Children's Cardiac Feeding Guidelines

Publication: 11/02/2021  
Next review: 30/06/2024  
Clinical Guideline
ID: 6851 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2021  


This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Children’s Cardiac Feeding Guidelines

Summary of Guideline

Guideline for the provision of nutrition for Children with a congenital cardiac diagnosis at Leeds Children’s Hospital. This documented should be used in conjunction with the Neonatal Feeding Guideline and  Guidelines for the Prescribing and Administration of Parenteral Nutrition (PN) for Children on Paediatric Intensive Care (PICU). This guideline advises on the initiation and establishment of enteral feeds both pre and post- surgery.

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Congenital heart disease in infancy and childhood can have a profound effect on energy expenditure and often results in faltering growth due to a lack of energy available for growth (Slicker et al., 2013). Other nutritional issues are also commonly seen which can increase the risks of malnutrition i.e. disturbed lipid metabolism and gastro-oesophageal reflux (Shaw, 2020). Malnutrition has been linked with poor post-op outcomes and increased post-operative mortality (Kelleher et al., 2006). Enteral nutrition is usually the preferred method of feeding due to benefits seen in maintaining gut integrity, promoting normal feeding patents (Slicker et al., 2013) and reduced risks associated with parenteral nutrition provision i.e. catheter related infections (Gavin et al., 2017).

Initiating nutritional support both pre- and post-op requires a multi-factorial assessment, dependant on disease pathology, assessment of current clinical status, and consideration of the patient’s feeding history. Incidence of necrotising enterocolitis (NEC) is also significantly higher in infants with congenital heart disease, compared with healthy term infants (Shaw, 2020; McElhinney et al, 2000). Reduced cardiac output can increase concerns around impaired mesenteric artery perfusion and gut ischaemia which can be seen, for example, in patients with HLHS following Noorwood stage 1 palliation (Harrison, 2005; Owens & Musa, 2009). Cardiopulmonary bypass can also cause damage to the intestinal mucosa due to altered gut permeability, which in turn may lead to NEC development (Malagon et al, 2005). Infants who develop NEC are likely to have an increase length of hospital admission, as well as the condition carrying a mortality risk.

The lack of well controlled, large trials in children with congenital heart defects has resulted in an absence of widely accepted evidence based guidelines for optimal nutritional management in this group. However the importance of locally implemented guidelines for introducing and establishing enteral nutrition is widely accepted. The implementation of post-operative feeding protocols and algorithms have been shown to reduce the incidence of NEC in infants with complex congenital cardiac defects (HLHS), leading to improved nutritional and patient outcomes (Del Castillo et al 2010Braudis et al, 2009). Standardised feeding protocols in critical care have also been shown to  result in more rapid initiation of enteral feeding, shortened the time taken to reach nutritional goals and improved the tolerance of enteral feeding (Gentles et al. 2014).

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Record: 6851
Objective: The objective of this documented is to provide clear guidance on appropriate nutrition provision for infants diagnosed with a cardiac condition.
Clinical condition:

Congenital cardiac diagnosis in children age <1 year of age.

Target patient group: Patients under the care of the Children’s Cardiac Team, Paediatric Intensive Care Unit and Neonatal Unit at Leeds Children’s Hospital.
Target professional group(s): Allied Health Professionals
Secondary Care Doctors
Secondary Care Nurses
Adapted from:

Evidence base

Shaw V. (2020). Congenital Heart disease. Clinical Paediatrics, fifth Edition. J Wiley & Sons Ltd. Pp. 287-314.

McElhinney D., Hendrick H., Bush D., Pereira G., Stafford P., Gaynor J., Spray T. & Wernovsky G. (2000). Necrotizing enterocolities in neonates with congenital heart disease: risk factors and outcomes.

Harrison A., Davis S. & Reid J. (2005) Neonates with hypoplastic left heart syndrome have ultrasound evidence of abnormal superior mesenteric artery perfusion before and after modified Norwood procedure. Pediatr Crit Care Med.6:445-447

Owens J. & Musa N. (2009) Nutrition support after neonatal cardiac surgery. Nutr Clin Pract. 24:242-249.

Slicker J., Hehir D. & Horsley, M. (2013) Nutrition algorithms for infants with hypoplastic left heart syndrome; birth through the first interstage period. Congenit Heart Dis. 8:89-102.

Gavin N., Button E., Keogh S., McMillan D. & Rickard C. (2017). Does parenteral nutrition increase the risk of catheter-related bloodstream infection? A systematic literature review. JPEN-Parenter Enter., 41 , pp. 918-928

del Castillo S., McCulley M. & Khemani R. (2010) Reducing the incidence of necrotizing enterocolitis in neonates with hypoplastic left heart syndrome with the introduction of an enteral feed protocol. Pediatr Crit Care Med. 11:373–377

Braudis N., Curley M.& Beaupre K. (2009) Enteral feeding algorithm for infants with hypoplastic left heart syndrome poststage I palliation. Pediatr Crit Care Med. 10:460–466

Kelleher D., Laussen P., Teixeira-Pinto A. & Duggan C. (2006) Growth and correlates of nutritional status among infants with hypoplastic left heart syndrome (HLHS) after stage 1 Norwood procedure. Nutrition 22:237–244

Malagon I., Onkenhout .W, Klok M., van der Poel P., Bovill J. & Hazekamp M. (2005) Gut permeability in neonates after a stage 1 Norwood procedure. Pediatr Crit Care Med 6:547–549

Gentles E., Mara J. & Diamantidi K (2014) Delivery of enteral nutrition after the introduction of practice guidelines and participation of dietitians in pediatric critical care clinical teams. J Acad Nutr Diet 114(1974–80):e3

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 2.0

Related information

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