Feeding Protocols for Infants with Hypoplastic Left Heart Syndrome - Hlhs

>> HI, MY NAME IS JULIE SLICKER. I'M FROM CHILDREN'S HOSPITAL OF WISCONSIN IN MILWAUKEE, AND THIS IS OUR POSTER ON NUTRITION AND FEEDING GUIDELINES FOR INFANTS WITH HYPOPLASTIC LEFT HEART SYNDROME. THIS WAS A COLLABORATIVE EFFORT THAT 10 HOSPITALS OUT OF THE 44 INVOLVED IN THE NATIONAL PEDIATRIC CARDIOLOGY QUALITY IMPROVEMENT COLLABORATIVE WAS INVOLVED IN. WE KNOW THAT FEEDING AND GROWTH PROBLEMS ARE COMMON IN INFANTS WITH HYPOPLASTIC LEFT HEART SYNDROME, AND THAT POOR GROWTH HAS BEEN ASSOCIATED WITH WORSE OUTCOMES DURING THE INTERSTAGE PERIOD. THERE WERE ALSO, CURRENTLY NO CONSENSUS NUTRITION GUIDELINES FOR INFANTS WITH HYPOPLASTIC LEFT HEART SYNDROME. THE NATIONAL PEDIATRIC QUALITY IMPROVEMENT COLLABORATIVE OR NPCQIC IS A NETWORK OF 44 CENTERS WORKING TO IMPROVE OUTCOMES FOR INFANTS WITH HYPOPLASTIC LEFT HEART SYNDROME. ONE OF THEIR PRIMARY AIMS IS TO IMPROVE THE QUALITY OF LIFE, AND ONE OF THEIR KEY DRIVERS IS TO IMPROVE THE NUTRITION AND GROWTH OF THESE INFANTS. THE FEEDING WORK GROUP OF THE NPCQIC WAS FORMED TO ASSESS BEST PRACTICES IN HYPOPLASTIC LEFT HEART SYNDROME NUTRITION MANAGEMENT, AND TO DEVELOP SAFE AND EFFECTIVE FEEDING GUIDELINES. IN FIGURE 1, WE HAVE OUR PRE-OPERATIVE ENTERAL NUTRITION FEEDING GUIDELINES. AT THIS POINT, ALL INFANTS SHOULD BE SUPPORTED FULLY BY TPN AND LIPIDS. FIGURE 5 DEMONSTRATES HOW TO INITIATE TPN AND HOW TO ADVANCE IT TO FULL SUPPORT. THE RISK OF IMPAIRED SYSTEMIC PERFUSION MAY OUTWEIGH ANY POTENTIAL BENEFIT IN ACHIEVING FULL ENTERAL NUTRITION PREOPERATIVELY, THOUGH THERE ARE BENEFITS ASSOCIATED WITH PRE-OPERATIVE ORAL FEEDING ON A LIMITED BASIS. SOME SINGLE-SITE CENTERS HAVE REPORTED USING NG FEEDS AND ADVANCING THEM PRE-OPERATIVELY. HOWEVER, THIS IS NOT BEEN STUDIED RIGOROUSLY. SO IT IS NOT ONE OF OUR RECOMMENDATIONS, BUT IT'S SOMETHING TO CONSIDER ON A CASE BY CASE BASIS. FIGURE 2 IS OUR POST-OPERATIVE ENTERAL FEEDING GUIDELINES. SO ONCE THE MULTI-DISCIPLINARY TEAM DECIDES THAT THE PATIENT IS READY FOR ENTERAL FEEDS, AT THIS POINT THEY SHOULD STILL BE SUPPORTED ON TPN AND LIPIDS, BUT YOU CAN INITIATE FEEDS AT 20 MLS PER KILO PER DAY, AND ADVANCE BY 20 MLS PER KILO PER DAY TO A GOAL RECOMMENDED VOLUME OF 120 TO 140 MLS PER KILO PER DAY AND A CALORIC GOAL OF 120 TO 150 CALORIES PER KILO PER DAY. AND AT THIS POINT, THE INFANT SHOULD BE ABLE TO ACHIEVE A WEIGHT GAIN OF 20 TO 30 GRAMS PER DAY. I SHOULD POINT OUT THAT DURING THIS TIME PERIOD, IT'S IMPORTANT TO CONSISTENTLY AND CONTINUOUSLY EVALUATE FOR GI AND CARDIAC RISK FACTORS FOR FEEDING, AND THOSE ARE LISTED HERE IN FIGURE 6. IN FIGURE 3, WE HAVE OUR POST-OPERATIVE ORAL FEEDING GUIDELINES. PRIOR TO FEEDING AN INFANT ORALLY, WE HIGHLY RECOMMEND THAT THERE'S A SPEECH OR FEEDING EVALUATION DONE FOR EACH INFANT. WHEN THEY ADVANCE ON THEIR ORAL FEEDINGS, ONCE THEY'RE TOLERATING ABOUT 50 TO 75% OF THEIR CALORIE GOALS FOR ABOUT 48 HOURS, YOU CAN REMOVE THE NG AND SEE IF THE INFANT CAN INDEED TAKE MORE THAN 100 MLS PER KILO PER DAY, AND CONTINUOUSLY ACHIEVE A WEIGHT GAIN OF 25 TO 30 GRAMS PER DAY. LASTLY, WE HAVE FIGURE 4 WHICH REPRESENTS OUR INTERSTAGE FEEDING GUIDELINES. INFANTS DURING THIS STAGE SHOULD CONTINUE TO GAIN 20 TO 30 GRAMS PER DAY, AND AT THIS POINT WE'RE EVALUATING FOR RED FLAGS. SO IF THE INFANT HAS A WEIGHT LOSS OF 30 GRAMS PER DAY IN ONE DAY, OR THEY FAIL TO GAIN 20 GRAMS OVER A THREE-DAY PERIOD, OR THEY'RE TAKING IN LESS THAN 100 MLS PER KILO PER DAY, THAT WILL CONSTITUTE A MULTI-DISCIPLINARY EVALUATION WHICH COULD RESULT IN READMISSION FOR THE INFANTS OR CHANGES IN FEEDING GUIDELINES AND PRACTICES. IN CONCLUSION, WE KNOW THAT PRE-OPERATIVELY THE RISK OF IMPAIRED SYSTEMIC PERFUSION FOR NORWOOD PATIENTS OUTWEIGHS ANY POTENTIAL BENEFIT OF ACHIEVING FULL ENTERAL NUTRITION PRE-OPERATIVELY, BUT THAT DOES NOT CONTRAINDICATE DOING ORAL FEEDS PRE-OPERATIVELY AS TOLERATED IN THE FACE OF ADEQUATE SYSTEMIC PERFUSION. CONTRAINDICATIONS TO PRE-OPERATIVE FEEDING CAN INCLUDE A CONCERN FOR NEC AND EVIDENCE OF LOW SYSTEMIC CARDIAC OUTPUT. POSTOPERATIVELY, WE ADVOCATE TO START FEEDS AT 20 MLS PER KILO PER DAY, AND ADVANCE THEM BY 20 MLS PER KILO PER DAY TO A GOAL OF 120 TO 140 MLS PER KILO, AND 120 TO 150 CALORIES PER KILO PER DAY. THIS IS DONE BY INCREASING CALORIC DENSITY BY TWO TO THREE CALORIES PER OUNCE EVERY 24 HOURS TO A MAX CONCENTRATION OF 30 CALORIES PER OUNCE. AND LASTLY, INTENSIVE INTERSTAGE MONITORING IS PARAMOUNT TO ACHIEVING ADEQUATE GROWTH VELOCITY IN THESE INFANTS.