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  • Quality Improvement Article
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Improving preoperative enteral feeding for newborns with congenital heart disease

Journal of Perinatology (2026)Cite this article

Subjects

Abstract

Objective

The aim of this quality improvement project was to increase preoperative enteral feeding and breastfeeding rates in term neonates with congenital heart disease (CHD).

Methods

A multidisciplinary team developed and implemented a preoperative feeding protocol for neonates with congenital heart disease. The primary outcome was the presence of preoperative enteral feeding by May 2025. Secondary outcomes included breastfeeding rates and time to first feed. The process measure was the rate of reference to the feeding protocol in provider notes. Our balancing measure was a rule out or diagnosis of necrotizing enterocolitis requiring medical or surgical treatment in the preoperative period. Infants were identified using the Pediatric Cardiac Critical Care Collaborative (PC4). Data was collected from chart review and analyzed with statistical process control charts. The pre-implementation period was from June 2022 to June 2023, the implementation period was from July 2023 to June 2024, and the sustainment period was from July 2024 through May 2025.

Results

The number of neonates that met the inclusion criteria was 121. The rate of overall enteral feeding increased significantly from 72% in the pre-implementation phase (June 2022-June 2023) to 93% in the sustainment phase (July 2024–May 2025) (p = 0.026). Additionally, we found an improvement in our secondary outcomes and no change to the balancing measures.

Conclusion

This quality improvement initiative, which centered on creating and implementing a clear, standardized, evidence-based feeding protocol while utilizing interdisciplinary collaboration, led to an increase in overall rates of preoperative enteral feeding for newborns with CHD in a level IV intensive care nursery.

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Fig. 1: Key driver diagram.
Fig. 2: Annotated P-chart for rate of preoperative enteral feeding.
Fig. 3: Annotated P-chart for rate of preoperative breastfeeding.
Fig. 4: Annotated X-chart for median time to first feed.

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Acknowledgements

The authors would like to thank all clinical and administrative staff in the UCSF ICN for their dedication to give high quality care throughout the unit and for their contributions to this project.

Funding

No funding was secured for this study.

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Authors and Affiliations

  1. Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA

    Paul B. Brandfonbrener, Katharine G. Gorsky, Katelin P. Kramer & Martina A. Steurer

  2. UCSF Benioff Children’s Hospital, San Francisco, CA, USA

    Catherine Marks & Maria Hetherton

Authors
  1. Paul B. Brandfonbrener
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  2. Katharine G. Gorsky
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  3. Catherine Marks
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  4. Maria Hetherton
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  5. Katelin P. Kramer
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  6. Martina A. Steurer
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Contributions

PBB was responsible for study design, data collection, data analysis, figure creation, manuscript writing, and revision. KGG was involved in study design, data analysis, and manuscript revision. CM was involved in study design, intervention implementation, and manuscript revision. MH was involved in study design, intervention implementation as the primary dietitian in the unit, leading protocol teaching, and manuscript revision. KPP gave advice for study design, data collection, and analysis. She critically revised the manuscript. MAS oversaw study design, data collection, and analysis. She critically revised the manuscript.

Corresponding author

Correspondence to Paul B. Brandfonbrener.

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Brandfonbrener, P.B., Gorsky, K.G., Marks, C. et al. Improving preoperative enteral feeding for newborns with congenital heart disease. J Perinatol (2026). https://doi.org/10.1038/s41372-026-02606-z

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