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

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

• Margo Humenczuk MBA, RD, CSP, LD
• The Magic of WIC
• October 23, 2012

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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

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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

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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

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Standard Cows 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.

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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.

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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

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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.
• 85of those children sensitive to milk formula
  will develop poor tolerance to soy.
• Much less expensive than hydrolyzed formula

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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.

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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.

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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
  kcalories-avoids 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

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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.

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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.

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Elemental formulas

• Taste and smell bad
• Can be more difficult to mix
• Not usually available on store shelves.
• Very high osmolality
• Short hang times

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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)

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Renal

• Similac PM 60/40 reduced Phosphorus, calcium and
  potassium, often used in combination with other
  formulas to just meet DRI of minerals.

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Pediatric Formulas for Children
FEEDING RATIONALE AVAILABILITY
Nutren Jr, Pediasure, Pediasure 1.5 Kid Essentials Kid Essential 1.5 Carnation Breakfast Essentials 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 Retail Pediasure, Kid Essentials Carnation Breakfast Essentials-need to mix with milk Nutren Jr (may be ordered from pharmacy at grocery store.
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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.

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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

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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

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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.

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Blended Foods via G-tube

• Good program at Cincinnati Childrens
  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 isnt.
• Avoid high nutrient supplements.

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Blended Diet via G-tube

• Very labor intensive
• Bacterial contamination more likely than in
  commercial product.
• Fluid content may be difficult to determine.

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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.

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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.

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Renal Formulas

• Renal Formulas appropriate for children
• Suplena, Nepro

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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 dont count as
  adequate nutrition, use some Pediasure in the
  interim as needed.

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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
  cows milk.

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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

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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