Nutrition in the Cardiac Newborns: Evidence-based Nutrition Guidelines for Cardiac Newborns

Key points

Nutritional requirements in neonates with congenital heart disease

In the simplest terms, malnutrition is result of inadequate energy intake or an increase in energy expenditure, resulting in an energy imbalance. Studies of critically ill children have estimated that energy requirements may increase by 30% for mild to moderate stress and up to 50% in severe stress.¹ Suboptimal nutrition during periods of critical illness, resulting in energy and protein deficits, has been associated with poor clinical outcomes in both pediatric and adult populations.² Poor

Protein studies in sick/preterm neonates

Critical illness, including CHD and surgical conditions, leads to increased protein catabolism and turnover. A constant flow of amino acids is necessary for the synthesis of new proteins and for tissue repair and growth. The goals of nutrition in critically ill patients are to provide sufficient dietary protein to enable adequate new protein synthesis, facilitate wound healing, modulate inflammatory responses, and preserve skeletal muscle mass.

In addition to poor caloric intake, critically ill

Necrotizing enterocolitis in cardiac newborns

Necrotizing enterocolitis (NEC) is the most common surgical emergency among premature neonates but is generally a rare event in term infants without CHD. Congenital heart defects are often associated with cyanosis, decreased cardiac output, or pulmonary overcirculation/congestive heart failure, often in combination. Each of these risk factors has been independently associated with the genesis of bowel ischemia.¹⁷ In contrast with the preterm population, in which NEC typically develops at 2 to

Necrotizing enterocolitis in preterm neonates with congenital heart disease

Preterm infants with CHD represent a uniquely vulnerable population with regard to NEC. Fisher and colleagues¹⁷ performed a large prospective VON (Vermont Oxford Network) database review of 235,643 infants, 1931 of whom had CHD (0.8%). Of those infants with CHD, 13% developed NEC compared with 9% NEC in those without CHD (adjusted odds ratio [AOR], 1.8). Concordant with the literature on NEC in preterm infants, NEC in neonates without CHD was associated with younger mean gestational age, lower

Standardized feeding protocols

Because of the concern for feeding intolerance and NEC, many clinicians are uncomfortable feeding patients with CHD preoperatively while on prostaglandins, although there is scant evidence to support or refute this practice. Many of these patients are gravely ill, requiring prolonged mechanical ventilation and vasoactive infusions, and have indwelling umbilical or central catheters. Surgical repair often requires cardiopulmonary bypass and deep hypothermic circulatory arrest. Postoperatively,

Breast milk studies

Breast milk is considered the ideal source of nutrition for all infants. Human milk feeding has been associated with a greatly reduced incidence of NEC,³⁵ gastroenteritis,³⁶ otitis media, respiratory illnesses,³⁷ and allergic and autoimmune disease³⁸ and is recommended as the exclusive diet for infants less than 6 months of age. Despite overwhelming evidence supporting the benefits of human milk, there have been no studies on the benefits of a human milk diet on outcomes in infants with CHD.

Intestinal microbiota and probiotics

Examination of the role of the fecal microbiota in the genesis and propagation of NEC has become an area of intense interest in the past decade. Numerous studies in the preterm population have associated alterations in gut immunity and intestinal microbial dysbiosis, colonization of the neonatal intestine with pathogenic bacteria that differ markedly from the flora in a healthy term newborn, with the development of NEC.42, 43, 44 A recent Cochrane Review examined high-quality data from 24

Postdischarge nutrition and growth

After discharge, growth failure in infants with CHD is a complex problem with contributions from a variety of issues (Fig. 4). These physical limitations are common features in infants with CHD and likely contribute to inadequate energy intake with resultant poor weight gain and linear growth.⁵¹ Multiple studies have documented a high rate of growth failure at hospital discharge following neonatal surgery for infants with both single-ventricle and biventricle physiology.52, 53

Schwalbe-Terilli

Need for gavage feeding at discharge

A variety of factors have been associated with risk of poor rates of oral feeding at discharge in patients with CHD, including vocal cord injury, duration of postoperative intubation, weight at time of surgery, use of transesophageal echocardiography, and prematurity.57, 58 Kogon and colleagues⁵⁹ found that 44.6% infants with CHD required feeding tubes at discharge for an inability to transition or a delay in the transition to oral feeds. Prolonged intubation and a higher risk-adjusted