Breast feeding after second birth ex-utero : A surgical experience Sahu M ; Singh SP; Menon RP All India Institute of Medical Sciences, New Delhi

Background Placental circulation and transition from fetal to neonatal circulation at birth is universal .Breast milk is recommended for all infants upto 6mo of age Inanition is the norm in infants with cardiac malformations. Cardiopulmonary bypass for open heart surgery induces a systemic inflammatory state. It is similar to a second placental circulation . Beneficial effects of breast milk in postoperative inflammation has not been studied yet, prospectively, because of the fear of mucosal transmigration in ischemic intestine.

Title A trial experience of exclusive early feeding therapy in infants after congenital heart Disease surgical repair Objective : To assess caloric supply in infants with early exclusive enteral feeding and their response after open heart surgery

Methods A prospective RCT in the cardiac intensive care unit (CICU) of a cardiac tertiary care referral centre. After IEC/IRB clearance, 50 consecutive infants < 6 months of age with congenital cardiac malformations who were electively operated were enrolled and 49 randomised (m:f = 43:6) into receiving expressed milk feeds(EBM: Group A) or fortified expressed breast milk feeds (EBM +HMF+ Simyl MCT oil; Group B) as early enteral /oral nutrition post-operatively from day 1 - 11. One baby from group A was excluded due to prolonged FI (Feed Interruption) and subsequent TPN.

Methods (Contd) Caloric need (requirement) for each infant was calculated as per EER using Diet Cal ® software @ 90 kcal/ kg/day as the target requirement. Caloric intake (supply) and fluid balance was assessed daily by dietician, along with cardiac function status assessment with 2D Echo and number of feed days were computed. The intra op and post op variables documented in a predesigned performa included cardiopulmonary bypass(CPB) and aortic cross clamp (AoXcl) times, hospital length of stay (LOS), mortality , anthropometric, hematological and biochemical profile. The data was analysed by Stata 14.1 The daily caloric supply was prospectively matched with the cardiovascular status (assessed by routine interval 2D Echo) and fluid balance and restriction prospectively.

Consort diagram

Results: The baseline characteristics of the infants of group A (control n = 24) and group B (intervention n=25) is comparable in terms of their age, length and weight . Majority (39/49) had cyanotic congenital cardiac malformations (CCHD- ToF 13; TGA 21;TAPVC 7) while 10 patients had acyanotic congenital heart disease (ACHD) comprising atrial septal defect(ASD-3) and ventricular septal defect (VSD-6). The median duration of hospital stay 16.5+-9.8 and 14.1+-7.03(p=0.17) was similar in both groups. Exclusive enteral feeding with breast milk (fortified and otherwise) was started within 12hrs (early) of coming off cardiopulmonary bypass in all babies

Results (Contd) The caloric supply (KCal/day) was 67.6± 18.5 -D1 which increased to 87.1 ±38.3 by D 10 (Grp A) . The caloric supply(KCal/day) was 87.8±29.6 (D1) which increased to 127.2±56.1 by D10.The protein (g/day) supply was 1±0.3 on D1 which increased to 1.5±0.5(D10) (Grp A); 1.3±0.5(D1) which increased to 2.1±1(D10) (GrpB). All differences were significant p<0.001. The mean weight (kg) of babies in both groups were 3.5+-0.83 which decreased to 3.1+-0.5 (GrpA) and 3.5±0.91 which increased to 3.6+-0.7(GrpB) ( between groups p=0.64). Enteral feeding was initiated in all enrolled infants within 12hrs and prospectively escalated by the dietician using DietCal. There were no adverse events related to early feeding.

Conclusion Uniquely, the higher nutritional supply could be achieved by starting exclusive enteral feeding with breast milk (with supplementation also) early after open heart surgical correction of congenital cardiac malformation.