1

Katie Page

NHM 567- 920

The Effects of High-Energy Enteral Feeds in Newborn

Babies/Infants with CHD for Adequate Weight Gain

11/17/2023
2

Background:

This review article is going to explore the effects of high-energy enteral nutrition feeds

within newborn infants (birth to one year) who have a congenital heart defect/disease. Infants

who are under such critical, clinical stress tend to undergo nutritional deficits, such as poor

growth rates, due to the severity of their disease state. Specifically, this review will discuss

providing high-energy enteral formula to infants with CHD and the effects this on has adequate

growth rates. CHD or “Congenital Heart Defects” is defined as the most common birth defect

and alters the structure of a child’s heart and its functionality. 1 CHD can affect how the blood

flows throughout the body and interfere with oxygenation to the organ systems. 1 One of the most

common congenital heart defects in newborns is PDA or Patent Ductus Arteriosus which is when

the connection of the aorta and the pulmonary artery does not adjoin after birth. 1 The PDA

usually closes shortly after a baby is born, but when it does not, the blood cannot flow in the

proper manner that it should and puts the baby at risk for severe clinical complications and

mortality.1 Other common CHD’s include Atrial Septal Defect, Pulmonary Atresia, Tetralogy of

Fallot, Atrioventricular Septal Defect, etc. 1 The causes of CHD within newborns are not known,

although studies have been conducted that links genetic and chromosomal changes in utero to a

possible etiology of this disease state. 1 Other factors that could contribute to the cause of CHD

include maternal diet during pregnancy, maternal health conditions, or medication use during

pregnancy, but overall, there is no concrete cause for the disease. 1 Studies show that cardiac

defects are present in one percent of around 40,000 births a year, and about 25% of them have

critical CHD meaning they require a procedure or surgery within infancy.1

The normal infant’s nutritional needs vary as the infant is growing at a quick and

consistent rate, but generally a preterm infant needs 110-130 kcal/kg/d and term infant needs
3

100-110 kcals/kg/d according to the Texas Children’s Hospital Pediatric Nutrition Reference

Guide- 13th Edition.2 The protein needs of a preterm infant is 3.5-4.3 g/kg/d and for a healthy

term infant, the protein requirements are around 1.5 g/kg/d. 2 Fluid needs and total fluid intake are

dependent on the clinical status of the infant and the number of drips and IV lines the patient is

receiving but are usually restricted within cardiology ICU patients. 2 An infant with CHD’s

energy needs is around 40-60 kcal/kg/d, increasing moderately to a goal of 90-120 kcal/kg/d, and

protein requirements are 1.8-2.2 g/kg/d with lipids at around 35% of total calories. 3 Total fluid

intake (TFI) should not exceed 150 mL/kg/d within this population as well. 3 These nutrition

recommendations may differ from the ranges slightly as each patient may have other clinical

diagnoses and/or specific clinical manifestation parameters, but they usually do not stray far

from the CHD recommendations as this disease state is usually at great severity. Overall, infants

with CHD may have stunted or impaired growth and likely will become underdeveloped and

undernourished overtime due to excess energy expenditure and increased needs. 4 It is of much

importance as a dietitian working within this patient population to ensure CHD infant’s

nutritional needs are met to combat these growth and development obstacles. This review article

will investigate the use of high-energy enteral nutrition support to analyze the nutritional

implications it has on adequate growth within this target population. Different Randomized

Control Trials will be utilized to analyze research findings associated with this intervention.

Analysis of Each Research Trial’s Findings:

Multiple randomized control trials have been conducted to analyze if high-energy enteral

nutrition support can increase growth rates within the patient population. This review paper will
4

begin by interpreting the data collected from the intervention groups receiving high-energy

formulas versus patients receiving normal enteral nutrition formula as the control groups. The

evaluation measures such as weight, length/height, weight gain, growth velocity, tolerance to

feeds, GI complications, etc. will be used to evaluate the effectiveness of the intervention on

adequate growth.

RCT 1:

The research trial being analyzed is a prospective, open-label, single-arm growth, safety,

and tolerance RCT with CHD infants aged one to eight months who are experiencing poor

growth. The intervention group received energy and protein enriched formula (EPFE) and the

control group received normal enteral nutrition formula. This study lasted 35 days and used stool

consistency, weight-for-length, head circumference, length-for-age, tolerance to feeds and

weight-for-age (WAZ) to analyze the effectiveness of the intervention.5 The study showed high-

energy and protein enriched formula to be tolerated well, improving the CHD infants’ weight

gain.5 The mean improvement in WAZ was 0.79 (+0.76) within baseline and the end of

participation of the study, with P=0.0001.5 Eighty-three percent of the participating infants

achieved a growth velocity greater or equal to the median during the study.5 Also, the P value for

length-for-age z-scores was P=0.003 and weight-for-length z-scores was P=0.0001.5 It is

important to note that feeding tolerances increased as the study went on as well.5 Overall, this

study seemed to show a correlation with weight gain and adequate growth within CHD infants

who uses high-energy and protein formula, but the study did have a few limitations. These

included having a difficult time recruiting participants and increased breastfeeding rates, leading

to a multitude of infants being excluded from the research criteria.5 It was also noted within the
5

study that using a high-energy and protein dense formula accommodates with fluid restrictions

that this population might have due to their cardiological clinical status.5

RCT 2:

The second research trial investigating this topic is a parallel randomized control trial

using 68 infants with CHD who underwent cardiovascular corrective surgery.6 The study uses an

intervention of high-density formula (90 kcal/100 mL) with the control group receiving standard

density formula (67 kcal/100 mL).6 It is also important to add that the participants were allowed

breastmilk and/or complimentary foods in addition to their formula.6 The measures used to

determine the effectiveness of the study were weight, length measurements, head circumference,

MUAC, and WAZ.6 The results of the study demonstrated a mean standard deviation for weight

z-scores of -2.38 ± 10.04 to -1.38 + 0.97 in the standard formula group, and -2.69 ± 1.19 to -0.89

± 0.90 in the high-density formula group at baseline to 8 weeks of the study.6 The P value

between the groups for weight z-scores was P=0.0001.6 The standard formula infants

demonstrated a drop in length z-scores, whereas the high-density formula infants had no decrease

within length.6 An additional point to note is serum albumin levels were increased within the

high-density group, but four parents of infants in this group reported constipation even though

tolerance was not factored into the research collection methods.6 The limitations on this study

were a small window to follow-up on participants, lack of a frequent food intake collection

within the duration of the study and no measurements taken for subcutaneous fat loss

evaluations.6 The research conducted concluded that infants receiving the higher-density formula

displayed better results within weight gain and a greater increase in WAZ scores.6
6

RCT 3:

The third research trial being evaluated was a randomized control trial in Brazil using 59

CHD infants who just underwent heart surgery. The intervention group received energy-enriched

formula at 1 kcal/mL, while the control group received “normocaloric” formula. 7 The study

lasted for thirty days post heart surgery and measured weight-for-age, weight-for-height, weight

gain, GI side effects, RACHS score, and readmission rates to determine the effectiveness of the

intervention on adequate growth.7 Along the duration of the study or during the follow-up

evaluation period, eight patients in the intervention group and four patients within the control

group passed away due to different etiologies (sepsis, multiorgan failure or heart failure) with

P=0.20.7 The mean discharge rate was 14 days within the intervention infants and 20 days in the

control infants, which was of decent significance at P=0.057.7 The research also discusses that

the use of antibiotics was lower in the intervention group (16 infants) versus the control group

(24 infants) with P=0.047.7 For the purpose of this review, the most important factor to analyze

within this study is weight gain variation. The weight gain rate within the intervention group was

higher than the control group and had a P value of 0.03.7 The control group had a mean growth

velocity of 10 g/d, while the intervention group was higher with a mean growth velocity of 16

g/d.7 Factors that limited the research design within this study include reduced sample size,

deaths during the research period and complementary intake and tolerance levels being reported

by parents which could lead to bias or inaccuracy.7 As a whole, this study concluded to

hospitalization stays being shorter within the intervention group, and a statistical significance in

increase of weight gain in the intervention group compared to the control group.7
7

RCT 4:

The next research trial being analyzed is a parallel randomized control trial including a

sample size of 59 infants who were diagnosed with CHD and undergoing open heart surgery.4

The intervention group within this study received high-energy formula of 100 kcal/100 mL as

opposed to the control group receiving standard formula of 67 kcal/mL.4 The factors used to

measure outcomes of the trial were weight gain trends, emesis frequency, abdominal distention,

GRV, and diarrhea amount.4 Along the duration of the study, five infants were excluded due to

death or admission to another outside hospital.4 It is also important to note that each participant

did not vary significantly in weight before the trial had begun.4 The study resulted with infants

that received high-energy formula having increased weight gain in comparison to the control

group with P=0.001.4 Although the intervention group had a higher weight gain rate and

improved nutritional status, they also experienced more feeding intolerance and GI

complications while using the high-energy formula.4 There was not a significant difference of

time on ventilation between the two groups with a P value of 0.749.4 The intervention limitations

within the study included bias of reports from medical staff, a limited follow-up time depending

on CICU admission period, and cariology limitations like fluid restriction or edema altering

weight trends.4 The research concluded that there can be improvement to weight status using the

high-energy formula versus a standard formula within CHD infants.4

RCT 5:

The last research trial that will be analyzed within this review is another parallel

randomized control trial including a larger sample size of 244 CHD infants who experienced

cardiac surgery between 2016 and 2018.8 The duration of this study is slightly longer than the
8

others at around two years using a 100 kcal/mL high-energy formula for the intervention group

and a standard formula for the control group.8 Evaluation measurements include age, weight, and

height at the time of surgery, time on ventilation, length of stay in the ICU, infection rate, and

nutrition recovery.8 At the conclusion of the study, patients in the intervention group had a higher

weight-for-height z-score at P<0.001, a higher weight-for-age z-score at P= 0.005 and

significantly lower ventilation support time (P=0.004), infection rate (P=0.001) and ICU stay (P=

0.045).8 It was also demonstrated that the intervention group was found to have a higher recovery

rate from malnutrition 3 months post-op in comparison to the control group at P=0.002.8 The

study limitations consisted of only short-term assessments and implementations being confined

to inpatient only with limited research and follow-up conducted outside hospitalization. 8

Conclusively, this study determined that high-energy formula within CHD infants increases

growth rates, reduces ICU admission time, decreases infection rate and ventilation support time,

and reduces the risk for continuation of malnutrition.8

Comparison of Findings:

Overall, each clinical research trial concluded to increased weight and adequate growth

with using a higher-energy formula versus a standard formula within CHD infants. Other

findings such as improved length of stay, infection rate and tolerance levels were included and

varied slightly. Differences in the number of participants and the duration of each study need to

be accounted for when analyzing the data as a whole. It is also important to note that some of the

trials included complementary food and supplement intake as others did not, which can alter

weight gain and growth trends. Another factor to consider is scale-variation between different

facilities and edema within patients as both factors can cause weight inaccuracy or fluctuations.
9

For example, the only two trials that included edema within the study limitations was RCT 1 and

4, but a common factor within cardiac clinical outcomes is fluid retention and monitoring.

Clinical needs for a hydrolyzed- formula could also be a factor within participants in each study

and was not mentioned within the research findings.

Clinical Implications:

It can be determined from the findings above that administering a higher-energy dense

formula versus a standard formula to CHD infants can improve weight gain, adequate growth,

and clinical outcomes of the disease state. From the results of each trial, there were slight

variations depending on the specifics of each participant, but overall, each study resulted in

similar outcomes. As a practitioner, one should take into consideration these findings, and assess

each patient as to whether they could potentially benefit from a high-energy formula. Registered

Dietitians specifically have the responsibility to provide the most accurate and adequate nutrition

recommendations and support to every patient seen. With the research conducted already, energy

enriched formulas should be used at the discretion of the RD. More research needs to be

conducted by dietitians and other practitioners to further explore the nutrition implications high-

energy formula has on CHD infants. Refer to Table 1 for specific recommendations regarding

the patient population discussed.

Most of the research trials mentioned using 1 kcal/mL formulas for the intervention

group. High-energy formulas were discussed as the intervention, but it was not specified within

any trial particular brands to use. Infatrini (Nutricia), Similac High Energy, and SMA High

Energy are a few examples of high-energy infant formulas that could be used to increase weight

gain and adequate growth.9 As clinicians, it is also important to ensure accessibility of formula
10

within patients that are seen. Formulas used inpatient will need to be on the hospital’s formulary,

and formulas prescribed for outpatient will need to be affordable and accessible to the patient.

WIC is a commonly used way for many families to access formula at home. WIC is state specific

as to what can be provided, and it is important to know the state’s specific WIC formulary.

Conclusion:

Overall, the research shown concludes that the use of high-energy formula within CHD

infants may increase weight gain, adequate growth, reduce malnutrition and improve clinical

outcomes. It can be recommended to provide energy enriched formula to this patient population

while closely monitoring weight trends and tolerance levels. More research will need to be

conducted to create concrete recommendations for specific formula brands and types, but the

findings within the trials used in this review suggest overall positive outcomes from the use of

high-energy formulas within CHD infants.

11

Table 1:

Recommendations: Justification:

1. Use a High-Energy Formula within  All trials showed an increase within

CHD infants experiencing poor weight weight gain and growth while using a
gain/ poor growth: high-energy formula.
 CHD infants burn more energy due to
more labor-intensive breathing and
their heart working harder to sustain
life.10
2. Monitor growth trends and tolerance  If the patient is having persistent
status while implementing care: emesis and/or diarrhea, change the
feeding regimen.
 Ensure that the high-energy formula is
promoting adequate growth.
 Intolerance issues may worsen the
patient’s disease state and/or cause
secondary clinical problems.
3. Weight adjust feeds regularly to  Infants are supposed to be growing at
reduce under or overfeeding: a fairly quick rate as it is the first year
of life.
 If feeds are not weight adjusted
regularly underfeeding may occur,
which can lead to a practitioner
changing feeds too quickly due to
perceived ineffectiveness.
 Overfeeding may occur if feeds are
not weight adjusted regularly, which
can lead to digestive issues such as
distention, gas, or diarrhea.
12

4. Encourage PO intake along with  Teaches infant to use oral motor skills
nutrition support when possible: and allows the infant to practice when
able.
 Reduces swallowing difficulty and
aspiration when patient reaches the
ability to take all feeds PO.
 Provide all nutrition via nutrition
support that is not taken PO.
 Work with SLP if patient is having PO
difficulties.

References:
13

1. What are congenital heart defects? Centers for Disease Control and Prevention. February 2,
2023. Accessed November 20, 2023. https://www.cdc.gov/ncbddd/heartdefects/facts.html.

2. Food and nutrition. Texas Children’s Hospital. Accessed November 17, 2023.
https://www.texaschildrens.org/departments/food-and-nutrition.

3. Luca A-C, Miron IC, Mîndru DE, et al. Optimal nutrition parameters for neonates and infants
with congenital heart disease. Nutrients. April 17, 2022. Accessed November 20, 2023.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9029500/.

4. Zhang H;Gu Y;Mi Y;Jin Y;Fu W;Latour JM; High-energy nutrition in paediatric cardiac
critical care patients: A randomized controlled trial. Nursing in critical care. Accessed October 6,
2023. https://pubmed.ncbi.nlm.nih.gov/30548121/.

5. Goday PS;Lewis JD;Sang CJ;George DE;McGoogan KE;Safta AM;Seth A;Krekel C; Energy-

and protein-enriched formula improves weight gain in infants with malnutrition due to
cardiac and noncardiac etiologies. JPEN. Journal of parenteral and enteral nutrition.
Accessed November 20, 2023. https://pubmed.ncbi.nlm.nih.gov/34822187/.

6. Aryafar M, Mahdavi M, Shahzadi H, Nasrollahzadeh J. Effect of feeding with standard or

higher-density formulas on anthropometric measures in children with congenital heart
defects after corrective surgery: A randomized clinical trial. Nature News. July 29, 2022.
Accessed October 6, 2023. https://www.nature.com/articles/s41430-022-01186-3.

7. Scheeffer VA;Ricachinevsky CP;Freitas AT;Salamon F;Rodrigues FFN;Brondani TG;Sutil

AT;Ferreira CHT;Matte UDS;da Silveira TR; Tolerability and effects of the use of energy-
enriched infant formula after congenital heart surgery: A randomized controlled trial.
JPEN. Journal of parenteral and enteral nutrition. Accessed November 20, 2023.
https://pubmed.ncbi.nlm.nih.gov/30900268/.

8. Chen X;Zhang M;Song Y;Luo Y;Wang L;Xu Z;Bao N; Early high-energy feeding in infants
following cardiac surgery: A randomized controlled trial. Translational pediatrics.
Accessed October 6, 2023. https://pubmed.ncbi.nlm.nih.gov/34765467/.

9. NHS choices. Accessed November 20, 2023.

https://www.rbht.nhs.uk/our-services/paediatrics/information-for-parents/childrens-diet/
nutrition-for-babies-born-chd#:~:text=High%2Denergy%20milks&text=Currently%20in
%20children%20under%20one,on%20prescription%20from%20the%20GP.

10. Helping children with congenital heart disease stay healthy, active & fit.
HealthyChildren.org. Accessed November 20, 2023.
https://www.healthychildren.org/English/health-issues/conditions/heart/Pages/Helping-
Children-With-Congenital-Heart-Disease-Stay-Healthy,-Active-&-
Fit.aspx#:~:text=Needing%20more%20calories%20in%20early,high%2Dcalorie
%20formula%20or%20supplements.
14