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Ganta S, Haley J, El-Said H, Lane B, Haldeman S, Karamlou T, Moore J, Rao R, Nigro JJ. Stage 1 and 2 Palliation: Comparing Ductal Stenting and Aorto-Pulmonary Shunts in Single Ventricles with Duct-Dependent Pulmonary Blood Flow. Pediatr Cardiol 2024; 45:471-482. [PMID: 38265483 PMCID: PMC10891206 DOI: 10.1007/s00246-023-03386-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 12/18/2023] [Indexed: 01/25/2024]
Abstract
Patent ductus arteriosus stenting (PDAS) for ductal-dependent pulmonary blood flow (DDPBF) provides a new paradigm for managing neonates with single ventricles (SV). Currently, sparse data exist regarding outcomes for subsequent palliation. We describe our experience with inter-stage care and stage 2 (S2P) conversion with PDAS in comparison to a prior era of patients who received surgical aorto-pulmonary shunts (APS). Retrospective review of 18 consecutive DDPBF SV patients treated with PDAS between 2016 and 2021 was done and compared with 9 who underwent APS from 2010 to 2016. Patient outcomes and pulmonary artery (PA) growth were analyzed. S2P was completed in all 18 with PDAS with no cardiac arrests and one post-S2P mortality. In the 9 APS patients, there was one cardiac arrest requiring ECMO and one mortality inter-stage. Off cardiopulmonary bypass strategy was utilized in 10/18 in the PDAS and 1/9 in the APS group (p = 0.005) at S2P. Shorter ventilation time, earlier PO feeding, and shorter hospital stay were noted in the PDAS group (p = 0.01, p = 0.006, p = 0.03) (S2P). Median Nakata index increase inter-stage was not significant between the PDAS and APS at 94.1 mm2/m2 versus 71.7 mm2/m2 (p = 0.94). Median change in pulmonary artery symmetry (PAS) was - 0.02 and - 0.24, respectively, which was statistically significant (p = 0.008). Neurodevelopmental outcomes were better in the PDAS group compared to the APS group (p = 0.02). PDAS provides excellent PA growth, inter-stage survival, progression along multistage single-ventricle palliation, and potentially improved neurodevelopmental outcomes. Most patients can be transitioned through 2 stages of palliation without CPB.
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Affiliation(s)
- Srujan Ganta
- Cardiothoracic Surgery, Rady Children's Hospital + University of California San Diego, 3020 Children's Way, MC5004, San Diego, CA, 92123, USA.
| | - Jessica Haley
- Pediatrics, Division of Cardiology, University of California San Diego, San Diego, CA, USA
| | - Howaida El-Said
- Pediatrics, Division of Cardiology, University of California San Diego, San Diego, CA, USA
| | - Brian Lane
- Pediatrics, Division of Cardiology, University of California San Diego, San Diego, CA, USA
| | - Shylah Haldeman
- Cardiothoracic Surgery, Rady Children's Hospital + University of California San Diego, 3020 Children's Way, MC5004, San Diego, CA, 92123, USA
| | - Tara Karamlou
- Division of Pediatric Cardiac Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - John Moore
- Pediatrics, Division of Cardiology, University of California San Diego, San Diego, CA, USA
| | - Rohit Rao
- Pediatrics, Division of Cardiology, University of California San Diego, San Diego, CA, USA
| | - John J Nigro
- Cardiothoracic Surgery, Rady Children's Hospital + University of California San Diego, 3020 Children's Way, MC5004, San Diego, CA, 92123, USA
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Beer SS, Wong Vega M. Malnutrition, sarcopenia, and frailty assessment in pediatric transplantation. Nutr Clin Pract 2024; 39:27-44. [PMID: 38088812 DOI: 10.1002/ncp.11105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 11/08/2023] [Accepted: 11/13/2023] [Indexed: 01/13/2024] Open
Abstract
Nutrition assessment can be challenging in children with end-stage organ disease and in those requiring an organ transplant. The effect of poor nutrition status can exert long-lasting effects on children with end-stage organ disease requiring transplantation. Malnutrition, sarcopenia, and frailty are conditions that require provision of optimal nutrition to prevent or support the treatment of these conditions. Unfortunately, the literature on the assessment of malnutrition, sarcopenia, and frailty in pediatric end-stage organ disease is scarce, thus leading to confusion on how to effectively identify them. Recently, the addition of a variety of validated nutrition and functional assessment techniques has assisted with appropriate assessment of these conditions. The objective of this narrative review is to provide an overview of the current literature for pediatric assessment of malnutrition, sarcopenia, and frailty in the setting of solid organ transplantation and provide practicing nutrition clinicians a solid foundation for learning how to effectively assess these conditions with the current literature available.
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Affiliation(s)
- Stacey Silver Beer
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Molly Wong Vega
- Renal Section, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
- Department of Health and Human Performance, University of Houston, Houston, Texas, USA
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3
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Dijkhuizen EI, Dulfer K, de Munck S, van Haren NEM, de Jonge RCJ, Vanhorebeek I, Wouters PJ, Van den Berghe G, Verbruggen SCAT, Joosten KFM. Early weight measures and long-term neuropsychological outcome of critically ill neonates and infants: a secondary analysis of the PEPaNIC trial. Eur J Pediatr 2024; 183:649-661. [PMID: 37950792 PMCID: PMC10912138 DOI: 10.1007/s00431-023-05298-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 10/17/2023] [Accepted: 10/18/2023] [Indexed: 11/13/2023]
Abstract
Neonates and infants surviving critical illness show impaired growth during critical illness and are at risk for later neuropsychological impairments. Early identification of individuals most at risk is needed to provide tailored long-term follow-up and care. The research question is whether early growth during hospitalization is associated with growth and neuropsychological outcomes in neonates and infants after pediatric intensive care unit admission (PICU). This is a secondary analysis of the PEPaNIC trial. Weight measurements upon PICU admission, at PICU discharge, at hospital discharge, at 2- and 4-year follow-up, and of different subgroups were compared using (paired) t-tests. Multiple linear regression analyses were performed to investigate the association between early growth in weight measures and neuropsychological outcomes at 4-year follow-up. One hundred twenty-one infants were included, and median age upon admission was 21 days. Growth in weight per week was less than the age-appropriate norm, resulting in a decrease in weight-for-age Z-score during hospitalization. Weight is normalized at 2- and 4-year follow-up. Weight gain in kilograms per week and change in weight Z-score were not associated with neurodevelopmental outcome measures at 4-year follow-up. Lower weight-for-age Z-score at PICU admission and at hospital discharge was associated only with lower weight and height Z-scores at 4-year follow-up. CONCLUSION Growth in weight during hospital stay of young survivors of critical illness is impaired. Worse early growth in weight is associated with lower weight and height but not with neuropsychological outcomes at 4-year follow-up. WHAT IS KNOWN • Critically ill neonates and infants show impaired early growth during admission and are at risk for later neuropsychological impairments. • Unraveling the association between early growth and later neuropsychological impairments is crucial since the first year of life is critical for brain development. WHAT IS NEW • Critically ill neonates and infants had age appropriate weight measures at 4-year follow-up. • Poor growth in weight during hospital stay was not associated with poorer cognitive, emotional, or behavioral functioning four years after critical illness.
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Affiliation(s)
- E I Dijkhuizen
- Department of Neonatal & Pediatric Intensive Care, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - K Dulfer
- Department of Neonatal & Pediatric Intensive Care, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - S de Munck
- Department of Neonatal & Pediatric Intensive Care, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - N E M van Haren
- Department of Child and Adolescent Psychiatry/Psychology, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - R C J de Jonge
- Department of Neonatal & Pediatric Intensive Care, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - I Vanhorebeek
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - P J Wouters
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - G Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - S C A T Verbruggen
- Department of Neonatal & Pediatric Intensive Care, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - K F M Joosten
- Department of Neonatal & Pediatric Intensive Care, Erasmus Medical Center, Sophia Children's Hospital, Rotterdam, The Netherlands.
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Marino LV, Collaḉo N, Coyne S, Leppan M, Ridgeway S, Bharucha T, Cochrane C, Fandinga C, Palframan K, Rees L, Osman A, Johnson MJ, Hurley-Wallace A, Darlington ASE. The Development of a Communication Tool to Aid Parent-Centered Communication between Parents and Healthcare Professionals: A Quality Improvement Project. Healthcare (Basel) 2023; 11:2706. [PMID: 37893780 PMCID: PMC10606263 DOI: 10.3390/healthcare11202706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 10/05/2023] [Accepted: 10/08/2023] [Indexed: 10/29/2023] Open
Abstract
Good communication is central to good healthcare. As a result of poor communication between parents and healthcare professionals (HCPs) in clinical settings, this study aimed to address this problem by developing a communication tool to empower parents and act as a prompt for HCPs to talk about the child's care and gather information at the point of admission to hospital about what is important to families, therefore supporting patient-centered communication. A design thinking process was used to develop a physical copy of Chloe's card and evaluate its use. Design thinking is a problem-solving approach, which uses an empathetic lens to integrate viewpoints of different stakeholders throughout the process of creating solutions. Design thinking involves five processes: (1) empathise-including a literature review and data synthesis, (2) define-by completing semi-structured interviews with parents about their experience of communication and HCPs perceptions of parent's experience of communication, (3) ideate-iterate the design of Chloe's card with parents and HCPs, (4) prototype-develop the design of Chloe's card, and (5) test-pilot test in clinical practice. Results from this initial study suggest that a small hand-held card, with emoticons and a place to write concerns, was acceptable to parents and feasible to use in clinical practice. Parents do not always feel heard by HCPs and a tool such as Chloe's card may help facilitate sharing of information about matters important to them and their child. However, some HCPs felt the need for a communication tool undermined their clinical skills. Feedback from HCP participants suggests that the idea of Chloe's card was acceptable and perceived as potentially being useful in clinical practice. Further work is required, as part of a larger study, to further refine this communication tool, identify those parents who would benefit most from Chloe's card, as well as to further refine the HCP process prior to implementing it into clinical settings. It was noted future iterations would benefit from a digital version linked with a child's electronic record, as well as multi-language versions and information for parents.
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Affiliation(s)
- Luise V Marino
- Paediatric Intensive Care, Southampton Children's Hospital, University Southampton Hospital NHS Foundation Trust, Southampton SO16 6YD, UK
| | - Nicole Collaḉo
- School of Health Sciences, Southampton University, Southampton SO17 1BJ, UK
| | | | | | | | - Tara Bharucha
- Paediatric Cardiology, Southampton Children's Hospital, University Southampton Hospital NHS Foundation Trust, Southampton SO16 6YD, UK
| | - Colette Cochrane
- Paediatric Cardiology, Southampton Children's Hospital, University Southampton Hospital NHS Foundation Trust, Southampton SO16 6YD, UK
| | - Catarina Fandinga
- Department of Dietetics/Speech Language Therapy, University Southampton Hospital NHS Foundation Trust, Southampton SO16 6YD, UK
| | - Karla Palframan
- Department of Dietetics/Speech Language Therapy, University Southampton Hospital NHS Foundation Trust, Southampton SO16 6YD, UK
| | - Leanne Rees
- Department of Dietetics/Speech Language Therapy, University Southampton Hospital NHS Foundation Trust, Southampton SO16 6YD, UK
| | - Ahmed Osman
- Paediatric Intensive Care, Southampton Children's Hospital, University Southampton Hospital NHS Foundation Trust, Southampton SO16 6YD, UK
| | - Mark J Johnson
- Neonatal Medicine, Princess Anne Hospital, University Southampton Hospital NHS Foundation Trust, Southampton SO16 6YD, UK
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Marino LV, Paulson S, Ashton JJ, Weeks C, Young A, Pappachan JVP, Swann JR, Johnson MJ, Beattie RM. A scoping review: urinary markers of metabolic maturation in infants with CHD and the relationship to growth. Cardiol Young 2023; 33:1879-1888. [PMID: 36325968 DOI: 10.1017/s1047951122003262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Luise V Marino
- Paediatric Intensive Care Unit, Southampton Children's Hospital, NIHR Southampton Biomedical Research Centre University Hospital Southampton NHS Foundation Trust; Faculty of Health Science, University of Southampton, Southampton, UK
| | - Simone Paulson
- Paediatric Intensive Care Unit, Southampton Children's Hospital, NIHR Southampton, UK
| | - James J Ashton
- Paediatric Gastroenterology, Southampton Children's Hospital, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust; Faculty of Human Genetics and Genomic Medicine, University of Southampton, Southampton, UK
| | - Charlotte Weeks
- Paediatric Intensive Care Unit, Southampton Children's Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Aneurin Young
- Department of Neonatal Medicine, Southampton Children's Hospital, University Hospital Southampton NHS Foundation Trust and NIHR Southampton Biomedical Research Centre, UK
| | - John V P Pappachan
- Paediatric Intensive Care Unit, Southampton Children's Hospital, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust; Faculty of Medicine, University of Southampton, Southampton, UK
| | - John R Swann
- Biomolecular Medicine, School of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Mark J Johnson
- Neonatal Medicine, Southampton Children's Hospital, NIHR Southampton Biomedical Research Centre University Hospital Southampton NHS Foundation Trust; Faculty of Medicine, University of Southampton, Southampton, UK
| | - R Mark Beattie
- Paediatric Gastroenterology, Southampton Children's Hospital, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust; Faculty of Human Genetics and Genomic Medicine, University of Southampton, Southampton, UK
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6
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Trabulsi JC, Lessen R, Siemienski K, Delahanty MT, Rickman R, Papas MA, Rovner A. Relationship Between Human Milk Feeding Patterns and Growth in the First Year of Life in Infants with Congenital Heart Defects. Pediatr Cardiol 2023; 44:882-891. [PMID: 36282285 DOI: 10.1007/s00246-022-03023-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 10/03/2022] [Indexed: 10/31/2022]
Abstract
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.
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Affiliation(s)
- Jillian C Trabulsi
- Department of Behavioral Health and Nutrition, University of Delaware, 318 STAR Tower, 100 Discovery Blvd., Newark, DE, 19713, USA.
| | - Rachelle Lessen
- Lactation Department, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Kathryn Siemienski
- Clinical Nutrition, Christiana Care, Avenue North, 4000 Nexus Drive, Wilmington, DE, 19803, USA
| | - Michelle T Delahanty
- Department of Behavioral Health and Nutrition, University of Delaware, 318 STAR Tower, 100 Discovery Blvd., Newark, DE, 19713, USA
| | - Rachel Rickman
- Department of Nutritional Sciences, University of Texas - Austin, Austin, TX, 78705, USA
| | - Mia A Papas
- Institute for Research on Equity and Community Health, Christiana Care, 4755 Ogletown-Stanton Road, Newark, DE, 19718, USA
| | - Alisha Rovner
- Department of Behavioral Health and Nutrition, University of Delaware, 318 STAR Tower, 100 Discovery Blvd., Newark, DE, 19713, USA
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Zhang Y, Lu L, Yang L, Yan W, Yu Q, Sheng J, Mao X, Feng Y, Tang Q, Cai W, Wang Y. Evaluation of a new digital pediatric malnutrition risk screening tool for hospitalized children with congenital heart disease. BMC Pediatr 2023; 23:126. [PMID: 36934232 PMCID: PMC10024365 DOI: 10.1186/s12887-023-03899-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 02/08/2023] [Indexed: 03/20/2023] Open
Abstract
BACKGROUND In a cohort of hospitalized children with congenital heart disease (CHD), a new digital pediatric malnutrition screening tool as a mobile application was validated, and its effectiveness and clinical value were determined as a prospective study. METHODS AND RESULTS Children with CHD (n = 1125) were screened for malnutrition risk. The incidence of risk and the differences among various age groups and types of CHD were characterized. The optimal threshold for the tool to determine if there is a risk of malnutrition is score 2, while the Youden index was 79.1%, and the sensitivity and specificity were 91.2% and 87.9%, respectively. Based on such criterion, 351 children were at risk of malnutrition accounting for 31.20% of the total. Compared with the non-malnutritional risk group, the median age for the group at risk for malnutrition was younger (8.641 months [4.8, 23.1] vs. 31.589 months [12.4, 54.3], P < 0.01), and the length of stay was longer (12.000 [8.0, 17.0] vs. (8.420 [5.0, 12.0], P < 0.01]. There were significant differences in malnutrition risk among different age groups (χ2 = 144.933, P < 0.01), and children under one year of age exhibited the highest risk for malnutrition and more extended hospital stay (H = 78.085, P < 0.01). The risk of malnutrition among children with cyanotic CHD was higher than in those with non-cyanotic CHD (χ2 = 104.384, P < 0.01). CONCLUSIONS The new digital pediatric malnutrition screening tool showed high sensitivity and specificity in children with CHD. The tool indicated that the malnutrition risk for young children and children with cyanotic or Bethesda moderate and complex CHD was higher, and the hospitalization time was longer than in the non-risk group. The tool provides a rational approach to targeted nutrition intervention and support and may improve clinical outcomes.
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Affiliation(s)
- Yajie Zhang
- Division of Pediatric Gastroenterology and Nutrition, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Institute for Pediatric Research, Shanghai, China
- Department of Pediatric Surgery, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China
| | - Lina Lu
- Division of Pediatric Gastroenterology and Nutrition, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China
| | - Ling Yang
- Pediatric Heart Center, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Weihui Yan
- Division of Pediatric Gastroenterology and Nutrition, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China
| | - Qun Yu
- Department of Nursing, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jinye Sheng
- Department of Clinical Nutrition, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaomeng Mao
- Department of Clinical Nutrition, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yi Feng
- Department of Clinical Nutrition, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Qingya Tang
- Department of Clinical Nutrition, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Wei Cai
- Division of Pediatric Gastroenterology and Nutrition, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
- Shanghai Institute for Pediatric Research, Shanghai, China.
- Department of Pediatric Surgery, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
- Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China.
| | - Ying Wang
- Division of Pediatric Gastroenterology and Nutrition, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
- Shanghai Key Laboratory of Pediatric Gastroenterology and Nutrition, Shanghai, China.
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Milligan C, Mills KI, Ge S, Michalowski A, Braudis N, Mansfield L, Nathan M, Sleeper LA, Teele SA. Cardiovascular intensive care unit variables inform need for feeding tube utilization in infants with hypoplastic left heart syndrome. J Thorac Cardiovasc Surg 2023; 165:1248-1256. [PMID: 35691711 DOI: 10.1016/j.jtcvs.2022.04.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 03/24/2022] [Accepted: 04/28/2022] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Caitlin Milligan
- Department of Cardiology, Boston Children's Hospital, Boston, Mass.
| | - Kimberly I Mills
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Shirley Ge
- Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Anna Michalowski
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass
| | - Nancy Braudis
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children's Hospital, Boston, Mass
| | - Laura Mansfield
- Department of Cardiology, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Meena Nathan
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, Mass; Department of Surgery, Harvard Medical School, Boston, Mass
| | - Lynn A Sleeper
- Department of Cardiology, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
| | - Sarah A Teele
- Division of Cardiovascular Critical Care, Department of Cardiology, Boston Children's Hospital, Boston, Mass; Department of Pediatrics, Harvard Medical School, Boston, Mass
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9
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Silva-Gburek J, Marroquín A, Flores S, Roddy J, Ghanayem NS, Shekerdemian LS, Coss-Bu JA. Perioperative Nutritional Status and Organ Dysfunction Following Surgery for Congenital Heart Disease. Pediatr Cardiol 2023:10.1007/s00246-023-03111-2. [PMID: 36745225 DOI: 10.1007/s00246-023-03111-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 01/23/2023] [Indexed: 02/07/2023]
Abstract
Children with congenital heart disease (CHD) are at risk of malnutrition; however, there is limited information regarding the impact of nutritional status on organ dysfunction and outcomes after surgery for CHD. The study aim was to assess the association between malnutrition, organ dysfunction, and outcomes after surgery for CHD. Retrospective cohort study of patients aged 30 days to 18 years admitted to the cardiac intensive care unit (CICU) following cardiac surgery. Nutritional status (malnutrition defined as weight for age z-score < - 2) and validated organ dysfunction scores (pSOFA and PELOD-2) on CICU days 1 and 3 were collected. The cohort included 967 patients with a median age of 2.8 years (IQR 0.46, 7.12) and hospital survival of 98.86%. The prevalence of malnutrition was 18.5% (n = 179). By multivariable logistic regression analysis including age, malnutrition, cardiopulmonary bypass time, and duration of mechanical ventilation; High STAT category (OR 7.51 [1.03-54], p = 0.0462) and PSOFA score > 5 day 1 (OR 1.84 [1.25-2.72], p = 0.0021) were associated with mortality; in a similar model including the same variables; High STAT category (OR 9.12 [1.33-62], p = 0.0243) and PELOD-2 score > 5 day 1 (OR 1.75 [1.10-2.77], p = 0.0175) were associated with mortality. Malnutrition was associated with persistent or worsening organ dysfunction by pSOFA (p < 0.05) and PELOD-2 (p < 0.01) on day 3. Malnutrition was present in infants and children undergoing surgery for congenital heart disease. Organ dysfunction and high surgical risk were associated with mortality. Malnutrition was not associated with mortality but was associated with postoperative organ dysfunction.
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Affiliation(s)
- Jaime Silva-Gburek
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Andrea Marroquín
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Saul Flores
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA.,Division of Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Jeramy Roddy
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Nancy S Ghanayem
- Division of Critical Care Medicine, Department of Pediatrics, University of Chicago, Chicago, IL, USA
| | - Lara S Shekerdemian
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA.,Division of Cardiology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA
| | - Jorge A Coss-Bu
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, TX, USA.
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10
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Matthews CR, Hartman D, Farrell AG, Colgate CL, Gray BW, Zborek K, Herrmann JL. Impact of Home Monitoring Program and Early Gastrostomy Tube on Interstage Outcomes following Stage 1 Norwood Palliation. Pediatr Cardiol 2023; 44:124-131. [PMID: 35727331 DOI: 10.1007/s00246-022-02947-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 05/31/2022] [Indexed: 01/24/2023]
Abstract
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.
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Affiliation(s)
- Caleb R Matthews
- Section of Pediatric Cardiothoracic Surgery, Department of Surgery, Indiana School of Medicine, 545 Barnhill Drive, Emerson 215, Indianapolis, IN, 46202, USA
| | - Dana Hartman
- Section of Pediatric Cardiology, Department of Surgery, Indiana School of Medicine, Indianapolis, IN, USA
- Riley Children's Health at IU Health, Indianapolis, IN, USA
| | - Anne G Farrell
- Section of Pediatric Cardiology, Department of Surgery, Indiana School of Medicine, Indianapolis, IN, USA
- Riley Children's Health at IU Health, Indianapolis, IN, USA
| | - Cameron L Colgate
- Center for Outcomes Research in Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Brian W Gray
- Division of Pediatric Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
- Riley Children's Health at IU Health, Indianapolis, IN, USA
| | - Kirsten Zborek
- Section of Pediatric Cardiothoracic Surgery, Department of Surgery, Indiana School of Medicine, 545 Barnhill Drive, Emerson 215, Indianapolis, IN, 46202, USA
- Riley Children's Health at IU Health, Indianapolis, IN, USA
| | - Jeremy L Herrmann
- Section of Pediatric Cardiothoracic Surgery, Department of Surgery, Indiana School of Medicine, 545 Barnhill Drive, Emerson 215, Indianapolis, IN, 46202, USA.
- Riley Children's Health at IU Health, Indianapolis, IN, USA.
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11
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Nasser BA, Abdulrahman M, Qwaee AAL, Alakhfash A, Mohamad T, Kabbani MS, Alseedi U, Obedien B, Chrit A. Growth assessment in down syndrome after cardiac surgery. EGYPTIAN PEDIATRIC ASSOCIATION GAZETTE 2022. [DOI: 10.1186/s43054-022-00109-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Objective
To assess the effect of cardiac surgery on growth catch-up of Down syndrome (DS) children with failure to thrive (FTT) and congenital heart disease (CHD) and investigate other causes of FTT in DS children.
Method
We conducted a retrospective observational study in tertiary cardiac center from 2015 to 2018. We included all cases of DS diagnosed with CHD and FTT who completed a 1-year follow-up after cardiac surgery. We divided the cases into two groups; “normalize group” includes children who normalized their growth parameters and “underweight group” includes those who remained in FTT category during the follow-up period. We compared both groups for multiple risk factors.
Result
Most of DS had FTT upon surgery. Fifty percent of cases completed 1-year follow-up including 29 (60%) in the normalized group and 19 (40%) in underweight group. Within 6 months post-surgery, the normalized group though did not reach yet normalization of growth parameters, demonstrated statically significant improvement in weight for age, weight Z-score in compared to underweight group.
Within 12 months post-surgery, the normalized group achieved normalization of growth parameters and continue to show more statistically significant differences in growth parameters.
Both groups had comparable post-operation course. Univariate analysis of possible peri-operative risk factors showed no difference between both groups except for presence of untreated subclinical hypothyroidism in 58% of the underweight group versus 17% in control group (p = 0.005).
Conclusion
FTT in DS patient is multifactorial which needs thorough investigation and work up by multidisciplinary team. Cardiac surgery may not guarantee the improvement of growth parameters.
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12
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Risk Factors for Tube Feeding at Discharge in Infants Undergoing Neonatal Surgery for Congenital Heart Disease: A Systematic Review. Pediatr Cardiol 2022; 44:769-794. [PMID: 36404346 DOI: 10.1007/s00246-022-03049-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 11/07/2022] [Indexed: 11/22/2022]
Abstract
Approximately 30-50% of infants undergoing neonatal surgery for congenital heart disease (CHD) cannot meet oral feeding goals by discharge and require feeding tube support at home. Feeding tubes are associated with increased readmission rates and consequent hospital, payer, and family costs, and are a burden for family caregivers. Identification of modifiable risk factors for oral feeding problems could support targeted care for at-risk infants. Therefore, the aim of this systematic review is to determine risk factors for tube feeding at discharge in infants undergoing neonatal surgery for CHD. Following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, a search was conducted using MEDLINE, CINAHL, and Cochrane Database of Systematic Reviews. Studies published before 2010 were excluded. The search resulted in 607 records, of which 18 were included. Studies were primarily retrospective cohort designs and results were often inconsistent. Study quality was assessed using the Joanna Briggs Critical Appraisal Tools. As a group, the studies exhibited substantial risk for bias. Based on the findings, infants who struggle with feeding preoperatively, experience increased nil per os duration and/or low oral feeding volume postoperatively, experience increased duration of mechanical ventilation, or have vocal cord dysfunction may be at risk for tube feeding at hospital discharge. Factors warranting further examination include cardiac physiology (e.g., aortic arch obstruction) and the relationship between neurodevelopment and oral feeding. Clinicians should use caution in assuming risk for an individual and prioritize early implementation of interventions that facilitate oral feeding development.
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13
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Paneitz DC, Zhou A, Yanek L, Golla S, Avula S, Kannankeril PJ, Everett AD, Mettler BA, Sen DG. Growth Differentiation Factor 15: A Novel Growth Biomarker for Children With Congenital Heart Disease. World J Pediatr Congenit Heart Surg 2022; 13:745-751. [PMID: 36300261 PMCID: PMC10947752 DOI: 10.1177/21501351221118080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
BACKGROUND Failure to thrive (FTT), defined as weight or height less than the lowest 2.5 percentile for age, is prevalent in up to 66% of children with congenital heart disease (CHD). Risk stratification methods to identify those who would benefit from early intervention are currently lacking. We aimed to identify a novel growth biomarker to aid clinical decision-making in children with CHD. METHODS This is a cross-sectional study of patients 2 months to 10 years of age with any CHD undergoing cardiac surgery. Preoperative weight-for-age Z scores (WAZ) and height-for-age Z scores (HAZ) were calculated and assessed for association with preoperative plasma biomarkers: growth differentiation factor 15 (GDF-15), fibroblast growth factor 21, leptin, prealbumin, and C-reactive protein (CRP). RESULTS Of the 238 patients included, approximately 70% of patients had WAZ/HAZ < 0 and 34% had FTT. There was a moderate correlation between GDF-15 and WAZ/HAZ. When stratified by age, the correlation of GDF-15 to WAZ and HAZ was strongest in children under 2 years of age and persisted in the setting of inflammation (CRP > 0.5 mg/dL). Diagnoses commonly associated with congestive heart failure had high proportions of FTT and median GDF-15 levels. Prealbumin was not correlated with WAZ or HAZ. CONCLUSIONS GDF-15 represents an important growth biomarker in children with CHD, especially those under 2 years of age who have diagnoses commonly associated with CHF. Our data do not support prealbumin as a long-term growth biomarker.
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Affiliation(s)
- Dane C Paneitz
- Department of Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Alice Zhou
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lisa Yanek
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Srujana Golla
- Division of Pediatric Cardiac Surgery, Department of Surgery, Johns Hopkins Children’s Center, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Sravani Avula
- Division of Pediatric Cardiology, Children’s Medical Center Dallas, Dallas, TX, USA
| | - Prince J Kannankeril
- Thomas P. Graham Jr. Division of Pediatric Cardiology and the Center for Pediatric Precision Medicine, Department of Pediatrics, Monroe Carell Jr. Children’s Hospital at Vanderbilt and Vanderbilt University Medical Center, Nashville, TN, USA
| | - Allen D Everett
- Division of Pediatric Cardiology, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Bret A Mettler
- Division of Pediatric Cardiac Surgery, Department of Surgery, Johns Hopkins Children’s Center, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Danielle Gottlieb Sen
- Division of Pediatric Cardiac Surgery, Department of Surgery, Johns Hopkins Children’s Center, Johns Hopkins Hospital, Baltimore, MD, USA
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14
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Mills KI, Kim JH, Fogg K, Goldshtrom N, Graham EM, Kataria-Hale J, Osborne SW, Figueroa M. Nutritional Considerations for the Neonate With Congenital Heart Disease. Pediatrics 2022; 150:189883. [PMID: 36317972 DOI: 10.1542/peds.2022-056415g] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 02/25/2023] Open
Abstract
The importance of nutrition in managing critically ill infants with congenital heart disease (CHD) is foundational to optimizing short- and long-term health outcomes. Growth failure and malnutrition are common in infants with CHD. The etiology of growth failure in this population is often multifactorial and may be related to altered metabolic demands, compromised blood flow to the intestine leading to nutrient malabsorption, cellular hypoxia, inadequate energy intake, and poor oral-motor skills. A dearth of high-quality studies and gaps in previously published guidelines have led to wide variability in nutrition practices that are locally driven. This review provides recommendations from the nutrition subgroup of the Neonatal Cardiac Care Collaborative for best evidence-based practices in the provision of nutritional support in infants with CHD. The review of evidence and recommendations focused on 6 predefined areas of clinical care for a target population of infants <6 months with CHD admitted to the ICU or inpatient ward. These areas include energy needs, nutrient requirements, enteral nutrition, feeding practice, parenteral nutrition, and outcomes. Future progress will be directed at quality improvement efforts to optimize perioperative nutrition management with an increasing emphasis on individualized care based on nutritional status, cardiorespiratory physiology, state of illness, and other vulnerabilities.
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Affiliation(s)
- Kimberly I Mills
- Division of Cardiovascular Critical Care, Department of Cardiology, Harvard Medical School and Boston Children's Hospital, Boston, Massachusetts.,Contributed equally as co-first authors
| | - Jae H Kim
- Division of Neonatology, Perinatal Institute, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati, College of Medicine, Cincinnati, Ohio.,Contributed equally as co-first authors
| | - Kristi Fogg
- Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Nimrod Goldshtrom
- Division of Neonatology, Department of Pediatrics, Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, New York
| | - Eric M Graham
- Division of Pediatric Cardiology, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina
| | - Jasmeet Kataria-Hale
- Division of Neonatology, Department of Pediatrics, Mission Children's Hospital, Asheville, North Carolina
| | - Scott W Osborne
- Section of Neonatology, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Mayte Figueroa
- Division of Cardiology and Critical Care, Department of Pediatrics, St Louis Children's Hospital, Washington University School of Medicine, St Louis, Missouri
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15
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Diao J, Chen L, Wei J, Shu J, Li Y, Li J, Zhang S, Wang T, Qin J. Prevalence of Malnutrition in Children with Congenital Heart Disease: A Systematic Review and Meta-Analysis. J Pediatr 2022; 242:39-47.e4. [PMID: 34742752 DOI: 10.1016/j.jpeds.2021.10.065] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 10/29/2021] [Accepted: 10/31/2021] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To evaluate the global prevalence of malnutrition in children with congenital heart disease (CHD). STUDY DESIGN A systematic review and meta-analysis were performed. Web of Science, PubMed, Embase, Wanfang Database, China National Knowledge Infrastructure, and China Biology Medicine disc databases were searched for studies published through April 2021. Random-effect model meta-analyses were performed to derive the pooled the prevalence of preoperative underweight, stunting, and wasting in children with CHD. Time-trend analyses of postoperative malnutrition prevalence were undertaken. Subgroup and sensitivity analyses were conducted to explore sources of heterogeneity. Egger test and funnel plots were used to explore public bias. RESULTS A total of 39 studies were included in this meta-analysis. The pooled estimates of preoperative malnutrition in children with CHD were 27.4% (95% CI, 21.7-34.0) for underweight, 24.4% (95% CI, 19.5-30.0) for stunting, and 24.8% (95% CI, 19.3-31.3) for wasting. Catch-up growth was found in the postoperative period among some children. Different continents were identified as heterogeneity moderators by subgroup analyses. CONCLUSIONS Children with CHD have a high prevalence of preoperative malnutrition and some show catch-up growth postoperatively. These data can be used as benchmarks in efforts to improve the nutritional status of children with CHD.
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Affiliation(s)
- Jingyi Diao
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China
| | - Letao Chen
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China
| | - Jianhui Wei
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China
| | - Jing Shu
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China
| | - Yihuan Li
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China
| | - Jinqi Li
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China
| | - Senmao Zhang
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China
| | - Tingting Wang
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China; National Health Council Key Laboratory of Birth Defect for Research and Prevention, Hunan Provincial Maternal and Child Health Care Hospital, Changsha, Hunan, China
| | - Jiabi Qin
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China; National Health Council Key Laboratory of Birth Defect for Research and Prevention, Hunan Provincial Maternal and Child Health Care Hospital, Changsha, Hunan, China; Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, Guangdong, China.
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16
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Irving SY, Ravishankar C, Miller M, Chittams J, Stallings V, Medoff-Cooper B. Anthropometry Based Growth and Body Composition in Infants with Complex Congenital Heart Disease. Clin Nurs Res 2022; 31:931-940. [PMID: 35135359 DOI: 10.1177/10547738221075720] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Sharon Y Irving
- University of Pennsylvania School of Nursing, Philadelphia, USA.,Children's Hospital of Philadelphia, PA, USA
| | - Chitra Ravishankar
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
| | - Mary Miller
- Eli Lilly and Company, Indianapolis, IN, USA
| | - Jesse Chittams
- University of Pennsylvania School of Nursing, Philadelphia, USA
| | - Virginia Stallings
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, USA
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17
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Zhang QL, Lin WH, Lin SH, Cao H, Chen Q. Using Telemedicine Strategy to Implementing Nutrition Management for Neonates After Congenital Heart Disease Surgery: A New Nutrition Management Strategy. Front Pediatr 2022; 10:918742. [PMID: 35783326 PMCID: PMC9243536 DOI: 10.3389/fped.2022.918742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 05/23/2022] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE The purpose of this study was to investigate the effect of remote nutrition management on promoting the growth and development of neonates after congenital heart disease (CHD) surgery. MATERIALS AND METHODS This study retrospectively analyzed the clinical data of 32 neonates after CHD surgery who received remote nutrition management from January 2021 to July 2021 in our hospital. The clinical data of 30 neonates after CHD surgery, who did not receive remote nutrition management from June 2020 to December 2020, was used as control. The growth and development of the two groups were compared. RESULTS Three months after discharge, the weight, height, and weight-for-age z score (WAZ) of the intervention group was significantly higher than those of the control group. The amount of milk in the intervention group was also significantly more than that of the control group, and more neonates in the intervention group added high-energy milk or breast milk fortifier than the intervention group. The parental care ability of the intervention group was significantly higher than that of the control group. The incidence of respiratory tract infection and readmission in the intervention group was significantly lower than that in the control group. CONCLUSION As a new nutrition management strategy for neonates after CHD surgery, remote nutrition management can effectively improve the nutritional status of neonates and promote their growth and development.
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Affiliation(s)
- Qi-Liang Zhang
- Department of Cardiac Surgery, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.,Fujian Children's Hospital, Fuzhou, China.,College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China
| | - Wen-Hao Lin
- Department of Cardiac Surgery, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.,Fujian Children's Hospital, Fuzhou, China.,College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China
| | - Shi-Hao Lin
- Department of Cardiac Surgery, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.,Fujian Children's Hospital, Fuzhou, China.,College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China
| | - Hua Cao
- Department of Cardiac Surgery, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.,Fujian Children's Hospital, Fuzhou, China.,College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China
| | - Qiang Chen
- Department of Cardiac Surgery, Fujian Branch of Shanghai Children's Medical Center, Fuzhou, China.,Fujian Children's Hospital, Fuzhou, China.,College of Clinical Medicine for Obstetrics & Gynecology and Pediatrics, Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Women and Children's Critical Diseases Research, Fujian Maternity and Child Health Hospital, Fuzhou, China
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18
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Ismail SR, Mehmood A, Rabiah N, Abu-sulaiman RM, Kabbani MS. Impact of the nutritional status of children with congenital heart diseases on the early post-operative outcome. EGYPTIAN PEDIATRIC ASSOCIATION GAZETTE 2021. [DOI: 10.1186/s43054-021-00077-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Children with congenital heart disease (CHD) frequently become malnourished due to many factors including hypermetabolic state, inadequate caloric intake, malabsorption, and fluid restriction as part of the hemodynamic intervention. The abnormal nutritional status may affect early outcome after pediatric cardiac surgery; we aim to prove the importance of nutritional assessment and patient nutritional preparation before performing pediatric cardiac surgery.
Results
We conducted a prospective observational cohort study from March 2013 till January 2015. All children from birth until 14 years of age admitted to the pediatric cardiac intensive care unit (PCICU) after cardiac surgery. Nutritional status was assessed preoperatively and prognostic nutritional index (PNI) was calculated. All post-operative outcome parameters, PCICU and hospital length of stay (LOS), ventilation time, the rate of infection, and ICU mortality were recorded. Two hundred fifty-nine children were evaluated. At admission, 179 patients (69%) had intake less than 50% of the recommended daily allowance (RDA) of calories intake. There was a statistically significant relationship between pre-admission RDA and the infection rate (P value 0.018). Severely malnourished patients had significantly longer ICU length of stay (LOS) (P value = 0.049). Similarly, weight and height percentiles have a significant effect on ICU LOS (P value 0.009 and 0.045) respectively. There was a significant relation between PNI ≥ 55 and the ICU LOS (P < 0.05), and ventilation time (P = 0.036). Delay in feeding postoperatively was associated with a higher risk of infection (P = 0.005), and higher mortality (P = 0.03).
Conclusions
Children with CHD were significantly malnourished preoperatively and had further weight loss postoperatively. Preoperative nutritional status and delayed postoperative enteral feeding were associated with a higher infection rate and mortality.
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19
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Ventura JC, Oliveira LDDA, Silveira TT, Hauschild DB, Mehta NM, Moreno YMF. Admission factors associated with nutritional status deterioration and prolonged pediatric intensive care unit stay in critically ill children: PICU-ScREEN multicenter study. JPEN J Parenter Enteral Nutr 2021; 46:330-338. [PMID: 33818806 DOI: 10.1002/jpen.2116] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Early identification of patients in the pediatric intensive care unit (PICU) at risk of nutritional status (NS) deterioration and poor outcomes is desirable. We aimed to identify factors associated with NS deterioration and prolonged PICU stay. METHODS Prospective cohort study in eight Brazilian PICUs with children <18 years with a PICU stay >72h. We used multivariable logistic regression to identify the clinical, laboratory, and nutrition variables at admission that were associated with outcomes. NS deterioration was defined as the reduction in weight-for-age, body mass index-for-age or mid-upper arm circumference-for-age z-score ≥1 during PICU stay. Prolonged PICU stay was defined as ≥13 days. RESULTS We enrolled 363 eligible patients, median age 11.3 months (interquartile range:3.1-45.6) and 46% had at least one complex chronic condition (CCC). NS deterioration was observed in 23% of participants and was associated with CCC (odds ratio [OR]:2.71; 95% confidence interval [CI]:1.44-5.09), after adjusting for severity risk score, leukocyte count, obesity, and PICU site. Prolonged PICU stay was associated with age <2 years (OR:1.95; 95%CI:1.03-3.66), fluid overload (>10%) over the first 72h (OR:2.66; 95%CI:1.50-4.73), and hypoalbuminemia (<3.0 g/dL) (OR:2.05; 95%CI:1.12-3.76), after adjusting for CCC, severity risk score, undernutrition, early nutrition therapy, and PICU site. CONCLUSIONS CCC at admission was associated with NS deterioration. Age <2 years, fluid overload, and hypoalbuminemia at PICU admission were associated with prolonged PICU stay. These factors must be further evaluated as part of an admission nutrition screening tool for critically ill children.
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Affiliation(s)
| | | | - Taís Thomsen Silveira
- Graduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, Brazil
| | | | - Nilesh M Mehta
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Yara Maria Franco Moreno
- Graduate Program in Nutrition, Federal University of Santa Catarina, Florianópolis, Brazil.,Department of Nutrition, Federal University of Santa Catarina, Florianópolis, Brazil
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20
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Feeding infants with complex congenital heart disease: a modified Delphi survey to examine potential research and practice gaps. Cardiol Young 2021; 31:577-588. [PMID: 33303041 PMCID: PMC8058165 DOI: 10.1017/s1047951120004370] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To determine clinical consensus and non-consensus in regard to evidence-based statements about feeding infants with complex CHD, with a focus on human milk. Areas of non-consensus may indicate discrepancies between research findings and practice, with consequent variation in feeding management. MATERIALS AND METHODS A modified Delphi survey validated key feeding topics (round 1), and determined consensus on evidence-based statements (rounds 2 and 3). Patients (n=25) were an interdisciplinary group of clinical experts from across the United States of America. Descriptive analysis used SPSS Statistics (Version 26.0). Thematic analysis of qualitative data provided context for quantitative data. RESULTS Round 1 generated 5 key topics (human milk, developing oral feeding skills, clinical feeding practice, growth failure, and parental concern about feeding) and 206 evidence-based statements. The final results included 110 (53.4%) statements of consensus and 96 (46.6%) statements of non-consensus. The 10 statements of greatest consensus strongly supported human milk as the preferred nutrition for infants with complex CHD. Areas of non-consensus included the adequacy of human milk to support growth, need for fortification, safety, and feasibility of direct breastfeeding, issues related to tube feeding, and prevention and treatment of growth failure. CONCLUSIONS The results demonstrate clinical consensus about the importance of human milk, but reveal a need for best practices in managing a human milk diet for infants with complex CHD. Areas of non-consensus may lead to clinical practice variation. A sensitive approach to these topics is needed to support family caregivers in navigating feeding concerns.
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21
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Martini S, Beghetti I, Annunziata M, Aceti A, Galletti S, Ragni L, Donti A, Corvaglia L. Enteral Nutrition in Term Infants with Congenital Heart Disease: Knowledge Gaps and Future Directions to Improve Clinical Practice. Nutrients 2021; 13:nu13030932. [PMID: 33805775 PMCID: PMC8002077 DOI: 10.3390/nu13030932] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 03/09/2021] [Indexed: 12/18/2022] Open
Abstract
Optimal nutrition is essential to improve short- and long-term outcomes in newborns with congenital heart disease (CHD). Nevertheless, several issues on nutritional management and concerns about the potential risk of complications related to enteral feeding exist. This narrative review aims to summarize and discuss the available literature on enteral feeding in term infants with CHD. A wide variability in feeding management exists worldwide. Emerging approaches to improve nutritional status and outcomes in infants with CHD include: implementation of a standardized enteral feeding protocol, both preoperative and postoperative, clearly defining time of initiation and advancement of enteral feeds, reasons to withhold, and definitions of feeding intolerance; early minimal enteral feeding; enteral feeding in stable term infants on hemodynamic support; evaluation of enteral feeding in term infants with umbilical arterial catheters and during prostaglandin infusion; assessment and support of oro-motor skills; and promotion and support of breastfeeding and provision of mother's own milk or donor milk when mother's own milk is not available. As evidence from term infants is scarce, available observations and recommendations partially rely on studies in preterm infants. Thus, well-designed studies assessing standardized clinically relevant outcomes are needed to provide robust evidence and shared recommendations and practices.
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Affiliation(s)
- Silvia Martini
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (S.M.); (I.B.); (M.A.); (S.G.); (L.C.)
| | - Isadora Beghetti
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (S.M.); (I.B.); (M.A.); (S.G.); (L.C.)
| | - Mariarosaria Annunziata
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (S.M.); (I.B.); (M.A.); (S.G.); (L.C.)
| | - Arianna Aceti
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (S.M.); (I.B.); (M.A.); (S.G.); (L.C.)
- Neonatal Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
- Correspondence: ; Tel./Fax: +39-051-342754
| | - Silvia Galletti
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (S.M.); (I.B.); (M.A.); (S.G.); (L.C.)
- Neonatal Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Luca Ragni
- Pediatric Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (L.R.); (A.D.)
| | - Andrea Donti
- Pediatric Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (L.R.); (A.D.)
| | - Luigi Corvaglia
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy; (S.M.); (I.B.); (M.A.); (S.G.); (L.C.)
- Neonatal Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
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22
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Percutaneous Endoscopic Gastrostomy Enhances Interstage Growth in Infants With Hypoplastic Left Heart Syndrome. Pediatr Crit Care Med 2021; 22:e213-e223. [PMID: 33055529 DOI: 10.1097/pcc.0000000000002596] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
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.
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23
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Li X, Li Z, Lin Y, Tan H, Chen C, Shen J. Growing-rod implantation improves nutrition status of early-onset scoliosis patients: a case series study of minimum 3-year follow-up. BMC Surg 2021; 21:106. [PMID: 33648467 PMCID: PMC7923317 DOI: 10.1186/s12893-021-01120-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 01/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Early onset scoliosis (EOS) may cause malnutrition in affected patients. Growing-rod treatment has been an effective protocol for treating EOS. The objective of this study is to demonstrate whether growing-rod treatment improves nutritional status of EOS patients. METHODS Fifty-two EOS patients who had dual growing-rod surgery was enrolled. The minimum follow-up was 3-years. Their body weights were normalized based on the data of two National Population Census of China. Z-scores were used to indicate the standard deviation from the median body weight-for-age. RESULTS The median follow-up time was 6 years. Preoperatively, the prevalence of malnutrition (Z < - 2) was 21.2%, and reduced to 9.6% at the end of the follow-up. Preoperatively, the average Z-score was - 0.94, and it increased to - 0.65 at the latest follow-up (p < 0.05). Patients with preoperative Z-score below - 1 had more significant increase of Z-scores (- 2.15 vs - 1.26, p < 0.001). A significant negative correlation between the change of Z-score and the preoperative Z-score (correlation coefficient - 0.65, p < 0.001). CONCLUSIONS The growing rod surgery and lengthening procedures significantly improves the nutrition status of EOS patients. The body weight gains are more significant in patients with lower body weights.
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Affiliation(s)
- Xingye Li
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Shuaifuyuan #1, Dongcheng District, Beijing, 100730, China
- Department of Orthopaedics, Peking University Fourth Clinical Medical College, Beijing Jishuitan Hospital, Beijing, 100035, China
| | - Zheng Li
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Shuaifuyuan #1, Dongcheng District, Beijing, 100730, China
| | - Youxi Lin
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Shuaifuyuan #1, Dongcheng District, Beijing, 100730, China
- Department of Orthopaedics, Guangdong Provincial People's Hospital, Guangzhou, 510080, China
| | - Haining Tan
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Shuaifuyuan #1, Dongcheng District, Beijing, 100730, China
| | - Chong Chen
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Shuaifuyuan #1, Dongcheng District, Beijing, 100730, China
- Department of Orthopaedics, Guangdong Provincial People's Hospital, Guangzhou, 510080, China
| | - Jianxiong Shen
- Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Shuaifuyuan #1, Dongcheng District, Beijing, 100730, China.
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24
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Overfeeding and obesity in young children with positive pressure ventilation via tracheostomy following cardiac surgery. Cardiol Young 2020; 30:1397-1404. [PMID: 32741396 DOI: 10.1017/s1047951120002073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Infants with CHD requiring positive pressure ventilation via tracheostomy are especially vulnerable to malnutrition following cardiac surgery. Current post-operative feeding recommendations may overestimate the caloric needs. DESIGN We retrospectively studied infants requiring tracheostomy after cardiac surgery. Anthropometric and nutritional data were collected, including caloric goals, weight-for-age z score, length-for-age z score, and weight-for-length z score. Changes in anthropometrics over time were compared to ascertain the impact of nutritional interventions. Data were shown as mean ± standard deviation. RESULTS Nineteen infants with CHD required tracheostomy at 160 ± 109 days (7-364 days), 13 had reparative surgery, and 6 had palliative surgery for single ventricle. The indications for tracheostomy consisted of airway abnormality/obstruction (n = 13), chronic respiratory failure (n = 7), and/or vocal cord paresis (n = 2). Initial maintenance nutritional target was set at 100-130 cal/kg per day. Fourteen patients (73.7%) became obese (maximum weight-for-length z score: 2.59 ± 0.47) under tracheostomy and gastrostomy feeding, whereas five patients did not (weight-for-length z score: 0.2 ± 0.83). Eight obese patients (weight-for-length z score: 2.44 ± 0.85) showed effective reduction of obesity within 6 months (weight-for-length z score: 0.10 ± 0.20; p < 0.05 compared with pre-adjustment) after appropriate feeding adjustment (40-90 cal/kg per day). Overall mortality was high (31.6%) in this population. CONCLUSION Standard nutritional management resulted in overfeeding and obesity in young children with CHD requiring positive pressure ventilation via tracheostomy. Optimal nutritional management in this high-risk population requires close individualised management by multidisciplinary teams.
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25
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Standardized Perioperative Feeding Protocol Improves Outcomes in Patients With d-Transposition of the Great Arteries Undergoing Arterial Switch Operation. Pediatr Crit Care Med 2020; 21:e789-e794. [PMID: 32433441 DOI: 10.1097/pcc.0000000000002393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine whether the presence of a standardized feeding protocol improves outcomes in a subset of neonates undergoing cardiac surgery. DESIGN Retrospective cohort study. SETTING Cardiovascular ICU at a freestanding academic children's hospital. PATIENTS Neonates with a diagnosis of d-transposition of the great arteries undergoing arterial switch operation from January 2007 to June 2017. INTERVENTIONS Initiation of perioperative feeding protocols. MEASUREMENTS AND MAIN RESULTS Patients were evaluated before and after implementation of standardized perioperative feeding protocols in neonates with d-transposition of the great arteries undergoing arterial switch operation. Low-risk patients born after initiation of nurse-driven protocols were compared with a similar historical group. Data obtained included time to achievement of feeding goals, with primary outcome being weight gain at hospital discharge. Other measures analyzed included duration of mechanical ventilation and postoperative hospital length of stay. Overall, 33 patients in the protocol group were compared with 44 patients in the historical group. No significant baseline differences existed between the two cohorts. The protocol group achieved improved feeding outcomes in nearly all measured categories, including introduction to enteral feeds preoperatively (91% vs 59%; p < 0.01) and earlier attainment of postoperative full enteral feeds of 120 mL/kg/d (2 vs 5 d; p < 0.01). Protocol patients had significantly improved weight gain at the time of discharge (60 vs 1 g; p < 0.01), while achieving shorter postoperative length of stay (10.1 vs 12.6 d; p = 0.04). CONCLUSIONS An aggressive, but safe, perioperative feeding protocol implemented in a homogenous low-risk neonatal cardiac surgical population improves feeding outcomes, including increased weight gain, as well as decreased postoperative length of stay. Consideration for perioperative feeding protocol implementation and further study should be given.
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26
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Hauschild DB, Oliveira LDA, Ventura JC, Farias MS, Barbosa E, Bresolin NL, Moreno YMF. Persistent inflammation, immunosuppression and catabolism syndrome (PICS) in critically ill children is associated with clinical outcomes: a prospective longitudinal study. J Hum Nutr Diet 2020; 34:365-373. [PMID: 32767403 DOI: 10.1111/jhn.12798] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/26/2020] [Accepted: 06/30/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Persistent inflammation, immunosuppression and catabolism syndrome (PICS) has been described in critically ill adults and may contribute to unfavourable outcomes. The present study aimed to describe and characterise PICS in critically ill children (PICS-ped) and to verify its association with clinical outcomes. METHODS A prospective longitudinal study was conducted in a paediatric intensive care unit (PICU) with children aged between 3 months and 15 years. PICS-ped, based on adult definition, was described. PICS-ped was defined as PICU length of stay >14 days; C-reactive protein > 10.0 mg L-1 ; lymphocytes <25%; and any reduction of mid-upper arm circumference Z-score. Clinical, demographic, nutritional status, nutrition therapy parameters and clinical outcomes were assessed. Statistical analysis comprised Mann-Whitney and Fisher's chi-squared tests, as well as logistic and Cox regression. P < 0.05 was considered statistically significant. RESULTS In total, 153 children were included, with a median age of 51.7 months (interquartile range 15.6-123.4 months), and 60.8% male. The mortality rate was 10.5%. The prevalence of PICS-ped was 4.6%. Days using vasoactive drugs and days using antibiotics were associated with PICS-ped. PICS-ped was associated with mortality in crude (odds ratio = 6.67; P = 0.013) and adjusted analysis (odds ratio = 7.14; P = 0.017). PICS-ped was also associated with PICU and hospital length of stay, as well as duration of mechanical ventilation. Similar results were found in a subset of critically ill children who required mechanical ventilation for more than 48 h. CONCLUSIONS Children with PICS-ped required antibiotics or vasoactive drugs for a longer period. PICS-ped was associated with poor clinical outcomes in critically ill children. More studies are needed to properly define PICS-ped for this population.
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Affiliation(s)
- D B Hauschild
- Nutrition Department, Federal University of Santa Catarina, Florianópolis, Brazil
| | - L D A Oliveira
- Federal University of Santa Catarina, Florianópolis, Brazil
| | - J C Ventura
- Federal University of Santa Catarina, Florianópolis, Brazil
| | - M S Farias
- Nutrition, Joana de Gusmão Children's Hospital, Florianópolis, Brazil
| | - E Barbosa
- Nutrition, Joana de Gusmão Children's Hospital, Florianópolis, Brazil
| | - N L Bresolin
- Pediatric Intensive Care Unit, Joana de Gusmão Children's Hospital, Florianópolis, Brazil
| | - Y M F Moreno
- Federal University of Santa Catarina, Florianópolis, Brazil
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27
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Marino LV, Johnson MJ, Davies NJ, Kidd CS, Fienberg J, Richens T, Bharucha T, Beattie RM, Darlington ASE. Improving growth of infants with congenital heart disease using a consensus-based nutritional pathway. Clin Nutr 2020; 39:2455-2462. [DOI: 10.1016/j.clnu.2019.10.031] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 10/25/2019] [Accepted: 10/28/2019] [Indexed: 01/12/2023]
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28
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Ross FJ, Radman M, Jacobs ML, Sassano-Miguel C, Joffe DC, Hill KD, Chiswell K, Feng L, Jacobs JP, Vener DF, Latham GJ. Associations between anthropometric indices and outcomes of congenital heart operations in infants and young children: An analysis of data from the Society of Thoracic Surgeons Database. Am Heart J 2020; 224:85-97. [PMID: 32353587 DOI: 10.1016/j.ahj.2020.03.012] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Accepted: 03/15/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Children with congenital heart disease are at risk for growth failure due to inadequate nutrient intake and increased metabolic demands. We examined the relationship between anthropometric indices of nutrition (height-for-age z-score [HAZ], weight-for-age z-score [WAZ], weight-for-height z-score [WHZ]) and outcomes in a large sample of children undergoing surgery for congenital heart disease. METHODS Patients in the Society of Thoracic Surgeons Congenital Heart Surgery Database having index cardiac surgery at age 1 month to 10 years were included. Indices were calculated by comparing patients' weight and height to population norms from the World Health Organization and Centers for Disease Control and Prevention. Outcomes included operative mortality, composite mortality or major complication, major postoperative infection, and postoperative length of stay. For each outcome and index, the adjusted odds ratio (aOR) (for mortality, composite outcome, and infection) and adjusted relative change in median (for postoperative length of stay) for a 1-unit decrease in index were estimated using mixed-effects logistic and log-linear regression models. RESULTS Every unit decrease in HAZ was associated with 1.40 aOR of mortality (95% CI 1.32-1.48), and every unit decrease in WAZ was associated with 1.33 aOR for mortality (95% CI 1.25-1.41). The relationship between WHZ and outcome was nonlinear, with aOR of mortality of 0.84 (95% CI 0.76-0.93) for 1-unit decrease when WHZ ≥ 0 and a nonsignificant association for WHZ < 0. Trends for other outcomes were similar. Overall, the incidence of low nutritional indices was similar for 1-ventricle and 2-ventricle patients. Children between the age of 1 month and 1 year and those with lesions associated with pulmonary overcirculation had the highest incidence of low nutritional indices. CONCLUSIONS Lower HAZ and WAZ, suggestive of malnutrition, are associated with increased mortality and other adverse outcomes after cardiac surgery in infants and young children. Higher WHZ over zero, suggestive of obesity, is also associated with adverse outcomes.
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Affiliation(s)
- Faith J Ross
- Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA.
| | - Monique Radman
- Critical Care, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA
| | - Marshall L Jacobs
- Cardiac Surgery, Johns Hopkins School of Medicine, 1800 Orleans St, Zayed Tower 7107, Baltimore, MD
| | - Claudia Sassano-Miguel
- Clinical Nutrition, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA
| | - Denise C Joffe
- Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA
| | - Kevin D Hill
- Pediatrics, Duke University, DUMC Box 3090, Durham, NC; Duke Clinical Research Institute, Duke University, 200, Morris, St, Durham, NC
| | - Karen Chiswell
- Duke Clinical Research Institute, Duke University, 200, Morris, St, Durham, NC
| | - Liqi Feng
- Duke Clinical Research Institute, Duke University, 200, Morris, St, Durham, NC
| | - Jeffrey P Jacobs
- Cardiothoracic Surgery, Johns Hopkins All Children's Heart Institute, 501 6th Ave S, OCC Suite 607, JHACH Box 6500000606, St Petersburg, FL
| | - David F Vener
- Anesthesiology, Perioperative, and Pain Medicine, Texas Children's Hospital, 6651 Main St, Houston, TX
| | - Gregory J Latham
- Anesthesiology and Pain Medicine, Seattle Children's Hospital, University of Washington, 4800 Sandpoint Way NE, Seattle, WA
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Abstract
Neonates with CHD are at increased risk of developing necrotising enterocolitis due to mesenteric hypoperfusion. Necrotising enterocolitis results in repeated feed interruptions contributing to poor growth during the early post-operative phase. Poor weight gain and longer hospital stay are risk factors for death in neonates with CHD. Abdominal radiography is used as a diagnostic tool for necrotising enterocolitis; however, its utility is limited in the early stages of necrotising enterocolitis when pneumatosis intestinalis is absent. Calprotectin is a neutrophil activation biomarker, and elevated levels are evident in inflammatory diseases such as necrotising enterocolitis. The aim of this study was to determine whether there is a correlation between faecal calprotectin concentration and gut inflammation in neonates with CHD. This prospective single-centre study recruited newly diagnosed term patients with duct-dependent CHD between March 2018 and March 2019. Faecal calprotectin concentrations were measured in post-surgical patients using enzyme-linked immunosorbent assay methods. A total of 30 patients were included in the analysis. Calprotectin concentration for patients who developed necrotising enterocolitis was 3528 µg/g compared with 390 µg/g without, compared with 1339 µg/g in patients with suspected necrotising enterocolitis (p = 0.0001). Patients with suspected necrotising enterocolitis had a significantly longer length of hospital stay, on average 18 days longer compared to patients without necrotising enterocolitis (p = 0.03). Faecal calprotectin concentrations may reflect severity of gut inflammation in neonates with CHD. Suspected necrotising enterocolitis contributes to longer days nil by mouth and an increase in length of hospital stay.
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30
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Tume LN, Valla FV, Joosten K, Jotterand Chaparro C, Latten L, Marino LV, Macleod I, Moullet C, Pathan N, Rooze S, van Rosmalen J, Verbruggen SCAT. Nutritional support for children during critical illness: European Society of Pediatric and Neonatal Intensive Care (ESPNIC) metabolism, endocrine and nutrition section position statement and clinical recommendations. Intensive Care Med 2020; 46:411-425. [PMID: 32077997 PMCID: PMC7067708 DOI: 10.1007/s00134-019-05922-5] [Citation(s) in RCA: 106] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 12/28/2019] [Indexed: 01/09/2023]
Abstract
Background Nutritional support is considered essential for the outcome of paediatric critical illness. There is a lack of methodologically sound trials to provide evidence-based guidelines leading to diverse practices in PICUs worldwide. Acknowledging these limitations, we aimed to summarize the available literature and provide practical guidance for the paediatric critical care clinicians around important clinical questions many of which are not covered by previous guidelines. Objective To provide an ESPNIC position statement and make clinical recommendations for the assessment and nutritional support in critically ill infants and children. Design The metabolism, endocrine and nutrition (MEN) section of the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) generated 15 clinical questions regarding different aspects of nutrition in critically ill children. After a systematic literature search, the Scottish Intercollegiate Guidelines Network (SIGN) grading system was applied to assess the quality of the evidence, conducting meta-analyses where possible, to generate statements and clinical recommendations, which were then voted on electronically. Strong consensus (> 95% agreement) and consensus (> 75% agreement) on these statements and recommendations was measured through modified Delphi voting rounds. Results The final 15 clinical questions generated a total of 7261 abstracts, of which 142 publications were identified relevant to develop 32 recommendations. A strong consensus was reached in 21 (66%) and consensus was reached in 11 (34%) of the recommendations. Only 11 meta-analyses could be performed on 5 questions. Conclusions We present a position statement and clinical practice recommendations. The general level of evidence of the available literature was low. We have summarised this and provided a practical guidance for the paediatric critical care clinicians around important clinical questions. Electronic supplementary material The online version of this article (10.1007/s00134-019-05922-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lyvonne N Tume
- Faculty of Health and Society, University of Salford, Manchester, M6 6PU, UK. .,Pediatric Intensive Care Unit, Alder Hey Children's NHS Foundation Trust, East Prescot Road, Liverpool, L12 2AP, UK.
| | - Frederic V Valla
- Pediatric Intensive Care Unit, Hôpital Femme Mère Enfant, CarMEN INSERM UMR, 1060 Hospices Civils de Lyon, Lyon-Bron, France
| | - Koen Joosten
- Intensive Care, Department of Pediatrics and Pediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Corinne Jotterand Chaparro
- Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Delémont, Switzerland.,Pediatric Intensive Care Unit, University Hospital of Lausanne, Lausanne, Switzerland
| | - Lynne Latten
- Nutrition and Dietetics, Alder Hey Children's Hospital Liverpool, Liverpool, UK
| | - Luise V Marino
- Department of Dietetics/Speech and Language Therapy, NIHR Biomedical Research Centre Southampton, University Hospital Southampton, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Isobel Macleod
- Pediatric Intensive Care Unit, Royal Hospital for Children, Glasgow, UK
| | - Clémence Moullet
- Geneva School of Health Sciences, HES-SO University of Applied Sciences and Arts Western Switzerland, Delémont, Switzerland.,Pediatric Intensive Care Unit, University Hospital of Lausanne, Lausanne, Switzerland
| | - Nazima Pathan
- Department of Pediatrics, University of Cambridge, Hills Road, Cambridge, UK
| | - Shancy Rooze
- Pediatric Intensive Care Unit, Queen Fabiola Children's University Hospital, Brussels, Belgium
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Sascha C A T Verbruggen
- Intensive Care, Department of Pediatrics and Pediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, The Netherlands
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Percutaneous Endoscopic Gastrostomy After Cardiothoracic Surgery in Children Less Than 2 Months Old: An Assessment of Long-Term Malnutrition Status and Gastrostomy Outcomes. Pediatr Crit Care Med 2020; 21:50-58. [PMID: 31568238 DOI: 10.1097/pcc.0000000000002129] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
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.
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Arslan A. Catch Up Growth with Enteral Nutrition Support in Children with Congenital Heart Disease. KOCAELI ÜNIVERSITESI SAĞLIK BILIMLERI DERGISI 2019. [DOI: 10.30934/kusbed.595676] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
INTRODUCTION Infants with CHD often experience growth failure. Ensuring optimal growth before surgery is associated with improved outcomes and has emerged as a significant cause of parental stress. Parents have reported a perceived lack of accessible feeding information for infants with CHD. To address this gap, the aim of this study was to develop feeding information to better support parents. MATERIALS AND METHODS A search for existing material on six electronic databases and an internet search for unpublished (grey) literature on feeding information for infants with CHD were carried out. Following the development of feeding information, semi-structured interview(s) with parents/health-care professionals were completed, focusing on whether the information was easy to understand, relevant, provided sufficient information around feeding/feeding difficulties, and whether there were any information gaps. Iterative changes were made to the information following each interview. The process was completed until thematic saturation was achieved. RESULTS A total of 23 unique articles were identified of which 5 studies were included. From the grey literature, four web pages were reviewed. A total of 22 parents and 25 health-care professionals were interviewed. All parents/health-care professionals felt that the feeding information developed provided sufficient information; however, many wanted information on how to introduce complementary food, particularly if weaning was delayed. CONCLUSIONS This study describes the development of feeding information for infants with CHD. From parent interviews, gaps identified focused on the introduction of complementary foods and uncertainty regarding the feeding journey beyond surgery.
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Abstract
INTRODUCTION Although chylothorax is an uncommon complication following paediatric cardiothoracic surgery, it has significant associated morbidities and increased in-hospital mortality, as well as results in higher costs. A lack of prospective evidence or consensus guidelines for management of chylothorax further hinders optimal management. The aim of this survey was to characterise variations in practice in the management of chylothorax and to identify areas for future research. MATERIALS AND METHODS A descriptive, observational survey investigating conservative management practices of chylothorax was distributed internationally to health-care professionals in paediatric intensive care and cardiology units. The survey investigated five domains: the first providing general information about health-care professionals and four domains focusing on clinical practice including diet composition and duration. RESULTS In total, sixty-four health-care professionals completed the survey, representing 38 organisations from 16 countries. The respondents were dietitians (80%), physicians (19%), and nurses (1%). In Australia and New Zealand, management was most commonly directed by physicians' preference (67%) as compared to unit protocols in Europe (67%), United States of America (67%), and Other regions (55%). Dietitians in Australia/New Zealand, United Kingdom, and Ireland followed the most restrictive diet therapy recommending <5 g long chain triglyceride fat per day (p < 0.00001). The duration of diet therapy significantly varied between regions: Australia/New Zealand: 4 weeks (36%) and 6 weeks (43%); Europe: 4 weeks (25%) and 6 weeks (57%); and North America: 4 weeks (18%) and 6 weeks (75%) (p < 0.00001). CONCLUSIONS This survey highlights international variations in practice in the management of chylothorax, particularly with respect to treatment duration and dietary fat restriction. Future research should include a multi-centre randomised controlled trial to inform evidence-based practice and reduce morbidity, particularly poor growth.
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Valla FV, Baudin F, Gaillard Le Roux B, Ford-Chessel C, Gervet E, Giraud C, Ginhoux T, Cour-Andlauer F, Javouhey E, Tume L. Nutritional Status Deterioration Occurs Frequently During Children's ICU Stay. Pediatr Crit Care Med 2019; 20:714-721. [PMID: 31162370 DOI: 10.1097/pcc.0000000000001979] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Malnutrition and faltering growth at PICU admission have been related to suboptimal outcomes. However, little is known about nutritional status deterioration during PICU stay, as critical illness is characterized by a profound and complex metabolism shift, which affects energy requirements and protein turnover. We aim to describe faltering growth occurrence during PICU stay. DESIGN Single-center prospective observational study. SETTING Twenty-three-bed general PICU, Lyon, France. PATIENTS All critically ill children 0-18 years old with length of stay longer than 5 days were included (September 2013-December 2015). INTERVENTIONS Weight and height/length were measured at admission, and weight was monitored during PICU stay, in order to calculate body mass index for age z score. Faltering growth was defined as body mass index z score decline over PICU stay. Children admitted during the first year of the study and who presented with faltering growth were followed after PICU discharge for 3 months. MEASUREMENTS AND MAIN RESULTS We analyzed 579 admissions. Of them, 10.2% presented a body mass index z score decline greater than 1 SD and 27.8% greater than 0.5. Admission severity risk scores and prolonged PICU stay accounted for 4% of the variability in nutritional status deterioration. Follow-up of post-PICU discharge nutritional status showed recovery within 3 months in most patients. CONCLUSIONS Nutritional deterioration is frequent and often intense in critically ill children with length of stay greater than 5 days. Future research should focus on how targeted nutritional therapies can minimize PICU faltering growth and improve post-PICU rehabilitation.
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Affiliation(s)
- Frédéric V Valla
- Pediatric Intensive Care, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 59 bd Pinel 69500 Lyon-Bron, France.,CarMEN INSERM UMR 1060 Equipe INFOLIP, 69100 Villeurbanne, France
| | - Florent Baudin
- Pediatric Intensive Care, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 59 bd Pinel 69500 Lyon-Bron, France.,Univ Lyon, Université Claude Bernard Lyon1, Ifsttar, UMRESTTE, UMR T_9405, F- 69373, Lyon, France
| | - Bénédicte Gaillard Le Roux
- Pediatric Intensive Care, Hôpital Femme Mère Enfant, CHU de Nantes, 38 boulevard Jean Monnet 44000 Nantes, France
| | - Carole Ford-Chessel
- Service diététique, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 59 bd Pinel 69500 Lyon-Bron, France
| | - Elodie Gervet
- Université Claude Bernard Lyon 1 - Villeurbanne, France
| | - Céline Giraud
- EPICIME-CIC 1407 de Lyon, Inserm, CHU-Lyon, F-69677, Bron, France
| | - Tiphanie Ginhoux
- EPICIME-CIC 1407 de Lyon, Inserm, Service de Pharmacologie Clinique, CHU-Lyon, F-69677, Bron, France
| | - Fleur Cour-Andlauer
- Pediatric Intensive Care, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 59 bd Pinel 69500 Lyon-Bron, France
| | - Etienne Javouhey
- Pediatric Intensive Care, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, 59 bd Pinel 69500 Lyon-Bron, France
| | - Lyvonne Tume
- Faculty of Health & Applied Sciences, University of the West of England, Bristol BS16 1DD, United Kingdom.,PICU Bristol Children's Hospital, Upper Maudlin Street, Bristol, United Kingdom
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The association between feeding protocol compliance and weight gain following high-risk neonatal cardiac surgery. Cardiol Young 2019; 29:594-601. [PMID: 31133078 DOI: 10.1017/s1047951119000222] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Children with congenital heart disease are at high risk for malnutrition. Standardisation of feeding protocols has shown promise in decreasing some of this risk. With little standardisation between institutions' feeding protocols and no understanding of protocol adherence, it is important to analyse the efficacy of individual aspects of the protocols. METHODS Adherence to and deviation from a feeding protocol in high-risk congenital heart disease patients between December 2015 and March 2017 were analysed. Associations between adherence to and deviation from the protocol and clinical outcomes were also assessed. The primary outcome was change in weight-for-age z score between time intervals. RESULTS Increased adherence to and decreased deviation from individual instructions of a feeding protocol improves patients change in weight-for-age z score between birth and hospital discharge (p = 0.031). Secondary outcomes such as markers of clinical severity and nutritional delivery were not statistically different between groups with high or low adherence or deviation rates. CONCLUSIONS High-risk feeding protocol adherence and fewer deviations are associated with weight gain independent of their influence on nutritional delivery and caloric intake. Future studies assessing the efficacy of feeding protocols should include the measures of adherence and deviations that are not merely limited to caloric delivery and illness severity.
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van Puffelen E, Hulst JM, Vanhorebeek I, Dulfer K, Van den Berghe G, Joosten KFM, Verbruggen SCAT. Effect of late versus early initiation of parenteral nutrition on weight deterioration during PICU stay: Secondary analysis of the PEPaNIC randomised controlled trial. Clin Nutr 2019; 39:104-109. [PMID: 30879734 DOI: 10.1016/j.clnu.2019.02.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Revised: 01/30/2019] [Accepted: 02/08/2019] [Indexed: 01/22/2023]
Abstract
BACKGROUND & AIMS Critically ill children are at increased risk of weight deterioration in the paediatric intensive care unit (PICU). Whether early initiation of parenteral nutrition (PN) prevents weight deterioration is unknown. The aims of this study were to assess the effect of withholding supplemental PN during the first week on weight Z-score change in PICU and to evaluate the association between weight Z-score change in the PICU and clinical outcomes. METHODS This is a secondary analysis of the Paediatric Early versus Late Parenteral Nutrition in Intensive Care Unit (PEPaNIC) randomised controlled trial (N = 1440), which focused on the subgroup of patients with longitudinal weight Z-scores available on admission and on the last day in PICU. Patients were randomly allocated to initiation of supplemental PN after one week (Late-PN) or within 24 h (Early-PN) when enteral nutrition was insufficient. The effect of Late-PN versus Early-PN on the change in weight Z-score was investigated, adjusted for risk factors. Moreover, the association between weight Z-score change and clinical outcomes was explored, adjusted for risk factors. RESULTS Longitudinal weight Z-scores were available for 470 patients. Enteral nutrition intake was equal in the Early-PN and Late-PN group. Less weight Z-score deterioration during PICU stay was associated with a lower risk of new infections (adjusted OR per Z-score increase 0.72 [0.55-0.96], p = 0.02), and with a higher likelihood of an earlier discharge from PICU alive (adjusted HR per Z-score increase 1.22 [1.10-1.37], p < 0.001). During PICU-stay, the change in weight Z-score did not differ among both groups (Late-PN median 0.00 [-0.34-0.12] vs Early-PN median -0.03 [-0.48-0.01], adjusted β = 0.10 [-0.05-0.25], p = 0.18). CONCLUSIONS Weight deterioration during the PICU stay was associated with worse clinical outcomes. Withholding supplemental PN during the first week did not aggravate weight Z-score deterioration during PICU stay. TRIAL REGISTRATION clinicaltrials.gov NCT01536275.
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Affiliation(s)
- E van Puffelen
- Department of Paediatrics and Paediatric Surgery, Intensive Care Unit, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - J M Hulst
- Department of Paediatrics, Division of Paediatric Gastroenterology, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - I Vanhorebeek
- Department of Cellular and Molecular Medicine, Clinical Division and Laboratory of Intensive Care Medicine, University Hospitals KU Leuven, Leuven, Belgium
| | - K Dulfer
- Department of Paediatrics and Paediatric Surgery, Intensive Care Unit, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - G Van den Berghe
- Department of Cellular and Molecular Medicine, Clinical Division and Laboratory of Intensive Care Medicine, University Hospitals KU Leuven, Leuven, Belgium
| | - K F M Joosten
- Department of Paediatrics and Paediatric Surgery, Intensive Care Unit, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - S C A T Verbruggen
- Department of Paediatrics and Paediatric Surgery, Intensive Care Unit, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Rotterdam, the Netherlands.
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Abstract
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.
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Zhang J, Cui Y, Ma, MD Z, Luo Y, Chen X, Li J. Energy and Protein Requirements in Children Undergoing Cardiopulmonary Bypass Surgery: Current Problems and Future Direction. JPEN J Parenter Enteral Nutr 2018; 43:54-62. [PMID: 30070710 DOI: 10.1002/jpen.1314] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Accepted: 05/16/2018] [Indexed: 01/10/2023]
Affiliation(s)
- Jian Zhang
- Clinical Physiology Research Laboratory Capital Institute of Pediatrics Beijing China
| | - Yan‐Qin Cui
- Cardiac Intensive Care Unit Guangzhou Women and Children's Medical Center Guangdong Province China
| | - Ze‐Ming Ma, MD
- Department of Cardiac Surgery Children's Hospital affiliated to Capital Institute of Pediatrics Beijing China
| | - Yi Luo
- Department of Cardiac Surgery Children's Hospital affiliated to Capital Institute of Pediatrics Beijing China
| | - Xin‐Xin Chen
- Department of Cardiac Surgery Guangzhou Women and Children's Medical Center Guangdong Province China
| | - Jia Li
- Clinical Physiology Research Laboratory Capital Institute of Pediatrics Beijing China
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Bioimpedance spectroscopy measurements of phase angle and height for age are predictive of outcome in children following surgery for congenital heart disease. Clin Nutr 2018; 37:1430-1436. [DOI: 10.1016/j.clnu.2017.06.020] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 05/12/2017] [Accepted: 06/20/2017] [Indexed: 12/29/2022]
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The development of a consensus-based nutritional pathway for infants with CHD before surgery using a modified Delphi process. Cardiol Young 2018; 28:938-948. [PMID: 29704905 PMCID: PMC5977758 DOI: 10.1017/s1047951118000549] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
UNLABELLED 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.
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Prodhan P, Tang X, Gossett J, Beam B, Simsic J, Ghanayem N, ElHassan NO. Gastrostomy tube placement among infants with hypoplastic left heart syndrome undergoing stage 1 palliation. CONGENIT HEART DIS 2018; 13:519-527. [PMID: 29756326 DOI: 10.1111/chd.12610] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 02/23/2018] [Accepted: 03/16/2018] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Different feeding strategies have been suggested to improve growth and survival of infants with hypoplastic left heart syndrome following stage 1 palliation. The study objective was to assess hospital mortality following stage 1 palliation among infants with hypoplastic left heart syndrome who had two feeding modalities, gastrostomy tube vs no gastrostomy tube. DESIGN Retrospective study design. SETTING Multicenter pediatric heath information system database. PATIENT About 4287 patients with hypoplastic left heart syndrome who underwent stage 1 Norwood procedure from 2004 through 2013. Infants who had gastrostomy tube with or without fundoplication procedure were identified and their clinical characteristics were compared. INTERVENTION None. OUTCOMES MEASURES The primary outcome was discharge hospital mortality following stage 1 palliation. RESULTS About 1214 patients who underwent stage 1 palliation had gastrostomy tube placement prior to hospital discharge. About 881 only had this procedure, while 333 patients also underwent fundoplication. Infants who had a gastrostomy tube placement vs no gastrostomy procedure had longer hospital stay, but significantly lower hospital mortality (5% vs 19%, P < .001). Hospital mortality was lower in infants who had only gastrostomy vs gastrostomy with fundoplication procedure (4% vs 8%, P = .004). In the multivariable analysis, gastrostomy procedure was associated with a higher likelihood of survival to hospital discharge (HR: 0.06, CI [0.04, 0.1]), whereas additional fundoplication procedure increased the risk of mortality (HR: 2.77, CI [1.52, 5.04]). CONCLUSIONS The gastrostomy procedure did not place infants with hypoplastic left heart syndrome at higher risk of mortality. These infants should be considered for gastrostomy tube placement if they had persistent difficulty in oral feeding following stage 1 palliation.
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Affiliation(s)
- Parthak Prodhan
- Pediatric Cardiology/Pediatric Critical Care, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas, USA
| | - Xinyu Tang
- Biostatistics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas, USA
| | - Jeffrey Gossett
- Biostatistics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas, USA
| | - Brandon Beam
- Bioinformatics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas, USA
| | - Janet Simsic
- Pediatric Cardiology, Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Nancy Ghanayem
- Cardiac Critical Care, Department of Pediatrics, Medical College of Wisconsin/Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Nahed O ElHassan
- Neonatology, Department of Pediatrics, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas, USA
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Simpson SA, Field SL, Xu M, Saville BR, Parra DA, Soslow JH. Effect of Weight Extremes on Ventricular Volumes and Myocardial Strain in Repaired Tetralogy of Fallot as Measured by CMR. Pediatr Cardiol 2018; 39:575-584. [PMID: 29238854 PMCID: PMC5831485 DOI: 10.1007/s00246-017-1793-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 12/05/2017] [Indexed: 10/18/2022]
Abstract
Pulmonary valve replacement (PVR) in patients with repaired tetralogy of Fallot (rTOF-TAP) is often based on cardiac MRI (CMR) right ventricular (RV) volumes indexed to body surface area (BSA). Weight extremes result in increased patient morbidity and affect indexed measurements. We hypothesized that patients with rTOF-TAP at extremes of weight have (1) over- or underestimated indexed volumes and (2) altered parameters of cardiac function. CMRs in patients with rTOF-TAP were retrospectively reviewed; analysis included right and left ventricular (LV) volumes and ejection fractions (EF) and peak global LV circumferential strain (ε cc) from myocardial tagged images. Indexed volumes were recalculated using ideal BSA. Weight categories were assigned: underweight, appropriate weight, overweight, and obese. Linear regression models with weight category, spline of age, and gender were created to assess the association of weight and parameters of volume and function. When RV volumes were corrected for ideal BSA, 11 (31%) additional overweight and obese patients met published criteria for PVR and 3 (38%) underweight patients no longer met criteria. Obese and overweight patients had larger absolute LV and RV diastolic volumes, but no difference in volumes indexed to ideal BSA. Modeling demonstrated no difference in LVEF or RVEF by weight categories but significant differences in global LV ε cc. Extremes of body weight may result in inappropriate timing of PVR. Extremes of weight lead to abnormalities in global LV ε cc. Although clinical implications of abnormal ε cc are unclear, these patients may be at higher risk for early ventricular dysfunction.
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Affiliation(s)
- Scott A. Simpson
- Division of Pediatric Cardiology, Department of Pediatrics, University of Mississippi Medical Center, Jackson, MS
| | - Suzanne L. Field
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Meng Xu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Benjamin R. Saville
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - David A. Parra
- Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | - Jonathan H. Soslow
- Division of Pediatric Cardiology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
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Preoperative malnutrition is associated with increased mortality and adverse outcomes after paediatric cardiac surgery. Cardiol Young 2017; 27. [PMID: 28625194 PMCID: PMC5908464 DOI: 10.1017/s1047951117001068] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Malnutrition is common in children with CHD and is likely to place them at an increased risk for adverse surgical outcomes. We sought to evaluate the impact of preoperative malnutrition on outcomes after paediatric cardiac surgery. METHODS We conducted a retrospective analysis of patients from age 0 to 5 years undergoing cardiac surgery at Seattle Children's Hospital from 2006 to 2015. We used regression modelling to examine the impact of malnutrition on surgical outcomes. RESULTS We found a non-linear relationship between low height-for-age and weight-for-age z-scores and mortality after surgery. In the range of z-score ⩽-2, each additional unit decrease in height-for-age or weight-for-age z-score was associated with a 2.9 or 2.1% increased risk for mortality, respectively. Each unit decrease in height-for-age z-score was associated with a 1.2% increased risk for cardiac arrest, 1.1% increased risk for infection, and an average of 1.7 additional hours of mechanical ventilation, 6 hours longer ICU stay, and 13 hours longer hospital stay. Each unit decrease in weight-for-age z-score was associated with a 0.7% increased risk for cardiac arrest, 0.8% increased risk for infection, and an average of 1.9 additional hours of mechanical ventilation and 5.3 additional hours of ICU stay. CONCLUSIONS This study is unique in demonstrating a significant association between malnutrition and 30-day mortality and other adverse outcomes after paediatric cardiac surgery in a mixed population of CHD patients. By evaluating nutritional status as a continuous variable, we were able to clearly distinguish the point at which malnutrition begins to affect mortality.
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Abstract
UNLABELLED 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.
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Jadcherla SR. Advances with Neonatal Aerodigestive Science in the Pursuit of Safe Swallowing in Infants: Invited Review. Dysphagia 2017; 32:15-26. [PMID: 28044203 PMCID: PMC5303645 DOI: 10.1007/s00455-016-9773-z] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 12/21/2016] [Indexed: 11/26/2022]
Abstract
Feeding, swallowing, and airway protection are three distinct entities. Feeding involves a process of sequential, neurosensory, and neuromotor interactions of reflexes and behaviors facilitating ingestion. Swallowing involves anterograde bolus movement during oral-, pharyngeal-, and esophageal phases of peristalsis into stomach. During these events, coordination with airway protection is vital for homeostasis in clearing any material away from airway vicinity. Neurological-airway-digestive inter-relationships are critical to the continuum of successful feeding patterns during infancy, either in health or disease. Neonatal feeding difficulties encompass a heterogeneous group of neurological, pulmonary, and aerodigestive disorders that present with multiple signs posing as clinical conundrums. Significant research breakthroughs permitted understanding of vagal neural pathways and functional aerodigestive connectivity involved in regulating swallowing and aerodigestive functions either directly or indirectly by influencing the supra-nuclear regulatory centers and peripheral effector organs. These neurosensory and neuromotor pathways are influenced by pathologies during perinatal events, prematurity, inflammatory states, and coexisting medical and surgical conditions. Approaches to clarify pathophysiologic mapping of aerodigestive interactions, as well as translating these discoveries into the development of personalized and simplified feeding strategies to advance child health are discussed in this review article.
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Affiliation(s)
- Sudarshan R Jadcherla
- The Neonatal and Infant Feeding Disorders Program, Department of Neonatology, Nationwide Children's Hospital, Columbus, OH, USA.
- Innovative Infant Feeding Disorders Research Program, Center for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, USA.
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, OH, USA.
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Burch PT, Spigarelli MG, Lambert LM, Loftus PD, Sherwin CM, Linakis MW, Sheng X, LuAnn Minich L, Williams RV. Use of Oxandrolone to Promote Growth in Neonates following Surgery for Complex Congenital Heart Disease: An Open-Label Pilot Trial. CONGENIT HEART DIS 2016; 11:693-699. [PMID: 27257953 DOI: 10.1111/chd.12376] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/19/2016] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Malnutrition and poor weight gain, common in neonates following repair of complex congenital heart disease (CHD), are associated with increased morbidity and mortality. Oxandrolone, an anabolic steroid, improves weight gain in older children at high-risk for growth failure. We sought to determine feasibility, safety, and efficacy of oxandrolone therapy in neonates following surgery for complex CHD. DESIGN Neonates with RACHS-1 score >3 were eligible to receive open-label oxandrolone for 28 days in this prospective pilot trial. There were 3 cohorts of 5 subjects receiving oxandrolone therapy under 3 specified dosage and preparation protocols: 0.1 mg/kg/day aqueous solution, 0.2 mg/kg/day aqueous solution, and 0.1 mg/kg/day preparation in medium chain triglyceride (MCT) oil. Age- and diagnosis-matched neonates who underwent surgery, but received no oxandrolone, served as a control cohort. Anthropometric measurements, physical examination for virilization, safety labs, and adverse events were monitored. RESULTS Of 25 eligible patients, 15 consented (60%, 13/15 with Norwood procedure). There was no evidence of virilization, no changes in safety labs, and no serious adverse events related to oxandrolone among subjects receiving therapy. No subject met criteria for termination of study drug. There was a significant difference in change in weight-for-age z-score among the four cohorts, with subjects receiving 0.1 mg/kg/day in MCT oil having the lowest decline during the study period (-1.8 ± 0.5 for controls, -1.7 ± 0.4 for 0.1 mg/kg/day aqueous, -1.0 ± 0.4 for 0.2 mg/kg/day aqueous, and -0.6 ± 0.7 for 0.1 mg/kg/day MCT oil, P = .012). CONCLUSIONS Oxandrolone therapy at the doses studied appears safe in neonates after surgery for complex CHD. The decline in weight-for-age z-score was lowest in those receiving the MCT oil preparation suggesting better bioavailability of this preparation and a potential growth benefit with oxandrolone therapy. Further investigation is needed to define optimal dosing and assess efficacy.
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Affiliation(s)
- Phillip T Burch
- Divisions of Cardiothoracic Surgery, University of Utah and Primary Children's Hospital, Salt Lake City, UT, USA
| | - Michael G Spigarelli
- Adolescent Medicine, University of Utah and Primary Children's Hospital, Salt Lake City, UT, USA.,Pediatric Clinical Pharmacology, University of Utah and Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Linda M Lambert
- Divisions of Cardiothoracic Surgery, University of Utah and Primary Children's Hospital, Salt Lake City, UT, USA
| | - Patrick D Loftus
- Divisions of Cardiothoracic Surgery, University of Utah and Primary Children's Hospital, Salt Lake City, UT, USA
| | - Catherine M Sherwin
- Pediatric Clinical Pharmacology, University of Utah and Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Matthew W Linakis
- Pediatric Clinical Pharmacology, University of Utah and Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Xiaoming Sheng
- Department of Pediatrics, University of Utah and Primary Children's Hospital, Salt Lake City, UT, USA
| | - L LuAnn Minich
- Pediatric Cardiology, University of Utah and Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Richard V Williams
- Pediatric Cardiology, University of Utah and Primary Children's Hospital, Salt Lake City, Utah, USA
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Wong JJM, Cheifetz IM, Ong C, Nakao M, Lee JH. Nutrition Support for Children Undergoing Congenital Heart Surgeries: A Narrative Review. World J Pediatr Congenit Heart Surg 2016; 6:443-54. [PMID: 26180163 DOI: 10.1177/2150135115576929] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Energy imbalance in infants and children with congenital heart disease (CHD) is common and influenced by age, underlying cardiac diagnoses, and presence or absence of congestive heart failure. During the surgical hospitalization period, these children are prone to nutritional deterioration due to stress of surgery, anesthetic/perfusion techniques, and postoperative care. Poor nutrition is associated with increased perioperative morbidity and mortality. This review aims to examine various aspects of nutrition in critically ill children with CHD, including (1) energy expenditure, (2) perioperative factors that contribute to energy metabolism, (3) bedside practices that are potentially able to optimize nutrient delivery, and (4) medium- to long-term impact of energy balance on clinical outcomes. We propose a nutrition algorithm to optimize nutrition of these children in the perioperative period where improvements in nutrition status will likely impact surgical outcomes.
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Affiliation(s)
- Judith J M Wong
- Department of Pediatric Medicine, KK Women's and Children's Hospital, Singapore
| | - Ira M Cheifetz
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Duke University Medical Center, Durham, NC, USA
| | - Chengsi Ong
- Department of Nutrition and Dietetics, KK Women's and Children's Hospital, Singapore
| | - Masakazu Nakao
- Department of Paediatric Cardiothoracic Surgery, KK Women's and Children's Hospital, Singapore
| | - Jan Hau Lee
- Department of Pediatric Subspecialties, Children's Intensive Care Unit, KK Women's and Children's Hospital, Singapore Office of Clinical Sciences, Duke-NUS Graduate School of Medicine, Singapore
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Tregay J, Brown K, Crowe S, Bull C, Knowles R, Wray J. "I was so worried about every drop of milk" - feeding problems at home are a significant concern for parents after major heart surgery in infancy. MATERNAL AND CHILD NUTRITION 2016; 13. [PMID: 26891904 DOI: 10.1111/mcn.12302] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 01/07/2016] [Accepted: 01/14/2016] [Indexed: 12/14/2022]
Abstract
Increasing numbers of operations in small infants with complex congenital heart disease are being carried out in the UK year on year, with more surviving the initial operation. However, even after successful surgery some of these infants remain fragile when they are discharged home. The aim of the study was to elicit parents' experiences of caring for a child with complex needs after major congenital heart surgery. We conducted a qualitative study involving semi-structured interviews with parents of 20 children (aged <1-5 months at hospital discharge), who had undergone open heart surgery and subsequently died or been readmitted unexpectedly to intensive care following their initial discharge home. Feeding difficulties following discharge from the specialist surgical centre emerged as one of the most significant parental concerns spontaneously raised in interviews. For some parents the impact of feeding difficulties overshadowed any other cardiac concerns. Key themes centred around feeding management (particularly the practical challenges of feeding their baby), the emotional impact of feeding for parents and the support parents received or needed after discharge with respect to feeding. Caring for a child with congenital heart disease following surgery is demanding, with feeding difficulties being one of the most significant parent stressors. Local health professionals can be a good source of support for parents provided that they are well informed about the needs of a cardiac baby and have realistic expectations of weight gain. Specialist surgical centres should consider addressing issues of parental stress around feeding and weight gain prior to hospital discharge. © 2016 Blackwell Publishing Ltd.
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Affiliation(s)
- Jenifer Tregay
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Katherine Brown
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Sonya Crowe
- Clinical Operational Research Unit, UCL, London, UK
| | - Catherine Bull
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Rachel Knowles
- MRC Centre of Epidemiology for Child Health, UCL Institute of Child Health, London, UK
| | - Jo Wray
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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