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Nutritional Management of Growth Faltering in 2-months-old Child With Congenital Heart Disease and Recurrent Infections

By: Dr. Zahid Ul Kareem

MBBS, DCH, FCPS, MRCPCH, FISCCM, Consultant Pediatric Intensivist, Ankura Hospital, Banjara Hills, Hyderabad

Key Points:

Introduction:

Malnutrition is common in hospitalized pediatric population.1 According to NFHS 4, in India, 38% of children under age five years are stunted (too short for their age) and 21% of children under age five years are wasted (too thin for their height).2 This is a sign of chronic undernutrition.3 Nutritional support is an important aspect in the clinical management of pediatric intensive care patients.1 Adequate nutrition during infancy and early childhood is essential to ensure the growth, health, and development of children to their full potential.4 Cumulative deficits not only lead to growth faltering but may also impact clinical and functional outcomes in these infants.5,6 Therefore, evaluation of nutritional status and provision of adequate nutrition are crucial components in the overall management of children during tillness.5 Faltering growth of organic origin occurs when an underlying medical cause results in suboptimal weight gain or growth in infants.7 Infants may have increased nutritional requirements and/or fluid restrictions due to various medical conditions, including congenital heart disease, chronic lung disease, cystic fibrosis, (athetoid) cerebral palsy, critical illness, surgical conditions, and failure to thrive.5,7

Here, we present to you a case report of a 2-month-old baby with Congenital heart disease and recurrent infections.

Patient Profile:

A 2-months-old child presented with complaints of bronchopneumonia, sepsis and cardio-respiratory failure. Patient’s weight was 2.7 kg, height was 58 cm, head circumference was 39 cm at admission.

Relevant Medical History:

Child was born at full term with low birth weight (2.4 kg). He suffered with neonatal jaundice and CHD. Surgical intervention was carried out to correct TPAVC. Post-operative, child developed left diaphragmatic palsy and underwent left diaphragmatic plication. Child was on oxygen therapy for prolonged period because of failed extubation. He also suffered with acute gastroenteritis (AGE) for 5 days and readmitted to the hospital in a week’s time.

Relevant Feeding History:

Child was on breastfeeding along with formula feeding with addition of medium chain triglyceride (MCT) oil.

Investigations:

Complete blood picture (CBP), C-reactive protein (CRP), Chest X-ray, tracheal aspirate culture and urine culture were ordered.

Diagnosis:

Chest X-ray suggested the diagnosis of bronchopneumonia. Tracheal aspirate culture was positive for Acinetobacter Baumannii.

Urine culture was positive for E-coli. Result of CBP and CRP were indicating sepsis. Patient’s weight was less than that for 3rd percentiles on WHO growth chart.

Child was diagnosed to be having growth faltering due to CHD and recurrent infections (bronchopneumonia, AGE, sepsis, and urinary tract infection).

Management:

Child was admitted to the hospital. He remained in PICU for 20 days and shifted toward for next 20 days, making total of 40 days of hospitalization.

Child was on the mechanical ventilator. Ionotropic support and antibiotics were given to manage child’s condition. He was on NPO for 8 days and then started on oral feeds.

Nutritional Management:

Child was showing growth faltering due to decreased intake (feeding difficulty with suck rest suck cycle, AGE and NPO status) and increased energy expenditure (critical illness, increased work for breathing due to diaphragmatic palsy and bronchopneumonia). Child was unable to gain weight from the past 2 months despite addition of MCT oil.

Aim of nutritional management was to achieve weight between 25th to 50th percentile. ENDF was started on day 4 with 50 kcal/kg/day and from next day increased to 100 kcal/kg/day for one-week period. As the child tolerated formula, the amount gradually increased to 150-160 kcal/kg/day. Every 2-hourly feed was given alternating between ENDF and expressed breast milk making total 6 feeds of ENDF and 6 feeds of expressed breast milk each day.

Child showed a weight gain of 870 g over 40 days period making his weight 3570 grams at the time of discharge.

Follow-up:

Post-discharge, the patient was continued on ENDF through bottle feeding. At follow up after 2 weeks from discharge, the child had gained 280 grams of weight making his weight 3850 grams. Child tolerated the formula well and was thriving well with acceptable weight gain.

Discussion:

Total anomalous pulmonary venous connection (TAPVC) is a rare but heterogeneous anomaly, accounting for = 1% to 3% of congenital heart disease (CHD) cases. It is characterized by failure of the pulmonary venous confluence to be absorbed into the dorsal portion of the left atrium in combination with a persistent splanchnic connection to the systemic venous systems.9 Typically, TAPVC presents in infancy and often requires early surgical intervention.9,10 Post-operatively, child may develop pulmonary complications like pleural effusion, atelectasis, pneumonia and diaphragmatic paralysis.11

Repair of TAPVC in the neonatal age has been found to be rewarding with significant improvement in the well-being of the child.10

case study 4 figure 1

Growth failure is also a significant issue in children with CHD.12 The underlying causes of faltering growth may be multifactorial, including innate growth potential, severity of cardiac disease, increased energy requirements, decreased nutritional intake, malabsorption, and poor utilization of absorbed nutrition.13

The management of newborns with CHD requires a multidisciplinary approach, in which the nutritional aspect plays a crucial role. An adequate caloric intake during either pre and post-surgical period, in fact, improves the outcome of these patients.14 However, maintaining infants with CHD in a good nutritional condition can be a challenge.15 Enteral nutrition has a favorable effect on the intestinal mucosa and has fewer complications compared with parenteral nutrition.13

The Breast milk is considered as an ideal nutrition for all newborns upto the age of 6 months. However, caloric intake of mother’s milk may not be enough to support growth of infants affected by CHD.14 Several studies have reported the judicious use of higher concentration formula in alleviating growth failure in children with CHD.12 In a study by Clarke SE et al., all 49 infants [median age of 5 weeks (range 2-3 weeks)] with faltering growth gained weight with ENDF. Intake of ENDF also resulted in significantly greater intakes of all nutrients; protein, sodium, potassium, calcium, zinc, iron, vitamin D, vitamin C and Vitamin A.7

In the case presented here, child was showing growth faltering due to CHD and recurrent infections. He was unable to gain weight with breast feeding and formula feeding with added MCT oil, therefore started on Energy and Nutrient Dense Formula (ENDF). ENDF along with expressed breast milk led to satisfactory weight gain. Use of ENDF can be considered as one of the important measures in critically ill children suffering from recurrent infections.

Key features of ENDF:

  • Highest energy in small volume – 1 kcal/ 1 ml
  • 15-40% more vitamin and minerals than standard infant formula
  • Suitable for tube feeding
  • Optimal protein: 2.6g/ 100 ml
  • Fortified with nucleotides
  • Osmolality within recommended guidelines

Conclusion:

We can conclude that ENDF can help in weight gain in children with CHD and recurrent infections who are not thriving well.

References:-

  1. Raju U, Choudhary S2, Harjai MM. Nutritional Support In The Critically Ill Child. Med J Armed Forces India. 2005 Jan;61(1):45-50.
  2. Chaudhary P, Agrawal M. Malnutrition and Associated Factors among Children below Five Years of Age Residing in Slum Area of Jaipur City, Rajasthan, India. Asian Journal of Clinical Nutrition, 11: 1-8.
  3. Global nutrition report. About malnutrition. Online. Available from: https://globalnutritionreport.org/resources/about-malnutrition/. Accessedon: 15.10.2019.
  4. WHO. Infant and young child feeding: model chapter for textbooks for medical students and allied health professionals. Online. Available from: https://apps.who.int/iris/bitstream/handle/10665/44117/9789241597494_eng.pdf?ua=1. Accessed on: 15.10.2019.
  5. Mehta NM, Corkins MR, et al. Defining pediatric malnutrition: a paradigm shift toward etiology-related definitions. JPEN J Parenter Enteral Nutr. 2013 Jul;37(4):460-81.
  6. Mehta NM, Skillman HE, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition. Pediatr Crit Care Med. 2017 Jul;18(7):675-715.
  7. Clarke SE, Evans S, et al. Randomized comparison of a nutrient-dense formula with an energy-supplemented formula for infants with faltering growth. J Hum Nutr Diet. 2007 Aug;20(4):329-39.
  8. Shi G, Zhu Z1, et al. Total Anomalous Pulmonary Venous Connection: The Current Management Strategies in a Pediatric Cohort of 768 Patients. Circulation. 2017 Jan 3;135(1):48-58.
  9. Kanter KR. Surgical repair of total anomalous pulmonary venous connection. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu. 2006:40-4.
  10. Warrier G, Dharan BS, et al. Repair of total anomalous pulmonary venous connection in neonates. Ind J Thorac Cardiovasc Surg, 2004; 20: 155–158.
  11. Cavenaghi S, Moura SC, et al. Importance of pre and post operative physiotherapy in pediatric cardiac surgery. Rev Bras Cir Cardiovasc. 2009 Jul-Sep;24(3):397-400.
  12. Medoff-Cooper B, Ravishankar C. Nutrition and growth in congenital heart disease: a challenge in children. Curr Opin Cardiol. 2013 Mar;28(2):122-9.
  13. Argent AC, Balachandran R, et al. Management of undernutrition and failure to thrive in children with congenital heart disease in low- and middle-income countries. Cardiol Young. 2017 Dec;27(S6):S22-S30.
  14. Mangili G, Garzoli E, Sadou Y. Feeding dysfunctions and failure to thrive in neonates with congenital heart diseases. Pediatr Med Chir. 2018 May 23;40(1).
  15. BS, Ystrom E, et al. Feeding infants with CHD with breast milk: Norwegian Mother and Child Cohort Study. Acta Paediatr. 2010 Mar;99(3):373-8.

Important Notice:

The World Health Organization (WHO)* has recommended that pregnant women and new mothers be informed of the benefits and superiority of breast-feeding, in particular, the fact that it provides the best nutrition and protection from illness for babies. Mothers should be given guidance on the preparation for and maintenance of lactation, with special emphasis on the importance of the well-balanced diet both during pregnancy and after delivery. Unnecessary introduction of partial bottle feeding or other foods and drinks should be discouraged since it will have a negative effect on breast-feeding. Similarly mothers should be warned of the difficulty of reversing a decision not to breastfeed. Before advising a mother to use an infant formula, she should be advised of the social and financial implications of her decision. For example, if a baby is exclusively bottle-fed, more than one can (500g) per week will be needed, so the family circumstances and cost should be kept in mind. Mother should be reminded that breast milk is not only the best but also the most economical food for babies. If a decision to use infant formula is taken, it is important to give instruction on correct preparation methods, emphasizing that unboiled water, unsterilized bottles or incorrect dilution can lead to illness.

*See: International Code of Marketing of Breast Milk Substitutes, adopted by the World Health Assembly in Resolution WHA 34.22, May 1981.

Mothers should be explained the following advantages & nutritional superiority of breastfeeding:

  1. Immediately after delivery, breast milk is yellowish and sticky. This milk is called colostrum, which is secreted during the first week of delivery. Colostrum is more nutritious than mature milk because it contains more protein, more anti-infective properties which are of great importance for the infant’s defence against dangerous neonatal infections. It also contains higher levels of, Vitamin ‘A’.
  2. Breast miIk:
    1. Is, a complete and balanced food and provides all the nutrients needed by the infant (for the first six months of life).
    2. Has anti-infective properties that protect the infants from infection in the early months.
    3. Is always available.
    4. Needs no utensils or water (which might, carry germs) or fuel for its preparation.
  3. Breastfeeding is much cheaper than feeding infant milk substitutes as the cost of the extra food needed by the mother is negligible compared to the cost of feeding infant milk substitutes.
  4. Mothers who breast-feed usually have longer periods of infertility after child birth than non-lactators.

Details of management of breast feeding, as under:

  1. Breast-feeding.
    1. Immediately after delivery enables the contraction of the womb and helps the mother to regain her figure quickly.
    2. Is successful when the infant suckles frequently and the mother wanting to breast-feed is confident in her ability to do so.
  2. In order to promote and support breast-feeding the mother’s natural desire to breast feed should always be encouraged by giving, where needed, practical advice and making sure that she has the support of her relatives.
  3. Adequate care for the breast and nipples should be taken during pregnancy.
  4. It is also necessary to put the infant to the breast as soon as possible after delivery.
  5. Let the mother and the infant stay together after the delivery, the mother and her infant should be allowed to stay together (in hospital, this is called “rooming-in”).
  6. Give the infant colostrum as it is rich in many nutrients and anti-infective factors protecting the infants from infections during the few days of its birth.
  7. The practice of discarding colostrum and giving sugar water, honey water, butter or other concoctions instead of colostrum should be very strongly discouraged.
  8. Let the infants suckle on demand.
  9. Every effort should be made to breast-feed the infants whenever they cry.
  10. Mother should keep her body and clothes and that of the infant always neat and clean.
    Breast-feeding is the best form of nutrition for babies and provides many benefits to babies and mothers. It is important that, in preparation for and during breast-feeding, you eat a healthy, balanced diet. Combined breast and bottle feeding in the first weeks of life may reduce the supply of your own breast-milk, and reversing the decision not to breast-feed is difficult.
    Always consult your Health-care Professional for advice about feeding your baby. The social and financial implications of using infant formula should be considered. Improper use of an infant formula or inappropriate foods or feeding methods may present a health hazard. If you use infant formula, you should follow manufacturer’s instructions for use carefully – failure to follow the instructions may make your baby ill.

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