Feeding in Infants with Complex Congenital Heart Disease. Rachel Torok, MD Southeastern Pediatric Cardiology Society Conference September 6, 2014

Transcription

1 Feeding in Infants with Complex Congenital Heart Disease Rachel Torok, MD Southeastern Pediatric Cardiology Society Conference September 6, 2014

2 Objectives Discuss common feeding issues in patients with complex congenital heart disease (CHD) Review previous practices and new feeding protocol at Duke Examine preliminary data after initiation of new protocol at Duke

3 Failure to Thrive Common among infants with complex CHD Inefficient circulation High metabolic demand during post-operative healing Alterations in growth factors and growth hormone Genetic syndromes Poor oral skills Gastrointestinal pathology Associated with worse outcomes in CHD patients

4 Peri-operative Feeding Considerations Pre-operatively Cyanosis and compromised systemic output Prostaglandin (PGE) dependent Umbilical catheters in place Post-operatively Tenuous clinical status High respiratory support Inotropic support Poor oral skills Gastric dysmotility Vocal cord paralysis

5 Pre-operative Feeding in PGE- Dependent Infants No increased risk of necrotizing enterocolitis (NEC) with early feeding in hemodynamically stable, cyanotic infants No increase in adverse events with enteral feeding on PGE No increased risk of NEC with umbilical artery catheters

6 Benefits of Early Enteral Feeding Improved nutritional status and growth prior to surgery Improved surgical outcome Enhanced intestinal maturation Improved feeding tolerance post-operatively Decreased length of parental nutrition Increased immunity

7 Consensus Feeding Guidelines National Pediatric Cardiology Quality Improvement Collaborative Created in 2009 to improve outcomes among single ventricle patients Multidisciplinary Feeding Work Group Devised first consensus feeding guidelines for single ventricle infants Released guidelines in 2011

8 Duke Feeding Guidelines Previous guidelines: No recommendations on timing of pre- or post-operative feed initiation Post-operative feeds started continuously at 1 ml/hr Increased by 1 ml/hr every 12 hours Once at goal volume, caloric density slowly increased Once at goal calories, compression to bolus schedule Multidisciplinary committee created to revise feeding guidelines New protocol implemented in January 2014

9 Duke Feeding Guidelines Focus of new guidelines: Early initiation of enteral feeds pre- and post-operatively Focus on oral feeding and breast feeding when possible Vocal cord paralysis assessment after arch interventions Bolus post-operative feeding Faster achievement of full caloric feeds post-operatively

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13 Quality Improvement Retrospective review of consecutive PGE-dependent neonates before and after new feeding protocol Diagnoses: HLHS Critical coarctation Unbalanced AVCD Tricuspid atresia Pulmonary atresia Transposition of the great arteries 22 patients pre-protocol (July-Dec 2013) 13 patients post-protocol (Jan-June 2014) All term infants

14 Preliminary Data Table 1. Major cardiac diagnoses of patient cohorts pre- (n=22) and post-protocol (n=13) initiation Table 2. Patient characteristics before and after initiation of new feeding protocol

15 Figure 1. Discharge feeding route Preliminary Data

16 Quality Improvement All patients fed pre-operatively after initiation of new feeding protocol No incidence of NEC before or after new protocol Average weight gain, length of stay, and rate of feed interruptions similar among both groups No difference in rate of gastrostomy tube at discharge

17 Future Directions Currently small sample sizes Continue to collect data from both before and after new protocol initiation Time points for future intervention: Decrease time to postoperative feed initiation Minimize feed interruptions

18 Summary Nutrition is a major focus in improving the outcome of children with complex CHD Early pre-operative enteral feeding in this patient population is safe Striving to reinitiate and advance post-operative feeds quickly using a standardized approach is likely to improve outcomes

19 References Anderson, J.B., et al., Predictors of poor weight gain in infants with a single ventricle. J Pediatr, (3): p , 413 e1. Ashburn, D.A., et al., Outcomes after the Norwood operation in neonates with critical aortic stenosis or aortic valve atresia. J Thorac Cardiovasc Surg, (5): p Barrington, K.J., Umbilical artery catheters in the newborn: effects of position of the catheter tip. Cochrane Database Syst Rev, 2000(2): p. CD Kugler, J.D., et al., Development of a pediatric cardiology quality improvement collaborative: from inception to implementation. From the Joint Council on Congenital Heart Disease Quality Improvement Task Force. Congenit Heart Dis, (5): p Lambert, L.M., et al., Variation in Feeding Practices following the Norwood Procedure. J Pediatr, Slicker, J., et al., Nutrition algorithms for infants with hypoplastic left heart syndrome; birth through the first interstage period. Congenit Heart Dis, (2): p Tyson, J.E. and K.A. Kennedy, Minimal enteral nutrition for promoting feeding tolerance and preventing morbidity in parenterally fed infants. Cochrane Database Syst Rev, 2000(2): p. CD Williams, R.V., et al., Factors affecting growth in infants with single ventricle physiology: a report from the Pediatric Heart Network Infant Single Ventricle Trial. J Pediatr, (6): p e2. Willis, L., et al., Enteral feeding in prostaglandin-dependent neonates: is it a safe practice? J Pediatr, (6): p