Nutrition algorithms for infants with hypoplastic left heart syndrome; birth through the first interstage period

Abstract

Failure to thrive is common in infants with hypoplastic left heart syndrome and its variants and those with poor growth may be at risk for worse surgical and neurodevelopmental outcomes. The etiology of growth failure in this population is multifactorial and complex, but may be impacted by nutritional intervention. There are no consensus guidelines outlining best practices for nutritional monitoring and intervention in this group of infants. The Feeding Work Group of the National Pediatric Cardiology Quality Improvement Collaborative performed a literature review and assessment of best nutrition practices from centers participating in the collaborative in order to provide nutritional recommendations and levels of evidence for those caring for infants with single ventricle physiology.

Figure 1

Preoperative enteral feeding (EN).,,,,- Benefits of preoperative enteral nutrition may include: development of normal feeding patterns, prevention of bacterial translocation, and promotion of immunologic and gut mucosal health. Oral feeding should be attempted only in the stable patient. PN, total parenteral nutrition; IL, intravenous lipid solution; NG, nasogastric; UA, umbilical arterial catheter; PGE prostaglandin infusion; GI, gastrointestinal.

Figure 2

Total parenteral nutrition (PN).,- Goal: PN should be initiated in all single ventricle patients preoperatively, and as soon as feasible postoperatively to minimize nutritional deficiencies. GIR, glucose infusion rate.

Figure 3

Considerations/possible contraindications to enteral feeding (EN).-,,, *Implications of inotropic support may differ during various phases of the hospital course. In the preoperative period, the need for inotropic support implies unstable systemic circulation, while in the patient with stabilized postoperative physiology, it is appropriate to enterally feed with evidence of good systemic output while weaning inotropic support. CO, cardiac output; AVO₂, arteriovenous oxygen difference; NIRS, near-infrared spectroscopy; MVO₂, mixed venous oxygen saturation; NEC, necrotizing enterocolitis.

Figure 4

Postoperative enteral feeding (EN).,,,,,-,,,,- Goal: Postoperative enteral nutrition should begin as soon as safe and feasible. PN, total parenteral nutrition; IL, intravenous lipid solution; NG, nasogastric; NJ nasojejunal.

Figure 5

Postoperative oral feeding.,,,,,-,,,,- Goal: Postoperative oral feeding should begin as soon as is safe and feasible in order to assess potential complications and promote natural feeding behavior. PO, by mouth; NG, nasogastric; EN, enteral nutrition; GERD, gastroesophageal reflux disease; ENT, ear, nose, and throat specialist; GI, gastrointestinal.

Figure 6

Interstage feeding program.,-,-,,,,,,,- Goal: Achieve normal infant growth during the interstage period. OFC, occipitofrontal head circumference; GI, gastrointestinal; FTT, failure to thrive; GER, gastroesophageal reflux; CHF, congestive heart failure; BNP, brain natriuretic peptide; ECHO, echocardiogram; cath, cardiac catheterization; S2R, stage two reconstruction.