The Impact of Neurobehavior on Feeding Outcomes in Neonates with Congenital Heart Disease

Abstract

Objective: To evaluate the association between neonatal neurobehavioral state and oral feeding outcomes following congenital heart disease (CHD) surgery.

Study design: This single center retrospective cohort study described neonates undergoing cardiac surgery evaluated perioperatively with the Neonatal Intensive Care Unit Network Neurobehavioral Scale (NNNS). We compared NNNS attention scores, which evaluates neonates' ability to orient and fixate on stimuli, with the feeding outcomes percentage of feeds taken orally at discharge and time to reach full oral feeds using regression analyses. Models were constructed for both preoperative and postoperative NNNS evaluations.

Results: Between August 2015 and October 2017, 124 neonates underwent 89 preoperative and 97 postoperative NNNS evaluations. In multivariable Cox regression, higher preoperative NNNS attention scores were associated with a shorter time to achieve full oral feeds (hazard ratio 1.4; 95% CI 1.0‒2.0; P = .047). This relationship was not seen for post-operative NNNS attention scores or percentage of oral feeds at discharge. Depending on the model, younger age at surgery, increased ventilator days, increased length of stay, and single or 2-ventricle anatomy with aortic arch obstruction were associated with lower percentage of oral feeds at discharge and/or delay in full oral feeds.

Conclusions: Higher neonatal attention before cardiac surgery is associated with improved feeding outcomes. Prospective assessment of neonatal neurobehavioral state may be a novel approach to predict and target interventions to improve feeding outcomes in CHD. Future studies should examine the impact of intrinsic neurodevelopmental delay vs environmental adaptation on the neurobehavioral state of neonates with CHD.

Keywords: congenital heart disease; neurodevelopment; oral feeding.

Copyright © 2019 Elsevier Inc. All rights reserved.

Figures

Figure 1:. Feeding Outcomes:

Distribution of outcomes is shown, with delineation based on whether NICU Network Neurobehavioral Scale (NNNS) assessment was done pre-operatively (open), post-operatively (closed) or at both time points (checkered). Histograms show the distribution of percent oral feeds taken at the time of discharge (A) and the time to reach 100% oral feeds in days (B). The majority of patients with non-recordable NNNS attention scores took 50% or fewer feeds at discharge. Most neonates achieved full oral feeds within 100 days of chest closure, but six patients took >365 days to achieve full oral feeds.

Figure 2;. Online: Attention, lethargy and multiple imputation.

Scatter plot of raw preoperative (“Pre-Op”) NICU Network Neurobehavioral Scale (NNNS) attention scores and raw pre-operative NNNS lethargy scores, including imputed attention scores from two randomly selected imputed data sets. Imputed attention scores were jittered on the x-axis.

Figure 3:. Normalized NICU Network Neurobehavioral Scale (NNNS) subdomain scores:

Boxplots demonstrate the median values and interquartile ranges of the differences of our cohorts’ pre-operative (A) and post-operative (B) NNNS subdomain scores. The attention, non-optimal reflexes, and stress scores are noticeably distributed away from the standardized normative range. (Hypertonic score was not standardized because normative summaries were not available.)