1. Yvonne Sarson, MS, RD, CNSD
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
Nutrient needs
Standard for nutritional needs -
a. for term infants - human breast milk
for preterm infants - growth rate and composition of weight gain that mimics in utero growth of the normal fetus of equivalent PCA
2. infants who receive only supplemental glucose lose 1% of their protein stores each day

10. Nutrition Goals Term Infant Preterm Infant Protein gm/kg Kcal/kg
Enteral nutrition
2.2
108
3.5
120
Parenteral nutrition 3
100
110
Neonates can be anabolic with 2.0 g/kg/day of amino acids and 50 kcal/kg/day
Appropriate growth and nitrogen retention occurs with gm protein/kg/day, but the smallest premies (<1500 gm. ) receiving enteral nutrition may need 4.0 gm protein/kg/day

11. Energy needs Components of energy needs Kcal/kg/day BMR 40 - 62
Thermogenic effect of feeding
3 - 11
Activity
Growth (15 gm/kg/day)
Total
90 – 130 (rarely 144)
Energy needs for basal metabolic rate vary from kcal/kg/day; depending on
severity of illness
medications
dietary intake
chronological needs – BMR increases during first week of life
ambient temperature – neutral thermal environment minimizes O2 consumption (decreases caloric expenditure)
Energy needs for activity
2-4 kcal/kg/day in stable, growing preterm infants
small contribution in comparison to older infants and toddlers
Energy needs for thermogenic effect of feeding
estimated to be 3-11 kcal/kg/day
difficult to measure, difficult to separate from BMR
Infants have high energy requirements relative to body size due to growth velocity
a. Each gram of weight gain, including the stored energy and energy cost of tissue synthesis requires between kcal or up to 10 kcal/gm for protein synthesis
Daily wt. gain of 15 gm/kg/day requires kcal/kg/day more than the 50 kcal/kg/day required for weight maintenance
Most infants will grow on parenteral non-protein kcal intakes of 100 kcal/kg/day or enteral intake of 120 kcal/kg/day 11

12. 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

13. 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
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

14. 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
Premature Enfamil Lipil, 20 cal/oz 2
Elecare, 20 cal/oz
PN 3 g Pro/kg, ml/kg
2.6 61
PN 3.5 g Pro/kg, 115 ml/kg 3 80
PN 3 g Pro/kg, D12.5% @ 135 ml/kg
2.2 69
PN 3.5 g Pro/kg, 135 ml/kg 81

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

16. Carbohydrates Polysaccharides –
Starch and glucose polymers- from tapioca starch or cornstarch hydrolysis 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
Carbohydrates – hydrolysis of carbohydrate polymers by treatment with acid and then enzymes (Size of CHO polymers is expressed in DE or dextrose equivalents. Cornstarch = 1, dextrose = 100.
Cornstarch (complex)
Maltodextrin – type of hydrolyzed cornstarch (DE <20)
Corn syrup solids – dehydrated corn syrup, more hydrolyzed than maltodextrin (DE = 20-65)
Glucose polymers (hydrolyzed cornstarch) (DE >80)

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

18. 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
2 of the major proteins in human milk (as well as cow’s milk) are whey and casein –
Whey is the protein remainins in the liquid portion in the cheese-making process
Casein forms the solid – casein forms a firm curd in the acidic environment of the stomach
Cow’s milk protein is 80% casein, so infant formulas with milk protein isolate usually need to have whey protein isolate added to mimic the whey: casein ration found in human milk.
Milk protein isolate is used instead of nonfat milk or milk protein concentrate when lactose is NOT wanted

19. 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,
ARA (Arachadonic acid) – 20: 4n6
DHA (Docosohexanoic acid)- 22: 6n3
3% of total energy should be from linoleic acid to prevent clinical signs of deficiency (recommendation by AAP-CON)
sources of both linoleic (parent -6 fatty acid) and -linolenic (parent -3 fatty acid) with 4-5% of total energy as linoleic acid and linolenic acid needed for biochemical normalcy
up to 12% of energy intake as linoleic acid and -linolenic acids a safe intake; target is gm /kg/day up to 1.5 gm/kg/day
linoleic acid should by gm/kg/day; -linolenic should be gm/kg/day

20. DHA and ARA Per 100 ml 24 cal DHA mg. ARA mg. Ratio
Similac Special Care 11
17.6
1.6:1
Premature Enfamil Lipil 14 28
2:1
Nestle Good Start Premature
13.5 27

21. Prebiotics vs 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

22. Composition of Breast Milk and Formulas

23. 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

24. Human Milk Fortification
Commercial human milk fortifiers – cow’s milk based
for infants <34 weeks or < 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 cal/oz,
iron content varies
Ex. - Similac or Enfamil Human Milk Fortifier
Commercial human milk fortifier – human milk based (Prolacta)
Targeted for <1250 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
For the growing ex-premie, breast milk fortified with Enfacare or Neosure powder to cal/oz.

26. 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)

27. 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
Caution typo correction on this slide.
Protein – 9% of energy content
Source – cow’s milk
Whey:casein ratio- 60:40 – 70:30
CHO – 41-44% of energy content
Source-lactose
Fat – % of energy content
Source – variety of vegetable & tropical oils, DHA, ARA
Examples –Nestle Good Start, Enfamil Lipil, Similac Advance, Bright Beginnings, Generic store brand

29. Premature Formulas Protein - CHO - Fat –
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
Protein –11-12% of energy content
Source – cow’s milk protein – whey protein concentrate and non-fat milk
Whey:casein ratio- 60:40
CHO – 42-44% of energy content
Source-lactose & glucose polymers or corn syrup solids
Fat – % of energy content
Source – MCT, soy & coconut oils, DHA, ARA
Indications – BW < 1800 gm until hospital d/c or wt. ~ 2.7 kg.
Examples –
Enfamil Premature Lipil, Similac Special Care Advance,

31. 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
Protein – 10% of energy content
Source – cow’s milk protein – whey protein concentrate and non-fat milk
Whey:casein ratio- 50:50 to 60:40
CHO – 41-44% of energy content
Source-lactose & glucose polymers or corn syrup solids
Fat – % of energy content
Source – MCT, soy & coconut oils, DHA, ARA
Indications – BW < 1800 gm until corrected age of 9 mos.
Examples –Enfamil Enfacare Lipil, Similac Neosure Advance

33. 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)
Congenital lactase deficiency – rare
belongs to the Finnish Disease Heritage and is a recessively inherited diarrheal disease of the newborn, in which the activity of the lactase enzyme of the epithelial cells of the small intestine is very low ever since the birth. For the newborn infant, ingestion of lactose causes symptoms so severe that breastfeeding is not possible. Untreated disease leads to dehydration that usually requires hospitalization. Congenital lactase deficiency is caused by mutations in the gene coding for the lactase enzyme (LCT). Seven mutations in a total of 43 patients have been found in Finland so far. + reported in 1 Italian pt and 2 Turkish siblings

34. 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)

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

36. 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
Give examples of brand names-
Soy – Nestle (was Alsoy) Good Start Essentials Soy
Partially hydrolyzed – Nestle Good Start Supreme and newly released Enfamil Gentlease Lipil; Difference between these 2 hydrolyzed formulas is
that Gentlease has ¼ the lactose of Good Start Supreme
Good Start Supreme protein source is whey protein

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

38. 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
Standard premature formula is 34 cal/1 gm protein; term formula is 49:1

39. Partially hydrolyzed 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

40. Partially hydrolyzed 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

41. 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

42. 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
Protein – 11-12% of energy content
Source – casein hydrolysates and/or L- amino acids
CHO – 41-44% of energy content
Source- sucrose, modified tapioca starch, corn syrup solids, or modified cornstarch
Fat – ____48 % of energy content
Source – MCT, variety of vegetable and tropical oils
Indications – protein sensitivity, malabsorption
Examples –
Semi-elemental (protein hydrolysates)
Enfamil Nutramigen Lipil (no MCT)
Enfamil Pregestimil Lipil,
Enfamil Product 3232A (for carbohydrate malabsorption, needs added CHO source)
Similac Alimentum Advance
Elemental
Neocate (SHS)
Elecare (Ross)

43. 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

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

45. Increased Caloric Density Formulas
Less water to powder
increases nutrient intakes
Additives
may decrease other nutrient intakes
Caloric density of premature formulas can be increased by addition of transition formula powder to ready-to-feed.

46. Modular Additives Protein - Carbohydrates - Fat -
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 kcal/ml
Microlipid (safflower oil emulsion)- 4.5 kcal/ml
Modular Additives
Protein -
Beneprotein kcal and 1.3 gram pro/teaspoon (weighs 1.55 gm per teaspoon)
Carbohydrates -
Polycose - 8 kcal/ tsp
Karo syrup - 4 kcal/cc but not under 6 months old
Fat -
Corn oil - 8 kcal/ml , use with bolus feeds
MCT oil kcal/ml, use with bolus feeds
Microlipid kcal/ml, use continuous feeds

47. Dietary Supplementation

48. Vitamin D needs at NICU discharge
Feeding
Wt at discharge
Vitamin D supplement dose*
Predominantly breastmilk
All
400 units
Term formula
< 6.2 kg.
> 6.2 kg
200 units
none
Neosure or Enfacare
< 4.2 kg
> 4.2 kg
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)

49. 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
Term infants
Breast fed -
Supplementation is usually not necessary for healthy, breast-fed infants with exception -
200 International Units/day of Vitamin D is recommended by AAP. Many infants do not receive adequate sunlight exposure to prevent rickets. Black-skinned infants are most at risk. Estimates for adequate sunlight exposure for white infants is 30 minutes per week clothed only in a diaper or 2 hours per week fully clothed with no hat.
Iron source after 4-6 months – usually iron-enriched cereal
Flouride after 6 months
Term infant with chronic intake less than 750 ml/day (a 10 lb. term infant drinking 20 cal/oz. milk at 160 ml/kg/day drinks this amount of formula)
Infants who receive Phenobarbital need additional Vitamin D due to increased Vitamin D turnover. For formula fed infants, 400 IU/day; for breast-fed infants, 800 IU/day.
Infants with malabsorption and diarrhea from short gut syndrome, bowel surgery, or cholestatic liver disease. These infants may need supplemental fat-soluble vitamins

50. 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
No daily multivitamin mineral supplements for stable, growing -
premies receiving preterm formulas or human milk fortifiers
Ex-premies receiving transitional/premature discharge formulas (Enfacare or Neosure)
If standard term infant formula is used for a premature or ex-premature infant – multivitamins, folic acid, calcium, phosphorus, and zinc may be needed.
Need for iron supplements depends on milk

51. 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
Bone meds is a term that is commonly used to refer to calcium and phosphorus supplements used to treat the osteopenia of prematurity
Ex-premies with birthweight <1800 gm have increased incidence of osteopenia of prematurity. This risk is further increased by prolonged administration of TPN or diuretics. Most bone mineralization occurs during the last trimester of fetal development. Use of premature formulas and human milk fortifiers designed for premature infants can improve bone mineralization.
Studies show that use of a physiologic ratio of 1.7:1 elemental weight (mg calcium:mg phosphorus) with intakes of 200 mg calcium/kg/day and 115 mg phosphorus/kg/day can result in calcium and phosphorus retention which equals in utero rates of accretion.
If unsupplemented breast milk or formulas other than premature formulas are used, calcium and phosphorus supplements may be needed.

52. Iron supplements Iron source -
Formulas provide ~ 2 mg/kg/day elemental iron per 160 ml/kg/day
Growing, preterm 1-2 months or 2X BW.
Healthy, term 4-6 months
Dose (elemental iron) -
Preterm = 4-6 mg/kg/day
Term = 2 mg/kg/day
Max= 15 mg/day of supplemental iron
Growing, preterm infants should have a source of iron by the time they are 1-2 months old or by the time that they double their birth weight (whichever comes first).
Healthy, term breastfed infants have adequate iron stores so that they do not need a dietary iron source until they reach 4-6 months of age. If iron-fortified infant cereals are not introduced by 4 months, an iron supplement should be prescribed.

53. Additional Issues

54. Formula handling
Enterobacter sakazakii - meningitis resulting in death linked to formula contamination; especially a concern with of cow’s milk protein formulas mixed from powder

55. 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

56. 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 (glucose+fructose)
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

57. Formula company web sites
Mead Johnson
Nestle nutrition
Abbott nutrition
Abbottnutrition.com
PBM nutritionals
Nutricia