High Calorie Infant Formula

Our office has participated in research for a 30 cal infant formula that is heading to the market in 2021. Nutricia is calling the formula Fortini. Link to website: Fortini (I have no financial ties/interest to this product or company).

I think having a commercial high calorie infant formula is advantageous and overcomes some of the limitations of concentrating infant formulas. Advantages:

  • This formula will eliminate problems with incorrect mixing and contamination. Despite careful oral and written instructions, many parents incorrectly prepare high calorie formulas
  • This formula, compared with concentrating a standard formula, is likely to have improved tolerability (less hyperosmolar) and better nutrient balance (eg. proper protein content)

The main potential disadvantage is going to be cost. I do not know the cost of the new formula but would be surprised if it is not significantly higher than concentrating a standard formula. At the same time, if the formula is able to improve tolerance and improve poor growth, there could be ‘downstream’ savings with less medical intervention/hospitalizations.

Related blog post: Rarely Seen and “Do Not Miss” Explanation for Failure to Thrive

Chattahoochee River. Sandy Springs, GA

NY Times: “U.S. Diet Guidelines Sidestep Scientific Advice”

NY Times (12/29/20): U.S. Diet Guidelines Sidestep Scientific Advice

An excerpt:

“Rejecting the advice of its scientific advisers, the federal government has released new dietary recommendations that sound a familiar nutritional refrain, advising Americans to “make every bite count” but dismissing experts’ specific recommendations to set new low targets for consumption of sugar and alcoholic beverages...

The dietary guidelines have an impact on Americans’ eating habits, influencing food stamp policies and school lunch menus and indirectly affecting how food manufacturers formulate their products…

The new guidelines do say for the first time that children under 2 should avoid consuming any added sugars, which are found in many cereals and beverages.”

USDA Website: Dietary Guidelines for Americans

Related article: NY Times (Print edition 12/27/20) Obesity Rates Soar in China and Officials Take Action. Online (12/24/20): Influencers May Face Fines as China Tackles Obesity and Food Waste An excerpt:

“34.3 percent of adults were overweight and 16.4 percent were obese. It looked at a group of 600,000 Chinese residents between 2015 and 2019. By comparison, 30 percent of Chinese adults were overweight and 11.9 obese in 2012…obesity among American adults has increased 12.4 percent over the past 18 years, with 42.4 percent of adults in the United States now living with the condition.

Related blog posts:

5 Signs Your Child Needs a Feeding Tube

The Nutrition4Kids website (developed by my partner Stan Cohen) has a lot of useful information for families. Here is a link to a recent addition: 5 Signs Your Child Needs a Feeding Tube

An excerpt:

Reasons for needing a feeding tube…

  • Medical necessity, where the child can’t meet their calorie needs due to a medical condition (like, say, a heart defect, neurologic and neuromuscular disorders, or a digestive disorder.)
  • Failure to thrive, often because of food aversions…
  • Trouble learning to suck, swallow, and breathe

Here are some of the most common signs your child may benefit from a feeding tube.

  • Sign #1: Your Physician Brings It Up 
  • Sign #2: You’ve Noticed Development Delays 
  • Sign #3: They’re Malnourished or Chronically Dehydrated
  • Sign #4: You’ve Tried Other Options Without Success
  • Sign #5: You’re Feeling Helpless as the Caregiver

If your child does end up needing enteral nutrition, understand that it doesn’t always mean it’s a forever situation.

Related blog posts:


www.feedingtubeawareness.com  This site contains a terrific PDF download which explains enteral tubes in an easy to understand style along with good graphics. “What You Need to Know Now, A Parent’s Introduction to Tube Feeding is the guidebook that every parent wished they had when they were first introduced to feeding tubes.”

Does SMOFlipid Improve Neurocognitive Outcomes?

M Thanhaeuser et al. J Pediatr 2020; 226: 142-148. A Randomized Trial of Parenteral Nutrition Using a Mixed Lipid Emulsion Containing Fish Oil in Infants of Extremely Low Birth Weight: Neurodevelopmental Outcome at 12 and 24 Months Corrected Age, A Secondary Outcome Analysis

This study evaluated neurodevelopmental outcomes using Bayley Scales. the authors provided a secondary outcome analysis of a double-blind randomized trial of 206 extremely low birth weight infants.  Participants received either SMOFlipid or soybean oil-based lipid. Lipids were dosed at </+ 3 g/kg/day.

Key findings:

  • Parenteral nutrition using a mixed lipid emulsion (SMOF) containing fish oil did not improve neurodevelopment of extremely low birth weight infants at 12 and 24 months corrected age
  • At 24 months of age, specifically, there was again no significant differences in any of the following areas (median values):
    • cognitive: SMOF: 95 & soybean oil: 95
    • language: SMOF: 89 & soybean oil 89
    • motor scores: SMO 94 & soybean oil: 94

Limitations: One of the reasons why this study did not find any difference is that it was not powered for assessment of neurodevelopmental outcomes. The authors provide other potential reasons:

  • DHA in SMOFlipid provided 43 mg/kg/d, while more than the soybean-lipid, is at the lower end of published fetal accretion rates (40-67 mg/kg/day)
  • DHA deficits may not have been pronounced enough in this study to see an effect of SMOFlipid on neurodevelopement
  • Full feeds were reached after 23 days (IQR, 17-37 days); thus, it is possible that infants with longer term dependency on parenteral nutrition would benefit more

My take: SMOFlipid has not been proven to have more favorable long-term neurocognitive effects than intralipid. However, for children with prolonged need for parenteral nutrition, SMOFlipid is more likely to allow full dosing which in itself may be an important contributor to better outcomes. That is, soybean-lipid emulsions are more likely to be reduced due to cholestasis and this could lead to nutritional deprivation.

Related blog posts:

How Helpful Are School-Based BMI Measurements?

KA Madsen et al. JAMA Pediatr. Published online November 16, 2020. doi:10.1001/jamapediatrics.2020.4768.Full text link: Effect of School-Based Body Mass Index Reporting in California Public Schools

Methods:  Cluster randomized clinical trial. The Fit Study (2014-2017) randomized 79 California schools (n=28 641 students) to BMI screening and reporting (group 1), BMI screening only (group 2), or control (no BMI screening or reporting [group 3]) in grades 3 to 8. The setting was California elementary and middle school

Key findings:

  • Among 6534 of 16 622 students with a baseline BMI in the 85th percentile or higher (39.3%), BMI reporting had no effect on BMI z score change (−0.003; 95% CI, −0.02 to 0.01 at 1 year and 0.01; 95% CI, −0.02 to 0.03 at 2 years)
  • Weight dissatisfaction increased more among students having BMI screened at school (8694 students in groups 1 and 2) than among control participants (5674 students in group 3).

My take: Tackling obesity will require a lot more than measuring BMIs. An interesting follow-up study would be to see if schools who reported BMIs were more likely to take other measures, such as providing nutritional counseling, improving school lunch selection, and providing opportunity for more activity/exercise.

Related blog posts:

“Leave Overweight Kids Alone”

Aubrey Gordon provides personal insight into the issue of weight stigma in her opinion piece: NY Times Leave Overweight Kids Alone

Here a few excepts:

The war on childhood obesity reached its zenith with the 2010 introduction of the national “Let’s Move!” campaign, “dedicated to solving the problem of obesity within a generation.” It was a campaign against “childhood obesity” — not specific health conditions or the behaviors that may contribute to those health conditions. It wasn’t a campaign against foods with little nutritional value, or against the unchecked poverty that called for such low-cost, shelf-stable foods. It was a campaign against a body type — specifically, children’s body types.

In 2012, Georgia began its Strong4Life campaign aimed at reducing children’s weight and lowering the state’s national ranking: second in childhood obesity. Run by the pediatric hospital Children’s Healthcare of Atlanta, it was inspired in part by a previous anti-meth campaign. Now, instead of targeting addiction in adults, the billboards targeted fatness in children…The billboards purported to warn parents of the danger of childhood fatness, but to many they appeared to be public ridicule of fat kids…

Despite ample federal and state funding, multiple national public health campaigns and a slew of television shows, the war on obesity does not appear to be lowering Americans’ B.M.I.s. According to the Centers for Disease Control and Prevention, since 1999 there has been a 39 percent increase in adult obesity and a 33.1 percent increase in obesity among children.

Weight stigma kick-starts what for many will become lifelong cycles of shame..Yet, despite its demonstrated ineffectiveness, the so-called war on childhood obesity rages on. This holiday season, for the sake of children who are told You’re not beautiful. You’re indulging too much. Your body is wrong. You must have done it, I hope some parents will declare a cease-fire.

Related blog posts:

Isle of Palms, SC

Bariatric Surgery Reduced Obesity’s Premature Death from 8 years to 5 years in SOS Study

A recent study (LMS Carlsson et al. NEJM 2020; 383: 1535-43) was summarized in a quick take. Essentially, obese subjects who underwent bariatric surgery survived three years longer than a control group who had not undergone surgery but lived 5 years shorter than a reference group without obesity.

The authors speculate on the reasons why the bariatric subjects continued to have a lower life expectancy than controls after surgery:

  • Above-normal BMI even after surgery
  • Irreversible effects of obesity-related metabolic dysfunction
  • Surgical complications
  • Higher risk of alcohol abuse, suicide, and trauma (including fall-related); these factors were identified in the SOS study more often than in those who had not undergone bariatric surgery

Since there have been improvements in bariatric surgery since the time of this cohort underwent surgery (1987-2001), it is possible that the average gain in life expectancy would be greater.

Here are a few screenshots:

Nutrition4Kids and Nutrition4IBD

My colleague and partner, Stan Cohen, along with his outstanding advisory board, have put together two terrific (free) resources for both children and adults:

Both are up-to-date, user-friendly, authoritative and attractive websites that feature advice families can trust to help them understand their disease and options to live as full a life as possible. Between the two, there are:

  • Over 700 articles
    • Nutrition4Kids Categories: Eating at different ages, Healthy lifestyle, Nutrients, Diseases and disorders and Patient experience
    • Nutrition4IBD Categories: Understanding IBD, Treatment Options, Nutrition for IBD and Patient options.
  • Over 60 videos including 35 on food allergies (including FPIES and eosinophilic disorders) and 14 on tube-feedings, including one about a lacrosse player that is quite inspirational.
  • Amazing tools:
    • A food log and a symptom diary that patients can download to record how they are doing
    • a BMI calculator
    • a table of milk alternatives (created by our nutritionist Bailey Koch)
    • a tool which provides over 150,000 food labels for restaurant and packaged foods.
    • a cool tool where a patient can indicate their age, gender, whether they’re breastfeeding or pregnant (even which trimester they’re in), and it will tell what’s in over 200,000 foods and what nutrients and calories they need.
  • Healthy recipes with their nutrient values per serving.
  • This website relies on a group of 42 contributors including many from our group, psychologists, speech-language pathologists, nurses, dietitians, and families.
  • Other practices can link to our site, so they can share our medically-curated and accurate content and tools with their patient-families.

Building a Bigger (Better?) Brain in Premature Infants

A recent retrospective study (PE van Beek et al. J Pediatr 2020; 223: 57-63. Increase in Brain Volumes after Implementation of a Nutrition Regimen in Infants Born Extremely Preterm) with 178 infants (median gestational age 26.6 weeks) found that a modification in the nutritional regimen resulted in improved brain volumes.

Key findings:

  • In cohort B (new regimen), mean protein and caloric intake were 3.4 g/kg/d & 109 kcal/kg/day which were significantly  increased compared to Cohort A: 2.7 g/kg/d and 104 kcal/kg/d for first 28 days of life.
  • At 30 weeks gestational age, 22 brain regions were significantly large in cohort B compared with cohort A, though at term age equivalence, only the caudate nucleus remained significantly larger.
  • key limitation: brain MRI can only be performed in relatively stable neonates; thus, sicker infants may be underrepresented.

My view: Optimizing nutrition as early as possible is likely to help improve cognitive outcomes.

Related blog posts:

Other nutrition-related articles in this issue:

DL Harris et al. J Pediatr 2020; 223: 34-41. Glucose Profiles in Healthy Term Infants in the First 5 Days: The Glucose in Well Babies (GLOW) Study

  • In term infants, plasma glucose concentrations of 47 mg/dL (2.6 mmol/L) approximated the 10th percentile in the first 48 hours, and 39% of infants had ≥1 episode below this threshold.
  •  The mean glucose concentrations increased over the first 18 hours, remained stable to 48 hours (59 ± 11 mg/dL; 3.3 ± 0.6 mmol/L)] before increasing to a new plateau by the fourth day (89 ± 13 mg/dL; 4.6 ± 0.7 mmol/L).

WG Sharp et al. J Pediatr 2020; 223: 73-80. Intensive Multidisciplinary Intervention for Young Children with Feeding Tube Dependence and Chronic Food Refusal: An Electronic Health Record Review  Congratulations to my colleagues at the Marcus Center for this work, particularly Valerie Volkert who has worked with so many of our kids and Barbara McElhanon who has been so helpful.  83 patients with complex medical-behavioral-developmental problems met study criteria.  Key finding:  58 patients (72%) weaned from tube feeding at follow-up.

From Pitt Street Bridge Park, Mount Pleasant, SC


Nutrition ‘Mythbuster’ Webinar

A recent Children’s Healthcare Webinar by Hillary Bashaw reviewed several nutrition topics.  I took some notes and some screenshots.  Some errors of omission and transcription may have occurred.

Key points from talk:

  • Cow’s milk overall is a healthy beverage for children, though there are several plant-based alternatives that can be effective substitutes.  Soy milk and pea-protein milk are often the best alternatives.
  • Fiber from foods is the best way to get fiber.  Gummy fiber products are not recommended.
  • Eating breakfast likely helps with school performance; however, this does not mean it is the ‘most important’ meal of the day.

Related article: RJ Merritt et al. JPGN 2020; 71: 276–81. Full text link: NASPGHAN Position Paper: Plant-based Milks

  • One of the slides from this talk modifies the Table 1 (adds skim milk) from this article.
  • Milk‘s contribution to the protein intake of young children is especially important. For almond or rice milk, an 8 oz serving provides only about 2% or 8%, respectively, of the protein equivalent found in a serving of CM.”
  • “As presently constituted, almond, rice, coconut, hemp, flax seed, and cashew “milks” are inappropriate replacements for CM in toddlers and young children for whom milk remains an important part of the diet.”

Milkrelated blog posts:


Fiberrelated blog posts:


Breakfast-related blog posts: