Special FormulasWho When Where Why and How Margo

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 p. H 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 • • • 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 1. 5 Kid Essentials Kid Essential 1. 5 Carnation Breakfast Essentials RATIONALE Standard oral or tube feeding supplement Pediasure comes in 30 and 45 kcal/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 8 oz 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 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