SUMMARY Metabolisable energy intake, determined by bomb calorimetry of food, vomit, stool and urine, and resting metabolism, assessed by respiratory gas exchange, were studied in 21 infants with congenital heart disease and nine control infants. Weight for age, growth rates, and daily metabolisable energy intake per kg tended to be lower in infants with heart disease than in control infants. Resting oxygen consumption was high in those infants with pulmonary hypertension and persistent cardiac failure. Energy intake, as a percentage of that recommended for age, correlated with weight gain, and resting oxygen consumption correlated inversely with both percentage body mass index and relative fatness. Failure to thrive in infants with congenital heart disease may be due to a combination of low energy intakes and, in some cases, high energy requirements allowing insufficient energy for normal growth. Increasing the energy intakes of infants with congenital heart disease may be a way of improving their growth.Many children with congenital heart disease are small.' Their failure to thrive usually dates from early infancy, and postmortem studies suggest infants dying with congenital heart disease and failure to thrive are malnourished.2 There are several possible explanations for this: hypoxia and breathlessness may lead to feeding problems; anoxia or venous congestion of the bowel may result in malabsorption; peripheral anoxia and acidosis may lead to inefficient utilisation of nutrients; and increased metabolic rate may mean that recommended energy intakes are insufficient for normal growth and nutrition.Many of the studies investigating failure to thrive and congenital heart disease review children over wide age ranges.1 3 The findings in children of school age or adolescents will not necessarily indicate causes of poor growth that date from infancy. We have compared total energy intake, metabolisable energy intake (total energy ingested minus energy losses in stool, urine, and vomit), resting oxygen consumption, and growth rates of infants with congenital heart disease and normal infants to try to determine the causes of failure to thrive in infants with congenital heart disease.

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A mother's expressed breast milk (MEBM) is overall the best feed for her preterm baby during the neonatal period, and is associated with improved short-term and long-term outcomes. Neonatal services should commit the resources needed to optimise its use. The place of banked donor expressed breast milk (DEBM) is less clear, but it probably has a role in reducing the risk of necrotising enterocolitis and sepsis in preterm infants at particularly high risk. There is considerable variation in the composition of human milk and nutrient fortification is often needed to achieve intrauterine growth rates. Human milk can transmit potentially harmful micro-organisms, and pasteurisation, which denatures some of the bioactive factors, is the only known way of preventing this. This is carried out for DEBM but not MEBM in the UK. Future research on human milk should focus on (a) critical exposure periods, (b) understanding better its bioactive properties, (c) the role of DEBM and (d) nutritional quality assurance.