Nutrition in Paediatric Cardiology. Karen Hayes Paediatric Dietitian Addenbrooke s Hospital

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1 Nutrition in Paediatric Cardiology Karen Hayes Paediatric Dietitian Addenbrooke s Hospital

2 Topics Who needs Nutrition support? Energy Requirements Meeting Energy and growth requirements Feeding Issues Chylothorax

3 Children with congenital heart disease are frequently undernourished.. Mitchell et al, Heart (1995) 73;

4 Who needs Nutrition Support? Low Coarctation of the aorta, Patent ductus arterious (PDA), Atrial Septal defect, Cor tratrium, Transportation of the great arteries, Total anomalous pulmonary venous drainage, Pulmonary Stenosis Variable risk Pulmonary atresia, Tetralogy of Fallot High Moderate to large Ventricular Septal defect, Atrioventricular septal defect, Hypoplastic left heart, Truncus arteriosus, Aorto pulmonary window, Large PDA, Tricuspid atresia, Ebstein s anomaly, Partial anomalous pulmonary venous drainage, Any patient in any risk group with faltering growth Shaw and Lawson (2007), The Cardiothoracic System, Manual of Clinical Paediatric Dietetics

5 Growth Expectations For the child to maintain normal growth General growth patterns suggest: Acyanotic lesions tend to be lower in weight Cyanotic lesions tend be stunted e.g. lower in weight and height Forchielle et al (1994) Nutrition Grand Rounds: 52; 10;

6 Energy Requirements Requirements range from: High: 0 1 year olds: kcals/kg/day, g/kg/day protein Children: 120% EAR for age Very high: 0 1 year olds: kcals/kg/day 6 g/kg/day 0 6 months, up to max 10 g/kg/day up to 1 year old Children: 150% EAR for age Nutritional requirements for Children in Health and Disease, Great Ormond Street Hospital for Children NHS Trust

7 Other factors affecting poor growth Early satiety Fatigue on feeding/breathlessness Anorexia Vomiting Frequent infections Frequent use of antibiotics affecting gut flora Insufficient absorption of nutrients in the gut Fluid restrictions Shaw and Lawson (2007) The Cardiothoracic System, Clinical Paediatric Dietetics

8 Meeting energy and growth requirements Use of high energy and protein feeds SMA High energy / Infatrini Tolerance Use of Modular supplements Duocal High energy weaning Food for the toddler years and use of Paediatric supplement drinks

9 Meeting energy and growth requirements Use of enteral feeding Nasogastric or Gastrostomy feeding Oral feeds with tube feed top-ups Continuous vs Bolus feeding Schwartz et al showed in a small population of patients that 24 hour continuous enteral feeding provided the most optimal nutrition vs overnight feeding with oral feeding vs sole oral feeding Schwartz et al, Paediatrics, 1990; 86;

10 Nutrition and Cardiac surgery Post-op most neonates have a heightened post-op requirement hours after surgery. Owens & Ndidamaka (2009) Nutrition in Clinical Practice; 24; Re-establishing full nutrition support will depend on the patients condition Owens & Ndidamaka (2009) Nutrition in Clinical Practice; 24; Enteral feeding alone is often suboptimal after neonatal cardiac surgery Schwalbe-Terilli et al, (2009) American Journal of Critical care; 18; Resting energy expenditure returns to normal after 1 week following corrective cardiac surgery Nydegger et al (2009) European Journal of Clinical nutrition; 63;

11 Chylothorax Accumulation of chyle in a pleural cavity from an internal lymphatic fistula Chyle contains fat from the intestinal lacteal system % of absorbed dietary fat passes through this system Chest drain samples that have >1.1 mmol/l of triglycerides will confirm diagnosis Can occur as complication of cardiac surgery

12 Chylothorax Nutritional Management Minimal Long Chian Triglyceride (LCT) diet 1g LCT per year of life up to 4 5g/day LCT As long as enteral feeding is indicated this should be first line treatment Should be initiated as a 5 day trial. If drain output <20 ml/kg/day then to continue. This diet should be maintained for 4 weeks from the last drain being removed.

13 Chylothorax Nutritional management Minimal LCT diet Monogen mimimal LCT, whole whey protein infant formula Weaning diet pureed vegetables, pureed fruit, pureed boiled rice mixed with minimal LCT milk, baby rice made with minimal LCT fat, tins and jars of baby food with less than 0.2g LCT per 100g For older children families can be taught to give LCT exchanges and the use of Medium chain triglyceride (MCT) fats. Diet may contain 40 70g of MCT fats and is built up over 7 10 days to avoid abdominal discomfort

14 Chylothorax Nutritional management Parenteral Nutrition (PN) Used when enteral feeding not indicated Observe for initial 5 day period. If drain <20ml/kg/day then for transition onto minimal LCT diet when indicated If drain >20ml/kg/day may need surgical correction Algorithm for suspected chylothorax produced by: Cormac et al (2004) Annals of Thoracic Surgery; 77:

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