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Ana Abad-Jorge, MS, RD, CNSC
Director, Dietetic Internship Program
PICU Nutrition Specialist
University of Virginia Health...
Learning Objectives
Identify major diagnoses that predispose infants and
children to GI impairment and malabsorption
Dis...
Severe GI impairment & resulting malnutrition
can occur as a result of the following:
Malabsorption as a result of a defi...
Challenges in Managing GI Impairment
in Pediatric Patients
Often difficult to determine whether an intact versus a
hydrol...
Formula Comparison Studies in Severe
GI Impairment: BASIC DEFINITIONS
Formula Type Macronutrient Content
Elemental
(Monome...
Factors Impacting EN
Management of SBS:
SBS characterized by: diarrhea, malabsorption,
fluid and electrolyte disturbances...
Guidelines for EN Initiation and Delivery
After initial course of parenteral nutrition, EN is best
administered via conti...
Controversy Surrounding Enteral
Formula Selection in SBS
Historically, elemental, semi-elemental or peptide-
based formul...
What about formula selection
in infants & children?
Limited randomized clinical trials comparing
effectiveness of polymer...
Limited Evidence Comparing Polymeric to
Hydrolyzed Formula in Pediatric SBS
Study: Ksiazyk, J. et al. (2002) J Pediatric
...
Summary: EN Recommendations
in Children with SBS
Depending on extent of bowel resection and function of
the remaining gut...
Enteral Nutrition in Children
with Cystic Fibrosis
Indications: Patients who remain in nutritional failure
despite use of...
Enteral Formula Selection
in Cystic Fibrosis
Standard polymeric formulas are usually tolerated as
well as elemental or pe...
Enzyme Dosing in Nocturnal EN
Source: Practical Gastroenterology, 2005
Method Dosing
Meal Dosing
Method
•“Meal dose” of 15...
Factors Contributing to Growth
Failure in Crohn’s Disease
Multifactorial etiology
Consequences of gut inflammation
Most...
Effect of EN Protein on Crohn’s Disease
Remission: Use of elemental formulas
Rationale: chemically synthesized amino acid...
Review of EN Formula Studies
in Crohn’s Disease
Study Study Design Results
Rigaud et al.
1991
(Adult Study)
Prospective st...
Enteral Nutrition Therapy for Inducing
Remission in Crohn’s Disease
Cochrane Database Systematic Review 2007; (1):
CD00054...
Effect of Enteral Nutrition Fat on Crohn’s
Disease Remission
Omega-6 PUFAs: precursor of arachidonic acid
Leads to incre...
Study: Dietary Fat Attenuates Role of EN in
Crohn’s Remission: Bamba et al. 2003
Sample: 28 patients randomized to low fa...
Summary of Formula
Selection Guidelines:
Short Bowel Syndrome: Depending on degree of
bowel resection, function of remain...
“Our” Approach to EN Management of
Severe GI Impairment
“Based on lack of clear data showing a definitive
advantage to sta...
•Breast milk
•Semi-elemental
•Elemental formulas
Use of Breast Milk in Severe
GI Impairment
Study: Andorsky et al, 2001, J Pediatr
Design: Retrospective chart review amo...
Hydrolyzed Formulas for Use in Infants with SBS
or Severe GI Impairment (0.67 kcal/ml)
Nutrient Pregestimil Lipil Alimentu...
Elemental Formulas for Use in Infants with SBS,
Severe GI Impairment or Allergy
(Powdered, not available commercially, ord...
Infant Formulas: Cost Comparison
(Costs may vary based on location)
Formula Name Cost per 100 kcal
Enfamil Lipil $0.72
Sim...
Hydrolyzed Formulas in
Children > 1 year: How to Select
Indicated for children > 1 year of age, who have severe
malabsorp...
Hydrolyzed Formulas for Use in Children with
SBS or Severe GI Impairment (1.0 kcal/ml)
Nutrient Peptamen Junior Pepdite Ju...
Elemental Formulas in
Children > 1 year: How to Select
Indicated for the young child whose severe GI
impairment is relate...
Elemental Formulas for Use in Children with
SBS, Severe GI Impairment or Allergy (Powder Base)
Nutrient Neocate One +
(1.0...
Infant
Yes
No
Normal GI
Function?
Normal GI
Function?
Yes Yes
Standard
Pediatric
Formula
(PediaSure)
Standard
Infant
Formu...
Summary & Conclusions
The literature does not clearly support the
advantages of semi-elemental or elemental
formulas over...
Summary & Conclusions
First, start with a semi-elemental or hydrolyzed
formula (less expensive than elemental)
If malabs...
References
References available as a handout.
All proprietary product information was
obtained from the manufacturer’s w...
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Abad Jorge 336 Fnce Ppt Handout

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Nutrition Management of Pediatric Patients with Severe GI Impairment

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  • Review slide
  • Malabsorption occurs with Crohn’s as a result of severe inflammation and ulcerations to the gut mucosa, with the resulting damage leading to malabsorption; 2) Maldigestion of macronutrients is a direct result of insufficient levels of pancreatic enzymes or bile salts as seen in CF, or due to bacterial overgrowth as seen in SBS; 3) increased intestinal losses of fluid, electrolytes, fats & protein through diarrhea and cholerheic diarrhea occurs in SBS and Crohn’s; 4) Infections and inflammation increase metabolic rate and energy requirements.
  • For the pediatric nutrition practitioner it is often challenging to determine the optimum formula to manage these children with GI impairment and malnutrition. Should an intact formula, a hydrolyzed or semi-elemental formula or an elemental, amino acid based formula be used. Moreover, it is often challenging to determine the optimum distribution of carbohydrates, fats and proteins. Might that optimal distribution vary depending on the disease state and etiology of the malnutrition? What we have come to find in clinical practice is that indeed that overall clinical course and nutritional outcomes are impacted by numerous factors and most important, this can vary significant from one patient to another. Today, we will focus on severe GI impairment requiring specialized EN in SBS, CF, and Crohn’s. My colleague, Brandis, will also cover the use of prebiotics and probiotics in these disease states in addition to ulcerative colitis, irritable bowel syndrome and cow’s milk protein allergy.
  • Elemental formulas, also known as monomeric, are comprised of individual amino acids, glucose polymers and are typically low in fat, with some containing only 2-3% of fats as LCT. Elemental formulas also contain part of the fat as MCT oil, consisting of 8 – 12 carbons in length, which for the most part are directly absorbed into the hepatic portal vein in the absence of lipase or bile salts. Semi-elemental, partially hydrolyzed formulas, also called oligomeric, consist of predominantly casein and lactalbumin hydrolysates with peptides of varying length, including di- and tri-peptides. These peptides have specific uptake mechanisms thought to be absorpbed more efficiently than amino acids alone (Silk et al. 1980). Polymeric or standard formulas consist of intact proteins, complex carbohydrates and mainly LCTs. Other formula categories including specialized or immunonutrition formulas contain biologically active substances such as glutamine, arginine, nucleotides and a higher level of omega-3 fatty acids such as EPA and DHA.
  • Review slide information on 1st bullet. Add … Peds patients with SBS tend to be considered the ideal candidates for elemental and semi-elemental formulas. However, there are various factors impacting the clinical course and nutritional management course and outcomes such as …. Review information.
  • Additionally, early introduction of partial intermittent feeds helps with oral-motor stimulation and normal feeding development in neonates, and the release of gut hormones which help promote gut adaptation.
  • However, research in the 1980s and 1990s in adult patients found no difference in nitrogen and total caloric absorption between semi-elemental and standard or polymeric formulas. But what about formula selection in children? Children, in general, have a higher risk or propensity for GI intolerances and food hypersensitivities or allergies. However, there are indeed advantages to providing complex nutrients found in polymeric or standard formulas in SBS, and that is that the complex macronutrients can help stimulate intestinal adaptation.
  • Review slide. Another key reason for using elemental and semi-elemental formulas in infants and children under 2 with SBS is that they have a greater incidence for allergic responses. Food allergy, particularly CMA, affects between 2-3% of infants. Young infants are more susceptible to developing food allergies due to immaturity of gut barrier and immune function. Additionally, bacterial overgrowth, which is common in SBS, predisposes infants to allergies.
  • In 2002, Ksiazyk et al conducted a prospective randomized cross-over double blind study in 10 children with SBS comparing clinical outcomes on a non-hydrolyzed vs. a hydrolyzed formula. The study lasted 60 days, and the cross-over day was day #31. Each child served as their own control. The average age was 4 + 2.45 years. The results of the study were that energy intake from EN was the same in both groups (31% of total intake). There were also no differences in nitrogen balance and intestinal permeability, as measured by lactulose-mannitol excretion ratio (glucose absorption test) given on days 1, 31 and 60.
  • Review slide
  • CF transition. Current standard of care for initiating EN in patients with CF is to do so in those children who remain in nutritional failure despite use of high calorie supplements and pancreatic enzymes.
  • In a study conducted by Erskine et al. in 1998 at Children’s Hospital Denver CF clinic, 16 children ranging in age between 4 – 20 completed two 6 day nocturnal TF trials of a non-elemental formula (Isocal) and a semi-elemental formula (Peptamen) offered in random order. During the Isocal feeding period, enzyme replacement was administered before and after the tube feedings. A total of 44% of total daily energy needs was consumed as TF and the remaining consisted of oral dietary intake. This remained constant throughout the study. The investigators looked at 72 hour fecal fat collections for each study period and analyzed for total fat, LCFAs and MCFAs. Fat absorption was 80% during the Peptamen period and 82% during the Isocal feeding period. All patients tolerated all the feedings with tolence measured by stool frequency, consistency, flatus, cramping. Also, weight gain was 1.8 + 0.3 kg with no difference between the trial periods.
  • Review slide. From my communications with our CF nutritionist, Viokase powder, however, is no longer available, and as of September of this year there was only a 5-6 month supply. However, there is an alternative enzyme powder called Zenpep, manufactured by Eurand, which will be available.
  • Malnutrition and growth failure in pediatric Crohn’s occurs in those children with severe Crohn’s, resistant to conventional medical therapy such as anti-infalmatories, steroid therapy. Crohn’s medical therapy, however, has improved significantly over the past 10 years with the advent of biologic therapy, consisting of TNF-alpha blockers such as Humira. The prevalence of nutritional failure and the need for EN for disease remission and reversal of growth failure, is no longer as prevalent as it was 10 – 15 years ago. In Crohn’s disease, the increase in pro-inflammatory cytokines such as IL-6 and TNF alpha interfere with IGF-1, which is a key mediator of growth hormone, and thus linear growth in children.
  • Giaffer et al. found a significantly higher clinical remission rate of 75% versus 36% in patients on the elemental formula Vivonex versus a polymeric formula, Fortison, after 10 days of feeding. However, these findings have not be replicated in subsequent studies.
  • Rigaud et al. found not significant difference in clinical remission rates based on CDAI scores measured during the last 7 days of a 28 day feeding period. With the Ludvigson et al studied in pediatric patients, conducted in Sweden, no significant differences in remission rate were found at 6 weeks, using intention to treat analysis. Remission rates were 69% in the elemental group and 82% in the Nutrition Standard group.
  • This systematic review aimed to provide an update on existing efficacy data for both corticosteroids versus EN and for one form of EN versus another for inducing remission of active Crohn’s disease. Avoiding dietary protein is unlike to be the mechanism by which EN induces Crohn’s remission.
  • Another macronutrient effect on EN induced remission rates which I would like to briefly touch on is the role of fat composition, that is omega-6 versus ombega-3 content of the formula. Some researchers have hypothesized that the beneficial effect of EN on Crohn’s disease may be in part due to the fat content of the formula. The theory is that omega-6 PUFAs are a precursor to arachidonic acid and lead to an increased production of inflammatory eicosanoids and thus accentuate the inflammatory response. Omega-3 PUFAs, however, serve as precursors to EPA and DHA, which serve as precursors to the less inflammatory mediators, which may be protective in Crohn’s.
  • Review of slide
  • Review of slide
  • Breast milk may not be the intuitive first choice for the clinician who is making feeding decisions for infants with GI impairment. However, Andorsky and colleagues found in a retrospective chart review that in 30 SBS infants, the percentage of days fed with breast milk was negatively correlated with duration of PN use. Also the man number of days (290 days) on PN was significantly lower in breast-fed infants compared with those fed formula (720 days).
  • However, in the event that an infant with SBS or other severe GI impairment does not tolerate standard infant formula or BM, a semi-elemental formula such as Pregestimil Lipil or Alimentum Advance can be used as the next logical choice. Discuss formula composition and subtle difference in the MCT versus LCT composition of Pregestimil versus Alimentum.
  • On those rare occasions when an semi-elemental formula is not tolerated, an elemental formula such as Neocate Infant or EleCare may be used. These formula are most commonly indicated for use in infants with severe protein allergy as opposed to severe GI impairment seen in the conditions we have discussed today. EleCare may be used in infants as well as children over 1 year of age.
  • As previously mentioned, standard formulas are more cost-effective than semi-elemental and elemental formulas, and this holds true for both infant and pediatric formulas. This table reviews cost comparisons of infant formulas ranging from standard formulas, semi-elemental or partially hydrolyzed and elemental.
  • Review of slide
  • Let’s review two semi-elemental pediatric formulas, which we have used in pediatric patients with GI impairment. Notice the variations in caloric distribution between carbohydrate and fat. For some children, this subtle variation may cause a difference in tolerance.
  • Review slide.
  • Review subtle compositional differences between Neocate One+ and Neocate Junior, with Neocate One+ having a higher percentage of calories from carbohydrate and Neocate Junior having a higher percentage of calories from fat (46% versus 32%).
  • Review presentation conclusions.
  • Review presentation conclusions.
  • Transcript of "Abad Jorge 336 Fnce Ppt Handout"

    1. 1. Ana Abad-Jorge, MS, RD, CNSC Director, Dietetic Internship Program PICU Nutrition Specialist University of Virginia Health System Food Nutrition Conference & Expo 2009 October 20th 2009
    2. 2. Learning Objectives Identify major diagnoses that predispose infants and children to GI impairment and malabsorption Discuss the available research & controversy surrounding formula selection based on level of protein hydrolysis Discuss the advantages of breast milk for use in neonates with GI impairment Review available elemental and semi-elemental infant and pediatric formulas for use with patients with persistent GI impairment despite trial of intact protein formula Discuss current guidelines for enteral formula selection in pediatric patients with GI impairment based on age and degree of impairment.
    3. 3. Severe GI impairment & resulting malnutrition can occur as a result of the following: Malabsorption as a result of a deficit in nutrient transport across the intestinal mucosa, i.e. Crohn’s Maldigestion due to intraluminal defects in the digestion of nutrients, i.e., pancreatic or bile salt in- sufficiency or bacterial overgrowth, i.e. CF, SBS Increased intestinal losses related to bowel resection with reduction in mucosal surface area, i.e. SBS and in severe Crohn’s. Increased metabolic needs related to catabolic state of illness due to inflammation & infections: Crohn’s, CF
    4. 4. Challenges in Managing GI Impairment in Pediatric Patients Often difficult to determine whether an intact versus a hydrolyzed (semi-elemental) or elemental formula is needed. Challenging to determine the appropriate, well-tolerated macronutrient distribution of carbohydrate, protein and fat Overall clinical course and nutritional outcomes are affected by numerous factors and can vary significantly from patient to patient. Severe GI impairment requiring specialized EN may occur in:  Short bowel syndrome (SBS)  Cystic Fibrosis  Crohn’s Disease (severe cases)  Others: pancreatitis, chronic diarrhea, severe allergies
    5. 5. Formula Comparison Studies in Severe GI Impairment: BASIC DEFINITIONS Formula Type Macronutrient Content Elemental (Monomeric) Individual amino acids, glucose polymers, typically low in fat. Some with only 2-3% of fat as LCT. Semi-elemental (oligomeric) Peptides of varying chain length, simple sugars, glucose polymers or starch and fat, combination of LCT/MCT Polymeric Intact proteins, complex carbohydrates, and mainly LCTs
    6. 6. Factors Impacting EN Management of SBS: SBS characterized by: diarrhea, malabsorption, fluid and electrolyte disturbances & losses Factors impacting clinical course:  Remaining intestinal length and function of remaining bowel  Site and functional differences between the proximal and distal small intestine.  Presence of ileum, ileocecal valve, & colon Thus …. EN management can vary significantly from patient to patient depending on above factors as well as: degree of intestinal adaptation & medical course
    7. 7. Guidelines for EN Initiation and Delivery After initial course of parenteral nutrition, EN is best administered via continuous feeds. Gradual advancement of rate based on outcome indicators degree of abdominal distention frequency and consistency of stools ostomy output and….  growth (weight gain & linear growth) Slow and gradual advancement of nutrient load promotes intestinal adaptation. Eventual transition to …. nocturnal EN with small intermittent/bolus feeds via oral/EN delivery
    8. 8. Controversy Surrounding Enteral Formula Selection in SBS Historically, elemental, semi-elemental or peptide- based formulas were recommended in SBS. However, research with adult patients has demonstrated similar clinical outcomes and absorption when compared to polymeric formulas. But what about formula selection in children? Advantages of complex nutrients in SBS:  Stimulate improved intestinal adaptation  “Functional workload” hypothesis: the greater the bowel must work to digest a nutrient, the greater the inducement to adapt.
    9. 9. What about formula selection in infants & children? Limited randomized clinical trials comparing effectiveness of polymeric vs. elemental or peptide- based formulas in infants & children with SBS Present standard of care in most U.S. healthcare institutions is to use protein hydrolysate (peptide based) or in some cases elemental formulas for children with SBS based on theoretical reasons. Allergic response is more common in infants & children with a disruption in their mucosal barrier. Infants may develop allergy in management of SBS if exposed to macromolecules.
    10. 10. Limited Evidence Comparing Polymeric to Hydrolyzed Formula in Pediatric SBS Study: Ksiazyk, J. et al. (2002) J Pediatric Gastroenterology & Nutrition Study Design: Prospective randomized cross-over double-blind study lasting 60 days. N = 10 children, Formulas: Non-hydrolyzed whey vs. Hydrolyzed Outcomes: Intestinal permeability, weight gain, and energy and nitrogen balance did not differ between infants fed polymeric versus hydrolyzed protein Study Limitations: small sample size
    11. 11. Summary: EN Recommendations in Children with SBS Depending on extent of bowel resection and function of the remaining gut, may begin with standard polymeric infant or pediatric formula. If significant gut resection and loss of ileum and/or ileocecal valve or polymeric formula not tolerated, use hydrolyzed protein (semi-elemental) formula. If hydrolyzed, peptide-based formula is not well tolerated, as demonstrated by outcome indicators, switch to trial of elemental formula In general, begin with continuous feeding schedule and slowly advance. Then, transition to nocturnal feeds with intermittent daytime feeds (oral and/or EN as indicated).
    12. 12. Enteral Nutrition in Children with Cystic Fibrosis Indications: Patients who remain in nutritional failure despite use of high calorie nutrition supplements and pancreatic enzymes EN Delivery Options:  Initial trial of nasogastric feedings OR  Consultation and evaluation for G-tube or PEG placement • Methods of Delivery: 1. Nocturnal feedings over 10 – 12 hours 2. Daytime oral feeds of high calorie foods and nutritional supplements. Examples: milk with Instant Breakfast, 1.5 kcal/ml supplements or Scandishakes (Axcan Scandipharm) 3. Nocturnal feeds + intermittent PEG feeds
    13. 13. Enteral Formula Selection in Cystic Fibrosis Standard polymeric formulas are usually tolerated as well as elemental or peptide based formulas providing that adequate enzymes are administered. Study Study Design Results Erskine et al. 1998 J Pediatr 132: 265-269 Prospective study of 16 patients (8 boys+8 girls) Ages 4-20. Completed two 6-day nocturnal TF trials of: Nonelemental (Isocal) with enzyme replacement vs. Semi- elemental (Peptamen) No differences bet- ween formulas in: • Fat absorption • Nitrogen absorption • Weight gain • Feeding tolerance (both well tolerated)
    14. 14. Enzyme Dosing in Nocturnal EN Source: Practical Gastroenterology, 2005 Method Dosing Meal Dosing Method •“Meal dose” of 150 – 250 Units/kg/meal at beginning of EN infusion •Half-meal dose of 75 -125 Units/kg/meal at end of EN infusion Pancreatic Enzyme Powder •Provide 2,000 Units lipase per gram of fat directly to the formula •Shake EN formula bag to distribute the enzyme and facilitate breakdown •Example: Viokase powder (limited supply). Alternative: Zenpep (Eurand)
    15. 15. Factors Contributing to Growth Failure in Crohn’s Disease Multifactorial etiology Consequences of gut inflammation Most pronounced in severe Crohn’s disease, resistant to conventional medical therapy Disturbances in growth hormone (GH)/insulin-like growth factor (IGF) axis Adverse effects of corticosteroid therapy: impact on linear growth
    16. 16. Effect of EN Protein on Crohn’s Disease Remission: Use of elemental formulas Rationale: chemically synthesized amino acids, are thought to be antigen free and thus less likely to expose a patient’s intestinal mucosa to antigens, and inducing a Crohn’s “flare”. Controversial study: Giaffer, North & Holdsworth, JPEN, 1990  Results: Significant reduction in Crohn’s Disease Activity Index (CDAI) in patients on 10 days of elemental formula (Vivonex) compared to polymeric formula (Fortison) after 10 days of feeding  Results have not been duplicated since ….
    17. 17. Review of EN Formula Studies in Crohn’s Disease Study Study Design Results Rigaud et al. 1991 (Adult Study) Prospective study to induce remission. Formulas: elemental (Vivonex HN) vs. polymeric (Nutrison). CDAI scores measured last 7 days of 28 day feeding period. No significant difference in clinical remission rates – (66% vs. 73%). Time to remission not signifi-cantly different. Ludvigson, J.F. et al., 2004 (Pediatric Study) Randomized, non-blind, multicenter, controlled trial of N = 33 children: 16 received Elemental (E028), 17 received Nutrition Standard. PCDAI were compared at 6 weeks. No significant dif- ference between the 2 groups in remission rate. No difference in decrease of PCDAI score. Pt. on Nutrison gained more weight
    18. 18. Enteral Nutrition Therapy for Inducing Remission in Crohn’s Disease Cochrane Database Systematic Review 2007; (1): CD000542, Zachos, M., Todeur, M. & Griffiths, A.M. Objective: to examine efficacy of formula protein composition on remission rates in Crohn’s disease Meta-analysis of 9 studies including 170 patients treated with elemental diet vs. 128 patients treated with non- elemental diet. Results: No significant differences in diet formulations; Significant heterogeneity was not present. No significant difference in efficacy of elemental vs. non-elemental diets for induction of remission of Crohn’s disease.
    19. 19. Effect of Enteral Nutrition Fat on Crohn’s Disease Remission Omega-6 PUFAs: precursor of arachidonic acid Leads to increased production of inflammatory eicosanoids, i.e. series-2 prostaglandins and series-4 leukotriences Accentuate the inflammatory response in Crohn’s Omega-3 PUFAs: such as linolenic acid, precursors of eicosapentanoic acid (EPA) and docosahexanoic acid (DHA) Leads to production of series-3 prostaglandins and series 5 leukotriences Less inflammatory & may be protective in Crohn’s
    20. 20. Study: Dietary Fat Attenuates Role of EN in Crohn’s Remission: Bamba et al. 2003 Sample: 28 patients randomized to low fat (3.06 gm), medium fat (16.56 gm) & high fat (30 gm) per day elemental diets for 4 weeks. The 3 formulas had identical total calories, nitrogen source, vitamins, minerals; differed in fat & carbohydrate content Results: Remission rates were 80%, 40%, and 25% respectively for high, medium and low fat diets. Extra fat in medium and high fat groups were made up of LCT: linoleic (52%), oleic (24%) & linolenic (8%).
    21. 21. Summary of Formula Selection Guidelines: Short Bowel Syndrome: Depending on degree of bowel resection, function of remaining bowel and presence of IC valve, ileum or colon, begin with polymeric formula, and if not tolerated, advance to semi-elemental, and last option would be elemental. Cystic Fibrosis: When using EN for CF patients with growth failure, begin with a standard polymeric formula with appropriate enzyme supplementation; overall more cost effective. Crohn’s Disease: In severe Crohn’s with associated growth failure, begin EN with standard polymeric. Only if not well tolerated, consider semi-elemental.
    22. 22. “Our” Approach to EN Management of Severe GI Impairment “Based on lack of clear data showing a definitive advantage to starting children with GI impairment on a hydrolyzed protein or elemental formula, our approach is to use a standard polymeric infant or pediatric formula initially, as the first choice for therapy for most children, even those who have the potential for severe GI impairment. In the face of persistent intolerance and malabsorption, when other causes have been ruled out, trials of semi-elemental and elemental amino-acid based formulas may be required.” Abad-Jorge, A. and Roman, B. Support Line, 2007; 29(2): 3 – 11.
    23. 23. •Breast milk •Semi-elemental •Elemental formulas
    24. 24. Use of Breast Milk in Severe GI Impairment Study: Andorsky et al, 2001, J Pediatr Design: Retrospective chart review among SBS infants (n = 30) Results: Percentage of days fed with BM was negatively correlated with duration of PN. The mean number of days on PN was significantly lower in breast-fed infants compared with formula fed infants. Possible cause: unique nutrient blend in breast milk with sIgA, nucleotides, trophic peptides, leukocytes, growth hormone and long-chain fatty acids (DHA).
    25. 25. Hydrolyzed Formulas for Use in Infants with SBS or Severe GI Impairment (0.67 kcal/ml) Nutrient Pregestimil Lipil Alimentum Advance Protein 1.9 gm per 100 ml (11%) Hydrolyzed casein 1.9 gm per 100 ml (11%) Hydrolyzed casein Carbohydrate 6.8 gm per 100 ml (41%) Corn syrup & Tapioca 6.8 gm per 100 ml (41%) Tapioca & sucrose Fat (Both have DHA & ARA) 3.8 gm per 100 ml (48%) MCT oil & corn oil LCT - 45% MCT - 55% 3.8 gm per 100 ml (48%) MCT oil, soy, safflower LCT - 67% MCT - 33% Osmolality mOsm/kg 340 370
    26. 26. Elemental Formulas for Use in Infants with SBS, Severe GI Impairment or Allergy (Powdered, not available commercially, order from manufact.) Nutrient Neocate Infant (0.67 kcal/ml) EleCare (1.0 kcal/ml) Protein 2.08 gm per 100 ml (12%) Free amino acids 3.01 gm per 100 ml (15%) Free amino acids Carbohydrate 7.8 gm per 100 ml (47%) Corn syrup solids 10.7 gm per 100 ml (43%) Corn syrup solids Fat 3.0 gm per 100 ml (41%) Safflower, soy, coconut LCT - 95% MCT - 5% 4.8 gm per 100 ml (42%) Safflower, coconut, soy LCT - 67% MCT - 33% Osmolality mOsm/kg 375 396
    27. 27. Infant Formulas: Cost Comparison (Costs may vary based on location) Formula Name Cost per 100 kcal Enfamil Lipil $0.72 Similac Advance $0.76 Pregestimil Lipil $1.29 Alimentum Advance $1.27 Neocate Infant $2.08 EleCare $1.68
    28. 28. Hydrolyzed Formulas in Children > 1 year: How to Select Indicated for children > 1 year of age, who have severe malabsorption or allergic complications and who demonstrate intolerance to intact protein formulas Semi-elemental:  Peptamen Junior (Nestle Nutrition): Ready to feed, also available in 1.5 kcal/ml, and with PreBio  Pepdite Junior (Nutricia, North America): Powdered  Vital Junior (Ross Products Division) • Selection Decision: Which formula to use? Decision individualized based on patient tolerance. A higher fat/lower carb blend may be better tolerated in some children due to reduced lactate & gas production.
    29. 29. Hydrolyzed Formulas for Use in Children with SBS or Severe GI Impairment (1.0 kcal/ml) Nutrient Peptamen Junior Pepdite Junior Protein 3.0 gm per 100 ml (12%) Whey hydrolysate 3.1 gm per 100 ml (12%) Soy & meat hydrolysates + free amino acids Carbohydrate (sucrose-free) 13.8 gm per 100 ml (55%) Maltodextrin, corn starch 10.6 gm per 100 ml (42%) Maltodextrin, corn syrup Fat 3.85 gm per 100 ml (33%) Coconut, soy, canola, soy oil, lecithin LCT - 40% MCT - 60% 5.0 gm per 100 ml (46%) Coconut, safflower, and soy oil LCT - 65% MCT - 35% mOsm/kg 260 430
    30. 30. Elemental Formulas in Children > 1 year: How to Select Indicated for the young child whose severe GI impairment is related to protein allergies & unable to tolerate hydrolysate formulas. Elemental:  EleCare (Ross Products): powdered  Neocate One + (Nutricia, North America): powdered  EO28 Splash (Nutricia): flavored, available in tetrapaks  Neocate Junior (Nutricia): powdered, higher in fat Selection Decision: Which formula to use? Decision individualized based on: patient tolerance, cost & availability.
    31. 31. Elemental Formulas for Use in Children with SBS, Severe GI Impairment or Allergy (Powder Base) Nutrient Neocate One + (1.0 kcal/ml) Neocate Junior (1.0 kcal/ml) Protein 2.5 gm per 100 ml (10%) Free amino acids 3.3 gm per 100 ml (12%) Free amino acids Carbohydrate 14.6 gm per 100 ml (58%) Corn syrup solids 10.4 gm per 100 ml (42%) Corn syrup solids Fat 3.5 gm per 100 ml (32%) Coconut, canola, safflower LCT - 65% MCT - 35% 5.0 gm per 100 ml (46%) Coconut, canola,safflower LCT - 65% MCT - 35% mOsm/kg Indication 610 Multiple food allergies 590 Mult. allergy, Malabsorp.
    32. 32. Infant Yes No Normal GI Function? Normal GI Function? Yes Yes Standard Pediatric Formula (PediaSure) Standard Infant Formula (Enfamil or Similac)No No Malabsorption, GI disease & Dysfunction Malabsorption, GI disease & Dysfunction Semi- elemental Pediatric Formula (Pepdite Jr.) Elemental Pediatric (EleCare) Semi- elemental Infant Formula (Pregestimil or Alimentum) Elemental Infant (Neocate Infant)Not tolerated Not tolerated
    33. 33. Summary & Conclusions The literature does not clearly support the advantages of semi-elemental or elemental formulas over polymeric, intact protein formulas in the management of severe GI impairment such as SBS, cystic fibrosis or Crohn’s disease. Use a standard polymeric infant or pediatric formula initially, as the first choice for therapy for most children, even those who have the potential for severe GI impairment. If standard formula not tolerated, take a systematic approach to formula selection.
    34. 34. Summary & Conclusions First, start with a semi-elemental or hydrolyzed formula (less expensive than elemental) If malabsorption, diarrhea & growth failure persist, then consider elemental formula. Select formula which will be covered by 3rd party payers, Medicaid or covered by the WIC program. Allow a reasonable trial period of 3 -5 days before evaluating the need to change formulas. Consider other factors: a) Medications should be reviewed. b) Consider addition of water soluble fiber to the formula. i.e. pectin
    35. 35. References References available as a handout. All proprietary product information was obtained from the manufacturer’s website. Ana Abad-Jorge, MS, RD, CNSC Pediatric Nutrition Support Specialist UVA Health System Charlottesville, VA ara6t@virginia.edu
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