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Formulas in the NICU. Yvonne Sarson, MS, RD, CNSD. Objectives. NICU nurse will be able to- Recognize the appropriate formula for his/her baby Identify key differences between infant formulas Identify babies who need routine vitamin and mineral supplements . Nutrition Standards & Goals.

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formulas in the nicu

Formulas in the NICU

Yvonne Sarson, MS, RD, CNSD

objectives
Objectives

NICU nurse will be able to-

Recognize the appropriate formula for his/her baby

Identify key differences between infant formulas

Identify babies who need routine vitamin and mineral supplements

nutritional standards
Nutritional Standards
  • Standard for determining nutritional needs -
    • for term infants - human breast milk
    • for preterm infants - growth rate that mimics in utero growth
  • Adequacy of growth compared to standards – growth charts
    • Birth weight charts – Babson, Fenton
    • Growth charts - WHO
fluid and nutrition needs term
Fluid and Nutrition Needs - Term

RDA for calories for term infant = 108 kcal/kg/day,

20 cal/oz breast milk has 68 kcal/100 ml,

How much milk does the baby need to meet RDA? x ml/kg/day = 108 kcal ÷ 68 kcal X 100 ml = 160 ml/kg/day

formula ingredient primer
Formula Ingredient Primer
  • Carbohydrates
  • Proteins
  • Fats
    • DHA
    • ARA
  • Prebiotics vs Probiotics
carbohydrates
Carbohydrates

Polysaccharides –

  • Starch and glucose polymers- from tapioca starch or cornstarchhydrolysis of carbohydrate polymers (cornstarch) by treatment with acid and then enzymes
    • Cornstarch (complex)
    • Maltodextrin
    • Corn syrup solids
    • Glucose polymers (or hydrolyzed cornstarch)

Oligosaccharides – in breast milk (prebiotic effect)

  • Influence microflora
  • Alter bacterial adhesion
carbohydrates cont
Carbohydrates (cont.)

Disaccharides –

  • Lactose (glucose + galactose)
  • Maltose (glucose + glucose)
  • Sucrose (glucose + fructose)

Monosaccharides –

  • Glucose
  • Galactose
  • Fructose
protein sources
Protein sources

Intact proteins

  • Cow’s milk sources – milk protein concentrate, nonfat milk,
    • Whey (whey protein isolate or concentrate)
    • Casein
  • Soy – soy protein isolate

Protein hydrolysates – partially vs extensively

  • Casein hydrolysates
  • Whey protein hydrolysates

Amino acids

fats of significance
Fats of significance

Medium chain triglycerides (6-12 carbon chain length) –

  • ~12% of total fatty acids in human breast milk
  • Added to all preterm formulas and some term formulas

Long-chain triglycerides (>12 carbon chain length)

  • Essential fatty acids (EFA) (18 carbon chain length); 4-5% of Kcal as EFA to prevent deficiency.
    • Linoleic acid – 18: 2n6
    • Alpha-linolenic acid – 18: 3n3
  • Long Chain Polyunsaturated Fatty Acids
    • ARA (Arachadonic acid) – 20: 4n6; source is M. alpina Oil
    • DHA (Docosohexanoic acid)- 22: 6n3;source is C. cohnii Oil,
prebiotics vs probiotics
Prebiotics vs Probiotics

Probiotics –

  • Live microorganisms which when administered in adequate amounts confer a health benefit on the host. (WHO def.)

Prebiotics –

  • Non-viable food substances that stimulate the growth or activity of microbial flora (microbiota) in the digestive system which are beneficial to the health of the body.
  • Most common now are non-digestible carbohydrates inulin, galacto-oligosaccharides and fructo-oligosaccharides
human breast milk
Human Breast Milk

Gold standard for modeling term infant formulas

Preferred source of enteral nutrition for all infants, including premature and sick newborns

  • Contraindications- galactosemia, congenital lactase deficiency, maternal HIV or use of some medications

Protein – whey:casein ratio-

  • early milk – 90:10 vs. mature milk – 60:40

CHO – lactose (40% of energy content)

Fat – (40-50% of energy content); ~ 12% of fatty acids are medium chain

human milk fortification
Human Milk Fortification

Commercial human milk fortifiers – cow’s milk based

  • for infants <34 weeks or <1500-1800 gm at birth until ~2.5 kg.
  • Higher calorie preparations or use in larger infants can provide excessive protein, fat-soluble vitamins & minerals
  • Available as powders
    • designed to increase to 22-24 cal/oz,
    • iron content varies
    • Ex. - Similac or Enfamil Human Milk Fortifier

Commercial human milk fortifier – human milk based (Prolacta)

  • Targeted for <1250 gm @ birth, for first 2 months of life
  • Nutritionally comparable to Similac Human Milk Fortifier (low iron)
  • Available as liquid – 4 different formulations designed to increase caloric density from 24 cal/oz – 30 cal/oz in 2 cal/oz increments

Other powdered formulas and modular supplements may be used to fortify human milk for term infants or growing premature infants

major formula brands
Major Formula Brands

Enfamil (Mead Johnson Nutrition)

  • Higher levels of DHA & ARA supplementation than Abbott; now market standard with exception of Abbott

Similac (Abbott Nutrition)

Nestle Good Start (Nestle Nutrition)

  • All infant cow’s milk protein formulas contain only partially hydrolyzed whey protein as protein source (`5 formulas)

Bright Beginnings (PBM Nutritionals)

  • PBM also manufactures store brand infant formulas (`5 formulas)
standard infant formulas
Standard Infant Formulas

Protein –

  • Source – cow’s milk
  • Whey:casein ratio- 60:40 – 70:30, except Good Start (100% partially hydrolyzed whey)

CHO – Source-lactose

Fat –

  • Source – variety of vegetable & tropical oils, DHA, ARA

Examples –

  • Enfamil Lipil, Nestle Good Start Gentle Plus, Nestle Good Start Nourish Plus*, Similac Advance or Advance EarlyShield, Bright Beginnings Milk *no DHA/ARA
premature formulas
Premature Formulas

Protein -

  • Source – cow’s milk protein – whey protein concentrate and non-fat milk
  • Whey:casein ratio- 60:40

CHO -

  • Source-lactose & glucose polymers or corn syrup solids

Fat –

  • Source – MCT, soy & coconut oils or,high-oleic sunflower and safflower, DHA, ARA

Vitamins & Minerals – higher fat-soluble vitamins esp. A & D, Ca & PO4

Indications – BW < 1800 gm & prematurity until hospital d/c or wt. ~ 2.7 kg.

Examples –

  • Enfamil Premature Lipil, Similac Special Care Advance, Nestle Good Start Premature 24
premature follow up formulas
Premature Follow-up Formulas

Protein –

  • Source – cow’s milk protein – whey protein concentrate and non-fat milk
  • Whey:casein ratio- 50:50 to 60:40

CHO –

  • Source-lactose & glucose polymers or corn syrup solids

Fat –

  • Source – MCT, soy & coconut oils, DHA, ARA

Indications – BW < 1800 gm until corrected age of 9 mos.

Examples –

  • Enfamil Enfacare Lipil, Similac Neosure Advance, Bright Beginnings Neocare
lactose free cow s milk formula
Lactose-free cow’s milk formula

CHO – Source- corn syrup solids; corn maltodextrin and sucrose (in Similac products) Lactose-free

Indication –

secondary lactase deficiency as after course of antibiotics

carbohydrate malabsorption after colectomy

Congenital lactase deficiency (exceedingly rare disease occurring in Finland

Examples -

Enfamil Lacto-free,

Similac Sensitive & Similac Sensitive R.S.

Bright Beginnings Lactose-free

(All soy, elemental & semi-elemental formulas are also lactose-free)

term formulas with prebiotics
Term formulas with Prebiotics

Oligosaccharides (def.) –

complex carbohydrates naturally occurring in human milk

stimulate the growth of beneficial bacteria

support mucosal immune function

Galacto-Oligosaccharides

Early Shield (Similac), Premium (Enfamil)

term formulas with probiotics
Term formulas with Probiotics

Examples

Good Start Protect Plus Bifidobacterium lactis

Enfamil Nutramigen Lipil with Enflora LGG–Lactobacillus rhamnosus GG (LGG)

cow s milk formulas with rice starch
Cow’s Milk Formulas with rice starch

Added rice starch

Indications- formulas with rice starch added to provide nutritionally balanced feedings where providers would add rice cereal (not suitable for oral dysphagia)

Examples -

Enfamil AR,

Similac Sensitive RS

Enfamil Restfull

cow s milk low mineral
Cow’s Milk – low mineral

Low mineral -

  • Indications- hypocalcemia or renal failure with hyperkalemia and hyperphosphatemia
  • Similac PM 60/40
cow s milk formulas low lct
Cow’s Milk Formulas – Low LCT

Low long chain fat – (High protein)

  • Indications- Chylothorax
  • Examples-
    • Portagen- powdered form, not marketed for infants,
      • 4.7 gm fat/100 cal with 87% MCT
      • 3.1% of calories as linoleic acid, trace alpha-linolenic acid
    • Enfaport- liquid form (30 cal/oz as packaged),
      • 5.4 gm fat/100 cal with 84% MCT
      • 3.2% of calories as linoleic acid,0.5% of calories as alpha-linolenic acid
partially hydrolyzed protein
Partially hydrolyzed protein
  • Protein –
    • Cow’s milk protein molecules partially broken down, but not as small peptide chains as semi-elemental hydrolyed
  • Indications – marketed as easier to digest
  • Examples -
    • Nestle Good Start Gentle Plus, Protect Plus, Nourish Plus,
    • Enfamil Gentlease
    • Bright Beginnings Gentle
partially hydrolyzed protein40
Partially hydrolyzed protein
  • Protein –
    • Cow’s milk protein molecules partially broken down, but not as small peptide chains as semi-elemental hydrolyed
  • Indications – marketed as easier to digest
  • Examples -
    • Nestle Good Start Gentle Plus, Protect Plus, Nourish Plus,
    • Enfamil Gentlease
    • Bright Beginnings Gentle
soy formula
Soy formula

Protein- soy

CHO – lactose-free

contraindicated in premature infants due to

phytate content,

lower protein bioavailability

aluminum content

Indication – term infant with galactosemia, vegetarian diet

elemental and semi elemental formulas
Elemental and Semi-elemental Formulas

Protein –

  • slightly higher protein content than standard formulas
  • Source – casein hydrolysates and/or L- amino acids

CHO –

  • Source- sucrose, modified tapioca starch, corn syrup solids, or modified cornstarch

Fat –

  • Source – MCT, variety of vegetable and tropical oils

Indications – protein sensitivity and/or malabsorption

semi elemental formulas
Semi-elemental Formulas

Extensively hydrolyzed proteins

Enfamil Nutramigen Lipil (no MCT)

Enfamil Pregestimil Lipil,

Enfamil Product 3232A (for CHO malabsorption, needs added CHO source)

Similac Alimentum Advance

elemental formulas
Elemental Formulas

Amino acids

Neocate (SHS)

Elecare (Abbott)

Nutramigen AA (Enfamil)

increased caloric density formulas
Increased Caloric Density Formulas

Less water to powder

  • increases nutrient intakes

Additives

  • may decrease other nutrient intakes
modular additives
Modular Additives

Protein -

Beneprotein – 1.3 gm protein/tsp

Carbohydrates -

Polycose - 8 kcal/ tsp

Rice cereal – 4 kcal/tsp

Karo syrup - 4 kcal/cc but not under 6 months old

Fat -

Corn or safflower oil - 8 kcal/ml

MCT oil - 7.7 kcal/ml

Microlipid (safflower oil emulsion)- 4.5 kcal/ml

vitamin d needs at nicu discharge
Vitamin D needs at NICU discharge
  • Poly-vi-sol drops, 400 units Vitamin D per 1 ml
  • Enfamil D-Vi-Sol Vitamin D (D3) Supplement Drops, 400 units per 1 ml (50 ml bottle costs ~$11)
term infants additional supplements
Term Infants – Additional supplements

Healthy

  • Breast fed
    • Iron after 4-6 months (usually enriched cereal)
    • Fluoride after 6 months
  • Formula fed – depending on intake

Chronic diseases

  • Multivitamin for chronic intake < 500 kcal/day
  • Seizures treated with phenobarbital – extra Vitamin D
  • Abnormal GI losses– ?need for zinc, copper, fat-soluble vitamins and electrolytes
preterm infants stable growing
Preterm Infants – Stable, Growing

No daily multivitamin mineral supplements -

  • premies on preterm formulas or human milk fortifiers

Ex-premies on transitional/premature discharge formulas <4.2 kg

If standard term infant formula or breast milk – multivitamins, folic acid, calcium, phosphorus, and zinc may be needed

Need for iron supplements depends on milk & presence of anemia

bone meds
Bone meds

Prevent need with optimal nutrition throughout NICU stay

Refer to Calcium and phosphorus supplements used to treat osteopenia

Target intake –

  • 200 mg elemental calcium/kg/day
  • 115 mg elemental phosphorus/kg/day

Doses must be staggered to prevent formation of calcium-phosphorus precipitates

iron supplements
Iron supplements

Iron source -

  • Formulas provide ~ 2 mg/kg/day elemental iron per 160 ml/kg/day
  • Growing, preterm infants @ 1-2 months or 2X BW.
  • Healthy, term infants @ 4-6 months
  • Dose (elemental iron) -
    • Preterm = 4-6 mg/kg/day
    • Term = 2 mg/kg/day
    • Max= 15 mg/day of supplemental iron
formula handling
Formula handling

Enterobacter sakazakii - meningitis resulting in death linked to formula contamination; especially a concern with of cow’s milk protein formulas mixed from powder

tube feeding breastmilk
Tube feeding breastmilk

Syringe pump vs kangaroo bag

Home on continuous breastmilk feedings? Evaluation growth with Kangaroo pump vs obtain appropriate pump – Zevex Infinity Orange

sucrose containing formulas
Sucrose containing formulas

Fructose absorption –not fully matured in young infant

  • Fruit juice malabsorption is dose dependent
  • Symptomatic malabsorption above 10 ml/kg/day

Sucrose disaccharide (glucose+fructose)

  • Fructose content may be excessive for young infant if this is sole nutrition source (malabsorption/diarrhea

Infant formulas containing sucrose

  • Similac Alimentum – 2.2 gm/100 ml
  • Similac Organic – 1 gm/100 ml
  • Similac Sensitive – 3.3 gm/100 ml
  • Similac Sensitive R.S. – 1.4 gm/100 ml
  • Portagen – 2.9 gm/100 ml