Alimentatia fortificatori

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



Nutrition Stan$ar$s )*oals



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'













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



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;



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#



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



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



Formula Ingre$ient

rimer Carboh#$rates roteins Fats

D0+ +R+

rebiotics vs robiotics



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



Carboh#$rates 9cont;

Disacchari$es Gactose 9glucose H galactose; Maltose 9glucose H glucose; Sucrose 9glucose H !ructose;

Monosacchari$es *lucose *alactose Fructose





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,



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



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



Comosition o! .reastMil% an$ Formulas



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



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





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;



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+





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





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





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;



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;



6erm !ormulas withrobiotics1Eamles

*oo$ Start rotectlus Bifdobacterium

lactis

1n!amil NutramigenGiil with 1noraG**Lactobacillus

rhamnosus GG 9G**;



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



Cows Mil% low mineral

Gow mineral - In$ications- h#ocalcemia or renal

!ailure with h#er%alemia an$h#erhoshatemia

Similac M 43"23



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$,3:L o! calories as alha-linolenic aci$



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



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



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



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



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



1lemental Formulas

+mino aci$s Neocate 9S0S;

1lecare9+bbott;

Nutramigen++ 91n!amil;



Increase$ Caloric Densit#Formulas Gess water to ow$er

increases nutrient inta%es

+$$itives ma# $ecrease other nutrient inta%es



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



Dietar#Sulementation

i i $



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)

!



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



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



.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



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



+$$itional Issues



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



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



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



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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Alimentatia fortificatori