Paediatricsmiddle twist
A 4-month-old girl with a large ventricular septal defect is reviewed before surgical repair. She breastfeeds every two hours but takes 40 minutes each time, sweats and becomes breathless while feeding, and stops before she is satisfied. Her weight has fallen from the 50th centile at birth to below the 3rd centile, while length and head circumference remain on the 50th. Her respiratory rate is 62 breaths per minute and the liver edge is 3 cm below the costal margin. She is taking furosemide. Which one of the following is the most appropriate nutritional management?