Feeding Complications in Hypoplastic Left Heart Syndrome After the Norwood Procedure: A Systematic Review of the Literature

University of Michigan Medical School, 1301 Catherine Road, Ann Arbor, MI 48109-5864, USA.
Pediatric Cardiology (Impact Factor: 1.31). 02/2011; 32(4):539-52. DOI: 10.1007/s00246-011-9907-x
Source: PubMed


Gastrointestinal and feeding complications after the Norwood procedure in infants with hypoplastic left heart syndrome increases morbidity and mortality. These problems are the result of intraoperative challenges, shunt-dependent physiology, and the absence of best-practice guidelines. In response, a systematic review of feeding-related complications and management strategies was performed. A literature search from 1950 to March 2010 identified 21 primary research articles and 4 reviews. Dysphagia, necrotizing enterocolitis (NEC), and poor nutritional status are significant feeding-related complications. Three studies directly compared the modified Blalock-Taussig shunt with the right ventricle-to-pulmonary artery conduit (RV-PA). Patients palliated with either shunt had impaired mesenteric blood flow. Mortality did not differ between shunt types. Three studies demonstrated improved outcomes, e.g., increased survival, decreased incidence of NEC, and decreased median time to recommended daily allowance of calories, with a postoperative feeding algorithm. Two studies showed increased survival between stage I and II surgical palliation after implementation of a home-monitoring system consisting of daily weight and systemic oxygen saturation measurements. The RV-PA shunt does not significantly alter mortality or increase mesenteric blood flow. A postoperative feeding algorithm and a home-monitoring system may improve outcomes and decrease average hospital length of stay (LOS). Additional studies are needed to determine which interventions, as part of a standardized protocol, improve survival and decrease complications.

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    • "A second component of oral motor stimulation is nonnutritive sucking, which allows infants to engage the neuromuscular structures necessary for sucking at a more efficient rate and with greater endurance. Efficient and coordinated feeding is critical for infants born with univentricle anatomy who are known to have deficits in nutritive sucking strength, endurance, and coordination in swallowing, which affects attainment of full oral feedings (Golbus et al., 2011; St. Pierre et al., 2010). "
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    ABSTRACT: The purpose of this pilot study was to determine the effects of oral motor stimulation on infants born with complex univentricle anatomy who required surgery shortly after birth. A quasi-experimental group design was used to compare 18 infants receiving an oral motor stimulation program with 10 infants who did not receive any oral motor intervention. Infants in the treatment group received the oral motor treatment prior to cardiac surgery and immediately following surgery, one time a day, 6 days a week. Outcomes data were collected for length of time to reach full bottle-feeds and length of hospital stay. A statistically significant difference was seen in the overall length of hospital stay between the two groups (p = .04). Infants in the experimental group were hospitalized for a mean of 28.6 days and infants in the comparison group for a mean of 35.3 days. Infants in the treatment group achieved full bottle-feeds 2 days earlier than infants in the comparison group, although this was not statistically significant. There is positive support for the use of oral motor stimulation for infants born with univentricle anatomy, but further study is needed to determine the long-lasting effects of this intervention.
    Full-text · Article · Apr 2012 · Journal of pediatric nursing
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    ABSTRACT: Improvement in operative survival of patients with hypoplastic left heart syndrome has led to increasing emphasis on prevention of interstage mortality. Many centres have improved interstage results through programmes of home monitoring following discharge after the Norwood (Stage 1) operation. Experience with heightened interstage surveillance has identified failure to thrive during infancy as a modifiable risk factor for this population, one that has been linked to concerning outcomes at subsequent palliative surgeries. Ensuring normal growth as an infant has thus become a priority of management of patients with functionally univentricular hearts. Herein, we review the existing evidence for best practices in interstage surveillance and optimal nutrition in infants with functionally univentricular hearts. In addition, we highlight data presented at HeartWeek 2011, from Cardiology 2011, the 15th Annual Update on Pediatric and Congenital Cardiovascular Disease, and the 11th Annual International Symposium on Congenital Heart Disease.
    No preview · Article · Dec 2011 · Cardiology in the Young
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    ABSTRACT: The study goal was to evaluate interstage growth variation among sites participating in the National Pediatric Cardiology Quality Improvement Collaborative registry caring for infants with hypoplastic left heart syndrome and to identify nutritional practices common among sites achieving best growth outcomes. This was a retrospective analysis of infants in the registry who had presented due to their superior cavopulmonary connection (SCPC) and whose surgical site had enrolled ≥ 4 eligible patients in the registry. The primary outcome variable was weight-for-age z-score (WAZ) change between Norwood discharge and presentation for SCPC (interstage period). Blinded, structured interviews were performed with each site regarding site-specific nutritional practices. Practices common among sites with positive interstage WAZ changes were identified. Sixteen centers enrolled 132 infants from December 2008 through December 2010. Median age at SCPC was 5 months (2.6-12.6), and median interstage WAZ change was -0.29 (-3.2 to 2.3). Significant variation in WAZ changes among sites was demonstrated (P < .001). Sites that used standard feeding evaluation prior to Norwood discharge and that closely monitored for specific weight gain/loss red flags in the interstage period demonstrated significantly better patient growth than those that did not use these practices (P = .002). Considerable variation exists in interstage growth among patients receiving care at these 16 surgical sites. Standardization of interstage nutritional management with focus on best nutritional practices may lead to improved growth in this high-risk population of infants.
    No preview · Article · Feb 2012 · The Journal of pediatrics
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