Formulas in the NICU
Yvonne Sarson, MS, RD, CNSD
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
Nutrition Standards & Goals
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
Nutrition Goals
Term Infant
Enteral nutrition
Preterm Infant
Protein gm/kg
Kcal/kg
Protein gm/kg
Kcal/kg
2.2
108
3.5
120
100
3.5
110
Parenteral nutrition 3
Energy needs
Components of energy needs
Kcal/kg/day
BMR
40 - 62
Thermogenic effect of feeding
3 - 11
Activity
2- 4
Growth (15 gm/kg/day)
45 - 67
Total
90 – 130 (rarely 144)
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
Fluids to meet nutritional needsenteral 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
160 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
120 ml/kg/day
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
68
Premature Enfamil Lipil, 20 cal/oz
2
68
Elecare, 20 cal/oz
2
68
PN 3 g Pro/kg, D15% @115 ml/kg
2.6
61
PN 3.5 g Pro/kg, D17%@ 115 ml/kg
3
80
PN 3 g Pro/kg, D12.5% @ 135 ml/kg
2.2
69
PN 3.5 g Pro/kg, D14.5% @ 135 ml/kg
2.6
81
Formula Ingredient Primer



Carbohydrates
Proteins
Fats
 DHA
 ARA

Prebiotics vs Probiotics
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 (cont.)


Disaccharides –
 Lactose (glucose + galactose)
 Maltose (glucose + glucose)
 Sucrose (glucose + fructose)
Monosaccharides –
 Glucose
 Galactose
 Fructose
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
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,
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
2:1
Prebiotics vs Probiotics

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
Composition of Breast Milk and
Formulas
Human Breast Milk


Gold standard for modeling term infant formulas
Preferred source of enteral nutrition for all infants, including
premature and sick newborns


Protein – whey:casein ratio


Contraindications- galactosemia, congenital lactase deficiency,
maternal HIV or use of some medications
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
Human Milk Fortification

Commercial human milk fortifiers – cow’s milk based



for infants <34 weeks or <1500-1800 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




Commercial human milk fortifier – human milk based (Prolacta)




designed to increase to 22-24 cal/oz,
iron content varies
Ex. - Similac or Enfamil Human Milk Fortifier
Targeted for <1250 gm @ 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
Major Formula Brands

Enfamil (Mead Johnson Nutrition)



Similac (Abbott Nutrition)
Nestle Good Start (Nestle Nutrition)


Higher levels of DHA & ARA supplementation than Abbott; now
market standard with exception of Abbott
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)
Standard Infant Formulas

Protein –




CHO – Source-lactose
Fat –


Source – cow’s milk
Whey:casein ratio- 60:40 – 70:30, except Good Start (100%
partially hydrolyzed whey)
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
Premature Formulas

Protein  Source – cow’s milk protein – whey protein concentrate and non-fat milk


CHO 

Whey:casein ratio- 60:40
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
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
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)

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)
Term formulas with Probiotics
Examples
 Good Start Protect Plus
Bifidobacterium lactis
 Enfamil Nutramigen Lipil
with Enflora LGG–
Lactobacillus rhamnosus GG
(LGG)
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
Cow’s Milk – low mineral

Low mineral  Indications- hypocalcemia or renal failure
with hyperkalemia and hyperphosphatemia
 Similac PM 60/40
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
Partially hydrolyzed protein



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
Partially hydrolyzed protein
• 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
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
Elemental and Semi-elemental Formulas

Protein –



CHO –


Source- sucrose, modified tapioca starch, corn syrup solids, or
modified cornstarch
Fat –


slightly higher protein content than standard formulas
Source – casein hydrolysates and/or L- amino acids
Source – MCT, variety of vegetable and tropical oils
Indications – protein sensitivity and/or malabsorption
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
Elemental Formulas

Amino acids



Neocate (SHS)
Elecare (Abbott)
Nutramigen AA
(Enfamil)
Increased Caloric Density Formulas

Less water to powder


increases nutrient intakes
Additives

may decrease other nutrient intakes
Modular Additives



Protein  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 - 7.7 kcal/ml
 Microlipid (safflower oil
emulsion)- 4.5 kcal/ml
Dietary Supplementation
Vitamin D needs at NICU discharge
Feeding
Wt at discharge
Vitamin D
supplement dose*
Predominantly breastmilk
All
400 units
Term formula
< 6.2 kg.
200 units
> 6.2 kg
none
< 4.2 kg
200 units
> 4.2 kg
none
Neosure or Enfacare
•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)
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
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
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
Iron supplements

Iron source 



Formulas provide ~ 2 mg/kg/day elemental iron per 160
ml/kg/day
Growing, preterm infants @ 1-2 months or 2X BW.
Healthy, term infants @ 4-6 months
Dose (elemental iron)  Preterm = 4-6 mg/kg/day
 Term = 2 mg/kg/day
 Max= 15 mg/day of supplemental iron
Additional Issues
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
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
Sucrose containing formulas

Fructose absorption –not fully matured in young infant



Sucrose disaccharide (glucose+fructose)


Fruit juice malabsorption is dose dependent
Symptomatic malabsorption above 10 ml/kg/day
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
Formula company web sites
Mead Johnson
www.mjn.com
Nestle nutrition
www.nestleinfantnutrition.com
Abbott nutrition
Abbottnutrition.com
PBM nutritionals
www.brightbeginnings.com
Nutricia
www.neocate.com