How can I assess nutritional status in pediatric cardiac surgical patients?

Nutritional Assessment in Pediatric Cardiac Surgical Patients

Regular anthropometric measurements expressed in z-scores, including weight, height/length, mid-upper arm circumference, and head circumference, are recommended for assessing nutritional status in pediatric cardiac surgical patients at admission and throughout hospitalization. 1, 2

Anthropometric Assessment

• Weight, height/length, mid-upper arm circumference, and head circumference should be measured at admission and regularly during hospitalization, with results expressed as z-scores to allow for standardized comparison 1, 2
• Serial triceps skin fold thickness and mid-arm circumference measurements are particularly reliable for nutritional assessment in pediatric cardiac patients, as they are less affected by fluid status than weight alone 1, 2
• Weight-for-height z-scores (for children <2 years) and BMI z-scores (for children ≥2 years) should be calculated to identify wasting and obesity 3
• Height-for-age z-scores should be calculated to identify stunting, which is common in children with congenital heart disease 4

Biochemical Assessment

• Serum albumin should be measured to assess visceral protein stores, though it should be interpreted alongside C-reactive protein due to the influence of inflammation 2, 5
• Prealbumin is a more sensitive marker for acute nutritional changes but must be interpreted with C-reactive protein due to its role as a negative acute-phase reactant 5
• Prognostic Nutritional Index (PNI), calculated using serum albumin and total lymphocyte count, can effectively predict postoperative outcomes in pediatric cardiac surgery patients (cutoff value ≤66.5 indicates higher risk) 6
• For patients with fluid issues, creatinine kinetics can be used to calculate fat-free, edema-free body mass, which better reflects somatic protein stores 1, 2

Clinical Assessment

• Evaluate for feeding problems, which are present in up to 58% of pediatric cardiac patients 7
• Assess for signs of malnutrition, which affects approximately 40% of children with congenital heart disease before surgery 7
• Screen for vocal cord dysfunction and oropharyngeal motor skills deficiencies to establish safe enteral nutrition 5
• Monitor for hyperglycemia, which may require insulin management to improve outcomes 5

Nutritional Intervention Based on Assessment

• Early enteral nutrition is recommended in children after cardiac surgery who are hemodynamically stable 1
• For cholestatic infants, use medium-chain triglyceride-containing formulas with normal protein administration 1
• Consider nasogastric tube feeding when oral intake is insufficient, as it has been shown to improve body composition in children with cardiac disease 1, 4
• Implement feeding protocols specific to cardiac conditions (e.g., hypoplastic left heart syndrome) to improve outcomes 5

Monitoring and Follow-up

• Reassess nutritional status regularly, as cardiac surgery has been shown to significantly improve weight gain and nutritional parameters 7, 4
• Monitor for catch-up growth, which typically occurs in weight before height after cardiac surgery 4
• Pay special attention to children who were small for gestational age (SGA) or premature, as they have higher nutritional risk 4

Common Pitfalls to Avoid

• Relying solely on weight measurements, which may overestimate nutritional adequacy due to fluid retention in cardiac patients 1, 2
• Overlooking the nutritional assessment as part of routine cardiac care, despite its significant impact on surgical outcomes 3, 6
• Failing to identify children with stunting or obesity preoperatively, who are at increased risk of adverse outcomes after surgery 3
• Not accounting for increased caloric requirements in children with congenital heart disease, who may need 20-80% more calories than healthy children 1