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Intervention In
Children – What’s
Available?
Siti Hawa Mohd Taib
Clinical Dietitian
UM Medical Centre
2010 1
Outline
Infant formulas
Pediatric Formulas
Modular Formulas
2010 2
GUIDELINES FOR FORMULA
SELECTION
Formula Factor
Patient Factor
• Age • Osmolality
• Diagnosis • Renal solute load
• Associated nutritional • Caloric density and
problems viscosity
• Nutritional • Nutrient composition
requirements • Type and amount of
• Gastrointestinal carbohydrate, fat
function and protein
• Product availability
and cost
2010 3
Contain lactose with intact
formulas
Standard Infant
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/100mL
2010 4
Higher in nutrients – protein,
Formulas
Premature formula
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)
2010 5
Post-discharge formula
• Calories
• 22 kcal/oz (0.72 kcal/ml)
• Protein
• 1.9 g/100mL
• Similac NeoSure
2010 6
Human Milk Fortification
Recommended for:
Human Milk Fortifier (HMF) Similac HMF Infants ≤1500 g at
S26/SMA HMF birth
Started when enteral Infants ≤34 weeks
feeding reach 100- gestation
150mL/kg/day Selected infants
>1500 g at birth based
Groh-Wargo S, on:
Sapsford A.
Enteral Nutrition • High acuity
Support of the
Preterm Infants in • A total of >2 weeks on PN
the NICU. • Suboptimal growth
Nutrition in Clinical
Practice. • Limited ability to tolerate
2009;24(3): 363- adequate volume
376
2010 7
•Lactose-free, Soy protein isolate
•Indications:
Soy-based formulas
2010
9
9
Lactose-free Formulas
2010 10
Milk-based • Added thickener
formula • rice starch/corn starch/carob bean gum
• Gastroesophageal reflux
with added • Enfalac A+ AR, Novalac AR, Frisolac
Comfort, Mamex Gold AR
thickener
2010 11
Anti reflux formulas Significantly more
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
Peptides and amino acids
Hydrolyzed
Proteins
Extensively
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
14
14
• Protein in form of amino acids
• Severe cow’s milk protein
intolerance, chronic diarrhea
• Neocate, Comidagen
• Calories: 0.71 kcal/ml
Elemental
Formula
Novalac AD
• Acute diarrhea
2010 16
16
Formula Comparison
Products
Pregestimil Alimentum Isomil Neocate Similac
Advance NeoSure
Energy (kcal/ml) 0.67 0.67 0.68 0.71 0.72
% Energy
CHO 39 41 40.6 45 41
Fat 50 48 48.8 44 49
Protein 11 11 10.6 11 10
2010 17
Complete Pediatric Formula
• Lactose-free, not indicated for galactosemia
• Calories: 1 kcal/ml
• Examples:
• PediaSure
•(RTU/powder)
• PediaSure Complete
•[chocolate/vanilla]
•Nutren Junior
2010
18
18
• Lactose-free, suitable
Soy based
formula
for galactosemia
• Examples
• Isomil Plus
• Mamex Gold Soya 2
2010 19
19
• Peptamen Junior
Peptide-based
Formula
• Vanilla flavored
• Calories: 1 kcal/ml
• High in MCT
• Indications
• Fat malabsorption
• Short bowel syndrome
2010
20
20
Elemental Formula 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
2010 21
21
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
2010 22
Formula Comparison
Products
Peptamen Generaid Nutren PediaSure Isomil
Junior Plus Junior Plus
Energy 1.0 1.0 1.0 1.0 0.69
(kcal/ml)
% Energy
CHO 55 53.5 53 43 47
Fat 33 37 35 45 40
Protein 12 9.5 12 12 13
% Fat calories 60 35 20 20 nil
from MCT Oil
% BCAA from
2010
32 23
protein
Protein
Fat
Carbohydrate
2010
24
For disorders of amino acid metabolism
Metabolic Formulas
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 maillard
reactions
• Causes loss of some sugars and amino acids
• Medical foods should not be heated beyond 130°F
(54°C)
2010
25 25
Metabolic Formulas
2010
26
Protein-free Formula
A protein-free formula with
additional energy, vitamins,
minerals and trace elements
2010 27
27
Basic-f Fat-free Formula
2010 28
Fructose-based
Formula
• Galactomin 19
• Infant formula containing cow’s milk
protein with carbohydrate source as
fructose
• Has minimal lactose, galactose and glucose
• Indication: Glucose-galactose
malabsorption
• Very expensive
2010 29 29
Low Carbohydrate
Formula
2010 30
Example:
Carbohydrate-
free Formula
• Basic-ch
• RCF (Ross Carbohydrate-Free )
Indications:
• Carbohydrate intolerance/malabsorption
• Glucose-galactose malabsorption
• Ketogenic diet
2010 31
31
ProViMin
(Protein-vitamin-mineral formula component with
iron)
2010
33
Modular supplements
2010
35
35
•MCT Oil
Supplement
Fat
2010
36
36
Protein Supplements
Examples
• Added to • Myotein
provide a (Valens)
specific • Whey
amount of protein
protein • Falkamin (Dr
• Whole protein Falk)
• Branched • BCAA
Chain Amino
Acids (BCAA)
2010
37 37
Use with caution
If abnormal stools occur, then the amount of CHO or fat added should
be reduced
• Protein: 10 – 20%
• Fat: 35 – 60%
2010
• Carbohydrate: 35 – 55%
38
Choosing a formula...
• Age
• Medical diagnosis
• Route of administration
2010 39