BNF for Children 2011-2012

470 9.4.2 Enteral nutrition BNFC 2011–20129 Nutrition and bloodEven when nutritionally complete feeds are given, waterand electrolyte balance should be monitored. Haematologicaland biochemical parameters should also bemonitored, particularly in the clinically unstable child.Extra minerals (e.g. magnesium and zinc) may beneeded in patients where gastro-intestinal secretionsare being lost. Additional vitamins may also be needed.Feeds containing vitamin K may affect the INR inchildren receiving warfarin—see interactions: Appendix1 (vitamins).Choosing the best formula for children depends onseveral factors including: nutritional requirements, gastro-intestinalfunction, underlying disease, nutrientrestrictions, age, and feed characteristics (nutritionalcomposition, viscosity, osmolality, availability andcost). Children have specific dietary requirements andin many situations liquid feeds prepared for adults aretotally unsuitable and should not be given. Expertadvice from a dietician should be sought before prescribingenteral feeds for a child.Infant formula feeds Child 0–12 months. Terminfants with normal gastro-intestinal function are giveneither breast milk or normal infant formula during thefirst year of life. The average intake is between 150 mLand 200 mL/kg/day. Infant milk formulas are based onwhey- or casein-dominant protein, lactose with or withoutmaltodextrin, amylose, vegetable oil and milk fat.The composition of all normal and soya infant formulashave to meet The Infant Formula and Follow-on FormulaRegulations (England and Wales) 2007, whichenact the European Community Regulations 2006/141/EC; the composition of other enteral and specialistfeeds has to meet the Commission Directive (1999/21/EC) on Dietary Foods for Special Medical Purposes.A high-energy feed (Appendix 2, p. 750), which contains9–11% of energy derived from protein can be used forinfants who fail to grow adequately. Alternatively,energy supplements (Appendix 2, p. 771) may beadded to normal infant formula to achieve a higherenergy content (but this will reduce the protein toenergy ratio) or the normal infant formula concentrationmay be increased slightly. Care should be taken not topresent an osmotic load of more than 500 milliosmols/kg water to the normal functioning gut, otherwiseosmotic diarrhoea will result. Concentrating or supplementingfeeds should not be attempted without theadvice of a paediatric dietician.Enteral feeds Child 1–6 years (body–weight 8–20 kg). Ready-to-use feeds (Appendix 2, p. 750) basedon caseinates, maltodextrin and vegetable oils (with orwithout added medium chain triglyceride (MCT) oil orfibre) are well tolerated and effective in improvingnutritional status in this age group. Although originallydesigned for children 1–6 years (body–weight 8–20 kg),some products have ACBS approval for use in childrenweighing up to 30 kg (approx. 10 years of age). Enteralfeeds formulated for children 1–6 years are low in sodiumand potassium; electrolyte intake and biochemicalstatus should be monitored. Older children in this agerange taking small feed volumes may need to be givenadditional micronutrients. Fibre-enriched feeds may behelpful for children with chronic constipation or diarrhoea.Child 7–12 years (body-weight 21–45 kg). Dependingon age, weight, clinical condition and nutritionalrequirements, ready-to-use feeds (Appendix 2, p. 750)formulated for 7–12 year olds may be given at appropriaterates.Child over 12 years (body-weight over 45 kg). Asthere are no standard enteral feeds formulated for thisage group, adult formulations are used. The intake ofprotein, electrolytes, vitamins, and trace mineralsshould be carefully assessed and monitored.Note Adult feeds containing more than 6 g/100 mL protein or2 g/100 mL fibre should be used with caution and expertadvice.Specialised formula It is essential that any infantwho is intolerant of breast milk or normal infant formula,or whose condition requires nutrient-specificadaptation, is prescribed an adequate volume of anutritionally complete replacement formula (see Appendix2, p. 763). In the first 4 months of life, a volume of150–200 mL/kg/day is recommended. After 6 months,should the formula still be required, a volume of600 mL/day should be maintained, in addition to solidfood.Products for cow’s milk protein intolerance or lactoseintolerance. There are a number of infant formulasformulated for cow’s milk protein intolerance or lactoseintolerance; these feeds may contain a residual amountof lactose (less than 1 g/100 mL formula)—sometimesdescribed as clinically lactose-free or ‘lactose-free’ bymanufacturers. If the total daily intake of these formulasis low, it may be necessary to supplement with calcium,and a vitamin and mineral supplement.Soya-based infant formulas have a high phytoestrogencontent and this may be a long-term reproductive healthrisk. The Chief Medical Officer has advised that soyabasedinfant formulas should not be used as the firstchoice for the management of infants with proven cow’smilk sensitivity, lactose intolerance, galactokinase deficiencyand galactosaemia. Most UK paediatricians withexpertise in inherited metabolic disease still advocatesoya-based formulations for infants with galactosaemiaas there are concerns about the residual lactose contentof low lactose formulas and protein hydrolysates basedon cow’s milk protein.Low lactose infant formulations, based on whole cow’smilk protein, are unsuitable for children with cow’s milkprotein intolerance. Liquid soya milks purchased fromsupermarkets and health food stores are not nutritionallycomplete and should never be used for infants under1 year of age.Protein hydrolysate formulas. Non-milk, peptidebasedfeeds containing hydrolysates of casein, whey,meat and soya protein, are suitable for infants withdisaccharide or whole protein intolerance. The totaldaily intake of electrolytes, vitamins and mineralsshould be carefully assessed and modified to meet thechild’s nutritional requirements; these feeds have a highosmolality when given at recommended dilution andneed gradual and careful introduction.Elemental (amino acid based formula). Specially formulatedelemental feeds containing essential and nonessentialamino acids are available for use in infants andchildren under 6 years with proven whole protein intolerance.Adult elemental formula may be used for chil-