Impact of a unit-wide feeding tolerance management protocol on enteral feeding outcomes in infants with congenital heart disease: a pre–post quality improvement cohort study

Background Infants recovering from congenital heart disease (CHD) surgery frequently experience feeding intolerance (FI), a major barrier to achieving adequate enteral nutrition (EN). This pre–post quality improvement study evaluated whether implementation of a standardized feeding-tolerance management pathway was associated with improved consistency of EN monitoring and corresponding trends in FI-related outcomes. Methods A single-center, consecutively enrolled quality improvement cohort included postoperative CHD infants admitted in 2022 (pre-implementation) and 2023 (post-implementation). The intervention consisted of unit-wide standardization of FI risk assessment, EN monitoring indicators, alert-trigger criteria, and documentation procedures. No feeding strategy was altered. The primary outcome was FI incidence; secondary outcomes included time to full EN, gastrointestinal symptoms, EN interruptions, and nutritional status. Statistical analyses included χ 2 tests, logistic regression, Cox models, and negative binomial regression. Results A total of 301 infants were analyzed (148 pre-implementation; 153 post-implementation). Documentation completeness increased from 68.4% to 91.7%, and adherence to predefined alert criteria rose from 54.7% to 92.2% (both P < 0.001). FI incidence decreased from 42.6% to 24.2% (RR 0.57, 95% CI 0.41–0.79), and adjusted odds of FI remained lower post-implementation (aOR 0.48, 95% CI 0.29–0.79). Time to full EN was shorter (median 9 to 6 days; HR 1.48, 95% CI 1.11–1.97). Gastrointestinal symptom burden and GI-related feeding interruptions were reduced, while nutritional decline was attenuated, reflected by improved weight-for-age z score (WAZ) change (ΔWAZ −0.22 to −0.04; P = 0.004). Subgroup and sensitivity analyses demonstrated consistent directional trends. Conclusions Implementation of a standardized feeding-tolerance pathway was associated with improved monitoring consistency and favorable trends in FI incidence, EN progression, and in-hospital nutritional stability among postoperative CHD infants.