Gastrointestinal Problems in Children With CHD: Impact and Management

1. Congenital Heart Defects and Impact on the Gastrointestinal System

Depending on the type of congenital heart defect, gut function can be affected due to altered blood flow and perfusion to the gut. Surgical intervention can also affect vagal nerve function, impacting the aerodigestive tract, resulting in challenges with tolerance and motility. Impaired gut function due to cardiac anatomy and physiology and/or surgery may lead to future feeding challenges.

2. Necrotizing Enterocolitis (NEC)

Infants with CHD are at high risk for NEC secondary to poor gut perfusion from decreased blood flow from the heart, as well as a consequence of cardiopulmonary bypass and cardiac surgery. Some management options can be very restrictive but necessary to prevent further gut damage or even death. However, this can impact oral feeding opportunities and development. The use of breast milk and feeding guidelines can help mitigate the risk of NEC after cardiac surgery.

3. Gastroesophageal Reflux (GER)

Infants with CHD have a higher incidence of GER than other infants. GER is associated with negative feeding experiences, resulting in poor weight gain, respiratory compromise, and oral aversion. Infants with GER often benefit from medical and nonmedical management strategies to decrease associated discomfort.

4. GI Motility Issues

Altered cardiac physiology and the side effects of cardiac surgery may result in motility challenges of the esophagus and the pharynx. Management of motility issues is important to ensure adequate growth and nutrition and to prevent oral aversion.

5. Chylothorax

Another consequence of cardiac surgery that can affect oral feeding development is chylothorax, which is the presence of chyle in the pleural cavity from damage to the lymph ducts during surgery. It can be a potentially life-threatening disorder that is managed by diet changes. However, for infants and newborns, it may disrupt normal oral feeding and cause subsequent oral aversion.

6. Congestive Heart Failure

Complete repair for cardiac defects is not always possible in infancy, resulting in the need for multiple cardiac interventions and/or staged surgeries. Congestive heart failure may occur when a child is close to needing cardiac intervention, resulting in physiologic instability. Feeding therapists who work with children with cardiac defects should understand these symptoms and how to adjust goals and expectations during this time.

7. Consequences of GI Problems

Hypermetabolism is common for children with CHD, with greater energy expenditure at rest than in age-matched healthy children. As a result, weight gain and nutrition are suboptimal, which can be detrimental for necessary surgery. Strategies to facilitate weight gain can be helpful but also have negative consequences. Good communication between the feeding therapist, cardiologist, dietitian, and family is crucial to optimize growth and development.

8. Tube-Feeding and Tube Weaning

Tube-feeding is common for children with CHD, as they have growth challenges due to altered cardiac anatomy and physiology as well as the consequences of cardiac intervention. While studies have shown improved survival rates with supplemental tube feeds, dependency on tube feeds can occur, impacting family/child feeding dynamics and resulting in oral feeding skill delays. Working with the child’s medical team to decrease tube-feeding dependence is a goal for outpatient feeding therapists with the right support.