Growth Failure and Feeding Difficulties: Guidelines for Enteral and Parenteral Nutrition

Nutrition support is a fundamental aspect of care for critically ill pediatric cardiac patients, with known effects on morbidity, wound healing, infection, and length of hospitalization. Provision of adequate nutrition support presents several unique challenges in the pediatric cardiac population. Pediatric patients hospitalized with congenital heart disease are usually born at normal weight but rapidly develop malnutrition (undernutrition). In fact, nearly half of children admitted for cardiac surgery are malnourished. Risk factors for preoperative growth failure in these patients include; the underlying cardiac physiology, the presence or absence of congestive heart failure, anorexia, poor oral feeding coordination, gastrointestinal abnormalities or dysfunction, and the presence or absence of genetic disease. Infants with single ventricle physiology are at particular risk for malnutrition, which is known to increase their risk for interstage mortality. Many of these children experience malabsorption due to decreased cardiac output, hypoxia, elevated right-sided cardiac pressure, and subsequent gastrointestinal dysfunction. Infants and children undergoing cardiac surgery may go on to develop further deterioration of their nutrition status due to postoperative fluid restrictions, interruptions to feeding for procedures, feeding intolerance, and delays initiating enteral nutrition due to provider concern for gastrointestinal complications of early postoperative enteral nutrition, such as necrotizing enterocolitis. Acute malnutrition that develops postoperatively further increases the risk of poor outcomes after surgical repair or palliation of congenital heart disease. Interstage monitoring programs for children with single ventricle physiology focus on screening for malnutrition and assessment of nutrition status, enteral nutrition interventions targeted to maintain normal growth, dietician care, and family engagement. Interstage monitoring programs are associated with improved malnutrition indices and with improved outcomes, including improved survival.