Choosing the right formula:

Considerations and available

options

Yoga Devaera
WS PIT IKA 2022
 Terms and definition
01
Outlines
Considerations and
02 Available options

Practical aspects
03
Introduction

• Diret breastfeeding
Mother’s own • Expreseed
breast milk breastmilk

Donor • Milk Bank

breastmilk • Milk Sharing

Solid food

Formula • standard
feeding • special

Clinical Nutrition (2006) 25, 180–

186
Nutritional support decision tree

Cámara-Martos, et al. (2019). Enteral Nutrition Formulas: Current Evidence and Nutritional Composition. Nutrients in Beverages, 467–508.
 Infant formula Terms and definition
Enteral formula
 Age
Sip feed
ONS  Standard vs special formula

Medical food/FSMP
PKGK
PDK
PKMK
Enteral nutrition PERATURAN MENTERI KESEHATAN REPUBLIK INDONESIA
NOMOR 29 TAHUN 2019
TENTANG
PENANGGULANGAN MASALAH GIZI BAGI ANAK AKIBAT PENYAKIT

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

e-SPEN, the European e-Journal of Clinical Nutrition and Metabolism 4 (2009) e223–e225
 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

T. Cederholm et al. / Clinical Nutrition 36 (2017) 49-64

What to look in a formula?

Carbohydrate Calorie density

• Lactose free?
• 20/oz = 0.67 kcal/mL
• Added sugar
• 22/oz = 0.74 kcal/mL
• Added fiber
• 24/0z = 0.8 kcal/mL
• 30/oz = 1 kcal/mL
Protein

• Protein source
• Intact/predigested • Preferences
• Protein energy ratio or %protein Flavour • Taste fatigue

Fat • Supplementation
Aims
• Substitution
• MCT%?
• Added DHA? Cost • Commercial vs homemade
Based on content

Polymeric
Whole protein/intact macronutrient

Oligomeric Pre-digested/peptide based

protein/semi-elemental

Monomeric
Elemental/amino-acid based
Single macronutrient: amino acid
Modular powder, whey protein, MCT oil, glucose
polymer
 PERATURAN BADAN PENGAWAS OBAT DAN MAKANAN
BPOM terminology NOMOR 1 TAHUN 2018
TENTANG
PENGAWASAN PANGAN OLAHAN UNTUK KEPERLUAN GIZI KHUSUS

PKGK Bayi dan Anak

(Pangan olahan
untuk keperluan
Gizi Khusus):
PDK (pangan (formula bayi, formula lanjutan,
Pangan olahan diet khusus) formula pertumbuhan, MPASI)
yang diproses atau
diformulasikan Dewasa
untuk secara
khusus untuk (makanan ibu hamil/menyusui,
memenuhi olahragawan, kontrol BB)
kebutuhan gizi
tertentu akibat
kondisi

PKMK (pangan Bayi dan Anak

fisik/fisiologis dan
penyakit/ganggua
n tertentu
keperluan medis
khusus)
Dewasa
PKMK untuk Anak
1. PKMK untuk Pasien Kelainan Metabolik (Inborn Errors of
Metabolism);
2. PKMK untuk Dukungan Nutrisi bagi Anak Berisiko PKMK untuk Gagal Tumbuh, Gizi Kurang
dan Gizi
Gagal Tumbuh, Gizi Kurang atau Gizi Buruk; Buruk berupa oral nutrition supplement
dengan
3. PKMK untuk Bayi Prematur; kandungan energi lebih besar dari 0,9
kkal/mL
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.
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
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
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
Carbohydrate
• Lactose content
• Fiber ? Available
Protein
• Intact
• Hdrolyzed
• Amino acid base
options
Lipid
• MCT
• LCPUFA
Available feeding solutions
Infant Pediatric
• Human milk + HMF • Standard enteral formula
• Standard infant formula • High density enteral formula
• Free lactose formula – 1.3 kcal/ml
Adult formula:
• Preterm formula – 1.5 kcal/ml
2 kcal/ml
• High density formula (1 • Oligomeric formula Disease specific formula
kcal/ml) – Partially hydrolyzed
• Oligomeric formula formula
– Extensive hydrolyzed • Elemental formula
formula – Amino acid based
• Elemental formula • Ketogenic 4: 1
– Amino acid base
• Ketogenic 3:1
• IEM special formula
 PERATURAN BADAN PENGAWAS OBAT DAN MAKANAN

Comparison of some PDK’s content NOMOR 1 TAHUN 2018

TENTANG
PENGAWASAN PANGAN OLAHAN UNTUK KEPERLUAN GIZI KHUSUS

Formula bayi/ Formula lanjutan/ Formula MPASI pokok MPASI kudapan

infant formula Follow-on formula pertumbuhan/
Growing up milk
Age (mo) 0-6 6-12 12-36 6-12 12-24 6-12 12-24
Calorie density 0.6-0.7 0.6-0.8 > 0.8 > 0.8
(kcal/mL)
Protein (g/100kcal) 1.9-5.5 0.8-5.5 1.9-5.5 0.8-5.5
Cow’s milk 1.8-3 1.82-3.5 3.2-5.5
Soy isolate 2.25-3 2.25-3.5 3.5-5.8
Iron (mg/100kcal) 0.45 -5 1-2 1-2 min 3.56 Min 0.86
Carbohydrate 9-14 8-14.2 7-(undefined)
(g/100 kcal)
Sucrose (if added) Max 20% Carb Max 20% carb Max 25% Carb Max 5 g/100 kcal Max 5 g/100 kcal
Similar but NOT the same
https://cekbpom.pom.go.id/
 Brand name kcal/mL Protein Scoop (g) Dilution
(g) /100 (mL)
ml
No data 2 4.5 30
Preterm formula BMT premature
Enfamil A+ 0.81 4.97 25
Selected special
premature 2.21 Infant Formula
Lactogen 5.37 28
premature 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

Hypoalergenic Neocate LCP 0.67 1.8 4.6 30

Nutramigen 0.68 1.91 4.5 30

Nutribaby royal 5.4 35
pepti 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

Enteral formula
PRACTICAL ASPECT: MIXING
ERROR

• Under and over-dilution

• Scoop size provided
Differentiate :

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)
Tell the difference
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
Catch-up growth
 o

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