Formula and Breast Milkadmin2021-09-28T12:31:18+00:00
It is possible to tube feed almost any type of diet, including breast milk, formula, specialized diets, and real food. Dietary choices should be made with your medical team. We often recommend that parents work with a dietitian who is well-versed in the available options for tube feeding diets. Often, pediatricians do not know the full range of options for children who use feeding tubes. Any formula, including those that are widely available, can be fed using a feeding tube. However, many children who require tube feeding need more specialized diets.
This page includes information on breast milk, formula, and specialized diets. See also our page on Blended Diets for information on feeding real food.
Breast Milk by Tube
Moving to tube feeding can be very emotional for moms who were breast feeding or who were planning on breast feeding. However, you can tube feed breast milk. You can also hold your baby while she is being tube fed and still bond during that time.
Breast milk can be fed just like you would feed formula. It can be fed through gravity bolus, syringe bolus, and using a feeding pump. The only thing you need to do differently is shake the bag or container occasionally, since breast milk has a habit of separating.
The Moog Infinity Orange pump is designed for feeding smaller volumes, such as feeding breast milk. The administration sets (feeding pump bags) are designed so that they funnel the milk towards the tubing, making it easier to use all the milk in the bag. You can use other pumps with breast milk, too.
One consideration with breast milk is that you do not want to waste any of the milk when using a pump to feed. Once the feed is completed, you can prime through all the remaining breast milk in the tubing. Another method is to add water to the bag and allow the pump to continue to run. See the videos below for more information.
Concerned about the fat content or calories of your breast milk?
The Children’s Hospital of Philadelphia offers tips on separating your foremilk and hindmilk. You can get your breast milk tested to find out the fat content and how many calories per ounce it is. Typically, breast milk is 20 calories per ounce.
Sometimes it is necessary to add calories or additional nutrients to breast milk. You can work with your doctor, nurse or dietitian on ways to increase the calories or nutrients in your breast milk so that you can continue to give your child breast milk and meet their nutrition needs. It is common to use infant formulas or breast milk fortifiers to fortify breast milk.
Formulas are made up of protein, carbohydrates, fats and vitamins/minerals. Most are designed to be nutritionally complete, meaning everything a child needs is available in the formula. Medical conditions can dictate the composition of these ingredients and if the proteins are whole, partially broken down (peptide) or are fully broken down to amino acids (elemental).
Many tube feeding formulas are made to also be consumed orally. There are some that have flavor options to encourage oral consumption, where others are usually reserved strictly for tube feeding.
Whole Protein Formulas
Whole protein formulas do not have the proteins broken down. Many children are able to tolerate whole protein formulas. These formulas cover a broad spectrum, from standard infant formulas to formulas that contain real foods. Examples include PediaSure, Nestle Compleat, or Similac. Most are milk- or soy-based, but some are made from real foods.
These formulas have the proteins partially broken down. Peptide formulas make digestion easier, so they move through the stomach more quickly, which can improve tolerance of feeds for some children. These formulas are recommended for any child with a feeding tube placed in the duodenum or jejunum, because they require less breaking down. Examples include Peptamen Jr and PediaSure Peptide. Most are milk- or soy-based.
Elemental/Amino Acid Based Formulas
Elemental proteins in these formulas are broken down to the amino acid level (the building blocks of proteins). These formulas are hypoallergenic. They also are easier for the body to process and absorb. They are commonly used in conditions like small bowel syndrome, eosinophilic disorders, motility issues, and severe food allergies. Elemental formulas are often used in children who are fed into the small intestine. Examples include Elecare, Neocate, or EO28 Splash.
There are also specialized formulas available for children with specific metabolic disorders, kidney diseases, the ketogenic diet and other conditions. These may restrict, eliminate, or add one component of the formula, such as a specific amino acid, carbohydrates, or proteins. In addition, there are modular formulas available, which piece together the building blocks of nutrition to accommodate rare conditions.
A Ketogenic Diet is specifically used in children who have seizures, for seizure control. It is a high-fat, low-carbohydrate diet that puts the body in ketosis, meaning it forces the body to burn fat for energy instead of carbohydrates. The diet can be administered either orally or by tube, or a combination of both.
While the classic Ketogenic Diet is still the most widely used, other versions, including the Modified Ketogenic Diet, Medium-Chain Triglyceride (MCT) Oil Supplement Diet, Modified Atkins Diet, and Low Glycemic Index Treatment (LGIT).
My name is Kari and I have a daughter named Kristin. She was born with a mystery brain disorder, and has no specific diagnosis. She started having seizures at 4 months old. Her seizures are very hard to control, and while we can manage them at home, they greatly affect her overall level of functioning. We haven been through over 16 different seizure meds. Sometimes they work briefly but never for long.
When Kristin was a year old, we were at a point where the ketogenic diet was less risky than the meds, so we decided to give it a try. I was nervous but very optimistic about the possibility of seizure control without all the side effects of the meds. Lets just say Kristin didn’t do too well with the change. It changes your body from burning sugar to burning fat for energy. Its like Atkins times 1000. (If you’ve ever done the low-carb thing, maybe you can relate.) She ended up with an NG-tube, but otherwise ate by mouth at that time. The diet stopped her seizures, but the side effects couldn’t be managed well enough, and we only stayed on it a few weeks.
When she was 6, we decided to give it another try. We chose to do it at a different hospital with more of an established program in place.
I will try to give you a basic overview of what’s involved. Different centers do it differently, so it may not be the same everywhere. There was a preliminary workup to be sure it was safe to proceed. We had to purchase a few basics- gram scales, some supplements, and a calculator.
To start the diet, you are admitted to the hospital for 4-5 days. It’s a huge change for your body, and doctors like to closely monitor the kids at this time to help them adjust to the changes. If you are strictly tube feeding, its actually easier than if your child eats. There are a few options: ketocal formula, RCF and microlipids, or a blended diet. In our case, Kristin has a GJ-tube and a history of GI issues, so we did RCF and microlipids mixed with water and possibly a touch of apple juice depending on the ratio, and it was given through her J-tube. They slow down feeds as they adjust because there is so much fat.
The diet can worsen constipation and reflux issues. We had to go back on Prevacid but it was manageable. There are usually supplements added because of the limitations of the diet.
In our case, I just had to make formula once a day. Her feeds ran over 15 hours. With the J you need slow feeds, but you can bolus if you use a G-tube. One of the biggest inconveniences for me was needing to take the scales for overnight trips, and also keeping the formula cold then being able to warm it up when needed. I ended up getting a bottle warmer and that worked well. It may be easier if you use ketocal in that respect.
The only added routine care for us was blood glucose monitoring as needed and daily urine dipsticks.
There are some great Facebook groups for keto. Our hospital had its own started by parents, and many centers do this. There is the Charlie Foundation website and a Facebook group called Keto Parents Rock that are very useful. Some hospitals follow the Charlie Foundation guidelines and some do not. This book, Ketogenic Diets, was a good reference when we were just getting started.
If your child eats some and is tube fed some, it is also doable. Wherever you choose to do the diet, they should be able to work with you to find what works for your situation. The keto team at our hospital was wonderful and extremely helpful.
Our daughter, Jenna, was born on July 8, 2009. She was small, had a cleft palate and difficulty feeding with the special Haberman bottle designed for cleft babies. We decided to have a G-tube placed when she was about one month old to ensure she would safely get the nutrition she needed to grow.
At about 5 months old, Jenna was diagnosed with Infantile Spasms. This is a catastrophic form of epilepsy, and the seizures are very difficult to control. We tried one medication, which worked for a while, but she continued having seizures. We decided to start the Ketogenic Diet as our second line of treatment.
Jenna was admitted to the hospital to begin the diet. While working with the Ketogenic dietician, we began the process of slowly weaning her normal diet and increasing the Ketogenic diet. There is a lot of blood work for her and a lot of training with the dietitians for us. The Ketogenic Diet can be difficult to manage because the ratio of fat, protein and carbohydrate needs to be exact to maintain the proper level of ketones to control the seizures. Jenna responded well to the diet and achieved ketosis pretty quickly and at a rather low ratio of fat to combined protein and carbohydrate. Finding the correct ratio is an ongoing process, and blood work is checked frequently and adjustments to the ratio are made accordingly.
Although we have never regretted having Jenna’s G-tube placed, it was at this point we began to really appreciate the benefits of having it as it made managing the diet so much easier. We used a Ketogenic formula as the base and added polycose powder for carbohydrate and healthy oil for fat. Each item needs to be weighed to the gram and mixed with an exact amount of water. We also had recipes for oral snacks that were calculated to the same ratio. Oral snacks are more challenging because each part needs to be weighed separately and then all mixed together so each bite is the same ratio. For example, if we were serving turkey, sweet potato and butter, everything needed to be weighed separately and then mixed together so the ratio was correct whether she ate one bite or ten.
Because of the G-tube, we were able to consistently feed her exactly the correct amount of formula, and this kept her blood sugars stable and significantly reduced her seizures. During an extremely stressful time, this was a comfort. We knew she was getting all of her medication and nutrition. The diet did not control all of her seizures, and we eventually added a third medication.
To properly manage the Ketogenic Diet, you will need a scientific scale that can precisely measure gram weight, a really good blender (or several!), a qualified dietician and commitment to the program. Honestly, I’m not sure we would have been as successful with the diet if she did not have the G-tube.
Jenna was weaned from her two other seizure medications during the course of the diet and weaned from the Ketogenic Diet in January 2013.
Infant formulas are 20 calories per ounce, which matches the approximate caloric concentration of breast milk
Reduced calorie (or 0.6 formulas) are 18 calories per ounce, or 18 calories per 30ml
Pediatric (or 1.0 formulas) are 30 calories per ounce, or 30 calories per 30ml
High-calorie (or 1.5 formulas) are 45 calories per ounce, or 45 calories per 30ml
Any formula, be it powder or ready to feed, can be modified to adjust the calories per ounce. For ready to feed formulas, you can add water to lower the calories per ounce. Some children do not easily tolerate an increase in the calories per ounce.
Using Gram Scales
Gram scales are more accurate than using the scoop with powdered formula. There can be a lot of variation in how people scoop powdered formulas. That can result in your child getting too few or too many calories over time, which can really impact weight. Using a scale to measure the weight of the powdered formula is more accurate. It also provides consistency no matter who is preparing the formula.
Most people prepare formula once or twice a day. Once powdered formula is mixed, or ready-to-feed formula is opened, it should be used within 24 hours. It should be stored in the refrigerator or in a cooler (for day trips). Manufacturers do not recommend that formula ever be frozen.
Most commercial formulas can hang in a feeding pump bag for 4 hours, but some food-based formulas without preservatives have shorter hang times. Check with the manufacturer to determine the hang time of your specific formula. We recommend using an ice pack to keep the formula cool if it will be longer than 2-4 hours. If you live in a warmer climate, you may consider using ice packs to keep formula cool even for shorter durations. You can safely hang formula overnight using a heavy duty ice pack. Keep the pump and feeding pump bag in a backpack, or rubber band the ice pack directly to the feeding bag.