Nutrition and Congenital Heart Disease. Jessica Hendricks, MS, RD, LD Clinical Nutritionist

Transcription

1 Nutrition and Congenital Heart Disease Jessica Hendricks, MS, RD, LD Clinical Nutritionist

2 Importance of Nutrition Support in Patients with Congenital Heart Disease (CHD) Overview Incidence of Malnutrition in CHD (Literature) Etiology of Malnutrition in CHD Dietitians Role Causes of Growth Failure Formula Selection Chylothorax Questions 2

3 Importance of Nutrition Support in Patients with Congenital Heart Disease (CHD) Overview Growth Neurological Development Wound Healing Resistance to Infection Positive Surgical Outcome 3

4 Incidence of Malnutrition in CHD Post-operative: 2008 study by Jia Le, et al. -assessed energy expenditure and caloric and protein intake in first 3 days s/p Norwood procedure In hospitalized pediatric patients with CHD and CHF there is an in the frequency and severity of acute/chronic malnutrition. (Wynn C et al 1995) - Incidence of significant CHD-related malnutrition ranges from 40%-80% Failure to thrive in infants with CHD may result in more frequent hospitalizations and longer LOS. (Silberback M et al 1993) 4 Aggressive nutrition intervention is vital to prevent unsuccessful outcomes associated with malnutrition. (Leitch CA et al 1998; Mitchell IM et al 1995)

5 Etiology of Malnutrition Inadequate caloric intake Increased energy expenditure due to increased respiratory rate and/or increase metabolic rate Contribution of associated non-cardiac problems Intestinal malabsorption Effects of hypoxia on cellular metabolism 5

6 Dietitians Role in Patient s with CHD 6

7 Nutrition Assessment Evaluation of growth parameters: sequential weight, height and head circumference measurements Classification of Undernutrition: 1. Acute undernutrition: - Deceleration in weight-for-age and low weight-for-height - Normal linear and head growth - Reveals a recent insult to nutritional status 2. Chronic undernutrition: 7 - Decrease in weight is followed by decrease in linear growth and ultimately head circumference - Stunting: adaptive physiological phenomenon that preserves and adequate weight-for-height at the expense of linear growth

8 Strategies for Nutrition Support Route of feeding Caloric density of feeds and target volume Goal for weight gain Normal physiological feeding behavior 8

9 Weight Gain Velocity AGE 0-3 months Avg gain (gm/day) months months years years 5-7 9

10 Methods for Determining Calorie Needs Growth History Diet History RDAs/DRIs BMRs Indirect calorimetry 10

11 Calorie Needs of Healthy Children (RDA) Group Age Energy (kcal/kg) Infants 0-6 months months Children 1-3 years years years Protein (gm/kg) Males years years Females years years

12 Calorie Needs in CHD Infants and children with CHD can have calorie needs of 120%-140% of the RDA. An infants calorie requirement can be kcal/kg or more to promote adequate weight gain 12

13 Energy Expenditure High calorie formula intake by mouth increased calorie intake from kcal/kg/day NG feeding increased calorie intake to 169 kcal/kg/day Weight gain observed in patient receiving > 170 kcal/kg/day Yahav J et al. Journal of Pediatric Gastroenterology and Nutriton.1985;4:

14 Energy Expenditure Supplemental formula increased energy intake by 37% Mean weight gains increase significantly with highenergy feedings Practical to increase nutrient density of feeds with glucose polymer (polycose) Jackson M et al. British Journal of Nutrition.1991;65:

15 Energy Expenditure 49% of study population with inadequate intake due to fatigue and tachypnea. Cyanotic patients with pulmonary hypertension severely affected with malnutrition Varan E et al. Arch Dis Child.1999;81:

16 Energy Expenditure Decreased rates of weight gain in group with CHD No significant difference in calorie intake and REE compared with controls Significant increase in TEE accounted for growth disturbances Leitch CA et al. J Pediatric.1998;133: Mitchell IM et al. Br Heart J.1995;73:

17 Feeding Problems in CHD Lack of coordination of sucking, swallowing and breathing Inefficient suck (i.e.fatigue) GERD Oral Aversion Respiratory Distress 17 Aspiration

18 Indications for Tube Feeding Unable to meet nutritional requirements (PO) Cannot or will not eat Conditions that alter absorption or metabolism Trophic feeding to stimulate gut and to prevent bacterial translocation 18

19 Formula Selection Standard Infant Formulas Cow s milk based formulas: -Similac Expert Care (replaced Similac Advance) -Enfamil Premium Lipil -Enfamil Gentlease -Gerber Good Start Gentle Plus 19

20 Formula Selection Infant Soy Formulas Soy formulas -Similac Isomil -Enfamil Prosobee Lipil -Gerber Good Start Soy 20

21 Formula Selection Infant Lactose Free Formulas Similac -Similac Sensitive for Spit-up -Similac Sensitive for Fussiness and Gas Enfamil -Enfamil Gentlease 21

22 Formula Selection Protein Hydrolysates Similac -Similac Alimentum Enfamil -Nutramigen Lipil -Pregestimil Lipil 22

23 Formula Selection 23 Neocate Infant 100% free amino acids with glutamate CHO source: corn syrup solids Fat: 95% LCT and 5% MCT Essentail fatty acids provide 8% of total kcals Milk, lactose, sucrose and soy free Palatable Elecare 100% free amino acids CHO source: corn syrup solids 1/3 of fat is MCT oil Milk, lactose, sucrose and soy free

24 Formula Selection Premature Infant Formulas Cow s milk based Formulas (normally used) -Enfacare Lipil -Similac Neosure Cow s milk based Formulas (reserved for NICUs) -Enfamil Premature Lipil -Similac Special Care 24

25 High Calorie Formula Concentrate formula to 24 calorie/ounce Add modulars to increase calorie density above 24 calorie/ounce - CHO modulars: Polycose/Moducal - Protein modulars: Beneprotein - Fat modulars: Microlipid, MCT Oil, Vegetable Oil 25

26 Formula Selection Pediatric Formulas (1-10 years) Pediasure Nutren Junior Nutren Junior w/ Fiber Peptamen Junior w/ Prebio Boost Kid Essentials 1.0 Compleat Pediatric Additional supplements: CIB, Resource Breeze 26

27 Chylothorax Chylothorax: presence of lymphatic fluid in the pleural space resulting from a leak in the thoracic duct or one of its major divisions Transporter of digestive fat to venous system 27 Composition of Chyle: -Milky color -High in Fat (TG >110 mg/dl) -High in Protein (>3 gm/dl) -T-Lymphocytes (400-7,000 cells) -Electrolytes (Na, K, Cl) -Fat Soluble Vitamins (A,D,E,K)

28 Dietary Management of Chylothorax 10 grams of fat (LCT) or less ( no fat diet ) Supplement with skim milk and Carnation Instant Breakfast Add MCT oil (Safflower, Corn or Soybean) as needed for calorie supplementation in infant formula 28

29 MCT Medium Chain Triglyceride (MCT) Does not depend upon entry into the lymphatic system for absorption Directly and rapidly absorbed into the portal system Does not contain essential fatty acids Do not store in plastic containers 29

30 Formula Selection Enfaport Contains 84% of fat as MCT oil; 16% as LCT Can be used for infants and children Taste concerns Meets 100% of essential fatty acid needs, contains DHA/ARA and carnitine (major role in fatty acid transport) Better for bone mineralization (Ca:PO4 is 1.8:1) Tolerex Essentially fat free, elemental formula Contraindicated in infants Needs supplement of LCT (soybean, corn, safflower) to provide essential fatty acid needs If used in infants and children need additional vitamin/mineral supplementation (poly-visol) Given via tube feeding 30

31 Summary (Optimizing Nutritional Status) Evaluate adequacy of intake Manage additional feeding problems as best able Increase calorie density of feeds/formula Use supplemental tube feeding and/or IV nutrition if necessary Frequent weight checks Use appropriate weight gain goals 31 Surgery

32 32 Questions