Childrens National Pediatric Case Study - VSD

The Nutritional Implications of VSD in the Developing Infant
Pediatric Case Study

Bethany Beaver UMCP Dietetic Intern
Outline
Overview of Ventricular Septal Defect (VSD)
Nutritional Implications of VSD

Case Study Initial Assessment Nutrition Follow Up
Ventricular Septal Defect (VSD)

Definition Hole in the septum that separates the right and left ventricles (lower chambers of the heart) Prevalent at birth (CHD)
Acyanotic Blood flows from the left-to-right ventricles Oxygenated blood mixes with deoxygenated blood Oxygenated blood returns to the lungs
Image retrieved from the American Heart Association
VSD Cont.
Diagnosis
Prenatally via fetal Echo Postnatally after signs/symptoms are evident Confirmed with chest x-ray, EKG, Echo, MRI
Etiology
Maternal smoking during pregnancy Genetics Chromosomal abnormalities
Epidemiology
VSD is the most common CHD Incidence of CHD reported at 1% US population
VSD Cont.
Presentation
Heart murmur Increased breathing rate Sweating Tiredness when feeding Failure to thrive
Complications
Heart failure Growth failure Arrhythmias Pulmonary hypertension
Treatment
Medications Cardiac catheterization Open heart surgery
Nutrition and VSD

Etiology of Malnutrition Inadequate intake Fatigue when feeding Frequent emesis or evidence of GERD Tachypnea Increased energy needs Chronic metabolic stress response Tachypnea Inefficient nutrient utilization/absorption GI distress (emesis) Reduced splanchnic blood flow Altered gut motility GI atrophy
Case Study
Background
CT is a 3.5 month old female
PMH/PSH
Large VSD
Admit date: 5/13

Scheduled VSD repair
Hospitalization
Procedures during admission
VSD repair on 5/14
Medications
Colace (docusate) Lasix (furosemide) Zantac (ranitidine) KCl Heparin
Initial Nutrition Assessment

Anthropometric Data Birth Hx Full term Birth weight: 3.2kg Birth length: 48.8cm Current findings Weight: 4.3kg Length: 58.5cm IBW: 5.5kg (50% weight-for-length) Current body weight at 73% of IBW Clinical Findings Physical appearance normal Family at bedside indicated possible facial swelling
WHO Growth Standards

Weight-for-age
50th percentile at birth <2nd percentile
Length-for-age
50th percentile at birth 10-25th percentile
WHO Growth Standards Cont.

Weight-for-length
50-75th percentile at birth <2nd percentile
Initial Assessment Cont.

Biochemical Data
Laboratory Values Date 5/15 5/14 5/13 Sodium 140 140 134 Potassium 3.6 3* 5.2 Chloride 102 100 102 Carbon Dioxide 30 27 22 BUN 7 4 2 Creatinine 0.3 0.4 0.3 Glucose 154* 194* 92 Calcium 8.7 10.8 9.8 Magnesium 2.2* 3.1* N/A
Initial Assessment Cont.

Diet History Feeding pattern
Approx 3oz breast milk at 6 feedings/day Three feeds nursing and three feeds with bottle
Oral Intake
Breast milk at 20kcal/oz Q4hr (average) Current intake at approximately 80kcal/kg Poly-Vi-Sol is given daily (1mL)
Additional Findings
No signs/symptoms of intolerance (N/V/D/C) Mother indicated patient seems irritated during breast feeding, possibly due to inadequate intake
Needs
Nutrient Needs
Increased needs for healing post-op and for catch-up growth Calories 120kcal/kg Protein 2.2g/kg Fluid 100mL/kg
Diagnosis
PES Statement: Underweight related to inadequate energy intake as evidenced by patients current weight-for-length below the 2nd percentile
Plan/Goals
1. Recommend fortifying breast milk with Enfamil to 24kcal/oz. Add 2.7 grams Enfamil powder to every 100mL breast milk to = 24kcal/oz. Goal intake is 80mL Q3hr providing 120kcal/kg and 150mL/kg fluid. 2. Recommend initiate PO/NG feeds if patient consumes <75% of needs PO. 3. Continue to monitor electrolytes 4. Monitor and trend daily weight gain, goal of 25-35 grams/day average for catch-up growth. If weight gain is inadequate, fortify breast milk to 26kcal/oz. 5. Measure length and HC weekly to trend. 6. Continue Poly-Vi-Sol 1mL/day per home regimen. 7. Nutritional education was provided to family at bedsite
Nutrition Follow-Up
Findings NGT was inserted for insufficient intake. Patient was tolerating TF without emesis , diarrhea or gastric distention Patient had new recorded weight of 5.13kg (+.83kg) in two days which is c/w fluid overload Plan
1. Continue with breast milk fortified to 24kcal/oz with Enfamil at
80mL Q3hr via PO/NG. Continue NG until pt consumes >75% of needs PO. 2. Monitor and trend daily weight gain, goal of 25-35 grams/day average for catch-up growth. If weight gain is inadequate, fortify breast milk to 26kcal/oz. 3. Measure length and HC weekly to trend. 4. Continue Poly-Vi-Sol 1mL/day per home regimen.
Questions
References
1. Parrish, C. (2011). Nourishing little hearts: Nutritional implications for congenital heart defects. Nutrition Issues in Gastroenterology (#98) 2. Ventricular septal defect (vsd). (n.d.). Retrieved from http://pediatricct.surgery.ucsf.edu/conditions-procedures/ventricular-septal-defect.aspx 3. Ventricular septal defect (vsd). (n.d.). Retrieved from http://www.childrenshospital.org/az/Site500/mainpageS50 0P4.html 4. Cardiac catheterization with vsd. (n.d.). Retrieved from http://www.cooperhealth.org/treatments/cardiaccatheterization-vsd

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The Nutritional Implications of VSD in the Developing Infant

Pediatric Case Study

Nutritional Implications of VSD

Ventricular Septal Defect (VSD)

Nutrition and VSD

Admit date: 5/13

Initial Nutrition Assessment

WHO Growth Standards

WHO Growth Standards Cont.

Initial Assessment Cont.

Initial Assessment Cont.

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