MODULE 26: INFANT WITH CONGESTIVE HEART FAILURE (CHF) Mary Matlin is a two-month old infant who was diagnosed with CHF as a neonate. She presented with tachypnea, respiratory distress, grunting, low cardiac output and difficulty feeding. Diagnosis of her condition was made following a careful evaluation, which included extensive history and physical examination , including upper and lower extremity blood pressure readings, and laboratory tests. Lab tests were performed for O2 saturation, CBC, hemoglobin levels, calcium levels, electrolytes, BUN and creatinine. The most likely causes of CHF, depending on the age of the child, may represent underlying anemia, respiratory illnesses or infections. Neonates and infants younger than 2 months are most likely to be diagnosed with CHF due to structural heart disease. This was found to be the cause in Mary’s case. The goals of medical management of CHF are to reduce the workload of the heart and prevent overload, enhance cardiac output and enhance nutrition by increasing the caloric content of the feedings, using a gastrostomy or nasogastric tube feeding when needed, and administering red blood cell transfusions as necessary to increase the O2- carrying capacity of the blood. The success of medical therapy is judged according to the child’s growth and development. Failure to thrive is a general term used to describe a child who does not measure up to growth and development standards for weight and height. It indicates need for increased nutrition/medical care. The option for surgical repair of her damaged heart exists when Mary’s weight is determined to be suitable to meet the demands of surgery. The role of nutrition is critical in the management of CHF. Nutrition Management Four major considerations are necessary in feeding children with CHF: 1. increased caloric content of the diet. Mary’s energy needs are much higher than those of a normal child, perhaps 30-60% above normal. CHF increases metabolic demands while making feeding more difficult. The use of tube feedings may be necessary depending on how much difficulty is encountered with oral feeding. 2. Renal load: overload of solutes from excessive electrolytes in feedings can cause critical problems. Special formulas that provide minimum electrolytes and protein without causing kidney overload are used. These formulas may be supplemented with fat and/or carbohydrate solutions that do not affect solute load. Fluid intake for Mary must be increased. There is great loss of water from tachypnea, vomiting, fever, gagging, and regurgitation and must be replaced. It is important to monitor urine and solute levels and a balance maintained. 3. Intolerance: increasing simple sugars may cause diarrhea and fats may cause steatorrhea and abdominal discomfort. 4. Vitamin and mineral content: because of the small amount of nutrients consumed by Mary, these should be carefully monitored to prevent deficiencies. Iron levels should be very carefully monitored and a supplement requested as needed to prevent anemia. Mary’s parents and caregivers are very concerned and anxious. The diet for Mary that they will administer when she gets out of the hospital is exacting and a child with CHF is difficult to feed. They often vomit, gag and regurgitate their food.
The parent’s will need guidance in purchasing the appropriate formulas, and techniques to minimize the gagging reflex and increase sucking ability. A list of low sodium formulas and the use of MCT’s (medium chain triglycerides) should be provided. The parents will need counseling, support and reinforcement. After discharge Mary’s nutritional status should be studied periodically to ensure that she is growing at a normal rate. It will give her parent’s more confidence in their ability to care for this child, and to prepare her for surgery in the future. Study Questions What are the effects of CHF on the nutritional status of Mary? Name 4 signs of CHF in an infant Describe the uses of lab tests for CBC, hemoglobin, electrolytes and BUN. What types of structural defects in the heart may cause CHF? Ask the pharmacist for a list of formulas suitable for infants with CHF and describe their nutrient content. 6. List 4 major considerations necessary in feeding children with CHF. 7. Name 2 energy supplements suitable for patients with CHF. 8. List 3 feeding problems in children with CHF and ways to overcome them. 9. Describe 5 ways the nurse/caregiver can maintain optimal nutritional status in the infant with CHF. List as many discharge procedures/ instructions for caregivers as you can think of to help Mary’s parents cope with her condition 1. 2. 3. 4. 5.