Novel Neonatal Nutritional Notes

INFANT FORMULA UPDATE

I. Term, newborn:

A. Cow-milk based (low & high Fe):

Similac
Enfamil, etc

B. Soy based:

Isomil
Prosobee, etc

Issues:

1. Protein quality – intolerance
2. Iron
3. Carbohydrate
4. Mineral availability
5. Caloric density, basic composition

 

What about Iron…any place for “low” iron formulas?

• Iron deficiency anemia is bad! – associated w/ longterm cognitive deficits
• Modest dietary requirement x 4-6 mo ( \ don’t have to initially provide high Fe formula)
• Current levels of fortification (12 mg/L) excessive? Probably could do as well w/ 6-8 mg/L;
• Lower level – 4 mg/L going to be new lower limit (some proponents favored 0!)
• Best choice for breastfed infants…effects on gi flora, other mineral absorption

Committee on Nutrition, American Academy of Pediatrics “Iron Fortification of Infant Formulas” (7/99)

• All infants not breastfed or partially breastfed, should receive Fe-fortified formula (4-12 mg/L) from birth through 12 mo
• Discontinue manufacturing of formulas w/ < 4 mg/L
• Labels for low iron formulas should read “nutritionally inadequate”; d/c term on label “with iron”
• Educate parents, physicians re lack of negative side effects (gi, colic, etc)

Soy based formulas: Committee on Nutrition, American Academy of Pediatrics “Soy Protein-based Formulas: Recommendations for Use in Infant Feeding” (1/98)

• Safe, no advantage over cow milk based formulas for breastfed infant
• Indications: galactosemia, hereditary lactase deficiency
• Vegetarians
• Secondary lactose intolerance
• No value in prevention/management of colic
• Not recommended for preterm infants (< 1800 g)
• No value in prevention/management of atopic disease
• Infants w/ cow milk protein enteropathy/enterocolitis should not be given soy formula (high degree cross-reactivity)
• Infants w/ IgE mediated allergy to cow milk protein will often do well on soy formula

C. Variations on the theme

1.  Lactose free (Lactofree, Similac Lactose Free)

• Post gastroenteritis?
• Colic?

2.  Added rice (Enfamil AR)

• Anti-reflux – data?

3.  Diarrhea formula/Dietary fiber (Isomil DF)

4.  In-store brands

• Old formulations, limited R&D, no professional support
• Meeting Infant Formula Act standards reflects only amounts of nutrients; no implications for forms of nutrients (e.g. protein, fat blend, etc) or other immunologic factors (nucleotides)

A.  Indications

Semi-elemental formulas

• Protein intolerance/Allergic reactions
• Malabsorption

B.  Composition (infant vs > 1 yr)

• Protein hydrolysate (peptides + some free amino acids)
• Fat – MCT vs LCT; total fat (50 vs 30%)
• CHO – (Glucose polymers, sucrose)

C.  Examples:

• Nutramigen
• Pregestimil
• Alimentum
• Peptamen Jr – not intended for infants (fat 30% of kcal)

Elemental

A.  Indications

• Protein intolerance/allergic reactions
• Malabsorption

B.  Composition: Free amino acids +/- MCT; % kcal fat

C.  Examples:

• Neocate
• Pediatric Vivonex
• Neocate 1 ⁺
• EleCare

Expense is directly (exponentially?!) proportional to degree of specialization!!

 

Preterm formulas

1. Higher protein, micronutrient levels
2. Higher caloric density
3. C. Higher MCT
4. Human milk fortifier

 

Preterm follow-up formulas – (between term & preterm)

1. Neosure, Enfamil 22
2. Energy & Nutritional composition intermediate between preterm & standard formulas