Improved Nutrition Delivery and

Nutrition Status in Critically Ill Children

With Heart Disease
Jon Kaufman, MDa,b, Piyagarnt Vichayavilas, MS, RD, CNSCa,c, Michael Rannie, RN, MSd, Christine Peyton, MS, CPNP-AC,
CCRNa,e, Esther Carpenter, BSN, CCRNa,e, Danielle Hull, MSc, Jennifer Alpern, BSN, RNa,e, Cindy Barrett, MD, MPHa,b,
Eduardo M. da Cruz, MDa,b, Genie Roosevelt, MD, MPHf

BACKGROUND: This initiative sought to improve nutrition delivery in critically ill abstract
children with heart disease admitted to the cardiac ICU (CICU) and neonates
undergoing stage 1 palliation (S1P) for single-ventricle physiology through
interdisciplinary team interventions. Specific goals were increased caloric and
protein delivery for all patients and a more nourished state for infants with
single ventricles at the time of discharge.
METHODS: We developed a nutrition flow sheet in the electronic health record to a
The Heart Institute at Children’s Hospital Colorado,
track whether daily nutrition goals were met. Interventions included nurses b
Department of Pediatrics, cClinical Nutrition at Children’s
reporting daily whether caloric and protein goals were met, mandatory Hospital Colorado, and dClinical Informatics at Children’s
Hospital Colorado, Aurora, Colorado; eSchool of Nursing,
involvement of feeding specialists, and introduction of an enteral nutrition University of Colorado Anschutz Medical Campus, Aurora,
guideline. For infants undergoing S1P, weight-for-age z score (as an indicator Colorado; and fDepartment of Emergency Medicine, Denver
Health Hospital Authority, Denver, Colorado
for assessing malnutrition) was calculated at admission and discharge.
Dr Kaufman, Ms Vichayavilas, and Mr Rannie
RESULTS:
The percentage of patient days per month when daily caloric goals conceptualized and designed the study, performed
were met increased from 50.1% to 60.7%, and protein goals met increased data analysis, and drafted the initial manuscript;
from 51.6% to 72.7%. Hospital length of stay, need for ventilation, and Ms Peyton, Ms Carpenter, Ms Hull and Ms Alpern
designed the study and assisted in data collection;
mortality did not differ. Patients undergoing S1P demonstrated a statistically
Dr Barrett and Dr da Cruz conceptualized and
significant improvement in weight-for-age z score compared with the designed the study and reviewed and revised the
preintervention group (P = .003). Thirteen S1P patients were discharged manuscript; Dr Roosevelt performed data and
undernourished in the preintervention group; 5 were severely statistical analysis and critically reviewed the
manuscript; and all authors approved the final
undernourished. In the intervention group, 4 patients were discharged manuscript as submitted.
undernourished, and none were severely undernourished.
www.pediatrics.org/cgi/doi/10.1542/peds.2014-1835
CONCLUSIONS:This initiative resulted in improved nutrition delivery for DOI: 10.1542/peds.2014-1835
a heterogeneous population of cardiac patients in the CICU as well as
Accepted for publication Oct 28, 2014
significant improvements in weight gain and nourishment status at discharge
Address correspondence to Jon Kaufman, MD,
in infants undergoing S1P. The Heart Institute and Department of Pediatrics,
Children’s Hospital Colorado, 13123 E. 16th Ave,
B100, Aurora, CO 80045. E-mail: jonathan.kaufman@
Outcomes for children with congenital recent Single Ventricle Reconstruction childrenscolorado.org
and acquired heart disease who Trial.5 For this population of infants in PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online,
undergo surgical correction or particular, significant postoperative 1098-4275).
palliation have improved dramatically complications and morbidity persist, Copyright © 2015 by the American Academy of
over the past 2 decades.1 Mortality and length of stay and cost of Pediatrics
rates for even the most complicated hospitalization are problematic.4,6 FINANCIAL DISCLOSURE: The authors have indicated
lesions have been reduced they have no financial relationships relevant to this
significantly.1–4 In particular, 30-day Morbidity prolongs hospitalization, article to disclose.
and hospital mortality for infants taxes institutional and financial FUNDING: No external funding.
undergoing stage 1 palliation (S1P), or resources, stretches family support,
POTENTIAL CONFLICT OF INTEREST: The authors have
the Norwood procedure, were 11.5% and places the child at risk for death. indicated they have no potential conflicts of interest
and 16%, respectively, according to the Malnutrition and poor nutrition are to disclose.

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PEDIATRICS Volume 135, number 3, March 2015 QUALITY REPORT
common complications in infants
with congenital and acquired heart
disease. Poor caloric and protein
delivery and inability or loss of ability
to orally feed and breastfeed may
contribute to neurodevelopmental
and neurocognitive delays as well as
to parental frustration, anxiety, and
disappointment.7–10 Lower than
growth velocity than that expected
for age and gender is prevalent in
infants and children with congenital
heart disease and may be due to
inadequate nutrition delivery.11–15 In
infants with single-ventricle
physiology, providing adequate
nutrition can be particularly
difficult.8,10 For infants undergoing
staged palliation, the interstage
period (after S1P and before the
Glenn procedure) can be particularly
challenging and is a time of increased
risk of mortality.16,17 Poor growth
patterns can negatively affect both
short- and longer-term outcomes,
including infection rates, length of
stay, and neurodevelopmental and
neurocognitive performance.18,19
Improvements in nutrition delivery,
consistent weight gain, and adequate
growth should be the expectation for
patients of all congenital heart
centers.
In 2011, the Children’s Hospital
Colorado’s Heart Institute identified
nutrition and feeding as areas for
practice improvement for all patients
with congenital and acquired heart
disease. A multistep quality
improvement project was initiated
that examined nutrition on
a macrosystem level as well as in
infants with single-ventricle
physiology. The first objective of this
study was to evaluate interventions
designed to improve caloric and
protein delivery for all patients
admitted to the cardiac ICU (CICU).
Second, a CICU subset population of
infants with single-ventricle
physiology was studied to evaluate
the impact of interventions on weight
gain and nourishment status at
discharge. The specific aims of this
quality improvement project were to
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e2
improve daily calorie and protein
delivery to all patients in the CICU, as
well as to improve the nourishment of
infants with single ventricles upon
discharge after undergoing S1P.
METHODS
Setting
Children’s Hospital Colorado is a free-
standing, 414-bed, children’s hospital
and a referral center for the Rocky
Mountain region. The Heart
Institute’s CICU admits ∼650 children
per year, and the Cardiovascular
Surgery Program performs ∼500
cardiac procedures per year. An
interdisciplinary team of nurses,
physicians, occupational and speech
therapists, and a dietitian was formed
in February 2011 to improve
nutrition delivery for all patients
admitted to the CICU and for infants
with single-ventricle physiology. The
primary outcome variables for the
CICU patients were percentage of
patient days in a month when daily
caloric and protein goals were met.
The primary outcome variable for the
single-ventricle infants was their
weight-for-age z scores (WAZ) at
discharge. WAZ is a World Health
Organization standard for assessing
malnutrition in children.20 We chose
to include 2 patient populations in
our study with different outcome
measures to better evaluate how the
same interventions would affect
different populations of critically ill
children with heart disease.
Interventions
The team developed a nutrition flow
sheet in the electronic health record
so the dietitian and informatics staff
could accurately track whether
nutrition goals were met each day
(Fig 1). The interdisciplinary team
then introduced a series of
interventions. First, Nurse Integrated
Rounds were instituted, which
involved the bedside nurse actively
participating in systems-structured
patient rounds. Several months later,
night-shift nurses began calculating
their patients’ 24-hour caloric
delivery, which was reported to the
day shift nurses for Nurse Integrated
Rounds. Next, every admitted patient
was screened by a feeding and/or
speech therapist to determine at-risk
characteristics for oral feeding failure.
An enteral nutrition guideline for
neonates and infants was also
implemented to promote safe,
standardized enteral nutrition
advancement (Fig 2). Finally, the
nutrition data were regularly
reviewed with the interdisciplinary
team, and feedback was provided to
the clinical staff monthly.
Outcome Measures
To evaluate the interventions, the
investigators queried the electronic
health record to identify all patients
receiving nutrition support, defined
as patients receiving enteral or
parenteral nutrition or both, in the
CICU during the study period.
Baseline data (the preintervention
phase) was collected over 8 months
from April 2011 to November 2011.
The intervention phase was from
December 2011 to July 2013 (20
months). Data included demographic
and clinical characteristics including
the presence of genetic abnormalities
defined as trisomy 21, 22q11, and
other microdeletions and
translocations abnormalities, surgical
versus medical admission and the
Risk Adjustment for Congenital Heart
Surgery (RACHS-1) score when
applicable. The RACHS-1 is
a procedure-driven complexity
categorization used by the Society of
Thoracic Surgeons to adjust for
baseline case-mix differences when
comparing discharge mortality
between groups of patients
undergoing pediatric congenital heart
surgery.21 Also collected was whether
daily protein and calorie goals were
met for each patient and, if goals were
not met, the percentage of goal
calories that was in fact delivered.
The following days were excluded:
days of admission and discharge, days
of cardiac surgery, days when
KAUFMAN et al
FIGURE 1
Electronic health record nutrition flow sheet.
neonates received only starter/stock
total parenteral nutrition (TPN;
composed of 10% dextrose, 3%
TrophAmine, and no electrolytes),
days when only trophic feeds were
delivered, and days when nutrition
support was not started. In the
preintervention phase, 22.5% of days
were excluded; in the intervention
phase, 28.3% days were excluded.
Examples of why nutrition support
was not started were volume
limitations, limited access, and
medication incompatibility. Starter/
stock TPN is typically only
administered within the first 24 hours
of a neonate’s life. Days with feeding
interruptions were included. Reasons
for interruptions in feedings are many
and varied and include clinical
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PEDIATRICS Volume 135, number 3, March 2015
indications such as emesis, abdominal
distention and fussiness, as well as
interruptions for procedures and
studies, and, rarely, staffing and supply
issues. As a part of the nutrition
assessment, the dietitian entered the
caloric and protein goals daily and
concluded whether those daily goals
were met in the nutrition flow sheet.
Goal calories for full-term intubated
infants were estimated to be 80
kcal/kg. This was calculated energy
expenditure with an additional 30%
to 40% for growth.20 For
nonventilated full-term infants, their
caloric goal ranges between 100 and
130 kcal/kg, with frequent
adjustments pending weight gain
velocity. Estimated energy
requirements are set higher for our
patients due to catch-up
requirements and high energy
expenditure. Patients who were
feeding on demand were not
included. We collected the following
variables on the CICU patients: the
proportion of patients who required
ventilation .24 hours, hospital
length of stay, proportion of patients
receiving TPN, the number of days of
TPN was received, incidence of
necrotizing enterocolitis (NEC)
requiring surgical exploration or
intervention, rates of central-line-
associated bloodstream infections,
and mortality.
Neonates with diagnoses of single
ventricles and who underwent S1P
were identified by the Heart
Institute’s database of all
e3
FIGURE 2
Children’s Hospital Colorado Heart Institute Enteral Nutrition Guideline. CRP, C-reactive protein; cx, culture; GI, gastrointestinal; inc, increasing; NIRS, near-infrared
spectroscopy; NPO, non per os; PCT, procalcitonin; PGE-1, prostaglandin E1; PO, per os; pt, patient; q, every; RD, registered dietitian; WBC, white blood cell count.

cardiothoracic surgical cases (Cardio
Access Inc, Fort Lauderdale, FL). All
neonates with single ventricle were
admitted to the CICU. Exclusion
criteria, for this subset, were
gestational age ,35 weeks and/or
genetic abnormalities or syndromes.
This cohort included a variety of
anatomic diagnoses; the majority had
a hypoplastic left ventricle and
a morphologically right systemic
ventricle. Three subjects of the 52
had hypoplastic right ventricles. The
preintervention group included
infants who underwent the Norwood
procedure from February 2009 to
November 2011 (34 months). The
intervention group included those

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e4 KAUFMAN et al
TABLE 1 All CICU Patients: Demographic and Clinical Characteristics discharged as malnourished: WAZ
Patient Characteristic Preintervention Period Intervention Period scores under –2 were categorized as
(8 mo), n = 106 (20 mo), n = 260 undernourished and less than –3 to
Admission median age, mo (IQR) 1.6 (0.03–6.4) 1.4 (0.03–6.9) be severely undernourished.22 This
Male gender, n (%) (95% CI) 66 (62) (53–71) 158 (61) (55–67) study was approved by the Children’s
Admission median wt, kg (IQR) 3.6 (3.0–6.0) 3.9 (3.0–6.4) Hospital Colorado Organizational
Genetic abnormalities,a n (%) (95% CI) 13 (12) (7–20) 50 (19) (15–24) Research Risk & Quality
Surgical admission, (%) (95% CI) 75 (71) (61–79) 189 (73) (67–78)
RACHS-1b Score 1–2 (95% CI) 16 (29) (19–42) 54 (34) (27–42)
Improvement Review Panel as
RACHS-1b Score 3 (95% CI) 18 (33) (22–46) 43 (27) (21–35) a quality improvement project.
RACHS-1b Score 4 (95% CI) 8 (14) (7–26) 29 (19) (13–25)
RACHS-1b Score 5-6 (95% CI) 13 (24) (14–36) 31 (20) (14–27)
RESULTS
A patient may be included in .1 group (eg, included in both preintervention and intervention periods). IQR, interquartile
range. Demographic, clinical characteristics,
a Included trisomy 21, 22q11, and other microdeletions and translocations abnormalities.
and outcomes for patients admitted
b Not all surgical procedures are assigned a RACHS score.
to the CICU during the preintervention
and intervention study periods are
who underwent the Norwood were performed with SPSS 22 (IBM presented in Tables 1 and 2. Age,
procedure from December 2011 to SPSS, Armonk, NY). The percentage of gender, admission weight, genetic
July 2013 (20 months). The patient days in a month when daily abnormalities, ventilation .24 hours,
preintervention group time frame caloric and protein goals were met length of hospital stay, TPN use,
was extended to ensure a similar was plotted on statistical process incidence of NEC, rates of central-line-
number of patients for comparison control (SPC) p charts. Three s limits associated bloodstream infections, and
with the intervention group. were used to set the upper and lower mortality were similar between the
For infants with single ventricle aged control limits. The SPC p charts were 2 groups. Three infants developed
,7 days, admit weight was the created using QI Charts Version NEC requiring surgical exploration
mean weight averaged over 6 days 2.0.22 (Scoville Associates, TX). and intervention. Two had never been
or until surgery to account for Because caloric delivery was analyzed enterally fed and were TPN
newborn fluid fluctuations. Infants as a dichotomous variable (ie, met vs dependent; the third was on oral feeds
typically undergo S1P between 3 and not met), the percentage of calories ad libitum. No infants on the enteral
6 days of life. Discharge weight was delivered on days when caloric goals feeding algorithm developed NEC.
the weight on day of discharge from were not met was also calculated. The percentage of patient days in
hospital or day before discharge For the infants undergoing S1P, the a month when daily caloric goals
when the former was not available. In World Health Organization 2006 were met increased from 50.1% to
the preintervention group, 3 infants Child Growth Standards were used.20 60.7% from the pre- intervention to
who died after undergoing S1P before Differences in the single-ventricle intervention period. The percentage
discharge were not included in physiology patients’ weights and WAZ of patient days when daily protein
analysis because there was no scores between preintervention and goals were met increased from
discharge weight. Also, 2 subjects in intervention periods were analyzed 51.6% to 72.7% from similar periods
the preintervention group were with an independent t test as they (Figs 3 and 4). After plotting the
excluded because of genetic were normally distributed. We pre-intervention monthly
abnormalities. The intervention reported the number of children percentages, standard SPC charting
group did not have any deaths or
genetic abnormality exclusions.
TABLE 2 All CICU Patients: Outcome Variables
Analytic Approach Patient Characteristic Preintervention Period Intervention Period
(8 mo), n = 106 (20 mo), n = 260
Continuous variables, except for the
Required ventilation .24 h, n (%) (95% CI) 91 (86) (78–91) 210 (81) (76–85)
single-ventricle admit weight,
Median LOS, d (IQR) 15.5 (9–30) 19 (10–34)
discharge weight, and WAZ scores, Received TPN, n (%) (95% CI) 66 (62) (53–71) 183 (70) (65–76)
and are reported as median and Median days of TPN use, n (IQR) 4 (2–7) 5 (2–10)
interquartile range given their Incidence of NEC,a n (%) (95% CI) 1 (1) (0–6) 2 (2) (0–3)
nonnormal distributions. Categorical Rate of CL-associated bloodstream 1.29 (0–3.1) 0.72 (0–1.5)
infection/1000 CL days (95% CI)
variables are reported as proportions
Mortality, n (%) (95% CI) 7 (7) (3–13) 15 (6) (4–9)
with 95% confidence intervals (CIs).
A patient may be included in .1 group (eg, included in both preintervention and intervention periods). CL, central line;
Relative risk and 95% CIs were IQR, interquartile range; LOS, hospital length of stay.
calculated. All statistical analyses a Requiring surgical exploration or intervention.

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PEDIATRICS Volume 135, number 3, March 2015 e5
FIGURE 3
SPC p chart: percentage of patient days in a month when daily caloric goals were met in the CICU.

rules for determining special cause
were used as evidence of
improvement.23 For the caloric goal
p chart, 2 of 3 consecutive points were
observed close to the upper control
limit; this was later followed by a run
of .8 consecutive points above the
preintervention mean. For the protein
goal p chart, there was a run of greater
than 8 consecutive points above the
preintervention mean. Updated mean
and control limits were plotted for the
intervention period in the SPC charts
after special cause was detected. The
percentage of calories delivered on
patient days when daily caloric goals
in a month were not met increased
from 60.6% to 76.4% from the

FIGURE 4
SPC p chart: percentage of patient days in a month when daily protein goals were met in the CICU.

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e6 KAUFMAN et al
FIGURE 5
Percentage of calories delivered on days when caloric goal was not met.
preintervention to intervention period
(Fig 5).
Demographic and clinical
characteristics for infants with single-
ventricle physiology who underwent
S1P during the preintervention and
intervention study periods are
presented in Table 3. Infants in both
groups experienced nonstatistically
significant absolute weight gain;
however, infants in the intervention
phase were significantly more
nourished at discharge than those in
the preintervention phase when their
weights were standardized for age
(eg, WAZ scores; P = .007). Infants in
the intervention phase group also had
a smaller difference in WAZ from
admit to discharge indicating
a greater standardized for age weight
gain when compared with the
preintervention group (P = .003;
TABLE 3 Single Ventricle Patients: Demographic and Clinical Characteristics
Patient Characteristic
Median age at surgery, d (IQR)
Male gender (%) (95% CI)
Median LOS, d (IQR)
IQR, interquartile range; LOS, hospital length of stay.
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PEDIATRICS Volume 135, number 3, March 2015
Table 4). Infants in the intervention
period were 1.6 times (95% CI:
1.1–2.3) more likely to be discharged
nourished than in the preintervention
period. Fewer subjects undergoing
S1P in the intervention group were
discharged undernourished, and none
in the intervention group were
discharged severely undernourished
(WAZ , –3; Table 5). No infants with
single-ventricle physiology developed
NEC during the study period.
DISCUSSION
This quality improvement initiative
successfully improved the daily
caloric and protein intake in
a heterogeneous population of
critically ill children. After initiation,
61% of all CICU inpatients met their
daily caloric goals, up from 50%.
Preintervention Period Intervention Period
(34 mo) n = 28 (20 mo) n = 28
4 (3–5) 5 (3–7)
18 (64) (46–79) 20 (71) (53–85)
31 (23–39.75) 30.5 (21.25–44)
Those who met daily protein goals
improved to 73%, up from 52%. This
project also improved nutrition as
measured by nourishment status for
infants in a specialized cohort: those
undergoing stage 1 palliation for
single-ventricle physiology. More of
these infants were discharged
nourished and less undernourished,
and they demonstrated an improved
weight gain during their
hospitalization.
In addition, close attention to these
data prompted investigation when
results were outside of control limits
to discern cases of special cause (eg,
in January 2013, a significant decline
in caloric goals met was linked to
lipid restrictions secondary to
a national shortage; Fig 3).
There were multiple interventions
initiated over a short time period, and
thus the practice change with the
greatest effect is difficult to identify.
Anecdotally, the authors believe that
the adoption of a feeding algorithm
and bedside CICU nurses reporting on
nutrition status during daily rounds
were the 2 most effective
interventions.8,10,24 These
e7
TABLE 4 Single-Ventricle Infants’ Admission and Discharge Weight and Admission and Discharge
WAZ Scores
Preintervention Period Intervention Period
(n = 28)
Mean admission wt, kg 3.16
Mean discharge, wt, kg 3.49
Mean difference from 0.341
discharge to admit wt
Mean admit WAZ 20.361
Mean discharge WAZ 21.805
Mean difference from 21.444
admit to discharge WAZ
interventions reduced variability in
feeding advancement, increased
visibility of the practice improvement
effort, and fostered nursing
ownership of nutrition practice.
The primary outcome variables of
percentage of patient days in a month
when daily caloric and protein goals
was met, was a dichotomous variable,
in contrast to analyzing the percentage
of daily caloric and protein goals
delivered. Therefore, the SPC charts
(Figs 3 and 4) do not distinguish
between a patient who met 20% of
the goal and a patient who met 80% of
the goal. Both values would be
reported as a “no,” that is, the patient’s
nutrition goal for that day was not
met. However, the authors were able
to increase the percentage of caloric
goal delivered to patients in whom
caloric goals were not met by 15%
during the intervention period. The
most significant and frequently
documented barrier to meeting
nutritional goals in the CICU was
feeding interruptions.
This initiative improved the delivery of
protein and calories, but there was no
significant difference in clinical
outcomes such as need for ventilation,
length of stay or mortality in the larger
CICU population, or length of stay in the
single-ventricle infants. These are
complex clinical outcomes of which
providing good nutrition is but 1
TABLE 5 Single-Ventricle Infants’ Nourishment Status at Discharge
Nourishment State at Discharge Mean WAZ
Nourished $ –2
Undernourished 22.01 to –3
Undernourished , –3
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e8
Difference in Means P for adverse events. Among these may
(n = 28) (95% CI)
3.27 0.11 (–0.14 to 0.36) .379
3.76 0.27 (–0.05 to 0.57) .104
0.486 0.145 (–0.06 to 0.350) .162
20.132 0.229 (–0.317 to 0.776) .404
21.031 0.774 (0.219 to 1.329) .007
20.899 0.545 (0.188 to 0.901) .003
contributor.7,8,10 For example,
Children’s Hospital Colorado’s Heart
Institute does not have a standardized
process for gastrostomy tube placement
for infants unable to meet their oral
intake goals. Approximately 40% of
infants with single-ventricle physiology
undergo gastrostomy tube placement;
and the variability in this practice is felt
to greatly affect length of stay.
In the single-ventricle population, we
observed an absolute decrease in
patients malnourished at the time
hospital discharge, after undergoing
S1P. Improved WAZ has been
associated with improved outcomes
in children with hypoplastic left heart
syndrome as they move through their
palliative course.18 Although infants
with single-ventricle physiology
represent a small subset of all
children with congenital heart
disease, they occupy
a disproportionate percentage of
a heart center’s clinical efforts and
financial resources.4,6 Their
outcomes, throughout their staged
palliations and beyond, are
considered markers of success for
congenital heart programs. Reduction
of postoperative morbidity and
complications in these patients
remains a formidable challenge.
Consistent delivery of nutritional
requirements may not be feasible for
children with congenital and acquired
Preintervention (n = 28) Intervention Period (n = 28)
15 24
8 4
5 0
heart disease. Efforts to sustain goal
calories may put these children at risk
be the development of NEC, a greater
reliance on central venous catheters to
delivery TPN, an increased risk of
infection with TPN use, hepatic
dysfunction, or prolongation of hospital
length of stay to ensure greater weight
gain before discharge. Processes should
be in place to ensure that attempts to
improve nutrition do not compromise
other aspects of patient care. During
the intervention period, our cohort did
not experience an increase in the
incidence of NEC, and there was
actually a reduction in catheter-
associated bloodstream infections.
There are a number of limitations to
this study. The results reflect a single
center’s experience. Success was
aided by a dedicated CICU dietitian
and nutrition assistant, as well as
clinical informatics support. These
positions may not be available at
other institutions. We recognize the
influence of the Hawthorne effect:
providers may have altered their
behavior as attention and visibility
were given to efforts to improve
nutrition. There were other practice
improvement initiatives in place
during the intervention period, such
as efforts to reduce hospital-acquired
infections. The positive results of our
study may have been influenced by
other coexistent quality improvement
initiatives. WAZ analysis was limited
to the single ventricles; results may
not be generalizable to infants with
other anatomic lesions. Finally, better
weight gain itself may not be
associated with improvements in
neurodevelopmental and
neurocognitive outcomes in infants
with single ventricles, as a recent
publication has demonstrated.19
CONCLUSIONS
This collaborative approach resulted in
improved caloric and protein delivery
to inpatient children with congenital
and acquired heart disease as well as
improved nourishment status in infants
KAUFMAN et al
undergoing S1P for single-ventricle
physiology. Improvements in these
areas would seem to offer
opportunities for program
improvement in congenital heart
centers where mortality rates are
already low.
ACKNOWLEDGMENTS
We acknowledge Sanja Batz, Emily
Bordier, Kaitlyn Goure, Angela Haas,
Shaunda Harendt, Debra Paul,
Jennifer Rogers, and Sharon Sables-
Baus for their contribution to the
quality improvement initiative as
feeding therapists and specialists. We
also acknowledge Samuel Schofield
for database support and the nurses
of the CICU for their support with the
entire initiative.
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Analysis of outcomes for congenital
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3. Wernovsky G, Kuijpers M, Van Rossem
MC, et al. Postoperative course in the
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Cassedy A, Schnell B, Cnota JF. Staged
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e9
Improved Nutrition Delivery and Nutrition Status in Critically Ill Children With
Heart Disease
Jon Kaufman, Piyagarnt Vichayavilas, Michael Rannie, Christine Peyton, Esther
Carpenter, Danielle Hull, Jennifer Alpern, Cindy Barrett, Eduardo M. da Cruz and
Genie Roosevelt
Pediatrics originally published online February 16, 2015;

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Services http://pediatrics.aappublications.org/content/early/2015/02/10/peds.2
014-1835
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Improved Nutrition Delivery and Nutrition Status in Critically Ill Children With
Heart Disease
Jon Kaufman, Piyagarnt Vichayavilas, Michael Rannie, Christine Peyton, Esther
Carpenter, Danielle Hull, Jennifer Alpern, Cindy Barrett, Eduardo M. da Cruz and
Genie Roosevelt
Pediatrics originally published online February 16, 2015;

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/early/2015/02/10/peds.2014-1835

Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. Pediatrics is owned, published, and trademarked by
the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,
60007. Copyright © 2015 by the American Academy of Pediatrics. All rights reserved. Print
ISSN: 1073-0397.

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