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