Surgical Management of VSD

Nutrition & VSDNutrition & VSDA case study on a term A case study on a term

infantinfant

Presented By:Presented By:Dong MeiDong Mei

Quah Su ChinQuah Su ChinLu HanLu Han

Goh Choon HuaGoh Choon Hua

Case StudyCase Study

• Baby Johan was born at term to a 35-year-Baby Johan was born at term to a 35-year-old woman. During breast feeding on the old woman. During breast feeding on the postnatal ward, Johan’s mother noticed postnatal ward, Johan’s mother noticed that he became blue. Investigation that he became blue. Investigation revealed that Johan had a ventricular revealed that Johan had a ventricular septal defect. He was scheduled for septal defect. He was scheduled for surgery. On his 3surgery. On his 3rdrd POD, his mother asked POD, his mother asked if she could continue breast feeding Johan if she could continue breast feeding Johan or switch to formula feeding.or switch to formula feeding.

Objectives Objectives • Discuss the pathophysiology and types of VSDsDiscuss the pathophysiology and types of VSDs

• Discuss how VSD affects the nutritional needs of Discuss how VSD affects the nutritional needs of Baby Johan Discuss nutritional needs of a term infantBaby Johan Discuss nutritional needs of a term infant

• Identify causes of malnutrition and its consequencesIdentify causes of malnutrition and its consequences

• Identify types of surgery for VSDIdentify types of surgery for VSD

• Discuss Feeding methodsDiscuss Feeding methods

• Discuss how to feed Baby Johan post-operativelyDiscuss how to feed Baby Johan post-operatively– Advice for Baby Johan’s MotherAdvice for Baby Johan’s Mother– Benefits of Breast-feedingBenefits of Breast-feeding– Psychosocial considerations Psychosocial considerations

Ventricular Septal DefectVentricular Septal Defect

• a communication between the right and a communication between the right and left ventricles, which is the most left ventricles, which is the most common congenital heart diseasecommon congenital heart disease

• can occur anywhere in the muscular or can occur anywhere in the muscular or membranous ventricular septummembranous ventricular septum

• The size of the defect is important in The size of the defect is important in determining the severity of the condition determining the severity of the condition or haemodynamic consequencesor haemodynamic consequences

Types of VSDTypes of VSD• Inlet VSDInlet VSD: usually part of an AV canal defect; 5% to 7% of all VSDs.: usually part of an AV canal defect; 5% to 7% of all VSDs.

• Perimembranous (Conoventricular, or infracristal) VSDsPerimembranous (Conoventricular, or infracristal) VSDs: 80% of all VSDs.: 80% of all VSDs.

• Muscular VSDMuscular VSD: can be single or multiple and of variable size in any given : can be single or multiple and of variable size in any given patient; 5% to 20% of all VSDs.patient; 5% to 20% of all VSDs.

• Conal septal malalignment VSDConal septal malalignment VSD: the conal septum is not properly aligned : the conal septum is not properly aligned with the rest of the ventricular septum, resulting in a defect; it’s always with the rest of the ventricular septum, resulting in a defect; it’s always large and unrestrictive.large and unrestrictive.– Anterior malalignment is associated with obstruction of the right ventricular (RV) Anterior malalignment is associated with obstruction of the right ventricular (RV)

outflow tract (e.g., tetralogy of Fallot)outflow tract (e.g., tetralogy of Fallot)

– Posterior malalignment is associated with obstruction of the left ventricular (LV) Posterior malalignment is associated with obstruction of the left ventricular (LV) outflow tract and aorta (e.g., posterior malalignment VSD with coarctation).outflow tract and aorta (e.g., posterior malalignment VSD with coarctation).

• Conal septal hypoplasia VSDConal septal hypoplasia VSD

• There also may be multiple VSDs of different types in a single patient.There also may be multiple VSDs of different types in a single patient.

• Many complex forms of congenital heart disease include a VSD.Many complex forms of congenital heart disease include a VSD.

Pathophysiology of VSDPathophysiology of VSD• The defect causes shunting of blood between The defect causes shunting of blood between

ventriclesventricles

• The direction of blood shunting depends on the The direction of blood shunting depends on the relative PVR and SVRrelative PVR and SVR

• Amount of shunting depends on the size of the Amount of shunting depends on the size of the defectdefect

• Small VSD: small left to right shunt; the workload of Small VSD: small left to right shunt; the workload of two ventricles is normal. ECG and CXR are normal.two ventricles is normal. ECG and CXR are normal.

• Moderate-sized VSD: amount of shunting can be Moderate-sized VSD: amount of shunting can be large and is affected by the relative of PVR and SVR. large and is affected by the relative of PVR and SVR. RV pressure is normal or only mildly increased.RV pressure is normal or only mildly increased.

Pathophysiology of VSDPathophysiology of VSD

• Large (unrestrictive) VSD: RV and LV pressures are Large (unrestrictive) VSD: RV and LV pressures are equal. Direction and amount of shunting is purely equal. Direction and amount of shunting is purely determined by PVR and SVR. determined by PVR and SVR.

• A large left-to-right shunt leads to increased A large left-to-right shunt leads to increased pulmonary blood flow, left atrial and left ventricular pulmonary blood flow, left atrial and left ventricular dilation, tachypnea, and congestive heart failure dilation, tachypnea, and congestive heart failure (CHF). Typical onset of CHF is at 2 to 8 weeks of age (CHF). Typical onset of CHF is at 2 to 8 weeks of age as the PVR falls post-natally.as the PVR falls post-natally.

• If a large VSD is left untreated, pulmonary vascular If a large VSD is left untreated, pulmonary vascular disease (irreversible increase in PVR) may develop, disease (irreversible increase in PVR) may develop, leading to reversal of the shunt, cyanosis, and right leading to reversal of the shunt, cyanosis, and right ventricular failure (Eisenmenger syndrome).ventricular failure (Eisenmenger syndrome).

VSD & Nutritonal NeedsVSD & Nutritonal Needs

• Feeding difficultiesFeeding difficulties– Tiring easily from the effort to suckTiring easily from the effort to suck– Poor eaterPoor eater– Poor oral intakePoor oral intake

• Fail to grow to thrive normallyFail to grow to thrive normally

Nutritional NeedsNutritional Needs• Infants’ diet must contain adequate Infants’ diet must contain adequate

nutrients, such as protein, carbohydrate, nutrients, such as protein, carbohydrate, fat, mineral, and vitamins.fat, mineral, and vitamins.

• Protein is needed for rapid cellular growth Protein is needed for rapid cellular growth and maintenance .and maintenance .

• Carbohydrate provides energy.Carbohydrate provides energy.• Fat is necessary for the normal Fat is necessary for the normal

development of the neonatal brain and development of the neonatal brain and neurologic system.neurologic system.

• Mineral and vitamins are needed to Mineral and vitamins are needed to prevent deficiency states such as scurvy, prevent deficiency states such as scurvy, cheilosis, and pellagra.cheilosis, and pellagra.

Energy RequirementEnergy Requirement

AgeAge kcal/kg/daykcal/kg/day

NeonateNeonate 100-120100-120

< 10kg< 10kg 100100

10kg – 20kg10kg – 20kg 1000 + 50 kcal/kg over 10kg1000 + 50 kcal/kg over 10kg

> 20kg> 20kg 1000 + 20 kcal/kg over 20kg1000 + 20 kcal/kg over 20kg

(Hendricks & Duggan, 2000)

Daily Reference Intake for Daily Reference Intake for Normal InfantsNormal Infants

Nutrient Nutrient 0-6 months (6kg)0-6 months (6kg) 7-12 months (9kg)7-12 months (9kg)

Protein (g)Protein (g) 9.39.3 1111

Carbohydrate (g)Carbohydrate (g) 6060 9595

Fat (g)Fat (g) 3131 3030

Fluid (mL)Fluid (mL) 700700 800800


Nutrition Nutrition

• Oral feedingOral feeding– Breast MilkBreast Milk– Formulas Formulas

• Oro-gastric tube feedingOro-gastric tube feeding– Expressed breast milkExpressed breast milk– Formulas Formulas

• Total parental nutrition Total parental nutrition

Causes of MalnutritionCauses of Malnutrition

• Inadequate intake Inadequate intake

• IllnessIllness

• Lack of access to food, e.g. Poverty Lack of access to food, e.g. Poverty

• Inappropriate feeding and caringInappropriate feeding and caring

• Insufficient healthcare servicesInsufficient healthcare services

Consequences of Consequences of MalnutritionMalnutrition• CatabolismCatabolism

– Impaired physical and cognitive developmentImpaired physical and cognitive development

• Depressed immunityDepressed immunity– Most commonly, infectious diarrhea, which causes anorexia, Most commonly, infectious diarrhea, which causes anorexia,

decreased nutrient absorption, increased metabolic needs, and decreased nutrient absorption, increased metabolic needs, and direct nutrient lossdirect nutrient loss

• Impaired organ functionImpaired organ function– Fatty degeneration of the liver and heartFatty degeneration of the liver and heart– Atrophy of small bowelAtrophy of small bowel– Decreased intravascular volume leading to secondary Decreased intravascular volume leading to secondary

hyperaldosteronismhyperaldosteronism

• Delayed wound healingDelayed wound healing• Prolonged morbidityProlonged morbidity• Increased mortalityIncreased mortality (Grigsby, 2006)

Surgical and Nutritional Surgical and Nutritional Management Management

Surgical Management of Surgical Management of VSDVSD

• Indicated when infants:Indicated when infants:– Fail to thriveFail to thrive– Develop complications despite medical Develop complications despite medical

managementmanagement– When VSD is severe or >5mm in size When VSD is severe or >5mm in size

and not responding to medical and not responding to medical managementmanagement

Surgical Management of Surgical Management of VSDVSD• Types of surgery depends on:Types of surgery depends on:

– Location of VSDLocation of VSD– Size of VSDSize of VSD– Number of VSDs Number of VSDs

• IsolatedIsolated

•Multiple Multiple

– Presence of other medical conditions e.g. Presence of other medical conditions e.g. co-existing with TOF, CoAco-existing with TOF, CoA

– SeveritySeverity

Surgical Management of Surgical Management of VSDVSD

• Types of SurgeryTypes of Surgery– Transcatheter closure of VSD for certain Transcatheter closure of VSD for certain

anatomic VSDsanatomic VSDs– Patch repair with CPB/open heart surgeryPatch repair with CPB/open heart surgery– Palliative repair Palliative repair

•For infants with complicated anatomical For infants with complicated anatomical access and co-morbiditiesaccess and co-morbidities

•To improve life expectancy To improve life expectancy – Usually can live up to 15-20 years of age. Usually can live up to 15-20 years of age.

Impact of Critical Illness on Impact of Critical Illness on Nutritional NeedsNutritional Needs

• Why is nutrition important?Why is nutrition important?– Critical illness coupled with poor Critical illness coupled with poor

nutrition leads to:nutrition leads to:•Prolonged ventilator dependencyProlonged ventilator dependency

•Prolonged ICU stayProlonged ICU stay

•Heightened susceptibility to nosocomial Heightened susceptibility to nosocomial infectionsinfections

• Increased mortality with mild/moderate or Increased mortality with mild/moderate or severe malnutritionsevere malnutrition

Impact of Critical Illness on Impact of Critical Illness on Nutritional NeedsNutritional Needs

• Goals of Nutritional Support Goals of Nutritional Support – support basic body function support basic body function – promote healingpromote healing– support normal immune function to support normal immune function to

prevent infection and other prevent infection and other complicationscomplications

– prevent catabolismprevent catabolism– promote growth promote growth

Post Surgery: FeedingPost Surgery: Feeding

• Feeding routes:Feeding routes:– Transpyloric feeding (Drip feeding)Transpyloric feeding (Drip feeding)

• Usually in premies and infants with respiratory distress Usually in premies and infants with respiratory distress who cannot tolerate enteral feedingwho cannot tolerate enteral feeding

– Enteral feedingEnteral feeding• Orogastric / NasogastricOrogastric / Nasogastric• Offers several advantages over TPN/PPNOffers several advantages over TPN/PPN

– Maintaining gut motility, improving mesenteric flow, Maintaining gut motility, improving mesenteric flow, support gut-associated lymphoid tissuesupport gut-associated lymphoid tissue

– Parenteral FeedingParenteral Feeding• Requires central venous accessRequires central venous access

Feeding GuidelinesFeeding Guidelines

Enteral Feeding Advancement GuideEnteral Feeding Advancement Guide

WeightWeight Initial volume/kg/dayInitial volume/kg/day Incremental advance per dayIncremental advance per day

< 1250g< 1250g 10 cc/kg/day10 cc/kg/day 10 cc/kg/d*10 cc/kg/d*

1250 - 1500g1250 - 1500g 10 - 15 cc/kg/d10 - 15 cc/kg/d 10 - 15 cc/kg/d*10 - 15 cc/kg/d*

> 1500g> 1500g 20 cc/kg/d20 cc/kg/d 20 cc/kg/d20 cc/kg/d

Maintenance Fluid RequirementsMaintenance Fluid Requirements

WeightWeight Volume /kg/dayVolume /kg/day

1 - 10 kg1 - 10 kg 100 ml/kg/day100 ml/kg/day

10 - 20kg10 - 20kg 1000 ml + 50 ml for each kg > 1000 ml + 50 ml for each kg > 10 kg10 kg

20 kg20 kg 1500 ml + 20ml for each kg > 1500 ml + 20ml for each kg > 20 kg20 kg


Feeding Baby JohanFeeding Baby Johan• Term BabyTerm Baby

– Fluid Management in the initial post-op periodFluid Management in the initial post-op period• 50% of calculated needs50% of calculated needs• Balance with fluid losses, diuresis, cardiac output needsBalance with fluid losses, diuresis, cardiac output needs

– Initiate enteral feeding with EBM (assuming his gut function Initiate enteral feeding with EBM (assuming his gut function is adequate) once constant diuresis is reached with is adequate) once constant diuresis is reached with adequate circulatory supportadequate circulatory support

• Assuming Baby Johan is ~3kgAssuming Baby Johan is ~3kg

– Initiate feeding at 50-60cc/kg/day. If well tolerated, advance by Initiate feeding at 50-60cc/kg/day. If well tolerated, advance by another 20cc/kg/day . Allow a pacifier for non-nutritive sucking another 20cc/kg/day . Allow a pacifier for non-nutritive sucking during feeding to enhance oromotor skills. during feeding to enhance oromotor skills.

– If no signs of feeding intolerance and has good oromotor skills: may If no signs of feeding intolerance and has good oromotor skills: may progress to breastfeeding. progress to breastfeeding.

Post-SurgeryPost-Surgery

Factors That May Delay Baby Factors That May Delay Baby Johan’s Progression to Oral Johan’s Progression to Oral

FeedsFeeds

Factors that can complicate Factors that can complicate JohanJohan’’s progression to oral s progression to oral feedsfeeds• Late return of bowel soundLate return of bowel sound

• InfectionInfection

• Difficulty in extubationDifficulty in extubation

• Intolerance to oral feedsIntolerance to oral feeds

Factors that can complicate Factors that can complicate JohanJohan’’s progression to oral s progression to oral feedsfeeds• Post-op ComplicationsPost-op Complications

– ArrhythmiasArrhythmias– BleedingBleeding– Gastrointestinal ComplicationsGastrointestinal Complications– Postoperative Pulmonary HypertensionPostoperative Pulmonary Hypertension– Postoperative infectionPostoperative infection

Signs of Feeding Intolerance Signs of Feeding Intolerance

• Excessive gastric residuals Excessive gastric residuals • > 2x the hourly rate on COG feeds > 2x the hourly rate on COG feeds • > > ½½ the feeding volume on bolus gavage feeds the feeding volume on bolus gavage feeds • Bilious or bloody gastric aspirates Bilious or bloody gastric aspirates • Vomiting Vomiting • Visible or palpable loops of bowel on abdominal Visible or palpable loops of bowel on abdominal

exam exam • A firm or distended abdomen A firm or distended abdomen • Stools Stools • Diarrhea Diarrhea

Assessing adequacy of oral Assessing adequacy of oral feeding feeding • Adequacy of milk intakeAdequacy of milk intake

• Assessed by voiding and stooling patterns Assessed by voiding and stooling patterns • And by aspiratingAnd by aspirating

• Fluids, Electrolytes, and NutritionFluids, Electrolytes, and Nutrition• Fluid retention Fluid retention • Fluid management :Diuretic therapy is typically Fluid management :Diuretic therapy is typically

started within 24 to 48 hours started within 24 to 48 hours

• Total body weightTotal body weight

Post SurgeryPost Surgery

Preparing Mother and Baby Preparing Mother and Baby Johan for homeJohan for home

Providing Advise: Feeding of Baby Providing Advise: Feeding of Baby JohanJohan

Benefits of breast feedingBenefits of breast feeding ““How to” of breast feedingHow to” of breast feeding Infection issuesInfection issues Psychological aspects: Allaying Psychological aspects: Allaying

Breastfeeding AnxietyBreastfeeding Anxiety

Benefits of breast feedingBenefits of breast feeding Human milk Human milk

• Contains anti-inflammatory factors and other factors that Contains anti-inflammatory factors and other factors that regulate the response of the immune system against infection.regulate the response of the immune system against infection.

• Contains immunologic agents and other compounds, such as Contains immunologic agents and other compounds, such as secretory antibodies, leukocytes, and carbohydrates that acts secretory antibodies, leukocytes, and carbohydrates that acts against viruses, bacteria, and parasites. The transfer of these against viruses, bacteria, and parasites. The transfer of these factors from human milk provides a distinct advantage that factors from human milk provides a distinct advantage that infants fed formula do not experience.infants fed formula do not experience.

• Contains a balance of nutrients that closely matches human Contains a balance of nutrients that closely matches human infant requirements for growth and development than does the infant requirements for growth and development than does the milk of any other species. Eg. compared to cow’s milk, human milk of any other species. Eg. compared to cow’s milk, human milk is low in total protein and low in casein, making it more milk is low in total protein and low in casein, making it more readily digestible and less stressful on immature infant kidneys. readily digestible and less stressful on immature infant kidneys. The lipids and enzymes in human milk promote efficient The lipids and enzymes in human milk promote efficient digestion and utilization of nutrients.digestion and utilization of nutrients.

Benefits of breast Benefits of breast feedingfeedingFor infantsFor infants

• Better gastrointestinal function and protection from Better gastrointestinal function and protection from gastrointestinal infections, such as vomiting and gastrointestinal infections, such as vomiting and diarrhea.diarrhea.

• A reduced risk of respiratory infections, ear infections, A reduced risk of respiratory infections, ear infections, and wheezing.and wheezing.

• Some studies suggest that breastfeeding reduces the Some studies suggest that breastfeeding reduces the risk of obesity, cardiovascular disease, and risk of obesity, cardiovascular disease, and autoimmune diseases, such as type 1 diabetes autoimmune diseases, such as type 1 diabetes mellitus.mellitus.

Benefits of breast Benefits of breast feedingfeedingFor womenFor women

• Reduced blood loss after childbirth as a result of a Reduced blood loss after childbirth as a result of a hormone, oxytocin, which is released into the mother’s hormone, oxytocin, which is released into the mother’s bloodstream while breastfeeding. Oxytocin helps the uterus bloodstream while breastfeeding. Oxytocin helps the uterus to contract, which reduces uterine bleedingto contract, which reduces uterine bleeding

• Reduced levels of stress in the mother as a result of several Reduced levels of stress in the mother as a result of several hormones released during breastfeedinghormones released during breastfeeding

• Increased weight loss after pregnancy (if breastfeeding Increased weight loss after pregnancy (if breastfeeding continues for at least six months).continues for at least six months).

• Reduced risk of ovarian and premenopausal breast cancers, Reduced risk of ovarian and premenopausal breast cancers, and possibly a reduced risk of osteoporosis.and possibly a reduced risk of osteoporosis.

For FamilyFor Family

• Reduced infant feeding costs. Infant formula and Reduced infant feeding costs. Infant formula and associated supplies are estimated to cost at least associated supplies are estimated to cost at least $1000 during the first 12 months.$1000 during the first 12 months.

• Reduced costs related to healthcare, including Reduced costs related to healthcare, including doctordoctor’’s visits, hospital costs, and lost time from s visits, hospital costs, and lost time from work. Infants who are breastfed are less likely to work. Infants who are breastfed are less likely to become ill and less likely to be hospitalized, become ill and less likely to be hospitalized, reducing the potential costs and anxieties of reducing the potential costs and anxieties of caring for an ill child.caring for an ill child.

Benefits of breast Benefits of breast feedingfeeding


Benefits of breast feedingBenefits of breast feeding ““How toHow to”” of breast feeding of breast feeding Infection issuesInfection issues Psychological aspects: Allaying Psychological aspects: Allaying


““How to” of breast How to” of breast feedingfeedingCorrect latch-onCorrect latch-on

• Mother should be comfortable and the infant positioned so that Mother should be comfortable and the infant positioned so that nothing interferes with mouth-to-breast contact.nothing interferes with mouth-to-breast contact.

• Nipple is stroke against the infant’s cheek nearest the nipple. Nipple is stroke against the infant’s cheek nearest the nipple. Entire nipple and most of the areola should be placed in the Entire nipple and most of the areola should be placed in the infant’s mouth.infant’s mouth.

• Infant latch-on by compressing the lips. Normal sucking include Infant latch-on by compressing the lips. Normal sucking include suction of 4-6 cm of the areola, compression of the nipple suction of 4-6 cm of the areola, compression of the nipple against the palate, stimulation of milk ejection by initial rapid against the palate, stimulation of milk ejection by initial rapid non-nutritive sucking, and extraction of milk from the non-nutritive sucking, and extraction of milk from the lactiferous sinuses by a slower suck-swallow rhythm of lactiferous sinuses by a slower suck-swallow rhythm of approximately one per second.approximately one per second.

• Infant may be removed from the breast by placing a clean Infant may be removed from the breast by placing a clean finger between the infant’s and the areola to release suction.finger between the infant’s and the areola to release suction.

PositioningPositioning

• Cradle hold Cradle hold

• Cross-cradle hold Cross-cradle hold

• Football hold (Clutch Position) Football hold (Clutch Position)

• Side-lying positionSide-lying position

““How to” of breast How to” of breast feedingfeeding

Cradle holdCradle hold

• Support the baby with Support the baby with the arm on the same the arm on the same side as the nursing side as the nursing breastbreast

• Sit up straight — Sit up straight — preferably in a chair preferably in a chair with armrests. with armrests.

• Cradle the baby and Cradle the baby and rest his or her head in rest his or her head in the crook of your elbow the crook of your elbow while he or she the while he or she the nursing breast. nursing breast.

• For extra support, place For extra support, place a pillow on your lap.a pillow on your lap.

Cross-cradle holdCross-cradle hold

• Ideal for early breast-feeding, Ideal for early breast-feeding, when you and your newborn when you and your newborn are getting used to the are getting used to the process. process.

• Sit up straight in a comfortable Sit up straight in a comfortable chair with armrests. chair with armrests.

• Hold your baby crosswise in Hold your baby crosswise in the crook of the arm opposite the crook of the arm opposite the breast you're feeding from the breast you're feeding from — left arm for right breast, — left arm for right breast, right arm for left. right arm for left.

• Support the baby's trunk and Support the baby's trunk and head with your forearm and head with your forearm and palm. Place your other hand palm. Place your other hand beneath your breast in a U-beneath your breast in a U-shaped hold (this guides the shaped hold (this guides the baby's mouth to your breast baby's mouth to your breast and make it easier for the and make it easier for the baby to latch on)baby to latch on)

• Don't bend over or lean Don't bend over or lean forward to bring your breast to forward to bring your breast to your baby. Instead, cradle your your baby. Instead, cradle your baby close to your breast.baby close to your breast.

Football holdFootball hold

• This position is especially This position is especially popular among mothers popular among mothers who:who:– Are recovering from Are recovering from

Caesarean births Caesarean births – Have large breasts Have large breasts – Nursing a premature baby or Nursing a premature baby or

two babies at once two babies at once – Need to encourage a baby to Need to encourage a baby to

take more of the nipple into take more of the nipple into his or her mouth his or her mouth

• Hold your baby at your side, Hold your baby at your side, with your elbow bent. With with your elbow bent. With your open hand, support your open hand, support your baby's head and face your baby's head and face him or her toward your him or her toward your breast. breast.

• Your baby's back will rest on Your baby's back will rest on your forearm. For comfort, your forearm. For comfort, put a pillow at your side and put a pillow at your side and use a chair with broad, low use a chair with broad, low arms.arms.

Side-lying holdSide-lying hold

• A lying position may help your A lying position may help your baby latch on to your breast baby latch on to your breast correctly in the early days of correctly in the early days of breast-feeding. breast-feeding. – It's also a good choice when It's also a good choice when

you're tired. you're tired. – If you're recuperating from a If you're recuperating from a

Caesarean birth, reclining may Caesarean birth, reclining may be your only option for the first be your only option for the first few days.few days.

• Lie on your side and face your Lie on your side and face your baby toward your breast, baby toward your breast, supporting baby with the hand supporting baby with the hand of the arm you're resting on. of the arm you're resting on.

• With your other arm and hand, With your other arm and hand, grasp your breast and then grasp your breast and then touch your nipple to your baby's touch your nipple to your baby's lips. lips.

• Once your baby latches on, use Once your baby latches on, use the bottom arm to support your the bottom arm to support your own head and your top hand and own head and your top hand and arm to help support the baby.arm to help support the baby.

““How to” of breast How to” of breast feedingfeedingAdvice for Mum: Determining Advice for Mum: Determining

effectiveness of breast-feeding effectiveness of breast-feeding

• Steady weight gain is often the most reliable sign Steady weight gain is often the most reliable sign

• Most newborns breast-feed eight to 12 times a day Most newborns breast-feed eight to 12 times a day

• If you listen carefully, youIf you listen carefully, you ’’ll be able to hear your baby ll be able to hear your baby swallowing swallowing

• Your breasts may feel firm or full before the feeding, and Your breasts may feel firm or full before the feeding, and softer or emptier afterward.softer or emptier afterward.

• Expect your baby to have six to eight wet diapers a day Expect your baby to have six to eight wet diapers a day

• A well-nourished baby also will have one to three or even A well-nourished baby also will have one to three or even more bowel movements a day more bowel movements a day

• A baby who seems satisfied after a feeding and is alert and A baby who seems satisfied after a feeding and is alert and active at other times is likely getting enough to eat active at other times is likely getting enough to eat

Advice for Mum: Milk production and Advice for Mum: Milk production and expressionexpression

• Ideally, infants who are medically stable and able to breastfed Ideally, infants who are medically stable and able to breastfed should be put to breast for all feedings. should be put to breast for all feedings.

• If infant is unable to breastfeed effectively, the mother should If infant is unable to breastfeed effectively, the mother should express her milk approximately 8 to 12 times / day to initiate, express her milk approximately 8 to 12 times / day to initiate, maintain or increase her milk supply. maintain or increase her milk supply.

• You should save any milk that is expressed.You should save any milk that is expressed.

• A mother who is expressing milk for an ill or hospitalized infant A mother who is expressing milk for an ill or hospitalized infant requires education concerning milk production, use of an electric requires education concerning milk production, use of an electric breast pump. She should be able to demonstrate how to breast pump. She should be able to demonstrate how to assemble the pump, use it, and clean it before she leaves the assemble the pump, use it, and clean it before she leaves the hospital.hospital.

““How to” of breast How to” of breast feedingfeeding


Benefits of breast feedingBenefits of breast feeding ““How to” of breast feedingHow to” of breast feeding Infection controlInfection control Psychological aspects: Allaying Psychological aspects: Allaying


Infection IssuesInfection IssuesInfection through Breast feedingInfection through Breast feeding

• Many maternal illnesses associated with fever do not require Many maternal illnesses associated with fever do not require separation of the mother and infant or additional precautions separation of the mother and infant or additional precautions to protect the infant. (eg. Breasts engorgement, atelectasis, to protect the infant. (eg. Breasts engorgement, atelectasis, UTI, etc)UTI, etc)

• Most anti-microbial agents used to treat infection can be Most anti-microbial agents used to treat infection can be used in infants and children. Additional amounts that are used in infants and children. Additional amounts that are ingested by the infant in breast milk are usually insignificant.ingested by the infant in breast milk are usually insignificant.

• Standard precaution include, avoiding direct contact with Standard precaution include, avoiding direct contact with blood and body fluids, broken skin and mucous membranes, blood and body fluids, broken skin and mucous membranes, careful hand washing before and after breastfeeding, and careful hand washing before and after breastfeeding, and washing the breast before and after breastfeeding.washing the breast before and after breastfeeding.

Infection IssuesInfection IssuesHealthy lifestyle choicesHealthy lifestyle choicesYour lifestyle choices are just as important when you’re breast-Your lifestyle choices are just as important when you’re breast-

feeding as they were when you were pregnant.feeding as they were when you were pregnant.• Eat plenty of fruits, vegetables and whole grains. Eat plenty of fruits, vegetables and whole grains. • Drink lots of fluids. Drink lots of fluids. • Rest as much as possible. Rest as much as possible. • Only take medication with your doctor’s consent. Only take medication with your doctor’s consent. • Don’t smoke. Don’t smoke. • Beware of caffeine and alcohol.Beware of caffeine and alcohol.

VSD managementVSD management• Because infection can occur up to 3 weeks after surgery, Because infection can occur up to 3 weeks after surgery,

parents need to be educated about signs of bacterial parents need to be educated about signs of bacterial endocarditis, wound infection, including purulent drainage, endocarditis, wound infection, including purulent drainage, fever, and a foul-smelling odor.fever, and a foul-smelling odor.

• Prophylactic antibiotics therapy is usually continued for up to 6 Prophylactic antibiotics therapy is usually continued for up to 6 months post VSD closure to prevent bacterial endocarditis. months post VSD closure to prevent bacterial endocarditis. – Teach Mum how to administer medications to Baby JohanTeach Mum how to administer medications to Baby Johan

• With early diagnosis and repair of a VSD, the outcome is With early diagnosis and repair of a VSD, the outcome is generally excellent, and minimal follow-up is necessary. Activity generally excellent, and minimal follow-up is necessary. Activity levels, appetite, and growth will return in most children. levels, appetite, and growth will return in most children.


Benefits of breast feedingBenefits of breast feeding ““How to” of breast feedingHow to” of breast feeding Infection issuesInfection issues Psychological aspects: Allaying Psychological aspects: Allaying


Psychological Issues: Psychological Issues: Allaying Breast-feeding Allaying Breast-feeding anxietyanxiety • Explain to the mother, the infant’s heart condition, Explain to the mother, the infant’s heart condition,

sign and symptoms and why it affect the feeding sign and symptoms and why it affect the feeding so that it will not affect the mother psychologically.so that it will not affect the mother psychologically.

• Allay the fear and anxiety of breastfeeding for the Allay the fear and anxiety of breastfeeding for the infant after surgical intervention.infant after surgical intervention.

• Provide educational resources and demonstrate Provide educational resources and demonstrate correct breastfeeding techniques for a surgical correct breastfeeding techniques for a surgical infant to ensure that their feeding decision is a infant to ensure that their feeding decision is a fully informed one.fully informed one.

• Support and encouragement by the father can Support and encouragement by the father can greatly assist the mother when problem arises.greatly assist the mother when problem arises.

• Encourage breastfeeding post operatively. Eg. Encourage breastfeeding post operatively. Eg. Provide private room, avoid procedure that Provide private room, avoid procedure that interfere with breastfeeding, teach infant feeding interfere with breastfeeding, teach infant feeding cues, the needs to establish and maintain an cues, the needs to establish and maintain an adequate milk supply, use of sample breastfeeding adequate milk supply, use of sample breastfeeding aids etc.aids etc.

SummarySummary

• Most baby born with a congenital heart defect may be Most baby born with a congenital heart defect may be medically managed or may require surgical intervention. medically managed or may require surgical intervention. Surgery can be accomplished in the immediate newborn Surgery can be accomplished in the immediate newborn period or planned for when the infant reaches a specific age or period or planned for when the infant reaches a specific age or weight. weight.

• Family support, education and participation in the infant’s care Family support, education and participation in the infant’s care is essential in assisting the family to cope with the diagnosis is essential in assisting the family to cope with the diagnosis and to ensure optimal outcomes for the infant. and to ensure optimal outcomes for the infant.

• Ongoing maternal support, education, and assistance with Ongoing maternal support, education, and assistance with breastfeeding or expressing milk for the infant unable to nurse breastfeeding or expressing milk for the infant unable to nurse is essential to ensure positive outcomes for the mother and is essential to ensure positive outcomes for the mother and her infant.her infant.

• Once discharged home, infants require follow-up to provide Once discharged home, infants require follow-up to provide appropriate health care and monitor of growth and nutrition.appropriate health care and monitor of growth and nutrition.

• Breastfeeding provides numerous benefits to infants and their Breastfeeding provides numerous benefits to infants and their mothers. Every attempt should be made to support the mothers. Every attempt should be made to support the breastfeeding Mum in achieving their goals.breastfeeding Mum in achieving their goals.

ReferencesReferencesAbdulla, R. (2007).Abdulla, R. (2007). Atrioventricular canal defect Atrioventricular canal defect [on-line]. Available: [on-line]. Available:

http://pediatriccardiology.uchicago.edu/PP/chd%20for%20parentshttp://pediatriccardiology.uchicago.edu/PP/chd%20for%20parents%20avc.htm (26 Jan, 2008).%20avc.htm (26 Jan, 2008).

Carole, K., Judy W.L. & Ann, A.F. (1998). Carole, K., Judy W.L. & Ann, A.F. (1998). Comprehensive neonatal nursing: a Comprehensive neonatal nursing: a physiologic perspectivephysiologic perspective. Philadelphia: W. B. Sauders Company.. Philadelphia: W. B. Sauders Company.

Gomella, T.L., Cunningham, M.D., Eyal, F.G. & Zenk, K.E. (2004). Gomella, T.L., Cunningham, M.D., Eyal, F.G. & Zenk, K.E. (2004). Management, Management, procedures, on-call problems, diseases, and drugsprocedures, on-call problems, diseases, and drugs (5 (5thth ed.). New York: ed.). New York: Lange Medical Books/McGraw-Hill Medical Pub.Lange Medical Books/McGraw-Hill Medical Pub.

Grigsby, D.G. (2006). Malnutrition. Grigsby, D.G. (2006). Malnutrition. Emedicine from WebMDEmedicine from WebMD [on-line]. [on-line].

Available: http://www.emedicine.com/ped/topic1360.htm (20 January, Available: http://www.emedicine.com/ped/topic1360.htm (20 January, 2008).2008).

Hendricks, K.M. & Duggan, C. (2000). Hendricks, K.M. & Duggan, C. (2000). Manual of pediatric nutrrtionManual of pediatric nutrrtion (3 (3rdrd ed.). ed.). Hamilton: B.C.Decker.Hamilton: B.C.Decker.

Hockenberry, M.J. & Wilson, D. (2007). Hockenberry, M.J. & Wilson, D. (2007). Wong’s nursing care of infants and Wong’s nursing care of infants and childrenchildren (8 (8thth ed.). St. Louis: Mosby. ed.). St. Louis: Mosby.

ReferencesReferencesKlossner, N.J. & Hatfield, N.T. (2006). Klossner, N.J. & Hatfield, N.T. (2006). Introductory maternal and pediatric Introductory maternal and pediatric

nursingnursing. Philadelphia: Lippincott Williams & Wilkins.. Philadelphia: Lippincott Williams & Wilkins.

Lawrence, R. M., Lawrence, R. A. (2004). Lawrence, R. M., Lawrence, R. A. (2004). Clin Perinatol: Breast milk and Clin Perinatol: Breast milk and infectioninfection. New York: Elsevier Inc.. New York: Elsevier Inc.

Merenstein, G.B. & Gardner, S. L. (2006). Merenstein, G.B. & Gardner, S. L. (2006). Hand Book of Neonatal Intensive Care Hand Book of Neonatal Intensive Care (6th ed.). St. Louis: Mosby.(6th ed.). St. Louis: Mosby.

Olds, S.B., London, M.L., Ladewig, P.A.W. & Davidson, M.R. (2004). Olds, S.B., London, M.L., Ladewig, P.A.W. & Davidson, M.R. (2004). Maternal-Maternal-Newborn nursing and women’s health careNewborn nursing and women’s health care (7 (7thth ed.). New Jersey: Prentice & ed.). New Jersey: Prentice & Hall.Hall.

Ruiz, M. (2006). Ruiz, M. (2006). Image:Ventricular septal defect.svgImage:Ventricular septal defect.svg [on-line]. Available: [on-line]. Available: http://commons.wikimedia.org/wiki/Image:Ventricular_septal_defect.svg (26 http://commons.wikimedia.org/wiki/Image:Ventricular_septal_defect.svg (26 January, 2008).January, 2008).

Ramaswamy, P., Anbumani, P., Srinivasan, K., Srinivasan, A., Natesan, V. & Ramaswamy, P., Anbumani, P., Srinivasan, K., Srinivasan, A., Natesan, V. & Srinivasan, S. (2006). Ventricular Septal Defect, General Concepts. Srinivasan, S. (2006). Ventricular Septal Defect, General Concepts. Emedicine from WebMDEmedicine from WebMD [On-line]. Available: [On-line]. Available: http://www.emedicine.com/ped/topic2402.htm (20 January, 2008).http://www.emedicine.com/ped/topic2402.htm (20 January, 2008).

ReferencesReferencesSlonim, A.D. & Pollack, M.M. (2006). Slonim, A.D. & Pollack, M.M. (2006). Pediatric critical care medicinePediatric critical care medicine (1 (1stst ed.). Philadelphia: ed.). Philadelphia:

Lippincott Williams & Wilkins.Lippincott Williams & Wilkins.

Spitzer, A. R. (1996). Spitzer, A. R. (1996). Intensive Care of the Fetus and Neonate.Intensive Care of the Fetus and Neonate. St Louis: Mosby-Year Book St Louis: Mosby-Year Book

US Department of Health and Human Services.(2000). US Department of Health and Human Services.(2000). HHS Blueprint for Action on HHS Blueprint for Action on BreastfeedingBreastfeeding. [On-line]. Available: www.. [On-line]. Available: www.cdc.govcdc.gov//breastfeedingbreastfeeding/pdf/bluprntbk2.pdf /pdf/bluprntbk2.pdf (31 January 2008)(31 January 2008)

Wilkinson, J. (2007).Wilkinson, J. (2007). Ventricular septal defects (VSD) – large Ventricular septal defects (VSD) – large [on-line]. Available: [on-line]. Available: http://www.rch.org.au/cardiology/health-info.cfm?doc_id=3579 (26 Jan, 2008).http://www.rch.org.au/cardiology/health-info.cfm?doc_id=3579 (26 Jan, 2008).

Yale University. (2001)Yale University. (2001) Perimembranous ventricular septal defects Perimembranous ventricular septal defects [on-line]. Available: [on-line]. Available: http://www.med.yale.edu/intmed/cardio/chd/e_vsd_memb/index.html (26 Jan, 2008).http://www.med.yale.edu/intmed/cardio/chd/e_vsd_memb/index.html (26 Jan, 2008).

Surgical Management of VSD

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