Adequate caloric intake plays a vital role in the course of illness and the recovery of critically ill patients. Nutritional status and nutrient delivery during critical illness have been linked to clinical outcomes such as mortality, incidence of infection, and length of stay. However, feeding practices with critically ill pediatric patients after cardiac surgery are variable. The Pediatric Cardiac Intensive Care Society sought to provide an expert review on provision of nutrition to pediatric cardiac intensive care patients, including caloric requirements, practical considerations for providing nutrition, safety of enteral nutrition in controversial populations, feeding considerations with chylothorax, and the benefits of feeding beyond nutrition. This article addresses these areas of concern and controversy.
BechardLJDugganCTouger-DeckerR. Nutritional status based on body mass index is associated with morbidity and mortality in mechanically ventilated critically ill children in the PICU. Crit Care Med. 2016;44(8):1530–1537.
2.
CastilloASantiagoMJLópez-HerceJ. Nutritional status and clinical outcome of children on continuous renal replacement therapy: a prospective observational study. BMC Nephrol. 2012;13:125.
3.
de Souza MenezesFLeiteHPKoch NogueiraPC. Malnutrition as an independent predictor of clinical outcome in critically ill children. Nutrition. 2012;28(3):267–270.
4.
DelgadoAFOkayTSLeoneCNicholsBDel NegroGMVazFA. Hospital malnutrition and inflammatory response in critically ill children and adolescents admitted to a tertiary intensive care unit. Clinics (Sao Paulo). 2008;63(3):357–362.
5.
MehtaNMBechardLJCahillN. Nutritional practices and their relationship to clinical outcomes in critically ill children—an international multicenter cohort study. Crit Care Med. 2012;40(7):2204–2211.
6.
MehtaNMBechardLJZurakowskiDDugganCPHeylandDK. Adequate enteral protein intake is inversely associated with 60-d mortality in critically ill children: a multicenter, prospective, cohort study. Am J Clin Nutr. 2015;102(1):199–206.
7.
RossPANewthCJLeungDWetzelRCKhemaniRG. Obesity and mortality risk in critically ill children. Pediatrics. 2016;137(3):e20152035.
8.
MittingRMarinoLMacraeDShastriNMeyerRPathanN. Nutritional status and clinical outcome in postterm neonates undergoing surgery for congenital heart disease. Pediatr Crit Care Med. 2015;16(5):448–452.
9.
Medoff-CooperBIrvingSYHanlonAL. The association among feeding mode, growth, and developmental outcomes in infants with complex congenital heart disease at 6 and 12 months of age. J Pediatr. 2016;169:154–159.
10.
Schwalbe-TerilliCRHartmanDHNagleML. Enteral feeding and caloric intake in neonates after cardiac surgery. Am J Crit Care. 2008;18(1):52–57.
11.
Petrillo-AlbaranoTPettignanoRAsfawMEasleyK. Use of a feeding protocol to improve nutritional support through early, aggressive, enteral nutrition in the pediatric intensive care unit. Pediatr Crit Care Med. 2006;7(4):340–344.
12.
VelazcoCSZurakowskiDFullertonBSBechardLJJaksicTMehtaNM. Nutrient delivery in mechanically ventilated surgical patients in the pediatric critical care unit. J Pediatr Surg. 2017;52(1):145–148.
13.
Abad-JorgeA. Nutrition management of the critically ill pediatric patient: minimizing barriers to optimal nutrition support. Infant Child Adolesc Nutr. 2013;5(4):221.
14.
MehtaNMSkillmanHEIrvingSY. 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. JPEN J Parenter Enteral Nutr. 2017;41(5):706–742.
15.
MehtaNMBechardLJLeavittKDugganC. Cumulative energy imbalance in the pediatric intensive care unit: role of targeted indirect calorimetry. JPEN J Parenter Enteral Nutr. 2009;33(3):336–344.
16.
PrietoMBCidJL. Malnutrition in the critically ill child: the importance of enteral nutrition. Int J Environ Res Public Health. 2011;8(11):4353–4366.
17.
OwensJLMusaN. Nutrition support after neonatal cardiac surgery. Nutr Clin Pract. 2009;24(2):242–249.
18.
MehtaNMDugganCP. Nutritional deficiencies during critical illness. Pediatr Clin North Am. 2009;56(5):1143–1160.
19.
SlickerJHehirDAHorsleyM. Nutrition algorithms for infants with hypoplastic left heart syndrome; birth through the first interstage period. Congenit Heart Dis. 2013;8(2):89–102.
20.
NydeggerABinesJE. Energy metabolism in infants with congenital heart disease. Nutrition. 2006;22(7-8):697–704.
21.
RomanB.Nourishing little hearts: nutritional implications for congenital heart defects. Pract Gastroenterol. 2011;98:11–34.
22.
AARC clinical practice guideline: metabolic measurement using indirect calorimetry during mechanical ventilation. American Association for Respiratory Care. Respir Care. 1994;39(12): 1170-1175.
23.
McClaveSATaylorBEMartindaleRG; Society of Critical Care Medicine; American Society for Parenteral and Enteral Nutrition. Guidelines for the provision and assessment of nutrition support in adult critically ill patient. JPEN J Parenter Enteral Nutr. 2016;40(2):159–211.
24.
KauffmanJVichayavilasPRannieM. Improved nutrition delivery and nutrition status in critically ill children with heart disease. Pediatrics. 2015;135(3):e717–e725.
25.
YoshimuraSMiyazuMYoshizawaS. Efficacy of an enteral feeding protocol for providing nutritional support after paediatric cardiac surgery. Anaesth Intensive Care. 2015;43(5):587–593.
26.
TooleBJTooleLEKyleUGCabreraAGOrellanaRACoss-BuJA. Perioperative nutritional support and malnutrition in infants and children with congenital heart disease. Congenit Heart Dis. 2014;9(1):15–25.
27.
AltenJARhodesLATabbuttS. Perioperative feeding management of neonates with CHD: analysis of the Pediatric Cardiac Critical Care Consortium (PC4) registry. Cardiol Young. 2015;25(8):1593–1601.
28.
BraudisNJCurleyMABeaupreK. Enteral feeding algorithm for infants with hypoplastic left heart syndrome poststage I palliation. Pediatr Crit Care Med. 2009;10(4):460–466.
29.
del CastilloSLMcCulleyMEKhemaniRG. Reducing the incidence of necrotizing enterocolitis in neonates with hypoplastic left heart syndrome with the introduction of an enteral feed protocol. Pediatr Crit Care Med. 2010;11(3):373–377.
30.
ManuriLMorelliSAgatiS. Early hybrid approach and enteral feeding algorithm could reduce the incidence of necrotising enterocolitis in neonates with ducuts-dependent systemic circulation. Cardiol Young. 2017;27(1):154–160.
31.
SlickerJSables-BausSLambertLM. Perioperative feeding approaches in single ventricle infants: a surgery of 46 centers. Congenit Heart Dis. 2016;11(6):707–715.
32.
NatarajanGAnneSRAggarwalS. Enteral feeding of neonates with congenital heart disease. Neonatology. 2010;98(4):330–336.
33.
ZyblewskiSCNietertPJGrahamEMTaylorSNAtzAMWagnerCL. Randomized clinical trial of preoperative feeding to evaluate intestinal barrier function in neonates requiring cardiac surgery. J Pediatr. 2015;167(1):47–51.
34.
BeckerKCHornikCPCottonCM. Necrotizing enterocolitis in infants with ductual-dependent congenital heart disease. Am J Perinatol. 2015;32(7):633–638.
35.
WillisLThureenPKaufmanJWymoreESkillmanHda CruzE. Enteral feeding in prostaglandin-dependent neonates: is it a safe practice?J Pediatr. 2008;153(6):867–869.
36.
TomsRJacksonKWDabalRJReebalsCHAltenJA. Preoperative trophic feeds in neonates with hypoplastic left heart syndrome. Congenit Heart Dis. 2015;10(1):36–42.
37.
PanchalAKManziJConnollyS. Safety of enteral feedings in critically ill children receiving vasoactive agents. JPEN J Parenter Enteral Nutr. 2016;40(2):236–241.
38.
SánchezCLópez-HerceJCarrilloABustinzaASanchoLVigilD. Transpyloric enteral feeding in the postoperative of cardiac surgery in children. J Pediatr Surg. 2006;41(6):1096–1102.
39.
LyonsKABrilliRJWiemanRAJacobsBR. Continuation of transpyloric feeding during weaning of mechanical ventilation and tracheal extubation in children: a randomized controlled trial. JPEN J Parenter Enteral Nutr. 2002;26(3):209–213.
40.
FivezRKerklaanDMesottenD. Early versus later parenteral nutrition in critically ill children. N Engl J Med. 2016;374(12):1111–1122.
41.
LambertLMPikeNAMedoff-CooperB. Variation in feeding practices following the norwood procedure. J Pediatr. 2014;164(2):237–242.e1
42.
RicciMFAltonGYRossDB. Gastrostomy tube feeding after neonatal complex cardiac surgery identified the need for early developmental intervention. J Pediatr. 2016;169:160–165.
43.
HillGDHehirDABartzPJ. Effect of feeding modality on interstage growth after stage I palliation: a report from the National Pediatric Cardiology Quality Improvement Collaborative. J Thorac Cardiovasc Surg. 2014;148(4):1534–1539.
44.
El-Sayed AhmedMMAl-NajjarRMAftabMAntonJMColenJSReulRM. Early detection of cavopulmonary tumor embolus with the use of transesophageal echocardiography. Tex Heart Inst J. 2015;42(1):66–69.
45.
TysonJEdeSaDJMooreS. Thromboatheromatous complications of umbilical arterial catheterization in the newborn period. clinicopathological study. Arch Dis Child. 1976;51(10):744–753.
46.
WesstromGFinnstromOStenportG. Umbilical artery catheterization in newborns. I. Thrombosis in relation to catheter type and position. Acta Paediatr Scand. 1979;68(4):575–581.
47.
TiffanyKFBurkeBLCollins-OdomCOelbergDG. Current practice regarding the enteral feeding of high-risk newborns with umbilical catheters in situ. Pediatrics. 2003;112(1 Pt 1):20–23.
48.
DaveyAMWagnerCLCoxCKendigJW. Feeding premature infants while low umbilical artery catheters are in place: a prospective, randomized trial. J Pediatr. 1994;124(5 pt 1):795–799.
49.
McElhinneyDBHedrickHLBushDM. Necrotizing enterocolitis in neonates with congenital heart disease: risk factors and outcomes. Pediatrics. 2000;106(5):1080–1087.
50.
JeffriesHEWellsWJStarnesVAWetzelRCMoromisatoDY. Gastrointestinal morbidity after Norwood palliation for hypoplastic left heart syndrome. Ann Thorac Surg. 2006;81(3):982–987.
51.
RandTWeningerMKohlhauserC. Effects of umbilical arterial catheterization on mesenteric hemodynamics. Pediatr Radiol. 1996;26(7):435–438.
ShahJBBraceroLAGewitzMHFishBGDweckHS. Umbilical artery catheters and blood flow velocities in the superior mesenteric artery: effect of insertion, removal, aspiration and infusion. J Clin Ultrasound. 1998;26(2):74–77.
54.
HavranekTJohanboekePMadramootooCCarverJD. Umbilical artery catheters do not affect intestinal blood flow responses to minimal enteral feedings. J Perinatol. 2007;27(6):375–379.
55.
KingWPetrilloTPettignanoR. Enteral nutrition and cardiovascular medications in the pediatric intensive care unit. JPEN J Parenter Enteral Nutr. 2004;28(5):334–338.
56.
PasqualiSKOhyeRGLuM. Variation in perioperative care across centers for infants undergoing the Norwood procedure. J Thorac Cardiovasc Surg. 2012;144(4):915–921.
57.
MavroudisCMavroudisCDJacobsJP. Procedure-based complications to guide informed consent: analysis of society of thoracic surgeons-congenital heart surgery database. Ann Thorac Surg. 2014;97(5):1838–1851.
58.
BaumanMEMoherCBruceAKKuhleSKaurSMassicotteMP. Chylothorax in children with congenital heart disease: incidence of thrombosis. Thromb Res. 2013;132(2):e83–e85.
59.
IsmailSRKabbaniMSNajmHKShaathGAJijehAMHijaziOM. Impact of chylothorax on the early post operative outcome after pediatric cardiovascular surgery. J Saudi Heart Assoc. 2014;26(2):87–92.
60.
McCullochMAConawayMRHaizlipJABuckMLBovbjergVEHokeTR. Postoperative chylothorax development is associated with increased incidence and risk profile for central venous thromboses. Pediatr Cardiol. 2008;29(3):556–661.
61.
MeryCMMoffettBSKhanMS. Incidence and treatment of chylothorax after cardiac surgery in children: analysis of a large multi-institution database. J Thorac Cardiovasc Surg. 2014;147(2):678–686.
62.
BuckleyJRGrahamEMGaiesM. Clinical epidemiology and centre variation in chylothorax rates after cardiac surgery in children: a report from the Pediatric Cardiac Critical Care Consortium. Cardiol Young. 2017;29:1–8.
63.
BeghettiMLa ScalaGBelliDBugmannPKalangosALe CoultreC. Etiology and management of pediatric chylothorax. J Pediatr. 2000;136(5):653–658.
64.
ChanEHRussellJLWilliamsWGVan ArsdellGSColesJGMcCrindleBW. Postoperative chylothorax after cardiothoracic surgery in children. Ann Thorac Surg. 2005;80(5):1864–1870.
65.
MilonakisMChatzisACGiannopoulosNM. Etiology and management of chylothorax following pediatric heart surgery. J Card Surg. 2009;24(4):369–373.
66.
PanthongviriyakulCBinesJE. Post-operative chylothorax in children: an evidence-based management algorithm. J Paediatr Child Health. 2008;44(12):716–721.
67.
TutorJD. Chylothorax in infants and children. Pediatrics. 2014;133(4):722–733.
68.
YehJBrownERKelloggKA. Utility of a clinical practice guideline in treatment of chylothorax in the postoperative congenital heart patient. Ann Thorac Surg. 2013;96(3):930–936.
69.
BrownKLPagelCBrimmellR. Definition of important early morbidities related to paediatric cardiac surgery. Cardiol Young. 2016:27(4):747–756.
70.
CormackBEWilsonNJFinucaneKWestTM. Use of monogen for pediatric postoperative chylothorax. Ann Thorac Surg. 2004;77(1):301–305.
71.
JaliliF. Medium-chain triglycerides and total parenteral nutrition in the management of infants with congenital chylothorax. South Med J. 1987;80(10):1290–1293.
72.
FoggKLDellaValleDMBuckleyJRGrahamEMZyblewskiSC. Feasibility and efficacy of defatted human milk in the treatment for chylothorax after cardiac surgery in infants. Pediatr Cardiol. 2016;37(6):1072–1077.
73.
KocelSLRusselJO’ConnorDL. Fat-modified breast milk resolves chylous pleural effusion in infants with postsurgical chylothorax but is associated with slow growth. JPEN J Parenter Enteral Nutr. 2016;40(4):543–551.
74.
AljazairiASBhuiyanTAAlwadaiAHAlmehiziaRA. Octreotide use in post-cardiac surgery chylothorax: a 12-year perspective. Asian Cardiovasc Thorac Ann. 2017;25(1):6–12.
75.
CheungYLeungMPYipM. Octreotide for treatment of postoperative chylothorax. J Pediatr. 2001;139(1):157–159.
76.
LandvoigtMTMullettCJ. Octreotide efficacy in the treatment of chylothoraces following cardiac surgery in infants and children. Pediatr Crit Care Med. 2006;7(3):245–248.
77.
PratapUSlavikZOfoeVDOnuzoOFranklinRC. Octreotide to treat postoperative chylothorax after cardiac operations in children. Ann Thorac Surg. 2001;72(5):1740–1742.
78.
BangJHKimSHParkCSParkJJYunTJ. Anatomic variability of the thoracic duct in pediatric patients with complex congenital heart disease. J Thorac Cardiovasc Surg. 2015;150(3):490–495.
79.
LiuCSTsaiHLChinTWWeiCF. Surgical treatment of chylothorax caused by cardiothoracic surgery in children. J Chin Med Assoc. 2005;68(5):234–236.
80.
MatsuoSTakahashiGKonishiASaiS. Management of refractory chylothorax after pediatric cardiovascular surgery. Pediatr Cardiol. 2013;34(5) 1094–1099.
81.
NathDSSavlaJKhemaniRGNussbaumDPGreeneCLWellsWJ. Thoracic duct ligation for persistent chylothorax after pediatric cardiothoracic surgery. Ann Thorac Surg. 2009;88(1):246–252.
82.
ItkinMKucharczukJCKwakATrerotolaSOKaiserLR. Nonoperative thoracic duct embolization for traumatic thoracic duct leak: experience in 109 patients. J Thorac Cardiovasc Surg. 2010;139(3):584–590.
83.
DoriYKellerMSRomeJJ. Percutaneous lymphatic embolization of abnormal pulmonary lymphatic flow as treatment of plastic bronchitis in patients with congenital heart disease. Circulation. 2016;133(12):1160–1170.
84.
ItkinMKrishnamurthyGNaimMYBirdGLKellerMS. Percutaneous thoracic duct embolization as a treatment for intrathoracic chyle leaks in infants. Pediatrics2011;128(1):e237–e241.
85.
NadolskiGItkinM. Thoracic duct embolization for the management of chylothoraces. Curr Opin Pulm Med. 2013;19(4):380–386.
86.
HoskoteAURamaiahRNCaleCMHartleyJCBrownKL. Role of immunoglobulin supplementation for secondary immunodeficiency associated with chylothorax after pediatric cardiothoracic surgery. Pediatr Crit Care Med. 2012;13(5):535–541.
87.
KozikDJTweddellJS. Characterizing the inflammatory response to cardiopulmonary bypass in children. Ann Thorac Surg. 2006;81(6):S2347–S2354.
88.
AnnaneDBellissantEBollaertPEBriegelJKehDKupferY. Corticosteroids for treating sepsis. Cochrane Database Syst Rev. 2015;(12):CD002243.
89.
HeylandDKDhaliwalRDroverJWGramlichLDodekP; Canadian Critical Care Clinical Practice Guidelines Committee. Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN J Parenter Enteral Nutr. 2003;27(5):355–373.
90.
HernandezGVelascoNWainsteinC. Gut mucosal atrophy after a short enteral fasting period in critically ill patients. J Crit Care. 1999;14(2):73–77.
91.
HadfieldRJSinclairDGHouldsworthPEEvansTW. Effects of enteral and parenteral nutrition on gut mucosal permeability in the critically ill. Am J Respir Crit Care Med. 1995;152(5 Pt 1):1545–1548.
92.
FlohAAManlhiotCClariziaNA. A pro-inflammatory, hyperinsulin state, not hyperglycemia, is associated with adverse outcomes after pediatric heart surgery. Circulation. 2011;124:A13917.
93.
FlohAANakadaMLa RottaG. Feeding modifies the relationship between glucose metabolism, inflammation, and outcomes after pediatric heart surgery. Circulation. 2012;126:A18800.
94.
MarikPEZalogaGP. Early enteral nutrition in acutely ill patients: a systematic review. Crit Care Med. 2001;29(12):2264–2270.
95.
WongJJOngCHanWMLeeJH. Protocol-driven enteral nutrition in critically ill children: a systematic review. JPEN J Parenter Enteral Nutr. 2014;38(1):29–39.
96.
ArabiYMAldawoodASHaddadSH. Permissive underfeeding or standard enteral feeding in critically ill adults. N Engl J Med. 2015;372(25):2398–2408.
97.
VanhorebeekIGunstJDerdeS. Insufficient activation of autophagy allows cellular damage to accumulate in critically ill patients. J Clin Endocrinol Metab. 2011;96(4):E633–E645.
98.
RugelesSJOchoa GautierJBDickersonRN. How many nonprotein calories does a critically ill patient require? A case for hypocaloric nutrition in the critically ill patient. Nutr Clin Pract. 2017;32(suppl 1):72S–76S.
99.
HeylandDKMurchLCahillN. Enhanced protein-energy provision via the enteral route feeding protocol in critically ill patients: results of a cluster randomized trial. Crit Care Med. 2013;41(12):2743–2753.
100.
DoigGSSimpsonFBellomoR. Intravenous amino acid therapy for kidney function in critically ill patients: a randomized controlled trial. Intensive Care Med. 2015;41(7):1197–1208.
101.
EkmarkLRooyackersOWernermanJFläringU. Plasma glutamine deficiency is associated with multiple organ failure in critically ill children. Amino Acids. 2015;47(3):535–542.
102.
NovakFHeylandDKAvenellADroverJWSuX. Glutamine supplementation in serious illness: a systematic review of the evidence. Crit Care Med. 2002;30(9):2022–2029.
103.
AkisuMOzmenDBakaM. Protective effect of dietary supplementation with l-arginine and l-carnitine on hypoxia/reoxygenation-induced necrotizing enterocolitis in young mice. Biol Neonate. 2002;81(4):260–265.
104.
AminHJZamoraSAMcMillanDDHumaSHelenLRAbhayKL. Arginine supplementation prevents necrotizing enterocolitis in the premature infant. J Pediatr. 2002;140(4):425–431.
