Nutritional Implications

in Infants with CDH

ERICA ABBARNO
 Review Review Congenital Diaphragmatic Hernia (CDH)

Understand the medical and nutritional interventions for

Understand infants with CDH

Objectives
Discuss Discuss a case study involving an infant with CDH

Analyze new research regarding feeding regimens to improve

Analyze growth velocity in CDH infants
Congenital Diaphragmatic Hernia 1
Defect in infant’s diaphragm

• Diaphragm does not close the correct way during infant’s development
• Organs herniate through into the chest cavity and can press on the lungs causing pulmonary hypoplasia
• Effect other organs including heart, liver, intestines, and nervous system development

Cause is unknown

• L+R
• Occurs in 2,200 live births
• Usually seen during routine prenatal ultrasound in the first or second trimester

Range from mild to severe

• Mild: Many can lead normal, active lives without long-term problems
• Severe: Long-term problems with breathing, feeding, growth, hearing and development
1
Medical Evaluation and Intervention for
CDH
Planning for Delivery and
Diagnostic Tests 1
Postnatal Care 1
• Ultrasound • Delivery to allow for
• Fetal MRI steady supply of oxygen
• Fetal echocardiography • Ventilator or ECMO
• Genetic studies • Surgery
 ASPEN 2
o Typically tolerate surgery well and can be transitioned relatively quickly to enteral feedings
o GI tract is fundamentally normal in terms of its motility and absorption capacity
o No specific recommendations for enteral feedings
o Considerations:
o Fluid restriction
o Concentration of formula
o Risk for reflux
o Provide continuous then transition to bolus feeds
o Assessment of caloric needs
o Many confounding factors such as level of sedation, possible chemical muscular relaxation, degree of mechanical respiratory support, level of
temp support
o Cardiopulmonary support
o Goal: Provide the essential components to allow for basic metabolic needs and repair of tissues
 o BGTB
o1 day old
oCDH, intubated and sedated with improved respiratory
acidosis, at risk for pulmonary HTN
oNutrition: NPO for surgery
o Birth
Patient Case: o Gestation Age: 39 1/7 weeks
o Weight: 3.264kg (53%, z-score: 0.07)
o Length: 49cm (47%, z-score: -0.08)
o HC: 35cm (83%, 0.95)
o AGA
Diagnosis

PES: Estimated Needs:

• Inadequate oral intake • 90-100kcal/kg
related to intubation for • 2.5-3g/kg protein
CDH as evidenced by need • 100mL/kg fluid
for TPN to provide 100% of
calorie and protein needs.
 o Begin 76mL/kg TPN 4 + 1 g/kg IL = 53kcal/kg, 2.7 g/kg
protein, GIR: 6.6 mg/kg/min
o Advance IL by 1g/kg/day to goal of 3g/kg/day

Nutrition o Monitor electrolytes until stable, then weekly.

Intervention & o Daily weights and weekly lengths and head circumference.
Goals
o Goal: Regain birth weight by DOL 14
Monitoring & Evaluation
Nutrition support tolerance / adequacy

Vitamin/ mineral intake

Weight trend
Article
 Background/Purpose 3
o CDH infants have 1 year mortality of 31%-46%
o Infants with CDH have an increased risk for postnatal growth failure and malnutrition
o Reported in up to 63% of survivors in first year of life

o Suboptimal nutrition has been associated with worse neurodevelopmental outcomes

o >60% of infants with CDH exhibit growth failure throughout hospitalization, and often through the first
year of life
o Evaluate the enteral feeding requirements of infants with CDH in relation to growth patterns
o Predominantly HM feeds
o Determine the prevalence and degree of fortification of HM feedings compared to formula feeds to
achieve adequate growth
o Assess the average daily weight gain and z-scores throughout hospital stay
 Methods 3
o Retrospective observational study
o Children’s Hospital of Philadelphia’s Newborn/Infant Intensive Care Unit
o Infants surviving to discharge with diagnosis of CDH between August 2012 and March 2017

o Approved by IRB
o Electronic medical records reviewed
o Gestational age, growth parameters at birth, problem list, length of stay, duration of ventilation, need for ECMO
o Nutrition Specific: Detailed feeding data (enteral and parental caloric provision, route of feedings, monthly anthropometrics
of weight, length, and head circumference)
o Growth parameter z-scores calculated using WHO standard for 0-24 months or Olson 2010 Growth Calculator for
Preterm Infants
o Malnutrition diagnosis based on ASPEN guidelines with weight for length as the primary indicator
o Mild malnutrition -1.0 to -1.99 ; Moderate -2.0 to -2.99 ; Severe -3.0 to -3.99

o Data stored in Redcap database

 Statistical Methods 3
oPearson Correlation: Determine association between lung to head ratio and weight for length z-
score at discharge
o ANOVA: Determine association between side of CDH and presence of the liver above or below
the diaphragm and weight for length z-score at discharge
o Kruskal – Wallis Test: Compare weight for length z-score at discharge among infants on
fortified vs. non fortified HM and formula
o Wilcoxon Rank Sum Test: Compare weight for length z-score at discharge for infants with
diagnosis of reflux vs. those without diagnosis
o Fischer’s Exact Test: Compare length of stay for infants with reflux vs. those without reflux
 Study
Population 3

Malnutrition: 45% (n=67)

- Mild: 24% (n=36)
- Moderate: 16% (n=24)
- Severe: 5% (n=7)
Results 3

Pearson Correlation:
o Severity of LHR correlated with severity of malnutrition as defined by
Determine association weight for length z-score at discharge (p=0.05)
between lung to head
o No significant association with side of CDH or presence of liver above
ratio and weight for or below the diaphragm and severity of malnutrition
length z-score at
Predict Severity of CDH: LHR, liver position, side of CDH
discharge
o Severity of CDH had significant correlation with length of stay
(p<0.001)
ANOVA: Determine
association between o No significant correlation between length of stay and weight for length
z score at discharge (p=0.64)
side of CDH and
presence of the liver
above or below the
diaphragm and weight
for length z-score at
discharge
 o Enteral feeds not started until after CDH repair and/or
Results 3 ECMO decannulation
o Infants NPO and required average of 34+/- 25 days of TPN
before starting enteral feeds
Kruskal – Wallis o Average calories on TPN were 77kcal/kg/day Maternal HM

Test: Compare initiated in 95% of infants

o 89% of infants required an enteral feeding tube at some
weight for length point during hospitalization
z-score at o 7% of infants fed higher calorie hindmilk, 9 needed
discharge among additional fortification in response to slowing ADWG
infants on o 60% of formula fed infants received fortification during
fortified vs. non hospitalization

fortified HM and o 21% of HM fed infants received fortification

formula o Most common fortifier: partially hydrolyzed whey fortifier

 o ADWG velocity was not affected by continuous (nasogastric, G-
Results 3 tube, nasoduodenal, nasojejunal) vs. bolus feeds (nasogastric,
G-tube, oral) (p=0.189)
o ADWG: 21+/-20 gm/day
Kruskal – Wallis o No correlation between ADWG and average caloric intake (110+/-
9.5kcal/kg/day)
Test: Compare o Average calories between HM fed infants and formula fed
weight for length infants were not significantly different (p=0.0003)
z-score at o HM fed: 22 +/- 2.3 kcal/oz
o Formula fed: 24 +/- 2.2 kcal/oz
discharge among o Fortified HM fed infants had significantly lower weight for
infants on length z-score at discharge of -1.2 compared to -0.75 in HM
fortified vs. non infants without fortification (p<0.05)

fortified HM and o Infants who received fortification later had lower weight for
length z-scores compared to those who received fortification
formula sooner
oOverall, infants formula fed had lower weight for length z-
scores compared to HM fed
Results 3

Wilcoxon Rank Sum

Test: Compare o 42% (n=62) had GER/D
weight for length z- o Average length of stay: 99 +/- 68 days vs. 47 +/- 27 days without
score at discharge for GER/D (p<0.001)
infants with diagnosis o Infants formula fed were more likely to experience GER/D
of reflux vs. those compared to infants fed HM (p=0.019)
without diagnosis
o Length of stay was significantly longer in infants fed formula
(p<0.01)
Fischer’s Exact Test:
Compare length of o Growth was significantly worse in GER/D populations
stay for infants with (p=0.002)
reflux vs. those
without reflux
 Strengths:

• Description of early nutritional management with CDH

• Data collected weekly from detailed dietitian notes (data
standardized)
• Nutritional data, caloric provisions, growth data
available for almost every infant
Strengths and • No major changes to nutritional practices over the study

Limitations 3 Limitations:

• Retrospective chart review (non-randomized sample)

• EMR which began in 2012
• Did not incorporate the AND Neonatal Malnutrition
Criteria (not published until 2018)
• Maternal milk estimated to be 20kcal/oz
 Conclusion 3
o 45% of cohort met criteria for malnutrition
o More aggressive approach to fortification is warranted for both formula and HM fed infants

o Infants with CDH have higher metabolic needs which are not recognized until after a few weeks
of poor weight gain
o Close surveillance of weight gain and nutrient provision necessary

o Infants requiring ECMO may especially benefit from earlier fortification of feeds
 Nutritional Implications & Future
Research 3
o Standardized feeding protocol
o Lead to earlier fortification, improved feeding intolerance, decreased rates of malnutrition, adequate
growth, shorter length of stay, less GER/D experienced
o HM should be encouraged
o Next Steps:
o Assess long term developmental outcomes and possible immunological benefits in relation to a feeding
protocol
 References
1. Congenital Diaphragmatic Hernia (CDH). Cincinnati Childrens.
https://www.cincinnatichildrens.org/service/f/fetal-care/conditions/congenital-diaphragmatic-
hernia?gclid=CjwKCAjw9r-DBhBxEiwA9qYUpbqzHfNQBd-
_d_2cfnVNgEw09Fb3E1NKiwsDK19UqyL1WRGt6k7ZshoCzj4QAvD_BwE. Accessed April 11,
2021.
2. Corkins MR, American Society for Parenteral and Enteral Nutrition. The A.S.P.E.N. Pediatric
Nutrition Support Core Curriculum. Vol 2nd edition. American Society for Parenteral and Enteral
Nutrition; 2015. Accessed April 7, 2021. http://search.ebscohost.com/login.aspx?
direct=true&db=nlebk&AN=1831578&site=ehost-live
3. Wild KT, Bartholomew D, Edwards TM, et al. Achieving Adequate Growth in Infants with
Congenital Diaphragmatic Hernia Prior to Discharge. Journal of Pediatric Surgery. 2021.
doi:10.1016/j.jpedsurg.2021.03.048