn, Germany
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