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Formulas in the NICU

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

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  1. Formulas in the NICU Yvonne Sarson, MS, RD, CNSD

  2. 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

  3. Nutrition Standards & Goals

  4. 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

  5. Nutrition Goals

  6. Energy needs

  7. 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

  8. Fluids to meet nutritional needs- enteral nutrition

  9. Comparison of nutrient concentrations of parenteral & enteral fluids

  10. Formula Ingredient Primer • Carbohydrates • Proteins • Fats • DHA • ARA • Prebiotics vs Probiotics

  11. 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

  12. Carbohydrates (cont.) Disaccharides – • Lactose (glucose + galactose) • Maltose (glucose + glucose) • Sucrose (glucose + fructose) Monosaccharides – • Glucose • Galactose • Fructose

  13. 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

  14. 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,

  15. DHA and ARA

  16. 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

  17. Composition of Breast Milk and Formulas

  18. 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

  19. 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

  20. 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)

  21. 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

  22. 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

  23. 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

  24. 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)

  25. 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)

  26. Term formulas with Probiotics Examples Good Start Protect Plus Bifidobacterium lactis Enfamil Nutramigen Lipil with Enflora LGG–Lactobacillus rhamnosus GG (LGG)

  27. 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

  28. Cow’s Milk – low mineral Low mineral - • Indications- hypocalcemia or renal failure with hyperkalemia and hyperphosphatemia • Similac PM 60/40

  29. 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

  30. 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

  31. 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

  32. 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

  33. 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

  34. 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

  35. Elemental Formulas Amino acids Neocate (SHS) Elecare (Abbott) Nutramigen AA (Enfamil)

  36. Increased Caloric Density Formulas Less water to powder • increases nutrient intakes Additives • may decrease other nutrient intakes

  37. 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

  38. Dietary Supplementation

  39. 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)

  40. 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

  41. 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

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