Low lactoseinfant formulations, based on whole cow’s milk
protein, are unsuitable for children with cow’s milk protein
intolerance. Liquid soya milks purchased from supermarkets
and health food stores are not nutritionally complete and
should never be used for infants under 1 year of age.
Protein hydrolysate formulas.Non-milk, peptide-based
feeds containing hydrolysates of casein, whey, meat and
soya protein, are suitable for infants with disaccharide or
whole protein intolerance. The total daily intake of
electrolytes, vitamins and minerals should be carefully
assessed and modified to meet the child’s nutritional
requirements; these feeds have a high osmolality when given
at recommended dilution and need gradual and careful
introduction.
Elemental (amino acid based formula).Specially
formulated elemental feeds containing essential and
nonessential amino acids are available for use in infants and
children under 6 years with proven whole protein
intolerance. Adult elemental formula may be used for
children over 6 years; the intake of electrolytes, vitamins and
minerals should be carefully assessed and modified to meet
nutritional requirements. These feeds have a high osmolality
when given at the recommended concentration and
therefore need gradual and careful introduction.
Modular feeds.Modular feeds (see Specialised Formulas
for Specific Clinical Conditions) are based on individual
protein, fat, carbohydrate, vitamin and mineral components
or modules which can be combined to meet the specific
needs of a child. Modular feeds are used when nutritionally
complete specialised formula are not tolerated, or if thefluid
and nutrient requirements change e.g. in gastro-intestinal,
renal or liver disease. The main advantage of modular feeds
is theirflexibility; disadvantages include their complexity
and preparation difficulties. Modular feeds should not be
used without the supervision of a paediatric dietician.
Specialised formula.Highly specialised formulas are
designed to meet the specific requirements in various
clinical conditions such as renal and liver diseases. When
using these formulas, both the biochemical status of the
child and their growth parameters need to be monitored.
Feed thickeners
Carob based thickenersmay be used to thicken feeds for
infants under 1 year with significant gastro-oesophageal
reflux. Breast-fed infants can be given the thickener mixed
to a paste with water or breast-milk prior to feeds.
Pre-thickened formulaMilk-protein- or casein-dominant
infant formula, which contains small quantities of pre-
gelatinized starch, is recommended primarily for infants
with mild gastro-oesophageal reflux. Pre-thickened formula
is prepared in the same way as normal infant formula and
flows through a standard teat. The feeds do not thicken on
standing but thicken in the stomach when exposed to acid
pH.
Starched based thickenerscan be used to thicken liquids
and feeds for children over 1 year of age with dysphagia.
Dietary supplements for oral use
Three types of prescribable fortified dietary supplements are
available: fortified milk and non-milk tasting (juice-style)
drinks, and fortified milk-based semi-solid preparations. The
recommended daily quantity is age-dependent. The
following is a useful guide: 1 – 2 years, 200 kcal ( 840 kJ);
3 – 5 years, 400 kcal ( 1680 kJ); 6 – 11 years, 600 kcal ( 2520 kJ);
and over 12 years, 800 kcal ( 3360 kJ). Supplements
containing 1. 5 kcal/mL are high in protein and should not be
used for children under 3 years of age. Many supplements
are high in sugar or maltodextrin; care should be taken to
prevent prolonged contact with teeth. Ideally supplements
should be administered after meals or at bedtime so as not to
affect appetite.Products for metabolic diseases
There is a large range of disease-specific infant formulas and
amino acid-based supplements available for use in children
with metabolic diseases (see under specific metabolic
diseases. Some of these formulas are nutritionally
incomplete and supplementation with vitamins and other
nutrients may be necessary. Many of the product names are
similar; to prevent metabolic complications in children who
cannot tolerate specific amino acids it is important to ensure
the correct supplement is supplied.Enteral feeding tubes
Care is required in choosing an appropriate formulation of a
drug for administration through a nasogastric narrow-bore
feeding tube or through a percutaneous endoscopic
gastrostomy (PEG) or jejunostomy tube. Liquid preparations
(or soluble tablets) are preferred; injection solutions may
also be suitable for administration through an enteral tube.
If a solid formulation of a medicine needs to be given, it
should be given as a suspension of particlesfine enough to
pass through the tube. It is possible to crush many
immediate-release tablets but enteric-coated or modified-
release preparations shouldnotbe crushed.
Enteral feeds may affect the absorption of drugs and it is
therefore important to consider the timing of drug
administration in relation to feeds. If more than one drug
needs to be given, they should be given separately and the
tube should beflushed with water after each drug has been
given.Clearing blockages
Carbonated (sugar-free) drinks may be marginally more
effective than water in unblocking feeding tubes, but mildly
acidic liquids (such as pineapple juice or cola-based drinks)
can coagulate protein in feeds, causing further blockage. If
these measures fail to clear the enteral feeding tube, an
alkaline solution containing pancreatic enzymes may be
introduced into the tube (followed after at least 5 minutes by
water). Specific products designed to break up blockages
caused by formula feeds are also available.6.1 Special diets
Nutrition in special diets
Overview
These are preparations that have been modified to eliminate
a particular constituent from a food or that are nutrient
mixtures formulated as food substitutes for children who
either cannot tolerate or cannot metabolise certain common
constituents of food.
Coeliac disease
Coeliac disease is caused by an abnormal immune response
to gluten. For management and further information, see
Coeliac disease p. 25.
Phenylketonuria
Phenylketonuria(hyperphenylalaninaemia, PKU), which
results from the inability to metabolisephenylalanine,is
managed by restricting dietary intake ofphenylalanineto a
small amount sufficient for tissue building and repair.
Aspartame(used as a sweetener in some foods and
medicines) contributes to thephenylalanineintake and
may affect control ofphenylketonuria. If alternatives are
unavailable, children with phenylketonuria should not be
denied access to appropriate medication; the amount of
aspartameconsumed can be taken in to account in the
management of the condition. Where the presence of
aspartamein a preparation is specified in the product
literature,aspartameis listed as an excipient in the relevant622 Nutrition (oral) BNFC 2018 – 2019
Blood and nutrition9