To determine an effective nutritional regimen for management of growth failure in infants with congenital heart disease and congestive heart failure, the authors studied 19 infants with cardiac anomalies who were not candidates for early corrective surgery. Patients were randomly assigned to one of three feeding groups: group 1 (n = 7) received continuous, 24-hour nasogastric alimentation; group 2 (n = 5) received overnight, 12-hour nasogastric infusions plus daytime oral feedings as tolerated; and group 3 (n = 7) received oral feedings alone. For all patients, commercial infant formula (cow's milk or soy protein) was supplemented to a calorie density of approximately 1 kcal/mL. During a 5.25 +/- 0.45 month study period, only group 1 infants achieved intakes greater than 140 kcal/kg per day (mean = 147 kcal). Serial anthropometric measurements demonstrated that only 24-hour infusions (group 1) were associated with significantly improved nutritional status, when assessed by z scores for weight (P less than .01) and length (P less than .05). Group 1 infants also showed marked increases in midarm muscle circumference and triceps and subscapular skinfold thicknesses (P less than .01, compared with groups 2 and 3). These data suggest that infants with congenital cardiac defects complicated by malnutrition manifest increased nutrient requirements for growth and weight gain. Continuous, 24-hour, nasogastric alimentation is a safe and effective method for achieving both increased nutrient intake and improved overall nutritional status in these infants.