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What is the gold standard for infant feedings?
- Human milk is the preferred source of enteral nutrition for infants including premature infants and sick newborns.
- The unique composition of human milk is “the gold standard” - the model for infant formulas.
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What is the composition of Infant Formulas?
- Protein – 8 – 12% of calories
- Fat - 43 – 49% of calories
- Carbohydrate – 41 – 43%
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What is the carbohydrate sources of lactose, sucrose, intermediate sugars (glucose, maltase, glucose oligomers) and starches?
- Lactose – Milk
- Sucrose – Cane, beets
- intermediate sugars (glucose, maltase, glucose oligomers)- Hydrolyis of corn or rice starch
- starches- corn, tapioca
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What type of carbohydrates are in term formulas?
100% lactose
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What type of formulas are in premie formulas?
50% lactose
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What is in lactose?
Lactose = galactose + glucose
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When do the major carbohydrate enzymes develop?
- Salivary amylase – 10 weeks
- Pancreatic amylase – 22 weeks
- Lactase – 24 weeks
- Glucoamylase – 24-28 weeks
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What is the osmolality of breastmilk?
300
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What is the side effect of formulas with a high osmolality?
Diarrhea, carbohydrate malabsorption
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What is the AAP recommendations for infant feedings osmolaity?
American Academy of Pediatrics recommendation is not to exceed 450 mOsm/kg water
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What is the osmolality of commercial formulas?
Commercially available infant formulas generally fall between 200 and 400 mOsm/kg water
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What is the osmolaity of high caloric formulas?
Osmolality of high calorie formulas may exceed 450 mOsm/kg water
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What is casein?
- An insoluble protein in suspension
- Coagulated by acid or remnet and forms a firm curd
- Primary component of cheese
- In high concentration can result can result in lactobezoar formation – like a hairball
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What is whey?
- Soluble, globular protein
- Forms small, soft curd
- Contains more cysteine than casein
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Compare the whey:casein ratio of breastmilk, cowsmilk and formula
- W:C
- Bst: 60:40
- Cowsmilk: 82:18
- Formula: 60:40
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What are the characteristics of soy proteins?
- A good quality plant protein with small amounts of sulfur containing amino acids and this is compensated for by using higher intake of this protein and/or supplementing with methionine
- Accompanied by phytic acid which reduces mineral absorption and this is compensated for by supplementing with increased minerals
- Also accompanied by anti-trypsin which reduces digestibility which is corrected by inactivating anti-trypsin
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What infant has to be fed soy formulas?
Galactosemia but they often times die before they are diagnosed
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How is antigenicity modified?
- Antigenicity is the ability of a certain substance to bind to certain products of adaptive immunity
- heat- disrupts the tertiary structure which generally decreases antigenicity
- hydrolysis – disrupts all structure and potentially eliminates antigenicity
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What is protein hydrolysis?
Decreases allergenicity and improves the rate of digestion
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What is partial protein hydrolysis?
Modest decrease in antigen load but some antigens that are dangerous to a sensitized person remains
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What is the result of protein Hydrolysate
- Casein has molecular weight of 70,000 daltons and whey can reach 150,000.
- Casein is incubated with enzyme until very few peptide bonds remain
- Average peptide molecular weight is about 200 with less than 1% having molecular weight > 500 and none detectable above 1200 daltons
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Why is casein used as a protein soarce in formulas
- It is thought to be the least allergic source of cows milk and can be broken down easier
- Whey is thought to be the cause of allergy in cows milk that’s why it isn’t used in hypoallergenic formulas
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What is extensive protein hydrolysis
- Virtually no antigens remain
- There is a balanced distribution of essential and nonessential amino acids
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What is crystalline amino acids
- A result of protein hydrolysis
- Antigen free
- Customized miz that can selectively eliminate an amino acid
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What is the Fatty acid profile of human milk
- No one vegetable fat source simulates the fatty acid pattern of human milk
- By combining vegetable fats, resultant blends can approximate the pattern found in human milk
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What are the undesirable effects of protein hydrolysis
- Increases free amino acids – causes an unpleasant taste
- Increases osmolality – large protein becomes many peptides and amino acids; replaces disaccharides with glucose oligomers to compensate
- Reduces fat emulsifying properties in formulas – starch is used as a substitute
- Increased cost
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What are Medium-chain Triglycerides
- Rapidly and easily hydrolyzed in the absence of pancreatic lipase and/or bile salts or when intestinal surface area is reduced
- 10 carbon atom chain length or less are known to be transported in unesterified form directly from the intestinal tract into the PORTAL circulation rather than via the LYMPHATIC system
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What are DHA and ARA and which formulas have it
- Present in breast milk
- Linoleic acid is the precursor of arachidonic acid (ARA)
- Linolenic acid is the precursor of docosahexaenoic (DHA)
- Mead Johnson = LIPIL
- Ross = Advance
- May be important for early brain development and visual acuity
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What are Long-chain Triglycerides
- Require bile salts and pancreatic lipase for digestion
- Provide essential fatty acids
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What is the partition of daily caloric expenditure in a typical growing premature infant?
120 cal/kg
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How do you increase calories in feedings?
- Verify accurate feeding order and intake
- Use HM with HMF or 24 kcal/oz formula
- Maximize volume tolerated for best nutrient mix before using additives
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What additives can be added to feeds to increase calories?
- Microlipid -long chain fatty acids, 4.5 kcal/mL
- MCT oil - medium chain triglycerides, 7.7 kcal/mL; should not be used in continuous feeds
- Polycose - Glucose polymers, 4 kcal per 1/2 tsp
- Rice Cereal - thickener for reflux or aspiration; amount used and effectiveness varies
- Powdered formula - 1/2 tsp per 50mL expressed HM= ~24 kcal/oz
- Similac Special Care 30 kcal/oz
- Beneprotein – 2.8 kcals per ½ tsp; source is whey protein
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What is Similac Advance Early Shield
– addition of oligosaccharides (prebiotic) which promotes growth of bifido “good” bacteria
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What is Nutramigen AA Lipil –
hypoallergenic amino acid based formula but with long-chain fats
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What is Nestle Good Start Premature
- Preterm Infant formula with hydrolyzed whey protein –
- 40% MCT
- 50% Lactose
- 50% corn syrup solids
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