Feeding dysfunction in children with single ventricle following staged palliation

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.

Cardiovascular intensive care unit variables inform need for feeding tube utilization in infants with hypoplastic left heart syndrome

OBJECTIVE

Feeding strategies in infants with hypoplastic left heart syndrome (HLHS) following stage 1 palliation (S1P) include feeding tube utilization (FTU). Timely identification of infants who will fail oral feeding could mitigate morbidity in this vulnerable population. We aimed to develop a novel clinical risk prediction score for FTU.

METHODS

This was a retrospective study of infants with HLHS admitted to the Boston Children's Hospital cardiovascular intensive care unit for S1P from 2009 to 2019. Infants discharged with feeding tubes were compared with those on full oral feeds. Variables from early (birth to surgery), mid (postsurgery to cardiovascular intensive care unit transfer), and late (inpatient transfer to discharge) hospitalization were analyzed in univariate and multivariable models.

RESULTS

Of 180 infants, 66 (36.7%) discharged with a feeding tube. In univariate analyses, presence of a genetic disorder (early variable, odds ratio, 3.25; P = .014) and nearly all mid and late variables were associated with FTU. In the mid multivariable model, abnormal head imaging, ventilation duration, and vocal cord dysfunction were independent predictors of FTU (c-statistic 0.87). Addition of late variables minimally improved the model (c-statistic 0.91). A risk score (the HV2 score) for FTU was developed based on the mid multivariable model with high specificity (93%).

CONCLUSIONS

Abnormal head imaging, duration of ventilation, and presence of vocal cord dysfunction were associated with FTU in infants with HLHS following S1P. The predictive HV2 risk score supports routine perioperative head imaging and vocal cord evaluation. Future application of the HV2 score may improve nutritional morbidity and hospital length of stay in this population.

Validation of the withdrawal assessment tool-1 (WAT-1) in pediatric cardiovascular patients on an inpatient unit

PURPOSE

Sedation and analgesia are administered to critically ill patients, which may result in physical dependence and subsequent iatrogenic withdrawal. The Withdrawal Assessment Tool-1 (WAT-1) was developed and validated as an objective measurement of pediatric iatrogenic withdrawal in intensive care units (ICUs), with a WAT-1 score ≥ 3 indicative of withdrawal. This study's objectives were to test interrater reliability and validity of the WAT-1 in pediatric cardiovascular patients in a non-ICU setting.

DESIGN AND METHODS

This prospective observational cohort study was conducted on a pediatric cardiac inpatient unit. WAT-1 assessments were performed by the patient's nurse and a blinded expert nurse rater. Intra-class correlation coefficients were calculated, and Kappa statistics were estimated. A two-sample, one-sided test of proportions of weaning (n = 30) and nonweaning (n = 30) patients with a WAT-1 ≥3 were compared.

RESULTS

Interrater reliability was low (K = 0.132). The WAT-1 area under the receiver operating curve was 0.764 (95% confidence interval; ± 0.123). There was a significantly higher proportion (50%, p = 0.009) of weaning patients with WAT-1 scores ≥3 compared to the nonweaning patients (10%). The WAT-1 elements of moderate/severe uncoordinated/repetitive movement and loose, watery stools were significantly higher in the weaning population.

PRACTICE IMPLICATIONS

Methods to improve interrater reliability warrant further examination. The WAT-1 had good discrimination at identifying withdrawal in cardiovascular patients on an acute cardiac care unit. Frequent nurse re-education may increase accurate tool use. The WAT-1 tool may be used in the management of iatrogenic withdrawal in pediatric cardiovascular patients in a non-ICU setting.

Prolonged Enteral Tube Feeding in Infants With a Functional Single Ventricle Is Associated With Adverse Outcomes After Fontan Completion

OBJECTIVES

To define the baseline characteristics of long-term tube-fed single ventricle patients, investigate associations between long-term enteral tube feeding and growth, and determine associations with long-term outcomes after Fontan procedure.

STUDY DESIGN

We performed a retrospective cohort study of patients in the Australia and New Zealand Fontan Registry undergoing treatment at the Royal Children's Hospital, the Children's Hospital at Westmead, Royal Melbourne Hospital, and Royal Prince Alfred Hospital from 1981-2018. Patients were defined as tube-fed (TF) or non-tube-fed (NTF) based on enteral tube feeding at age 90 days. Feeding groups were compared regarding BMI trajectory, BMI at last follow-up, and long-term incidence of severe Fontan failure.

RESULTS

Of 390 patients (56(14%) TF, 334(86%) NTF), TF was associated with right ventricular dominance, hypoplastic left heart syndrome, Norwood procedure, increased procedures prior to Fontan, extracardiac conduit Fontan, Fontan fenestration, and atrioventricular valve repair/replacement. TF patients were less likely to be in the higher compared with lowest 0-6 month BMI trajectory (P<0.01,P=0.03), had lower 6month weight-for-age z-scores (P<0.01) and length-for-age z-scores (P=0.01). TF were less likely to be overweight/obese at pediatric follow-up (HR=0.31,95%CI:0.12-0.80;P=0.02) and more likely to be underweight at adult follow-up ((HR=16.51; 5%CI:2.70-101.10;P<0.01).TF compared with NTF was associated with increased risk of severe Fontan failure (HR=4.13;95%CI=1.65,10.31;P<0.01).

CONCLUSIONS

Prolonged infant enteral tube feeding is an independent marker of poor growth and adverse clinical outcomes extending long-term post-Fontan procedure.

Impact of Home Monitoring Program and Early Gastrostomy Tube on Interstage Outcomes following Stage 1 Norwood Palliation

Nutritional management and home monitoring programs (HMPs) may be beneficial for improving interstage morbidity and mortality following stage I Norwood palliation (S1P) for hypoplastic left heart syndrome (HLHS). We recognized an increasing trend towards early feeding gastrostomy tube (GT) placement prior to discharge in our institution, and we aimed to investigate the effect of HMPs and GTs on interstage mortality and growth parameters. Single-institutional review at a tertiary referral center between 2008 and 2018. Individual patient charts were reviewed in the electronic medical record. Those listed for transplant or hybrid procedures were excluded. Baseline demographics, operative details, and interstage outcomes were analyzed in GT and non-GT patients (nGT). Our HMP was instituted in 2009, and patients were analyzed by era: I (early, 2008-2012), II (intermediate, 2013-2016), and III (recent, 2017-2018). 79 patients were included in the study: 29 nGTs and 50 GTs. GTs had higher number of preoperative risk factors more S1P complications, longer ventilation times, longer lengths of stay, and shorter times to readmission. There were no differences in interstage mortality or overall mortality between groups. There was one readmission for a GT-related issue with no periprocedural complications in the group. Weight gain doubled after GT placement in the interstage period while waiting periods for placement decreased across Eras. HMPs and early GTs, especially for patients with high-risk features, provide a dependable mode of nutritional support to optimize somatic growth following S1P.

Nutritional Management of Patients with Fontan Circulation: A Potential for Improved Outcomes from Birth to Adulthood

Fontan circulation (FC) is a surgically achieved palliation state offered to patients affected by a wide variety of congenital heart defects (CHDs) that are grouped under the name of univentricular heart. The procedure includes three different surgical stages. Malnutrition is a matter of concern in any phase of life for these children, often leading to longer hospital stays, higher mortality rates, and a higher risk of adverse neurodevelopmental and growth outcomes. Notwithstanding the relevance of proper nutrition for this subset of patients, specific guidelines on the matter are lacking. In this review, we aim to analyze the role of an adequate form of nutritional support in patients with FC throughout the different stages of their lives, in order to provide a practical approach to appropriate nutritional management. Firstly, the burden of faltering growth in patients with univentricular heart is analyzed, focusing on the pathogenesis of malnutrition, its detection and evaluation. Secondly, we summarize the nutritional issues of each life phase of a Fontan patient from birth to adulthood. Finally, we highlight the challenges of nutritional management in patients with failing Fontan.

Prevalence of Feeding and Swallowing Disorders in Congenital Heart Disease: A Scoping Review

Feeding and swallowing difficulties are commonly reported as comorbidities in infants and children with congenital heart disease. These difficulties have negative health consequences for the child and impact the quality of life of both the child and caregivers. This scoping review presents an integrated summary of the published literature on the prevalence of feeding and swallowing difficulties in congenital heart disease. Fifteen peer-reviewed articles, written in English and published in the last 25 years, were included in the review, following a search of relevant databases. The studies reported on a total of 1,107 participants across the articles ranging in age from premature infants to children aged 17 years. An overall pooled prevalence of 42.9% feeding and swallowing difficulties was reported, with a prevalence of 32.9% reporting aspiration. A wide prevalence range of feeding and swallowing difficulties was reported across the articles and factors that contributed to this included the ages of participants, and the definition and assessment of feeding and swallowing difficulties used in the studies. The review confirms that feeding and swallowing difficulties are common in infants and children with congenital heart defects, and that assessment and management of these difficulties should be considered part of the standard of care.

Performance of remote health education via WeChat to improve the pre-operative nutritional status of infants with non-restrictive ventricular septal defects: A prospective randomised controlled study

AIM

This study aimed to explore the effect of performing remote health education via WeChat to improve the pre-operative nutritional status of non-restrictive ventricular septal defects (VSD).

METHODS

A prospective randomised controlled study was conducted in a provincial maternity and child hospital in China. Participants were randomised regarding education to the intervention group (WeChat) and the control group (leaflets). The nutritional status and complications of the patients were compared after intervening for 1 month.

RESULTS

Nutrient status comparison at 1 month after intervention showed that the body weight, head circumference, haemoglobin, albumin and pre-albumin of the WeChat group were significantly higher than those of the leaflet group (P < 0.05). The STRONGkids score of the WeChat group was significantly lower than that of the leaflet group (P < 0.05). The incidence of feeding intolerance and respiratory tract infection in the WeChat group was significantly lower than that found in the leaflet group (P < 0.05). There was no significant difference in the incidence of liver insufficiency and jaundice between the two groups (P > 0.05).

CONCLUSION

Providing pre-operative feeding and care guidance for parents of infants with non-restrictive VSD, via remote health education through WeChat, can effectively improve nutritional status and reduce the risk of malnutrition and feeding complications.

Surgical Gastrostomy in Pediatric Patients Undergoing Cardiac Surgery

BACKGROUND

Practices of performing gastrostomy tubes vary across institutions for patients undergoing cardiac surgery. We aim to elucidate the outcomes of gastrostomy and the duration of feeding assistance in these patients.

MATERIALS AND METHODS

Patients undergoing cardiac surgery (CS) at our institution from 2013 to 2017 were retrospectively reviewed using the Society of Thoracic Surgery database. A cohort of non-CS patients undergoing gastrostomy tube (g-tube) placement from 2013 to 2015 was used as control. Technical complications and postoperative feeding intolerance were analyzed. Duration of need for g-tube was also analyzed in patients undergoing CS.

RESULTS

The CS group had 144 patients, and the non-CS group had 677 patients. CS patients had a higher incidence of feeding intolerance (18.8% versus 5.6%, P < 0.001) and took longer to attain full feeds (median of 2 versus 1 d, P < 0.001), and this was confirmed on propensity matched analysis. In addition, technical g-tube complications were similar in the two groups. No mortality in CS was attributed to the g-tube. 58% of patients undergoing CS were able to wean from g-tube feeding by 6-12 mo after g-tube placement.

CONCLUSIONS

G-tube placement in patients undergoing CS by any technique is safe without increased complications. A significant portion of these patients was able to wean off supplemental enteral feeding assistance by a year after g-tube placement.

Use of a Digital Monitoring Platform to Improve Outcomes in Infants With a Single Ventricle

Background:

Despite advances, infants with single ventricle heart disease continue to have high morbidity and mortality in the first year of life. Home monitoring programs (HMPs) have reduced mortality and have grown to use integrative digital platforms. The objective was to evaluate how implementation of a digital HMP platform affects nutritional outcomes in infants undergoing staged single ventricle palliation.

Methods:

We conducted a retrospective, multicenter, observational study of all infants who required a neonatal operation as part of staged single ventricle palliation between 2013 and 2018. Patients were excluded if less than 35 weeks’ gestation or underwent biventricular repair in the first year of life. Implementation of a digital monitoring platform that allows for secure monitoring of nasogastric feed advancement and oxygen saturation occurred in 2016, creating the two groups in a similar surgical era.

Results:

There were 38 patients who fell under a standard HMP compared to 31 utilizing the digital platform. There was no difference in baseline demographics, anatomy, or preoperative factors between the groups. Use of a digital platform was associated with reduced postoperative length of stay (30.1 vs 33.1 days, P = .04). More children in the digital platform monitoring group were able to achieve oral feeding at one year of age (90% vs 68%, P = .03). A total of 25% of infants went home with a nasogastric tube, all but one transitioning to full oral feeds.

Conclusions:

Use of a digital, fully electronic medical record (EMR)-integrated, comprehensive HMP was associated with shorter postoperative length of stay in neonates undergoing staged single ventricle palliation and allowed for higher rates of full oral feeding.

The Nutritional Status of Pediatric Patients with Single Ventricle Undergoing a Bidirectional Glenn Procedure

Single ventricle (SV) physiology is associated with growth retardation in children. The nutritional status of pediatric patients with SV undergoing a bidirectional Glenn (BDG) procedure vitally affects the feasibility of the next operation stages. To explore the nutritional status and to identify specific anthropometric parameters relevant to short-term surgical outcomes in children with SV after the BDG procedure, this study included 151 patients who underwent the BDG procedure. Anthropometric assessments and Infant and Child Feeding Index (ICFI) scores were used to evaluate nutritional status. There was a significant statistical correlation between ICFI and malnutrition in both the height-for-age Z-score (HAZ) and weight-for-age Z-score (WAZ) groups (P < 0.05). The clinical data, including ventilation time, nosocomial infection presence, pressure injury presence, peritoneal dialysis status, and total intensive care unit days, after BDG surgery were significantly different among the HAZ groups (P < 0.05), while nosocomial infection was different among the WAZ groups (P < 0.05). Children after BDG procedure had a high incidence of malnutrition, in addition to disease factors, the type and frequency of dietary intake were also important factors leading to worse clinical outcomes during hospitalization. Therefore, it is vital to maintain an optimal nutritional status in infants with SV who are undergoing a series of surgical procedures.

Longitudinal growth in patients with single ventricle cardiac disease receiving tube-assisted feeds

OBJECTIVE

Children with single ventricle cardiac disease (SVCD) have poor growth in early life. Tube-assisted feeding (TF) is used to improve weight gain, but its impact on long-term growth remains unknown. We sought to compare the longitudinal growth of SVCD patients receiving TF after initial cardiac surgery with those fed entirely by mouth.

DESIGN

We conducted a retrospective cohort study of SVCD patients who underwent initial surgical palliation between 1999 and 2009. We defined TF as the use of nasogastric, gastrostomy, or jejunostomy TF. We compared maximal attained growth z-scores for each year of life between TF and non-TF patients. A secondary analysis compared surgical and clinical factors between groups.

RESULTS

A total of 134 patients were included; 64% were male and 68% underwent the Norwood operation. One third of patients (44) received TF. Adjusting for age, TF patients had an average of 0.56 lower weight-for-age z-score (WAZ) than non-TF patients (P = 0.007) through the age of 6 years. Longitudinal height was not affected by TF status (P = 0.15). In a subanalysis of Norwood patients, TF patients had lower WAZ at initial hospital discharge despite longer LOS. TF patients had diminished WAZ after adjusting for complications, interstage hospitalizations, and timing of subsequent operations.

CONCLUSIONS

In this single-center study, patients with SVCD requiring TF at discharge from initial surgical palliation had diminished WAZ at discharge and on long-term follow-up, despite controlling for other identifiable risk factors. Further investigation is needed to understand the mechanisms underlying this phenomenon and to risk stratify infants who go home on TF.

Factors Associated with Delayed Transition to Oral Feeding in Infants with Single Ventricle Physiology

OBJECTIVES

To describe the duration of time to achieve exclusive oral feeding in infants with single ventricle physiology and to identify risk factors associated with prolonged gastrostomy tube dependence.

STUDY DESIGN

Single center, retrospective study of infants with single ventricle physiology. The primary outcome was duration of time required to achieve oral feeding. Transition periods were defined as exclusive oral feeding by Glenn palliation (early), by 1 year of age (mid), or after 1 year of age (late).

RESULTS

Seventy-eight infants were analyzed; 46 (59%) were discharged to home with a gastrostomy tube after the initial hospitalization. Overall, 39 infants (50%) achieved early transition, 14 (18%) mid, and 18 (23%) late. The group who achieved early transition had a higher percentage of preoperative oral feeding (P < .01), greater weight-for-age z score at initial discharge (P = .03), shorter initial intensive care unit duration (P < .01), shorter initial hospital length of stay (P < .01), and greater weight-for-age z score at Glenn admission (P = .02). No preoperative oral feeding (OR = 0.12, P = .02) and greater number of cardiac medications at initial discharge (OR = 3.8, P = .03) were associated with failure to achieve early transition. No preoperative oral feeding (OR = 0.09, P = .01) and longer initial intensive care unit duration (OR = 1.1, P = .03) were associated with failure to achieve mid transition.

CONCLUSION

Preoperative oral feeding may potentially be a modifiable factor to help improve early transition to oral feeding.

Improving neurodevelopment in infants with complex congenital heart disease

Worldwide, more than 400,000 infants are born each year with complex congenital heart disease (CCHD) requiring surgical intervention within the first months of life. Although improvements in perioperative care have resulted in increased rates of survival, more than half of infants with CCHD have neurodevelopmental impairments affecting subsequent educational achievements, job opportunities, and mental health. Brain maturity and impaired outcomes in infants with CCHD are similar to those of prematurely born infants. Developmentally supportive care, including foundational application of kangaroo care (KC), improves neurodevelopment in premature infants. Provision of developmentally supportive care with KC during the early hospitalization of infants with CCHD has the potential to similarly improve neurodevelopment. The purposes of the article are to describe common congenital heart defects, describe developmentally supportive care with an emphasis on KC, and to offer specific recommendations for KC and research in infants with CCHD.

A clinical description of children with solid organ transplants who present with feeding disorder

Pediatric solid organ transplant recipients have long-standing malnutrition concerns related to their pretransplant medical status. The targeted nutrition therapy utilized pre-, peri-, and post-transplantation may have the adverse effect of impeding normally developing feeding skills, particularly in very young children. Little is known about the relationship between transplantation and feeding disorders of childhood. The purpose of this study was to describe severity of feeding disorder and parental stress in patients with transplant compared to children followed in a specialty feeding clinic and the general community. Sixty-four children, comprised of 32 children with solid organ transplant ages 2 months to 12 years and 32 matched control patients diagnosed with a feeding disorder without history of solid organ transplant, were reviewed. All children were from the Feeding, Swallowing, and Nutrition Clinic at a single children's hospital. Findings indicate that patients who received a transplant and presented with a feeding problem had worse symptoms of feeding disorder than are typically found in the general community. These feeding problems disrupt mealtime behavior, caregiver and child relationship within a mealtime context, and may result in maladaptive feeding strategies used by families. When transplanted children present with feeding disorders, they are severe and have multiple effects on both the child and the feeding dynamic between the child and the child's caregivers. Further investigation may help us to better understand the relationship between transplantation and symptoms of feeding disorder.

Symptoms of problematic feeding in children with CHD compared to healthy peers

Children with CHD often experience difficulty with oral feeding, which contributes to growth faltering in this population. Few studies have explored symptoms of problematic feeding in children with CHD using valid and reliable measures of oral feeding. The purpose of this study was to describe symptoms of problematic feeding in children with CHD compared to healthy children without medical conditions, taking into account variables that may contribute to symptoms of problematic feeding. Oral feeding was measured by the Pediatric Eating Assessment Tool, a parent report assessment of feeding with evidence of validity and reliability. This secondary analysis used data collected from web-based surveys completed by parents of 1093 children between 6 months and 7 years of age who were eating solid foods by mouth. General linear models were used to evaluate the differences between 94 children with CHD and 999 children without medical conditions based on the Pediatric Eating Assessment Tool total score and four subscale scores. Covariates tested in the models included breathing tube duration, type of CHD, gastroesophageal reflux, genetic disorder, difficulty with breast- or bottle-feeding during infancy, cardiac surgery, and current child age. Children with CHD had significantly more symptoms of problematic feeding than healthy children on the Pediatric Eating Assessment Tool total score, more physiologic symptoms, problematic mealtime behaviours, selective/restrictive eating, and oral processing dysfunction (p &lt;0.001 for all), when taking into account relevant covariates. Additional research is needed in children with CHD to improve risk assessment and develop interventions to optimise feeding and growth.

Feeding methods for infants with single ventricle physiology are associated with length of stay during stage 2 surgery hospitalization

BACKGROUND

Tube feedings are often needed to achieve the growth and nutrition goals associated with decreased morbidity and mortality in patients with single ventricle anatomy. Variability in feeding method through the interstage period has been previously described, however, comparable information following stage 2 palliation is lacking.

OBJECTIVES

To identify types of feeding methods following stage 2 palliation and their influence on length of stay.

DESIGN

Secondary analysis of the National Pediatric Cardiology Quality Improvement Collaborative registry was performed on 932 patients. Demographic data, medical characteristics, postoperative complications, type of feeding method, and length of stay for stage 2 palliation were analyzed.

RESULTS

Type of feeding method remained relatively unchanged during hospitalization for stage 2 palliation. Gastrostomy tube fed only patients were the oldest at time of surgery (182.7 ± 57.7 days, P < .001) and had the lowest weight-for-age z scores at admission (-1.6 ± 1.4, P < .001). Oral + gastrostomy tube groups had the longest median bypass times (172.5 minutes, P = .001) and longest length of stay (median 12 days, P < .001). Multivariable modeling revealed that feeding by tube only (P < .001), oral + tube feeding (P ≤ .001), reintubation (P < .001), and prolonged intubation (P < .001) were associated with increased length of stay. Neither age (P = .156) nor weight-for-age z score at admission (P = .066) was predictive of length of stay.

CONCLUSIONS

Feeding methods established at admission for stage 2 palliation are not likely to change by discharge. Length of stay is more likely to be impacted by tube feeding and intubation history than age or weight-for-age z score at admission. Better understanding for selection of feeding methods and their impact on patient outcomes is needed to develop evidence-based guidelines to decrease variability in clinical practice patterns and provide appropriate counseling to caregivers.

Pediatric Feeding Disorder: Consensus Definition and Conceptual Framework

Pediatric feeding disorders (PFDs) lack a universally accepted definition. Feeding disorders require comprehensive assessment and treatment of 4 closely related, complementary domains (medical, psychosocial, and feeding skill-based systems and associated nutritional complications). Previous diagnostic paradigms have, however, typically defined feeding disorders using the lens of a single professional discipline and fail to characterize associated functional limitations that are critical to plan appropriate interventions and improve quality of life. Using the framework of the World Health Organization International Classification of Functioning, Disability, and Health, a unifying diagnostic term is proposed: "Pediatric Feeding Disorder" (PFD), defined as impaired oral intake that is not age-appropriate, and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction. By incorporating associated functional limitations, the proposed diagnostic criteria for PFD should enable practitioners and researchers to better characterize the needs of heterogeneous patient populations, facilitate inclusion of all relevant disciplines in treatment planning, and promote the use of common, precise, terminology necessary to advance clinical practice, research, and health-care policy.

Impact of a Standardized Clinical Assessment and Management Plan (SCAMP®) on growth in infants with CHD

BACKGROUND

Growth failure is prevalent among infants with CHD. A Standardized Clinical Assessment and Management Plan was introduced at Boston Children's Hospital's cardiac medical ward to identify patients with growth failure, evaluate relevant contributing conditions, and recommend a management plan including collaboration with nutrition physicians.

OBJECTIVE

The objective of this study was to determine whether enrolled patients had improved growth compared with historical controls.

METHODS

A total of 29 patients were enrolled in the period July, 2013-June, 2014. In all, 42 historical controls who met eligibility criteria for enrolment were selected for comparison from patients admitted to the same ward in the period June, 2010-June, 2011. Patients with CHD aged <1 year , with growth failure defined as weight-for-age z-score <-2, or failure to sustain adequate weight gain were eligible for participation. Primary outcome was change in weight-for-age z-score from enrolment to most recent weight measurement among patients with at least 6 months of follow-up.

RESULTS

Control patients were older at baseline admission weight (118 versus 95 days, p=0.33), and had a higher weight-for-age z-score, -2.9 (-3.1, -2.6) versus -3.7 (-4.3, -3.0) (p=0.02), compared with enrolled patients. Enrolled patients had greater gain in weight-for-age z-score, 2.7 (2.0, 3.4) versus 1.8 (1.5, 2.2) (p=0.03), from baseline to most recent follow-up.

CONCLUSION

Patients enrolled in a nutrition-focused protocol had greater weight improvement than historical controls. Identification of growth failure and collaboration with a nutrition support team was associated with improved weight gain among CHD patients experiencing growth failure. CHD programmes should consider a structural approach, including nutrition expertise to address growth failure.

Maternal factors and preoperative nutrition in children with mild cases of congenital heart disease

AIM

The preoperative poor nutrition of children with congenital heart disease (CHD) impacts the postoperative rehabilitation process of pediatric CHD cases. The factors of these children's preoperative poor nutrition, excluding the disease, have been underreported. The aim was to investigate the preoperative nutritional status of children with CHD who required a simple surgical repair and to analyze the maternal characteristics that are associated with poor nutrition in these sick children.

METHODS

This was a cross-sectional survey. The weight and height of the children were measured, maternal data were collected via a questionnaire and a univariate analysis and multivariate logistic regression were used to analyze the association between maternal factors and the preoperative poor nutrition of the children with CHD.

RESULTS

A total of 119 children with simple CHD were recruited to the study. The prevalence of poor nutrition was higher in the children with CHD ("cases") than in the healthy children ("controls"). An increased risk of poor nutrition was associated with lower mothers' perception, education level, understanding of the disease, and higher anxiety.

CONCLUSIONS

Paying attention to maternal anxiety, depression, and knowledge and providing interventions for the mothers of children with CHD are important in order to promote the nutritional status of these children.

Toward standardization of care: The feeding readiness assessment after congenital cardiac surgery

BACKGROUND

Feeding practices after neonatal and congenital heart surgery are complicated and variable, which may be associated with prolonged hospitalization length of stay (LOS). Systematic assessment of feeding skills after cardiac surgery may earlier identify those likely to have protracted feeding difficulties, which may promote standardization of care.

METHODS

Neonates and infants ≤3 months old admitted for their first cardiac surgery were retrospectively identified during a 1-year period at a single center. A systematic feeding readiness assessment (FRA) was utilized to score infant feeding skills. FRA scores were assigned immediately prior to surgery and 1, 2, and 3 weeks after surgery. FRA scores were analyzed individually and in combination as predictors of gastrostomy tube (GT) placement prior to hospital discharge by logistic regression.

RESULTS

Eighty-six patients met inclusion criteria and 69 patients had complete data to be included in the final model. The mean age of admit was five days and 51% were male. Forty-six percent had single ventricle physiology. Twenty-nine (42%) underwent GT placement. The model containing both immediate presurgical and 1-week postoperative FRA scores was of highest utility in predicting discharge with GT (intercept odds = 10.9, P = .0002; sensitivity 69%, specificity 93%, AUC 0.913). The false positive rate was 7.5%.

CONCLUSIONS

In this analysis, systematic and standardized measurements of feeding readiness employed immediately before and one week after congenital cardiac surgery predicted need for GT placement prior to hospital discharge. The FRA score may be used to risk stratify patients based on likelihood of prolonged feeding difficulties, which may further improve standardization of care.

Feeding difficulties in neonates following cardiac surgery: determinants of prolonged feeding-tube use

Aim The aims of this study were to examine the prevalence and potential correlates of feeding difficulties in infants who underwent cardiac surgery in the neonatal period and to investigate resource utilisation by infants with feeding difficulties.

METHODS

All neonates who underwent their first cardiac surgery at the Heart Centre for Children, The Children's Hospital at Westmead, between January and December, 2009 were included. Demographic, preoperative, intraoperative, and postoperative data were collected via electronic medical records. For the purpose of this study, feeding difficulty was defined as the requirement for ongoing tube feeding at the time of discharge home or transfer to another hospital.

RESULTS

Out of a total of 79 neonates, 24 (30%) were discharged home or transferred to another hospital with a feeding tube. Feeding difficulties were associated with the presence of a genetic syndrome (p<0.0001), assisted feeding preoperatively (odds ratio (OR)=4.4, p=0.03), and having a palliative procedure before biventricular repair (OR=5.1, p=0.02). Infants with feeding difficulties had significantly more reviews by speech pathologists (M=5.9, SD=7.9), dieticians (M=5.9, SD=5.4), and cardiac clinical nurse consultants (M=1.2, SD=1.4) compared with those without feeding difficulties.

CONCLUSIONS

This study identified factors that can be used in the early recognition of infant feeding difficulties, to help guide the direction of limited health resources, as well as being focal points for future research and clinical practice improvement.

Effects of milk flow on the physiological and behavioural responses to feeding in an infant with hypoplastic left heart syndrome

Infants with hypoplastic left heart syndrome often experience difficulty with oral feeding, which contributes to growth failure, morbidity, and mortality. In response to feeding difficulty, clinicians often change the bottle nipple, and thus milk flow rate. Slow-flow nipples have been found to reduce the stress of feeding in other fragile infants, but no research has evaluated the responses of infants with hypoplastic left heart syndrome to alterations in milk flow. The purpose of this study was to evaluate the physiological and behavioural responses of an infant with hypoplastic left heart syndrome to bottle feeding with either a slow-flow (Dr. Brown's Preemie) or a standard-flow (Dr. Brown's Level 2) nipple. A single infant was studied for three feedings: two slow-flow and one standard-flow. Oral feeding, whether with a slow-flow or a standard-flow nipple, was distressing for this infant. During slow-flow feeding, she experienced more coughing events, whereas during standard-flow she experienced more gagging. Disengagement and compelling disorganisation were most common during feeding 3, that is slow-flow, which occurred 2 days after surgical placement of a gastrostomy tube. Clinically significant changes in heart rate, oxygen saturation, and respiratory rate were seen during all feedings. Heart rate was higher during standard-flow and respiratory rate was higher during slow-flow. Further research is needed to examine the responses of infants with hypoplastic left heart syndrome to oral feeding and to identify strategies that will support these fragile infants as they learn to feed. Future research should evaluate an even slower-flow nipple along with additional supportive feeding strategies.

Noncardiac Challenges in the Cardiac ICU: Feeding, Growth and Gastrointestinal Complications, Anticoagulation, and Analgesia

Outcomes following cardiac intensive care unit (CICU) admission are influenced by many factors including initial cardiac diagnosis, surgical complexity, and burden of critical illness. Additionally, the presence of noncardiac issues may have a significant impact on outcomes and the patient experience during and following an intensive care unit stay. This review focuses on three common noncardiac areas which impact outcomes and patient experience in and beyond the CICU: feeding and growth, pain and analgesia, and anticoagulation. Growth failure and feeding dysfunction are commonly encountered in infants requiring cardiac surgery and have been associated with worse surgical and developmental outcomes. Recent studies most notably in the single ventricle population have demonstrated improved weight gain and outcomes when feeding protocols are implemented. Children undergoing cardiac surgery may experience both acute and chronic pain. Emerging research is investigating the impact of sedatives and analgesics on neurodevelopmental outcomes and quality of life. Improved pain scores and standardized management of pain and withdrawal may improve the patient experience and outcomes. Effective anticoagulation is a critical component of perioperative care but may be complicated by inflammation, multiorgan dysfunction, and patient factors. Advances in monitoring of anticoagulation and emerging therapies are reviewed.

Parent questionnaires measuring feeding disorders in preschool children: a systematic review

AIM

Preschool feeding disorders are common and debilitating and are associated with a range of developmental and medical issues. Parent report allows assessment of feeding in a naturalistic environment over time, with advantages over time-limited, clinic-based observations. However, little is understood about the limitations and advantages of current parent-report measures. We aimed to systematically review the psychometrics and clinometrics of parent-administered feeding questionnaires.

METHOD

Five search engines were used to identify questionnaires that met inclusion criteria, i.e. being norm-or criterion-referenced, child focused, appropriate for preschool children, and measured two or more feeding domains (e.g. dysphagia/oral motor delay, food refusal).

RESULTS

In total 3535 abstracts were identified and 215 full-text articles were evaluated. Five questionnaires met the criteria. The Behavioral Pediatrics Feeding Assessment Scale (BPFAS) was the most reliable questionnaire identified, with good test-retest reliability and internal consistency. More predictive and concurrent validity data was available for the BPFAS, the Mealtime Behavior Questionnaire, and the Montreal Children's Hospital Feeding Scale than for other measures.

INTERPRETATION

Further research is needed on the psychometric properties of feeding questionnaires used in research and clinical practice. To date, the BPFAS has the most comprehensive reliability and validity data of any parent-administered feeding questionnaire for preschool children.

Systematic review: mealtime behavior measures used in pediatric chronic illness populations

OBJECTIVE

This systematic review evaluates the utility and psychometric properties of pediatric mealtime assessments (direct observation and parent-report measures) using evidence-based criteria developed by the Division 54 Evidence-Based Assessment Task Force.

METHOD

Measures of mealtime behavior used in at least one chronic illness pediatric population were eligible for inclusion. A total of 23 assessment measures were reviewed (16 parent-/self-report; 7 direct observation).

RESULTS

3 parent-report and 4 direct observation measures were classified as well-established, 3 met criteria for approaching well-established, and 13 were categorized as promising. Measures have been primarily used in children with feeding disorders, cystic fibrosis, and autism spectrum disorders.

CONCLUSIONS

Overall, the literature of pediatric mealtime assessment tools shows a strong evidence base for many direct observation methods and subjective parent-report measures. Exploratory and confirmatory factor analyses are available for some measures; recommendations for future validation research and measure development across pediatric populations are discussed.