Transitioning Tube Feeding Formula to Real Food Ingredients in a Patient Less than the Age of One

Patients with intestinal failure (IF) have complex metabolic and nutritional requirements and pose a dietary challenge, especially in pediatric patients, as they age. Enteral nutrition in patients with IF has consisted of breast milk and elemental formulas because they have been shown to decrease the duration of parenteral nutrition.1, 2 However, elemental formulas lack complex nutrients, are costlier, and can have higher osmolality. Intact protein formulas can lead to malabsorption and diarrhea.1 Blended food formulas have several proposed advantages, including low cost, positive perception by parents, improved stooling patterns, and increased intestinal adaptation.1, 3 In the adult population, patients have self-reported better tolerance, decreased diarrhea, nausea, constipation, and bloating.4 In studying patients over the age of one with IF transitioned to a commercially prepared food-based formula, Compleat (Nestle Health Science, Bridgewater, NJ) Pediatric patients were found to have improved stooling patterns, decreased retching, and high parental satisfaction.1 The use of commercially prepared food-based formulas has not yet been described in patients less than the age of one. A 25 6/7-week gestational-age infant with a birth weight of 930 g developed stage III necrotizing enterocolitis on day of life (DOL) 27. She underwent resection of multiple segments of necrotic small bowel, fecal diversion, and on DOL 75, subsequent ostomy closure. On DOL 96, she developed recurrent pneumatosis and pneumoperitoneum and required another laparotomy, resection of the ileocolic anastomosis and ascending colon, and diversion with ileostomy. After ileostomy closure, she had approximately 50 cm of small bowel, no ileocecal valve, and intact colon distal to the transverse. On DOL 215, she underwent an open Nissen fundoplication and gastrostomy tube placement. Her nutritional support initially consisted of total parenteral nutrition (TPN) followed by gradual advancement of Neocate Infant formula (Nutricia North America, Gaithersburg, MD) continuous gastric feeds. Even after stoma reversal, high ostomy output prevented fully weaning from TPN until a real food-based formula, Compleat Pediatric was added to the patient’s enteral regimen on DOL 251. Before the addition of Compleat Pediatric, enteral nutrition was 75 per cent of caloric intake. Eighteen days after beginning Compleat Pediatric, TPN was stopped. The addition of Compleat Pediatric formula was gradually increased to achieve a mixture of 75 per cent Compleat Pediatric when discharged on DOL 313. Nutritional composition of Compleat Pediatric is unlike any infant formula on the market because it is composed of real food ingredients such as chicken, milk, and peas. With the addition of Compleat Pediatric, the patient had significant decreases in quantity of stools, improved consistency of stools, and improvement in weight gain (Figs. 1 and 2). She was able to be fully weaned from TPN, and at the time of discharge from the NICU, she was tolerating full enteral feeds, primarily via gastrostomy tube but also with some oral intake. Patient was transitioned as tolerated using the following ratios: 33 per cent Compleat : 67 per cent Neocate , 50 per cent C: 50 per cent N, 55 per cent C: 45 per cent N, 70 per cent C: 30 per cent N, and 75 per cent C: 25 per cent N to 100 per cent Compleat three months after discharge. With each increase in Compleat Pediatric, a temporary increase in stooling was seen. After several days of intestinal adaptation, the stooling pattern decreased (Fig. 2—each increase in Compleat Pediatric is indicated with an asterisk). Since the patient’s discharge, she has had continued success with the Presented at the Southeastern Surgical Congress, February 13, 2018, Tampa, FL. Address correspondence and reprint requests to Jessica L. Simpson, M.S., Wake Forest University School of Medicine, Bowman Gray Center, 475 Vine St, Winston-Salem, NC 27101. E-mail: jlsimpso@wakehealth.edu.