Acute Care Pediatric Nurse Practitioner Children's National Hospital Bethesda, Maryland, United States
Abstract: Introduction/Objective
Malnutrition and growth restrictions are common in children with congenital heart disease, worse in the presence of congestive heart failure. Common contributors to malnutrition include hypermetabolism, poor oral intake, feeding intolerance and fluid restriction. Even though intensive nutritional support is associated with better outcomes, delivering optimal nutrition is inherently challenging for this patient population. The most common strategy to enhance nutritional intake for this patient population is high energy feeds with fortified formula and NG feeding. Total parenteral nutrition (TPN) is also used to provide nutritional support, but it is typically reserved for patients with hemodynamic instability and/or intolerance to enteral nutrition (EN). Currently, there is no data that directly compares the nutritional efficacy and safety of TPN vs. fortified EN in children with heart failure. Furthermore, there are no studies that describe the outcome of partial supplementation with TPN in pediatric heart failure patients who are unable to gain weight on optimized EN. This study aims to investigate the efficacy and safety of supplemental TPN to EN in pediatric patients with heart failure.
Methods This was a retroactive single center study. Study period was 2015-2021. Inclusion criteria included patients 0-18 years of age with heart failure requiring vasoactive support and/or ventricular assist device, who underwent treatment with supplemental TPN for failure to gain adequate weight, despite stable and optimized EN. Patients unable to tolerate feeds due to GI pathologies were excluded. Physiologic, laboratory and nutritional data were collected two weeks pre/post treatment with supplemental TPN in addition to EN.
Results 4 patients met inclusion criteria for analysis. The age range was 6 months - 6 years. 3 out of 4 patients were < 10% percentile on weight. No consistent pattern of positive weight gain was observed during treatment follow up. Two patients gained weight, whereas two patients demonstrated weight loss. However, daily caloric intake was significantly improved with supplemental TPN compared to EN alone (98kcal/kg/day vs 72kcal/kg/day). Protein intake was also significantly improved with supplemental TPN (3.09g/kg/day vs. 2.1g/kg/day). Fluid intake was increased in 2 patients, with an average addition of 12ml/kg/day of fluid with supplemental TPN. However, there was no corresponding significant change in daily fluid balance in those patients. BUN was higher in 2 patients post treatment (32mg/dL vs. 27mg/dL), but creatine was unchanged (0.28mg/dL vs. 0.28mg/dL). Vasoactive support, heart rate and blood pressure were not significantly different between pre/post treatment period. There was also no significant change in respiratory status for all patients between pre/post treatment period.
Conclusion No significant weight gain was seen after two weeks of initiation of supplemental TPN. However, patients received more calories and more protein when receiving the combination of EN and TPN. Importantly, there was no adverse impact on the cardiovascular, renal or respiratory systems.
