Nutrition Month: The Cardiac Infant

We're continuing on with our Nutrition Series this week, with the help of resident expert Emily LaRose, dietitian at Children's Hospital Los Angeles. Today, Emily discusses the nutritional concerns of the cardiac infant into early toddlerhood. Thank you, Emily for continuing to share your knowledge and advice with our families!

I’m back for week two of the National Nutrition Month series!  In this post, I’m very excited to write about what happens for baby’s nutrition once he is discharged home from the hospital the first time.  This post will take us through starting solids and transitioning to cow’s milk.  The postings I make on this site are my own personal opinions and do not reflect the opinions or views of Children’s Hospital Los Angeles.

As I’d mentioned in my last post, nutrition and growth are both big parts of the interstage period.  While we can establish a nutrition plan in the hospital, our plans may change once a baby has had some time at home so we’re always ready to make adjustments.  Once babies are home, we rely on parents to tell us what is and isn’t working.

We focus a lot on growth and weight gain in the interstage period because babies who grow well tend to stay healthier, do better with their future surgeries, and have better overall development than those who haven’t grown as well.  A good nutritional foundation helps with the body’s response to surgery and with healing afterward. Good nutrition also helps with immune function and brain development.

After the Glenn, weight gain and growth are generally less of a concern for a few reasons:
• Babies tend to gain weight a little more easily after then Glenn than in the interstage period.
• The blood flow to the baby’s belly is usually more stable so digestive problems are usually less of an issue.
• There isn’t as much focus on rapid growth because there usually isn’t another surgery planned for the near future (since the Fontan is usually many months away).

After the Glenn, we are still trying to get babies to grow (so we do usually continue with high calorie breastmilk or formula) but, in a lot of ways, post-Glenn nutrition becomes more like ‘typical’ baby nutrition.  Babies progress toward taking solid foods, develop regular eating schedules, and eventually start taking cow’s milk just like other babies.

So going forward how much weight gain should we expect?
As I’d mentioned before, usually we say that weight gain of 20 to 30 grams per day (five to seven ounces per week) is normal for babies for the first three months or so.  But, after the first few months, growth goals for the remainder of the first year are very individual for kiddos with HLHS.

There are standard growth goals, but if a baby gets a slower start, he may go through periods of faster growth (which we call ‘catch-up growth’).  If a baby gets sick or spends some extra time in the hospital, she may grow a little more slowly for awhile before her weight gain picks up.  Again, there is no set way that all kiddos grow, but sometimes averages can help us figure out how things are going.

For growth goals, the following will give you an idea of what would be average, but keep in mind that your kiddo may be growing on his or her own curve.
• 3 to 6 months: average weight gain may slow down a little to an average of about 18 grams per day (about four to six ounces per week).  Length gains should be about 0.5 centimeters per week (or about an inch every five weeks).
• 6 to 12 months: weight gain slows down a little more to an average of about 12 grams per day (about three ounces per week).  Length gains also slow down a little more to about 0.3 centimeters per week (or about an inch every seven or eight weeks).

Another good rule of thumb for weight gain is that a baby should double her birth weight by six months and triple it by one year.  So if your little one was born at seven pounds, she should be about 14 pounds at six months, and about 21 pounds at her first birthday- if everything goes exactly according to plan.

When can I start giving my baby solids?
People ask about when to start babies on solids all the time… and, unfortunately, there are a lot of different answers.  The American Academy of Pediatrics recommends solely breastfeeding for the first six months of age though multiple other sources suggest that between four and six months is a good age to start solid foods.  Giving solid foods is not recommended for infants less than four months of age.

For an HLHS kiddo, cardiologists will often suggest that families wait to start a baby on solids after her Glenn but that isn’t always the rule.  If you’re thinking that your little one may be ready to try some solid foods, talking to your baby’s cardiologist and pediatrician is a good idea.

The way the solids are introduced to an HLHS infant is just like a non-cardiac baby.  Basically, we rely on the baby to tell us when he’s ready and we go from there.  For more information, this website (http://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/default.aspx) was created by the American Academy of Pediatrics and is a great resource.  They have covered everything from how to know if your baby is ready for solids, what kinds of foods are good to start with, how much to give, and much more.  They have even included a sample menu that could be helpful for older babies.

A few things to remember:
• If your baby turns her head away and refuses to eat, don’t force her.  It’s okay to wait to try solid foods another day.
• Your baby will learn to eat by watching other people eat.  Include your baby in family meals and feed him when other people are eating.
• Babies are messy eaters, but that’s how they learn to eat.  It is normal for meals to end up on the baby’s clothes, bib, and face.
• Your baby isn’t going to like all of the foods that you offer her but tastes change quickly so it’s okay to repeat a food a few days later.  You may be surprised with what happens!
• We always want to make sure our cardiac babies are safe so if you notice that your baby is coughing, gagging, or choking with his feedings, check in with his medical team to make sure that you are okay to continue.
• If your baby has a feeding tube, he may be able to have some solids added to his feeding plan as well.  Once he is at the right age and developmental level for solids, ask your dietitian, cardiologist, and/or pediatrician if this may be an option for your kiddo.

What about food allergies?
Allergies are an important subject since food allergies have become more common in recent years.  No one knows what is leading to so many more cases of food allergy, but everything from household cleaners and antibiotics to environmental changes and genetically modified foods has been blamed.  At this point, we just don’t know (and, in my opinion, there are probably many factors at play).

While the current American Academy of Pediatrics feeding guidelines don’t specifically address when to introduce allergenic foods to babies, some of the most current academic papers (including one published earlier this year in the Journal of Allergy & Clinical Immunology: In Practice) on prevention of food allergies suggest starting highly allergenic foods like soy, wheat, shellfish, and even tree nuts early on.

Recommendations are always changing so, again, this is something you will want to talk to your kiddo’s pediatrician about.

How do I transition my baby from a bottle-feeding schedule to a meal schedule?
As your baby grows, solid foods will play a larger and larger role in his nutrition plan; the goal remains to get the baby to grow as normally as possible.  It’s important to remember that all babies and kiddos are different so allowing them to develop at their own pace is important.

Some babies wean themselves off of the bottle and transition to meals all by themselves.  They can be so excited about meals that the bottles fall away and sippy cups of milk fill in where some of the bottles once were.  Other kiddos demand a more gradual transition.

If you’re having trouble, I often suggest that parents write out the baby’s schedule (of meals and bottles).  At around one year, she will probably need four or five meals per day (of solids) to keep her energy levels up and to keep her growing normally.  If she is taking four or five bottles per day, but only taking solids two times per day, replacing once bottle at a time with a meal or snack is a good place to start if your medical team is okay with it.

A few other things that may help include the following:
• When you can, eat with her so that she knows that it is mealtime.
• It can help to offer solids first and then formula or milk so that she’s not too full for her ‘big girl’ meals.
• You can make a schedule change every few days (give or take) to get her onto her grown up schedule.
• We try to wean babies off of the bottle between 12 to 14 months so encouraging them to use a cup earlier on really helps (if they’re ready).

We see many picky eaters in the next stage of development.  When kiddos aren’t growing well or when parents worry about whether or not kids are getting enough nutrition in, the question of supplmental drinks often arises.  Stay tuned for my next post which focuses on feeding our picky cardiac toddlers.