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Monitoring micronutrients in children with complex, multiple diagnoses on Amino Acid Formulas (AAF)

Children who are commenced on AAFs require regular monitoring and review, and follow-up is essential to ensure they receive adequate nutrition1. AAFs are formulated to be nutritionally complete and in line with Foods for Special Medical Purposes (FSMP) legislation. However it is important to regularly check nutritional status, as requirements can change (e.g. with changes in clinical condition, medication use or clinical interventions). Monitoring can include a review of nutritional intake and requirements, anthropometry, assessment of symptoms and micronutrient status1. This document focuses only on micronutrient monitoring of children who are receiving an AAF as a sole source of nutrition who have complex, multiple diagnoses.

Which children should be monitored?

Children with complex systematic disease involving multiple diagnosis who are on AAFs and have any of the following risk factors for developing bone disease:

  • History of prematurity2-4
  • Gastrointestinal disease2-4
  • Use of proton pump inhibitors and/or jejunal feeding2-4
  • Immobility4

Why should these children be monitored?

  • Children with complex systematic disease involving multiple diagnosis and intestinal disease or a history of prematurity have the potential to develop hypophosphatemia and bone disease2-4
  • Medically complex children may have increased micronutrient losses, a reduced absorptive capacity and/or higher micronutrient demands impacting micronutrient status2-6
  • It can be difficult to establish the micronutrient status of a medically complex child through dietary assessment alone and so reliable blood markers can be helpful7.

What macronutrients should be monitored?

  6 months after commencing AAF If continuing on AAF review annually
Iron profile: full blood count & ferritin(8) Yes Yes
Bone profile: vitamin D, parathyroid hormone (PTH), phosphate, calcium, and alkaline, phosphate (ALP) (2,3,4,9) Yes Yes
Electrolytes: sodium, potassium, magnesium (9) Yes Yes
Zinc (9)   Yes
Selenium (8,9)   Yes

Monitoring may be required earlier or more frequently where there is a clinical concern, or with children that are likely to have/with known unstable micronutrient profiles. Serum levels of micronutrients, particularly phosphorus, should be routinely monitored by clinicians when Neocate is used as a primary or sole source or nutrition for patients with complex systemic diseaseinvolving multiple diagnoses and intestinal disease, *especially in combination with tube feeding and/or a history of prematurity. Neocate** formulas are intended for use under medical supervision.

*A retrospective review identified case studies of patients on primary or sole source of nutrition with diagnoses covering multiple systems, including congenital gastrointestinal anomalies and GI surgeries (such as necrotizing enterocolitis, esophageal atresia, tracheoesophagael fistula); neurological conditions (such as seizures intraventricular hemorrhage, hydrocephalus); respiratory (lung disease, tracheostomy, aspiration); cardiac (congenital heart disease); and other systemic conditions, often in conjunction with tube feeding and/or a history of prematurity2.

**Neocate is an amino acid-based formula for the dietary management of cow’s milk allergy, multiple food protein allergies, and other conditions where an amino acid diet is recommended.

  1. Shaw V. Cinical Paediatric Dietetics: Wiley, 2014; 282-307.
  2. Ballesteros Gonzalez LF, Ma NS, Gordan RJ, Ward L et al. Unexpected and widespread hypophosphatemia and bone disease associated with elemental formula use in infants and children. Bone, 2017; 97: 287-292.
  3. Uday S, Sakka S, Davies, JH, Randell T, Arya V, Brian C et al. Elemental formula associated with hypophosphataemic rickets. Clinical Nutrition, 2018. https://doi.org/10.1016/j.clnu.2018.09.028
  4. Liddicoat INM, Tighe MP. Supplementation in hypophosphatemic rickets: the bare bones of management. Arch Dis Child Educ Pract Ed, 2018; 0: 1-4. doi:10.1136/archdischild-2018-31499.
  5. Ojuawo A, Keith L. The serum concentrations of zinc, copper and selenium in children with inflammatory bowel disease. Central Afr J Med, 2002; 48(9-10): 116-9.
  6. Yang CF, Duro D, Zurakowski D, Lee M, Jaksic T, Duggan C. High prevalence of multiple micronutrient deficiencies in children with intestinal failure: a longitudinal study. J Pediatr, 2011; 159: 39-44.
  7. Meyer R, De KC, Dziubak R, Skrapac AK, Godwin H, Reeve K et al. A practical approach to vitamin and mineral supplementation in food allergic children. Clin Transl Allergy, 2015; 5: 11.
  8. Ekunno N, Munsayac K, Pelletier A, Wilkins T. Eosinophilic gastroenteritis presenting with severe anemia and near syncope. J Am Board Fam Med, 2012; 25: 913-918.
  9. BAPEN Enteral Feed Monitoring, 2016. Available from www.bapen.org.uk/nutrition-support/enteral-nutrition/enteral-feed-monitoring.

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