Malnutrition on admission to the paediatric cardiac intensive care unit increases the risk of mortality and adverse outcomes following paediatric congenital heart surgery: A prospective cohort study

Achieving caloric goal in postoperative management of CHD surgery

BACKGROUND

This study investigated the prevalence of malnutrition, time to achieve caloric goals, and nutritional risk factors after surgery for CHD in a cardiac ICU.

METHOD

This retrospective study included patients with CHD (1 month-18 years old) undergoing open-heart surgery (2021-2022). We recorded nutritional status, body mass index-for-age z-score, weight-for-length/height z-score, cardiopulmonary bypass and aortic cross-clamp time, Paediatric Risk of Mortality-3 score, Paediatric Logistic Organ Dysfunction-2 score, vasoactive inotropic score, total duration of mechanical ventilation, length of stay in the cardiac ICU, mortality, and time to achieve caloric goals.

RESULTS

Of the 75 included patients, malnutrition was detected in 17% (n= 8) based on the body mass index-for-age z-score and in 35% (n= 10) based on the weight-for-length/height z-score. Sex, mortality, cardiopulmonary bypass and aortic cross-clamp time, Paediatric Risk of Mortality-3, Paediatric Logistic Organ Dysfunction-2, and vasoactive inotropic score, duration of mechanical ventilation, and length of cardiac ICU stay were similar between patients with and without malnutrition. Patients who achieved caloric goals on the fourth day and those who achieved them beyond the fourth day showed statistical differences in mortality, maximum vasoactive inotropic score, duration of mechanical ventilation, cardiopulmonary bypass and aortic cross-clamp time, Paediatric Risk of Mortality-3, Paediatric Logistic Organ Dysfunction-2, and length of cardiac ICU and hospital stay (p< 0.05). Logit regression analysis indicated that the duration of mechanical ventilation, Paediatric Logistic Organ Dysfunction-2 and Paediatric Risk of Mortality-3 score was a risk factor for achieving caloric goals (p< 0.05).

CONCLUSIONS

Malnutrition is prevalent in patients with CHD, and concomitant organ failure and duration of mechanical ventilation play important roles in achieving postoperative caloric goals.

Postoperative complications in the pediatric population. Malnutrition or phase angle? Which one do we use?

Background and Aims

Malnutrition increases post-operative risks like infections and prolonged stays. Pediatric assessment challenges require using anthropometric measurements and phase angle, which reflects body cell mass and health outcomes. Phase angle varies by maturation stages, making it crucial for pre-surgical evaluations alongside BMI. This study aimed to determine the relationship between nutritional status, phase angle, and postoperative complications in pediatric patients who underwent surgery.

Methods

Prospective study with patients aged 3-17 undergoing major non-ambulatory surgery. Anthropometric measurements (weight, height, BMI Z-scores) hand grip strength, dietary intake and body composition via bioimpedance to assess phase angle were recorded. Postoperative complications were monitored, including surgical site infections, morbidity (pneumonia, inotropic support, infections, thromboembolism), and mortality. Surgical risks and pre- and postoperative conditions were documented.

Results

After the application of the selection criteria, a total of 391 patients who underwent surgery were included; 60% (n = 235) were within the range of the preschool and school-age groups. During the follow-up period, 51 (13%) patients developed at least one postoperative complication, with surgical site infections being the most common. Moreover, as phase angle decreased, the length of stay (LOS) increased in all the participants. Among children aged ≤12 years old, malnutrition was a risk factor for complications [OR 3.86 (1.61-9.27 95%CI)], whereas among adolescents, phase angle served as a protective factor [OR 0.63 (0.42-0.94 95%CI)].

Conclusion

Significant associations were observed between nutritional status, by BMI z-score, and post-surgical complications in younger patients. Additionally, in adolescents, the phase angle emerged as a protective factor against these complications.

Association of Hyperoxia During Cardiopulmonary Bypass and Postoperative Delirium in the Pediatric Cardiac ICU

OBJECTIVE

ICU delirium commonly complicates critical illness associated with factors such as cardiopulmonary bypass (CPB) time and the requirement of mechanical ventilation (MV). Recent reports associate hyperoxia with poorer outcomes in critically ill children. This study sought to determine whether hyperoxia on CPB in pediatric patients was associated with a higher prevalence of postoperative delirium.

DESIGN

Secondary analysis of data obtained from a prospective cohort study.

SETTING

Twenty-two-bed pediatric cardiac ICU in a tertiary children's hospital.

PATIENTS

All patients (18 yr old or older) admitted post-CPB, with documented delirium assessment scores using the Preschool/Pediatric Confusion Assessment Method for the ICU and who were enrolled in the Precision Medicine in Pediatric Cardiology Cohort from February 2021 to November 2021.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 148 patients, who underwent cardiac surgery, 35 had delirium within the first 72 hours (24%). There was no association between hyperoxia on CPB and postoperative delirium for all definitions of hyperoxia, including hyperoxic area under the curve above 5 predetermined Pao2 levels: 150 mm Hg (odds ratio [95% CI]: 1.176 [0.605-2.286], p = 0.633); 175 mm Hg (OR 1.177 [95% CI, 0.668-2.075], p = 0.572); 200 mm Hg (OR 1.235 [95% CI, 0.752-2.026], p = 0.405); 250 mm Hg (OR 1.204 [95% CI, 0.859-1.688], p = 0.281), 300 mm Hg (OR 1.178 [95% CI, 0.918-1.511], p = 0.199). In an additional exploratory analysis, comparing patients with delirium within 72 hours versus those without, only the z score for weight differed (mean [sd]: 0.09 [1.41] vs. -0.48 [1.82], p < 0.05). When comparing patients who developed delirium at any point during their ICU stay (n = 45, 30%), MV days, severity of illness (Pediatric Index of Mortality 3 Score) score, CPB time, and z score for weight were associated with delirium (p < 0.05).

CONCLUSIONS

Postoperative delirium (72 hr from CPB) occurred in 24% of pediatric patients. Hyperoxia, defined in multiple ways, was not associated with delirium. On exploratory analysis, nutritional status (z score for weight) may be a significant factor in delirium risk. Further delineation of risk factors for postoperative delirium versus ICU delirium warrants additional study.

Supplemental nutrition, feeding disorders, and renourishment in pediatric heart failure through transplantation

BACKGROUND

Tube feeds are used commonly in children listed for heart transplant; however, rates of renourishment and development of feeding disorders are not sufficiently characterized.

METHODS

Retrospective review of pediatric heart transplant recipients from January 1, 2014, to January 3, 2021. Demographics, anthropometric, and nutritional data were collected from heart transplant listing through 3 years post-transplant. Renourishment rates, presence of a feeding disorder, and need for a gastric feeding tube were analyzed. Multivariable analysis was conducted to identify risks for poor nutritional outcomes.

RESULTS

Of 104 patients, 35 (34%) and 36 (35%) were malnourished at heart transplant listing and transplant, respectively, persisting in 21/91 (23%) 1 year postheart transplant. Forty (38%) received tube feeds at listing, 42 (40%) at heart transplant, and 18/90 (20%) 1 year post-transplant. Rates of feeding disorders fell from 23% at transplantation to 10% 1 year post-transplant. Feeding disorders were associated with younger age at heart transplant (p < .001) and congenital heart disease (p = .03). Forty-six percent of infants required a gastric feeding tube. Renourishment occurred in 20% during listing and was associated with ventricular assist device support (p = .03) and noncalorically dense feeds (p = .03). Malnutrition at transplant was associated with inferior post-transplant survival (6/36 (17%) vs. 2/68 (3%); p = .02).

CONCLUSIONS

Malnourishment requiring tube feeds is common in pediatric heart transplant candidates; however, most patients who eventually survive to transplant remain malnourished at time of transplantation and 1 year later. While some children develop feeding disorders, they generally resolve by 1 year post-transplant.

The Incidence, Prevalence and Clinical Characteristics of Failure to Thrive in Children at King Abdullah Specialized Children Hospital, Riyadh, Saudi Arabia

Introduction Failure to thrive (FTT) in children involves insufficient weight or height gain, affecting general and hospitalized populations which leads to cognitive and behavioral changes. Causes include inadequate caloric intake and underlying diseases (organic - OFTT) or psychosocial factors (non-organic - NOFTT). Our study in King Abdullah Specialized Children Hospital (KASCH) aims to assess FTT incidence, prevalence, and clinical characteristics, and also, to distinguish between different causes. Methodology It is a retrospective cohort study, conducted at KASCH, Riyadh, Saudi Arabia. This study includes children under three years old with documented FTT from 2017 to 2019. Data was collected from the hospital's electronic system and it was analyzed by the Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, IBM Corp., Version 29.0, Armonk, NY). Results Our study, including 214 FTT patients, revealed a balanced gender distribution of 109 males (50.9%), and 105 females (49.1%), with a majority of Saudi nationality 208 (97.2%). In most cases, 120 (56.1%) are in the 0-12 months age group. The prevalence of FTT was 26.75% (267 cases per 1000). Antenatal/post-natal features showed diverse delivery modes and NICU admissions. Chronic diseases like gastrointestinal diseases 62 (29.1%), cardiac 50 (23.4%), and pulmonary 50 (23.4%) conditions were prevalent. Associations were found between NICU admission and pre-term births, birth weight status, and congenital anomalies, highlighting significant clinical correlations. Conclusion Our study concluded the significant burden of FTT at KASCH. Chronic diseases were playing a major role as a cause of FTT. Thus, emphasizing the causes and knowing the importance of addressing the prevalence and incidence is effective for appropriate intervention.

Association of underweight and obesity with adverse postoperative renal outcomes in infants and young children undergoing congenital heart surgery

Postoperative acute kidney injury (AKI) is a prevalent condition and associated with increased morbidity and mortality following cardiac surgery. This study aimed to investigate the association of underweight and obesity with adverse postoperative renal outcomes in infants and young children undergoing congenital heart surgery. This retrospective cohort study included patients aged from 1 month to 5 years who underwent congenital heart surgery with cardiopulmonary bypass at the Second Xiangya Hospital of Central South University from January 2016 to March 2022. On the basis of the percentile of body mass index (BMI) for age and sex, eligible participants were divided into three nutritional groups: normal bodyweight, underweight (BMI P5), and obesity (BMI P95). Primary outcomes included postoperative AKI and major adverse kidney events within 30 days (MAKE30). Multivariable logistic regression was performed to determine the association of underweight and obesity with postoperative outcomes. The same analyses were reproduced for classifying patients using weight-for-height instead of BMI. A total of 2,079 eligible patients were included in the analysis, including 1,341 (65%) patients in the normal bodyweight group, 683 (33%) patients in the underweight group, and 55 (2.6%) patients in the obesity group. Postoperative AKI (16% vs. 26% vs. 38%; P < 0.001) and MAKE30 (2.5% vs. 6.4% vs. 9.1%; P < 0.001) were more likely to occur in the underweight and obesity groups. After adjusting for potential confounders, underweight (OR1.39; 95% CI 1.08-1.79; P = 0.008) and obesity (OR 3.85; 95% CI 1.97-7.50; P < 0.001) were found to be associated with an increased risk of postoperative AKI. In addition, both underweight (OR 1.89; 95% CI 1.14-3.14; P = 0.014) and obesity (OR 3.14; 95% CI 1.08-9.09; P = 0.035) were independently associated with MAKE30. Similar results were also found when weight-for-height was used instead of BMI.    Conclusion: In infants and young children undergoing congenital heart surgery, underweight and obesity are independently associated with postoperative AKI and MAKE30. These results may help assess prognosis in underweight and obese patients, and will guide future quality improvement efforts. What is Known: • Postoperative acute kidney injury (AKI) is prevalent and associated with increased morbidity and mortality following pediatric cardiac surgery. • Major adverse kidney events within 30 days (MAKE30) have been recommended as a patient-centered endpoint for evaluating AKI clinical trajectories. A growing concern arises for underweight and obesity in children with congenital heart disease. What is New: • Prevalence of underweight and obesity among infants and young children undergoing congenital heart surgery was 33% and 2.6%, respectively. • Both underweight and obesity were independently associated with postoperative AKI and MAKE30 following congenital heart surgery.

Risk factors for early occurrence of malnutrition in infants with severe congenital heart disease

To identify the risk factors of early occurrence of malnutrition in infants with severe congenital heart disease (CHD) during their first year of life. Retrospective longitudinal multicenter study carried out from January 2014 to December 2020 in two tertiary care CHD centers. Four CHD hemodynamic groups were identified. Malnutrition was defined by a Waterlow score under 80% and/or underweight under -2 standard deviations. A total of 216 infants with a severe CHD, e.g., requiring cardiac surgery, cardiac catheterization, or hospitalization for heart failure during their first year of life, were included in the study. Malnutrition was observed among 43% of the cohort, with the highest prevalence in infants with increased pulmonary blood flow (71%) compared to the other hemodynamic groups (p < 0.001). In multivariate analysis, low birthweight (OR 0.62, 95% CI 0.44-0.89, p = 0.009), CHD with increased pulmonary blood flow (OR 4.80, 95% CI 1.42-16.20, p = 0.08), heart failure (OR 9.26, 95% CI 4.04-21.25, p < 0.001), and the number of hospitalizations (OR 1.35, 95% CI 1.08 l-1.69, p = 0.009) during the first year of life were associated with malnutrition (AUC 0.85, 95% CI 0.79-0.90).  Conclusions: In infants with a severe CHD, early occurrence of malnutrition during the first year of life affected a high proportion of subjects. CHD with increased pulmonary blood flow, low birthweight, heart failure, and repeated hospitalizations were risk factors for malnutrition. Further studies are required to identify optimal nutritional support in this population. What is Known: • Malnutrition is a known morbidity and mortality factor in children with severe congenital heart disease. What is New: • Early occurrence of malnutrition during the first year of life in infant severe congenital heart disease (CHD) was high (43%). • CHD with increased pulmonary blood flow, low birthweight, heart failure, and repeated hospitalizations during the first year of life were risk factors for malnutrition.

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.