Risk Factors for Adverse Outcomes in Term Infants with CHD and Definitive Necrotising Enterocolitis.

OBJECTIVES: To define the incidence of definitive necrotising enterocolitis in term infants with CHD and identify risk factors for morbidity/mortality. METHODS: We performed a 20-year (2000-2020) single-institution retrospective cohort study of term infants with CHD admitted to the Boston Children's Hospital cardiac ICU with necrotising enterocolitis (Bell's stage ≥ II). The primary outcome was a composite of in-hospital mortality and post-necrotising enterocolitis morbidity (need for extracorporeal membrane oxygenation, multisystem organ failure based on the paediatric sequential organ failure assessment score, and/or need for acute gastrointestinal intervention). Predictors included patient characteristics, cardiac diagnosis/interventions, feeding regimen, and severity measures. RESULTS: Of 3933 term infants with CHD, 2.1% (n = 82) developed necrotising enterocolitis, with 67% diagnosed post-cardiac intervention. Thirty (37%) met criteria for the primary outcome. In-hospital mortality occurred in 14 infants (17%), of which nine (11%) deaths were attributable to necrotising enterocolitis. Independent predictors of the primary outcome included moderate to severe systolic ventricular dysfunction (odds ratio 13.4,confidence intervals 1.13-159) and central line infections pre-necrotising enterocolitis diagnosis (odds ratio 17.7, confidence intervals 3.21-97.0) and mechanical ventilation post-necrotising enterocolitis diagnosis (odds ratio 13.5, confidence intervals 3.34-54.4). Single ventricle, ductal dependency, and feeding related factors were not independently associated with the primary outcome. CONCLUSIONS: The incidence of necrotising enterocolitis was 2.1% in term infants with CHD. Adverse outcomes occurred in greater than 30% of patients. Presence of systolic dysfunction and central line infections prior to diagnosis and need for mechanical ventilation after diagnosis of necrotising enterocolitis can inform risk triage and prognostic counseling for families.

Enteral feeding algorithm for infants with hypoplastic left heart syndrome poststage I palliation.

BACKGROUND: Infants with hypoplastic left heart syndrome (HLHS) experience a high incidence of growth failure in the postoperative period following stage I palliation. Because of an increased risk of necrotizing enterocolitis in this population, clinicians may be reluctant to initiate early enteral feedings. Published guidelines for initiating and advancing enteral feedings in this population are limited. OBJECTIVE: To test the safety and efficacy of an enteral feeding algorithm in infants with HLHS following stage I palliation. DESIGN: Single-center, prospective case series with historical comparisons. SETTING: Pediatric cardiovascular intensive care unit in tertiary care children's hospital. PATIENTS: The study group consisted of consecutive patients > or =35 wks gestational age and weight > or =2 kg admitted to our cardiac intensive care unit over an 18-month period following stage I palliation of HLHS (n = 36). Excluded were nonsurvivors, patients supported on extracorporeal membrane oxygenation or those with a history of NEC or fetal intervention. These data were compared with a similar cohort of patients admitted to the cardiac intensive care unit over an 18-month period before the implementation of the feeding algorithm (n = 27). INTERVENTION: A feeding algorithm was implemented in the study group in the postoperative period for initiation and advancement of enteral nutrition. MEASUREMENTS AND MAIN RESULTS: The median duration of total parenteral nutrition was significantly higher in the control group (116 vs. 51 hrs; p = 0.03) compared with the study group. The median time to achieve recommended daily allowance of calories defined as 108 kcal/kg per day was significantly reduced in the study group (9 vs. 13 days; p = 0.01). Despite the rapid advancement of enteral feedings on the algorithm, there was no incidence of NEC in the study group compared with 11% in the control group. CONCLUSION: The use of an enteral feeding algorithm is a safe and effective means of initiating and advancing enteral nutrition in infants with HLHS following stage I palliation.

Management of the pediatric postoperative cardiac surgery patient.

Optimal management of the postoperative pediatric cardiac surgical patient requires a thorough understanding of patient anatomy, physiology, surgical repair or palliation, and clinical condition. This necessitates a dedicated team of clinicians including skilled nurses, physicians, and respiratory therapists specialized in the care of patients who have complex congenital heart disease. This article provides an overview of the multisystemic risk factors and consequences associated with cadiopulmonary bypass and cardiac surgery. An evaluation of cardiac hemodynamics and a review of major organ systems are included. Essential assessment information and interventional strategies for managing the pediatric postoperative cardiac surgery patient are detailed.