Pediatric Nutrition in Practice

252 Steltzer  Lafranchi

particularly for those families with language and/
or educational challenges. With any fortification,
some patients may not tolerate the higher caloric
density and show more signs of gastrointestinal
distress and less weight gain [5]. Fortification
above 26–28 calories per ounce (90 kcal/100 ml)
[10] commonly results in more gastrointestinal
distress signs. When using breast milk for fortifi-
cation, its source is an important issue, because
hindmilk is higher in calories than is foremilk.
This becomes particularly important with an in-
fant failing to demonstrate growth. Some lactoen-
gineering options are available at different insti-
tutions [9] to aid in assessment of caloric density
of the breast milk being delivered. Breastfeeding
has become a more acceptable practice. In some
institutions, patients may be started on enteral
feedings with available colostrum and/or breast
milk by nasogastric, nutritive and/or nonnutri-
tive breastfeeding before Norwood palliation,
based on physiological status and recommenda-
tions by the medical care team [5, 8].

Normal Infant Growth and Development and
Gastroesophageal Reflux

Infants are known to have gastroesophageal reflux
(GER) in the early months of infancy. GER not
only comprises vomiting but may also manifest as
silent reflux (pain during or after feeds and posi-
tion changes, or with stooling). Promotion of nor-
mal infant developmental milestones throughout
the entire feeding experience is crucial. Engaging
the primary caregivers in proper positioning of the
infant during and after all forms of feeding can
help minimize GER. If there is intolerance of forti-
fied formula/breast milk, as evidenced by irritabil-
ity, vomiting, diarrhea and poor weight gain, con-
sider adjusting back to 20 cal (65–70 kcal/100 ml)
or to straight breast milk or formula for a few days
and reassess whether the infant can make up the
missed calories with increased volume. The feed-
ing team (speech/feeding therapist and/or otolar-

yngologist) is important to facilitate the instalment

of safe, positive and effective feeding strategies.

Pediatric gastroenterologists may also be

team-consulting members. Although no firm,

consistent recommendations, minimizing high

caloric density, maximizing doses of GER med-

ications (specifically proton pump inhibitors,

PPI) and/or changing to elemental formulae [5]

are encouraged and can be done simultaneously.

Consultation with a pediatric gastroenterologist

during t he interstage period is idea l to ensure op-

timal titration of gastrointestinal medications

and/or reassessment of the plan of care; if possi-

ble, administer medications 20–30 min before

feed to let them reach the small bowel, where they

work. Recognition of the safety profile with anti-

coagulants is important in this population. Prac-

titioners need to weigh the benefits and risks with

the team. If using these medications, adjustment

for weight gain should be considered if the infant

seems to have recurring symptoms, and treat-

ment should be allowed for 7 days before declar-

ing the intervention not to be effective.

A n t i c o a g u l a n t s

The use of anticoagulants to prevent shunt throm-

bosis is common in this population. Aspirin use

is irritating to the stomach, and thus acid sup-

pression is often recommended. In symptomatic

patients, use a ‘top-down’ approach and start with

a PPI (omeprazole or lansoprazole) rather than

an H 2 blocker (ranitidine). Ranitidine is often less

effective after several weeks of exposure; however,

for infants with very difficult-to-manage reflux,

ranitidine is used in conjunction with a PPI to

smooth over the peaks, i.e. the periods when PPI

coverage is waning (PPI twice daily and H 2 block-

er daily halfway between the 2 PPI doses). Team

members may also be gastroenterologists, and al-

though no firm and consistent recommendations

can be achieved among centers of excellence, our

team at Boston Children’s Hospital focuses on

Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 250–253

DOI: 10.1159/000360346