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Off Hours Metabolic Formula Preparation for Pediatric Patients with Inborn Errors of Metabolism (Pediatric) (2.26)

Off Hours Metabolic Formula Preparation for Pediatric Patients with Inborn Errors of Metabolism (Pediatric) (2.26) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Gastrointestinal



Effective Date:
July 29, 2016

Administrative Manual
Nursing Manual (Red)
Other ______________

Policy #: 2.26P


of 4

Title: Off Hours Metabolic Formula
Preparation for Pediatric Patients with
Inborn Errors of Metabolism (Pediatric)


A. To establish guidelines ensuring the safe and accurate ordering, storage,
preparation, distribution and administration of metabolic formula during
hospitalization of pediatric patients with inborn errors of metabolism when the
milk lab is closed.
B. To delineate responsibility for the preparation of metabolic formulas between the
Waisman Center, Nursing, Clinical Nutrition Service, Culinary Service and


A. Preparation of Metabolic Formula
1. The provider will order the diet. When an order is placed and formula is
needed during hours that the milk lab is closed, nursing is responsible
for mixing metabolic formulas according to the prescribed order.
Formula is typically mixed for each feeding due to the rapidly changing
needs of the patient. Note the recipe may change more than once during
the day.
2. It is the expectation that the formula change be implemented as soon as
possible after the order is written. The provider will specify the
timeframe in which the change needs to be implemented.
B. Storage of Metabolic Formula
1. Metabolic formulas needed for infants and children during the hospital
stay will be provided by the Waisman Center. Commonly used products
will be stored at the American Family Children’s Hospital (AFCH), in
the P5N nourishment room (P5218).
2. The Waisman Center will be responsible for stocking and removal of
expired products. Milk Lab staff checks metabolic formula supply
routinely and notifies Waisman Center when stock levels are not up to
par or formula has expired.
3. If a formula is prescribed and not available in the stock when needed,
contact the Genetics provider on-call after hours to obtain it.


A. Health Link Order Entry and Orders Management
B. Metabolic formula recipe instructions
C. Formula label for metabolic formula

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D. Gloves, gown, and hairnet
E. Gram scale for powder measurement
F. Beaker for liquid measurement
G. Sterile water container and hard plastic utensils/containers
H. Sterile water
I. Formula (powder and/or liquid)


A. Diet Order and Instructions for Formula Mixing
1. The diet will be ordered by the provider.
2. The provider will notify the patient’s nurse of the new diet order.
3. It is recommended that the nurse select Room Service classification “2”
for menu selections. This will allow nutrition technicians to assist
parents with menu selection.
4. The diet order will contain the following information:
a. Patient’s name
b. Medical record number
c. Room number
d. Formula type and caloric level
e. Total volume to be prepared for prescribed timeframe
f. Amount of formula to be prepared
g. Amount of formula powder or concentrate
h. Amount of sterile water to be mixed together
i. Any other additives or special instructions for formula preparation.
5. The provider will prescribe the timeframe the new formula order needs
to be started.
6. Medium Chain Triglyceride (MCT) Oil and Amino Acids will be
provided by Pharmacy and will be stored in the patient’s medication
B. Gowning and Hand Asepsis
1. Hand washing with an antiseptic hand wash is required whenever
entering the formula room, prior to mixing formula, and whenever hands
are visibly soiled. Hands are rinsed and dried with a single use paper
towel from a dispenser. Alcohol-based hand-rub gel may be used when
handling but not mixing formula. Refer to Policy 13.08, Hand Hygiene.
2. Non-sterile latex free gloves must be used while preparing metabolic
formula. They must be changed whenever soiled, and after mixing each
formula to prevent cross-contamination.
3. Always wear a clean gown when preparing metabolic formula.
4. A surgical face mask must be used during formula preparation when the
employee has any minor respiratory illness.
5. Hair should be covered with a surgical-type hat or hair cover.
C. Work Area for Formula Preparation
1. All work surfaces and equipment must be washed and sanitized with an
anti-bacterial sanitizing solution, following product instructions, prior to
and following formula preparation.
2. Surfaces will be dried with a paper towel.
3. Surfaces should be cleaned after any spills during the preparation

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4. Cleaning supplies must be stored separately from formula products and
5. Single use disposable equipment and utensils are preferred for formula
6. During preparation, no other activity should be permitted in the room.
7. Only authorized personnel should have access to the room.
8. Doors to the room are to be kept closed during formula preparation. A
sign must be placed on the door indicating formula preparation is in
progress to minimize disruption.
D. Powdered Formula Mixing Procedure
1. The can should be inspected before use. Check expiration date on the
can. Do NOT use can if beyond an expiration date, or if a container
is damaged, leaking or swollen. Formula powder cans and additives,
once opened, must be labeled, dated and discarded 30 days or 1 month
after opening (or sooner if indicated on the label) if not used. Mark as
follows: “Opened on _____, Discard by _____.”
2. Wipe the top surface with an alcohol pad before popping open the can.
3. Powdered metabolic formulas should be measured or weighed on a gram
scale, in a new or sanitized container.
4. Combine all weighed metabolic formula powders into a container for
5. Measure room temperature sterile water needed for the formula recipe.
Room temperature water aids the mixing process.
6. Add room temperature water to the metabolic formula powders to the
desired final formula volume. Metabolic formula recipes will usually be
written as (x) metabolic formula powder + water to make a total of
(y) ounces/mL.
7. Stir metabolic formula and water until all lumps disappear.
8. If the volume of metabolic formula is less than the total volume
prescribed in the recipe, add water and blend again until the final volume
equals the prescribed amount in the recipe. When larger formula
volumes are needed, mix in two (2) batches.
9. Transfer the metabolic formula from the mixing container into
individual bottles or containers.
10. Label containers with the following:
a. Product name
b. Ingredients
c. Calories per ounce
d. Patient’s name and room number
e. Date/time prepared
f. Expiration date/time
g. Preparer’s name
11. Preprinted labels are available in the formula preparation kitchen. The
date and time of preparation, date and time of expiration and name of the
staff member preparing the metabolic formula must be noted on the
12. Prepared metabolic formula is considered good if it remains refrigerated.
The refrigerated product must be discarded if not used within 24 hours.

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13. Prepared metabolic formula at room temperature for two (2) hours or
more must be discarded.
14. Powdered metabolic formula cans should be stored at room temperature
(never refrigerated) after use. They should be discarded 30 days from the
date it was opened.
15. For questions regarding the formula order, contact the Metabolic
Physician On-call. Additional resources for questions are the Waisman
Center Dietitians.
E. Staff Training
1. Designated employees will demonstrate competency for metabolic
formula preparation by successfully interpreting formula instructions for
preparation and identifying appropriate formulas to mix.
2. Dress code per UWHC Administrative Policy 9.16, UW Health Dress
Code and Appearance will apply. Personnel will be in good health and
maintain appropriate personal hygiene.


A. Clinical Nutrition Policy 1.9, Human Milk and Formula Storage, Preparation and
B. UWHC Administrative Policy 9.16, UW Health Dress Code and Appearance
C. UWHC Administrative Policy 13.08, Hand Hygiene


A. Academy of Nutrition and Dietetics (2016). Pediatric Nutrition Care Manual –
online subscription accessible with Sign In identification at:
B. A.S.P.E.N. Enteral Nutrition Practice Recommendations. (2009). Journal of
Parenteral and Enteral Nutrition, 33(122), 122-167.
C. Centers for Disease Control and Prevention Recommendations for Hand Washing.
Accessed at http://www.cdc.gov/handwashing/.
D. Genetest. Accessed at www.genetest.org.
E. New England Consortium of Metabolic Programs. Acute illness protocol,
description of diseases, newborn screen protocol, discussion groups, slideshows.
Accessed at http://newenglandconsortium.org/.
F. Online Mendelian Inheritance in Man (OMIM). Accessed at

Clinical Nurse Specialist, Universal Care Unit
Director, Clinical Nutrition Services
Waisman Center Clinical Nutritionists
Nursing Patient Care Policy and Procedure Committee, July 2016

Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer