Nutritional

Intervention In
Children – What’s
Available?
Siti Hawa Mohd Taib

Clinical Dietitian

UM Medical Centre

2010 1
 Outline

Infant formulas

Pediatric Formulas

Nutrient Modified 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

Associated with higher weights and

lengths when compared with preterm
infants fed term formulas
• Lucas (2001)

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

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 •Lactose-free, Soy protein isolate
•Indications:
Soy-based formulas

• 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)
2010 • Mamex GOLD Soya 1 (sucrose-free)
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 Milk-based and lactose-free
formula
Similac LF,
Enfalac A+ LF
Lactose Morinaga NL33
intolerance Dulac FL
Mamex Gold LF
Nan AL110

2010
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 Lactose-free Formulas

• 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

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

Cereal thickened formula

Anti Reflux Formulas
reduce daily emesis and efficacious than postural
regurgitation in infants therapy in decreasing the
but have not been shown frequency of
to improve growth and regurgitation
development Results in an increased
More convenient caloric intake related to
Do not require increased gain in weight
enlargement of nipple and length in comparison
holes 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
 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
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 • Protein in form of amino acids
• Severe cow’s milk protein
intolerance, chronic diarrhea
• Neocate, Comidagen
• Calories: 0.71 kcal/ml

Elemental
Formula

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

2010 evaluate the efficacy of 4 different plan on the nutrition management of 15
children with persistent diarrhea
 Other Formulas

Novalac IT Novalac AC &

• constipation Bebelac EC
• Colic

Novalac AD
• Acute diarrhea
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 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

% Fat calories 50 33 nil 5 25

from MCT Oil

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

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 • Lactose-free, suitable
Soy based
formula

for galactosemia
• Examples
• Isomil Plus
• Mamex Gold Soya 2

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 • Peptamen Junior
Peptide-based
Formula

• Vanilla flavored
• Calories: 1 kcal/ml
• High in MCT
• Indications
• Fat malabsorption
• Short bowel syndrome
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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
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 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
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protein
 Protein
Fat
Carbohydrate

Nutrient Modified Formulas

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 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
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 Metabolic Formulas

PKU Idiopathic Idiopathic Glutaric

Hypercalcemia Hypercalcemia AciduriaType 1

Isovaleric MSUD MSUD Organic

Acidemia Acidemia

2010
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 Protein-free Formula
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

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 Basic-f Fat-free Formula

• 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 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

• To administer classic (4:1)

Ketogenic Diet
• For children over 1 year of age
• Energy distribution
• Fat 90%
• Carbohydrate 1.6%
• Protein 8.4%

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 Example:
Carbohydrate-
free Formula
• Basic-ch
• RCF (Ross Carbohydrate-Free )
Indications:
• Carbohydrate intolerance/malabsorption
• Glucose-galactose malabsorption
• Ketogenic diet

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 ProViMin
(Protein-vitamin-mineral formula component with
iron)

• 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
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2010
 Carbohydrate
Fat
Protein
Modular supplements

2010
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 Modular supplements

• May be added for infants with increased

nutrient needs

Modules in the forms of

carbohydrate and fat

• May be used to increase caloric intake

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 Less osmotic effect on the gut
Glucose
polymers
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

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 •MCT Oil
Supplement
Fat

• 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

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 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
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 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%
2010
• Carbohydrate: 35 – 55%
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 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