Transcript Special Formulas-Who, When, Where, Why and How?

Special Formulas-Who,
When, Where, Why and
How?
Margo Humenczuk MBA, RD, CSP, LD
The Magic of WIC
October 23, 2012
American Academy of
Pediatrics
• Breast milk is best-the gold standard
• Milk banks growing, breast milk available to
more infants, especially preemies
• No soy formula until 6 months of age for
premature infants-phytates can bind essential
minerals
• Premature follow up formulas (Enfacare or
Neosure) for first year, higher calcium and
phosphorus for bone mineralization
Breast Milk in Tube Feedings
• Mom must be taught safe storage and
collection practices
• Continuous drip is associated with
appreciable fat losses
– Fat separates and collects in infusion system
– Loss of 20% of calories is typical
– Residual milk flush may deliver fat bolus that may
not be tolerated if impaired GI function
– Potential loss of cholesterol, EFA, phospholipids,
& fat soluble vitamins
Breast Milk/Neosure 22
calorie/oz Comparison
• 3 IU vitamin D per 100 calories (150 ml )
– Neosure 70 IU in 100 calories, Enfamil 60 IU
• Vitamin A 322 mg in breast milk, Neosure
470 mg, Enfamil 300 mg
• Iron 0.1 mg, Neosure & Enfamil Lipil 8
mg Fe
• Supplement with 1 ml multivitamin with
iron drops
Standard Cow’s Milk Formula
• Suitable for most infants
• Breast milk is very high in lactose but is
well tolerated, however, low lactose
formulas are popular and a better choice
than soy for most infants with gassiness,
colic, etc.
Formulas for Babies with GERD
• Added starch in commercial formulas does
not interfere with nutrient density or add
extra calories but does not work well with
meds that lower pH of stomach
• Overfeeding or feeding practices such as
bottle propping (air in stomach if nipple not
full of formula) or tightening ring on nipple
super tight can be as much a problem as
medical issues.
Iron in Formulas
• Does not affect constipation or fussiness
• Low iron formulas off the shelf now,
available only for those children with
medical need for low iron formula
Soy Formulas
• Children have grown and gained well on
soy formulas for years but soy is not the
first choice for infants unless they have a
true milk allergy.
• Should not be used just because other
family members required soy.
• 85%of those children sensitive to milk
formula will develop poor tolerance to soy.
• Much less expensive than hydrolyzed
formula
Follow-up formula for older
premature babies.
• 22 cal/oz, increased levels of certain
vitamins (D) & minerals Ca, P
• Enfacare or Neosure
• Do not use soy formulas for premature
babies per AAP.
Protein Hydrolysate Formulas
• Use for malabsorption-liver disease, short bowel
syndrome, other malabsorptive states. Tolerated
by some infants with cow milk and soy
intolerance.
• Use for some inborn errors of metabolism such
as galatosemia.
Partially Hydrolyzed Formulas
• Pregestimil 55% fat from MCT
– Ready to feed in liters and volu-feeds at 20
calories/oz., in volu-feeds at 24 kcaloriesavoids use of powdered formula in some
preemies
– Nutramigen with enflora LGG –powdered,
RTF and liquid concentrate- appropriate for
galactosemia
• Alimentum 33% fat from MCT
– Ready to feed at 20 calories/oz, powder
Necrotizing Enterocolitis
• Breast milk trophic feedings are best to
preserve gut health.
• Hydrolyzed formula from ready-to-feed
product is the next safest product.
• Avoid powdered formulas and Simply
Thick gel thickener until more research is
done.
Elemental Formulas
• Able to be immediately absorbed as amino
acids, simple sugars and mostly MCT.
• Good for gut rest, severe allergy and post
NEC feeding.
• Neocate, Elecare Infant, Elecare JR,
Neocate Jr. and Nutramigen Amino Acid.
• Some children need elemental products
long-term, other can be transitioned when
well.
Elemental formulas
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Taste and smell bad
Can be more difficult to mix
Not usually available on store shelves.
Very high osmolality
Short hang times
Fat Modified
• Enfaport Lipil (formerly Portagen)
• Used in chylothorax and
Lymphangiectasia
• Usually used acutely with transition to
standard hydrolyzed protein formula
longer term
• Vivonex TEN-amino acid product very low
in fat (3% of calories)
Renal
• Similac PM 60/40 reduced Phosphorus,
calcium and potassium, often used in
combination with other formulas to just
meet DRI of minerals.
Pediatric Formulas for Children
FEEDING
Nutren Jr,
Pediasure,
Pediasure 1.5
Kid Essentials
Kid Essential 1.5
Carnation
Breakfast
Essentials
RATIONALE
Standard oral or tube feeding supplement
Pediasure comes in 30 and 45kcal/oz with
and without fiber.
Pediasure contains some soy protein, Nutren
Jr does not.
Kid Essentials come 30 and 45 kcal/oz, with
and without fiber, 3 flavors
Carnation Instant Breakfast Essentials is a
powder that is mixed with 8oz whole milk.
More economical that other options
AVAILABILITY
Retail: Pediasure, Kid Essentials
Carnation Breakfast Essentials-need
to mix with milk
Nutren Jr (may be ordered from
pharmacy at grocery store.
Pediatric Formulas
• Resource Breeze-really an adult product,
low in calcium, does not nutritionally match
Pediasure or comparable milk-based
products. NOT a complete feeding.
• OK to use to supplement calories and
protein, especially post op
• Bright Beginnings Pediatric Soy-soy
product very close to Pediasure in nutrient
content.
Peptide Products
• Shorter chain proteins, more MCT oil
• For malabsorption, may be used with
delayed emptying, trauma, high healing
needs
• some contain whey but no casein, may be
tolerated by some milk sensitive children.
• Good transition for those on an elemental
infant formula to make a gradual change
to a less fully hydrolyzed product
Peptide Formulas
• Peptamen Jr, Peptamen Jr Pre-bio,
Peptamen Jr with fiber
• Peptamen Jr 1.5 with fiber
• Pediasure Peptide 1.0 and 1.5 calorie
options
• Multiple flavors for both products
• Use vanilla or unflavored for tube feeding
Blended Foods
• Compleat Pediatric 1 kcal and 0.6 kcal/ml
• Lower kcal product contains similar
nutrition to 1 kcal product but with 60% of
the calories.
• For those with retching, milk intolerance
long-term formula intolerance and parents
who are reluctant about the sugar in
Pediasure. Does have traces of milk.
• Tube feeding only, not good for oral
consumption.
Blended Foods via G-tube
• Good program at Cincinnati Children’s
Hospital-developed for long-term retching
in children with a fundoplication.
• Should not be done in the community
without medical supervision. Need to
have a back up plan for times of illness,
hospital admission, post op, etc.
• “Just what my other kids eat” really isn’t.
• Avoid high nutrient supplements.
Blended Diet via G-tube
• Very labor intensive
• Bacterial contamination more likely than in
commercial product.
• Fluid content may be difficult to determine.
Thickeners in Formulas
• Thickening increases safety of swallow
and lessens risk of aspiration in
laryngomalacia and other swallowing
problems.
• Thickeners may dilute calorie and nutrient
content of beverage, or can increase
calories, depending on the product used.
More on Thickeners
• Recall of Simply Thick for preemies and
infants recently.
• Cereal thickens beverages, but lowers
fluid contribution of product and increases
calories form cereal, may displace some
nutrients.
Renal Formulas
Renal Formulas appropriate for children:
Suplena, Nepro
When to Consider Transition
from a Specialty Formula
• Child with milk sensitivity is eating yogurt,
cheese, etc.
• Preemie is a full year of age
• Child can take a variety of foods from all
food groups
– therapeutic tastes of baby foods don’t count
as adequate nutrition, use some Pediasure in
the interim as needed.
Transition to Other Formula
• Infant was put on amino acid formula at a
few weeks of age due to danger of NEC,
no documented formula intolerances-work
with PCP to make a determination on most
appropriate product.
• Some children at a year move from
hydrolyzed product to peptide product to
standard formula or cow’s milk.
Formula Mixing
• Use full scoops of formula powder, level
with lid of can
• When altering recipes start with scoops of
formula, not water volume, displacement
differs
• Most about 45 kcal/scoop, Nutramigen AA
23 kcal/scoop, Neocate 20 kcal/scoop
• Packed scoops for Nutramigen,
Pregestamil, NOT for Nutramigen AA
Formulas from WIC
• We appreciate your perseverance in
teaching safe feeding practices and good
nutrition.
• Monitor bottles for cleanliness and safety
• Constipation may be from low fluid intake,
especially in very young, sleepy infants