Download - Nutrition Intervention_what's Available
Siti Hawa Mohd Taib
Clinical Dietitian
UM Medical Centre
Nutritional Intervention In
Children – What’s Available?
2010 1
Infant formulas
Pediatric Formulas
Nutrient Modified Formulas
Modular Formulas2010 2
Ou
tlin
e
2010 3
Pat
ien
t F
acto
r • Age
• Diagnosis
• Associated nutritional problems
• Nutritional requirements
• Gastrointestinal function
Fo
rmu
la F
acto
r • Osmolality
• Renal solute load
• Caloric density and viscosity
• Nutrient composition
• Type and amount of carbohydrate, fat and protein
• Product availability and cost
GUIDELINES FOR FORMULA
SELECTION
2010
Sta
nd
ard
Infa
nt
form
ula
s Contain lactose with intact protein
With iron (varies)
• Iron-fortified cow’s milk-based infant formula is the most appropriate milk feeding from birth to 12 months for infants who are not breastfed or who are partially breastfed. AAP(1999)
Economy vs. premium vs. super premium
Calories:
• 0.67 kcal/mL (20 kcal/oz)
Protein:
• 1.2 – 1.7 g/100mL4
2010 5
Pre
mat
ure
form
ula
F
orm
ula
s Higher in nutrients – protein, calcium, phosphorus, and some vitamins
Contains MCTs
Lower lactose
Calories
• 24 kcal/oz (0.8 kcal/ml)
Protein
• 2.0 – 2.4 g/100mL
Enfalac A+ Premature, PreNAN, Mamex Gold Premature, Similac Special Care (RTF)
Post-discharge formula
• Calories
• 22 kcal/oz (0.72 kcal/ml)
• Protein
• 1.9 g/100mL
• Similac NeoSure
Associated with higher weights and lengths when compared with preterm infants fed term formulas
• Lucas (2001)
2010 6
Human Milk Fortification
Hu
man
Milk
Fo
rtif
ier
(H
MF
) Similac HMF
S26/SMA HMF
Started when enteral feeding reach 100-150mL/kg/day
Rec
om
men
ded
for: Infants ≤1500 g at
birth
Infants ≤34 weeks gestation
Selected infants >1500 g at birth based on:
• High acuity
• A total of >2 weeks on PN
• Suboptimal growth
• Limited ability to tolerate adequate volume
2010 7
Groh-Wargo S, Sapsford A. Enteral Nutrition Support of the Preterm Infants in the NICU. Nutrition in Clinical Practice. 2009;24(3): 363-376
So
y-b
ased
fo
rmu
las
•Lactose-free, Soy protein isolate
•Indications:
• Should be limited to infants with galactosemia or congenital lactase deficiency (Bhatia,2008)
• Strict vegan
•Not recommended for low birth-weight preterm infants (ESPGHAN, 2005)
• Slower gains in weight and length
• Reduced bone mineralization in preterm <1800 g
•Examples:
• Isomil Advance• Nursoy• Enfalac A+ Soya (sucrose-free)
• Mamex GOLD Soya 1 (sucrose-free)2010
8
2010
9
9
Milk-based and lactose-free formula
Lactose intolerance
Similac LF,
Enfalac A+ LF
Morinaga NL33
Dulac FL
Mamex Gold LF
Nan AL110
• Soy and lactose-free formulas shorten the course of diarrhea, but do not change overall recovery or weight 2 weeks after illness
• Most infants can safely continue breast milk or standard formula during diarrheal illnesses (Sandhu, 1997)
• At-risk infants might benefit from a switch to lactose-free formula following AGE (Heyman,2006)
• Younger than 3 months or
• Who are malnourish
Lactose-free Formulas
2010 10
• Added thickener
• rice starch/corn starch/carob bean gum
• Gastroesophageal reflux
• Enfalac A+ AR, Novalac AR, FrisolacComfort, Mamex Gold AR
Milk-based formula
with added thickener
2010 11
An
ti R
eflu
x F
orm
ula
s Anti reflux formulas reduce daily emesis and regurgitation in infants but have not been shown to improve growth and development
More convenient
Do not require enlargement of nipple holes
Cer
eal t
hic
ken
ed fo
rmu
la Significantly more efficacious than postural therapy in decreasing the frequency of regurgitation
Results in an increased caloric intake related to increased gain in weight and length in comparison with regular formula and positioning therapy
• (Chao & Vandenplas, 2007)
May clog feeding tube
2010 12
Formula with partially hydrolyzed protein
• Partially hydrolyzed infant formulas are not hypoallergenic and should not be used to treat infants with documented allergies. AAP(2000)
• Allergy prevention – to reduce the risk of cow’s milk protein allergy
• Nan HA Pro, Enfalac HA, Mamex Gold HA
2010 13
2010
14
14
Exte
nsiv
ely
H
ydro
lyzed
Pro
tein
s Peptides and amino acids
Partial MCT content
Pregestimil, Alimentum
Calories: 20 kcal/oz (0.67 kcal/ml)
Hypoallergenic formula is effective for the treatment of milk protein allergy and the prevention of atopic disease
Other indications:
• Chronic diarrhea, chronic liver disease, short bowel syndrome
2010 15
An amino acid based diet should be considered as priority for the nutrition management of the unresponsive and severe cases of persistent diarrhea
Mattos A et al (2004) Randomized, double blinded clinical trial to evaluate the efficacy of 4 different plan on the nutrition management of children with persistent diarrhea
• Protein in form of amino acids
•Severe cow’s milk protein intolerance, chronic diarrhea
•Neocate, Comidagen
• Calories: 0.71 kcal/ml
Elemental Formula
Other Formulas
2010 1616
Novalac IT
• constipation
Novalac AC & Bebelac EC
• Colic
Novalac AD
• Acute diarrhea
Formula Comparison
ProductsPregestimil Alimentum Isomil
AdvanceNeocate Similac
NeoSure
Energy (kcal/ml) 0.67 0.67 0.68 0.71 0.72
% Energy
CHO
Fat
Protein
39
50
11
41
48
11
40.6
48.8
10.6
45
44
11
41
49
10
% Fat calories from MCT Oil
50 33 nil 5 25
2010 17
2010
18
18
Complete Pediatric Formula
• Lactose-free, not indicated for galactosemia
• Calories: 1 kcal/ml
• Examples:
•PediaSure
•(RTU/powder)
•PediaSure Complete•[chocolate/vanilla]
•Nutren Junior
2010 1919
Soy b
ased
form
ula •Lactose-free, suitable
for galactosemia
•Examples
•Isomil Plus
•Mamex Gold Soya 2
2010
20
20
Peptide-b
ased
Form
ula • Peptamen Junior
• Vanilla flavored
• Calories: 1 kcal/ml
• High in MCT
• Indications
• Fat malabsorption
• Short bowel syndrome
2010 21
Ele
men
tal F
orm
ula Complete nutrition with
amino-acid based formula
• 1 year and above
Indications
• Ongoing management of cow’s milk protein allergy
• Short bowel syndrome
• Chronic diarrhea
Examples
• Neocate Advance
• Comidagen Plus
21
2010 22
Generaid Plus
• Formula supplemented with branched chain amino acids (BCAA)
• For 1 year and above
• Indication
• Dietary managment of hepatic disease
• Cholestatic liver disease
• Calories – 1 kcal/ml (standard dilution)
• Protein – 2.4g/100 mL
Formula Comparison
Products
Peptamen Junior
Generaid Plus
NutrenJunior
PediaSure Isomil Plus
Energy (kcal/ml)
1.0 1.0 1.0 1.0 0.69
% Energy CHOFatProtein
553312
53.5379.5
533512
434512
474013
% Fat calories from MCT Oil
60 35 20 20 nil
% BCAA from protein
322010 23
Nutrient Modified Formulas
Protein
Fat
Carbohydrate
201024
Met
abo
lic F
orm
ula
s For disorders of amino acid metabolism such as PKU, MSUD, tyrosinemia, or other metabolic disorders
Formulated without the primary offending amino acid(s) for the specific disorders
Not intended to be fed as sole source of nutrition
When heated can cause maillardreactions
• Causes loss of some sugars and amino acids
• Medical foods should not be heated beyond 130°F (54°C)
20102525
Metabolic Formulas
201026
PKU Idiopathic Hypercalcemia
Idiopathic Hypercalcemia
GlutaricAciduriaType 1
IsovalericAcidemia
MSUD MSUD Organic Acidemia
Protein-free Formula
2010 2727
A protein-free formula with additional energy, vitamins, minerals and trace elements
For dietary management of infants and children who require a protein restricted diet
• Metabolic cases
May also be used as modular feed
Fat-free Formula
28
Bas
ic-f • Extremely low in fat
• For dietary management disorders of fat metabolism, chylothorax and inborn errors of ß-oxidation
• Calories – 49 kcal/100 mL
• Protein – 1.8 g/100 mL
2010
201029
Fru
cto
se-b
ased
F
orm
ula • Galactomin 19
• Infant formula containing cow’s milk protein with carbohydrate source as fructose
• Has minimal lactose, galactose and glucose
• Indication: Glucose-galactosemalabsorption
• Very expensive
29
Lo
w C
arb
oh
ydra
te
Fo
rmu
la • To administer classic (4:1) Ketogenic Diet
• For children over 1 year of age
• Energy distribution• Fat 90%
• Carbohydrate 1.6%
• Protein 8.4%
2010 30
2010 31
Car
bo
hyd
rate
-fr
ee F
orm
ula Example:
• Basic-ch
• RCF (Ross Carbohydrate-Free )
Indications:
• Carbohydrate intolerance/malabsorption
• Glucose-galactose malabsorption
• Ketogenic diet
31
2010
32
• Carbohydrate and Fat Free Formula
• Protein base in the preparation of liquid diets that requires restriction of fat and carbohydrate intake
• Type of carbohydrate and fat can be added according to needs and tolerance
• Examples:
• Chylothorax
• Glucose-galactose malabsorption
• Protein source: casein
ProViMin
(Protein-vitamin-mineral formula component with iron)
Modular supplements
Carbohydrate
Fat
Protein
201033
20103434
• May be added for infants with increased nutrient needs
Modular supplements
• May be used to increase caloric intake
Modules in the forms of carbohydrate and fat
2010
35
35
Glu
cose
poly
mers
Less osmotic effect on the gut compared to monosaccharides
Indication:
• when fluid intake is restricted (cardiac, renal disease)
Calories: 3.8 kcal/g
Mixes well with formula
Low mineral and electrolyte contents
Side effect: osmotic diarrhea
Examples:
• PolyCose®
• CarborieTM
Fat
Supple
ment •MCT Oil
• Higher osmotic effect
• Supplement for fat malabsorption
• Calories - 7.7 kcal/ml (8.3 kcal/g)
• Average dose: 2.5 – 4.0 g/kg/day
• Side effects:
•Osmotic diarrhea, abdominal cramps, nausea, vomiting
• Examples:
•Enersos MCT Oil
•Essential MCT Oil
201036
36
201037
Pro
tein
Su
pp
lem
ents • Added to
provide a specific amount of protein
• Whole protein
• Branched Chain Amino Acids (BCAA)
Exa
mp
les • Myotein
(Valens)
• Whey protein
• Falkamin (Dr Falk)
• BCAA
37
201038
Use with caution
• CHO and fat supplements do not increase renal solute load
• Protein supplements will increase renal solute load
Increments are best tolerated when advanced gradually (2 – 4 kcal/oz/day)
If abnormal stools occur, then the amount of CHO or fat added should be reduced
Recommended calorie distribution ≤ 2 years of age:
• Protein: 10 – 20%
• Fat: 35 – 60%
• Carbohydrate: 35 – 55%
Choosing a formula...
Factors to consider – Individual needs
• Age
• Medical diagnosis
• Route of administration
Can be a critical adjunct to the medical management of certain diseases in infants and children
2010 39