Andersons pediatric cardiology 1896

FIG 72.5 Interstage events by shunt type in consecutive patients enrolled in the local home monitoring program for interstage care after stage I palliation (From Rudd NA, Frommelt MA, Tweddell JS, et al Improving interstage survival after Norwood operation: outcomes from 10 years of home monitoring J Thorac Cardiovasc Surg 2014;148[4]:1540–1547.) FIG 72.6 Interstage management for home monitored patients with outpatient events Events are defined as SpO2 90%, weight loss of 30 g, or failure to gain 30 g in 3 days (From Rudd NA, Frommelt MA, Tweddell JS, et al Improving interstage survival after Norwood operation: outcomes from 10 years of home monitoring J Thorac Cardiovasc Surg 2014;148[4]:1540–1547.) Nutritional Management Historically, growth failure during the interstage period was common, but, with the introduction of weight and enteral intake tracking as part of interstage surveillance programs, the nutritionally at-risk stage I palliation infant has shown the ability to gain weight at rates near or equal to healthy peers.9,10 A minimum of weekly reassessment of weight trends, volume and caloric intake, and growth velocity is recommended during the interstage period The ability to modify nutrition plans before growth failure occurs requires diligence in optimizing caloric intake to achieve desired weight gain by the infant without causing volume overload or feeding intolerance Due to the metabolic demands of stage I palliation physiology, most infants will require a minimum of 100 mL/kg per day for adequate hydration and between 100 and 130 cal/kg per day to demonstrate consistent weight gain Guidance from a clinical dietician familiar with the physiologic demands of stage I palliation infants can be invaluable in managing enteral feeds and optimizing nutritional outcomes during the interstage period Management of failure to thrive may include outpatient modification of the enteral nutrition plan, outpatient clinic evaluation for cardiac reevaluation, or inpatient admission to assess for potential causative conditions such as infection, cardiac pathology, or gastrointestinal disease Interventions may include increasing feed volumes if tube supplementation in place or increasing caloric density of formula or expressed breast milk if infant feeding exclusively by bottle For the infant being fed every 3 hours, increasing bolus volume by 5 or 40 mL for the day will typically result in increased weight gain after 1 to 2 days of the increase If caloric density is adjusted, it is recommended to increase by a maximum or 2 to 3 calories per ounce to a maximum of 30 calories per ounce.46 With change in caloric density of formula or expressed breast milk, it is vital to consult with a clinical dietician and reputable resources for fortification recipes and mixing instructions Errors in formula preparation can lead to metabolic and gastrointestinal disturbances Progressive circulatory insufficiency during the interstage period may result in a decline in oral intake or intolerance of enteral tube feeds If the exclusively orally fed infant struggles to meet goal volumes for hydration and growth, feeding supplementation via tube may be indicated If placement of a nasogastric tube for supplementation is planned, it is highly recommended that initial placement be performed in a setting able to manage any potential complications of tube placement should cardiorespiratory decompensation with tube insertion Outpatient therapy to optimize oral-motor skills should be in place during the interstage period Infants who fail to grow despite focused nutritional management require medical evaluation of the cardiovascular status and the potential need for early cardiac intervention High-Risk Clinic/Follow-Up Evolution of interstage home monitoring programs has resulted in the development of additional outpatient strategies to enhance the surveillance between stages I and II palliation, specifically weekly communication with families and dedicated high-risk clinics Weekly communication between parents and the interstage care team provides opportunity to review call criteria or redflag concerns, review weight and vital sign trends, discuss nutritional management, assess for family stress, reinforce education, provide anticipatory guidance, and obtain a general impression of the infant's clinical status while providing regular family support Weekly contact can be made via telephone, email, or text messaging Such communication can be beneficial in detecting