binung membuat formula yang pas.. baik dan benar.. disini bisa dipilih dan dilihat cara pembuatan dan komposisinya..

1. Choosing the right
formula: Considerations
and available options

2. Outlines
T
e
r
m
sa
n
ddefinition
01
Considerationsa
n
dAvailableoptions
02
Practicalaspects
03

3. Introduction
Clinical Nutrition (2006) 25,
180–186
•Diret
breastfeeding
•Expreseed
breastmilk
Mother’s own
breast milk
•Milk Bank
•Milk Sharing
Donor
breastmilk
Solid food
•standard
•special
Formula
feeding

4. Nutritional support decision tree
Cámara-Martos, et al. (2019). Enteral Nutrition Formulas: Current Evidence and Nutritional Composition. Nutrients in Beverages, 467–508.

5. Terms and definition
 Age
 Standard vs special formula
Infant Formula
Enteral Formula
SIP Feed
ONS
Medical Food/
FSMP
PKGK
PDK
PKMK

6. Enteral nutrition
e-SPEN, the European e-Journal of Clinical Nutrition and Metabolism 4 (2009)
e223–e225
EN is used to comprise all forms of
nutritional support that imply the use of
‘‘dietary foods for special medical
purposes’’ independent of the route of
application. It includes oral nutritional
supplements (ONS) as well as tube
feeding.
This definition differs from definitions used
in many other publications where ‘‘EN’’ is
rather used for tube feeding only.
ASPEN, 2006
PERATURAN MENTERI KESEHATAN REPUBLIK INDONESIA
NOMOR 29 TAHUN 2019
TENTANG
PENANGGULANGAN MASALAH GIZI BAGI ANAK AKIBAT PENYAKIT

7. T. Cederholm et al. / Clinical Nutrition 36 (2017) 49-64
Oral Nutritional Supplements (ONS) are
sterile liquids, semi-solids or powders,
which provide macro and micro nutrients.
They are widely used within the acute and
community health settings for individuals
who are unable to meet their nutritional
requirements through oral diet alone.
(BAPEN)
Liquid ONS (either ready to drink or
made up from powders) are sometimes
referred to as sip feeds

8. What to look in a formula?
• Lactose free?
• Added sugar
• Added fiber
Carbohydrate
• Protein source
• Intact/predigested
• Protein energy ratio or %protein
Protein
• MCT%?
• Added DHA?
Fat
Flavour
• Preferences
• Taste fatigue
Aims • Supplementation
• Substitution
Cost • Commercial vs homemade
• 20/oz = 0.67 kcal/mL
• 22/oz = 0.74 kcal/mL
• 24/0z = 0.8 kcal/mL
• 30/oz = 1 kcal/mL
Calorie density

9. Based on content
Polymeric
Whole protein/intact macronutrient
Pre-digested/peptide based
protein/semi-elemental
Oligomeric
Monomeric
Elemental/amino-acid based
Single macronutrient: amino acid
powder, whey protein, MCT oil, glucose
polymer
Modular

11. PKGK
(Pangan olahan
untuk keperluan
Gizi Khusus):
Pangan olahan
yang diproses atau
diformulasikan
untuk secara
khusus untuk
memenuhi
kebutuhan gizi
tertentu akibat
kondisi
fisik/fisiologis dan
penyakit/ganggua
n tertentu
PDK (pangan
diet khusus)
Bayi dan Anak
(formula bayi, formula lanjutan,
formula pertumbuhan, MPASI)
Dewasa
(makanan ibu hamil/menyusui,
olahragawan, kontrol BB)
PKMK (pangan
keperluan medis
khusus)
Bayi dan Anak
Dewasa
PERATURAN BADAN PENGAWAS OBAT DAN MAKANAN
NOMOR 1 TAHUN 2018
TENTANG
PENGAWASAN PANGAN OLAHAN UNTUK KEPERLUAN GIZI KHUSUS

12. 1. PKMK untuk Pasien Kelainan Metabolik (Inborn Errors
of Metabolism);
2. PKMK untuk Dukungan Nutrisi bagi Anak Berisiko
Gagal Tumbuh, Gizi Kurang atau Gizi Buruk;
3. PKMK untuk Bayi Prematur;
4. Suplemen Air Susu Ibu (Human Milk Fortifier);
5. PKMK untuk Pasien Alergi Protein Susu Sapi;
6. PKMK untuk Pasien Anak Kejang Intraktabel (Epilepsi);
7. PKMK untuk Pasien Malabsorpsi;
8. PKMK untuk Pasien Penyakit Hati Kronik; dan
9. PKMK untuk Pasien Inflammatory Bowel Diseases.
PKMK untuk Gagal Tumbuh, Gizi
Kurang dan Gizi
Buruk berupa oral nutrition
supplement dengan
kandungan energi lebih besar dari 0,9
kkal/mL
Peraturan badan pengawas obat dan makanan Nomor 1 tahun 2018
Tentang Pengawasan pangan olahan untuk keperluan gizi khusus
Peraturan menteri kesehatan republik Indonesia Nomor 29 tahun 2019
Tentang Penanggulangan masalah gizi bagi anak akibat penyakit

13. Choice of feeding solution
• Is gastrointestinal function normal?
– Yes – Choose a whole protein feed
– No – Consider a semi-elemental/elemental product
• Is the fluid volume restricted and/or is a higher energy
containing feed needed?
– Yes – Choose a high energy feed and consider
whether a disease specific formula might be
needed
– No – Choose a standard feed
• Is there a specific dietary restriction or other nutritional
need?
– Yes – Consider a disease specific formulation
– No – Choose a standard feed
P. Howard / e-SPEN, the European e-Journal of Clinical Nutrition and Metabolism 4 (2009) e223–e225

14. Children vs adult standard formula
Infant and Children
• 10-15% of energy from
proteins
• 30-50% of energy from
lipids
• 50-60% of energy from
carbohydrates
• Proportion of energy from
proteins, lipids and
carbohydrates depends on
the age of the child
• ~ 80-90% Water
• 0,65-1 kcal/1ml
Adult
• 15-20% of energy from proteins
• 25-40% of energy from lipids
• 40-60% of energy from
carbohydrates
• ~ 1kcal/1ml
• ~ 85% Water
After the age of 8 to 10 years can an
adult formulation be used, in the
event that the appropriate paediatric
formula is not available

15. Availabl
e
options
Carbohydrate
•Lactose content
•Fiber ?
Protein
•Intact
•Hdrolyzed
•Amino acid base
Lipid
•MCT
•LCPUFA

16. Available feeding solutions
Infant
• Human milk + HMF
• Standard infant
formula
• Free lactose formula
• Preterm formula
• High density formula
(1 kcal/ml)
• Oligomeric formula
– Extensive
hydrolyzed formula
• Elemental formula
– Amino acid base
• Ketogenic 3:1
• IEM special formula
Pediatric
• Standard enteral formula
• High density enteral formula
– 1.3 kcal/ml
– 1.5 kcal/ml
• Oligomeric formula
– Partially hydrolyzed
formula
• Elemental formula
– Amino acid based
• Ketogenic 4: 1
Adult formula:
• 2 kcal/ml
• Disease specific
formula

17. Formula bayi/
infant formula
Formula lanjutan/
Follow-on formula
Formula
pertumbuhan/
Growing up milk
MPASI pokok MPASI kudapan
Age (mo) 0-6 6-12 12-36 6-12 12-24 6-12 12-24
Calorie density
(kcal/mL)
0.6-0.7 0.6-0.8 > 0.8 > 0.8
Protein (g/100kcal) 1.9-5.5 0.8-5.5 1.9-5.5 0.8-5.5
Cow’s milk
Soy isolate
1.8-3
2.25-3
1.82-3.5
2.25-3.5
3.2-5.5
3.5-5.8
Iron (mg/100kcal) 0.45 -5 1-2 1-2 min 3.56 Min 0.86
Carbohydrate
(g/100 kcal)
9-14 8-14.2 7-(undefined)
Sucrose (if added) Max 20% Carb Max 20% carb Max 25% Carb Max 5 g/100 kcal Max 5 g/100 kcal
Comparison of some PDK’s
content
PERATURAN BADAN PENGAWAS OBAT DAN MAKANAN
NOMOR 1 TAHUN 2018
TENTANG
PENGAWASAN PANGAN OLAHAN UNTUK KEPERLUAN GIZI KHUSUS

18. Similar but NOT the same

22. https://cekbpom.pom.go.id/

23. Selected special Infant
Formula
Brand name kcal/mL Protein (g)
/100 ml
Scoop
(g)
Dilution
(mL)
Preterm formula BMT premature No data 2 4.5 30
Enfamil A+
premature
0.81 4.97 25
2.21
Lactogen
premature
5.37 28
0.80 2.3
SGM BBLR 0.80 2.6 5.4 28
S26 LBW 0.82 2.1 sediaan cair
High density SGM Gain 100 1.00 2.6 4.2 18
Infatrini (powder) 1.01 2.7 5 22.5
Hypoallergenic Neocate LCP 0.67 1.8 4.6 30
Nutramigen 0.68 1.91 4.5 30
Nutribaby royal
pepti
5.4 35
0.66 1.7
Pregestimil 0.70 2 4.5 30
Puramino 0.68 1.87 4.5 30
SGM Gain 74 0.74 1.7 5.1 30

25. Enteral formula
Brand
nameNutrinidrink
Kcal/m
L
Protein
(g)/100 ml
Fe mg/100 mL Scoop (g) Water to
dilute (mL)
Entrakid 1.0 3 N/A 15 60
Nutren junior 1.0 2.01 1.04 7.8 30
Pediacomplete 1.0 3.02 1.12 9.8 38
SGM Gain Optigrow 1.0 2.4 0.54 8 29
Pan-enteral 1.0 3 1 40 (sachet) 180
Blenuten 1.3 3 1.38 14 40
Blenut up 1.3 3 1.38 8 40
Nutrinidrink 1.5 3.4 1.5 6.1 15

26. • Under and over-dilution
• Scoop size provided
PRACTICAL ASPECT: MIXING
ERROR

27. How do you choose
Pediacomplete Pediasure Triplesure
SGM Gain 100 SGM Gain Optigrow
Difference?

28. Differentiate the indication
5 scoops (49 g) + 190 ml water =
226 ml = 226 kcal (1 kcal/mL)
5 scoops (39 g) + 190 ml water =
219 mL = 180 kcal (0.8 kcal/mL)

29. Differentiate the age

30. Concentrated formula?
The concentration should be increased stepwise according to
individual tolerance.
Concentrations >17% (+30% energy density) should usually be
avoided.
Disadvantage: The increased formula density
increases renal solute load and may reduce tolerance.
- Constipation or diarrhea
- Reported : hypernatremic dehydration

33. Catch-up growth

37. Let's work together in
upcoming workshop
o