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8/17/2019 Alimentatia fortificatori
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NICU nurse will be able to- Recognize the aroriate!ormula !or his"her bab#
I$enti!# %e# $i&erences between
in!ant !ormulas I$enti!# babies who nee$ routine
vitamin an$ mineral sulements
'b(ectives
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Nutrition Stan$ar$s )*oals
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Nutritional Stan$ar$s
Stan$ar$ !or $etermining nutritionalnee$s -
!or term in!ants - human breast mil%
!or reterm in!ants - growth rate thatmimics in utero growth
+$euac# o! growth comare$ tostan$ar$s growth charts
.irth weight charts .abson, Fenton *rowth charts - /0'
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Nutrition *oals
Term 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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1nerg# nee$s
Components of energy needs Kcal/kg/day
.MR 23 - 45
6hermogenic e&ect o! !ee$ing 7 - 88
+ctivit# 5 - 2
*rowth 98: gm"%g"$a#; 2: - 4<
6otal =3 873 9rarel# 822;
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Flui$ an$ Nutrition Nee$s - 6erm RD+ !or calories !or term in!ant > 83?
%cal"%g"$a#, 53 cal"oz breast mil% has 4? %cal"833 ml, 0ow much mil% $oes the bab# nee$ to
meet RD+@ x ml"%g"$a# > 83? %cal A 4? %cal B 833
ml > 843 ml"%g"$a#
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Flui$s to meet nutritional nee$s-
enteral nutrition
Formula KCAL densityVolume to =108 kcal/k/day 1!0 kcal/k/day
20 cal/oz (67.6 cal/100 ml) 160 ml/kg/da 180 ml/kg/da22 cal/oz (7! cal/100 ml) 1!5 ml/kg/da 160 ml/kg/da
2! cal/oz (81 cal/100 ml) 135 ml/kg/da 150 ml/kg/da
27 cal/oz ("1 cal/100 ml) 120 ml/kg/da 130 ml/kg/da
30 cal/oz (100 cal/100 ml) 110 ml/kg/da 120 ml/kg/da
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Comarison o! nutrient concentrationso! arenteral ) enteral ui$s
Pro m/dl Kcal/dl
E#$re%%ed &rea%t milk 1.1 68
'erm imilac d*ance+ 20 cal/oz 1.! 68Premature En,amil -i$il+ 20 cal/oz 2 68
Elecare+ 20 cal/oz 2 68
P 3 g Pro/kg+ 15 115 ml/kg 2.6 61
P 3.5 g Pro/kg+ 17 115 ml/kg 3 80
P 3 g Pro/kg+ 12.5 135 ml/kg 2.2 6"
P 3.5 g Pro/kg+ 1!.5 135 ml/kg 2.6 81
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Formula Ingre$ient
rimer Carboh#$rates roteins Fats
D0+ +R+
rebiotics vs robiotics
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Carboh#$rates
ol#sacchari$es Starch an$ glucose ol#mers- !rom taioca starch or
cornstarchh#$rol#sis o! carboh#$rate ol#mers 9cornstarch; b#treatment with aci$ an$ then enz#mes Cornstarch 9comleE; Malto$eEtrin Corn s#ru soli$s *lucose ol#mers 9or h#$rol#ze$ cornstarch;
'ligosacchari$es in breast mil% 9rebiotic e&ect; Inuence microora +lter bacterial a$hesion
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Carboh#$rates 9cont;
Disacchari$es Gactose 9glucose H galactose; Maltose 9glucose H glucose; Sucrose 9glucose H !ructose;
Monosacchari$es *lucose *alactose Fructose
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Fats o! signiJcance
Me$ium chain trigl#ceri$es 94-85 carbon chain length; K85L o! total !att# aci$s in human breast mil% +$$e$ to all reterm !ormulas an$ some term !ormulas
Gong-chain trigl#ceri$es 985 carbon chain length;
1ssential !att# aci$s 91F+; 98? carbon chain length;2-:L o! Ocal as 1F+ to revent $eJcienc# Ginoleic aci$ 8?P 5n4 +lha-linolenic aci$ 8?P 7n7
Gong Chain ol#unsaturate$ Fatt# +ci$s
+R+ 9+racha$onic aci$; 53P 2n4source is M alina 'il D0+ 9DocosoheEanoic aci$;- 55P 4n7
source is C cohnii 'il,
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D0+ an$ +R+
er 833 ml 52 cal D0+mg
+R+mg
Ratio
Similac Secial Care 88 8<4 84P8
remature 1n!amil Giil 82 5? 5P8
Nestle *oo$ Startremature
87: 5< 5P8
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rebiotics vs robiotics
robiotics Give microorganisms which when a$ministere$ in
a$euate amounts con!er a health beneJt on thehost 9/0' $e!;
rebiotics Non-viable !oo$ substances that stimulate the
growth or activit# o! microbial ora 9microbiota; inthe $igestive s#stem which are beneJcial to the
health o! the bo$# Most common now are non-$igestible
carboh#$rates inulin, galacto-oligosacchari$es an$!ructo-oligosacchari$es
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Comosition o! .reastMil% an$ Formulas
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0uman .reast Mil%
*ol$ stan$ar$ !or mo$eling term in!ant !ormulas re!erre$ source o! enteral nutrition !or all
in!ants, inclu$ing remature an$ sic% newborns Contrain$ications- galactosemia, congenital lactase
$eJcienc#, maternal 0IQ or use o! someme$ications
rotein whe#Pcasein ratio- earl# mil% =3P83 vs mature mil% 43P23
C0' lactose 923L o! energ# content; Fat 923-:3L o! energ# content; K 85L o! !att#
aci$s are me$ium chain
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0uman Mil% FortiJcation
Commercial human mil% !ortiJers cows mil% base$ !or in!ants 72 wee%s or 8:33-8?33 gm at birth until K5: %g 0igher calorie rearations or use in larger in!ants can rovi$e
eEcessive rotein, !at-soluble vitamins ) minerals +vailable as ow$ers
$esigne$ to increase to 55-52 cal"oz, iron content varies 1E - Similac or 1n!amil 0uman Mil% FortiJer
Commercial human mil% !ortiJer human mil% base$ 9rolacta; 6argete$ !or 85:3 gm birth, !or Jrst 5 months o! li!e Nutritionall# comarable to Similac 0uman Mil% FortiJer 9low iron;
+vailable as liui$ 2 $i&erent !ormulations $esigne$ to increasecaloric $ensit# !rom 52 cal"oz 73 cal"oz in 5 cal"oz increments 'ther ow$ere$ !ormulas an$ mo$ular sulements ma#
be use$ to !orti!# human mil% !or term in!ants or growingremature in!ants
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Ma(or Formula .ran$s
1n!amil 9Mea$ Tohnson Nutrition; 0igher levels o! D0+ ) +R+ sulementation than
+bbott now mar%et stan$ar$ with eEcetion o! +bbott
Similac 9+bbott Nutrition;
Nestle *oo$ Start 9Nestle Nutrition; +ll in!ant cows mil% rotein !ormulas contain onl#
artiall# h#$rol#ze$ whe# rotein as rotein source9: !ormulas;
.right .eginnings 9.M Nutritionals; .M also manu!actures store bran$ in!ant !ormulas
9: !ormulas;
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Stan$ar$ In!ant Formulas
rotein Source cows mil% /he#Pcasein ratio- 43P23 <3P73, eEcet *oo$ Start
9833L artiall# h#$rol#ze$ whe#;
C0' Source-lactose Fat
Source variet# o! vegetable ) troical oils, D0+, +R+
1Eamles
1n!amil Giil, Nestle *oo$ Start *entle lus, Nestle*oo$ Start Nourish lusV, Similac +$vance or +$vance1arl#Shiel$, .right .eginnings Mil%Vno D0+"+R+
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remature Formulas
rotein - Source cows mil% rotein whe# rotein concentrate an$
non-!at mil% /he#Pcasein ratio- 43P23
C0' -
Source-lactose ) glucose ol#mers or corn s#ru soli$s Fat
Source MC6, so# ) coconut oils or,high-oleic sunower an$saWower, D0+, +R+
Qitamins ) Minerals higher !at-soluble vitamins es + ) D,Ca ) '2
In$ications ./ 8?33 gm ) rematurit# until hosital $"c orwt K 5< %g
1Eamles 1n!amil remature Giil, Similac Secial Care +$vance, Nestle
*oo$ Start remature 52
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remature Follow-u Formulas
rotein Source cows mil% rotein whe# rotein concentrate
an$ non-!at mil% /he#Pcasein ratio- :3P:3 to 43P23
C0' Source-lactose ) glucose ol#mers or corn s#ru soli$s
Fat Source MC6, so# ) coconut oils, D0+, +R+
In$ications ./ 8?33 gm until correcte$ age o! =
mos 1Eamles
1n!amil 1n!acare Giil, Similac Neosure +$vance, .right.eginnings Neocare
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Gactose-!ree cows mil%!ormula C0' Source- corn s#ru soli$s corn
malto$eEtrin an$ sucrose 9in Similacro$ucts; Gactose-!ree
In$ication secon$ar# lactase $eJcienc# as a!ter
course o! antibiotics carboh#$rate malabsortion a!ter
colectom# Congenital lactase $eJcienc# 9eEcee$ingl#
rare $isease occurring in Finlan$
1Eamles - 1n!amil Gacto-!ree, Similac Sensitive ) Similac Sensitive RS .right .eginnings Gactose-!ree
9+ll so#, elemental ) semi-elemental !ormulasare also lactose-!ree;
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6erm !ormulas withrebiotics 'ligosacchari$es 9$e!;
comleE carboh#$ratesnaturall# occurring inhuman mil%
stimulate the growth o!beneJcial bacteria
suort mucosalimmune !unction
*alacto-'ligosacchari$es
1arl# Shiel$ 9Similac;,remium 91n!amil;
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6erm !ormulas withrobiotics1Eamles
*oo$ Start rotectlus Bifdobacterium
lactis
1n!amil NutramigenGiil with 1noraG**Lactobacillus
rhamnosus GG 9G**;
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Cows Mil% Formulas with ricestarch
+$$e$ rice starch In$ications- !ormulas with
rice starch a$$e$ to rovi$enutritionall# balance$
!ee$ings where rovi$erswoul$ a$$ rice cereal 9notsuitable !or oral $#shagia;
1Eamles - 1n!amil +R, Similac Sensitive RS
1n!amil Rest!ull
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Cows Mil% low mineral
Gow mineral - In$ications- h#ocalcemia or renal
!ailure with h#er%alemia an$h#erhoshatemia
Similac M 43"23
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Cows Mil% Formulas GowGC6 Gow long chain !at 90igh rotein;
In$ications- Ch#lothoraE 1Eamles-
ortagen- ow$ere$ !orm, notmar%ete$ !or in!ants,
2< gm !at"833 cal with ?<L MC6 78L o! calories as linoleic aci$,
trace alha-linolenic aci$ 1n!aort- liui$ !orm 973 cal"oz as
ac%age$;, :2 gm !at"833 cal with ?2L MC6 75L o! calories as linoleic
aci$,3:L o! calories as alha-linolenic aci$
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artiall# h#$rol#ze$ rotein
rotein Cows mil% rotein molecules
artiall# bro%en $own, but not assmall eti$e chains as semi-elemental h#$rol#e$
In$ications mar%ete$ aseasier to $igest
1Eamles - Nestle *oo$ Start *entle lus,rotect lus, Nourish lus,
1n!amil *entlease .right .eginnings *entle
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artiall# h#$rol#ze$ rotein
X rotein
Cows mil% rotein molecules artiall# bro%en $own,but not as small eti$e chains as semi-elementalh#$rol#e$
X In$ications mar%ete$ as easier to $igestX 1Eamles -
Nestle *oo$ Start *entle lus, rotect lus, Nourishlus,
1n!amil *entlease
.right .eginnings *entle
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So# !ormula
rotein- so# C0' lactose-!ree contrain$icate$ in
remature in!ants $ue to h#tate content, lower rotein bioavailabilit# aluminum content
In$ication term in!ant withgalactosemia, vegetarian$iet
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1lemental an$ Semi-elementalFormulas
rotein slightl# higher rotein content than stan$ar$
!ormulas
Source casein h#$rol#sates an$"or G- amino aci$s C0'
Source- sucrose, mo$iJe$ taioca starch, corn s#rusoli$s, or mo$iJe$ cornstarch
Fat Source MC6, variet# o! vegetable an$ troical oils
In$ications rotein sensitivit# an$"ormalabsortion
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Semi-elemental Formulas
1Etensivel# h#$rol#ze$roteins 1n!amil Nutramigen
Giil
9no MC6; 1n!amil regestimil Giil, 1n!amil ro$uct 7575+
9!or C0' malabsortion,nee$s a$$e$ C0'
source; Similac +limentum
+$vance
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1lemental Formulas
+mino aci$s Neocate 9S0S;
1lecare9+bbott;
Nutramigen++ 91n!amil;
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Increase$ Caloric Densit#Formulas Gess water to ow$er
increases nutrient inta%es
+$$itives ma# $ecrease other nutrient inta%es
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Mo$ular +$$itives
rotein - .enerotein 87 gm
rotein"ts Carboh#$rates -
ol#cose - ? %cal" ts Rice cereal 2 %cal"ts Oaro s#ru - 2 %cal"cc but
not un$er 4 months ol$ Fat -
Corn or saWower oil - ?
%cal"ml MC6 oil - << %cal"ml Microlii$ 9saWower oil
emulsion;- 2: %cal"ml
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Dietar#Sulementation
i i $
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Qitamin D nee$s at NICU$ischarge
Fee$ing /t at $ischarge Qitamin Dsulement $oseV
re$ominantl#breastmil%
+ll 233 units
6erm !ormula 45 %g
45 %g
533 units
none
Neosure or 1n!acare 25 %g
25 %g
533 units
none
Pol*i%ol dro$%+ !00 unit% 4itamin $er 1 ml
En,amil 4iol 4itamin (3) u$$lement ro$%+ !00 unit% $er 1 ml (50 ml&ottle co%t% 11)
!
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6erm In!ants +$$itional sulements 0ealth#
.reast !e$ Iron a!ter 2-4 months 9usuall# enriche$ cereal;
Fluori$e a!ter 4 months
Formula !e$ $een$ing on inta%e
Chronic $iseases Multivitamin !or chronic inta%e :33 %cal"$a#
Seizures treate$ with henobarbital eEtra QitaminD
+bnormal *I losses @nee$ !or zinc, coer, !at-soluble vitamins an$ electrol#tes
! S bl
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reterm In!ants Stable,*rowing No $ail# multivitamin mineral sulements
- remies on reterm !ormulas or human mil%
!ortiJers 1E-remies on transitional"remature
$ischarge !ormulas 25 %g I! stan$ar$ term in!ant !ormula or breast
mil% multivitamins, !olic aci$, calcium,hoshorus, an$ zinc ma# be nee$e$
Nee$ !or iron sulements $een$s on mil%) resence o! anemia
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.one me$s
revent nee$ with otimal nutritionthroughout NICU sta#
Re!er to Calcium an$ hoshorus
sulements use$ to treat osteoenia 6arget inta%e
533 mg elemental calcium"%g"$a# 88: mg elemental hoshorus"%g"$a#
Doses must be staggere$ to revent!ormation o! calcium-hoshorusreciitates
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Iron sulements
Iron source - Formulas rovi$e K 5 mg"%g"$a# elemental iron er
843 ml"%g"$a#
*rowing, reterm in!ants 8-5 months or 5B ./
0ealth#, term in!ants 2-4 months Dose 9elemental iron; -
reterm > 2-4 mg"%g"$a#
6erm > 5 mg"%g"$a#
MaE> 8: mg"$a# o! sulemental iron
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+$$itional Issues
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Formula han$ling
1nterobacter sa%aza%ii - meningitisresulting in $eath lin%e$ to !ormulacontamination eseciall# a concern with
o! cows mil% rotein !ormulas miEe$!rom ow$er
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6ube !ee$ing breastmil%
S#ringe um vs %angaroo bag 0ome on continuous breastmil%
!ee$ings@ 1valuation growth with
Oangaroo um vs obtain aroriateum eveE InJnit# 'range
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Sucrose containing !ormulas
Fructose absortion not !ull# mature$ in #oungin!ant Fruit (uice malabsortion is $ose $een$ent S#mtomatic malabsortion above 83 ml"%g"$a#
Sucrose $isacchari$e 9glucoseH!ructose; Fructose content ma# be eEcessive !or #oung in!ant i! this is
sole nutrition source 9malabsortion"$iarrhea
In!ant !ormulas containing sucrose Similac +limentum 55 gm"833 ml
Similac 'rganic 8 gm"833 ml Similac Sensitive 77 gm"833 ml Similac Sensitive RS 82 gm"833 ml ortagen 5= gm"833 ml
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Formula coman# web sites
ead o9n%on :::.m;n.com
e%tle nutrition :::.ne%tlein,antnutrition.com
&&ott nutrition &&ottnutrition.com
P< nutritional% wwwbrightbeginningscom
utricia wwwneocatecom
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