Skip to main content

Advertisement

SpringerLink
Log in

Effect of high-energy and/or high-protein feeding in children with congenital heart disease after cardiac surgery: a systematic review and meta-analysis

  • Review
  • Published:
European Journal of Pediatrics Aims and scope Submit manuscript

A CORRESPONDENCE to this article was published on 27 September 2023

Abstract

High-energy or high-protein feeding offers a promising approach to improving malnutrition in children after congenital heart surgery. However, the effect of high-energy or high-protein feeding in this population has not yet been systematically reviewed. Therefore, we aimed to assess the safety and effectiveness of high-energy or high-protein feeding in children after congenital heart surgery. Five electronic databases (PubMed, Embase, CENTRAL, CINAHL, and Scopus) were searched from inception to April 23, 2022. After screening the literature according to inclusion and exclusion criteria, a risk of bias assessment was performed using version 2 of the Cochrane risk-of-bias tool for randomized trials, and the certainty of the evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluations system. Finally, the random effects model was used to perform a meta-analysis of all data. A total of 609 subjects from 9 studies were included for qualitative analysis, and meta-analyses were performed on data from 8 of these studies. The results showed that high-energy and/or high-protein feeding did not increase feeding intolerance (RR = 1.09, 95% CI: 0.80, 1.48) or fluid intake (MD =  − 12.50 ml/kg/d, 95% CI: − 36.10, 11.10); however, the intervention was beneficial in increasing weight (MD = 0.5 kg, 95% CI: 0.23, 0.77) and reducing the duration of mechanical ventilation (MD =  − 17.45 h, 95% CI: − 27.30, − 7.60), intensive care unit (ICU) stay (MD =  − 1.45 days, 95% CI: − 2.36, − 0.54) and hospital stay (MD =  − 2.82 days, 95% CI: − 5.22, − 0.43). However, high-energy and/or protein feeding did not reduce the infection rate (RR = 0.68, 95% CI: 0.25, 1.87) or mortality (RR = 1.50, 95% CI: 0.47, 4.82).

Conclusion: The certainty of the evidence was graded as moderate to high, which suggests that high-energy and/or high-protein feeding may be safe in children after congenital heart surgery. Furthermore, this intervention improves nutrition and reduces the duration of mechanical ventilation, length of ICU stay, and length of hospital stay. However, the overall conclusion of this meta-analysis will need to be confirmed in a cohort of patients with different cardiac physiologies.

What is Known:

• Malnutrition is highly prevalent in children with congenital heart disease (CHD) and can negatively affect the prognosis of these children.

• High-energy and/or high-protein feeding can improve nutrition status and facilitate recovery; however, evidence on its safety and efficacy is lacking.

What is New:

• Pooled data suggest that high-energy and/or high-protein feeding does not increase fluid intake or feeding intolerance in children with CHD.

• High-energy and/or high-protein feeding may reduce the duration of mechanical ventilation, length of intensive care unit stay, and length of hospital stay.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

Data availability

The data supporting the findings of this study have all been published.

Abbreviations

CHD:

Congenital heart disease

CIs:

Confidence intervals

EN:

Enteral nutrition

ICU:

Intensive care unit

MDs:

Mean differences

RCTs:

Randomized controlled trials

RRs:

Risk ratios

References

  1. Pierpont ME, Brueckner M, Chung WK, Garg V, Lacro RV, McGuire AL, Mital S, Priest JR, Pu WT, Roberts A, Ware SM, Gelb BD, Russell MW (2018) Genetic basis for congenital heart disease: revisited: a scientific statement from the American Heart Association. Circulation 138(21):e653–e711. https://doi.org/10.1161/CIR.0000000000000606

    Article  PubMed  PubMed Central  Google Scholar 

  2. Hehir DA, Easley RB, Byrnes J (2016) Noncardiac challenges in the cardiac ICU: feeding, growth and gastrointestinal complications, anticoagulation, and analgesia. World J Pediatr Congenit Heart Surg 7(2):199–209. https://doi.org/10.1177/2150135115615847

    Article  PubMed  Google Scholar 

  3. Medoff-Cooper B, Ravishankar C (2013) Nutrition and growth in congenital heart disease: a challenge in children. Curr Opin Cardiol 28(2):122–129. https://doi.org/10.1097/HCO.0b013e32835dd005

    Article  PubMed  Google Scholar 

  4. Toole BJ, Toole LE, Kyle UG, Cabrera AG, Orellana RA, Coss-Bu JA (2014) Perioperative nutritional support and malnutrition in infants and children with congenital heart disease. Congenit Heart Dis 9(1):15–25. https://doi.org/10.1111/chd.12064

    Article  PubMed  Google Scholar 

  5. Mehta NM, Corkins MR, Lyman B, Malone A, Goday PS, Carney LN, Monczka JL, Plogsted SW, Schwenk WF (2013) Defining pediatric malnutrition: a paradigm shift toward etiology-related definitions. J Parenter Enteral Nutr 37(4):460–481. https://doi.org/10.1177/0148607113479972

    Article  Google Scholar 

  6. Trabulsi JC, Irvin SY, Papas MA, Hollowell C, Ravishankar C, Marino BS, Medoff-Cooper B, Schall JI, Stallings VA (2015) Total energy expenditure of infants with congenital heart disease who have undergone surgical intervention. Pediatri Cardiol 36(8):1670–1679. https://doi.org/10.1007/s00246-015-1216-3

    Article  Google Scholar 

  7. Hames DL, Sleeper LA, Ferguson MA, Mehta NM, Salvin JW, Mills KI (2022) Fluid restriction contributes to poor nutritional adequacy in patients with congenital heart disease receiving renal replacement therapy. J Ren Nutr 32(1):78–86. https://doi.org/10.1053/j.jrn

    Article  CAS  PubMed  Google Scholar 

  8. Hanot J, Dingankar AR, Sivarajan VB, Sheppard C, Cave D, Guerra GG (2019) Fluid management practices after surgery for congenital heart disease: a worldwide survey. Pediatr Crit Care Med 20(4):357–364. https://doi.org/10.1097/PCC.0000000000001818

    Article  PubMed  Google Scholar 

  9. Lee ZY, Ibrahim NA, Mohd-Yusof BN (2018) Prevalence and duration of reasons for enteral nutrition feeding interruption in a tertiary intensive care unit. Nutrition 53:26–33. https://doi.org/10.1016/j.nut.2017.11.014

    Article  PubMed  Google Scholar 

  10. Ferhatoglu SY, Yurdakok O, Yurtseven N (2021) Malnutrition on admission to the paediatric cardiac intensive care unit increases the risk of mortality and adverse outcomes following paediatric congenital heart surgery: a prospective cohort study. Aust Crit Care S1036–7314(21):00114–00124. https://doi.org/10.1016/j.aucc.2021.07.004

    Article  Google Scholar 

  11. Ross FJ, Radman M, Jacobs ML, Sassano-Miguel C, Joffe DC, Hill KD, Feng LQ, Jacobs JP, Vener DF, Latham GJ (2020) Associations between anthropometric indices and outcomes of congenital heart operations in infants and young children: an analysis of data from the Society of Thoracic Surgeons Database. Am Heart J 224:85–97. https://doi.org/10.1016/j.ahj.2020.03.012

    Article  PubMed  Google Scholar 

  12. Tsintoni A, Dimitriou G, Karatza AA (2020) Nutrition of neonates with congenital heart disease: existing evidence, conflicts and concerns. J Matern Fetal Neonatal Med 33(14):2487–2492. https://doi.org/10.1080/14767058.2018.1548602

    Article  PubMed  Google Scholar 

  13. Singal A, Sahu MK, Kumar GT, Amit K (2022) Effect of energy- and/or protein-dense enteral feeding on postoperative outcomes of infant surgical patients with congenital cardiac disease: a systematic review and meta-analysis. Nutr Clin Pract 37(3):555–566. https://doi.org/10.1002/ncp.10799

    Article  CAS  PubMed  Google Scholar 

  14. Chen X, Zhang MJ, Song YX, Luo YW, Wang LP, Xu ZM, Bao N (2021) Early high-energy feeding in infants following cardiac surgery: a randomized controlled trial. Transl pediatr 10(10):2439–2448. https://doi.org/10.21037/tp-21-360

  15. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, Shamseer L, Tetzlaff JM, Akl EA, Brennan SE et al (2021) The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 372:n71. https://doi.org/10.1136/bmj.n71

    Article  PubMed  PubMed Central  Google Scholar 

  16. Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, Cates CJ, Cheng HY, Corbett MS, Eldridge SM, et al (2019) RoB 2: a revised tool for assessing risk of bias in randomised trials. 366: l4898. https://doi.org/10.1136/bmj.l4898

  17. Altman DG (1991) Practical Statistics for Medical Research, 1st edn. Chapman and Hall, London

    Google Scholar 

  18. GRADE Working Group (2004) Grading quality of evidence and strength of recommendations. BMJ 328(7454):1490. https://doi.org/10.1136/bmj.328.7454.1490

  19. Higgins JP, Thompson SG, Deeks JJ, Altman DG (2003) Measuring inconsistency in meta-analyses. BMJ 327(7414):557–560. https://doi.org/10.1136/bmj.327.7414.557

    Article  PubMed  PubMed Central  Google Scholar 

  20. Goday PS, Lewis JD, Sang CJJr, George DE, McGoogan KE, Safta AM, Seth A, Krekel C (2021) Energy- and protein-enriched formula improves weight gain in infants with malnutrition due to cardiac and noncardiac etiologies. J Parenter Enteral Nutr 1–13. https://doi.org/10.1002/jpen.2308

  21. Huang JT, Lu XL, Xiao ZH, Zang P, Gong L, Zhou W, Huang P (2019) Clinical effect of feeding with calorie-enriched formula in children with ventricular septal defect and severe pneumonia. Zhongguo Dang Dai Er Ke Za Zhi 21(10):998–1004. https://doi.org/10.7499/j.issn.1008-8830.2019.10.009(InChinese)

    Article  PubMed  Google Scholar 

  22. Geukers VG, Dijsselhof ME, Jansen NJG, Breur JMPJ, Harskamp DV, Schierbeek H, Goudoever JBV, Bos AP, Sauerwein HP (2015) The effect of short-term high versus normal protein intake on whole-body protein synthesis and balance in children following cardiac surgery: a analysized double-blind controlled clinical trial. Nutr J 14:72. https://doi.org/10.1186/s12937-015-0061-9

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Yu XR, Xie WP, Liu JF, Wang LW, Cao H, Chen Q (2021) Effect of the addition of human milk fortifier to breast milk on the early recovery of infants after congenital cardiac surgery. Front Pediatr 9:661927. https://doi.org/10.3389/fped.2021.661927

    Article  PubMed  PubMed Central  Google Scholar 

  24. Zhang J, Cui YQ, Luo Y, Chen XX, LI J, (2021) Assessment of energy and protein requirements in relation to nitrogen kinetics, nutrition, and clinical outcomes in infants receiving early enteral nutrition following cardiopulmonary bypass. J Parenter Enteral Nutr 45(3):553–566. https://doi.org/10.1002/jpen.1863

    Article  CAS  Google Scholar 

  25. Zhang H, Gu Y, Mi YP, Jin Y, Fu WJ, Latour JM (2019) High-energy nutrition in paediatric cardiac critical care patients: a randomized controlled trial. Nurs Crit Care 24(2):97–102. https://doi.org/10.1111/nicc.12400

    Article  PubMed  Google Scholar 

  26. Cui YQ, Li LJ, Hu CM, Shi H, Li JB, Gupta RK, Liang HY, Chen XX, Gong ST (2018) Effects and tolerance of protein and energy-enriched formula in infants following congenital heart surgery: a randomized controlled trial. J Parenter Enteral 42(1):196–204. https://doi.org/10.1002/jpen.1031

    Article  CAS  Google Scholar 

  27. Scheeffer VA, Ricachinevsky CP, Freitas AT, Salamon F, Rodrigues FFN, Brondani TG, Sutil AT, Ferreira CHT, Matte UDS, da Silveira TR (2020) Tolerability and effects of the use of energy-enriched infant formula after congenital heart surgery: a randomized controlled trial. J Parenter Enteral Nutr 44(2):348–354. https://doi.org/10.1002/jpen.1530

    Article  Google Scholar 

  28. Pillo-Blocka F, Adatia I, Sharieff W, McCrindle BW, Zlotkin S (2004) Rapid advancement to more concentrated formula in infants after surgery for congenital heart disease reduces duration of hospital stay: a randomized clinical trial. J Pediatr 145(6):761–766. https://doi.org/10.1016/j.jpeds.2004.07.043

    Article  PubMed  Google Scholar 

  29. Sahu MK, Singal A, Menon R, Singh SP, Mohan A, Manral M, Singh D, Devagouru V, Talwar S, Choudhary SK (2016) Early enteral nutrition therapy in congenital cardiac repair postoperatively: a randomized, controlled pilot study. Ann Card Anaesth 19(4):653–661. https://doi.org/10.4103/0971-9784.191550

    Article  PubMed  PubMed Central  Google Scholar 

  30. Evans DC, Corkins MR, Malone A, Miller S, Mogensen KM, Guenter P, Jensen GL; ASPEN Malnutrition Committee (2021) The use of visceral proteins as nutrition markers: an ASPEN position paper. Nutr Clin Pract 36(1):22–28. https://doi.org/10.1002/ncp.10588

  31. Al-Jundi A, Sakka S (2016) Protocol writing in clinical research. J Clin Diagn Res 10(11): ZE10–ZE13. https://doi.org/10.7860/JCDR/2016/21426.8865

  32. Hysong SJ, Woodard L, Garvin JH, Murawsky J, Petersen LA (2014) Publishing protocols for partnered research. J Gen Intern Med 29(Suppl 4):820–824. https://doi.org/10.1007/s11606-014-3037-0

    Article  PubMed  PubMed Central  Google Scholar 

  33. Ohkuma RE, Crawford TC, Brown PM, Grimm JC, Magruder JT, Kilic A, Suarez-Pierre A, Snyder S, Wood JD, Schneider E (2017) A novel risk score to predict the need for nutrition support after cardiac surgery. Ann Thorac Surg 104:1306–1312. https://doi.org/10.1016/j.athoracsur.2017.03.013

    Article  PubMed  Google Scholar 

  34. Irving SY, Medoff-Cooper B, Stouffer NO, Schall JI, Ravishankar C, Compher CW, Marino BS, Stallings VA (2013) Resting energy expenditure at 3 months of age following neonatal surgery for congenital heart disease. Congenit Heart Dis 8(4):343–351. https://doi.org/10.1111/chd.12035

    Article  PubMed  PubMed Central  Google Scholar 

  35. Martini S, Beghetti I, Annunziata M, Aceti A, Galletti S, Ragni L, Donti A, Corvaglia L (2021) Enteral nutrition in term infants with congenital heart disease: knowledge gaps and future directions to improve clinical practice. Nutrients 13(3):932. https://doi.org/10.3390/nu13030932

    Article  PubMed  PubMed Central  Google Scholar 

  36. Corkins KG, Teague EE (2017) Pediatric nutrition assessment. Nutr Clin Pract 32(1):40–51. https://doi.org/10.1177/0884533616679639

  37. Ruiz AJ, Buitrago G, Rodríguez N, Gómez G, Sulo S, Gómez C, Partridge J, Misas J, Dennis R, Alba MJ (2019) Clinical and economic outcomes associated with malnutrition in hospitalized patients. Clin Nutr 38(3):1310–1316. https://doi.org/10.1016/j.clnu.2018.05.016

    Article  PubMed  Google Scholar 

  38. Compher C, Chittams J, Sammarco T, Nicolo M, Heyland DK (2017) Greater protein and energy intake may be associated with improved mortality in higher risk critically ill patients: a multicenter, multinational observational study. Crit Care Med 45(2):156–163. https://doi.org/10.1002/CCM.0000000000002083

    Article  PubMed  Google Scholar 

  39. Grippa RB, Silva PS, Barbosa E, Bresonlin NL, Mehta NM, Moreno YM (2017) Nutritional status as a predictor of duration of mechanical ventilation in critically ill children. Nutrition 33:91–95. https://doi.org/10.1016/j.nut.2016.05.002

    Article  PubMed  Google Scholar 

  40. Valla FV, Berthiller J, Gaillard -Le-Roux B, Ford-Chessel C, Ginhoux T, Rooze S, Cour-Andlauer F, Meyer R, Javouhey E (2018) Faltering growth in the critically ill child: prevalence, risk factors, and impaired outcome. Eur J Pediatr 177(3):345–353. https://doi.org/10.1007/s00431-017-3062-1

Download references

Acknowledgements

The authors would like to express their gratitude to the authors of the RCTs for providing data for the systematic review.

Author information

Authors and Affiliations

  1. Department of Thoracic and Cardiovascular Surgery, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China

    Ping Ni & ZhuoMing Xu

  2. Department of Cardiology, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China

    XiuLi Wang

  3. Nursing Department, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, 1678 Dong-fang Road, Shanghai, 200127, China

    Wenyi Luo

Authors
  1. Ping Ni
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. XiuLi Wang
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. ZhuoMing Xu
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Wenyi Luo
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Ping Ni and Xiuli Wang. The first draft of the manuscript was written by Ping Ni, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Wenyi Luo.

Ethics declarations

Ethics approval

Not applicable.

Consent to participate

Not applicable.

Consent for publication

Not applicable.

Conflict of interest

The authors declare no competing interests.

Additional information

Communicated by Gregorio Milani

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Ni, P., Wang, X., Xu, Z. et al. Effect of high-energy and/or high-protein feeding in children with congenital heart disease after cardiac surgery: a systematic review and meta-analysis. Eur J Pediatr 182, 513–524 (2023). https://doi.org/10.1007/s00431-022-04721-3

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00431-022-04721-3

Keywords

Search

Navigation