Growth and Nutrition





Malnutrition


Nutrition is fundamental for growth and neurologic development during childhood. However, malnutrition and growth impairment are common worldwide in infants and children with congenital heart disease (CHD). Growth failure is often multifactorial and may be attributable to inadequate energy intake, disordered oral feeding, increased metabolic demands, and disturbances in gastrointestinal (GI) function contributing to malabsorption. Associated genetic syndromes and chromosomal abnormalities may also lead to altered growth velocity. The combination of acute and chronic disease and pediatric malnutrition can have further detrimental effects on cognitive development, surgical outcomes, and disease-related morbidity and mortality.


Neonates with CHD are more vulnerable to nutrition deficits than at any other time during childhood, particularly preterm neonates or infants with intrauterine growth restriction. The risk of malnutrition is related to reduced nutrient stores at birth, immature absorption and utilization of nutrients, organ immaturity, delayed advancement of parenteral and enteral feeds, and dependence on health care providers to accurately identify and effectively provide optimal nutrition during a period of rapid growth and development. Nutrition requirements for infants and children with cardiac defects changes frequently throughout infancy through adulthood and will vary significantly depending on disease severity, cardiorespiratory status, surgical status (e.g., prior to or after surgery), and recovery status (e.g., acutely ill, chronically ill, early recovery, and recovered). The risk for growth failure depends on the particular lesion and its severity ( Table 86.1 ). Ongoing nutrition surveillance, screening, evaluation, and reevaluation throughout the stages of growth are necessary to improve early detection and intervention of nutrition deficits.



Table 86.1

Congenital Heart Defects and Risk for Malnutrition


































High Risk
Prior to and After Surgical Management 		High Risk
Prior to Surgical Management; Improved by Surgery 		Low Risk
Prior to and After Surgical Management
Functionally univentricular heart (including hypoplastic left heart syndrome, pulmonary atresia, tricuspid atresia, isomerism and more; see Chapter 68 , Chapter 69 , Chapter 70 , Chapter 71 , Chapter 72 , Chapter 73 ) Large ventricular septal defect (see Chapter 32 ) Atrial septal defect (see Chapter 29 )
Atrioventricular septal defect with large ventricular component (see Chapter 31 ) Tetralogy of Fallot (see Chapter 35 )
Common arterial trunk (see Chapter 40 ) Transposition of the great arteries (see Chapter 37 )
Large patent arterial duct (see Chapter 41 ) Totally anomalous pulmonary venous return (see Chapter 28 )
Pulmonary artery hypertension (which is not amenable to surgery other than lung transplantation, see Chapter 75 ) Aortic valve disease and left ventricular outflow tract obstruction (see Chapter 44 )
Anomalous left coronary artery from the pulmonary artery (see Chapter 46 ) Pulmonary stenosis (see Chapter 42 )
Coarctation of the aorta and interruption of the aortic arch (see Chapter 45 )


However, it is important to also consider that infants, children, and adolescents with CHD may not be immune to risk of overweight and obesity. These children may have more sedentary lifestyles from restricted physical activity given perceived strain on the heart. Families may also continue a high-calorie diet that was previously encouraged during the period of time prior to surgery or resolution of heart failure.


Definition of Malnutrition


In 2014 the Academy of Nutrition and Dietetics and the American Society of Parenteral and Enteral Nutrition published a consensus statement defining pediatric malnutrition as, “an imbalance between nutrient requirement and intake, resulting in cumulative deficits of energy, protein or micronutrients that may negatively affect growth, development and other relevant outcomes” ( Table 86.2 ). Prior to this consensus statement, the prevalence of malnourished children in the United States was documented between 6% and 51%. Factors contributing to this large variance in documented malnutrition included a lack of uniform definitions, lack of heterogeneous nutrition screening practices, and failure to prioritize nutrition as part of patient care.



Table 86.2

Pediatric Malnutrition Classification (for Infants ≥1 Month of Age)


















Severe protein-calorie malnutrition
ICD-10 (E43)		 Single data point indications:


  • ■

    Weight for length or BMI for age −3 or greater z-score


  • ■

    Length/height-for-age −3 or greater z-score


  • ■

    Mid-upper arm circumference −3 or greater z-score

Multiple data point indicators:


  • ■

    <25% of norm for expected weight gain over ≥1 month (<2 years of age)


  • ■

    ≥10% weight loss from usual body weight over ≥1 month (2–20 years of age)


  • ■

    Unintended decline of 3 or greater z- score from initial/baseline weight for length or BMI for age over ≥1 month


  • ■

    ≤25% estimated energy/protein needs for at least 2 weeks

Moderate malnutrition
ICD-10 (E44.0)		 Single data point indications:


  • ■

    Weight for length or BMI for age −2 to −2.9 z- score


  • ■

    Length/height-for-age −2 to −2.9 z- score


  • ■

    Mid-upper arm circumference −3 or greater z- score

Multiple data point indicators:


  • ■

    <50% of norm for expected weight gain over ≥ 1 month (<2 year of age)


  • ■

    7.5%–9.9% weight loss from usual body weight over ≥1 month (2–20 years of age)


  • ■

    Unintended decline of −2 to −2.9 z- score from initial/baseline weight for length or BMI for age over ≥1 month


  • ■

    26%–50% estimated energy/protein needs for at least 2 weeks

Mild malnutrition
ICD-10 (E44.1)		 Single data point indications:


  • ■

    Weight for length or BMI for age −1 to −1.9 z- score


  • ■

    Length/height for age −1 to −1.9 z- score


  • ■

    Mid-upper arm circumference −3 or greater z- score

Multiple data point indicators:


  • ■

    <75% of norm for expected weight gain over ≥1 month (<2 years of age)


  • ■

    5%–7.4% weight loss from usual body weight over ≥1 month (2–20 years of age)


  • ■

    Unintended decline of 1–1.9 z- score from initial/baseline weight for length or BMI for age over ≥1 month


  • ■

    51%–75% estimated energy/protein needs for at least 2 weeks


BMI, Body mass index.


Table 86.3

Pediatric Malnutrition Classification (for Infants 2–4 Weeks of Age)

Modified from Goldberg DL, Becker PJ, Brigham K, et al. Identifying malnutrition in preterm and neonatal populations: recommended indicators. J Acad Nutr Diet. 2018;118(9):1571–1582.


















Severe protein-calorie malnutrition
ICD-10 (E 43)		 Primary indicator requiring 1 indicator:


  • ■

    Decline of weight-for-age z- score of >2 SD


  • ■

    <25% of expected rate of weight gain to maintain growth rate


  • ■

    Receiving ≤75% of estimated protein/energy needs for >7 consecutive days

Primary indicator requiring two or more indicators:


  • ■

    >21 days to regain birth weight (use in conjunction with nutrient intake)


  • ■

    <25% of expected rate of linear gain to maintain expected growth rate


  • ■

    Decline in length-for-age z- score of >2 SD

Moderate malnutrition
ICD-10 (E44.0)		 Primary indicator requiring one indicator:


  • ■

    Decline in weight-for-age z- score of >1.2–2 SD


  • ■

    <50% of expected rate of weight gain to maintain growth rate


  • ■

    Receiving ≤75% of estimated protein/energy needs for ≥5–7 consecutive days

Primary indicator requiring two or more indicators:


  • ■

    19–21 days to regain birth weight


  • ■

    <50% of expected rate of linear gain to maintain expected growth rate


  • ■

    Decline in length-for-age z- score of >1.2–2 SD

Mild malnutrition
ICD-10 (E44.1)		 Primary indicator requiring one indicator:


  • ■

    Decline in weight-for-age z- score of 0.8–1.2 SD


  • ■

    <75% of expected rate of weight gain to maintain growth rate


  • ■

    Receiving ≤75% of estimated protein/energy needs for ≥3–5 consecutive days

Primary indicator requiring two or more indicators:


  • ■

    15–18 days to regain birth weight


  • ■

    <5% of expected rate of linear gain to maintain expected growth rate


  • ■

    Decline in length-for-age z- score of 0.8–1.2 SD


SD, Standard deviation.


Table 86.4

Weight Gain Goals




























































Age WEIGHT GAIN a
Boys Girls
0–1 month 27–41 g/day 23–36 g/day
1–2 months 33–47 g/day 28–40 g/day
2–3 months 22–33 g/day 19–29 g/day
3–4 months 16–26 g/day 15–24 g/day
4–5 months 13–22 g/day 12–21 g/day
5–6 months 10–19 g/day 9–18 g/day
6–7 months 7–17 g/day 7–16 g/day
7–8 months 6–15 g/day 6–15 g/day
8–9 months 5–14 g/day 5–14 g/day
9–10 months 4–14 g/day 4–13 g/day
10–12 months 3–13 g/day 3–13 g/day
12–24 months 5–10 g/day
2–10 years 2–3 kg/year

a Based on World Health Organization standards between 25th and 75th percentiles.



Table 86.5

Length/Height and Head Circumference












































Age Length/Height Head Circumference
Premature <2 kg 0.8–1.1 cm/wk 0.8–1 cm/wk
Premature ≥2 kg 0.8–1.1 cm/wk 0.8–1 cm/wk
0–4 months 0.8–0.93 cm/wk 0.38–0.48 cm/wk
4–8 months 0.37–0.47 cm/wk 0.16–0.2 cm/wk
8–12 months 0.28–0.37 cm/wk 0.08–0.11 cm/wk
12–16 months 0.24–0.33 cm/wk 0.04–0.08 cm/wk
16–20 months 0.21–0.29 cm/wk 0.03–0.06 cm/wk
20–24 months 0.19–0.26 cm/wk 0.02–0.04 cm/wk
2–10 years 5–8 cm/y N/A


Table 86.6

Estimated Energy and Protein Requirements for Children
































































Age Recommended Dietary Allowance Energy Required for Catch-up Growth (kcal/kg per day) Protein (g/kg per day)
0–6 months 108 120–150+ 2.2–3.5
7 months to 1 year 98 110–140 1.5–2.5
1–3 years 102 100–120 1.2–2.0
4–6 years 90 80–100 1.2–1.5
7–10 years 70 60–90 1.2–1.5
11–14 years
Male 55 55–60 1.0–1.5
Female 45 45–60 1.0–1.5
15–18 years
Male 47 45–55 1.0–1.5
Female 40 45–55 1.0–1.5

Special considerations: Estimated needs may be affected by ventilation, sedation, or mechanical support.


Table 86.7

Estimated Fluid Requirements
















Weight (kg) Fluid
1–10 kg 100 mL/kg per day
11–20 kg 1000 mL + 50 mL/kg for each kg >10 kg
>20 kg 1500 mL + 20 mL/kg for each kg >20 kg


Table 86.8

Formulas for Chylothorax (High Medium-Chain Triglyceride and/or Low Long-Chain Triglyceride Content)

Data from manufacturers’ product labels as of April 2018. Please note product composition may be changed by the discretion of manufacturers.




















































Formula Type MCT:LCT Ratio Percent Calories From LCT Fat LCT Fat g/100 Calories
Enfaport a
(Mead Johnson)		 Liquid concentrate 30 calories/ounce 83:17 7.8 0.9
Lipistart a
(Néstle)		 Powder 80:20 7.6 0.82
Monogen a
(Nutricia)		 Powder 83:17 4.5 0.5
Portagen a,b
(Mead Johnson)		 Powder 87:13 5.5 0.6
Tolerex c
(Néstle)		 Powder 0:100 2 0.2
Vivonex Pediatric c (Néstle) Powder 70:30 7.5 0.87
Vivonex TEN c
(Néstle)		 Powder 0:100 3 0.3

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Jan 19, 2020 | Posted by in CARDIOLOGY | Comments Off on Growth and Nutrition

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