“Pediatric Formula Basics”

CHOA Nutrition Support Core Seminar -Thanks to Kipp Ellsworth for organizing this series and sharing content. This lecture is a really good review and would be a great place to start when discussing formulas with medical students and residents.

Link to Webex (49 min): “Pediatric Formula Basics” by Clancy Bryant, MS, RD (March 2, 2021). Password: FbhSgup5

Also, can reach via: Our first Nutrition Support Core Lecture of 2021: “Pediatric Formula Basics” by Clancy Bryant, MS, RD-20210302 1810-1

Key points:

  • This lecture reviewed selection of formulas for infants, children and adolescents; some of the most common formula choices (but not all) were reviewed
  • This talk reviewed reflux guidelines as reflux symptoms often impact decisions on formula choice in infancy. Thickened formulas like Enfamil AR and Similac Spit Up do not work with acid suppression medications.
  • WIC resources (for children <5 years) -can identify through website: https://dph.georgia.gov/WIC/wic-formula-resources
    • WIC script requires 2 ICD-10 diagnosis which are relevant to chosen formula
    • For standard formula, no prescription is needed; if formula is not on WIC formulary, it will not be covered
    • If child is NPO, write for “patient is NPO, please give maximum formula”
  • For cholestatic liver disease: high MCT formulas include pregestamil (55%), Alimentum (33%) and elemental formulas (33-49%)
  • For chylous effusions, very high MCT formulas (83%, 84%) include enfaport and monogen (needs EFA supplementation)
  • Formulas for children and adolescents come in concentrations of 0.6 kcal/mL to 2.0 kcal/mL
    • Reduced calorie formulas (eg. Pediasure Reduced Calorie or Compleat Pediatric Reduced Calorie) are helpful to provide adequate micronutrients/protein in children with hypocaloric needs
  • Blenderized formulas often helpful for children with retching (when given via gastric route); some of these may increase vitamin A levels and beta-carotene (eg. Nourish, Compleat Pediatric Organic Blends). Real food blends are not nutritionally-complete. Harvest is able to run through enteral tube without dilution.
    • For those older than 10 years of age, Liquid Hope is similar to Nourish and Compleat Organic Blends is similar to Compleat Pediatric Organic Blends
  • Low electrolyte formulas, like Renalcal and Renastart, may be useful for children with kidney dysfunction. Corresponding formulas for >10 years of age include Suplena and Novasource Renal
  • Kate Farms is often a good choice for patients with multiple allergies or eosinophilic esophagitis

Some of the slides:

Formulas for 1-10 years of age.

Adult formulas (>10 years):

Related blog posts:

Nutritional Anemia -Expert Review

At Children’s Healthcare of Atlanta, there has been a long-standing nutritional lecture series coordinated by Kipp Ellsworth.

A recent webinar: Link to WebEx (password PmSU6JPt): Nutrition Support Colloquium featuring Dr. Parmi Suchdev: “The Prevention, Diagnosis, and Treatment of Nutritional Anemia” (30 minute lecture)

Dr. Parmi Suchdev affiliations:

  • Associate Director, Emory Global Health Institute
    Director, Global Health Office of Pediatrics
    Professor of Global Health, Rollins School of Public Health
    Professor of Pediatrics, Emory University School of Medicine

Here are a few of the slides:

Related blog posts:

Disclaimer: This blog, gutsandgrowth, assumes no responsibility for any use or operation of any method, product, instruction, concept or idea contained in the material herein or for any injury or damage to persons or property (whether products liability, negligence or otherwise) resulting from such use or operation. These blog posts are for educational purposes only. Specific dosing of medications (along with potential adverse effects) should be confirmed by prescribing physician.  Because of rapid advances in the medical sciences, the gutsandgrowth blog cautions that independent verification should be made of diagnosis and drug dosages. The reader is solely responsible for the conduct of any suggested test or procedure.  This content is not a substitute for medical advice, diagnosis or treatment provided by a qualified healthcare provider. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a condition

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.