Adsa.org.za

Final: April 2007
Review: 2007
Christiaan Barnard Memorial Hospital
Nutrition in the Paediatric Cardiac Patient
2. Summary of recommendations for nutrition management of infants and
children with congenital heart disease
2.1 Summary: Anthropometry
2.5 Summary: Entry and exit criteria for nutrition support 2.7 Appendix 1 Treatment algorithm for congenital heart disease 2.8 Appendix 2 Treatment algorithm for chylothorax Definition
Arm muscle area [requires MUAC & TSF to calculate] Integrated management of childhood illness Severe Malnutrition:Very low weight < 60% EWA.
Visible signs of severe wastingOedema on the feetNot Growing Well:Low weight < 3rd centile; gPoor weight gain - gaining weight but curve flattening orMother reports weight loss.
Growing Well:Not low weight andGood weight gain.
Mid upper arm circumference [6months – 5 years of age]> 15cm normal>11.5cm - <14.5cm moderately malnourished<11.5 cm [<-3SD] severely malnourished Nutrition supplementation programme (NSP) Birth – 5 years: when an infant or child’s growth curveflattens or drops over two consecutive visits on his/herRtHC.
>5 - < 18 yrs: when a child's growth curve flattens or dropsover two consecutive months on his/her weight-for-agegrowth chart.
Supplementation must be continued for only 6 months if
entered onto the Nutrition Supplementation Programme.
Infants: 0 – 12months growth curve flattens or drops over
two consecutive visits on his/her RtHC and the mother is
unable to breastfeed because of the following reasons:
Serious systemic, on long-term medication or treatment e.g.
chemotherapy, hypothyroidism; is addicted to alcohol or
drugs (condition must be formally documented/assessed); is
mentally disabled and poses a threat to the baby; the infant
is in foster care.
Children > 5 years < 18 years: When child’s growth curveflattens or drops over two consecutive months.
Successful:
Birth – 5 years: gained sufficient weight to attain a growth
curve in relation to his/her normal growth curve and
maintains the curve for three consecutive months.
>5< 18 years: gained sufficient weight to attain normal
growth curve according to the growth chart within the 6
months period on the scheme
Unsuccessful:
Birth – 5 years: Failure to attain growth curve in relation to
his/her normal growth curve over a period of 6 months and if
no underlying disease/condition is present e.g. Foetal
Alcohol Syndrome
>5< 18 years: who do not attain a normal growth curve
according to the growth chart with in the 6 months period.
Defaulter:
Birth – 5 years: Failure to attend the clinic for a period of
three consecutive months.
three consecutive months.
> 5 - <18 years: Failure to attend the clinic for a period ofthree consecutive months within the 6 months period.
Client has a history of irregular clinic attendance (less thanthree visits in a 6 month period) with in the 6 months period.
** Re-entry:UNSUCCESSFUL and DEFAULT cases MAY NOT be re-entered onto the programme.
SUCCESSFUL cases MAY be re-entered onto theprogramme according to entry criteria.
Predicting estimated energy requirements [Appendix 1] Standard Deviations used to determine moderate to severemalnutrition:0 - <-1 SD Normally Nourished>-2 – -3 SD Moderately Malnourished>-3SD Malnourished Used to determine malnutrition:Acute malnutrition: Weight/ HeightNormal WH >90%,Mild 81% - 90%,Moderate 70% - 80%,Severe <70%.
Chronic malnutrition: height for ageNormal >95%,Mild 90 –95%,Mild – moderate 85% to 89%Severe < 85%.
2. Summary of recommendations for nutrition management of
infants and children with congenital heart disease
Summary Recommendations: Congenital Heart Disease 1, 2, 12, 25
2.1 Anthropometry
Plot weight & height on appropriate growth charts. (CDC or WHO or disease specific e.g. Downs Syndrome) Expected weight gain for an infant (< 6 months) with CHD is 10 – 20g per day and for infants (6 – 12 months) 120 – % EWA
% EWH
% EHA
HA
WA
WH
Classify degree of malnutrition
Waterlow: Acute malnutrition: Weight for Height
(wasting)
Normal WH >90%
Mild 81% - 90%
Moderate 70% - 80%
Severe <70%
Waterlow: Chronic malnutrition: height for age
(stunting)
Normal >95%
Mild 90 –95%
Mild – moderate 85% to 89%
Severe < 85%
Gomez: Acute wasting: Weight for age
Obese >120%
Normal > 90%
Mild malnutrition 76 – 90%
Moderate malnutrition 61 – 75%
Severe malnutrition < 60%
2.2 Biochemistry
U & E: Urea, creatinine, sodium, potassium Once in recovery complete x Calcium, magnesium and phosphorus2 week until discharge 2.3 Clinical
Mechanisms of malnutrition effected by:
Comments:
Common clinical signs are:
MedicationCardiac cachexiaUrinary sodium losses(especially on Frusemide-Lasix) failure thrive. Establish sodium balanceover a 24 hour periodCheck Iron statusCheck folate and Vit B12 levelsInfants with cyanotic CHD may have anormal Hb but iron deficient. Check ironstatus using ferritin, red cell indices and 2.4 Dietary
At each follow up a thorough nutrition history should be completed
Components of a nutrition history include
Components of a nutrition history include (cont.)
Long-term disease(s) affecting absorption/use of nutrients Dietary history – 24 hour recall/ food frequency Use of vitamin/ mineral or nutritional supplements Over the counter medications, vitamins and herbal remedies.
Shortness of breath on feedingDiet history Method of feed administration (employ a stepwise downward
Review through 24 hour dietary recall quarterly or at each approach)
Offer smaller volumes and more frequent feeds orally Use in conjunction with food frequency.
Give any unfinished feeds via naso-gastric tube if required Many patients may eat < 65% of RDI.
Give small frequent bolus feeds via naso-gastric tube
Top up small frequent daytime feeds with continuous overnight feeds via an
enteral feeding pump
Give feeds continuously over 24 hours via an enteral feeding pump.
NOBI (Non occlusive Bowel Injury)
Initiation of enteral feeds in patients with cirulatory compromise (sepsis,
cardiogenic shock, haemodynamic instability) may lead to delterious
changes on the structure and function of the gut. It is therefore imperitive to
monitor for any signs of feeding intollerance.
Fluid Ranges
Age (years)
ml/kg actual weight
Fluid Volume per 24 hours
Neonates and infants 2 – 10kg0 – 6 months DO NOT ALTER MEDICALLY INDICATED
FLUID RESTRICTION
(Fluid requirements include fluid from feed,
medication, IV fluids and oral sips)
Ventilated: Schofield equation or WHO/FAO/UNU x 1.3 – Post definitive operation (Cardiac Repair) Post definitive operation (Cardiac Repair) Ventilated: Schofield equation or WHO/FAO/UNU x 1.3 – Not ventilated: Schoflied using abw + activity 1.2 + 1.5 [No activity factor]stress 1.5 – 1.6 Non ventilated: Schofield using abw + activity 1.2 + stress1.5 – 1.6 In sedated, ventilated children’s energyexpenditure if often significantly reduced.
Aim to feed at 150kcal/kg and only increase to170kcal/kg if other factors effecting growth havebeen excluded Energy Supplementation
Infants:
No additional energy may be required in the pre-repair infant and breast milk and or standard ready to use/
hang infant formula [0.67kcal/ml] should be given.
If the patient is volume-restricted breast milk may be supplemented with a human milk fortifier or
carbohydrate/fat powder and or a ready to use/hang energy dense infant feed [1kcal/ml] should be given.
Children:
No additional energy may be required and a standard feed [1kcal/ml] should meet requirements in the volume
prescribed.
If the patient is volume restricted an energy dense [1.5 kcal/ml] ready to use/hang feed should be given.
NB:
No powders or liquids e.g. oil should be added to a sterile ready to use feed.
If additional energy is required in non-ventilated children then flushes of energy boluses should be provided
prior to a drink or feed including breastmilk.
Recommendations for fat, protein and carbohydrate concentrations should not be exceeded. [See sections
below]
Carbohydrate
The following concentrations of CHO per 100ml will be tolerated if a CHO/fat powder is used.
Infants8-9mg/kg/min [11.5g –12.9g/kg/day] 10-12% carbohydrate concentrations in infants under 6 months (i.e. 7g from formula, 3-5g added) Infants:Pre-operative or post shunt9 – 11% of total energy Up to 4 g/kg abwPost definitive operation (Cardiac Repair)9 – 11% of total energyDRV’s ChildrenPre-operative, post shunt and post definitiveoperation (Cardiac Repair)Up to 2 g/kg abw Adding Fat to formula/enteral feeds: Should be done as a last resort – rather add extra oil/ Infants will tolerate a total fat concentration of 5 – 6 %[e.g. 5 – 6g per 100ml of feed].
Children > 1yr will tolerate a fat concentration of 7% -concentrations above this may cause nausea/ vomiting.
It is recommended that a soluble carbohydrate/fat powderbe used in bolus form over modulars such as oil and/or aglucose polymer Micronutrients
A daily multi-vitamin should be given e.g. Abidec® The multivitamin should contain folate, niacin, thiamineor Vidaylin® Do not supplement Zinc for longer than 2 weeks.
Selenium and Zinc should only be supplemented if failing Selenium 2mg/kg abw with a max of 30mg/day to thrive and low serum levels.
Do not supplement iron during the first 10 days post- operatively as it increases the risk of redox.
Discharge Planning
Government: Supply sufficient micronutrient supplements supplementation of feeds (this can be started prior until follow up appointmentto discharge). The caregiver is asked to make up Private: 7 day TTO on hospital discharge and provide a the child’s supplemented feeds at ward level as a second script for at least 1 month supply.
way of educating him/her under supervision.
Continue multi-vitamins until catch up growth has been Provide caregiver with a date for dietetic follow up achieved.
or refer to a private practising dietitian.
Ask the doctor to write up a prescription TTO (ToTake Out) for multivitamins Post Discharge
Poor growth: monthlyIf failing to thrive, follow guidelines belowThriving: Quarterly 2.5 Entry and Exit Criteria for Nutrition Support
Entry Criteria Nutrition Support
Exit Criteria for nutrition support
NSP
NSP
Supplementation must be continued for only 6 months if Birth – 5 years: gained sufficient weight to attain a growth curve in relation entered onto the Nutrition Supplementation Programme.
to his/her normal growth curve and maintains the curve for three Children > 5 years < 18 years: When child’s growth curve flattens or drops over two consecutive months.
> 5yrs – 18 years who attain normal growth curve according to the growth Or Private Patients
chart within the 6 months period on the NSP scheme.
Or Private Patients
Downward crossing 2 or more centiles over a period of 1 monthUpward crossing of 2 or more centiles over a period of 1 month or 2or 2 consecutive visits.
MUAC < 12.5cm in children < 5years of age MUAC >15cm in children < 5 years of age.
Acute malnutrition: Weight/ Height Chronic malnutrition: height for age
< 89%
Referral
Additional Requirements
Nutritionally complete age appropriate supplement.
Access from local day hospital/ CHC 2.6 Complications
2.6.1 Chylothorax
Chylothorax is an uncommon post operative complication resulting in leakage of lymphatic fluid into the
pleural space due to surgical disruption of the thoracic duct or increased venous pressure of one of it's
main tributatries resulting in increased pressure within the intrathoracic lymph system
Diagnosis
The following needs to be present in the pleural fluid:
1) Triglycerides > 1.1 mmol/L
2) Chylomicrons positive
3) Chylomicrons negative with a lymphatic fraction > 80%
Treatment
1) Dietary
Bowel rest with total parenteral nutrition
Fat free diet or high LCT diet: this type of diet should be followed in a clinical environment only due to
the high risk of developing essential fatty acid (EFA) deficiency and should not be followed for more than
2 weeks.
High MCT enteral nutrition: Use monogen
2) Surgical
3) Octreotide
Refer to Appendix 2 for the recommended treatment algorithm
2.6.2 Chylous Ascites
Chylous ascites is an accumulation of chyle in the peritoneal cavity due to obstruction or rupture of the
peritoneal or reperitoneal lymphatic glands, increased venous pressure or congestive cardiac failure.
Diagnosis (Paracentesis)
The following needs to be present in the fluid
1) Triglycerides 200mg/dl
2) Predominance of lymphocytes > 75%
Treatment
Bowel rest with total parenteral nutrition
2.6.3 Acute Myocarditis
Treatment
CCME:
L-carnitine 5 – 15 mg/kg (max 1g) 6H(IV) or orally 25 mg/kg 6 – 12H (max 3g/day)
Co-enzyme Q10 1 – 4 mg/kg daily oral
Magnesium Sulphate IV 2 mmol/ml (max 10ml) 12H slow IV
Vitamin E 50 – 1000IU < 3yr or 200 – 400IU >3yr
2.7 Appendix 1:The CHD patient
To ensure that each patient with congenital heart disease attains/ maintains an
optimal nutrition status.
Assess patient using the following approach: To read the chart:
Implement nutrition support where appropriate Anthropometric assessment determine patient’s nutritional status & risk:
Height
Is there growth falteringor failing during last Assess dietary intake
Encourage caregiver and child around good food intake.
Advise caregiver around food based dietary guidelines Is the intake appropriate according to the Entry to Nutrition Support:
Calculate Dietary Requirements & recommend nutrition supplementation according to treatment Advise caregiver around food based dietary guidelines modality (pre operative/post shunt or post Promote small frequent meals x 3 and snacks 2 – 3 per day.
Recommend energy & nutrient dense foods & drinks Exit Nutrition Support when:
Birth to 5 years – Normal growth
curve RTCH following 3 months on
NSP scheme.
Provide sufficient energy & protein to Biochemistry & Clinical
Monitor the following:
Paediatric Supplements available:
Hospitalised
Infants
Paediatric Supplements available:
Supplementation of complementary
Discharged
foods: Discharged
0.67kcal/ml RTU/H feed1kcal/ml RTU/H feed (fluid restricted) Breast milk with a breast milk fortifier if 1kcal/ml RTU/H nutritionally complete feed.
For additional energy required for bothinfants and children consider a supersoluble CHO/fat p 10 2.8 APPENDIX 2 9 Chylothorax Management Diagram
Persistent Chest Tube Drainage
(> 5mL/kg/day)
Or
Presence of Milky Drainage
Chyle presentChyle not present withLymphocyte faction >80% Pleural Fluid sent for:+/- Triglyceride > 1.1mmol/L NO
PHASE 2
Start TPN/NPO for 5 daysAttain longer-term vascular accessStop suction of chest tube if had aortic archreconstruction,notify surgeon toconsider earlythoracic duct PHASE 3
Start Prednisone (1mg/kg/day twice
daily) for 5 – 7 days
decreasing drainageReturn to MCT/minimal fat dietStop TPN when adequate enteral PHASE 4
Start Octreotide (0.5 – 4 mcg/kg/hr IV
continuous infusion) for 5 days
Octreotide 5mcg/kg/dose IV q8th if
Stop prednisoneStop suction of chest tubes if decreasingdrainageContinue MCT/minimal fat diet NO
Return to Phase 3 with slower
wean of prednisone
NO
Wean Octreotide by 25% daily
over 4 days
Cardiac catheterisation
Fat Challenge
5 – 6 g/kg fat given as a bolus using a 1kcal/ml shunt if chest tubescontinue to drain > 11 If there is no chyle present then remove the Recommend that a low fat diet be followed forat least 2 weeks and a follow up chest X-raybe done weekly.
2.9 APPENDIX 3 1
Minimal LCT (Long Chain Triglycerides) diet (In Hospital)
Requirement of LCT: 1g LCT per year of life up to a maximum of 4 – 5g LCT per day Suitable foods for use in a low LCT diet
Average Portion Size (g)
LCT per portion (g)
Breakfast Cereals
Cornflakes
Bread
White, large thin slice
Fish
White hake fillet
Meat and Poultry
Roast Turkey, light meat
Legumes, Pasta, Rice
Baked beans in tomato sauce 200
Fortify skimmed milk with a glucose polymer.
Free Foods for a Minimal LCT Diet
All fruit, fresh, frozen or tinned (except olives and avocado)All vegetables fresh, tinned or frozenSugar, honey, golden syrup, treacle, jam and marmalade bies, wine gums, lollie pops or fruit pastilles Boiled sweets, mints (not butter mints)Fruit sorbets (milk free), water ices and ice lolliesMeringue, egg whiteSpices and essencesSalt, pepper, vinegar, herbs, tomato sauce, most chutneys, Marmite, Oxo and BovrilFruit juices, fruit squashes, bottle fruit saucesFizzy drinks, lemonade, cola

Source: http://www.adsa.org.za/Portals/14/Documents/Clinical20Guidelines20Congenital20Heart20Disease20Annotated.pdf