Nutrition & VSD

A case study on a term

infant

Presented By:
Dong Mei
Quah Su Chin
Lu Han
Goh Choon Hua
Case Study

• Baby Johan was born at term to a 35-

year-old woman. During breast
feeding on the postnatal ward,
Johan’s mother noticed that he
became blue. Investigation revealed
that Johan had a ventricular septal
defect. He was scheduled for
surgery. On his 3rd POD, his mother
asked if she could continue breast
feeding Johan or switch to formula
 Objectives
• Discuss the pathophysiology and types of
VSDs
• Discuss how VSD affects the nutritional needs
of Baby Johan Discuss nutritional needs of a
term infant
• Identify causes of malnutrition and its
consequences
• Identify types of surgery for VSD
• Discuss Feeding methods
• Discuss how to feed Baby Johan post-
operatively
Ventricular Septal Defect

• a communication between the right

and left ventricles, which is the most
common congenital heart disease
• can occur anywhere in the muscular
or membranous ventricular septum
• The size of the defect is important in
determining the severity of the
condition or haemodynamic
consequences
(RuizVentricular Septal Defect, 2006)
Types of VSD
• Inlet VSD: usually part of an AV canal defect; 5% to 7% of all
VSDs.

• Perimembranous (Conoventricular, or infracristal) VSDs: 80% of all

VSDs.

• Muscular VSD: can be single or multiple and of variable size in any

given patient; 5% to 20% of all VSDs.

• Conal septal malalignment VSD: the conal septum is not properly

aligned with the rest of the ventricular septum, resulting in a
defect; it’s always large and unrestrictive.
– Anterior malalignment is associated with obstruction of the right ventricular
(RV) outflow tract (e.g., tetralogy of Fallot)

– Posterior malalignment is associated with obstruction of the left ventricular

(LV) outflow tract and aorta (e.g., posterior malalignment VSD with
coarctation).

• Conal septal hypoplasia VSD

• There also may be multiple VSDs of different types in a single

Atrioventricular Canal Defect
Perimembranous VSD
Muscular VSD
Pathophysiology of VSD
• The defect causes shunting of blood between
ventricles

• The direction of blood shunting depends on the

relative PVR and SVR

• Amount of shunting depends on the size of the

defect

• Small VSD: small left to right shunt; the

workload of two ventricles is normal. ECG and
CXR are normal.

• Moderate-sized VSD: amount of shunting can be

large and is affected by the relative of PVR and
SVR. RV pressure is normal or only mildly
increased.
Pathophysiology of VSD
• Large (unrestrictive) VSD: RV and LV pressures are
equal. Direction and amount of shunting is purely
determined by PVR and SVR.

• A large left-to-right shunt leads to increased

pulmonary blood flow, left atrial and left ventricular
dilation, tachypnea, and congestive heart failure
(CHF). Typical onset of CHF is at 2 to 8 weeks of age
as the PVR falls post-natally.

• If a large VSD is left untreated, pulmonary vascular

disease (irreversible increase in PVR) may develop,
leading to reversal of the shunt, cyanosis, and right
ventricular failure (Eisenmenger syndrome).
VSD & Nutritonal Needs

• Feeding difficulties
– Tiring easily from the effort to suck
– Poor eater
– Poor oral intake

• Fail to grow to thrive normally

Nutritional Needs
• Infants’ diet must contain adequate
nutrients, such as protein,
carbohydrate, fat, mineral, and
vitamins.
• Protein is needed for rapid cellular
growth and maintenance .
• Carbohydrate provides energy.
• Fat is necessary for the normal
development of the neonatal brain and
neurologic system.
• Mineral and vitamins are needed to
Energy Requirement

Age kcal/kg/day
Neonate 100-120
< 10kg 100
10kg – 20kg 1000 + 50 kcal/kg over 10kg
> 20kg 1000 + 20 kcal/kg over 20kg

(Hendricks & Duggan, 2000)

Daily Reference Intake for
Normal Infants

Nutrient 0-6 months (6kg) 7-12 months (9kg)

Protein (g) 9.3 11

Carbohydrate (g) 60 95
Fat (g) 31 30
Fluid (mL) 700 800

(Hendricks & Duggan, 2000)

Nutrition
• Oral feeding
– Breast Milk
– Formulas

• Oro-gastric tube feeding

– Expressed breast milk
– Formulas

• Total parental nutrition

Causes of Malnutrition

• Inadequate intake
• Illness
• Lack of access to food, e.g. Poverty
• Inappropriate feeding and caring
• Insufficient healthcare services
Consequences of
Malnutrition
• Catabolism
Catabolism
– Impaired physical and cognitive development

• Depressed immunity
– Most commonly, infectious diarrhea, which causes anorexia,
decreased nutrient absorption, increased metabolic needs, and
direct nutrient loss

• Impaired organ function

– Fatty degeneration of the liver and heart
– Atrophy of small bowel
– Decreased intravascular volume leading to secondary
hyperaldosteronism

• Delayed wound healing

• Prolonged morbidity
• Increased mortality
(Grigsby, 2006)
Surgical and Nutritional
Management
Surgical Management of
VSD
• Indicated when infants:
– Fail to thrive
– Develop complications despite medical
management
– When VSD is severe or >5mm in size
and not responding to medical
management
Surgical Management of
VSD
• Types of surgery depends on:
– Location of VSD
– Size of VSD
– Number of VSDs
• Isolated
• Multiple
– Presence of other medical conditions
e.g. co-existing with TOF, CoA
– Severity
Surgical Management of
VSD
• Types of Surgery
– Transcatheter closure of VSD for certain
anatomic VSDs
– Patch repair with CPB/open heart
surgery
– Palliative repair
• For infants with complicated anatomical
access and co-morbidities
• To improve life expectancy
– Usually can live up to 15-20 years of age.
Impact of Critical Illness on
Nutritional Needs
• Why is nutrition important?
– Critical illness coupled with poor
nutrition leads to:
• Prolonged ventilator dependency
• Prolonged ICU stay
• Heightened susceptibility to nosocomial
infections
• Increased mortality with mild/moderate or
severe malnutrition
Impact of Critical Illness on
Nutritional Needs
• Goals of Nutritional Support
– support basic body function
– promote healing
– support normal immune function to
prevent infection and other
complications
– prevent catabolism
– promote growth
Post Surgery: Feeding
• Feeding routes:
– Transpyloric feeding (Drip feeding)
• Usually in premies and infants with respiratory
distress who cannot tolerate enteral feeding

– Enteral feeding
• Orogastric / Nasogastric
• Offers several advantages over TPN/PPN
– Maintaining gut motility, improving mesenteric
flow, support gut-associated lymphoid tissue

– Parenteral Feeding
• Requires central venous access
Feeding Guidelines
Maintenance Fluid Requirements
Weight Volume /kg/day
1 - 10 kg 100 ml/kg/day
10 - 20kg 1000 ml + 50 ml for each kg >
10 kg
20 kg 1500 ml + 20ml for each kg >
20 kg

Enteral Feeding Advancement Guide

Weight Initial volume/kg/day Incremental advance per day

< 1250g 10 cc/kg/day 10 cc/kg/d*

1250 - 1500g 10 - 15 cc/kg/d 10 - 15 cc/kg/d*
> 1500g 20 cc/kg/d 20 cc/kg/d

(Hendricks & Duggan, 2000)

 Feeding Baby Johan
• Term Baby
– Fluid Management in the initial post-op period
• 50% of calculated needs
• Balance with fluid losses, diuresis, cardiac output needs

– Initiate enteral feeding with EBM (assuming his gut function

is adequate) once constant diuresis is reached with
adequate circulatory support

• Assuming Baby Johan is ~3kg

– Initiate feeding at 50-60cc/kg/day. If well tolerated, advance by
another 20cc/kg/day . Allow a pacifier for non-nutritive sucking
during feeding to enhance oromotor skills.

– If no signs of feeding intolerance and has good oromotor skills: may

progress to breastfeeding.
 Post-Surgery
Factors That May Delay Baby
Johan’s Progression to Oral
Feeds
Factors that can complicate
Johan’s progression to oral
feeds
• Late return of bowel sound
• Infection
• Difficulty in extubation
• Intolerance to oral feeds
Factors that can complicate
Johan’s progression to oral
feeds
• Post-op Complications
– Arrhythmias
– Bleeding
– Gastrointestinal Complications
– Postoperative Pulmonary Hypertension
– Postoperative infection
Signs of Feeding Intolerance
• Excessive gastric residuals
• > 2x the hourly rate on COG feeds
• > ½ the feeding volume on bolus gavage feeds
• Bilious or bloody gastric aspirates
• Vomiting
• Visible or palpable loops of bowel on abdominal
exam
• A firm or distended abdomen
• Stools
• Diarrhea
Assessing adequacy of oral
feeding
• Adequacy of milk intake
• Assessed by voiding and stooling patterns
• And by aspirating

• Fluids, Electrolytes, and Nutrition

• Fluid retention
• Fluid management :Diuretic therapy is typically
started within 24 to 48 hours

• Total body weight

 Post Surgery
Preparing Mother and Baby
Johan for home
Providing Advise: Feeding of Baby
Johan

 Benefits of breast feeding

 “How to” of breast feeding
 Infection issues
 Psychological aspects: Allaying
Breastfeeding Anxiety
Benefits of breast feeding
Human milk
• Contains anti-inflammatory factors and other factors that
regulate the response of the immune system against
infection.

• Contains immunologic agents and other compounds, such

as secretory antibodies, leukocytes, and carbohydrates that
acts against viruses, bacteria, and parasites. The transfer of
these factors from human milk provides a distinct
advantage that infants fed formula do not experience.

• Contains a balance of nutrients that closely matches human

infant requirements for growth and development than does
the milk of any other species. Eg. compared to cow’s milk,
human milk is low in total protein and low in casein, making
it more readily digestible and less stressful on immature
infant kidneys. The lipids and enzymes in human milk
Benefits of breast
feeding
For infants

• Better gastrointestinal function and protection

from gastrointestinal infections, such as vomiting
and diarrhea.

• A reduced risk of respiratory infections, ear

infections, and wheezing.

• Some studies suggest that breastfeeding reduces

the risk of obesity, cardiovascular disease, and
autoimmune diseases, such as type 1 diabetes
mellitus.
Benefits of breast
feeding
For women

• Reduced blood loss after childbirth as a result of a

hormone, oxytocin, which is released into the mother’s
bloodstream while breastfeeding. Oxytocin helps the uterus
to contract, which reduces uterine bleeding

• Reduced levels of stress in the mother as a result of several

hormones released during breastfeeding

• Increased weight loss after pregnancy (if breastfeeding

continues for at least six months).

• Reduced risk of ovarian and premenopausal breast cancers,

and possibly a reduced risk of osteoporosis.
Benefits of breast
feeding
For Family

• Reduced infant feeding costs. Infant formula and

associated supplies are estimated to cost at least
$1000 during the first 12 months.

• Reduced costs related to healthcare, including

doctor’s visits, hospital costs, and lost time from
work. Infants who are breastfed are less likely to
become ill and less likely to be hospitalized,
reducing the potential costs and anxieties of
caring for an ill child.
Providing Advise: Feeding of Baby
Johan

 Benefits of breast feeding

 “How to” of breast feeding
 Infection issues
 Psychological aspects: Allaying
Breastfeeding Anxiety
“How to” of breast
feeding
Correct latch-on

• Mother should be comfortable and the infant positioned so

that nothing interferes with mouth-to-breast contact.

• Nipple is stroke against the infant’s cheek nearest the

nipple. Entire nipple and most of the areola should be
placed in the infant’s mouth.

• Infant latch-on by compressing the lips. Normal sucking

include suction of 4-6 cm of the areola, compression of the
nipple against the palate, stimulation of milk ejection by
initial rapid non-nutritive sucking, and extraction of milk
from the lactiferous sinuses by a slower suck-swallow
rhythm of approximately one per second.

• Infant may be removed from the breast by placing a clean

finger between the infant’s and the areola to release
“How to” of breast
feeding
Positioning

• Cradle hold
• Cross-cradle hold
• Football hold (Clutch Position)
• Side-lying position
Cradle hold

• Support the baby with

the arm on the same
side as the nursing
breast
• Sit up straight —
preferably in a chair
with armrests.
• Cradle the baby and
rest his or her head in
the crook of your
elbow while he or she
the nursing breast.
• For extra support,
place a pillow on your
Cross-cradle hold
• Ideal for early breast-feeding,
when you and your newborn
are getting used to the
process.
• Sit up straight in a
comfortable chair with
armrests.
• Hold your baby crosswise in
the crook of the arm opposite
the breast you're feeding
from — left arm for right
breast, right arm for left.
• Support the baby's trunk and
head with your forearm and
palm. Place your other hand
beneath your breast in a U-
shaped hold (this guides the
baby's mouth to your breast
and make it easier for the
baby to latch on)
• Don't bend over or lean
forward to bring your breast
Football hold
• This position is especially
popular among mothers
who:
– Are recovering from
Caesarean births
– Have large breasts
– Nursing a premature baby
or two babies at once
– Need to encourage a baby
to take more of the nipple
into his or her mouth

• Hold your baby at your

side, with your elbow bent.
With your open hand,
support your baby's head
and face him or her toward
your breast.
• Your baby's back will rest
on your forearm. For
comfort, put a pillow at
your side and use a chair
Side-lying hold
• A lying position may help
your baby latch on to your
breast correctly in the early
days of breast-feeding.
– It's also a good choice when
you're tired.
– If you're recuperating from a
Caesarean birth, reclining
may be your only option for
the first few days.

• Lie on your side and face

your baby toward your
breast, supporting baby with
the hand of the arm you're
resting on.
• With your other arm and
hand, grasp your breast and
then touch your nipple to
your baby's lips.
• Once your baby latches on,
use the bottom arm to
“How to” of breast
feeding
Advice for Mum: Determining
effectiveness of breast-feeding
• Steady weight gain is often the most reliable sign
• Most newborns breast-feed eight to 12 times a day
• If you listen carefully, you’ll be able to hear your baby
swallowing
• Your breasts may feel firm or full before the feeding, and
softer or emptier afterward.
• Expect your baby to have six to eight wet diapers a day
• A well-nourished baby also will have one to three or even
more bowel movements a day
• A baby who seems satisfied after a feeding and is alert and
active at other times is likely getting enough to eat
“How to” of breast
feeding
Advice for Mum: Milk production
and expression
• Ideally, infants who are medically stable and able to
breastfed should be put to breast for all feedings.

• If infant is unable to breastfeed effectively, the mother

should express her milk approximately 8 to 12 times / day
to initiate, maintain or increase her milk supply.

• You should save any milk that is expressed.

• A mother who is expressing milk for an ill or hospitalized

infant requires education concerning milk production, use
of an electric breast pump. She should be able to
demonstrate how to assemble the pump, use it, and clean it
before she leaves the hospital.
Providing Advise: Feeding of Baby
Johan

 Benefits of breast feeding

 “How to” of breast feeding
 Infection control
 Psychological aspects: Allaying
Breastfeeding Anxiety
Infection Issues
Infection through Breast feeding
• Many maternal illnesses associated with fever do not require
separation of the mother and infant or additional precautions
to protect the infant. (eg. Breasts engorgement, atelectasis,
UTI, etc)

• Most anti-microbial agents used to treat infection can be

used in infants and children. Additional amounts that are
ingested by the infant in breast milk are usually insignificant.

• Standard precaution include, avoiding direct contact with

blood and body fluids, broken skin and mucous membranes,
careful hand washing before and after breastfeeding, and
washing the breast before and after breastfeeding.
 Infection Issues
Healthy lifestyle choices
Your lifestyle choices are just as important when you’re breast-
feeding as they were when you were pregnant.
• Eat plenty of fruits, vegetables and whole grains.
• Drink lots of fluids.
• Rest as much as possible.
• Only take medication with your doctor’s consent.
• Don’t smoke.
• Beware of caffeine and alcohol.

VSD management
• Because infection can occur up to 3 weeks after surgery,
parents need to be educated about signs of bacterial
endocarditis, wound infection, including purulent drainage,
fever, and a foul-smelling odor.
• Prophylactic antibiotics therapy is usually continued for up to
6 months post VSD closure to prevent bacterial endocarditis.
– Teach Mum how to administer medications to Baby Johan
• With early diagnosis and repair of a VSD, the outcome is
generally excellent, and minimal follow-up is necessary.
Activity levels, appetite, and growth will return in most
Providing Advise: Feeding of Baby
Johan

 Benefits of breast feeding

 “How to” of breast feeding
 Infection issues
 Psychological aspects: Allaying
Breastfeeding Anxiety
Psychological Issues:
Allaying Breast-feeding
anxiety
• Explain to the mother, the infant’s heart
condition, sign and symptoms and why it affect
the feeding so that it will not affect the mother
psychologically.
• Allay the fear and anxiety of breastfeeding for the
infant after surgical intervention.
• Provide educational resources and demonstrate
correct breastfeeding techniques for a surgical
infant to ensure that their feeding decision is a
fully informed one.
• Support and encouragement by the father can
greatly assist the mother when problem arises.
• Encourage breastfeeding post operatively. Eg.
Provide private room, avoid procedure that
interfere with breastfeeding, teach infant feeding
cues, the needs to establish and maintain an
Summary

• Most baby born with a congenital heart defect may be

medically managed or may require surgical intervention.
Surgery can be accomplished in the immediate newborn
period or planned for when the infant reaches a specific age
or weight.
• Family support, education and participation in the infant’s
care is essential in assisting the family to cope with the
diagnosis and to ensure optimal outcomes for the infant.
• Ongoing maternal support, education, and assistance with
breastfeeding or expressing milk for the infant unable to
nurse is essential to ensure positive outcomes for the
mother and her infant.
• Once discharged home, infants require follow-up to provide
appropriate health care and monitor of growth and
nutrition.
• Breastfeeding provides numerous benefits to infants and
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