Evaluating the Impact of a Feeding Protocol in Neonates before and after Biventricular Cardiac Surgery

Abstract

Introduction: Feeding difficulties and malnutrition are important challenges when caring for newborns with critical congenital heart disease (CCHD) without clear available guidelines for providers. This study describes the utilization of a feeding protocol with the focus on standardization, feeding modality, and total parenteral nutrition (TPN) utilization postoperatively.

Methods: Patients included neonates with CCHD undergoing complex biventricular repair using cardiopulmonary bypass. Data were collected in 2013 preintervention and from 2015 to 2017 postintervention. The feeding protocol outlined guidelines for and postoperative use of TPN. Adverse outcomes data included rates of central line-associated bloodstream infections, necrotizing enterocolitis, chylothorax, and vocal cord dysfunction. Balance outcomes measured were weight for age Z-score at discharge, number of abdominal radiographs obtained, readmission within 90 days, and central venous line utilization.

Results: We included a total of 121 neonates: 49 in the preintervention group and 72 in the postintervention group. The protocol standardized feeding practices in CCHD neonates undergoing surgery with improved compliance from 70% early in the study period to 90% at the end of the study. Infants were fed enterally more preoperatively (86% versus 67%; P = 0.023), reached a fluid goal sooner (63 hours versus 72 hours; P = 0.035), and postoperative duration of TPN usage was significantly shorter in the postintervention period (48 hours versus 62 hours; P = 0.041) with no increase in adverse outcome events or unintended consequences.

Conclusions: By implementing a feeding protocol, we reduced practice variation among providers, increased the number of patients fed enterally preoperatively and reduced postoperative use of TPN without increased complications.

Fig. 1.

Key driver diagram showing framework for implementation of the moderate risk feeding protocol with presenting aims, outcome measures, and the theories for improvement (key drivers).

Fig. 2.

Xbar S control chart showing reduction in total duration of TPN. LCL, lower control limit; UCL, upper control limit; , mean; , average SD 1: point more than 3 SD from center line. Figure made with Minitab18.

Fig. 3.

p chart showing initiation compliance and advancement compliance over time. Years are divided into 4 quarters with 3 months in each quarter and amount of patients screened in parentheses. LCL, lower control limit a: education reinforced amount to feed during open sternum vs. closed sternum b: education reinforced how to increase feeds by weight in milliliters every 6 hours to reach 135 ml/kg. UCL, upper control limit. Education to providers regarding inclusion criteria and definition of hemodynamic stability.Education to providers regarding nothing by mouth status before and after chest closure and amount of feeds with an open chest. Amount of feeds aligned with high risk protocol causing confusion and requiring education. Re-education regarding advancement. Re-education regarding initiation of feeds in patients with primary chest closure verses delayed sternal closure.