Enteral Nutrition, by Nancy Braudis.
My name is Nancy Braudis, and I am a clinical nurse specialist in the Cardiac ICU at Children's
Hospital Boston.
The topic today is enteral nutrition in infants and children with congenital heart disease.
The objectives of this presentation are to understand the importance of early enteral
nutrition, identify the risks associated with enteral nutrition, and to reduce barriers
to providing optimal nutrition in infants and children with congenital heart disease.
Importance of Nutrition.
Providing enteral nutrition is important because of the high risk of growth failure in infants
and children with complex congenital heart disease.
Many infants with congenital heart disease have lower birth weights-- especially those
with Tetralogy of Fallot, complete atrioventricular canal, ventricular septal defects, and hypoplastic
left heart syndrome.
Providing important nutrients will help to optimize growth and development, improve tissue
healing, and reduce the risk of infection.
The high rate of growth failure that develops in infants may be related to inadequate nutritional
intake-- infants require more calories than they are able to take in.
Reduced gastrointestinal absorption-- the body is unable to absorb the nutrients that
are required for adequate growth.
High energy expenditure-- infants with congenital heart disease are thought to have an increased
metabolic rate because of the increased workload on the cardiac and respiratory systems.
Physical growth is the most important parameter in the assessment of nutritional status.
Periodic assessments should be made to determine if weight, height, length, and head circumference
are within normal limits for age.
Children who are hospitalized should have daily assessments of weight and monthly assessments
of height or length to determine the effectiveness of a feeding plan.
Nutritional Goals.
Infants with complex congenital heart disease require approximately 120 to 150 calories
per kilogram per day to achieve significant growth.
In studies evaluating nutritional intake, it was found that most patients only receive
50% to 70% of their actual caloric requirements.
Standard guidelines identify a target weight gain for infants of 10 to 35 grams per day.
Calorie counts are done to determine the daily intake of calories.
To calculate calories, take the total volume of formula in 24 hours-- example, 600 milliliters--
and divide by 30 milliliters.
Then multiply by the calories per ounce-- example, 20 calories-- and divide by the infant's
weight-- example, 5 kilograms.
The answer is 80 calories per kilogram per day.
A feeding plan should be developed to improve caloric intake.
The goal should be 120 to 150 calories per kilogram per day.
So either the volume of feedings or the concentration of calories of the feedings should be increased
to reach the nutritional goal.
Please note, if you do not use ounces at your institution, the equation would instead read--
600 milliliters in 24 hours.
Since there are 30 milliliters in 1 ounce, the formula has 20 calories per 30 milliliters,
or 0.67 calories per 1 milliliter.
Feeding Routes.
Although the ideal route of enteral nutrition is oral feeding, it is often difficult for
infants to take in enough calories with limited energy stores and to coordinate feeding patterns
with rapid respirations.
Breastfeeding should be encouraged with supplementation as needed.
Infants with significant growth failure may still breastfeed, which should alternate breastfeeding
with high caloric formula to improve weight gain.
Tube feedings should be initiated in infants and children with an altered mental state,
congenital anomalies, dysphasia, prematurity, increased metabolic needs or significant growth
failure.
Transpyloric feeding should be implemented when there is gastric distress, delayed gastric
emptying, or an increased risk of aspiration.
Difficulty with oral feeding is common in infants following cardiac surgery.
Risk factors include entry to the vocal cords from prolonged intubation, low weight at time
of surgery, or surgical intervention close to the aortic arch.
Paralysis of the vocal cords should be suspected if the infant has a weak cry after extubation.
It may compromise the infant's ability to swallow and increase the risk of aspiration.
Management includes thickening of oral feedings or in severe cases, implementing tube feedings.
Pediatric cardiac patients have a high rate of gastroesophageal reflux disease.
Clinical signs include recurrent vomiting, poor weight gain, abdominal pain, and persistent
respiratory symptoms.
Treatment options include formula thickening, prone positioning with head of bed 30 degrees,
and tube feeding supplementation.
Benefits of Enteral Nutrition.
Many studies have evaluated the benefits of early enteral nutrition.
The studies found that critically ill children are at risk for fat and protein depletion,
leading to malnutrition and that early enteral feedings improve nutritional outcomes.
Early enteral nutrition lowered the risk of infection, decreased the length of hospital
stay, and showed a significant improvement in wound healing.
Implementing an evidence-based feeding protocol in critically ill patients produced a significant
reduction in the duration of mechanical ventilation and a marked reduction in mortality.
Risks of Enteral Nutrition.
The risks of enteral nutrition include feeding intolerance and necrotizing enterocolitis.
Feeding intolerance can be defined as two or more episodes of vomiting, three or more
episodes of diarrhea or loose stool, Bowel sounds and gastric residual volumes are poor
indicators of feeding intolerance.
Gastric residual volumes vary greatly, and they can vary throughout the day.
They should be part of an overall assessment, but not the only criteria in a decision to
stop feeds.
Infants with congenital heart disease are at much greater risk for developing necrotizing
enterocolitis because of potential hypoxia or hypoperfusion to the gastrointestinal system.
The incidence of necrotizing enterocolitis in neonates with congenital heart disease
was reported at 3.5%.
And that is 10 times higher than in neonates without congenital heart disease.
The rate of necrotizing enterocolitis for infants with single ventricle physiology was
found to be as high as 7.6%.
Symptoms of necrotizing enterocolitis include feeding intolerance, delayed gastric emptying,
abdominal distension, decreased bowel sounds, and blood in the stool.
Feeding Guidelines.
Barriers to providing adequate nutritional support include individual practice variation,
under-prescription, fluid restriction, frequent interruptions in feeds, mechanical problems
with tubes, hemodynamic instability, procedures, daily care, and gastrointestinal distress.
The use of standardized feeding guidelines have consistently promoted the use of early
enteral nutrition, improved nutritional outcomes, reduced barriers to providing optimal nutrition,
reduced the time to achieve goal calories, and reduced the incidence of feeding intolerance.
We use this feeding algorithm to initiate and advance feedings in infants and children
after cardiac surgery.
It is a systematic way of introducing feeds and monitoring for signs of gastric distress.
As you follow the arrows to the boxes, you see that an intervention occurs every four
hours while starting feeds.
Conclusion.
Infants with complex congenital heart disease are at high risk for growth failure.
They require approximately 120 to 150 calories per kilogram per day to achieve significant
growth.
Clinicians are often reluctant to initiate and advance early enteral feedings because
of the increased risk of necrotizing enterocolitis.
Multiple barriers exist to providing optimal nutrition.
Feeding guidelines consistently reduce barriers and improve nutritional outcomes.
That concludes the topic of enteral nutrition in infants and children with cardiac disease.
Thank you.
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