Review Article

World Journal for Pediatric and

Congenital Heart Surgery
Nutrition Support for Children Undergoing 2015, Vol. 6(3) 443-454
ª The Author(s) 2015
Reprints and permission:
Congenital Heart Surgeries: A Narrative sagepub.com/journalsPermissions.nav
DOI: 10.1177/2150135115576929
Review pch.sagepub.com

Judith J. M. Wong, MBBCh, BAO, MRCPCH1,

Ira M. Cheifetz, MD, FCCM, FAARC2, Chengsi Ong, MS, RD3,
Masakazu Nakao, MD, FRCSCTh4, and
Jan Hau Lee, MBBS, MRCPCH, MCI5,6

Abstract
Energy imbalance in infants and children with congenital heart disease (CHD) is common and influenced by age, underlying cardiac
diagnoses, and presence or absence of congestive heart failure. During the surgical hospitalization period, these children are
prone to nutritional deterioration due to stress of surgery, anesthetic/perfusion techniques, and postoperative care. Poor
nutrition is associated with increased perioperative morbidity and mortality. This review aims to examine various aspects of
nutrition in critically ill children with CHD, including (1) energy expenditure, (2) perioperative factors that contribute to energy
metabolism, (3) bedside practices that are potentially able to optimize nutrient delivery, and (4) medium- to long-term impact of
energy balance on clinical outcomes. We propose a nutrition algorithm to optimize nutrition of these children in the perioperative
period where improvements in nutrition status will likely impact surgical outcomes.

Keywords
cardiac intensive care, children, congenital heart disease, congenital heart surgery, nutrition, pediatric, intensive care

Submitted December 02, 2014; Accepted February 16, 2015.

Introduction palliative surgeries (Table 1). This review aims to examine

various aspects of nutrition in critically ill children with CHD,
Children with underlying congenital heart disease (CHD) are at
including (1) energy expenditure, (2) perioperative factors
risk of energy imbalance and malnutrition.1,2 Infants with iso-
that contribute to energy metabolism, (3) bedside practices
lated cardiac defects are generally born with a normal birth
that are potentially able to optimize nutrient delivery, and
weight but develop nutritional and growth difficulties there-
after.3,4 Factors causing failure to thrive in these children
include the underlying cardiac disease, presence/absence of
1
congestive cardiac failure, decreased energy intake (eg, feeding Department of Pediatric Medicine, KK Women’s and Children’s Hospital,
difficulties, anorexia, and hepatomegaly causing reduced gas- Singapore
2
Department of Pediatrics, Division of Pediatric Critical Care Medicine, Duke
tric volume), and disturbances in gastrointestinal function University Medical Center, Durham, NC, USA
(eg, gut edema, reflux).5,6 In addition, children with CHD asso- 3
Department of Nutrition and Dietetics, KK Women’s and Children’s
ciated with an underlying syndrome/genetic condition (eg, Hospital, Singapore
4
Down syndrome and Turner syndrome) are at an even higher Department of Paediatric Cardiothoracic Surgery, KK Women’s and
risk of energy imbalance.5,7 Children’s Hospital, Singapore
5
Department of Pediatric Subspecialties, Children’s Intensive Care Unit, KK
Malnutrition is associated with poor outcomes in children Women’s and Children’s Hospital, Singapore
with CHD.8-10 Contributing factors in this group of children 6
Office of Clinical Sciences, Duke-NUS Graduate School of Medicine,
include malnutrition-induced myocardial dysfunction, vascu- Singapore
lar endothelial dysfunction, skeletal muscle atrophy, immuno-
suppression, insulin resistance, and lipolysis.10-12 Therefore, Corresponding Author:
Jan Hau Lee, Department of Pediatric Subspecialties, Children’s Intensive Care
it is crucial for care providers of patients with CHD to under- Unit, KK Women’s and Children’s Hospital, 100 Bukit Timah Road, Singapore
stand energy metabolism in these children and innovate ways 229899.
to improve nutrition delivery before and after corrective and Email: lee.jan.hau@kkh.com.sg

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444 World Journal for Pediatric and Congenital Heart Surgery 6(3)

Table 1. Factors that Influence Energy Expenditure in Children With

Abbreviations and Acronyms Congenital Heart Disease.
CHD congenital heart disease
CHF congestive heart failure Factors that contribute to preoperative resting energy expenditure
CI confidence interval  Age (younger children have higher energy expenditure)
CPB cardiopulmonary bypass  Underlying cardiac diagnosis
EN enteral nutrition  Cyanotic congenital heart disease
GER gastroesophageal reflux  Significant left to right shunts
IC indirect calorimetry
LOS length of stay Factors that contribute to the immediate postoperative resting energy
OR odds ratio expenditure
PICU pediatric intensive care unit
PN parenteral nutrition  Preoperative nutritional status
REE resting energy expenditure  Preoperative fasting
TEE total energy expenditure  Sedation and neuromuscular blockade
TSFZ triceps skinfold Z score  Cardiopulmonary bypass
WHO World Health Organization  Perioperative thermoregulation
 Inotropes/other drugs
(4) medium- to long-term effects of energy balance on clinical
outcomes. patients. Its use has been validated in large-scale adult stud-
ies.16,17 The REE is best measured using indirect calorimetry
(IC). The difference between TEE and REE is attributed to the
Methods energy expended during physical activity. In children with
We carried out an online search in MEDLINE using the follow- CHD, it is likely that these activities are more energy costly
ing key words and MESH terms: enteral nutrition, feeding, than healthy children, as patients with CHD may experience
nutrition support, energy requirements, congenital heart dis- increased work of breathing and cardiac output for the same
ease, cardiac surgery, pediatrics, pediatric intensive care unit level of physical exertion.2
(search strategy for MEDLINE is outlined in Supplementary
Appendix A). Based on our review of the current literature, Cyanotic CHD. For the purpose of this review, we considered cya-
we summarized pertinent studies with the intention to provide notic CHD as cardiac lesions with resultant arterial oxygen desa-
some recommendations for the nutritional support of children turation with the exception of single-ventricle lesions, which we
with CHD during the perioperative period. These recommenda- considered separately. We found three studies examining energy
tions and algorithms are proposed based on the consistency and expenditure in children with cyanotic CHD (Table 2). The TEE
strength of the underlying evidence. but not REE was observed to be significantly higher in patients
with cyanotic CHD compared to healthy controls. This is postu-
lated to be due to energy expended during physical activity.
Results Interestingly, differences in blood oxygenation were not demon-
Energy Expenditure of Children With CHD strated to influence oxygen consumption.18
Total energy expenditure (TEE) is the sum of all energy Congestive heart failure. The hallmark of congestive heart failure
expended in daily life including resting energy expenditure (CHF) is increased cardiorespiratory work and sympathetic
(REE), diet-induced thermogenesis, physical activity, and, in activity.2,19 It is also observed that patients with CHF have
children, growth. These components vary with age and body higher resting oxygen consumption and more severe growth
composition—the energy used for growth is high in the first retardation.3,20 Although few in number, several observational
three months of life (45% of energy consumed) and decreases studies consistently reported increased energy expenditure in
as the child grows older (4% of energy consumed after patients with CHF when compared to patients without CHF
12 months of age).13 The TEE can be measured using the dou- (Table 1).21,7 In patients with VSD, a strong positive correla-
bly labeled water technique, which allows patients to be mon- tion was shown between the magnitude of pulmonary blood
itored without major alterations to their daily care settings.14 flow to systemic blood flow ratio (Qp-Qs) with TEE (r ¼ .73,
The doubly labeled water technique is a noninvasive procedure P  .0001) and energy expenditure from physical activity
involving the ingestion of a quantity of water labeled with a (r ¼ .62, P  .0002), indicating that the larger the left-to-right
known concentration of stable isotopes of hydrogen and oxy- shunt, the larger increase in energy expenditure.
gen.15 As energy is expended in the body, hydrogen isotopes
are eliminated as water, and oxygen isotopes are eliminated Single-ventricle defects. There is little known about the energy
as both water and carbon dioxide. The differences between metabolism and requirements for patients with univentricu-
the isotope elimination rates are used to calculate TEE. Other lar physiology.22 Three studies explored postoperative
than requiring periodic sampling of body fluids (eg, urine), this energy expenditure in children with single-ventricle defects
method is nonrestrictive and ideally suited to use in free-living (Table 2).1,22,23 Of note, eight hours postsurgery, patients

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 Table 2. Summary of Studies Examining Energy Expenditure in Children With Congenital Heart Disease During Perioperative Period.
Mean REE + SD, kcal/kg/d

Study Subgroups of CHD Preop Postop POD1 POD2 POD3 POD5 POD  1 Week Healtdy Controls

Krauss 1975a (n ¼ 7) CHF 63 + 12

No CHF 45 + 8

Gebara 1992b (n ¼ 26) Mixed 55 + 8

Mitchell 1994d (n ¼ 53) Mixed 116 + 31d 75 + 21d 112 + 6d

Barton 1994d (n ¼ 12) Mixed 101 + 25d 91 + 39d

42 + 9 44 + 14
Ackerman 1998b,d (n ¼ 18) VSD
88 + 11d 62 + 10d

64 + 17 56 + 7
Leitch 1998b,d (n ¼ 22) Cyanotic
94 + 23d 72 + 13d

67 + 8 58 + 8
Leitch 2000b,d (n¼17) Cyanotic
70 + 14d 76 + 9d

Avitzur 2001b (n ¼ 29) Cyanotic 57 + 13 59 + 10

Acyanotic 58 + 9 62 + 10
b,d
Farrel 2001 (n ¼ 30) 52 + 14 44 + 12
CHF
92 + 20d 61 + 9d

44 + 8
No CHF
77 + 17d

van der Kuip 2003d (n ¼ 34) Mixed 91 + 10d 71 + 9d

Jia Li 2003c (n ¼ 17) Single ventricle 43 + 11 39 + 8 39 + 8 41 + 6

b
Nydegger 2009 (n ¼ 38) Mixed 59 + 9 49 + 9 50 + 5
b
De Wit 2010 (n ¼ 21) Overall 68 + 15 52 + 3 77 + 15 40 + 10

Cyanotic 66 + 17

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Acyanotic 70 + 14

Require CPB 74 + 15

No CPB 58 + 11

Mehta 2012b (n ¼ 26) Single ventricle 57 + 20

Irving 2013b (n ¼ 93) Overall 324 + 55e 328 + 52e

Single ventricle 325 + 59e

Double ventricle 322 + 54e

Abbreviations: CHF, congestive heart failure; CHD, congenital heart disease; Preop, preoperative; Postop, postoperative; POD, postoperative day; REE, resting energy expenditure; SD, standard deviation; VSD,
ventricular septal defect.
a
Diaferometry used to determine REE.
b
Indirect calorimetry used to determine REE.
c
Respiratory mass spectrometry was used to determine oxygen consumption (VO2) and carbon dioxide production (VCO2). REE was then calculated using the modified Weir equation.
d

445
Doubly labeled water used to determine total energy expenditure.
e
kcal/d.
446
with single-ventricle defects were demonstrated to be either
hypometabolic or normometabolic when compared with
World Health Organization (WHO) equation-estimated REE
in the majority of patients (73%).1
Intraoperative Factors That Affect Energy Expenditure
Postcardiac Surgery
Studies examining energy expenditure in children with CHD
and the effect of cardiac surgery are summarized in Table 2.
Factors that influence energy metabolism during surgery are
discussed subsequently.
Cardiopulmonary bypass. Patients who undergo cardiopulmonary
bypass (CPB) exhibit complex neuroendocrine responses that
lead to hypercatabolism.24-27 There is only one clinical study of
21 patients postcardiac surgery, which found that REE was higher
in patients who underwent CPB compared to those without CPB
(73.69 + 15.11 vs 58.31 + 10.88 kcal/kg/d; P ¼ .02).28
Neuromuscular blockade. There is conflicting data on oxygen
consumption and energy expenditure in patients with neuro-
muscular blockade.29-33 The likely explanation for this discre-
pancy is the patients who were deeply sedated and did not have
regular movements before paralysis did not demonstrate a
decrease in oxygen consumption after establishing paralysis.33
Inotropic drugs. Early physiological studies in healthy humans
showed a dose-dependent increase in metabolic rate during
adrenaline infusion.34 However, in the clinical setting, only one
study examined the effect of inotropes on energy expenditure
and showed that the degree of inotropic support (including
adrenaline, noradrenaline, dopamine, and milrinone) was not
associated with increased REE.28
Energy Expenditure After Cardiac Surgery
After surgical correction of the underlying cardiac lesion, REE
is expected to decrease to within normal levels within one week
(Table 2).35 Beyond two years, TEE and REE continue to
match that of healthy controls, and anthropometric measure-
ments were on par, indicating satisfactory catch-up growth.36
Successful cardiac surgery, therefore, is expected to be fol-
lowed by improvements in weight within a few months, with
height and head circumference catching up within a year.37
Nutritional Status and Outcomes in CHD
Poor preoperative nutrition is associated with poor clinical out-
comes. The nutritional status is partially attributed to insuffi-
cient caloric intake (as well as increased energy expenditure
as discussed above).38 Weight for age, growth rates, and daily
metabolizable energy intake per kg has been shown to be lower
in infants with CHD compared to normal infants.20 When
viewed in relation to actual weight, energy intake in children
with CHD averaged 88% + 17% of that recommended by the
Food and Agriculture Organization, WHO, and United Nations
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World Journal for Pediatric and Congenital Heart Surgery 6(3)
University. Caloric intake and weight-for-age Z scores signifi-
cantly correlated with each other (r ¼ .55, P < .01).39 The pre-
operative nutritional status was also associated with changes in
energy metabolism in the postoperative period. Those with
poorer nutritional status preoperation had a higher REE in the
postoperative period. A negative correlation was demonstrated
between weight-for-height Z scores (r ¼ .521, P < .005),
weight-for-age Z scores (r ¼ .584, P < .005), and postopera-
tive REE.28
The impact of poor nutritional status on postoperative out-
comes in children with CHD is highlighted by the following
studies. In 100 infants aged 5.1 (range: 2.4-10) months under-
going bidirectional Glenn procedure with preoperative weight-
for-age Z score of 1.3 (range 3.9-0.6), demonstrated that,
independent of hemodynamic or echocardiographic variables,
a lower weight-for-age Z score was associated with a longer
postoperative hospital stay.40 Among 55 infants aged 47 (range
18–71) months undergoing Fontan surgery, those with a
weight-for-age Z score of less than 2.0 were more likely to
have postoperative infections (odds ratio [OR] 8.7; 95% confi-
dence interval [CI]: 1.5-48.6).41 Data from the Society of Thor-
acic Surgeons Congenital Heart Surgery Database also
demonstrated the association between lower weight-for-age Z
score and poor surgical outcomes.42 In patients undergoing
Fontan surgery, independent of patient and center characteris-
tics, weight-for-age Z score <2.0 was associated with
increased in-hospital mortality (OR 2.73; 95% CI: 1.09-6.86),
Fontan failure (OR 2.59, 95% CI: 1.24-5.40), and longer length
of stay (mean difference þ1.2 days, 95% CI: 0.1-2.4).42
A prospective double-center cohort study (n ¼ 71) involving
children less than 5 years of age who required surgery for CHD
showed an association between preoperative total body fat
mass and markers of acute and chronic indices of malnutrition
and postoperative clinical outcomes.43 After adjusting for age,
gender, and severity of heart disease, investigators found that
low triceps skinfold Z score (TSFZ) was significantly associ-
ated with longer pediatric intensive care unit (PICU) length
of stay (LOS), duration of mechanical ventilation, and dopa-
mine and milrinone infusion hours. These investigators also
demonstrated a relationship between TSFZ and preoperative
plasma pro-brain natriuretic peptide (BNP) levels (indicator
of myocardial function) as well as postoperative duration of
inotropic infusion. The same study showed that a higher albu-
min level was associated with decreased BNP.43 Larsen et al
found that patients who had a ‘‘low-caloric intake (below
mean for the group)’’ had longer duration of mechanical ven-
tilation, duration of parenteral nutrition (PN) use, and PICU
LOS.44 Both acute and chronic protein energy malnutrition
states were prevalent (51.2% and 40.5%, respectively) in
patients undergoing cardiac surgery and associated with lon-
ger hospital LOS.45
A case–control study involving children (n ¼ 74) who have
undergone open heart surgery showed that patients who died
had progressively decreasing median weight-for-age Z score
from birth, operation, and last recorded weight (0.12, 1.31,
and 2.09, respectively) in comparison with the control
Wong et al
Table 3. Barriers and Strategies to Optimize Nutrition.
Barriers to Optimal Nutrition
Inadequate intake:
 Feeding difficulties
 Poor suck swallow coordination
 Vocal cord dysmotility
 Feed refusal
 Early satiety
Inability to absorb nutrients:
 Gastroesophageal reflux disease (GERD)
 Feed intolerance
 Gut edema
Inpatient/perioperative factors:
 Fluid restriction
Frequent feed interruptions:
 Hemodynamic instability
 High lactate levels
 High ventilator requirements
 Hyperglycemia
 Concerns of necrotizing enterocolitis/bowel ischemia
 Radiological procedures
 Surgical procedures (including chest tube insertion/
removal, cardiac catheterization, etc)
 Intubation and extubation
Energy estimation:
 Over- or underestimation of energy expenditure
Special conditions
 Chylothorax
 Acute kidney injury/oliguria
group.46 Those who had a drop in weight-for-age Z score >0.67
had increased odds of dying (OR 13.5, 95% CI: 3.6-51).
In summary, poor anthropometry in children with CHD is
associated with increased morbidity (eg, frequent hospitaliza-
tions, poor surgical outcomes, and persistent growth retardation)
and mortality. Because of this association, it is important for
clinical care providers to innovate techniques to improve pre-
and perioperative nutrition delivery. In the following section,
we will discuss the barriers to nutrition in patients with CHD and
propose some methods to overcome them.
Barriers to Optimal Nutrition in Children With Congenital
Heart Disease
When admitted for surgery, children with CHD are at risk of
further nutritional depletion (Table 3).47-50 A retrospective
study (n ¼ 47) examining postoperative nutrition found declin-
ing median weight-for-age Z score between admission for stage
1 palliation (1.14, range: 2.3 to 0.6) and hospital discharge
(1.81, 4.9 to 0.5). Enteral nutrition (EN) was started on
median postoperative day 4 (range: 1-12), and caloric intake
took more than two weeks to reach a target of 110 to 120
kcal/kg/d.48 Other studies conducted in children with different
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447
Strategies to Optimize Nutrition
Facilitate enteral feeding:
 Nasogastric, small bowel, gastrostomy feeding
 Continuous feeds
 High-calorie feeds
 Enteral feeding protocol
 Supplementation with parenteral nutrition
 Referral to feeding specialist
 Treat GERD (may involve medical therapy, continuous feeding, small
bowel feeding or gastrostomy with fundoplication)
 Treat congestive cardiac failure
 High-calorie feeds
 Supplementation with parenteral nutrition
 Enteral feeding protocol to minimize feed interruptions
 Regular and accurate nutritional assessments including use of indirect
calorimetry when indicated
 Individualized nutrition prescription
 Treat the underlying condition
types of CHD over the perioperative period have also demon-
strated similar slow rate of establishment of optimal nutrient
delivery.47,51
Fluid restriction is the single most important barrier in post-
cardiac surgery nutrition.52,53 After cardiac surgery, fluid restric-
tion is common to avoid fluid retention and its associated
morbidities. Fluid administration is regulated meticulously so
that total fluid intake does not exceed a specific volume over a
24-hour period.49 This leaves very little room for nutritive solu-
tions.54 The PN offers some benefit in this regard as it is capable
of providing a concentrated form of nutrition.49 However, it
lacks other benefits of EN such as promotion of gut integrity,
motility, and immune function. Some clinicians have therefore
initiated trophic feeding while supplementing nutrition with
PN until target calories can be achieved via the enteral route.55,56
Feed interruption is another important barrier to optimal
nutrition. A retrospective chart review of 100 neonates under-
going cardiac surgery with CPB demonstrated that enteral
feeds were interrupted temporarily 21.1% of the time for pro-
cedures (eg, cardiac catheterization, magnetic resonance ima-
ging of the brain, and placement of gastrostomy tube).57 In
addition, feeding difficulties including feed refusal and paren-
tal distress due to feeding pose significant challenges.58-62
448
One important postoperative complication that results in
profound difficulty in providing nutrition support is chy-
lothorax. Chylothorax is an uncommon complication of car-
diac surgery with a reported incidence of 1% to 9% of
cardiac surgeries.63-65 It often leads to severe and prolonged
protein, fat, and fat-soluble vitamin deficits. The management
of chylothorax after cardiac surgery may include a diet low in
long-chain triglycerides and enriched with medium-chain tri-
glycerides or total parenteral nutrition to allow gut rest.65 Pro-
teins including immunoglobulins, electrolytes, and fat-soluble
vitamins also need replacement. We refer the reader to other
reports on chylothorax for a more in-depth discussion.65,66
Strategies to Optimize Nutrient Intake in Children With
Congenital Heart Disease
Individualized nutrition prescriptions. Metabolic profiles of chil-
dren with CHD evolve throughout the postoperative period.
Predictive equations had been demonstrated to be inaccurate
in estimating energy requirements.1,18,27 Where possible, IC
should be used to assess individual energy requirements, and
the frequency of assessments needs to depend on the course of
the acute phase response. Indirect calorimetry, however, has
limitations due to equipment availability, staffing, and cost.67
The accuracy of measurements is also affected by low tidal
volumes, low oxygen consumption, and high fraction of
inspired oxygen.68
Optimizing nutrition support in these children encompasses
meeting not only energy needs but also macro- and micronutri-
ent needs. Providing sufficient energy without sufficient pro-
tein may result in overall muscle breakdown and decreased
lean body mass. Recommendations for protein intake range
from 1.5 to 2.5 g/kg/d in infants and 0.8 to 1.5 g/kg/d in older
children.69,70 In the immediate postoperative period, recom-
mended protein requirements are generally 2 to 3 g/kg/d for
children between 0 and 2 years, 1.5 to 2 g/kg/d for children
between 2 and 13 years, and 1.5g/kg/d for children between
13 and 18 years.71 However, specific studies on protein
requirement in children with CHD, using either nitrogen bal-
ance studies or stable isotope methodology, are lacking.72 Lit-
tle is also known about micronutrient requirements in children
with CHD.
Parenteral nutrition. Most children undergoing open heart sur-
gery are initiated on enteral feeds within 3 to 4 days.47,48,51,73
Some patients with feeding difficulties require a prolonged
period of time to reach full enteral feeds.73 The PN can be used
to supplement the enteral route until sufficient calories can be
achieved by feeding. Good use of PN according to internation-
ally accepted guidelines allows the provision of concentrated
nutrition to accommodate fluid restrictive policies.74,75
Nevertheless, PN has been associated with increased risk of
infection.10 Because of this risk, most centers will stop PN once
enteral feeds reach 90 to 100 mL/kg/d. However, given the fre-
quency of feed interruptions, some investigators propose the
use of intravenous lipids in addition to enteral feeds until these
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World Journal for Pediatric and Congenital Heart Surgery 6(3)
patients consistently receive at least 100 kcal/kg/d.57 Intrave-
nous lipid can be administered without central access.57 At the
moment, there is insufficient evidence to support the use of
intravenous lipid supplementation as routine practice, however,
it can be considered on a case-by-case basis. Because of the
ability to attenuate the inflammatory response from CPB, some
investigators have proposed supplementing with lipid emul-
sions containing eicosapentaenoic and docosahexaenoic acid
during the pre- and postoperative period.76,77 These studies
show improvement in surrogate markers of the inflammatory
response (eg, tumor necrosis factor-alpha, leukotriene B4, pro-
calcitonin, and lymphocyte count).
Nasogastric, small bowel, and gastrostomy feeding. After cardiac
surgery, children are at significant risk of aspiration and pul-
monary injury due to vocal cord dysfunction, gastroesophageal
reflux (GER), and dysphagia. Surgical injury to the recurrent
laryngeal nerve, associated neurodevelopmental delay, and
suck–swallow–breathe incoordination are potential causes.
Another significant risk factor is prolonged postoperative intu-
bation (>7 days). Prolonged intubation is associated with the
risk of dysphagia and directly increases the risk of not achiev-
ing oral feeding by time of discharge by 10% per day for each
day of intubation.73,78 As a result, many infants depend on tube
feeding to achieve nutritional needs during hospital stay and
some even after hospital discharge.61,73,79
Transpyloric feeding allows a larger volume of feeds to be
delivered in critically ill children and may be safer in the peri-
extubation period. It does not, however, prevent aspiration of
gastric fluids. In a retrospective study involving 17 patients
with CHD, a duodenal tube facilitated enteral feeding and
resulted in improvement in weight gain and reduced clinical
symptoms of persistent emesis or respiratory wheezing after
feeding.80
Another strategy to optimize caloric intake may be early
placement of gastrostomy feeding tubes, especially in infants
who are exclusively fed via a nasogastric tube.57 This route
is particularly useful in patients with evidence of GER. Percu-
taneous endoscopic gastrostomy can be performed under deep
sedation and allows EN support without the disadvantages
related to long-term nasogastric tube feeding.81 Complications
are uncommon, and the tube can be removed when enteral sup-
port is no longer necessary.
High-calorie enteral and continuous feeds. High-caloric feeds refer
to concentrated formula feeds or feeds with additives (eg, glu-
cose polymers) that increase caloric content. High-calorie feeds
have been reported in this population in two studies. The first
involved 14 infants with CHD and failure to thrive who were
given high-energy feeds by addition of glucose polymers to
achieve an energy density of 125% standard formula.82 They
measured physiological variables and conducted bomb calori-
metry to determine energy content of vomit, urine, and stools.
This study showed that the mean gross energy intakes increased
by 31.7% on high-energy feeding, with mean weight gain
improving from 1.3 to 5.8 g/kg/d. There was no difference in
Wong et al
Figure 1. Proposed preoperative nutrition algorithm.
physiological variables and energy losses from vomit, urine,
and stools, showing good tolerability. It was recommended that
infants with CHD and failure to thrive should be fed on high-
energy diets from the time of diagnosis to optimize growth.
Of note, there was reduced gastric emptying in one small study
involving seven patients who received feeds supplemented
with glucose polymers. However, the net transfer of energy
to the intestine was larger after the supplemented feed than the
standard feed.83
In another cohort of 46 infants, investigators used standard
formula on day 1 postoperation (0.67 kcal/mL), 1.18 times con-
centration (0.79 kcal/mL) on day 2, 1.36 times concentration
(0.9 kcal/mL) from day 3 onward, and 1.5 times concentration
(1 kcal/mL) from discharge.84 They found that with this
regime, patients received higher energy intake (median per-
centage of the estimated energy requirement before discharge
was 98% vs 78% in control group), had greater median weight
gain (þ20 g/d vs 35 g/d), and were discharged from the hos-
pital earlier. A similar study of 21 infants receiving standard
density formula and high-density formula showed higher
energy and protein intake per body weight, weight gain, and
serum albumin in the latter group without an increase in
adverse effects.85
Continuous feeding is another option to improve nutrient
delivery.86 A study of 11 infants with CHD who were not gain-
ing weight adequately despite the use of hypercaloric formulas
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449
and nutritional supplementation were given continuous enteral
feeds, and this approach improved mean daily caloric intake
and weight gain.87 A randomized controlled trial of 19 infants
showed that continuous feeds were effective in improving
nutritional status as measured by weight-for-age Z scores and
length. The patients were randomly assigned to one of the fol-
lowing three feeding groups: group 1 (n ¼ 7) received continu-
ous 24-hour nasogastric alimentation, group 2 (n ¼ 5) received
overnight 12-hour nasogastric infusions plus daytime oral feed-
ings as tolerated, and group 3 (n ¼ 7) received oral feedings
alone.88 The trial period lasted over five months, and the group
on continuous nasogastric alimentation showed marked
increases in mid-arm muscle circumference and triceps and sub-
scapular skinfold thicknesses compared to the other two groups.
Enteral feeding protocols. Even with accurate energy estimation,
delivering nutrition to critically ill children can be challen-
ging.89-91 It was found that only 38% of the nutrition prescrip-
tion is received by the patient.89 Reasons for this include the
frequent interruptions of enteral feeds as discussed earlier.
Implementation and adherence to a feeding protocol have
demonstrated to improve the amount of prescribed nutrition
that is actually received.
Investigators have shown that feeding protocols improve
nutrition delivery.10,56,92-94 A systematic review that included
nine studies (two of which involved a cohort of neonates with
450
Figure 2. Proposed perioperative nutrition algorithm.
hypoplastic left heart syndrome) showed that feeding protocols
improve time to initiation of feeds, decrease time to achieving
goal feeds, reduce gastrointestinal and infective complications,
and improve safety.95 In the two studies that involved postopera-
tive patients with hypoplastic left heart syndrome, the feeding
protocol group had more rapid advancement of feeds with no
significant increased incidence of necrotizing enterocolitis.96,97
We propose a nutrition algorithm for children with CHD to
optimize their nutrition in the perioperative period (Figures 1
and 2). These are crucial periods where improvements in nutri-
tion status will likely impact surgical outcomes. In general, the
preoperative goal should be to improve existing nutritional sta-
tus (eg, weight for age Z scores) and to maintain this score dur-
ing the postoperative period.
Nutrition-Based Biomarkers in Children With CHD
It is important to appreciate that even a simple nutrition assess-
ment in children with CHD can be challenging. Although daily
weight estimation is routine in most centers, its value is limited,
given significant fluid shifts and diuretic use in these patients.58
Triceps skinfold thickness and mid-arm circumference have
been used to estimate fat stores and lean body muscle mass,
respectively, but again, these measurements are affected by
edema.72 Biochemical markers, therefore, seem appealing, and
Downloaded from pch.sagepub.com at University of Otago Library on July 21, 2015
World Journal for Pediatric and Congenital Heart Surgery 6(3)
their use as surrogate markers of nutritional status have been
studied—including serum albumin, prealbumin, transferrin,
transerythrin, retinol-binding protein, and C-reactive protein.
In the population with CHD, albumin is the most widely
studied biomarker.98 Leite et al (n ¼ 30) prospectively studied
children with CHD admitted after cardiac surgery and found
that preoperative albumin of less than 3 g/dL was associated
with increased postoperative infections (P ¼ .0026) and mor-
tality (P ¼ .0138).99 Patients with postoperative (postoperative
day 2) albumin of less than 3 g/dL had longer hospital stay
compared to those greater than or equal to 3 g/dL (median
14.5 vs 10 days, P < .05). Another study showed that a higher
albumin (and prealbumin) level was associated with a decrease
in BNP and a trend toward lower inotrope duration.43
Limitations
The published literature on energy metabolism in CHD
involves small numbers of patients as well as nonstandardized
measurement methods and timing of measurements. These lim-
itations make comparisons and statistical pooling difficult.35
The pathophysiology of CHD is also diverse, and there are
many physiological changes that occur from the age of infancy
through childhood and play a major role in energy metabolism.
These factors are potential confounders in current studies. On
Wong et al
the other hand, data from a solitary group of CHD at a partic-
ular age bracket may not be generalizable to other children with
other types of CHD.
Future Directions
Because of the inherent differences across the spectrum of
children with CHD, the feasibility of using individual nutrition
prescriptions based on IC measurements should be explored
and investigated. The need for accurate provision of nutrition
is further strengthened by the demonstration of possible detri-
mental effects of over- and underfeeding.100,101 An algorithm
for safe initiation and optimization of enteral feeds in this group
of children is proposed, but this will likely need further modi-
fication, taking into account local practices and resources.
Conclusion
Children with CHD are generally at risk of malnutrition, and
this is exacerbated by further nutritional depletion during the
frequent hospital admissions. Poor anthropometry is associated
with increased morbidity and mortality. Energy metabolism is
affected by age, cardiac diagnoses, preoperative nutritional sta-
tus, the surgery itself (surgical techniques, anesthesia manage-
ment and CPB strategies), and postoperative care. Nutrition
algorithms can potentially optimize nutrition in these children
during the perioperative period.
Authors’ Note
Judith JM Wong, Ira M Cheifetz, Chengsi Ong, Masakazu Nakao, and
Jan Hau Lee designed the structure of this review article, critically
reviewed the manuscript, and approved the final manuscript as
submitted.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
Supplemental Material
The online [appendices/data supplements/etc] are available at
http://pch.sagepub.com/supplemental’’
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