Nutrition in the treatment of acute heart failure in children

The article was written by MSc Ma Van Tham - Department of Pediatrics - Neonatology, Vinmec Phu Quoc International General Hospital.

In children, acute heart failure often progresses rapidly and severely while clinical signs are subtle, so rapid diagnosis and timely first aid management are difficult, especially in children. small. Nutrition and supportive care is one of the most important principles of acute heart failure treatment in children.

Acute heart failure (STC) is a condition in which the heart muscle suddenly loses its ability to ensure blood flow, so it cannot meet the metabolic needs of the body.
There are many causes of STC in children, varying by age, geographic region. The main symptom is rapid left-sided or global heart failure. The clinical picture is a sudden severe decompensation of cardiac output, resembling cardiogenic shock, presenting with acute peripheral circulatory failure along with central and peripheral blood stasis.

2.1 Principles of nutrition in the treatment of heart failure Bed rest in severe cases, lying with the head elevated, the neck slightly tilted; Limit fluid, implement a salt-reduced diet of 1-2g/day; Eat foods rich in energy (1 kcal/ml), to avoid fluid overload (<100ml/kg/24 hours), it is necessary to eat small meals, helping to reduce the burden on the heart and digestive system; Avoid constipation and any strenuous activity, avoid sudden extreme heat or cold; Avoid gas-producing foods because the air sacs in the stomach push up the diaphragm, affecting the heart when the patient is lying down. After eating, you should rest for about 30-40 minutes and the meal should be far from bedtime about 3 hours; Assess the patient's nutritional status prior to nutritional intervention; The nutritional management of patients with heart failure begins with an assessment of the child's nutritional status. Children should reach their desired weight and monitor their weight regularly. Energy requirements vary with the child's body weight. However, it is necessary to provide nutritional support for children with cardiovascular disease, depression and malnutrition; Instruct children and mothers to eat a nutrient-balanced diet rich in fresh fruits and vegetables, as they are a source of electrolytes and vitamins; Water restriction is not really necessary for patients with mild to moderate heart failure. However, it is not recommended that patients drink a lot of water, daily water needs should be in the range of 1000 - 1200ml/day. For cases of hyponatremia, severe renal failure, severe heart failure, diuretic resistance, patients need to limit water intake by the amount of urine the previous day + 15ml/kg/day; Magnesium, potassium, and calcium levels should be monitored and these electrolytes added as needed. Vitamin B1 supplementation for patients receiving long-term high-dose loop diuretics of Henle. Daily supplementation of vitamins and minerals can be beneficial for patients with heart failure. 2.2. Nutritional recommendations for patients with heart failure Salt requirements Salt is the main source of sodium in the diet. Salt contains 40% sodium, so 1 teaspoon of salt with 6 grams of salt will contain 2.4g of sodium (equivalent to 2400mg of sodium). So for every 1 gram of table salt will give 400mg of sodium.
The recommended salt requirements according to the degree of heart failure are as follows:
Severe heart failure (irreversible heart failure – stage 4 heart failure), congestive heart failure, acute pulmonary edema or severe edema: Limit salt to level < 1g/day; Mild heart failure (NYHA stages 1 and 2): Limit salt to 2-3g/day; Chronic heart failure being treated at home: Limit salt to 2-3g/day. In addition to salt, sodium is also present in many other foods and in some food additives (such as monosodium glutamate, seasoning powder, soup powder...) so it is necessary to calculate the total amount of sodium in the diet including:
Calculation Calculate the amount of sodium in food: Based on the sodium content per food unit (serving size) noted on the food label. For example: 1 serving size of cookies is 5 cookies, sodium content in each serving size is 140mg. Eating 10 cookies means consuming 280mg of sodium. Calculating and carefully recording the amount of sodium in each food will help patients adhere to a low-salt diet by balancing high-sodium and low-sodium foods; Should use fresh food, avoid using processed food such as canned food, chili sauce, sausage, snack cake; Choose to buy foods labeled “unsalted” (no salt in the process), “sodium-free” (less than 5mg sodium per serving) or “low-sodium” (less than 140 mg sodium per serving). ). However, foods labeled "reduced-sodium" can still contain a lot of sodium. Water requirements The recommended water requirements according to the degree of heart failure are as follows:
Mild to moderate heart failure, good kidney function: No need for water restriction. However, do not drink too much water during the day, the average water requirement is about 1000 - 1200ml/day; Severe heart failure with hyponatremia, severe renal failure, resistance to diuretics: Daily water requirement is calculated as the total amount of urine the previous day + 15ml/hour/day. Water in the diet includes drinking water, milk, fruit; water in porridge, soup, soup... and in infusion.
For daily fluid control, the patient should have a full record of fluid intake (through milk, medication, drinking water) and fluid output (faeces, urine), every 24 hours or every 6 hours if the patient is severe for timely adjustment.

Energy requirements During the period of acute congestive heart failure, heart failure after acute myocardial infarction, acute myocarditis, the patient is fed mainly with intravenous dextrose with a daily energy level of only 50 % of the calculated energy demand. Vitamins and minerals (both macro and microelements) are supplemented intravenously according to baseline needs and biochemical test results.
Once the condition is stable, start oral feeding with a light, low-fat liquid diet (12% of dietary calories). The level of energy provided in the first days is about 500-800 kcal for 2 to 3 days. By day 4 - 5, increase the amount of food by mouth to provide about 1000 - 1200 kcal/day. The diet should be divided into many small meals with soft, easy-to-digest, and palatable foods (milk, porridge). The energy deficit compared to the calculated need can be supplemented intravenously if the patient has persistent malnutrition or accompanying depletion.
When the patient is discharged from the hospital, the average daily energy requirement is about 1600 - 1800kcal/day. This need depends on the patient's condition as follows:
Malnourished patients: 32 kcal/kg/day; Patients in average condition: 28 kcal/kg/day; Overweight and obese patients: 24-28 kcal/kg/day. Fat requirement Fat requirement must be less than 25% of total dietary energy; in which cholesterol is less than 300mg/day, energy from saturated fat accounts for less than 10% of dietary energy and energy from trans fat is less than 2% of total energy. Omega-3 fatty acid requirements are about 1.3g/day from fish in food or supplements.
Protein requirements The protein requirement is reduced compared to normal children because protein increases basal metabolism, increases energy for metabolism and elimination of metabolites from nitrogen, increases the need for oxygen use. increase blood flow and make the heart work harder.
For mild cases of heart failure, the amount of protein provided is about 0.8 - 1g/kg/day. For children who are exhausted or malnourished, it can be increased to 1.2 - 1.5g/kg/day. Priority should be given to "white meat" providing easily absorbed protein such as milk, fish, tofu; limit "red meat" such as cattle meat, seafood... which are rich in minerals and cholesterol.
Demand for glucose This is the main source of energy for the body. The need for glucose in children with acute heart failure is slightly higher than in normal children, which can account for about 55-65% of total energy. Glucose requirements are usually about 5-7g/kg/day.
It is necessary to limit the foods that produce gas, stretch the intestinal loops, cause the diaphragm to rise, which will affect the heart's activity such as beans, eggs, carbonated drinks...
The need for vitamins and nutrients Minerals Vitamins are very important in order to meet the needs of heart failure, especially for children who suffer from prolonged malnutrition, exhaustion... are places where there is a reserve of vitamins in the body. body is very poor as well as the metabolism and utilization of vitamins are not taking place optimally. Vitamin deficiency will aggravate the deterioration of the body, including the heart muscle, making heart failure worse.
The vitamins that need the most attention are B vitamins, especially vitamin B1. Vitamin B1 is abundant in peanuts, cereals, eggs, fish, poultry. Vitamins C, E, and beta-carotene are antioxidants that help prevent free radicals from further damaging blood vessel walls and heart muscle tissue. In cases where the daily diet cannot supply the needs, additional oral or intravenous supplements are required.
Potassium is a macronutrient that should be closely monitored in patients with heart failure. Most patients with heart failure use diuretics, in which there are 2 main groups of drugs that need attention: diuretics that act on the loop of Henle, causing hypokalemia due to urinary excretion of potassium, and diuretics. Potassium retention causes hyperkalemia. In particular, electrolyte disturbances will have an early and more severe clinical impact on heart failure patients with hyperkalemia or hypokalemia. Manifestations of dyskalemia include fatigue, muscle weakness, numbness, muscle cramps or spasticity, abdominal distension, and cardiac arrhythmias.
Depending on the degree of heart failure, the type of drug used in the treatment and the patient's kidney condition, the amount of potassium provided needs to be adjusted down or up. Potassium is abundant in fresh fruits and vegetables (broccoli, bananas, avocados), beans, cereals, potatoes, low-fat dairy products, mineral water, fish... Decomposition regularly and promptly supplemented with medication when the patient has an indication for hospital stay rather than relying on potassium from the diet.
Patients with heart failure often use diuretics, causing loss of calcium and magnesium through the urine, so the diet should pay attention to providing enough foods rich in these minerals. Calcium is most abundant in milk and dairy products, small shrimp eat whole bones, shells or calcium-fortified foods. However, when advocating to provide calcium from milk, heart failure patients must pay attention to the amount of water entering the body from this source and must choose skimmed milk. Daily calcium requirement is 1,000mg/day.
Magnesium is found in many foods, especially foods of plant origin including green vegetables (magnesium is a component of chlorophyll), sprouts, cereals, seafood, tofu, milk and nuts.
Daily weight monitoring Daily weight monitoring will help patients better monitor their disease, detect small stagnation causing discreet weight gain before there are bad signs of the disease.
Monitor your weight by weighing several times a day in the morning, right after waking up, after cleaning and before breakfast. When weighing should wear minimal clothing. Carefully record the results of each weighing on a tracking sheet (along with a flow chart). If you gain about 0.5 - 1 kg within 2-3 days, you should check the progress of the disease and check the fluid in and out.

Limiting physical activity Depending on the clinical severity of heart failure as well as the etiology leading to heart failure to choose different modes of physical activity. Proper physical activity improves the efficiency of myocardial oxygen use, reduces the work of the heart, helps restore cardiac function, and increases the patient's quality of life.
Patients with decompensated heart failure require complete bed rest until the decompensation resolves. Absolute rest minimizes myocardial oxygen demand, avoiding aggravation of circulatory overload and symptoms of heart failure.
When the heart failure is stable, give the patient gentle and gradual physical activity.
In summary, acute heart failure is a rather complex pathological syndrome. This is a medical condition that can cause many dangerous complications and even death if not diagnosed early and treated promptly.
Acute heart failure often occurs on the background of a cardiovascular disease, such as congenital heart disease, valvular disease, cardiomyopathy. Acute heart failure causes a sudden decrease in cardiac output, thereby not being able to meet the blood supply to maintain metabolism according to the needs of the child's activities and growth. Therefore, acute heart failure in children, if not treated correctly, can cause chronic heart failure, which will directly affect the child's growth, making the child stunted and retarded.
The diagnosis of acute heart failure should be done early and promptly so as not to endanger the child's life. There are many drugs used in the treatment of acute heart failure with high efficiency, saving children's lives and maintaining stable health for children. In particular, a suitable diet is extremely important to help improve acute heart failure and ensure the development of children.