How do I prepare 24 kcal/oz infant formula for an infant?

How to Prepare 24 kcal/oz Infant Formula

To prepare 24 kcal/oz formula, add fat modules (long- or medium-chain triglycerides) or carbohydrate modules (glucose polymers) to standard 20 kcal/oz formula under medical supervision, maintaining proper macronutrient balance. 1

Preparation Methods

The American Academy of Pediatrics recommends several evidence-based approaches to increase caloric density from standard 20 kcal/oz to 24 kcal/oz:

Primary Methods

• Add fat modules using long-chain or medium-chain triglycerides to standard formula, which increases caloric density while maintaining nutritional balance 1
• Add carbohydrate modules using glucose polymers as an alternative method to increase calories 2, 1
• Use ready-to-use preterm formulas that come pre-prepared at 24 kcal/oz concentration 2

Alternative Concentration Method

• Prepare more concentrated standard formula by reducing water volume during mixing, though this requires careful physician or dietitian supervision 2

Additional Options

• Add 1 teaspoon of rice cereal per ounce of formula to increase density by 5 kcal/oz 1
• Use blended avocado to increase caloric density while adding potassium 1

Critical Macronutrient Requirements

You must maintain strict macronutrient ratios when fortifying formula:

• Protein: 8-12% of total calories 1
• Carbohydrate: 40-50% of total calories 1
• Fat: 40-50% of total calories 1

These ratios ensure nutritional adequacy and prevent metabolic complications 1

Fluid Volume Adjustments

When using 24 kcal/oz formula, adjust fluid volumes accordingly:

• Start with 75-90 mL/kg/day for smaller or immature infants 1
• Advance to 95-150 mL/kg/day as clinical status improves 1
• This reduced volume compared to standard formula (typically 150 mL/kg/day) accounts for the higher caloric density 3

Osmolality Safety

• Ensure formula osmolality remains below 450 mOsm/L to prevent renal stress and ensure adequate free water provision 1
• Medications and carbohydrate modules can increase osmolality, requiring monitoring 1

Transition Strategy

Implement slow transition to improve tolerance:

• Start at 24 kcal/oz concentration 1
• Gradually advance based on infant tolerance and growth response 1
• Rapid advancement reduces tolerance and causes feeding intolerance 1

Monitoring Parameters

Watch for signs of intolerance:

• Test stools for fat content if they become loose and greasy with poor growth 1
• Test for reducing substances if stools become frequent and watery 1
• Monitor weight, length, and head circumference serially 1

Common Pitfalls to Avoid

• Do not add excessive fat modules - this decreases gastric emptying, worsens gastroesophageal reflux, and may cause ketosis 1
• Do not exceed macronutrient balance ranges - improper ratios compromise nutritional adequacy 1
• Do not ignore osmolality - excessive concentration causes renal stress 1
• Do not advance caloric density too rapidly - this reduces tolerance 1
• Do not attempt fortification without medical supervision - any infant requiring concentrated formula needs comprehensive medical evaluation and ongoing monitoring by a physician or dietitian 2

Safety Considerations

• Formula fortification should only be done under medical supervision with full nutritional assessment 2
• Powdered formulas are not sterile and require proper preparation technique to minimize bacterial contamination risk 4
• Freshly prepare each feed and discard any remaining milk rather than saving for the next feeding 4
• Never keep formula warm in bottle heaters or thermoses 4