1. Special Formulas-Who, When, Where, Why and How? Margo Humenczuk MBA, RD, CSP, LD The Magic of WIC October 23, 2012

2. American Academy of Pediatrics Breast milk is best-the gold standard Milk banks growing, breast milk available to more infants, especially preemies No soy formula until 6 months of age for premature infants-phytates can bind essential minerals Premature follow up formulas (Enfacare or Neosure) for first year, higher calcium and phosphorus for bone mineralization

3. Breast Milk in Tube Feedings Mom must be taught safe storage and collection practices Continuous drip is associated with appreciable fat losses –Fat separates and collects in infusion system –Loss of 20% of calories is typical –Residual milk flush may deliver fat bolus that may not be tolerated if impaired GI function –Potential loss of cholesterol, EFA, phospholipids, & fat soluble vitamins

4. Breast Milk/Neosure 22 calorie/oz Comparison 3 IU vitamin D per 100 calories (150 ml ) –Neosure 70 IU in 100 calories, Enfamil 60 IU Vitamin A 322 mg in breast milk, Neosure 470 mg, Enfamil 300 mg Iron 0.1 mg, Neosure & Enfamil Lipil 8 mg Fe Supplement with 1 ml multivitamin with iron drops

5. Standard Cow’s Milk Formula Suitable for most infants Breast milk is very high in lactose but is well tolerated, however, low lactose formulas are popular and a better choice than soy for most infants with gassiness, colic, etc.

6. Formulas for Babies with GERD Added starch in commercial formulas does not interfere with nutrient density or add extra calories but does not work well with meds that lower pH of stomach Overfeeding or feeding practices such as bottle propping (air in stomach if nipple not full of formula) or tightening ring on nipple super tight can be as much a problem as medical issues.

7. Iron in Formulas Does not affect constipation or fussiness Low iron formulas off the shelf now, available only for those children with medical need for low iron formula

8. Soy Formulas Children have grown and gained well on soy formulas for years but soy is not the first choice for infants unless they have a true milk allergy. Should not be used just because other family members required soy. 85%of those children sensitive to milk formula will develop poor tolerance to soy. Much less expensive than hydrolyzed formula

9. Follow-up formula for older premature babies. 22 cal/oz, increased levels of certain vitamins (D) & minerals Ca, P Enfacare or Neosure Do not use soy formulas for premature babies per AAP.

10. Protein Hydrolysate Formulas Use for malabsorption-liver disease, short bowel syndrome, other malabsorptive states. Tolerated by some infants with cow milk and soy intolerance. Use for some inborn errors of metabolism such as galatosemia.

11. Partially Hydrolyzed Formulas Pregestimil 55% fat from MCT –Ready to feed in liters and volu-feeds at 20 calories/oz., in volu-feeds at 24 kcalories- avoids use of powdered formula in some preemies –Nutramigen with enflora LGG –powdered, RTF and liquid concentrate- appropriate for galactosemia Alimentum 33% fat from MCT –Ready to feed at 20 calories/oz, powder

12. Necrotizing Enterocolitis Breast milk trophic feedings are best to preserve gut health. Hydrolyzed formula from ready-to-feed product is the next safest product. Avoid powdered formulas and Simply Thick gel thickener until more research is done.

13. Elemental Formulas Able to be immediately absorbed as amino acids, simple sugars and mostly MCT. Good for gut rest, severe allergy and post NEC feeding. Neocate, Elecare Infant, Elecare JR, Neocate Jr. and Nutramigen Amino Acid. Some children need elemental products long-term, other can be transitioned when well.

14. Elemental formulas Taste and smell bad Can be more difficult to mix Not usually available on store shelves. Very high osmolality Short hang times

15. Fat Modified Enfaport Lipil (formerly Portagen) Used in chylothorax and Lymphangiectasia Usually used acutely with transition to standard hydrolyzed protein formula longer term Vivonex TEN-amino acid product very low in fat (3% of calories)

16. Renal Similac PM 60/40 reduced Phosphorus, calcium and potassium, often used in combination with other formulas to just meet DRI of minerals.

17. Pediatric Formulas for Children FEEDINGRATIONALEAVAILABILITY Nutren Jr, Pediasure, Pediasure 1.5 Kid Essentials Kid Essential 1.5 Carnation Breakfast Essentials Standard oral or tube feeding supplement Pediasure comes in 30 and 45kcal/oz with and without fiber. Pediasure contains some soy protein, Nutren Jr does not. Kid Essentials come 30 and 45 kcal/oz, with and without fiber, 3 flavors Carnation Instant Breakfast Essentials is a powder that is mixed with 8oz whole milk. More economical that other options Retail: Pediasure, Kid Essentials Carnation Breakfast Essentials-need to mix with milk Nutren Jr (may be ordered from pharmacy at grocery store.

18. Pediatric Formulas Resource Breeze-really an adult product, low in calcium, does not nutritionally match Pediasure or comparable milk-based products. NOT a complete feeding. OK to use to supplement calories and protein, especially post op Bright Beginnings Pediatric Soy-soy product very close to Pediasure in nutrient content.

19. Peptide Products Shorter chain proteins, more MCT oil For malabsorption, may be used with delayed emptying, trauma, high healing needs some contain whey but no casein, may be tolerated by some milk sensitive children. Good transition for those on an elemental infant formula to make a gradual change to a less fully hydrolyzed product

20. Peptide Formulas Peptamen Jr, Peptamen Jr Pre-bio, Peptamen Jr with fiber Peptamen Jr 1.5 with fiber Pediasure Peptide 1.0 and 1.5 calorie options Multiple flavors for both products Use vanilla or unflavored for tube feeding

21. Blended Foods Compleat Pediatric 1 kcal and 0.6 kcal/ml Lower kcal product contains similar nutrition to 1 kcal product but with 60% of the calories. For those with retching, milk intolerance long-term formula intolerance and parents who are reluctant about the sugar in Pediasure. Does have traces of milk. Tube feeding only, not good for oral consumption.

22. Blended Foods via G-tube Good program at Cincinnati Children’s Hospital-developed for long-term retching in children with a fundoplication. Should not be done in the community without medical supervision. Need to have a back up plan for times of illness, hospital admission, post op, etc. “Just what my other kids eat” really isn’t. Avoid high nutrient supplements.

23. Blended Diet via G-tube Very labor intensive Bacterial contamination more likely than in commercial product. Fluid content may be difficult to determine.

24. Thickeners in Formulas Thickening increases safety of swallow and lessens risk of aspiration in laryngomalacia and other swallowing problems. Thickeners may dilute calorie and nutrient content of beverage, or can increase calories, depending on the product used.

25. More on Thickeners Recall of Simply Thick for preemies and infants recently. Cereal thickens beverages, but lowers fluid contribution of product and increases calories form cereal, may displace some nutrients.

26. Renal Formulas Renal Formulas appropriate for children: Suplena, Nepro

27. When to Consider Transition from a Specialty Formula Child with milk sensitivity is eating yogurt, cheese, etc. Preemie is a full year of age Child can take a variety of foods from all food groups –therapeutic tastes of baby foods don’t count as adequate nutrition, use some Pediasure in the interim as needed.

28. Transition to Other Formula Infant was put on amino acid formula at a few weeks of age due to danger of NEC, no documented formula intolerances-work with PCP to make a determination on most appropriate product. Some children at a year move from hydrolyzed product to peptide product to standard formula or cow’s milk.

29. Formula Mixing Use full scoops of formula powder, level with lid of can When altering recipes start with scoops of formula, not water volume, displacement differs Most about 45 kcal/scoop, Nutramigen AA 23 kcal/scoop, Neocate 20 kcal/scoop Packed scoops for Nutramigen, Pregestamil, NOT for Nutramigen AA

30. Formulas from WIC We appreciate your perseverance in teaching safe feeding practices and good nutrition. Monitor bottles for cleanliness and safety Constipation may be from low fluid intake, especially in very young, sleepy infants