NUTRITION SERVICES 2007

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					          Appendix 9




NUTRITION SERVICES
       2007

 La Rabida Children’s Hospital
                            NUTRITION SERVICES


Aimee Henrikson, RD, LDN, CDE - Department Manager
Coverage:    SAND Service, Diabetes, Burn
Desk:        Ext. 5945
Pager:       312-295-1928


Megan Aronson, RD, LDN, DNSD – Clinical Dietitian
Coverage:   SEA Service, Diabetes, FitMatters
Desk:       Ext. 5948
Pager:      312-367-3944

Mark Spielmann, RD, LDN – Outpatient Dietitian
Coverage:    Outpatient clinics (Chronic DZ, Vent, BPD, etc.)
Desk:        Ext. 5997
Pager:       312-295-9308

                                  FOOD SERVICE
Raquel Frazier, MS, RD, LD – Director of Food Services
Desk:         Ext. 9603

Food Service Supervisors
Martha Turner        Ext. 5992
Harriet Varnado      Ext. 5992
Who should receive a nutrition consult?

   All patients who receive enteral feedings or parenteral nutrition (TPN) must receive a
   nutrition consult.
   All patients admitted with one or more of the following diagnoses also must receive a
   nutrition consult:
   ⇒ Failure to Thrive
   ⇒ Diabetes Mellitus
   ⇒ Morbid Obesity
   ⇒ GI/Metabolic Disorder
   Any patient who is screened at nutritional risk through the Admission Nursing Assessment
   by answering ‘yes’ to any of the following questions:
   - Is the patient unable to tolerate oral feedings?
   - Does the patient have any food allergies?
   - Does the patient have problems chewing or swallowing?
   - Has the patient had an acute weight loss of >10% PTA?
   - Has there been significant (10%) weight loss or gain in the past 6 months?
   - Has there been failure to grow or gain weight (per caretaker)?
   Any patient for which a Registered Dietitian can be of assistance, please consult as needed,
   for example:
   - Food allergy
   - Introducing solids
   - Formula preparation
   - Etc.

How do I order a nutrition consult?

1. Write for a “nutrition consult” in the physician orders.

2. Patients requiring a nutrition consult may also be identified in multidisciplinary patient care
   rounds.

3. The nutrition consult will be entered into the computer by Nursing and sent to Nutrition
   Services.

4. Nursing may request an order for a nutrition consult from Medical Services for reasons other
   than those listed above if deemed necessary.
                            NUTRITION FORMULARY
INFANT FORMULAS**
Similac Advance (20, 24, 27, 30 kcal/oz)
Similac Special Care (24 kcal/oz)
Similac Neosure (22 kcal/oz)
Similac Lactose Free
Similac Isomil (20, 24, 27, 30 kcal/oz)
Pregestimil (20,24, 27, 30 kcal/oz)
Neocate (20, 24, 27, 30 kcal/oz)

ENTERAL FORMULAS/ORAL SUPPLEMENTS
Nutren Jr./Nutren Jr. with Fiber/Nutren 1.5
Ensure/Ensure Plus/Ensure with Fiber
Jevity/Jevity Plus
Neocate One Plus
Optimental
Peptamen Junior/Peptamen 1.5
Promote/Promote with Fiber
Ketocal

ORAL SUPPLEMENTS
Carnation Instant Breakfast Juices
Mighty Shakes

ORAL REHYDRATION SOLUTIONS
Pedialyte (maintenance)
Rehydralyte (rehydration)

MODULAR NUTRIENT SOURCES
Polycose Powder (carbohydrate)
Prosource
MCT oil (medium chain triglycerides)
Vegetable oil (long-chain triglycerides)
Pectin (soluable fiber)
Benefiber (fiber)

*Other formulas available as required for patients’ medical condition

**All infant formulas contain iron
                  THE SPEECH PATHOLOGIST’S ROLE IN FEEDING

The speech-language pathologist receives referrals for children who have feeding problems
and/or oral-motor (movement) dysfunction. Some of the behaviors these children may exhibit
are:

   1. excessive drooling,
   2. poor seal around the nipple and loss of liquid during bottle feeding,
   3. choking or coughing during feeding,
   4. inability to suck on a nipple,
   5. excessive oral defensiveness (dislike of touch or taste in or near the mouth),
   6. signs of neurological impairment, such as abnormal biting on the spoon and abnormal
      movements of the face and mouth during feeding,
   7. difficulty making the normal transition from simple to more advanced food textures,
   8. taking an excessively long period of time to consume a meal, due to lack of coordination
      or aversive behaviors,
   9. history of aspiration pneumonia

When a child is identified as having any of the above characteristics, particularly when they
interfere with feeding and weight gain, a speech-language pathologist should be consulted for a
feeding/ oral-motor assessment. During this assessment, the SLP will evaluate the child’s ability
to perform various kinds of oral movements, and will probably observe the child’s response to
stimuli in or around the mouth, including use of various food textures, liquids, and utensils.

Before making a referral for a feeding evaluation, it is important to remember that at certain
times of their development, some children will exhibit aversions to particular types of food. Or,
they may eat willingly with one caregiver but not with another. Some children require the
consistency of the same person feeding them each day. Some babies take an unusually long time
to consume their formula because they require one or more “breaks” or rest stops, within the
feeding session. This is particularly true of children with respiratory difficulties.
STANDARD DIET PROGRESSION

Diet Order        Menu          Special Instructions           Comment
4 months          None          Rice cereal only               Formula as ordered
                                (Available on unit)

5-6 months        Infant menu   5-6 months                     -Strained fruits and vegetables
                                - only cereal, fruit and       -Rice cereal
                                 vegetables                    -Formula as ordered
                                -baby food from jar

7-9 months        Infant menu   7-9 months                     -Strained fruit, mashed banana
                                -above, plus meat, cheese,     -Strained vegetables
                                 yogurt                        -Rice cereal, grits, oatmeal
                                -Baby food from jar            -Strained meats
                                                               -Cottage cheese and yogurt
                                                               -Formula as ordered

Chopped           General       -All food chopped into tiny    -Medium diced meats/entrees
(10 months or                    bites (medium dice = ½ inch   -Sandwich cut into tiny bites
older                            cube)                         -Chopped fruit & vegetables
                                -Gravy on side for all trays   -Cooked or cold cereal
                                                               -Cut-up pancakes, waffles
                                                               -Cut-up toast, bread, Fr. Toast
                                                               -Cut-up cheese, cottage cheese,
                                                               soups
                                                               -Whole milk*, fruit juice
                                                               -Whole crackers
                                                               -Desserts: pudding, jello, ice
                                                               cream, yogurt, sherbet

Finger Foods      General       -Finger foods                  -Finger food meats
w/soft solids                   -Tender meats                  -Pastas and other entrees
                                -Gravy on side                 -Sandwich cut into 6 pieces
                                                               -Cooked or cold cereal
                                                               -Canned fruit/banana
                                                               -Cooked vegetables
                                                               -Whole milk*, fruit juice
                                                               -Pancakes, waffles, French toast,
                                                                bread, toast, crackers
                                                               -Cheese, cottage cheese
                                                               -All desserts allowed

Regular           General
4 years – older                                                -All food allowed
MODIFIED CONSISTENCY DIET PROGRESSION

Diet Order      Menu                Special Instructions             Comment
Thin Puree      Thin Puree/         -All food pureed to a strained   -Thinly pureed meats/entrees (no
(10 months or   Texturized Puree/    consistency (thin puree,         eggs or bacon)
older           Finely chopped       uniform consistency, free of    -Thinly pureed canned fruits
**if younger                         lumps)                          -Thinly pureed cooked veg.
use age                             -Gravy on side for all trays     -Cooked cereal (except oatmeal),
appropriate                                                           pancakes
menu                                                                 -Thinly pureed cottage cheese,
                                                                      and soups
                                                                     -Whole milk*, fruit juice
                                                                     -Desserts: smooth pudding, jello,
                                                                      ice cream, plain yogurt, sherbet

Texturized      Thin Puree/         -All food blended to a thick     -Blended meat/entrees, and
Puree           Texturized Puree/    puree (textured consistency,     scrambled eggs* (no bacon)
(10 months or   Finely chopped       small lumps are acceptable)     -Blended canned fruit/banana
older)                              -Gravy on side for all trays     -Blended cooked vegetables
**if younger,                                                        -Cooked cereal including oatmeal,
use age                                                               pancakes
appropriate                                                          -Blended cottage cheese and
menu                                                                  soups
                                                                     -Whole milk*, fruit juice
                                                                     -Desserts: pudding, jello, ice
                                                                      cream, yogurt, sherbet

Finely          Thin Puree/         -All meats finely chopped      -Finely chopped meat/entrees
Chopped         Texturized Puree/   (brunoise cut = 1/8 inch cube) scrambled eggs* (no bacon)
                Finely chopped      -Gravy on side for all trays   -Finely chopped cooked
                                                                    vegetables
                                                                   -Finely chopped canned fruit,
                                                                    banana
                                                                   -Cooked cereal, finely chopped
                                                                    pancakes
                                                                   -Cottage cheese and soups
                                                                   -Whole milk*, fruit juice
                                                                   -Desserts: pudding, jello, ice
                                                                    cream, yogurt, sherbet

Transitional    Thin Puree/         -1/2 of each item on tray is     -Texturized puree mixed with
Level One       Texturized Puree/    textured puree                   finely chopped (small dice)
                Finely chopped      -1/2 of each item is finely
                                     chopped
MODIFIED CONSISTENCY DIET PROGRESSION - continued

Diet Order     Menu         Special Instructions              Comment
Transitional   General      -1/2 of each item on tray is      -Texturized puree mixed with
Level Two                    textured puree                    chopped (medium dice)
                            -1/2 of each item is chopped

Chopped        General      - See previous page for guidelines for chopped

Soft           General      -All meats tender                 -All foods that are easy to chew
                            -Gravy on side for all trays      -NO fried foods or hard to chew
                                                               foods

SPECIAL DIETS

Diet Order    Menu          Special Instructions/Comments
ADA Diet or   Diabetic      -Use the pre-calculated meal plan to select menu for the patient
Carbohydrate                 upon admission. Put in snacks as needed
Counting Diet               -Notify the dietitian. After the dietitian sees the patient, the
                             dietitian will select the menu and snacks with the patient/family.
                            -If no calorie level is stated on diet order –
                             for children under 3 years – send 1200 calories
                             for children between 3-6 years – send 1500 calories
                             for children between 5-10 years – send 1800 calories
                             for children 11-14 years – send 1800 for females
                                                           send 2200 for males
                             for children 14 years or older - send 2000 for females
                                                                 send 2400 for males

Low Fat        Low Fat      -Select items from low fat menu only

Calorie        Low Fat      -Use the pre-calculated menu to select menu for patient upon
Controlled                   admission. Put in snacks as needed. Notify the dietitian. After
and Low Fat                  the dietitian sees the patient, the dietitian will select the menu.

Low Sodium     General      -Follow guidelines in diet manual for sodium restriction
                             1,000 mg restriction – page 507 (4th edition)
                             2,000 mg restriction – page 503 (“ “ )
                             3-4,000 mg restriction – page 501 (“ “ )
                            **If no level given, follow 3-4,000 mg restriction

Low Residue    General      -Follow guidelines in diet manual page 405 (4th edition)

Bland Diet     General      -NO fried foods, spicy foods or pepper
AGE APPROPRIATE GUIDELINES

4 months old                              Rice cereal only (available on unit)

5-6 months old                            Infant menu 5-6 months

7-9 months old                            Infant menu 7-9 months

10 months – 2 year                        Chopped

2 – 3 years                               Finger Foods

4 years – older                           General


*GENERAL GUIDELINES

NO milk on tray until 1 year of age

NO eggs on tray until 1 year of age

NO whole hot dogs until 5 years of age
 - For ages 2-5 years: finely chopped hot dog only

NO meat with bone until 5 years of age

Limit fruit juice to one meal per day

Add a fruit OR vegetable to tray if patient has not selected either one
  - If on a calorie controlled diet, DO NOT add an additional fruit or vegetable

DEFAULT Menu for Puree
  - If a diet order comes down stating “Puree” or “Blenderized” without specifying whether it is a thin or
    texturized consistency, then default to a Texturized Puree tray.
                                         LA RABIDA FORMULAS

Formula              Company        Description                               Kcals/cc   Grams     % H2O
                                                                                         Pro/cc
Carnation Instant                   130 kcal/pkg, acceptable taste, variety
Breakfast            Nestle         of flavors                                  1.1       0.05      80%
Enlive Juice         Ross           Fruit beverage, high kcal/pro               1.25      0.041     80%
Ensure               Ross           Adult supp., lactose free                   1.06      0.037     84%
Ensure Fiber         Ross           2.8 g fiber/240 cc, FOS                     1.06      0.037     82%
Ensure Plus          Ross           Adult high kcal/high protein                1.5       0.055     76%
Ensure Pudding       Ross           Similar to 1 can of Ensure                170/cup     4g/cup
Jevity               Ross           Adult, isotonic, with fiber                 1.06      0.044     83%
Jevity Plus          Ross           High kcal/prot., isotonic, fiber            1.2       0.056     81%
Isomil 20            Ross           Infant soy, no lactose                      0.676     0.027     90%
Isomil 24            Ross           Infant soy, no lactose                      0.811     0.02      88%
Isomil 27            Ross           Isomil 24 plus MCT                          0.897     0.02      88%
Isomil 30            Ross           Isomil 24 + MCT, polycose                   1.0       0.02      85%
Neocate 20           SHS            Free AA, no lactose, MCT                    0.676     0.02      90%
Neocate 24           SHS            Free AA, no lactose, MCT                    0.811     0.025     88%
Neocate 27           SHS            Neocate 24 plus added MCT                   0.897     0.025     88%
Neocate 30           SHS            Neocate 24 + MCT, polycose                  1.0       0.025     85%
Neocate One Plus     SHS            1-10 yrs, Free AA, MCT                      1.0       0.025     85%
Nubasics Juice       Nestle         High kcal/prot juice (5.5 oz can)           1.0       0.065     79%
Nutren Junior        Nestle         1-10 yrs, 50% whey, 25% MCT                 1.0       0.03      85%
Nutren Jr. w/Fiber   Nestle         1-10 yrs, 1.5 fiber per 250 mL              1.0       0.03      84%
Osmolite             Ross           Adult, isotonic, low-residue                1.06      0.037     84%
Peptamen Junior      Nestle         Peptides, 60% MCT (elemental)               1.0       0.03      85%
Peptamen             Nestle         Adult, peptides, 70% MCT                    1.0       0.04      85%
Pregestimil          Mead Johnson   Infant, hydrolyzed protein, MCT             0.676     0.019     90%
Pregestimil 24       Mead J         Infant, hydrol. Prot, MCT                   0.811     0.023     88%
Pregestimil 27       Mead J         Preg 24 plus added MCT                      0.897     0.023     88%
Pregestimil 30       Mead J         Preg 24 + MCT, polycose                     1.0       0.023     85%
Promote              Ross           Adult, high-protein                         1.0       0.06      84%
Promote w/Fiber      Ross           Above w/14.8 g fiber in 237 cc              1.0       0.06      83%
Similac 20           Ross           Infant, lactose based                       0.676     0.015     90%
Similac 24           Ross           Infant, lactose based                       0.811     0.02      88%
Similac 27           Ross           Similac 24 plus added MCT                   0.897     0.02      88%
Similac 30           Ross           Sim 24 plus MCT, polycose                   1.0       0.02      85%
Sim Spec Care 20     Ross           Premature Infant (<3.6 kg)                  0.676     0.018     90%
Sim Spec Care 24     Ross           Premature Infant (<3.6 kg)                  0.812     0.022     88%
Similac Neosure      Ross           Preemie transition (>3.6 kg)                0.744     0.019     89%
Sim Lactose Free     Ross           Infant, no lactose                          0.676     0.015     90%
Additives
MCT oil           Mead J   Fractionated coconut oil, no EFA’s   7.67       0
                           Glucose polymers
Polycose powder   Ross     1 tsp=2g, 1T=6g, 1c=100 g            3.8/gm     0
                           Whey protein powder
Promod powder     Ross     1 scoop=6.6g, 1 tsp=1.3g, 1T=4g      4.2/g    0.76/g
Rice cereal                                                     5/tsp     .083
Vegetable oil              Max 1cc/50 cc for <6-% of cals           8        0

Milks
Chocolate milk                                                  0.8      0.035    80%
Skim milk                                                       0.36     0.035    94%
2% milk                                                         0.5      0.035    92%
Whole milk                                                      0.65     0.035    91%
                      INFORMATION REGARDING TPN
TPN orders are written by Nutrition Services (Aimee Henrikson RD, LDN, or Megan Aronson,
RD, LDN, CNSD) or Michael Gallery, Director of Pharmacy.

If questions or concerns arise regarding any aspect of TPN, please contact:

       Ellen Newton, RN (UCCH)                            pager 8347
       Aimee Henrikson, RD, LDN (La Rabida)               pager (312)295-1928 or x 5945
       Michael Gallery, RPh (La Rabida)                   pager (312)295- 1931 or x 8655
       Megan Aronson, RD, LDN, CNSD (La Rabida)           pager (312)367-3944 or x 5948

For questions regarding surgical issues, such as central line or gastrostomy repair, contact the
UCCH Pediatric Surgical nurse who will provide a solution:

            Beth Zimmerman, RN (UCCH)                     pager 6173

For questions regarding PICC lines, contact UCCH

            William Boettcher, RN                         pager 6135

For questions regarding short gut syndrome patients (family queries, OPD scheduling, potential
transfers), please contact:

            Dr. Izhar Qamar (La Rabida)                   pager 8548

Please order the following labs q Monday (Rotate Weekly)

            BMP (Basic Metabolic Panel) plus Ca, Mg, phosphorus               or

            CMP (Comprehensive Panel) plus Ca, Mg, Phosphorus, Triglycerides and GGTP

Nursing, please check TPN orders which are located in front of physicians orders q Wednesday
for any changes.

   •    Please inform Aimee Henrikson, RD, LDN or Megan Aronson, RD, LDN, CNSD about
        any new issues regarding TPN patients such as excess stooling, vomiting, transfer to
        UCCH, infections, etc.
                Page (312) 363-3944 or (312) 295-1928

   •    If children on TPN are to be admitted to La Rabida, discharged from La Rabida, or
        transferred as inpatients to another institution, you must notify 3 persons: Nutrition
        Services (Megan Aronson – SEA service, Aimee Henrikson – SAND service); Dr. Izhar
        Qamar; and Ellen Newton, RN (UCCH). This will allow for coordination of care.
•   Residents and medical students are prohibited from drawing blood for chemistries or
    cultures from central lines, to limit infection. Only staff certified in these procedures are
    allowed to touch the lines. Certified nurses can be identified, on all shifts, by contacting
    the nursing office (Patient Care Administration) at La Rabida x 524 (Administrative
    Coordinators).

•   TPN-dependent children, transferred to UCCH, may be admitted only to the Peds GI
    Service. Others will serve as consultant.

•   TPN-dependent children at La Rabida have long term nutrition care plans, designed to
    reduce TPN dependency and facilitate discharge home. Please do not adjust this plan,
    without permission of Nutrition Services.

•   When children on Home TPN are admitted, they may bring in some of their unused home
    bags for use in La Rabida (to avoid wastage). Some Home TPN is in the form 3:1, with
    Intralipid premixed into the solution. Such solutions will not pass through the filters
    used routinely for La Rabida TPN. Special 1.2-micron filters are available in the
    Pharmacy, for use with Home 3:1 bags. Home bags must be checked by Nutrition
    Services (Aimee Henrikson or Megan Aronson) or by the Pharmacy before use and must
    be kept refrigerated, until used.
                                          PEDIATRIC TPN GUIDE
1.  Determine calculation weight (non-edematous, non-dehydrated)
2.  Determine volume allowed for TPN (total volume = HAL + IL)
3.  Source of calories
    a. Carbohydrate: Dextrose: start at ~ 4-5 mg/kg/min and advance daily by 1.0-1.5 mg/kg/min; usually do not
       exceed 10 (>12 yrs); 10-12.0 (<12 yrs) mg/kg/min, especially if patient is NPO. Pts. On cycled TPN (see
       #17) may go above these limits since TPN is infusing over shorter time, therefore faster rate. Check BG
       CHEMSTRIPS daily. Do not exceed 10% in a PIV and usually 25-30% in Central line; Central PICC line
       (confirmed by x-ray): as central line.
       Peripheral PICC: 12.5%
                              To determine mg/kg/min – (% Dext. X infusion rate)/(6 x wt)
    b. Fat: Intralipid: start at 1.0 gm/kg using 20% Intralipid and advance 0.5 gm/kg every day to help achieve
       caloric goals. Check triglyceride q weekly. Do not advance if TG > 200 mg/dl.
                     To determine cc/hr: 1.0gm x wt (kg) x 100cc ÷ 24 hrs. e.g. 20% IL = 20 gm/100 cc
                                                kg                  20 gm
    c. Protein: Amino Acids: Using Travesol (don’t need to write on line); Trophamine for stressed, transplant,
       immunosuppressed, or Crohn/UC patients, start at 1.0 gm/kg and advance daily by 0.5 gm/kg/day to protein
       goal as stated. CYSTEINE may need to be added at 40 mg/gm of amino acids in HAL bag to help prevent
       precipitation of Ca and Phos. Will need to limit protein in renal/liver failure to 1.0 gm/kg.
4. Determining kcal content: Caloric goals: individualized; see nutritional assessment in chart
         See Neonatal TPN Guide re: calculations
5. Calcium: 15-100 mg Ca Acetate (Chloride)/kg; 79 mg CaAc2 provides 1mEq Ca & 2mEq Acetate; 74 mg
    CaC12 provides 1mEq Ca and 2mEq Cl; 50-100 mg Ca Gluconate/kg (usually a max of 4.0 gm Ca
    gluconate/bag for teenagers and young adults; cross out mEq; write in mg Ca Ac/Cl/gluconate
6. Phosphorus: Usually start at 0.3-1.0 mmol/kg; write as mEq of cation
    (1 mmol Phos = 1.5 mEq KPhos or 1 mmol Phos = 1.3 mEq Na Phos). Restrict in renal failure.
7. Magnesium: 0.2-0.5 mEq/kg. Restrict in renal failure; requirements may increase with Ampho
8. Electrolyte requirements:
         a. Sodium: 3.5 mEq/kg
         b. Potassium: 2-4 mEq/kg; restrict in renal failure; requirements may increase with Ampho
         c. Acetate, chloride; per CO2, chloride values
9. Vitamins: <11 yrs: write PEDS: 2 ml/kg up to 5 ml maximum
                   >/ = 11 yrs: write MVI-12: 10 cc/day + Phytonadione 1 mg
10. Trace elements: < 11 yrs: write PEDS: neonatal and postneonatal: 0.2 cc/kg
                         >/ = 11 yrs: write MTE-4; 1cc/d
                     Withhold in cholestasis; decrease dose to 0.1 cc/kg if urine output inadequate
11. Zinc: May be needed if pt has ostomy output or diarrhea; contact PNSS
12. Selenium: 2 mcg/kg to max of 30 mcg per day
13. Heparin: Not used for CL unless infusion rate is slow (<10cc/hr). PCVC’s require heparin @ 1U/cc
14. TPN Renewals: Write” “Renew HAL & IL order from date of last completely written order”
                   Renewals can be written in every order space, not only in the ‘TPN renewal’ box
15. Peripheral TPN: Do not exceed 800 mOxm/L. Dextrose and Protein contribute the most; limit dextrose to
    maximum of 12.5% and protein to 1.5% (gm amino acids/vol of Hal)
16. To avoid precipitation: We use precipitation curves to determine Ca and Phos limits in TPN
17. Cycling: Determine # of hrs in cycle (e.g. 24 → 20 → 16 → 12). Divide volume of HAL by 1 hr less than
    desired (e.g. if 20 hour cycle, divide by 19 = rate for 18 hours then divide rate in half to give the rate for the 1st
    hour and the 20th hour)
ROUTINE MONITORING:
         I/O, blood glucose: 1-2 X/wk while advancing; then as needed; esp. if h/or ↑ BG or on steroids
         weight: at least qo day; head circumference: (if less than 3 yrs) q 2 weeks
         length/height: q 2 weeks
         kidney profile, Ca, Mg, PO4: q day until stable, then 2-3 times/week
         liver profile and triglyceride level: baseline, then 1x/wk
DESIRABLE LABORATORY VALUES FOR PEDIATRIC (NON-NEONATAL) PATIENTS ON TPN
Electrolytes         Renal Function                    Minerals
Sodium *135-145      Chloride *95-108                  BUN**5-25                Phos**child or infant: 4.5-6.5; teens: 3.0-4.2
Potassium *3.5-5.2   Bicarbonate *20-25                Creatinine **<1.0        Magnesium *1.8-2.3; Ca**8.5-10

Liver Function                                         Visceral proteins        Misc.
Alk Phos #<300       GGTP #inf <120; child <65         Albumin @ 3.5-4.5        Glucose **80-120
Conj. bili **<0.5    SGPT #<30                                                  Trigylceride **<200
*mEq/L; **mg/dl;     @gm/dl; #U/L
            La Rabida Recommended Vitamin/Mineral Supplementation Guide

                Consult with Nutrition Services for additional input as needed

< 1 year       1 cc polyvitamin/day                Vitamin Supplement only, no minerals.
                                                   Folic Acid not included.

< 1 year       1 cc polyvitamin with Iron/day      Vitamin Supplement only, no minerals.
                                                   Folic Acid or B12 not included.
                                                   Contains 9 mg iron/cc.

1-3 years      5-10 cc (1-2 tsp)                   Vitamin and mineral liquid supplement.
               Cerovite liquid/day                 Contains no folic acid, calcium, phos.
                                                   Copper, magnesium, Vitamin K,
                                                   Selenium, low zinc (contains 3 mg iron
                                                   per tsp or 5 cc)

1-3 years      ½ tab Centrum Jr                    Vitamin and mineral supplement. More
                                                   complete than Cerovite liquid (contains
                                                   above minerals). If g-tube: crush, mix with
                                                   water & bolus via g-tube (contains 18 mg
                                                   iron per tablet)

>4 years       10-15 cc (2-3 tsp)
               Cerovite liquid/day                 (see above)

> 4 years      1 tab Centrum Jr.                   (see above

If Additional Calcium is Needed:                State amount of elemental calcium on order

Liquid         5 cc Calcium Carbonate/day          provides 500 mg elemental Ca
               1 tsp – once daily w/meal

               10 cc Calcium Carbonate/day         provides 1000 mg elemental Ca
               1 tsp – twice daily w/meals

               15 cc Calcium Carbonate/day         provides 1500 mg elemental Ca
               1 tsp – 3 times/day w/meals

Tablet         1 tab Oscal                         provides 500 mg elemental Ca

If Additional Phosphorus is Needed:             State amount of elemental phos on order

Powder         1 packet Neutraphos                 provides 250 mg elemental Phosphorus

If Additional Iron is Needed:                   State amount of elemental iron on order

Liquid Drops   0.6 mL Ferrous Sulfate              provides 15 mg elemental Fe
                                                   (3-6 mg/elemental Fe/kg/day
                                                   recommended for Rx of deficiency)
                              La Rabida Nutrition Formulary
                                    And Appropriate Substitutions

Formulas that                                       Common Substitutions that
La Rabida Has in Stock                              Rabida DOES NOT Have in Stock
Standard Infant Formulas
(note: all powders can be concentrated to 22, 24, 27 and 30 kcals per ounce)
Similac Advance                                       Enfamil, Carnation Good Start/Follow-up
Similac Advance 24                                    Enfamil, Carnation Good Start/Follow-up
Similac Isomil Advance                                Prosobee, Carnation Alsoy
Similac Isomil Advance 24                             Prosobee, Carnation Alsoy
Similac Neosure Advance                               Similac Spec. Care, Enfamil Premature LIPIL Enfacare
Elemental Infant Formulas
Neocate                                               Elecare
Enfamil Pregestimil                                   Alimentum, Nutramigen
Enfamil Pregestimil 24                                Alimentum, Nutramigen

Standard Pediatric (age 1-10) Formulas
Nutren Jr.                                          Pediasure, Kindercal
Nutren Jr. w/fiber                                  Pedisure w/ Fiber, Kindercal w/ Fiber

Elemental Pediatric (age 1-10) Formulas
Peptamen Jr.                                        Neocate Junior, Pepdite One Plus
Neocate One+                                        Elecare 30

Standard Adult (age 11+) Formulas
Jevity                                              Nutren 1.0 w/Fiber, Boost w/ Fiber
Jevity 1.2                                          Probalance
Osmolite                                            Nutren 1.0 unflavored, Isocal
Promote                                             Replete
Promote w/fiber                                     Replete w/Fiber
Ensure                                              Nubasics 1.0, Boost, Nutren 1.0
Ensure w/fiber                                      Nutren Fiber, Boost w/fiber
Nutren 1.5                                          Ensure Plus, Boost Plus, Nubasics 1.5

Elemental Adult (age 11+) Formulas
Optimental                                          Peptamen, Subdue, Vivonex
Peptamen 1.5                                        Optimental, Subdue, Peptamen

Ketogenic Formula
Ketocal                                             No Substitute

Oral Supplements
Carnation Instant Breakfast Juice                   Enlive, Resource fruit Beverage, Nubasics juice
Mighty Shakes                                       Ensure, Nutren Jr., Pediasure

Oral Rehydration Formulas
Pedialyte                                           Enfalyte

Supplemental Nutrient Sources
Polycose powder (carbohydrate)                      Moducal
Prosource (protein)                                 Casec, Resource Beneprotein, Promod powder
MCT oil (medium chain triglycerides)                No Substitute
Vegetable oil (fat)                                 may substitute MCT oil, corn oil
Pectin (soluable fiber)                             Benefiber, Fiber One, Metamucil
Benefiber (fiber)                                   Fiber One, Metamucil