Pediatric Nutrition in Practice

Heart Disease 253

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optimizing caloric density as needed to the lowest
density tolerated to promote growth, maximizing
GER medications and/or changing formula type
[5]. Consultation with a pediatric gastroenterolo-
gist during the interstage period is also recom-
mended to ensure optimal titration of medica-
tions and/or reassessment of the plan of care.

Constipation

If an infant is struggling with reflux, vomiting, poor
feeding, etc., consider starting to use a preparation
containing polyethylene glycol 3350 given twice
daily – do not wait for hard or infrequent stools.
The goal is for the infant to have stool 3–4 times per
day, and for the process to be easy and not painful.
Consider polyethylene glycol to help with ‘sludgy’
bowel patterns that are often associated with di-
uretic use, high-calorie formulae or protein aller-
gies. When the infant bears down to stool, the pres-
sure in the chest increases, and the infant vomits or
has reflux. Polyethylene glycol is a helpful stool
softener for any infant who works to pass stool (e.g.
grunting, crying with stooling even in the setting of
soft stools, vomiting and not eating). It binds to wa-
ter molecules, keeps them in the colon, and makes
the stool a bit softer. Drug safety profiles typically

do not give recommendations for this population,

so please consult the primary team and a gastroen-

terologist. The infant may initially have somewhat

watery stools, but this resolves with time.

Milk Protein Allergy

Milk, soy and egg protein allergy (or inability to

digest large protein molecules) is important to con-

sider in this population. Symptoms may include:

loose or mucous stools (possibly containing blood);

constipation; reflux; vomiting; gagging; refusing

food; irritability or colic; and skin rashes (cradle

cap, diaper rash and eczema). Breastfeeding moth-

ers can attempt dairy, soy and egg elimination diets

(read fine print of all labels). Formula-fed infants

can transition to hypoallergenic amino acid-based

formulae (e.g. EleCare or Neocate). A gastroenter-

ology consult is recommended and EleCare is often

preferred due to its higher medium-to-long-chain

triglyceride ratio. If the infant does not like the

taste, start with 1 oz (30 ml) elemental to 4 oz (120

ml) regular formula. Gradually increase by 1 oz (30

ml) every week until consistently only elemental

formula is achieved. The threshold for use of ele-

mental formulae in this patient population is often

higher for the entire first year of life.

following the Norwood operation: can

we change the outcome? Cardiol Young

2012; 22: 520–527.

8 Steltzer M, Connor J, Sussman-Karten

K: Case study: transition to full breast-

feeding in an infant with single ventricle

heart disease in the interstage period

(poster presentation). Boston Children’s

Hospital, May 2013.

9 Nutrition month: breastfeeding the

HLHS baby – the practitioner perspec-

tive. March 7, 2013. http://www.sisters-

by-heart.org/2013/03/nutrition-month-

breastfeeding-hlhs-baby_7.html.

10 Boctor D, Pillo-Blocka F, McCrindle B:

Nutrition after cardiac surgery for in-

fants with congenital heart disease. Nutr

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References

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5 Slicker J, Hehir D, Horsley M, et al: Nu-

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6 Kugler J, Beekman R 3rd, Rosenthal G,

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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