Infant Formulas, Diaper Rash, Prickly Heat

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Infant Formulas, Diaper Rash, Prickly Heat

• Mahshid Roayaee, Pharm.D.
• Nutrition Support Pharmacist
• Childrens Mercy Hospital
• mroayaee_at_cmh.edu
• 816-234-3089

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Objectives

• Learn infant nutritional,fluid and growth
  requirements
• List advantages/disadvantages of breast-feeding
• Differentiate between lactose intolerance and
  milk-allergy
• Learn various types of infant formulas
• In depth understanding of product selection
• Learn about proper management of diarrhea
• Properly counsel patients on formula preparation
  and problems to watch for

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Infant Physiology

• Digestive enzymes
• Full term infants can digest carbohydrates
  (lactase, sucrase, maltase,isomaltase
  glucoamylase)
• Preterms may be deficient in lactase

• Stomach capacity
• Term infant 20-90cc
• Increases to 90-150cc by 1 month
• Frequent small feedings are required (see
  tables 26-14 26-15)

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Growth

• Average birth weight
• Full term baby 3.5 kg
• Pre-term infant 1.5 kg
• Weight gain is usually 25-30 grams per day in 1st
  4 months, 15 grams/day in next 8 months.
• Usually double birth weight by 4 months, and
  triple it by 12 months.

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Nutritional Standards

• RDA for energy needs vary with age
• Infants birth-6 mos 108 kcal/kg/day
• 6 to 12 months 98 kcal/kg/day
• RDA for protein
• Birth to 6 mos 1.52 grams/kg/day
• 6 months to 1 year 1.5 grams/kg/day
• See table 26-1

• Maintenance fluids
• 1-10kg 100cc/kg
• 11-20kg 50cc/kg for each kg over 10
• gt 20kg 20cc/kg for each kg over 20
• 14kg 10kg x100cc/kg 1000cc 4 kg x 50cc/kg
  200cc, total 1200cc/day

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Carbohydrates

• Lactose is primary CHO in human milk and
  milk-based formulas
• Lactose is hydrolyzed to glucose and galactose by
  the enzyme lactase
• Lactose intolerance may occur due to immature
  lactase activity in premature infants
• Manifested as diarrhea, abd. pain,
  distention/bloating, gas and cramping

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Carbohydrates (contd)

• Secondary lactase deficiency is a temporary
  reduction of intestinal lactase caused by
  gastroenteritis or malnutrition
• Congenital lactase deficiency is a rare metabolic
  disorder
• These pts. cannot metabolize the quantity of
  lactose found in breast milk or regular infant
  formulas and may need a lactose-free formula

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Benefits of Breast-feeding

• Promotes mother-child bonding
• Shortens post-partum recovery time
• Less expensive than formulas
• Less time spent in preparation

• Protects against GI and respiratory infections
• Fewer episodes of diarrhea
• Lower incidence of otitis media

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Potential Problemswith Breast-feeding

• HIV AAP recommends that women who are HIV
  should not breast-feed nor donate breast milk
  since the virus can be transmitted in breast milk

• Medications
• Low-dose combo. and progesterone only oral
  contraceptives are OK
• Other OCPs decrease milk production and/or
  composition

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Reduced-fat Whole Milks

• Whole milk is not recommended in the first year
  of life
• Skim or 2 milk is not recommended during the
  first 2 years of life
• Whole milk has been associated with the
  development of iron-deficiency anemia, due to its
  low concentration and low bioavailability of iron

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Commercial Infant Formulas

• Standard caloric density of infant formulas is 20
  kcal/oz (oz30 ml)
• Directions for diluting concentrated formulas
  (powder or liquid) must be followed exactly to
  prevent hyperosmolar states like diarrhea and
  dehydration

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Types and Selection of Infant Formulas

• Milk-based formulas (e.g. Similac)
• Prepared from nonfat cow milk, vegetable oils and
  added carbohydrate (lactose)
• Vitamins and minerals are added according to the
  RDA guidelines
• Available as iron-fortified OR low-iron
• Lactofree is a milk-based formula that contains
  corn-syrup solids as its CHO rather that lactose,
  thus can be used in infants with lactose
  intolerance

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Types and Selection of Infant Formulas (contd)

• Milk-based formulas with added whey protein (e.g.
  Enfamil)
• Whey is added to nonfat cow milk to increase the
  protein content to that of human milk (60 whey/
  40 casein)
• The high nutritional quality and relatively low
  renal solute load of these formulas is an asset
  in management of ill infants

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Milk based formulas

• Refer to table 26-6
• Nestle Good Start
• Enfamil Lipil Enfamil Lipil with Iron
• Enfamil with Iron
• Similac Advance
• Similac with Iron

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Enfamil AR

• Has 10x more viscosity than ready to feed Enfamil
  with Iron
• Needs acidic stomach pH to get activated
• It is used for babies with acid reflux (GERD)
• H2 antagonists (zantac) and PPIs (Prevacid) will
  decrease the effectiveness of this formula

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Therapeutic Formulas

• Used on an individual basis for infants being
  treated by medical specialists for conditions
  that require dietary adjustment (see Table 26-7)
• Include soy-protein, casein-based, casein or whey
  hydrolysate-based, low-sodium, and formulas for
  specific medical problems, LBW infants, or
  special age groups

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Therapeutic Formulas (contd)

• Soy-protein formulas (e.g. Isomil, ProSobee, Good
  Start Soy)
• These are lactose free and can be used for
• Primary lactase deficiency (galactosemia)
• Secondary lactase deficiency (gastritis/ mucosal
  damage)
• Resumption of milk formula is possible 2-4 weeks
  after cessation of diarrhea

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Cow Milk Protein Allergy

• Cow milk allergy has symptomatology involving the
  respiratory tract (Wheezing), skin (rash), or GI
  tract (Diarrhea, bloody stools) that disappears
  when cow milk is removed
• AAP recommends the use of protein hydrolysate
  formulas rather than soy-protein formulas b/c
  15-50 of infants can be sensitive to the
  soy-protein as well as milk protein
• However, protein hydrolysate formulas taste
  horrible, and trying a soy-protein first (with
  close monitoring) may work fine

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Therapeutic Formulas (contd)

• Casein hydrolysate-based formulas (e.g.
  Pregestimil, Nutramigen, Alimentum)
• Effective for use in GI abnormalities that cause
  intolerance and malabsorption of standard forms
  of protein,fat and CHO (Sever diarrhea, Cystic
  fibrosis)
• Can be used for cow-milk allergy

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Therapeutic Formulas (contd)

• Whey hydrolysate-based formulas (e.g.
  Carnation Good Start)
• Used in GI intolerance to Cows Milk
• Whey hydrolysate should NOT be used in pts. with
  documented IgE mediated cow milk allergy
• Pleasant taste,smell and appearance, so may be
  better tolerated than casein hydrolysate

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Therapeutic Formulas (contd)

• Amino-acid based formulas (e.g.Neocate)
• For those infants who are intolerant to
  casein-hydrolysate formulas
• Used in Cows Milk allergy, Multiple protein
  intolerances
• High MCT Formula (Portagen)
• Used in patients with pancreatic enzyme
  deficiency (cystic fibrosis) or Biliary tract
  problems (Biliary atresia), or lymphatic
  abnormalities (Chylothorax)

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Therapeutic Formulas (contd)

• Low Birth weight and Preterm formulas (e.g.
  Enfamil premature, Similac Special Care, Similac
  PM 60/40)
• Standard caloric density is 24 kcal/ounce, rather
  than 20kcal/oz with normal formulas
• Protein,CHO, and Fat are present in the most
  tolerable and bioavailable forms
• Ca/phos ratio

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Human Milk Fortifiers

• Enfamil Human Milk Fortifier is a powder that
  adds nutrients to human milk (without displacing
  volume)
• Similac Natural Care is a liquid form
• These increase the caloric content of human milk
• Table 26-9 lists the composition

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Concentrated Formulas

• Used for children with special needs under a MDs
  supervision
• Ready-to-use forms that are available in 24-27
  kcal/oz
• Variations of caloric concentrations are made by
  adding different amounts of water (see Tables
  26-10 and 26-11)
• When these formulas are used monitor the infants
  fluid intake and output, weight and electrolytes
  carefully to prevent hyperosmolar dehydration

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Childrens Formulas (1-10 yrs)

• Designed for young children who cant tolerate
  normal diet or eat solid foods
• Can also be used as a supplement to normal diet
  to increase caloric intake
• PediaSure, PediaSure w/ fiber, and Kindercal are
  examples

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Potential Problems with Infant Formulas

• Diarrhea- infants are particularly susceptible to
  dehydration, and it may occur quickly
• Ascertain the severity duration of diarrhea,
  frequency of stools, and method of preparation of
  formula
• Refer to a MD if its continued more that 48
  hours OR if infant also has fever, lethargy,
  decreased wet diapers and tear production, or
  weight loss

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Diarrhea (Contd)

• Pedialyte can be cautiously used for short-term
  management of fluid and electrolyte losses while
  feedings are held
• Restart feeds at ½ strength for 24 hrs after
  diarrhea has stopped then increase to full
  strength over 48 hours (can not find
• this info in the book)

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Potential Problems with Infant Formulas (contd)

• Tooth Decay
• Can occur in children who are bottle-fed beyond
  the typical weaning period
• Especially prevalent in those who are put to bed
  with bottles after 1 year of age

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Formula Preparation

• The directions on the product container should be
  followed closely!!! (Tables 26-13) Know how to
  prepare standard 20 kcal/oz formula
• Formulas are available in liquid ready-to-use,
  liquid concentrate, and powdered concentrate
• Failure to properly dilute a formula can result
  in a concentrated, hypertonic solution,
  precipitating diarrhea and dehydration
• Overdiluting a formula can lead to water
  intoxication leading to irritability,
  hyponatremia, coma or brain damage
• AAP recommends some sterile technique be used
  during preparation

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Product Selection

• Most normal healthy full-term infants will need a
  milk-based formula or milk-based with added whey
  protein (Similac or Enfamil)
• Recommendations should take into consideration
  method of preparation parents ability to
  follow directions
• Also cost is a big factor, concentrated liquids
  and powders are cheaper than ready-to-use products

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Supplementation

• Breast-fed, full-term infants
• Iron supplement of 2 mg/kg/day elemental iron is
  usually needed after 6 months of age (i.e. after
  neonatal stores become depleted)
• Flouride supplement is needed if child lives in
  area where water is not flouridated to at least
  0.3 ppm (See Table 20-5)
• Vitamin D 400 IU/day is recommended to protect
  from the development of rickets ONLY if mothers
  diet is inadequate in Vitamin D

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Supplementation (contd)

• Formula-fed full-term infants
• No supplements needed before 6 months of age if
  consuming adequate amounts of iron-fortified
  milk-based formula.
• Infants older that 6 months who receives a diet
  of formula,mixed feedings and some table food do
  not require any supplements.
• Flouride (same as breast-fed) ready to use
  formulas are not mixed with flouridated water, so
  if baby doesnt drink any water besides formula,
  may need a supplement

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Supplementation (contd)

• Pre-term infants (breast or formula fed)
• Should receive special formula that contains
  appropriate Calcium, Phos, Vit D.
• Iron supplementation should be started around 2
  months of age, when fetal stores become
  depleted. (elemental iron 2mg/kg/day)
• If started too early iron may induce hemolytic
  anemia due to babys low Vitamin E stores

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QUESTIONS??
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Diaper Rash Objectives

• To understand the etiology of diaper rash and
  prickly heat.
• Learn various complications of diaper rash and
  when to refer to a physician
• To learn the best ways to prevent diaper rash and
  prickly heat
• Understand the various products used to treat
  diaper rash and why
• Be able to counsel parents on proper hygiene,
  treatment and complications of diaper rash.

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Definition of Diaper Rash

• Inflammatory skin condition in diaper area (i.e.
  perineum, buttocks, lower abd., and inner thighs)
• Caused by 1 or more of following factors
• moisture - occlusion - friction
• continued contact w/ urine, feces or both
• mechanical or chemical irritation

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Etiology

• Exposure of skin to urine and feces
• Urine causes skin damage after 10 days of
  continuous exposure, alone no damage for up to 48
  hours
• Feces is a known irritant after any length of
  time
• Moisture Retention
• Soiled diapers cause skin to become waterlogged,
  leading to keratotic plugging and thus irritation

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Etiology (contd)

• Mechanical and Chemical Irritants
• tight fitting and plastic diapers prevent
  adequate air flow and increase moisture retention
• constant rubbing of tight diapers can erode skin
  and increase risk of infection
• harsh soaps, antiseptic wipes, clothing
  detergents can all irritate infant skin

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Complications

• Opportunistic Infections
• 1) Bacterial (staph
• and strep)
• 2) Fungal (Yeast)
• 3) Viral (Herpes)

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Assessment

• Pharmacist plays an important role in determining
  cause, educating parents and preventing
  occurrence!!!!
• See Figure 36-1
• If rash persists 1 week or more after proper
  diaper changing and nonprescription treatment
  refer to MD!!

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Treatment

• Steps in treatment of diaper rash
• remove source of irritation
• reduce immediate skin reaction
• relieve discomfort
• prevent secondary infection and other
  complications

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Treatment (contd)

• Ordinary, mild diaper rash
• responds to very frequent diaper changes, ASAP
  after becoming soiled
• cleansing with plain water to avoid irritating
  chemicals, allow to dry completely before apply
  new diaper
• Application of good protective agent to provide a
  barrier to protect skin from moisture

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Pharmacologic Agents

• Protectants- act as physical barrier to irritants
  and seals out or absorbs moisture
• Zinc Oxide is a mild astringent with weak
  antiseptic properties (Balmex, Desitin)
• Often combined with petrolatum and corn starch as
  Zinc Oxide Paste and is a highly protective and
  water-absorptive base
• Has been proven more effective than white
  petrolatum alone
• Counsel parents that its best removed with
  mineral oil

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Pharmacologic Agents (contd)

• Powdered protectant agents (talc, cornstarch,
  magnesium stearate)
• Talc is a natural magnesium silicate that
  prevents irritation/chafing, absorbs sweat and
  adheres well to the skin
• Never apply to an oozing rash to prevent crusting
  and secondary infection
• Apply powders close to body and away from
• childs face to prevent inhalation!!

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Pharmacologic Agents (contd)

• Topical products that should NOT be used
• External Analgesics - Antimicrobials
• Antifungals - Steroids
• Newborn and infant skin is thin and more delicate
  and thus more susceptible to absorption of
  applied agents that could be toxic.

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Treatment of Secondary Complications

• An Infant with a suspected bacterial or fungal
  infection in the diaper area that has persisted
  for a week or more should be referred to a
  physician!!

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Prevention

• Proper Hygiene in Diaper Area
• Change diaper as soon as its soiled
• Clean area well at each diaper change, esp. skin
  folds
• Use plain water or unscented, hypoallergenic
  soaps and wipes
• Allow area to completely dry before new diaper is
  applied
• Protectant or dusting powder may be used after
  washing

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Disposable vs. Cloth Diapers

• Incidence of Diaper rash is lowest in those who
  use cloth diapers that are professionally
  cleaned. (1,268/year)
• Disposable diapers are similarly low
  (1,352/year)
• Cloth diapers that are laundered at home without
  a bacteriostatic rinse have the highest
  incidence.( 526/year)

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New Improved Disposables

• Many newer diapers contain absorbent gel material
  to control skin wetness
• Improved leakage control and fastening quality
  makes disposables more user friendly
• Still not biodegradable though!

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Prickly Heat

• Lesions can occur anywhere on body and result
  from obstructed sweat gland pores
• Retained sweat causes dilation and rupture of
  pores, thus causing swelling and inflammation of
  skin
• Usually causes stinging and some itching

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Prickly Heat (contd)

• Often occurs during hot, humid weather OR during
  a febrile illness with profuse sweating
• Also occurs with excessive clothing, esp. at
  night in warm, humid rooms
• Lesions are red papules, that may become pustular
  and are localized to the site of occlusion.

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Prickly Heat (contd)

• Treatment is primarily to cool the patient to
  reduce sweating (if fever, give antipyretics)
• Wear light, loose clothing for adequate air
  circulation
• Irritation may be reduced with baths at least
  twice a day with mild soaps followed by a bland
  dusting powder.

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QUESTIONS??