“Enteral Nutrition” by Nancy Braudis, RN for OPENPediatrics


Enteral Nutrition, by Nancy Braudis. My name is Nancy Braudis, and I am a clinical
nurse specialist in the Cardiac ICU at Children’s Hospital Boston. The topic today is enteral nutrition in infants
and children with congenital heart disease. The objectives of this presentation are to
understand the importance of early enteral nutrition, identify the risks associated with
enteral nutrition, and to reduce barriers to providing optimal nutrition in infants
and children with congenital heart disease. Importance of Nutrition. Providing enteral nutrition is important because
of the high risk of growth failure in infants and children with complex congenital heart
disease. Many infants with congenital heart disease have lower birth weights– especially
those with Tetralogy of Fallot, complete atrioventricular canal, ventricular septal defects, and hypoplastic
left heart syndrome. Providing important nutrients will help to optimize growth and development,
improve tissue healing, and reduce the risk of infection. The high rate of growth failure that develops
in infants may be related to inadequate nutritional intake– infants require more calories than
they are able to take in. Reduced gastrointestinal absorption– the body is unable to absorb
the nutrients that are required for adequate growth. High energy expenditure– infants
with congenital heart disease are thought to have an increased metabolic rate because
of the increased workload on the cardiac and respiratory systems. Physical growth is the most important parameter
in the assessment of nutritional status. Periodic assessments should be made to determine if
weight, height, length, and head circumference are within normal limits for age. Children
who are hospitalized should have daily assessments of weight and monthly assessments of height
or length to determine the effectiveness of a feeding plan. Nutritional Goals. Infants with complex congenital heart disease
require approximately 120 to 150 calories per kilogram per day to achieve significant
growth. In studies evaluating nutritional intake, it was found that most patients only
receive 50% to 70% of their actual caloric requirements. Standard guidelines identify
a target weight gain for infants of 10 to 35 grams per day. Calorie counts are done to determine the daily
intake of calories. To calculate calories, take the total volume of formula in 24 hours–
example, 600 milliliters– and divide by 30 milliliters. Then multiply by the calories
per ounce– example, 20 calories– and divide by the infant’s weight– example, 5 kilograms.
The answer is 80 calories per kilogram per day. A feeding plan should be developed to improve
caloric intake. The goal should be 120 to 150 calories per kilogram per day. So either
the volume of feedings or the concentration of calories of the feedings should be increased
to reach the nutritional goal. Please note, if you do not use ounces at your
institution, the equation would instead read– 600 milliliters in 24 hours. Since there are
30 milliliters in 1 ounce, the formula has 20 calories per 30 milliliters, or 0.67 calories
per 1 milliliter. Feeding Routes. Although the ideal route of enteral nutrition
is oral feeding, it is often difficult for infants to take in enough calories with limited
energy stores and to coordinate feeding patterns with rapid respirations. Breastfeeding should
be encouraged with supplementation as needed. Infants with significant growth failure may
still breastfeed, which should alternate breastfeeding with high caloric formula to improve weight
gain. Tube feedings should be initiated in infants
and children with an altered mental state, congenital anomalies, dysphasia, prematurity,
increased metabolic needs or significant growth failure. Transpyloric feeding should be implemented
when there is gastric distress, delayed gastric emptying, or an increased risk of aspiration. Difficulty with oral feeding is common in
infants following cardiac surgery. Risk factors include entry to the vocal cords from prolonged
intubation, low weight at time of surgery, or surgical intervention close to the aortic
arch. Paralysis of the vocal cords should be suspected if the infant has a weak cry
after extubation. It may compromise the infant’s ability to swallow and increase the risk of
aspiration. Management includes thickening of oral feedings
or in severe cases, implementing tube feedings. Pediatric cardiac patients have a high rate
of gastroesophageal reflux disease. Clinical signs include recurrent vomiting, poor weight
gain, abdominal pain, and persistent respiratory symptoms. Treatment options include formula
thickening, prone positioning with head of bed 30 degrees, and tube feeding supplementation. Benefits of Enteral Nutrition. Many studies have evaluated the benefits of
early enteral nutrition. The studies found that critically ill children are at risk for
fat and protein depletion, leading to malnutrition and that early enteral feedings improve nutritional
outcomes. Early enteral nutrition lowered the risk of infection, decreased the length
of hospital stay, and showed a significant improvement in wound healing. Implementing
an evidence-based feeding protocol in critically ill patients produced a significant reduction
in the duration of mechanical ventilation and a marked reduction in mortality. Risks of Enteral Nutrition. The risks of enteral nutrition include feeding
intolerance and necrotizing enterocolitis. Feeding intolerance can be defined as two
or more episodes of vomiting, three or more episodes of diarrhea or loose stool, or an
increased abdominal girth greater than 10% above baseline. Bowel sounds and gastric residual
volumes are poor indicators of feeding intolerance. Gastric residual volumes vary greatly, and
they can vary throughout the day. They should be part of an overall assessment, but not
the only criteria in a decision to stop feeds. Infants with congenital heart disease are
at much greater risk for developing necrotizing enterocolitis because of potential hypoxia
or hypoperfusion to the gastrointestinal system. The incidence of necrotizing enterocolitis
in neonates with congenital heart disease was reported at 3.5%. And that is 10 times
higher than in neonates without congenital heart disease. The rate of necrotizing enterocolitis
for infants with single ventricle physiology was found to be as high as 7.6%. Symptoms
of necrotizing enterocolitis include feeding intolerance, delayed gastric emptying, abdominal
distension, decreased bowel sounds, and blood in the stool. Feeding Guidelines. Barriers to providing adequate nutritional
support include individual practice variation, under-prescription, fluid restriction, frequent
interruptions in feeds, mechanical problems with tubes, hemodynamic instability, procedures,
daily care, and gastrointestinal distress. The use of standardized feeding guidelines
have consistently promoted the use of early enteral nutrition, improved nutritional outcomes,
reduced barriers to providing optimal nutrition, reduced the time to achieve goal calories,
and reduced the incidence of feeding intolerance. We use this feeding algorithm to initiate
and advance feedings in infants and children after cardiac surgery. It is a systematic
way of introducing feeds and monitoring for signs of gastric distress. As you follow the arrows to the boxes, you
see that an intervention occurs every four hours while starting feeds. Each box contains
a number that corresponds to another document that gives more details on the intervention.
The corresponding box has more details so that each nurse or doctor is making the same
decision. Conclusion. Infants with complex congenital
heart disease are at high risk for growth failure. They require approximately 120 to
150 calories per kilogram per day to achieve significant growth. Clinicians are often reluctant
to initiate and advance early enteral feedings because of the increased risk of necrotizing
enterocolitis. Multiple barriers exist to providing optimal
nutrition. Feeding guidelines consistently reduce barriers and improve nutritional outcomes.
That concludes the topic of enteral nutrition in infants and children with cardiac disease.
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