Sagiv E, Tjoeng YL, Davis M, Keenan E, Fogel J, Fogg K, Slater N, Prochaska-Davis S, Frontier KD, Fridgen J, Chan T.Pediatr Cardiol. 2022 Jun;43(5):1141-1155. doi: 10.1007/s00246-022-02837-9. Epub 2022 Feb 14.PMID: 35157095
Take Home Points:
- Preoperative oral feeding was not associated with tube-free feeding in the first year of life
- Preoperative oral feeding was also not associated with increased risk of NEC, but markers of increased severity of illness and more difficult post-operative clinical course were
- Oral feeding can and should be offered to the appropriate risk patients, but our expectations of outcomes may need to be tempered and defining that patient group may not always be simple
Commentary from Dr. Jared Hershenson (Greater Washington DC), section editor of Pediatric Cardiology Journal Watch:
Patients with HLHS or single ventricular lesions with no or decreased systemic outflow require a patient ductus arteriosus for systemic perfusion. Due to significant diastolic run-off to the pulmonary vasculature, systemic and primarily splanchnic circulation may be compromised, increasing the risk for necrotizing enterocolitis (NEC), and enteral feeding may increase risk. However, there is some data to suggest early feeding may reduce perioperative morbidity, lower length of hospital stay, and improve parental bonding and neurodevelopmental outcomes. Since optimal nutrition leads to better interstage survival and decreased morbidity at the 2nd stage palliation surgery, many patients will have a feeding tube to ensure adequate calories. Previous NPC-QIC data and the Single Ventricle Reconstruction (SVR) trial showed that about ~60% of patients are discharged home with feeding tubes after stage 1 palliation (S1P). Tube free feeding (TFF) is an important goal for parents and tube dependance has a negative effect on neurodevelopment. This study performed a secondary analysis of NPC-QIC phase II registry data and hypothesized that preoperative introduction of oral and enteral feedings would be associated with earlier TFF in the first year of life.
All data was obtained from the registry. The independent variable was preoperative enteral feeding and categorized as oral only, oral with tube feedings, tube feeds only, NPO for clinical reasons, and NPO due to institutional practice. Timing, volume, and reasons for these choices were not available. Dependent variables included TFF at hospital discharge after S1P, at the time of S2P admission, and 1st birthday. Patients were grouped as HLHS and non-HLHS, and secondary factors such as restrictive atrial septum, anomalous pulmonary veins, AV valve regurgitation, arrhythmias, low birth weight, prematurity, genetic syndrome, and non-cardiac anomalies were also assessed with regards to outcomes.
The authors provide a lot of demographic and preoperative characteristics. 944 patients from 57 institutions completed both surgeries and survived to age 1 and were included in the study with regards to TFF. To summarize, 41% were fed orally, 5% oral and tube, 11% tube only, 12% not fed for institutional practice and 30% not fed for a clinical reason. There were some clinical differences between those, with those receiving oral feeds having lower rates of markers suggesting higher severity illness. At hospital discharge after S1P, 57% of patients required tube feeding, and 39% still required tube feeding at the 1st birthday.
When comparing those that achieved TFF with univariate analysis, while the pre-op feeding group had the highest rates of TFF, this was not significantly different compared to those who were not fed for institutional reasons. This was significantly different when compared to those fed via feeding tube or NPO due to clinical reasons. However, on multivariate analysis pre-op feeding was not associated with TFF at one year (OR 1.3, CI 0.8-2). For pre-op feeding variables, the OR was calculated comparing to patients not fed enterally for institutional practice. For feeding mode at discharge, OR was calculated comparing to patients who were discharged without a feeding tube. Need for a feeding tube at S1P discharge though was significantly negatively associated with TFF at one year. Other risk factors for less likelihood to TFF included genetic syndrome, lower GA, need for PA band or AV valve repair, ECMO, and >2 postop complications. See Figure 1
Data from 1740 patients were available to determine the risk of NEC. 229 patients (13.2%) developed NEC, most occurring post-operatively (88%). Patients who received both oral and tube feeding pre-operatively had the highest risk of both pre- and post-op NEC, but when compared to those not fed for institutional practice, there was no significant risk of NEC. PO feeding alone was also not associated with increased risk. However, on multivariate analysis, for pre-op NEC, the group that received both oral and tube feeds did have an increased risk (OR 4.0). However, tube feeding only was not a risk factor. This was a small overall cohort, and the authors discuss reasons why this group may have been unique. But, other risk factors were also present, including pre-op neurologic deficit and PA banding prior to S1P. On the other hand, for post-op NEC, pre-op feeding type was not associated with post-op NEC. Other risk factors were present, most of which were due to higher severity of illness or complicated post-op clinical course. See Figure 2. Notably, those that were NPO preoperatively based on institutional practice did not have a decreased risk of NEC post-operatively.
One of the more difficult decisions in the preoperative and postoperative single ventricle patients is feeding; when to feed, who to feed, how to feed. Due to the sheer amount of data, sometimes the article was at times a bit hard to follow. However, the important take home point is that for the lower risk patient, there is not a significant increase risk of NEC, and with the overall positive benefits of feeding including earlier time to full feeds, lower hospital stay, and psychosocial and neurodevelopmental benefits (even without a statistically significant difference TFF at one year), it is possible that more patients could and should be fed, especially at those institutions who currently do not feed at all. With additional time and data, the hope is that standardized feeding algorithms based on clearly defined risk stratification can be developed for use across institutions.