Parenteral Nutrition: Formula Additives

 Used to provide adequate calories and balanced nutrition to promote growth during times of fluid restriction and increased metabolic needs.
Begin fortifying formula when goal feeds have been reached.  Increasing formula concentration increased osmolality of formula and can lead to intolerance (see Contraindications)
Types 
  • Polycose: glucose polymers.  1/4 tsp per ounce = 2 kcal/ounce.  More than 6 kcal/ounce can cause an osmotic diarrhea.
  • MCT oil: medium chain triglycerides for malabsorption of fat.  1 cc = 7.7 kcal.
  • Safflower or Canola Oil: fat source for nromal digestion.  1 cc = 8 kcal
  • Promod: whey protein.  1 tsp = 1 g protein = 4 kcal.
  • Human Milk Fortifier:  protein, carbohydrate, fat, calcium, phosphorus, vitamins, and minerals.  Not available on the market.  1 pkt + 50 cc = 22 kcal/ounce; 2 pt + 50 cc = 24 kcal/ounce.
  • Neocare: powder to fortify breast milk: protein, carbohydrate, fat, calcium, phosphorus, vitamins, and minerals.  Can fortify breast milk up to 10 kcal/ounce with Neocare if needed for discharge instead of HMF.
  • Rice or Oatmeal Cereal: carbohydrate source to thicken feeds.  One tsp = 3 kcal
Considerations when concentrating or supplementing formulas: 
  • Renal solute load is the amount of solutes to be excreted by the kidney.  It includes the intakes of protein, sodium, potassium, chloride, and phosphate.  Excessive solutes passing through the kidney can shift fluid and lead to dehydration.  The RSL of a given formula should be less than 350 mOsm per 100 cc or 10 -30 mOsm/kgday to minimize the risk of dehydration.  If the RSL is greater than recommended, monitor urine output, urine specific gravity, and BUN/Cr ratio for dehydration and renal tolerance.
  • Osmolality is the amount of osmotically active particles that pass through the gut.  It is affeced mostly by carbohydrate and mineral concentrations and not RSL.  Fomulas are considered hyperosmolar when their osmolality exceeds 300 mOsm/kg water (comparable to the osmolality of serum).  Hyperosmolar feeds can lead to osmotic diarrhea.  Formula osmolality should be less than 450 mOsm/kg water to minimize the rist of osmotic diarrhea.
 

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