Total Energy Expenditure of Infants with Congenital Heart Disease Who Have Undergone Surgical Intervention

A scoping review: urinary markers of metabolic maturation in infants with CHD and the relationship to growth

BACKGROUND

Growth failure in infants born with CHD is a persistent problem, even in those provided with adequate nutrition.

OBJECTIVE

To summarise the published data describing the change in urinary metabolites during metabolic maturation in infants with CHD and identify pathways amenable to therapeutic intervention.

DESIGN

Scoping review.

ELIGIBILITY CRITERIA

Studies using qualitative or quantitative methods to describe urinary metabolites pre- and post-cardiac surgery and the relationship with growth in infants with CHD.

SOURCES OF EVIDENCE

NICE Healthcare Databases website was used as a tool for multiple searches.

RESULTS

347 records were identified, of which 37 were duplicates. Following the removal of duplicate records, 310 record abstracts and titles were screened for inclusion. The full texts of eight articles were reviewed for eligibility, of which only two related to infants with CHD. The studies included in the scoping review described urinary metabolites in 42 infants. A content analysis identified two overarching themes of metabolic variation predictive of neurodevelopmental abnormalities associated with anaerobic metabolism and metabolic signature associated with the impact on gut microbiota, inflammation, energy, and lipid digestion.

CONCLUSION

The results of this scoping review suggest that there are considerable gaps in our knowledge relating to metabolic maturation of infants with CHD, especially with respect to growth. Surgery is a key early life feature for CHD infants and has an impact on the developing biochemical phenotype with implications for metabolic pathways involved in immunomodulation, energy, gut microbial, and lipid metabolism. These early life fingerprints may predict those individuals at risk for neurodevelopmental abnormalities.

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

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

Effect of high-energy and/or high-protein feeding in children with congenital heart disease after cardiac surgery: a systematic review and meta-analysis

High-energy or high-protein feeding offers a promising approach to improving malnutrition in children after congenital heart surgery. However, the effect of high-energy or high-protein feeding in this population has not yet been systematically reviewed. Therefore, we aimed to assess the safety and effectiveness of high-energy or high-protein feeding in children after congenital heart surgery. Five electronic databases (PubMed, Embase, CENTRAL, CINAHL, and Scopus) were searched from inception to April 23, 2022. After screening the literature according to inclusion and exclusion criteria, a risk of bias assessment was performed using version 2 of the Cochrane risk-of-bias tool for randomized trials, and the certainty of the evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations system. Finally, the random effects model was used to perform a meta-analysis of all data. A total of 609 subjects from 9 studies were included for qualitative analysis, and meta-analyses were performed on data from 8 of these studies. The results showed that high-energy and/or high-protein feeding did not increase feeding intolerance (RR = 1.09, 95% CI: 0.80, 1.48) or fluid intake (MD =  - 12.50 ml/kg/d, 95% CI: - 36.10, 11.10); however, the intervention was beneficial in increasing weight (MD = 0.5 kg, 95% CI: 0.23, 0.77) and reducing the duration of mechanical ventilation (MD =  - 17.45 h, 95% CI: - 27.30, - 7.60), intensive care unit (ICU) stay (MD =  - 1.45 days, 95% CI: - 2.36, - 0.54) and hospital stay (MD =  - 2.82 days, 95% CI: - 5.22, - 0.43). However, high-energy and/or protein feeding did not reduce the infection rate (RR = 0.68, 95% CI: 0.25, 1.87) or mortality (RR = 1.50, 95% CI: 0.47, 4.82).

CONCLUSION

The certainty of the evidence was graded as moderate to high, which suggests that high-energy and/or high-protein feeding may be safe in children after congenital heart surgery. Furthermore, this intervention improves nutrition and reduces the duration of mechanical ventilation, length of ICU stay, and length of hospital stay. However, the overall conclusion of this meta-analysis will need to be confirmed in a cohort of patients with different cardiac physiologies.

WHAT IS KNOWN

• Malnutrition is highly prevalent in children with congenital heart disease (CHD) and can negatively affect the prognosis of these children. • High-energy and/or high-protein feeding can improve nutrition status and facilitate recovery; however, evidence on its safety and efficacy is lacking.

WHAT IS NEW

• Pooled data suggest that high-energy and/or high-protein feeding does not increase fluid intake or feeding intolerance in children with CHD. • High-energy and/or high-protein feeding may reduce the duration of mechanical ventilation, length of intensive care unit stay, and length of hospital stay.

Anthropometry Based Growth and Body Composition in Infants with Complex Congenital Heart Disease

BACKGROUND

Infants with congenital heart disease (CHD) often have poor growth and altered body composition (fat and muscle accretion).

AIM

Describe growth patterns in infants with CHD using interval weight, length, head circumference (HC), triceps (TSF), subscapular skinfolds (SSSF), and mid-upper arm circumference (MUAC) measurements.

SUBJECTS AND METHODS

A total of 120 infants enrolled: 48% healthy and 58% with CHD (45% single ventricle [SV]; 55% two ventricle [2V] physiology). Weight, length, HC, TSF, SSSF, and MUAC measured at 3-, 6-, 9-, and 12-months of age.

RESULTS

CHD infants had lower weight, length, and HC z-scores at 3-, 6-, and 9-months. At 9-months, infants with SV physiology had larger TSF and SSSF z-scores over 2V and healthy infants. Overall MUAC z-scores were smaller at 3- and 6-months in infants with CHD.

CONCLUSISON

Infants with CHD have a complex pattern of growth. Longitudinal growth and body composition measurements provide information to better understand this pattern.

High-Energy Enteral Nutrition in Infants After Complex Congenital Heart Surgery

BACKGROUND

Malnutrition is common in complex congenital heart disease (CCHD). The purpose of this study was to compare the safety and efficacy of early initiation of high-energy enteral nutrition (EN) with regular energy EN in infants after surgery for CCHD.

METHODS

This is a subgroup analysis of a randomized controlled trial (RCT) which was conducted in the cardiac intensive care unit (CICU) of the largest pediatric heart center in China. Eighty children with CCHD after surgery were from two groups, the intervention group (n = 40) was given high-energy EN and the control group (n = 40) was given regular energy EN. We analyzed the effects of the two interventions on outcomes such as caloric attainment rate, gastrointestinal intolerance, duration of mechanical ventilation, and anthropometry at discharge.

RESULTS

There was no difference in the daily milk intake between the two groups, but the calorie intake (50.2 vs. 33.4, P < 0.001), protein intake (1.1 vs. 0.9, P < 0.001) and caloric attainment rate were higher in the intervention group (77.5 vs. 45.0%, P = 0.003). In addition, the incidence of pneumonia (P = 0.003) and duration of mechanical ventilation (P = 0.008) were less in the intervention group, and biceps circumference and triceps skinfold thickness at hospital discharge were greater than those in the control group (P < 0.001). We have not found statistical differences in gastrointestinal intolerance, glycemic fluctuations, incidence of pressure ulcers, length of CICU stay and postoperative hospital days between the two groups.

CONCLUSIONS

Early initiation of high-energy EN may be safe and effective in infants after complex cardiac surgery. Low doses high-energy EN did not increase gastrointestinal intolerance or glycemic fluctuations and also improved post-operative nutrition by increasing caloric and protein intake without increasing fluid intake.

Estimated Energy Requirements of Infants and Young Children up to 24 Months of Age

BACKGROUND

Establishing energy requirements in infants and young children is important in developing age-appropriate diet recommendations but most published guidelines for energy requirements have 1 or more limitations related to the data underlying the calculations.

OBJECTIVE

To develop a comprehensive set of daily energy requirements for infants and young children aged 0-24 mo meeting the ideals of worldwide applicability to all healthy children based on the use of the doubly labeled water (DLW) technique to measure total energy expenditure (TEE), the use of recent, international growth charts, and calculation of values across a wide range of body weight.

METHODS

Daily estimated energy requirements (EERs) were calculated in 1-mo increments from 0 to 24 mo for boys, girls, and combined, using as inputs the following: 1) TEE measured using the DLW technique, 2) energy deposition estimates from the Institute of Medicine, and 3) body weight values from the 25th to 75th percentiles from the 2006 WHO growth charts. EERs were combined for age groups 0 to <6, 6-8, 9-11, and 12-24 mo by averaging EERs from individual months. The EER calculations were supported by a systematic literature review and a meta-regression of existing studies.

RESULTS

Energy requirements naturally increase with age and are slightly higher in boys than in girls. The EERs derived in this study are similar to those in other recent international efforts.

CONCLUSIONS

This updated set of EERs for infants and young children expand and improve upon the methodology used to establish previous published guidelines. These estimates have multiple potential uses including planning age-appropriate menus for the complementary feeding period, the development of foods that are more precisely targeted to the needs of infants and children at particular ages, and establishing macronutrient requirements within specific age groups based on a percentage of energy, such as dietary fat.

Percutaneous Endoscopic Gastrostomy Enhances Interstage Growth in Infants With Hypoplastic Left Heart Syndrome

OBJECTIVES

Infants with hypoplastic left heart syndrome undergoing staged palliation commonly experience chronic growth failure and malnutrition. Greater patient weight at stage 2 palliation (Glenn) is thought to be associated with improved perioperative outcomes. We aimed to compare weight for age z score and interstage growth velocity in children with and without a percutaneous endoscopic gastrostomy prior to Glenn and hypothesize that those with a percutaneous endoscopic gastrostomy experience-enhanced interstage growth and reduced malnutrition rates.

DESIGN

Single-center, retrospective cohort study.

SETTING

A total of 259-bed, quaternary, pediatric referral center.

PATIENTS

Infants with hypoplastic left heart syndrome from 2007 to 2016 with and without percutaneous endoscopic gastrostomy insertion after initial palliation (Norwood).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Primary outcomes were weight for age z score (at birth, Norwood, Norwood discharge, and Glenn), interstage growth velocity, and moderate-to-severe malnutrition (weight for age z score<-2) rates. Secondary outcomes were lengths of stay, mechanical ventilation rates after Glenn, and mortality. Statistical analyses included chi-square, Wilcoxon rank-sum, student's t, paired testing, and exploratory logistic regression. Of the 69 infants studied, 47 (68%) had percutaneous endoscopic gastrostomy insertion at a median of 156 (interquartile range, 115-158) days prior to Glenn. Among children with and without percutaneous endoscopic gastrostomy, we observed no differences in demographics, comorbidities, cardiothoracic surgical times, postoperative Glenn outcomes (length of stay, mechanical ventilation rate, peak 24-hr lactate, nitric oxide use, extracorporeal life support rate, or mortality), weight for age z score at birth, and weight for age z score at Norwood. At the time of percutaneous endoscopic gastrostomy insertion, weight for age z score was -2.5 ± 1.3 and subsequent growth velocity increased from 8 ± 7 to 40 ± 59 g/d (p < 0.01). From Norwood discharge to the date of Glenn, weight for age z score increased in infants with percutaneous endoscopic gastrostomy (-2.5 ± 1.1 to -1.5 ± 1.4 [p < 0.01]) with a large reduction in moderate-to-severe malnutrition rates (76-36%; p < 0.01). In general, weight for age z score at the time of Glenn was associated with reduced postoperative mortality (odds ratio, 0.3; 95% CI, 0.09-0.95; p = 0.04).

CONCLUSIONS

Infants undergoing palliation for hypoplastic left heart syndrome with percutaneous endoscopic gastrostomy insertion prior to Glenn had improved growth velocity and dramatically reduced rates of moderate-to-severe malnutrition rates (40% reduction). In addition, we noted weight for age z score at when Glenn was associated with improved postoperative Glenn survival. No complications from percutaneous endoscopic gastrostomy were noted. Placement of a percutaneous endoscopic gastrostomy improved weight for age z score, enhanced interstage growth, and reduced malnutrition rates for this at-risk population of malnourished children.

[Effect of calorie-enriched formula on postoperative catch-up growth in infants with cyanotic congenital heart disease: a propective randomized controlled study]

OBJECTIVE

To study the effect of calorie-enriched formula on postoperative catch-up growth in infants with cyanotic congenital heart disease (CHD).

METHODS

A total of 100 infants with cyanotic CHD who underwent surgical operation from January to December, 2017, were randomly divided into a high-calorie group (receiving calorie-enriched formula after surgery) and a conventional group (receiving standard formula after surgery), with 50 infants in each group. All infants were followed up for 6 months. The observation indices included body height, body weight, prealbumin, and N-terminal pro-brain natriuretic peptide before surgery, at the time of ventilator weaning and extubation after surgery, and at 1, 3, and 6 months after surgery. Height-for-age Z-score (HAZ), weight-for-age Z-score (WAZ), and weight-for-height Z-score (WHZ) were also assessed. Adverse reactions were recorded for both groups.

RESULTS

There were 25 cases (50%) and 21 cases (42%) of malnutrition in the high-calorie group and the conventional group respectively before surgery (P > 0.05). The nutritional status of the two groups improved 6 months after surgery (P < 0.05). At 6 months after surgery, compared with the conventional group, the high-calorie group had a lower proportion of infants with malnutrition (18% vs 36%, P < 0.05) and also a lower proportation of infants with a WAZ score of < -2 (P < 0.05). The infants with malnutrion in the high-calorie group had higher HAZ, WAZ, and WHZ than those in the conventional group (P < 0.05). No gastrointestinal intolerance was observed in both groups during hospitalization.

CONCLUSIONS

Compared with the standard formula, calorie-enriched formula can better help with postoperative catch-up growth in infants with cyanotic CHD.

Nutrition of neonates with congenital heart disease: existing evidence, conflicts and concerns

Introduction: Congenital heart disease is one of the most of the groups of congenital anomalies with an incidence of about 1 per 100 live births. Almost one-third of these infants require some type of intervention, usually in the first year of life and increasingly often in the neonatal period. Innovative reparative and palliative surgical procedures and advanced medical support in the Neonatal Intensive Care Unit have significantly reduced the mortality related to congenital heart disease. Achieving survival is not the only target of clinicians for these patients. Appropriate growth, development, and improved quality of life are also very important. Growth failure is a very common problem of these children and nutritional support and management are a challenge for health care providers. Early intervention and identification of at-risk patients have the potential to decrease morbidity and mortality related to malnutrition.Aim/methods: The purpose of this article is to analyze the existing evidence and common concerns about perioperative and postdischarge nutritional management of neonates with congenital heart disease based on the special issues or complications that may arise. Furthermore, we reviewed the recent literature about current practices and proposed policies that could prevent malnutrition and improve the outcomes of neonates with congenital heart disease.Results/conclusion: A standardized institutional protocol and clear guidelines referring to feeding initiation, prompt estimation of caloric needs and provision of adequate and appropriate nutrient intake is likely to benefit these patients. Clear definitions for the nutritional approach in the setting of medical complications and close assessment of growth by pediatricians and specialized nutritionists are crucial for the long-term outlook and quality of life of these infants.

Percutaneous Endoscopic Gastrostomy After Cardiothoracic Surgery in Children Less Than 2 Months Old: An Assessment of Long-Term Malnutrition Status and Gastrostomy Outcomes

OBJECTIVES

Infants with critical congenital heart disease undergoing cardiothoracic surgery commonly experience chronic malnutrition and growth failure. We sought to determine whether placement of a percutaneous endoscopic gastrostomy was associated with reduced moderate-severe malnutrition status and to describe percutaneous endoscopic gastrostomy-related clinical and safety outcomes in this population.

DESIGN

Single-center, retrospective cohort study.

SETTING

Two hundred fifty-nine-bed, tertiary care, pediatric referral center.

PATIENTS

Children with congenital heart disease less than 2 months old undergoing cardiothoracic surgery from 2007 to 2013 with and without percutaneous endoscopic gastrostomy.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Primary outcomes were weight for age z scores during hospitalization, at 6 months, and 1 year after cardiothoracic surgery. Secondary outcomes were frequency of percutaneous endoscopic gastrostomy revision, percutaneous endoscopic gastrostomy complications, and mortality. Statistical analyses included Wilcoxon rank-sum, Fisher exact, and Student t tests. Two hundred twenty-two subjects met study criteria, and 77 (35%) had percutaneous endoscopic gastrostomy placed at a mean of 45 ± 31 days after cardiothoracic surgery. No differences were noted for demographics, comorbidities, and weight for age z score at birth and at the time of cardiothoracic surgery. The percutaneous endoscopic gastrostomy cohort had greater Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery risk category (4 [4-5] vs 4 [2-4]) and length of stay (71 d [49-101 d] vs 26 d [15-42 d]). Mean weight for age z score at the time of percutaneous endoscopic gastrostomy was -2.8 ± 1.3. Frequency of moderate-severe malnutrition (weight for age z score, ≤ -2) was greater in children with percutaneous endoscopic gastrostomy at discharge (78% vs 48%), 6 months (61% vs 16%), and 1 year (41% vs 2%). Index mortality was lower in children with percutaneous endoscopic gastrostomy at 30 days (8% vs 0%) and hospital discharge (19% vs 4%). However, no mortality differences were observed after discharge. Growth velocity after percutaneous endoscopic gastrostomy was greater (44 ± 19 vs 10 ± 9 g/d). Children tolerated percutaneous endoscopic gastrostomy without hemodynamic compromise, minor percutaneous endoscopic gastrostomy complications, and anticipated percutaneous endoscopic gastrostomy revisions. Children without mortality had percutaneous endoscopic gastrostomy removal at a median duration of 253 days (133-545 d). Children with univentricular physiology had improved in-hospital mean growth velocity (6.3 vs 24.4 g/d; p < 0.01) and reduced 1-year rate moderate-severe malnutrition (66.7% vs 36.9%; p < 0.01) after percutaneous endoscopic gastrostomy placement.

CONCLUSIONS

Percutaneous endoscopic gastrostomy placement was well tolerated and associated with improved postoperative growth velocity in children with critical congenital heart disease undergoing cardiothoracic surgery less than 2 months old. These findings were also noted in our subanalysis of children with univentricular physiology. Persistent rates of moderate-severe malnutrition were noted at 1-year follow-up. Although potential index mortality benefit was observed, definitive data are still needed.

A Comparative Analysis of Equations to Estimate Patient Energy Requirements Following Cardiopulmonary Bypass for Correction of Congenital Heart Disease

Background

No consensus exists on the optimal method to estimate resting energy expenditure (REE) in critically ill children following cardiopulmonary bypass (CPB). This study assesses the accuracy of REE estimation equations in children with congenital heart disease following CPB and tests the feasibility of using allometric scaling as an alternative energy prediction equation.

Methods

A retrospective analysis of a pediatric cohort following CPB (n = 107; median age 5.2 months, median weight 5.65 kg) who underwent serial measures (median 5 measurements) of REE using indirect calorimetry for 72 hours following CPB. We estimated REE using common estimation methods (Dietary Reference Intake, Harris Benedict, Schofield, World Health Organization [WHO]) as well as novel allometric equations. We compared estimated with measured REE to determine accuracy of each equation using overall discrepancy, calculated as a time‐weighted average of the absolute deviation.

Results

All equations incorrectly estimated REE at all time points following CPB, with overestimation error predominating. WHO had the lowest discrepancy at 10.7 ± 8.4 kcal/kg/d. The allometric equation was inferior, with an overall discrepancy of 16.9 ± 10.4. There is a strong nonlinear relationship between body surface area and measured REE in this cohort, which is a key source of estimation error using linear equations.

Conclusion

In a cohort of pediatric patients with congenital heart disease following CPB, no currently utilized clinical estimation equation reliably estimated REE. Allometric scaling proved inferior in estimating REE in children following CPB. Indirect calorimetry remains the ideal method of determining REE after CPB until nonlinear methods can be derived due to overestimation using linear equations.

High-energy nutrition in paediatric cardiac critical care patients: a randomized controlled trial

BACKGROUND

Previous studies have shown that feeding a high-energy formula (HF) to infants after cardiac surgery increases energy intake, with fewer side effects on cardiopulmonary function. However, impacts on weight gain and gastrointestinal function remain unclear.

AIMS AND OBJECTIVES

To determine the impact of HF compared with standard formula on weight gain and gastrointestinal tolerance in postoperative infants with congenital heart disease.

DESIGN

This was a randomized controlled trial.

METHODS

The setting of the study was at a 20-bed cardiac intensive care unit at a tertiary children's hospital in China. Study population included infants <1 year of age who underwent cardiac surgery and were allocated to the intervention group (n = 32) or control group (n = 32). The intervention group received HF (100 kcal/100 mL), and the control group received standard formula (67 kcal/100 mL) for 7 days during the stabilized postoperative period at the cardiac intensive care unit. Primary outcomes were weight gain and gastrointestinal intolerance. Secondary outcomes were energy intake and standard intensive care characteristics.

RESULTS

Infants who received HF (n = 30) showed less weight loss than those who received standard formula (n = 29); -16 g [95% confidence interval (CI): -74 to 42] versus -181 g (95% CI: -264 to -99), P = 0·001. The evaluation of gastrointestinal intolerance showed that the intervention group had several side effects, such as abdominal distension (n = 1), gastric retention (n = 2) and diarrhoea (n = 1), while the control group had no problems. Enteral energy intake in the intervention group was higher than the control group from day three.

CONCLUSION

Infants after cardiac surgery fed with HF gained more weight but had increased feeding intolerance. However, the feeding intolerance symptoms could be relieved by medication and did not affect feeding advancement.

RELEVANCE TO CLINICAL PRACTICE

Paediatric intensive care clinicians should consider gradually increasing the energy density of the formula during feeding and assess feeding intolerance signs in some children with malnutrition after cardiac surgery.

Postoperative feeding problems in patients with tetralogy of Fallot, pulmonary atresia, and major aortopulmonary collaterals undergoing unifocalisation surgery

BACKGROUND

Patients with tetralogy of Fallot, pulmonary atresia, and major aortopulmonary collaterals are at risk for prolonged hospitalisation after unifocalisation. Feeding problems after congenital heart surgery are associated with longer hospital stay. We sought to determine the impact of baseline, intra-operative, and postoperative factors on the need for feeding tube use at the time of discharge.

METHODS

We included patients with the aforementioned diagnosis undergoing unifocalisation from ages 3 months to 4 years from 2010 to 2016. We excluded patients with a pre-existing feeding tube. Patients discharged with an enteric tube were included in the feeding tube group. We compared the feeding tube group with the non-feeding-tube group by univariable and multi-variable logistic regression.

RESULTS

Of the 56 patients studied, 41% used tube feeding. Median age and weight z-score were similar in the two groups. A chromosome 22q11 deletion was associated with the need for a feeding tube (22q11 deletion in 39% versus 15%, p=0.05). Median cardiopulmonary bypass time in the feeding tube group was longer (335 versus 244 minutes, p=0.04). Prolonged duration of mechanical ventilation was associated with feeding tube use (48 versus 3%, p=0.001). On multi-variable analysis, prolonged mechanical ventilation was associated with feeding tube use (odds ratio 10.2, 95% confidence intervals 1.6; 63.8).

CONCLUSION

Among patients with tetralogy of Fallot, pulmonary atresia, and major aortopulmonary collaterals who were feeding by mouth before surgery, prolonged mechanical ventilation after unifocalisation surgery was associated with feeding tube use at discharge. Anticipation of feeding problems in this population and earlier feeding tube placement may reduce hospital length of stay.

The development of a consensus-based nutritional pathway for infants with CHD before surgery using a modified Delphi process

IntroductionDespite improvements in the medical and surgical management of infants with CHD, growth failure before surgery in many infants continues to be a significant concern. A nutritional pathway was developed, the aim of which was to provide a structured approach to nutritional care for infants with CHD awaiting surgery.Materials and methodsThe modified Delphi process was development of a nutritional pathway; initial stakeholder meeting to finalise draft guidelines and develop questions; round 1 anonymous online survey; round 2 online survey; regional cardiac conference and pathway revision; and final expert meeting and pathway finalisation.

RESULTS

Paediatric Dietitians from all 11 of the paediatric cardiology surgical centres in the United Kingdom contributed to the guideline development. In all, 33% of participants had 9 or more years of experience working with infants with CHD. By the end of rounds 1 and 2, 76 and 96% of participants, respectively, were in agreement with the statements. Three statements where consensus was not achieved by the end of round 2 were discussed and agreed at the final expert group meeting.

CONCLUSIONS

Nutrition guidelines were developed for infants with CHD awaiting surgery, using a modified Delphi process, incorporating the best available evidence and expert opinion with regard to nutritional support in this group.

Optimizing Nutrition in Pediatric Heart Failure: The Crisis Is Over and Now It's Time to Feed

Pediatric heart failure is a complex disease occurring when cardiac output is unable to meet the metabolic demands of the body. With improved surgical interventions and medical therapies, survival rates have improved, and care has shifted from focusing on survival to optimizing quality of life and health outcomes. Based on current literature, this review addresses the nutrition needs of infants and children in heart failure and describes the pathophysiology and metabolic implications of this disease. The prevalence of wasting in pediatric heart failure has been reported to be as high as 86%, highlighting the importance of nutrition assessment through all stages of treatment to provide appropriate intake of energy, protein, and micronutrients. The etiology of malnutrition in pediatric heart failure is multifactorial and involves hypermetabolism, decreased intake, increased nutrient losses, inefficient utilization of nutrients, and malabsorption. Children in heart failure often present with tachypnea, tachycardia, fatigue, nausea, and vomiting and consequently may not be able to meet their nutrition requirements through oral intake alone. Nutrition support, including enteral nutrition and parenteral nutrition, should be considered an essential part of routine care. The involvement of multiple allied health professionals may be needed to create a feeding therapy plan to support patients and their families. With appropriate nutrition interventions, clinical outcomes and quality of life can be significantly improved.

Body Weights in Adults With Congenital Heart Disease and the Obesity Frequency

Obesity may associate with greater cardiovascular risk in adults with congenital heart disease (ACHD) than in the general population. As ACHD often have exercise limitations, they may be uniquely predisposed to obesity. Nevertheless, obesity prevalence in ACHD, compared with the general population, has not been quantified in a large US cohort. Hence, we sought to determine the prevalence of obesity (30 ≤ body mass index <40) and morbid obesity (body mass index ≥40), in a large cohort of ACHD, compared with matched controls. Retrospective analysis was thus performed on all ACHD seen in an academic system in 2013. CHD severity was classified as simple, complex, or unclassified, using recently published criteria. A control group without CHD was randomly generated matching for age, gender, and race/ethnicity; 1,451 ACHD met inclusion criteria; 59.5% of ACHD were overweight to morbidly obese. Compared with controls, ACHD had similar prevalence of overweight (odds ratio [OR] 1.04, 95% confidence interval [CI] 0.89 to 1.22, p = 0.63) and obesity (OR 0.96, 95% CI 0.81 to 1.15, p = 0.69) but lower prevalence of morbid obesity (OR 0.24, 95% CI 0.16 to 0.34, p <0.001). These relationships were not attenuated by adjustment for CHD severity. In conclusion, ACHD are at equal risk as their matched peers to be overweight and obese. This is the largest study of obesity in US ACHD and the highest reported obesity prevalence in ACHD to date. As obesity is associated with significant cardiovascular risk, our findings indicate a need for improved lifestyle counseling in patients with CHD of all ages.

Beyond Pressure Gradients: The Effects of Intervention on Heart Power in Aortic Coarctation

BACKGROUND

In aortic coarctation, current guidelines recommend reducing pressure gradients that exceed given thresholds. From a physiological standpoint this should ideally improve the energy expenditure of the heart and thus prevent long term organ damage.

OBJECTIVES

The aim was to assess the effects of interventional treatment on external and internal heart power (EHP, IHP) in patients with aortic coarctation and to explore the correlation of these parameters to pressure gradients obtained from heart catheterization.

METHODS

In a collective of 52 patients with aortic coarctation 25 patients received stenting and/or balloon angioplasty, and 20 patients underwent MRI before and after an interventional treatment procedure. EHP and IHP were computed based on catheterization and MRI measurements. Along with the power efficiency these were combined in a cardiac energy profile.

RESULTS

By intervention, the catheter gradient was significantly reduced from 21.8±9.4 to 6.2±6.1mmHg (p<0.001). IHP was significantly reduced after intervention, from 8.03±5.2 to 4.37±2.13W (p < 0.001). EHP was 1.1±0.3 W before and 1.0±0.3W after intervention, p = 0.044. In patients initially presenting with IHP above 5W intervention resulted in a significant reduction in IHP from 10.99±4.74 W to 4.94±2.45W (p<0.001), and a subsequent increase in power efficiency from 14 to 26% (p = 0.005). No significant changes in IHP, EHP or power efficiency were observed in patients initially presenting with IHP < 5W.

CONCLUSION

It was demonstrated that interventional treatment of coarctation resulted in a decrease in IHP. Pressure gradients, as the most widespread clinical parameters in coarctation, did not show any correlation to changes in EHP or IHP. This raises the question of whether they should be the main focus in coarctation interventions. Only patients with high IHP of above 5W showed improvement in IHP and power efficiency after the treatment procedure.

TRIAL REGISTRATION

clinicaltrials.gov NCT02591940.

Interstage somatic growth in children with hypoplastic left heart syndrome after initial palliation with the hybrid procedure

Introduction The hybrid procedure is one mode of initial palliation for hypoplastic left heart syndrome. Subsequently, patients proceed with either the "three-stage" pathway - comprehensive second stage followed by Fontan completion - or the "four-stage" pathway - Norwood procedure, hemi-Fontan, or Fontan completion. In this study, we describe somatic growth patterns observed in the hybrid groups and a comparison primary Norwood group.

METHODS

A retrospective analysis of patients who have undergone hybrid procedure and Fontan completion was performed. Weight-for-age and height-for-age z-scores were recorded at each operation.

RESULTS

We identified 13 hybrid patients - eight in the three-stage pathway and five in the four-stage pathway - and 49 Norwood patients. Weight: three stage: weight decreased from hybrid procedure to comprehensive second stage (-0.4±1.3 versus -2.3±1.4, p<0.01) and then increased to Fontan completion (-0.4±1.5 versus -0.6±1.4, p<0.01); four stage: weight decreased from hybrid procedure to Norwood (-2.0±1.4 versus -3.3±0.9, p=0.06), then stabilised to hemi-Fontan. Weight increased from hemi-Fontan to Fontan completion (-2.7±0.6 versus -1.0±0.7, p=0.01); primary Norwood group: weight decreased from Norwood to hemi-Fontan (p<0.001) and then increased to Fontan completion (p<0.001). Height: height declined from hybrid procedure to Fontan completion in the three-stage group. In the four-stage group, height decreased from hybrid to hemi-Fontan, and then increased to Fontan completion. The Norwood group decreased in height from Norwood to hemi-Fontan, followed by an increase to Fontan completion.

CONCLUSION

In this study, we show that patients undergoing the hybrid procedure have poor weight gain before superior cavopulmonary connection, before returning to baseline by Fontan completion. This study identifies key periods to target poor somatic growth, a risk factor of morbidity and worse neurodevelopmental outcomes.

The impact of length and weight on survival after heart transplantation in children less than 24 months of age

Adults, older children, and adolescent patients with a BMI categorized as overweight or obese have decreased survival after HTx. Anthropometric correlates of survival after HTx in infants have not been well defined. In a retrospective analysis of the UNOS registry, patients age 0-24 months were classified according to the WHO height-for-age and weight-for-age norms, as well as arbitrary BMI-for-age percentiles. Outcomes of 1-year survival, conditional long-term survival, and cause-specific mortality were examined. Infants with stunted growth according to the WHO definition had increased risks of early mortality, late mortality, and death due to graft failure after HTx. Secondary analysis of first-year survival demonstrated increased mortality in children who were underweight according to weight-for-age, but a survival disadvantage in the highest BMI-for-age category, likely due to short recumbent length leading to relatively high BMI values. Stunted growth relative to WHO standards predicts mortality following heart transplant in children less than 2 years of age. The association between post-transplant mortality and high BMI-for-age, as demonstrated in older cohorts, was observed in the infant cohort only due to stunting, and not due to overweight classification.

Nutrition and Mesenteric Issues in Pediatric Cardiac Critical Care

OBJECTIVES

The objectives of this review are to discuss the challenges of delivering adequate nutrition to children with congenital heart disease, including pre- and postoperative factors and the role of enteral and parenteral nutrition, as well as the evidence supporting current practices.

DATA SOURCE

MEDLINE and PubMed.

CONCLUSION

Providing adequate nutritional support is paramount for critically ill infants with congenital heart disease, a population at particular risk for malnutrition. Improved nutritional support has been associated with increased survival and reduction in overall morbidity. Further gains can be achieved by creating a clinical culture that emphasizes optimal perioperative nutritional support. Additional research is required to identify the specific nutrient composition, optimal mode, and timing of delivery to maximize clinical benefit.

Nutrition in the Cardiac Newborns: Evidence-based Nutrition Guidelines for Cardiac Newborns

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.