Formulas in the NICU

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Formulas in the NICU

• Yvonne Sarson, MS, RD, CNSD

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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

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Nutrition Standards Goals
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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

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Nutrition Goals
Term Infant Term Infant Preterm Infant Preterm Infant
Protein gm/kg Kcal/kg Protein gm/kg Kcal/kg
Enteral nutrition 2.2 108 3.5 120
Parenteral nutrition 3 100 3.5 110
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Energy needs
Components of energy needs Kcal/kg/day
BMR 40 - 62
Thermogenic effect of feeding 3 - 11
Activity 2 - 4
Growth (15 gm/kg/day) 45 - 67
Total 90 130 (rarely 144)
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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

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Fluids to meet nutritional needs- enteral
nutrition
Formula KCAL density Volume to 108 kcal/kg/day 120 kcal/kg/day
20 cal/oz (67.6 cal/100 ml) 160 ml/kg/day 180 ml/kg/day
22 cal/oz (74 cal/100 ml) 145 ml/kg/day 160 ml/kg/day
24 cal/oz (81 cal/100 ml) 135 ml/kg/day 150 ml/kg/day
27 cal/oz (91 cal/100 ml) 120 ml/kg/day 130 ml/kg/day
30 cal/oz (100 cal/100 ml) 110 ml/kg/day 120 ml/kg/day
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Comparison of nutrient concentrations of
parenteral enteral fluids
Pro gm/dl Kcal/dl
Expressed breast milk 1.1 68
Term Similac Advance, 20 cal/oz 1.4 68
Premature Enfamil Lipil, 20 cal/oz 2 68
Elecare, 20 cal/oz 2 68
PN 3 g Pro/kg, D15 _at_115 ml/kg 2.6 61
PN 3.5 g Pro/kg, D17_at_ 115 ml/kg 3 80
PN 3 g Pro/kg, D12.5 _at_ 135 ml/kg 2.2 69
PN 3.5 g Pro/kg, D14.5 _at_ 135 ml/kg 2.6 81
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Formula Ingredient Primer

• Carbohydrates
• Proteins
• Fats
• DHA
• ARA
• Prebiotics vs Probiotics

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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

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Carbohydrates (cont.)

• Disaccharides
• Lactose (glucose galactose)
• Maltose (glucose glucose)
• Sucrose (glucose fructose)
• Monosaccharides
• Glucose
• Galactose
• Fructose

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Protein sources

• Intact proteins
• Cows 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

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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 (gt12 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 6n3source is C.
  cohnii Oil,

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DHA and ARA
Per 100 ml 24 cal DHA mg. ARA mg. Ratio
Similac Special Care 11 17.6 1.61
Premature Enfamil Lipil 14 28 21
Nestle Good Start Premature 13.5 27 21
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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

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Composition of Breast Milk and Formulas
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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 wheycasein ratio-
• early milk 9010 vs. mature milk 6040
• CHO lactose (40 of energy content)
• Fat (40-50 of energy content) 12 of fatty
  acids are medium chain

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Human Milk Fortification

• Commercial human milk fortifiers cows milk
  based
• for infants lt34 weeks or lt1500-1800 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 lt1250 gm _at_ 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

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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 cows 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)

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Standard Infant Formulas

• Protein
• Source cows milk
• Wheycasein ratio- 6040 7030, 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

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Premature Formulas

• Protein -
• Source cows milk protein whey protein
  concentrate and non-fat milk
• Wheycasein ratio- 6040
• 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 lt 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

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Premature Follow-up Formulas

• Protein
• Source cows milk protein whey protein
  concentrate and non-fat milk
• Wheycasein ratio- 5050 to 6040
• CHO
• Source-lactose glucose polymers or corn syrup
  solids
• Fat
• Source MCT, soy coconut oils, DHA, ARA
• Indications BW lt 1800 gm until corrected age of
  9 mos.
• Examples
• Enfamil Enfacare Lipil, Similac Neosure Advance,
  Bright Beginnings Neocare

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Lactose-free cows 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)

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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)

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Term formulas with Probiotics

• Examples
• Good Start Protect Plus Bifidobacterium lactis
• Enfamil Nutramigen Lipil with Enflora
  LGGLactobacillus rhamnosus GG (LGG)

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Cows 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

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Cows Milk low mineral

• Low mineral -
• Indications- hypocalcemia or renal failure with
  hyperkalemia and hyperphosphatemia
• Similac PM 60/40

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Cows 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

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Partially hydrolyzed protein

• Protein
• Cows 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

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Partially hydrolyzed protein

• Protein
• Cows 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

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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

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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

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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

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Elemental Formulas

• Amino acids
• Neocate (SHS)
• Elecare (Abbott)
• Nutramigen AA (Enfamil)

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Increased Caloric Density Formulas

• Less water to powder
• increases nutrient intakes
• Additives
• may decrease other nutrient intakes

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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

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Dietary Supplementation
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Vitamin D needs at NICU discharge
Feeding Wt at discharge Vitamin D supplement dose
Predominantly breastmilk All 400 units
Term formula lt 6.2 kg. gt 6.2 kg 200 units none
Neosure or Enfacare lt 4.2 kg gt 4.2 kg 200 units none

• 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)

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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 lt 500 kcal/day
• Seizures treated with phenobarbital extra
  Vitamin D
• Abnormal GI losses ?need for zinc, copper,
  fat-soluble vitamins and electrolytes

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Preterm Infants Stable, Growing

• No daily multivitamin mineral supplements -
• premies on preterm formulas or human milk
  fortifiers
• Ex-premies on transitional/premature discharge
  formulas lt4.2 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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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

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Iron supplements

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

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Additional Issues
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Formula handling

• Enterobacter sakazakii - meningitis resulting in
  death linked to formula contamination especially
  a concern with of cows milk protein formulas
  mixed from powder

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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

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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 (glucosefructose)
• 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

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Formula company web sites
Mead Johnson www.mjn.com
Nestle nutrition www.nestleinfantnutrition.com
Abbott nutrition Abbottnutrition.com
PBM nutritionals www.brightbeginnings.com
Nutricia www.neocate.com
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