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

Rarely Seen and “Do Not Miss” Explanation for Failure to Thrive

A fascinating case report (MA Curran et al. NEJM 2017; 377: 1468-77) provides a useful exercise in understanding how to evaluate difficult cases of “failure to thrive.”

From NEJM twitter feed

In essence, a 19 month girl with good linear growth had stopped gaining weight around 7 months of age.  After exhaustive evaluation, detailed in this report, the patient had an MRI which revealed a brain tumor and she was diagnosed with diencephalic syndrome. Key features include good appetite/caloric intake, happy appearance, and cachexia.

The discussion explains that in most children, poor weight gain results from poor caloric intake, which can be related to social issues including poverty, neglect, parental mental health issues, and lack of understanding by caregivers.

In children with good caloric intake, the potential reasons for poor growth are reviewed:

  • Endocrine causes: thyroid dysfunction
  • Renal, pulmonary, cardiac, liver, and pancreatic disease
  • GI diseases: Celiac disease, Inflammatory Bowel disease
  • Infections including tuberculosis, parasites, HIV

Despite the numerous potential causes, beyond basic laboratory assessment,  “extensive testing is usually not warranted: in one study, only 1.4% of additional laboratory tests were helpful in making the diagnosis.”

In many cases of diencephalic syndrome, symptoms like vomiting may be present on an intermittent basis as well as nystagmus or strabismus; these symptoms develop due to obstructive hydrocephalus.

My take: In children with good caloric intake, diencephalic syndrome is a rare but important etiology.



Nutrition Symposium Georgia AAP (Part 3)

Along with Kylia Crane, I presented the final lecture at this year’s Georgia AAP Nutrition Symposium: Optimizing Nutrition and Formula Selection in Toddler’s and Children.  Kylia is a nutritionist and dietician at the Georgia AAP who works on a multitude of projects to enhance nutrition for pediatric patients across the state.  This lecture was intended as a practical review of feeding problems and poor growth.

After a brief discussion of some basic feeding principles, the lecture focused on specific case presentations and then reviewed formula selection.  At the end, I quickly mentioned some of the big nutrition stories for 2015. The entire talk will be available at the Nutrition4Kids website.

Here are some of the slides:

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Additional resources that I discussed:


—Ellyn Satter:

  • —“Child of Mine”
  • —“The Secrets of Feeding a Healthy Family”

—Laura Jana/Jennifer Shu:

  • —“Food Fights”

In the lecture, I credited some of the material to Dr. Praveen Goday who shared his slides from a previous lecture.  In addition, I am grateful to Dr. Seth Marcus who provided input into the lecture content.

Related blog posts:



N2U -Part 2: Poor Growth and Short Bowel Syndrome

Chicago -from Lincoln Park

Chicago -from Lincoln Park

2015 N2U Syllabus & Presentations

Failure to Thrive –Praveen Goday

These sessions were case-based learning.

Case 1

2 mo birth weight 4.5 kg, taking 80 cal/kg/day –20 cal, formula-fed.  Taking 8 gm/day

What to do?

Point –If infant has a high birth weight (relative to height), there is a tendency to drop significant percentiles.  Often, careful observation is best approach. (Taal et al. Obesity. 2013;21:1261-8.)

Case 2: 14 mo birth weight 2.2 kg (at term), weight and length below the 3rd percentile but tracking. Weight-for-length is at the 25th percentile.

What to do?

For SGA babies, ensure adequate calories, avoid juice, ensure no GI symptoms, follow their growth

Case 3: Patient born at 36 weeks gestation, birth weight 3 lb. 14 oz. lbs., birth length 17 in.; Growth was a consistent problem throughout pregnancy; Dysmorphic; genetic workup – negative (Growth curves on pg 72-73 of syllabus).

More data: Taking 27 cal/oz, high-calorie baby foods, no GI symptoms, screening labs negative.  What are your options?  Make sure the length is accurate.  If the weight-for-length is really decreasing, then probably a trial of nasogastric feedings.  In Milwaukee, AMT bridle is often used to prevent dislodgement youtube video (7:37 min), uses magnets.  Still, tubes need to be changed month.  The AMT bridle can work for tubes as small as 5 Fr.

Practical definition of Failure to Thrive:

  • Weight-for-length <2nd percentile (WHO growth chart for kids <2 yrs) or BMI ❤rd percentile. BMI more problematic in infants because of accuracy of length. If any inaccurate measurement, BMI value squares the length value; thus exponentially inflating any discrepancy.
  • Poor or no weight gain over a period of time that varies according to the age of the child
  • Significant downward trend in weight percentiles; however, 30% of full-term infants cross one percentile and 23% cross two percentiles between birth and 2 years of age
  • Keep in mind parental heights and correction for prematurity (where applicable).

Key points:

  • Large for gestational infants often have “catch-down” growth. Avoid overly aggressive nutritional intervention
  • In small infants who are growing steady and with good wt-for-ht, avoid overly aggressive nutritional intervention.
  • Older kids with poor growth –screening labs: TTG IgA, IgA, CBC, ESR, CMP, TSH, Urinalysis, and possibly fecal elastase.
  • Older kids with poor growth—1st steps: avoid juices, avoid grazing (no feeding outside mealtimes except water)/scheduled meals & snacks, and probably cyprohepatadine. Management: Have child sit at table for 20 minutes, feedings every 3 hours, and avoid force feeding.
  • In children with history of prematurity under 32 weeks gestation who do not catch up by ~6 months of age — usually never catch up.
  • In infants/children with highly selective diets, may be presentation of autism. Often, an approach in those with food selectivity is to start by offering only foods the child used to eat (for a day) and see if this will work (should be safe for at least one day).

Short Bowel Syndrome –Valeria Cohran (pages 9-20 in syllabus)

Case:  3 ½-year-old AAF who presents for a second option. She is a former 26-week infant who had NEC. She has approximately 45 cm of residual bowel anastomosed to the transverse colon.

  • TPN-dependent
  • Minimal oral intake
  • Diarrhea up to 60 ml/kg with Enfacare


GI Fluid losses –see page 15 of syllabus (Wessel et al Semin Perinat 2007; 31: 104-11).  Sodium losses ~140 mEq/L from stomach, 80-140 mEq/L from ileostomy –in comparison, normal stool with sodium of ~5 mEq/L.

Key points:

  • Normal intestinal length varies greatly by gestational age; so residual 45 cm length in a 26 week infant suggests much greater potential for improvement than 45 cm length in a full term infants (page 14 in syllabus).
  • Avoid probiotics in patients with central lines.
  • Sodium depletion (urine sodium <10) associated with poor growth. Probably urine sodium >20 is adequate. Though, if high urine potassium (more than double urine sodium), this could indicate that urine sodium is retained at the expense of spilling potassium (ie. May need more sodium) Related post: Don’t Forget to Check Urine Sodium | gutsandgrowth
  • Pectin (liquid) can be helpful: 1% of volume intake. Benefiber can be helpful –expensive. Related blog post: Green beans for short gut syndrome | gutsandgrowth
  • Bacterial overgrowth –treatment can help diarrhea. Try to minimize PPIs –6 months after resection (period of gastric hypersecretion). Cholestyramine is not a popular option due to trouble with usage. Related post: Rehabilitation for Short Bowel Syndrome | gutsandgrowth
  • Micronutrient/vitamin monitoring. Page 16 in syllabus lists the micronutrient concentration of parenteral products and RDAs of micronutrients. “Don’t take copper out of TPN” –unless high level. ‘Worry some about micronutrient deficiency while on TPN but perhaps worry even more when transitioning off.’ Ubesie et al J Pediatr 2013 162: 1692-96. 93% anemic in this study of transitioning off TPN (iron,copper, other causes –pg 18 in syllabus). Related blog posts:Missing ingredients in TPN -Case Report | gutsandgrowth and TPN Drug Shortages -A Useful Reference | gutsandgrowth
  • B12 deficiency. If high MMA (likely due to B12 deficiency), then B12 shots recommended. B12 important for cognition. Related posts: Are we missing Vitamin B12? | gutsandgrowth and What I Didn’t Know About Vitamin B12 and Crohn’s Disease …
  • Iron deficiency. Consider anastomotic ulcers/ulceration of STEP procedure.
  • Lipid minimization/fish oil lipid formulations
  • Follow kids even after coming off TPN –at least annually. These kids can develop problems many years later.

More related posts:

Disclaimer: This blog entry has abbreviated/summarized this presentation. Though not intentional, some important material is likely to have been omitted; in addition, transcription errors are possible as well.

These blog posts are for educational purposes only. Specific dosing of medications/diets (along with potential adverse effects) should be confirmed by prescribing physician/nutritionist.  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.










Don’t Forget to Check Urine Sodium

In patients with short bowel syndrome and excessive ostomy losses, salt depletion is associated with failure to thrive.  An easy way to screen for this is checking a “spot” urine sodium level; a urine sodium <10 mmol/L is too low.  While this has been recognized in infants for a long time, a recent case report shows that this can be an issue for older children (up to 19 years) as well (Nutr Clin Pract 2014 vol. 29 no. 397-401 -thanks to Kipp Ellsworth’s twitter feed for this reference & link: http://goo.gl/TkjKyd).

The authors conclusion: “We advise that patients of all ages with high stoma output have routine urine sodium levels checked, particularly in the setting of weight loss or poor gain. Furthermore, instances of TBSD [total body salt depletion] should be treated with sodium supplementation.”