1. 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

2. 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

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

4. 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

5. 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Unpublished data: Runzheimer “Outcomes of BDG.”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)

6. 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

7. 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

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

9. 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

10. 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 minutes
Goal: developmental, not full nutrition

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

12. WAZ improved after TOF repair
Carmona et al 2012 Card Young

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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%

19. 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 and HAZ -1.3), and be from single parent household

20. 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 gm/day
Monitor CO (NIRS) and for feeding intolerance

21. 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

22. Thanks