Growth and Feeding Issues in the CICU: No Pain, No Gain David A. Hehir MD, MS Associate Professor of Pediatrics Cardiac Intensivist / Staff Cardiologist Children’s Hospital of Wisconsin Medical College of Wisconsin

Disclosures I have no relevant financial or commercial disclosures or conflicts to report The majority of the data presented will be in reference to the single ventricle population

Impact of growth and feeding issues Hospital Stay Pre Post - ETT Sick - Drips Feed and Grow Improved growth = Improved outcomes

Implications of growth failure in CHD? Pre-op albumin < 3 gm/dL in infants with CHD associated with mortality, infection, and longer LOS Leite 2004 “Serum albumin and clinical outcome in CHD surgery” Weight for age z-score (WAZ) < -2 at Fontan associated with longer LOS, infection Anderson 2011 “Low WAZ and infection after Fontan” Short stature following Fontan (HAZ <-1.5) associated with lower cognitive scores, more behavioral problems, and greater AV valve regurgitation Cohen 2010 PHN Fontan Study

BDG Length of Stay (days) In 150 BDG patients, the mode of feeding at the time of admission most important predictor of LOS Unpublished data: Runzheimer “Outcomes of BDG.” Feed Mode at time of BDG admit: PO Not PO BDG Length of Stay (days)

Growth as a therapeutic target: What is “normal” growth in SV? NORMAL = NORMAL CDC: currently recommend using WHO standards for children 0-2 years WHO: {median, (5-95%)} (all boys) 1st month: 34 (15-50) gm/day 1-2 months: 39 (23-57) gm/day 2-3 months: 27 (15-41) gm/day

Hospital growth – How are we doing? Poor growth associated with ≥ mod AVVR, low BW, time with ETT Hospital growth – How are we doing? Medoff-Cooper 2011 CITY

Pre-op feeding: Opportunity for Improvement? Johnson, B.A., et al, 2008, Pediatric Cardiology

Feeding the pre-op infant Is it safe to feed with a UA in place? Survey of NICU directors. Tiffany et al 2003 Pediatrics: “Current practice of feeding with UA” 79% will feed trophics “some” or “most” of time 51% will feed complete “some” or “most” of time Is it safe to feed while on PGE? 62/67 (92%) neonates able to feed pre-op Natarajan Neonataology 2010 34 infants fed by mouth or tube, 97% success Willis 2008 J Peds Pre-op feeding not associated with improved growth

CHW Pre-operative SV Feeding Guidelines: Focus on oral feeding Feed with cues IF: heart rate < 170 at baseline AVO2 difference by NIRS is < 30% absence of respiratory stress Oral feeding limited to 10-15 minutes Goal: developmental, not full nutrition

Impact of staged palliation on growth Growth failure is common in SV patients , but improves following palliative surgery From: Anderson et al. ATS 2011

WAZ improved after TOF repair Carmona et al 2012 Card Young

Weight for age Z-score (WAZ) Hehir et al. Normal Interstage Growth associated with HMP Growth parameters improve during the interstage period p < .001 p < .001 Δ – 0.9 Δ + 0.3 ± - 0.4 - 1.3 - 1.0 N=145

Barriers to Feeding PICU patients receive a median of <40% estimated energy requirements (EER) CICU patients < 32% Probability of 50% of patients achieving full ERR is 8 days in PICU and 19 days in CICU Barriers to reaching EER found to be: Fluid restriction Feed interruptions Intolerance of feed From: Rogers et al. Nutrition 2013: Barriers to nutrition in the ICU

The problem of feeding intolerance Gastric dysmotility following CHD surgery Vagotomy may cause gastroparesis Low CO, CHF associated with delayed peristalsis Vocal fold immobility (VFI) is common and highly morbid Inability to auto-PEEP = tachypnea Aspiration risk Disordered feeding

Feeding intolerance work up Key question: is it a problem? Indicator of CV health, risk of GI complications If so, what is etiology? Etiology leads to targetted therapy What tools do we have to help us? Residual volume Emesis: frequency and volume Heme positive stools Abdominal girth Objective assessment of GI obstruction Objective hemodynamic assessment Vital signs NIRS BNP / ECHO / Invasive monitoring

NEC in CHD– chicken or egg? NEC in HLHS associated with: Shock Positive blood culture Acidosis Larger shunt Smaller BW Feeding protocol reduced NEC (27% to 7%) del Castillo 2010 PCCM In protocol group, feeds initiated later and full feeds reached later but LOS shorter No Sano patients in the pre-protocol group

NEC in HLHS S1R types Davies et al (2013): NEC more common after hybrid (27 vs 3%) Weiss et al (2011) Incidence of intra-abdominal complications: Hybrid = 75% mBTS = 31% Sano = 9%

Feeding Dysfunction: A long term issue Garick Hill, 2014 (J Peds): Feeding Dysfunction in children with single ventricle following staged palliation 56 children age 2-6 at CHW 50% found to have feeding dysfunction Those with feeding dysfunction more likely to have a GT, be small (WAZ -0.84 and HAZ -1.3), and be from single parent household

Proposed post-op feeding protocol Begin enteral feeds at 20 cc/kg/d NG or PO Formula or preferrably breastmilk May be bolus Q3 or continuous at 1 cc/kg/hour Advance 20 cc/kg/d to goal of 120 cc/kg/day Once volume goal is reached, fortify to 24 kcal/kg/day Titrate volume and calories to weight gain goal of 20-30 gm/day Monitor CO (NIRS) and for feeding intolerance

Conclusions Growth is a problem, and is associated with worse outcomes In-hospital growth is opportunity for improvement Pre-Norwood feeding safe but does not improve growth Interstage growth can be normal in context of HMP Feeding dysfunction contributes to growth failure, and may predict CV or GI complications Feeding protocols improve growth and decrease complications

Thanks