Assessment of Energy and Protein Requirements in Relation to Nitrogen Kinetics, Nutrition, and Clinical Outcomes in Infants Receiving Early Enteral Nutrition Following Cardiopulmonary Bypass

Abstract

Background Nutrition therapies in children with congenital heart disease (CHD) after cardiopulmonary bypass (CPB) is crucial, but energy and protein requirements remain undefined. We assessed energy and protein requirements, with nitrogen kinetics and clinical outcomes, in infants with complex CHD following CPB. Methods Infants were randomized to control (1.3 g/kg/d), moderate protein (MP, 2.5 g/kg/d), or high protein (HP, 4 g/kg/d) groups. Resting energy expenditure (REE) was measured 6 hours post‐CPB and then at 24‐hour intervals, using indirect calorimetry to formulate energy intakes. Enteral formula feeding was initiated 6 hours post‐CPB and continued for 5 days. Nitrogen balance (NB); urea nitrogen waste and nitrogen retention; serum prealbumin level; and hepatic, renal, and cardiac function were measured daily. Mid‐upper arm circumference and triceps skinfold were measured preoperatively and 5 days after CPB. Adverse outcomes (bacterial infection, reintubation, and cardiac intensive care unit (CICU) stay > 8 days) were recorded. Results REE was not different across the 3 groups (P = .37). It declined from 62 ± 6 to 57 ± 7 kcal/kg/d over 5 days post‐CPB (P = .02). NB and nitrogen retention became positive by day 3 in the HP group but remained negative in the other 2 groups (P = .045–.003), despite higher urea nitrogen waste in the HP group (P < .0001). The HP group had a greater increase in serum prealbumin level and anthropometric measures (P = .009–.03). Other measures were not significantly different across the 3 groups. Conclusions In infants with complex CHD in the first 5 days post‐CPB, protein and energy intakes of ≈4 g/kg/d and 60 kcal/kg/d, respectively, led to improved nutrition outcomes without increased adverse events.

Current Strategies to Optimize Nutrition and Growth in Newborns and Infants with Congenital Heart Disease: A Narrative Review

“…Increasing the quality and quantity of dietary nutrients, and focusing on nutrient energy-dense feed, are associated with improved weight gain and the achievement of nutritional targets [ 1 , 2 ]. Total fluid intake in conjunction with optimal energy protein supply, guided by a multidisciplinary team is essential [ 50 , 51 ].…”

“…A primary aim in infants with CHD is also to provide sufficient dietary protein to enable adequate new protein synthesis. Proteins are necessary for tissue repair and growth, and they facilitate wound healing, modulate inflammatory responses, and preserve skeletal muscle mass [ 8 , 51 ].…”

Effect of energy‐ and/or protein‐dense enteral feeding on postoperative outcomes of infant surgical patients with congenital cardiac disease: A systematic review and meta‐analysis

“…An imbalance between energy intake and requirements leads to malnutrition among these infants postoperatively. It has been well documented that the energy intake of infants with congenital cardiac repair is less than their requirements because of fluid restrictions, feeding intolerance, and frequent feeding interruptions 2–5 . Breast milk is considered as the ideal nutrition that provides several benefits to the infants 6 .…”

“…Clinical trials have shown that the supplementation of expressed breast milk (EBM) or energy‐dense formula feeds via tube feeding (nasogastric/orogastric) in the immediate postoperative period increases the energy or protein intakes postoperatively 11,12 . Thus supplemented feeding improves weight as compared with those fed with EBM or standard formula feed 4,11,12 . One randomized controlled trial (RCT) has reported that feeding interruption and feeding intolerance are the major problems that hinder energy consumption, even in supplemented group of patients 3 .…”

“…However, the literature has shown conflicting results regarding the efficacy of nutrition intervention on postoperative nutrition and clinical outcomes 2–6 . The variability in the results of each outcome has been reported to be due to heterogeneity and the presence of selection bias, performance bias, detection bias, reporting bias, and publication bias.…”