Journal of Human Nutrition (1978) 32, 264-269.
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Hyperosmolar infant formulae: potential problems in clinical use Karen M. CASHEL, BSc, Dip. Nutrition & Dietetics, M. Paula THOMAS, FRCS (Ed), FRACS and Janne PROPERJOHN, Dip AIMLT Senior Dietitian; Paediatric Surgeon and Scientific Officer, Department of Surgery, Adelaide Children S Hospital, Adelaide, S A , Australia. There are numerous reports in the literature (Dudrick et al., 1968, 1969;Jamum, 1976;Jonxis, 1973; Sherman, Hamley & Khachadurian, 1975; Wilmore, 1972) on the management of the patient who is unable to sustain nutrition by the normal absorptive mechanisms as a result of temporary gastrointestinal failure. The reports relating to oral nutrition (Jarnum, 1976;Jonxis, 1973; Sherman et al., 1975) discuss in some detail the use of elemental and synthetic diets. Clinical situations in which such diets are of use include the short-gut syndrome, longsegment Hirschprung’s disease, gastroschisis and exomphalos, regional ileitis and colitis, severe gastroenteritis and gastrointestinal fistulae. Two major, generally related problems are frequently discussed. These are first, the need to provide an adequate nutritional intake within a reasonable fluid volume, particularly an adequate energy intake; and, secondly, the frequent incidence of a profuse, watery diarrhoea often described as ‘explosive’. This ‘explosive’ diarrhoea is known t o be associated with high-osmolar oral feeds (Dundon et al., 1975;Jonxis, 1973; Weinberger & Rowe, 1973). It may be avoided or treated by monitoring and manipulating the osmolality of the feed. Osmotic diarrhoea can be associated with a secondary disaccharide intolerance that results in unhydrolysed carbohydrate remaining within the intestinal lumen thus augmenting intraluminal fluid secretion by virtue of its osmotic effect (Gray, 1975). The high intraluminal concentration of lactose resulting from such intolerance may be fermented by bacterial flora producing an excess of lactic acid, and aggravating the diarrhoea (Leonard et al., 1967). Feeds containing hydrolysed protein and/or monosaccharides have a high osmolar load and may also augment intraluminal fluid secretion. In addition the considerable increase in gastric secretion which follows extensive small-bowel resection (Dudrick et al., 1970; Bunch, 1971) may further aggravate’the malabsorption and diarrhoea. Weinberger & Rowe (1973), reporting o n their experiences with the use of elemental diet following neonatal gastrointestinal surgery, are of the opinion that the time needed for osmolar adaptation t o occur together with the maximum 264
Int J Food Sci Nutr Downloaded from informahealthcare.com by McMaster University on 01/07/15 For personal use only.
concentration tolerated, depends on the functional intestinal absorptive surface available. They made the point that episodes of abdominal distention and voiniting, with or without profuse watery stools, can indicate intolerance to diet hypertonicity and not partial intestinal obstruction. In the infant whose diarrhoea isspartly or wholly due to the oral osmotic load, adequate oral nutrition is a problem. The alternatives available in such a situation are: (1) Expressed breast milk (Osmolality 250 mOsm/kg); (2) Cow’s milk (Osmolality 263 mOsm/kg); (3) A commercial formula based on cow’s milk; (4) A diluted and therefore hypocaloric form of elemental feeding, or ( 5 ) A specially formulated milk mixture. Although commercial elemental feeds are readily available there are practical drawbacks to their use in the young infant. The essential fatty acid, vitamin and trace element content are inadequate for the young infant. At energy levels isocaloric with milk, the elemental feed is hyperosmolar. It usually has t o be given continuously via a naso-gastric tube. The taste is unacceptable to may patients; and it is expensive. An alternative low-osmolar synthetic-milk mixture, based on modular formulation using the individual constituents, has been developed and used successfully at this hospital since 1970 (Dundon et al., 1975; Dundon, Thomas & Cashel, 1977; M.P. Thomas, to be published). There are four clinical situations in which such a modular milk formulation is of great use. These are: first, during the recovery stages of gastrointestinal failure, particularly following gastrointestinal sufgery in the newborn; secondly, during the transition phase from total parenteral to total oral nutrition, so as t o keep both nitrogen and energy input adequate; thirdly, in the treatment of the under-weight catabolic patient, for true oral hyperalimentation; and fourthly, in the treatment of acute renal failure, when the protein and electrolyte content can be tailored to the needs of the individual patient. As an extension of this work, we have, over the past three years, become increasingly interested in using modified conimercial feeds for patients on complementary intravenous and oral nutrition, and for those recovering from gastrointestinal failure. These modified commercial feeds are most useful following gastrointestinal surgery and severe gastroenteritis. In each of these two clinical conditions the patients may have secondary maldigestion and/or malabsorption. The feeds commonly used for infants exhibiting symptoms of secondary intolerance are shown in Table 1. The comparative osinolalities of these feeds, in relation t o that of breast milk, cow’s milk ( 5 per cent dextrose) and sweetened condensed milk are shown in Table 2a. There is considerable variation. We have found it necessary to check these levels regularly, because the osmolar level may vary considerably with small changes in the composition of feeds (Table 2b). I t is obviously important that we be notified by the’manufacturers of all changes in the composition of a feed, as even the presence o r absence of a nonnutritive additive, such as imitation vanilla flavouring can have significant effects on the osmolality. Recognising these problems, particularly that o f a suitable feed for the infant with a secondary disaccharide intolerance, we have developed our own lowosmolar feeding regime, based on a commercially prepared milk formula CF1. 26 5
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Table 1. Feeds used for infants with secondary intolerance Protein source
Fat source
Carbohydrate source
PregestimiI*
Casein hydrolysate
Medium-chain triglycerides
Glucose-modif ied t a pi oca-starch
Trig1yde *
Casein
Medium-cha in trig1y cer ides
Sucrose Corn syrup solids
Glucose Nutramigen"
Casein hydrolysate
Corn oil
Glucose Tapioca starch
Digestalactt
Casein
Milk fat
Glucose Galactose
* Mead Johnson, Caringbah, NSW, Australia. t Hunter Valley Sharpe Pty. Ltd., Hexham, NSW, Australia.
This is a cow's-milk-based liquid concentrate, containing protein, fat, vitamins and minerals, but no carbohydrate. To give a normal energy level o f 3000 kJ (7 1 7 kcal)/l, 7.7 per cent carbohydrate must be added. This feed is, of course, nutritionally inadequate and potentially dangerous if carbohydrate additions are not made within a 24 to 48-hour period. The choice and the percentage of carbohydrate to be added are all in the control of the user. To prepare the low-osmolar feed we add the glucose polymer, Caloreen. Caloreen is a chemically defined mixture of dextrins derived from the controlled hydrolysis of corn starch by bacterial amylase, with the straight-chain polymer containing, on an average, five glucose molecules. It is colourless, only mildly sweet in flavour and dissolves easily. A 50 per cent solution prepared by the pharmacy department provides a simple and accurate means of adding Caloreen to the CF1 base (either by our staff or by the parents). The advantage of using a glucose polymer as a carbohydrate source is that it has an osmolality which is one-fifth Table 2. Osmolality of various milk mixtures and fluids (As measured a t the Adelaide Children's Hospital, September, 1977) a. Milk mixtures (FS = Full strength) FS Pregestimil" 898 rnOsm/kg 209 mOsm/kg FS Triglyde" 279 mOsm/kg FS Glucose Nutramigen* 250 mOsm/kg Breast milk 263 mOsm/kg FS Cow's milk 5% Dextrose 277 mOsm/kg S.C.M. - (1:8)t 441 mOsm/kg
'
* Manufactured and distributed in Australia by Mead Johnson Pty. Ltd., Caringbah, NSW. t Sweetened condensed milk, a concentrated cow's milk with added sucrose. Manufactured and distributed in Australia by Tongala Milk Company, Melbourne, Victoria. b. Variations of FS Triglyde, FS Triglyde. FS Triglyde,
Triglyde (FS = Full strength) 1970" 570-580 mOsm/kg 1974t 465-480 mOsm/kg 1975+ 220-225 mOsm/kg
* Contained imitation vanilla essence t Contained skim milk powder as protein source with lactose as carbohydrate Contained sodium caseinate as protein source with corn syrup solids and sucrose as the carbohydrate
+
266
of that of the monosaccharides such as glucose or fructose (Table 3a) As the mineral content of Caloreen is small (sodium
Int J Food Sci Nutr Downloaded from informahealthcare.com by McMaster University on 01/07/15 For personal use only.
Hyperosmolar infant formulae: potential problems in clinical use Karen M. CASHEL, BSc, Dip. Nutrition & Dietetics, M. Paula THOMAS, FRCS (Ed), FRACS and Janne PROPERJOHN, Dip AIMLT Senior Dietitian; Paediatric Surgeon and Scientific Officer, Department of Surgery, Adelaide Children S Hospital, Adelaide, S A , Australia. There are numerous reports in the literature (Dudrick et al., 1968, 1969;Jamum, 1976;Jonxis, 1973; Sherman, Hamley & Khachadurian, 1975; Wilmore, 1972) on the management of the patient who is unable to sustain nutrition by the normal absorptive mechanisms as a result of temporary gastrointestinal failure. The reports relating to oral nutrition (Jarnum, 1976;Jonxis, 1973; Sherman et al., 1975) discuss in some detail the use of elemental and synthetic diets. Clinical situations in which such diets are of use include the short-gut syndrome, longsegment Hirschprung’s disease, gastroschisis and exomphalos, regional ileitis and colitis, severe gastroenteritis and gastrointestinal fistulae. Two major, generally related problems are frequently discussed. These are first, the need to provide an adequate nutritional intake within a reasonable fluid volume, particularly an adequate energy intake; and, secondly, the frequent incidence of a profuse, watery diarrhoea often described as ‘explosive’. This ‘explosive’ diarrhoea is known t o be associated with high-osmolar oral feeds (Dundon et al., 1975;Jonxis, 1973; Weinberger & Rowe, 1973). It may be avoided or treated by monitoring and manipulating the osmolality of the feed. Osmotic diarrhoea can be associated with a secondary disaccharide intolerance that results in unhydrolysed carbohydrate remaining within the intestinal lumen thus augmenting intraluminal fluid secretion by virtue of its osmotic effect (Gray, 1975). The high intraluminal concentration of lactose resulting from such intolerance may be fermented by bacterial flora producing an excess of lactic acid, and aggravating the diarrhoea (Leonard et al., 1967). Feeds containing hydrolysed protein and/or monosaccharides have a high osmolar load and may also augment intraluminal fluid secretion. In addition the considerable increase in gastric secretion which follows extensive small-bowel resection (Dudrick et al., 1970; Bunch, 1971) may further aggravate’the malabsorption and diarrhoea. Weinberger & Rowe (1973), reporting o n their experiences with the use of elemental diet following neonatal gastrointestinal surgery, are of the opinion that the time needed for osmolar adaptation t o occur together with the maximum 264
Int J Food Sci Nutr Downloaded from informahealthcare.com by McMaster University on 01/07/15 For personal use only.
concentration tolerated, depends on the functional intestinal absorptive surface available. They made the point that episodes of abdominal distention and voiniting, with or without profuse watery stools, can indicate intolerance to diet hypertonicity and not partial intestinal obstruction. In the infant whose diarrhoea isspartly or wholly due to the oral osmotic load, adequate oral nutrition is a problem. The alternatives available in such a situation are: (1) Expressed breast milk (Osmolality 250 mOsm/kg); (2) Cow’s milk (Osmolality 263 mOsm/kg); (3) A commercial formula based on cow’s milk; (4) A diluted and therefore hypocaloric form of elemental feeding, or ( 5 ) A specially formulated milk mixture. Although commercial elemental feeds are readily available there are practical drawbacks to their use in the young infant. The essential fatty acid, vitamin and trace element content are inadequate for the young infant. At energy levels isocaloric with milk, the elemental feed is hyperosmolar. It usually has t o be given continuously via a naso-gastric tube. The taste is unacceptable to may patients; and it is expensive. An alternative low-osmolar synthetic-milk mixture, based on modular formulation using the individual constituents, has been developed and used successfully at this hospital since 1970 (Dundon et al., 1975; Dundon, Thomas & Cashel, 1977; M.P. Thomas, to be published). There are four clinical situations in which such a modular milk formulation is of great use. These are: first, during the recovery stages of gastrointestinal failure, particularly following gastrointestinal sufgery in the newborn; secondly, during the transition phase from total parenteral to total oral nutrition, so as t o keep both nitrogen and energy input adequate; thirdly, in the treatment of the under-weight catabolic patient, for true oral hyperalimentation; and fourthly, in the treatment of acute renal failure, when the protein and electrolyte content can be tailored to the needs of the individual patient. As an extension of this work, we have, over the past three years, become increasingly interested in using modified conimercial feeds for patients on complementary intravenous and oral nutrition, and for those recovering from gastrointestinal failure. These modified commercial feeds are most useful following gastrointestinal surgery and severe gastroenteritis. In each of these two clinical conditions the patients may have secondary maldigestion and/or malabsorption. The feeds commonly used for infants exhibiting symptoms of secondary intolerance are shown in Table 1. The comparative osinolalities of these feeds, in relation t o that of breast milk, cow’s milk ( 5 per cent dextrose) and sweetened condensed milk are shown in Table 2a. There is considerable variation. We have found it necessary to check these levels regularly, because the osmolar level may vary considerably with small changes in the composition of feeds (Table 2b). I t is obviously important that we be notified by the’manufacturers of all changes in the composition of a feed, as even the presence o r absence of a nonnutritive additive, such as imitation vanilla flavouring can have significant effects on the osmolality. Recognising these problems, particularly that o f a suitable feed for the infant with a secondary disaccharide intolerance, we have developed our own lowosmolar feeding regime, based on a commercially prepared milk formula CF1. 26 5
Int J Food Sci Nutr Downloaded from informahealthcare.com by McMaster University on 01/07/15 For personal use only.
Table 1. Feeds used for infants with secondary intolerance Protein source
Fat source
Carbohydrate source
PregestimiI*
Casein hydrolysate
Medium-chain triglycerides
Glucose-modif ied t a pi oca-starch
Trig1yde *
Casein
Medium-cha in trig1y cer ides
Sucrose Corn syrup solids
Glucose Nutramigen"
Casein hydrolysate
Corn oil
Glucose Tapioca starch
Digestalactt
Casein
Milk fat
Glucose Galactose
* Mead Johnson, Caringbah, NSW, Australia. t Hunter Valley Sharpe Pty. Ltd., Hexham, NSW, Australia.
This is a cow's-milk-based liquid concentrate, containing protein, fat, vitamins and minerals, but no carbohydrate. To give a normal energy level o f 3000 kJ (7 1 7 kcal)/l, 7.7 per cent carbohydrate must be added. This feed is, of course, nutritionally inadequate and potentially dangerous if carbohydrate additions are not made within a 24 to 48-hour period. The choice and the percentage of carbohydrate to be added are all in the control of the user. To prepare the low-osmolar feed we add the glucose polymer, Caloreen. Caloreen is a chemically defined mixture of dextrins derived from the controlled hydrolysis of corn starch by bacterial amylase, with the straight-chain polymer containing, on an average, five glucose molecules. It is colourless, only mildly sweet in flavour and dissolves easily. A 50 per cent solution prepared by the pharmacy department provides a simple and accurate means of adding Caloreen to the CF1 base (either by our staff or by the parents). The advantage of using a glucose polymer as a carbohydrate source is that it has an osmolality which is one-fifth Table 2. Osmolality of various milk mixtures and fluids (As measured a t the Adelaide Children's Hospital, September, 1977) a. Milk mixtures (FS = Full strength) FS Pregestimil" 898 rnOsm/kg 209 mOsm/kg FS Triglyde" 279 mOsm/kg FS Glucose Nutramigen* 250 mOsm/kg Breast milk 263 mOsm/kg FS Cow's milk 5% Dextrose 277 mOsm/kg S.C.M. - (1:8)t 441 mOsm/kg
'
* Manufactured and distributed in Australia by Mead Johnson Pty. Ltd., Caringbah, NSW. t Sweetened condensed milk, a concentrated cow's milk with added sucrose. Manufactured and distributed in Australia by Tongala Milk Company, Melbourne, Victoria. b. Variations of FS Triglyde, FS Triglyde. FS Triglyde,
Triglyde (FS = Full strength) 1970" 570-580 mOsm/kg 1974t 465-480 mOsm/kg 1975+ 220-225 mOsm/kg
* Contained imitation vanilla essence t Contained skim milk powder as protein source with lactose as carbohydrate Contained sodium caseinate as protein source with corn syrup solids and sucrose as the carbohydrate
+
266
of that of the monosaccharides such as glucose or fructose (Table 3a) As the mineral content of Caloreen is small (sodium
