title: Early enteral nutrition therapy in congenital cardiac repair postoperatively: A randomized, controlled pilot study.
abstract: OBJECTIVE
  Adequate nutritional supplementation in infants with cardiac malformations after surgical repair is a challenge. Critically ill infants in the early postoperative period are in a catabolic stress. The mismatch between estimated energy requirement (EER) and the intake in the postoperative period is multifactorial, predisposing them to complications such as immune deficiency, more infection, and growth failure. This study aimed to assess the feasibility and efficacy of enriched breast milk feed on postoperative recovery and growth of infants after open heart surgery.
  
  
  METHODS
  Fifty infants <6 months of age were prospectively randomized in the trial for enteral nutrition (EN) postoperatively from day 1 to 10, after obtaining the Institute Ethics Committee's approval. They were equally divided into two groups on the basis of the feed they received: Control group was fed with expressed breast milk (EBM; 0.65 kcal/ml) and intervention group was fed with EBM + energy supplementation/fortification with human milk fortifier (7.5 kcal/2 g)/Simyl medium-chain triglyceride oil (7.8 kcal/ml). Energy need for each infant was calculated as per EER at 90 kcal/kg/day, as the target requirement. The intra- and post-operative variables such as cardiopulmonary bypass and aortic cross-clamp times, ventilation duration, Intensive Care Unit (ICU), and hospital length of stay and mortality were recorded. Anthropometric and hematological parameters and infection control data were recorded in a predesigned pro forma. Data were analyzed using Stata 14.1 software.
  
  
  RESULTS
  The duration of mechanical ventilation, length of ICU stay (LOIS), length of hospital stay (LOHS), infection rate, and mortality rate were lower in the intervention group compared to the control group although none of the differences were statistically significant. Infants in control group needed mechanical ventilation for about a day more (i.e., 153.6 ± 149.0 h vs. 123.2 ± 107.0 h; P = 0.20) than those in the intervention group. Similarly, infants in control group stayed for longer duration in the ICU (13.2 ± 8.9 days) and hospital (16.5 ± 9.8 days) as compared to the intervention group (11.0 ± 6.1 days; 14.1 ± 7.0 days) (P = 0.14 and 0.17, respectively). The LOIS and LOHS were decreased by 2.2 and 2.4 days, respectively, in the intervention group compared to control group. The infection rate (3/25; 5/25) and mortality rate (1/25; 2/25) were lower in the intervention group than those in the control group. The energy intake in the intervention group was 40 kcal more (i.e., 127.2 ± 56.1 kcal vs. 87.1 ± 38.3 kcal) than the control group on the 10th postoperative day.
  
  
  CONCLUSIONS
  Early enteral/oral feeding after cardiac surgery is feasible and recommended. In addition, enriching the EBM is helpful in achieving the maximum possible calorie intake in the postoperative period. EN therapy might help in providing adequate nutrition, and it decreases ventilation duration, infection rate, LOIS, LOHS, and mortality.
authors.affiliation: Department of CTVS, Intensive Care for CTVS, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Manoj Kumar
authors.initials: MK
authors.lastname: Sahu
authors.affiliation: Department of Dietetics, Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Anuradha
authors.initials: A
authors.lastname: Singal
authors.affiliation: Department of CTVS, Intensive Care for CTVS, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Ramesh
authors.initials: R
authors.lastname: Menon
authors.affiliation: Department of CTVS, Intensive Care for CTVS, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Sarvesh Pal
authors.initials: SP
authors.lastname: Singh
authors.affiliation: Department of Dietetics, Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Alka
authors.initials: A
authors.lastname: Mohan
authors.affiliation: Department of Dietetics, Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Mala
authors.initials: M
authors.lastname: Manral
authors.affiliation: Department of Dietetics, Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Divya
authors.initials: D
authors.lastname: Singh
authors.affiliation: Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: V
authors.initials: V
authors.lastname: Devagouru
authors.affiliation: Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Sachin
authors.initials: S
authors.lastname: Talwar
authors.affiliation: Department of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Shiv Kumar
authors.initials: SK
authors.lastname: Choudhary
mesh_terms: D006348:Cardiac Surgical Procedures; D003422:Critical Care / Q000379:methods; D004750:Enteral Nutrition / Q000379:methods*; D005260:Female; D006330:Heart Defects, Congenital / Q000601:surgery*; D006801:Humans; D007223:Infant; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D010865:Pilot Projects; D011182:Postoperative Care / Q000379:methods*; D016896:Treatment Outcome