P1.241: Development and implementation of a pre-operative feeding protocol for neonates with congenital heart disease: a quality improvement project

Purpose/Objectives: Nutrition is a key factor in the care of neonates with congenital heart disease (CHD). One in 4 patients with CHD require cardiac surgery in their lifetime. Inadequate nutrition prior to surgery is associated with poor post-surgical outcomes such as increased inotrope score, longer need for mechanical ventilation and longer time to reach full feeds. A standard feeding protocol for this population is not widely used but has potential to improve time to feed initiation and post-operative outcomes. The objective of this study is to develop and implement a pre-operative feeding protocol for neonates with CHD requiring surgical repair, with an overall aim that neonates will reach higher enteral feeding volumes prior to surgery.

Design/Methods: This is a single-center quality improvement project at a Level IV neonatal intensive care unit, exempt from IRB review. The inclusion criteria are gestational age ≥ 35 weeks, and the need for cardiac surgery under bypass within 30 days. Exclusion criteria are the presence of a genetic/anatomic anomaly that impacts feeding, the need for inotropes, and a diagnosis ≥ 24 hours after birth. Baseline data from 2021-2022 was collected. A feeding protocol was created with a multi-disciplinary team and implemented in June 2024, with neonates stratified into groups based on cardiac lesion (ductal dependent for pulmonary or systemic blood flow, non-ductal dependent). The primary outcome is the total enteral feeding volume prior to surgery. Secondary outcomes include the need for nasogastric tube at discharge, in-hospital mortality and anthropometric measurements. The preliminary results are displayed in a run chart.

Results: From June – December 2024, there were 21 patients with congenital heart disease born at or admitted to our hospital, with 10 meeting inclusion criteria for the feeding protocol (1 ductal dependent for pulmonary blood flow, 4 ductal dependent for systemic blood flow, 5 non-ductal dependent). The median pre-operative feeding volume increased from 20 mL/kg/day to 30 mL/kg/day in the post-implementation group. One secondary outcome showed a decrease in the percentage of patients who discharged home with a nasogastric tube (70% vs 60%).

Conclusion/Discussion: The preliminary results suggest that a feeding protocol and standardization of care have the potential to improve enteral nutrition in patients with congenital heart disease. Strengths of the study include a multi-disciplinary approach for the care of complex patients in the NICU and a perceived increased efficiency of care. Limitations include the small number of patients and a short duration of study interval. Additional data collection is ongoing and necessary to evaluate this quality improvement work and to study longer term post-surgical outcomes.