Nutrition Implications of Heart Failure and Heart Transplantation in Children With Dilated Cardiomyopathy

Abstract

This article describes nutrition implications of pediatric dilated cardiomyopathy leading to heart transplantation with a focus on nutritional management of patients during the waiting time for a donor organ and the inpatient postoperative period. Optimization of nutritional status is essential during these periods as weight loss and malnutrition contribute to muscle atrophy, decreased functional capacity, reduced immune function, and prolonged hospital stay. Nutrition implications of heart failure vary with patient's age and degree of symptoms. Infants may have increased caloric needs and poor feeding often due to tachypnea. Older children, 1-18 years, may have decreased appetite, abdominal pain, and vomiting. Ventricular assist devices or extracorporeal membrane oxygenation, necessary to sustain life in some cases, have additional nutrition implications related to wound healing from insertion of the device and device-related complications that can include pancreatitis and the need for total parenteral nutrition. Once symptomatic heart failure is relieved and heart transplant occurs, caloric needs often decrease while interest in eating can increase profoundly, changing the overall nutrition diagnosis and the need for nutrition support. A case series involving an infant, a young child, and an adolescent is presented to illustrate nutritional challenges and interventions for pediatric patients awaiting heart transplant and the inpatient postoperative period.

Optimizing Nutrition in Pediatric Heart Failure: The Crisis Is Over and Now It’s Time to Feed

“…Suboptimal nutrition during periods of critical illness has been associated with poor surgical and clinical outcomes . This includes muscle atrophy, decreased functional ability, compromised immune function, prolonged hospital stays, increased morbidity, and a higher risk of mortality (see Figure ) …”

“…Growth may also be compromised by intestinal malabsorption and dysfunction . Chronic hypoxia and gut edema from venous congestion can lead to insufficient utilization of nutrients and malabsorption . Bowel wall edema may cause structural changes to the gastrointestinal system, including increased wall thickness of the terminal ileum, ascending colon, transverse colon, descending colon, and sigmoid .…”

“…Chronic hypoxia and gut edema from venous congestion can lead to insufficient utilization of nutrients and malabsorption . Bowel wall edema may cause structural changes to the gastrointestinal system, including increased wall thickness of the terminal ileum, ascending colon, transverse colon, descending colon, and sigmoid . Appropriate monitoring could help to improve nutrition status and provide increased endogenous substrate to better meet the metabolic demands imposed by surgical stress during cardiac transplant …”

“…7,8 This includes muscle atrophy, decreased functional ability, compromised immune function, prolonged hospital stays, increased morbidity, and a higher risk of mortality (see Figure 1). 9,10 Studies have shown that weight-for-age z scores can positively and independently correlate with survival. 4 In a pediatric single-center study, poor growth preoperatively was found to be a risk factor for posttransplant mortality, as well as decreased time to first rejection, decreased graft survival, and increased graft vasculopathy.…”

“…Infants often present with tachypnea, tachycardia, and fatigue, while older children may experience exercise intolerance, decreased appetite, abdominal pain, nausea, and shortness of breath. 9 Furthermore, HF may lead to chronic autonomic sympathetic and parasympathetic imbalance. 18 Continuous sympathetic stimulation activates the renin-angiotensin-aldosterone axis system.…”