Enteral Nutrition in Term Infants with Congenital Heart Disease: Knowledge Gaps and Future Directions to Improve Clinical Practice

Abstract

Optimal nutrition is essential to improve short- and long-term outcomes in newborns with congenital heart disease (CHD). Nevertheless, several issues on nutritional management and concerns about the potential risk of complications related to enteral feeding exist. This narrative review aims to summarize and discuss the available literature on enteral feeding in term infants with CHD. A wide variability in feeding management exists worldwide. Emerging approaches to improve nutritional status and outcomes in infants with CHD include: implementation of a standardized enteral feeding protocol, both preoperative and postoperative, clearly defining time of initiation and advancement of enteral feeds, reasons to withhold, and definitions of feeding intolerance; early minimal enteral feeding; enteral feeding in stable term infants on hemodynamic support; evaluation of enteral feeding in term infants with umbilical arterial catheters and during prostaglandin infusion; assessment and support of oro-motor skills; and promotion and support of breastfeeding and provision of mother’s own milk or donor milk when mother’s own milk is not available. As evidence from term infants is scarce, available observations and recommendations partially rely on studies in preterm infants. Thus, well-designed studies assessing standardized clinically relevant outcomes are needed to provide robust evidence and shared recommendations and practices.

Clinical Characteristics and Potential Pathogenesis of Cardiac Necrotizing Enterocolitis in Neonates with Congenital Heart Disease: A Narrative Review

“…When compared with previous variable practitioner preferences, the standardized protocol increased rates of preoperative feeding and reduced postoperative total parenteral nutrition (TPN), without increasing complications [ 97 ]. Based on available studies, our institution has developed standardized preoperative feeding protocols for neonates with critical CHD ( Figure 3 ), focused largely on hemodynamic stability and the perceived risk of NEC development [ 97 , 99 , 100 , 101 , 102 , 103 , 104 ]. Globally, however, extreme variability in enteral feeding guidelines puts CHD neonates at risk of malnutrition, growth failure, and poor postoperative outcomes [ 105 , 106 ].…”

“…Additionally, injury to the recurrent laryngeal or vagus nerves, known complications of CHD surgery, can negatively impact feeding [ 111 ]. Feeding intolerance in CHD infants is characterized similarly to that of preterm infants, with abdominal distension, increased gastric residuals, and guaiac-positive or bloody stools [ 99 ]. Interestingly, preemptive placement of a gastrostomy tube in infants between first and second stage Norwood palliation, in an effort to avoid postsurgical feeding complications, increased survival, but did not improve weight gain or shorten hospital LOS [ 112 ].…”

Nutritional Management of Patients with Fontan Circulation: A Potential for Improved Outcomes from Birth to Adulthood

“…A feeding algorithm for patients destined to Fontan palliation has been elaborated, showing a significantly less negative WAZ change from birth to hospital discharge after implementation of the postoperative feeding algorithm [ 52 ]. However, the most challenging phase is the critical post-stage 1 surgery, where malnutrition is often associated with postoperative complications: delayed sternal closures, vocal cord palsy, and chylothorax might hamper the provision of adequate nutrition in this phase [ 23 , 53 , 54 , 55 ]. Aware of the adverse impact of feeding difficulties on these patients [ 56 , 57 , 58 , 59 ], the main factor determining a reduction in delivered EN remains fluid restriction [ 60 ].…”

Feeding Difficulties Following Vascular Ring Repair: A Contemporary Narrative Review

“…These studies also focus solely on implementing feeding protocols in the immediate postoperative period in critical care units rather than on feeding difficulties that persist long after repair [ 17 , 18 ]. These studies do agree that optimizing perioperative nutrition in patients with congenital heart disease is important for achieving appropriate growth and development [ 19 ].…”