Preparing 24-27 kcal/oz Formula for Infants with Microcephaly and Accelerated Linear Growth
To prepare 24-27 kcal/oz formula, add fat modules (long- or medium-chain triglycerides) or carbohydrate modules (glucose polymers) to standard 20 kcal/oz formula, maintaining macronutrient balance of 8-12% protein, 40-50% carbohydrate, and 40-50% fat. 1
Preparation Methods
Fat Module Addition
- Add long- or medium-chain triglycerides to increase caloric density beyond 24 kcal/oz while potentially reducing CO2 production, though this may slow gastric emptying and contribute to gastroesophageal reflux 1
- Monitor stools qualitatively and quantitatively for fat content if loose, greasy stools and poor growth occur 1
Carbohydrate Module Addition
- Add glucose polymers as an alternative method to increase caloric density 1
- Test stools for reducing substances if they become frequent and watery, and reduce carbohydrate modules if abnormal 1
Rice Cereal Method
- Add 1 teaspoon of rice cereal per ounce of formula to increase caloric density by 5 kcal/oz 1
- This provides a simple, practical method for modest caloric increases 1
Alternative Fat Source
- Blended avocado can be used to increase caloric density while adding potassium 1
Critical Macronutrient Balance
When concentrating formula and adding modules, maintain strict macronutrient ratios: 1
- Protein: 8-12% of total calories
- Carbohydrate: 40-50% of total calories
- Fat: 40-50% of total calories
Fluid and Osmolality Considerations
- Start with 75-90 mL/kg/day for smaller, immature infants receiving 24-28 kcal/oz formula, advancing to 95-150 mL/kg/day as clinical status improves 1
- Ensure formula osmolality remains below 450 mOsm/L as recommended by the American Academy of Pediatrics, since medications and carbohydrate modules can increase osmolality 1
- Monitor renal solute load and provide adequate free water frequently 1
Transition Strategy
Implement slow transition to calorically dense formulas to improve tolerance, starting at 24 kcal/oz and gradually advancing to 27 kcal/oz or higher based on growth response 1
Monitoring Parameters
Stool Assessment
- Test stools for fat content if loose and greasy with poor growth 1
- Test for reducing substances if stools become frequent and watery 1
- Reduce the problematic module if abnormalities occur 1
Growth Tracking
- Monitor weight, length, and head circumference serially to determine adequacy of nutritional support 1
- For infants with microcephaly, head circumference growth is particularly important as it correlates with brain development during the critical growth period 2
Special Considerations for Microcephaly with Accelerated Linear Growth
- Calculate catch-up growth calories using: (RDA for chronological age in kcal/kg × ideal weight for height) ÷ actual weight, with energy needs potentially reaching 150 kcal/kg/day or more 1, 3
- Start with 120 kcal/kg per day to achieve catch-up weight gain, adjusting upward if weight does not respond 1
- Early high-energy feeding can support successful catch-up growth of head circumference in infants with growth retardation 2
Common Pitfalls to Avoid
- Do not add excessive fat modules, as this decreases gastric emptying, contributes to gastroesophageal reflux, and may lead to ketosis 1
- Do not exceed macronutrient balance ranges, as improper ratios compromise nutritional adequacy 1
- Do not ignore osmolality, as excessive concentration can cause renal stress and inadequate free water provision 1
- Do not advance caloric density too rapidly, as this reduces tolerance and may cause feeding intolerance 1