Review paper

Medium chain triglycerides (MCT) formulas

in paediatric and allergological practice
Ewa Łoś-Rycharska, Zuzanna Kieraszewicz, Mieczysława Czerwionka-Szaflarska
Department and Clinic of Paediatrics, Allergology, and Gastroenterology, Nicolaus Copernicus University in Torun,
Ludwik Rydygier Collegium Medicum in Bydgoszcz, Poland

Gastroenterology Rev 2016; 11 (4): 226–231

DOI: 10.5114/pg.2016.61374

Key words: fat, medium chain triglycerides, feeding, infant formula, allergy.

Address for correspondence: Prof. Mieczysława Czerwionka-Szaflarska MD, PhD, Department and Clinic of Paediatrics, Allergology,
and Gastroenterology, Collegium Medicum, Nicolaus Copernicus University, 9 Skłodowskiej-Curie St, 85-094 Bydgoszcz, Poland,
phone: +48 52 585 48 50, e-mail: klped@cm.umk.pl

Abstract
Fats constitute the most significant nutritional source of energy. Their proper use by the body conditions a number of
complex mechanisms of digestion, absorption, distribution, and metabolism. These mechanisms are facilitated by fats made of
medium chain fatty acids; therefore, they are an easy and quick source of energy. Thus, an increased supply of medium chain
triglycerides (MCT) is particularly important in patients with disturbances of digestion and absorption such as disturbed bile
secretion, classic coeliac disease, short bowel syndrome, inflammatory diseases of the intestines, disturbed outflow of lymph,
some metabolic disease, and severe food allergies, as well as in prematurely born neonates. Use of preparations containing an
additive of MCT is limited, especially if they are to be used for a longer period of time. With a large quantity of MCT in a diet,
there is a risk of deficiency of necessary unsaturated fatty acids and some fat-soluble vitamins. The caloricity of MTC compared
to long-chain triglycerides is lower, and formulas with MCT are characterised by higher osmolality. Medium chain triglycerides is
not recommended as an additive to standard formulas for healthy children. The use of MCT should be limited to strictly specified
medical indications.

Fats constitute the most significant nutritional roid hormones, and vitamin D3. It also takes part in my-
source of energy. They provide approximately 9 kcal/g elinisation of the brain and the central nervous system.
of energy, which is over two times more than carbohy- Thus, it is particularly important during early develop-
drates and proteins. Fats originating from food not only ment. Dietary fats are also a carrier of ADEK vitamins
provide us with energy, but are also a source of building and flavour substances in food products [2].
substances and take part in the synthesis of important Triglycerides (glycerol esters and three molecules of
biological compounds such as prostaglandins, throm- identical or different fatty acids) constitute the basic di-
boxanes, leukotrienes, and prostacyclins. Particularly etary fats (approximately 98%). Moreover, food contains
crucial is a proper supply of the necessary unsaturated free fatty acids, phospholipids, sphingolipids, glycolip-
fatty acids, which are a building material for cell mem- ids, sterols, waxes, carotenes, vitamins A and D, choles-
branes (especially in the nervous system and the reti- terol, and many others. The structure of fats is diverse,
na of the eye). Among them, linoleic acid (LA: 18:2n-6) both as regards their type (number of carbon atoms in
and linolenic acid (ALA: 18:3n-3) are exclusively exog- the chain, presence or absence of unsaturated bonds
enous. All the other acids (mainly arachidonic acid AA: and their number) and their position in the triglyceride
C20:4n-6, docosahexaenoic acid DHA C22:6n-3, and molecule. Depending on the number of carbon atoms
eicosapentaenoic acid EPA: C20:5n-3) can theoretically in a molecule, fatty acids are divided into short- (C4-6),
be synthesised by the body from their precursors (i.e. medium- (C6-10), and long-chain variants (C12-26). If
LA and ALA). However, this synthesis is insufficient in triglycerides contain long-chain acids, they make the
most cases [1]. Cholesterol is a significant element of so-called fats, i.e. long-chain triglycerides (LCT); if they
cell membranes and precursors of bile acids, some ste- contain medium chain acids, they make fats, i.e. medi-

Gastroenterology Review 2016; 11 (4)

Medium chain triglycerides (MCT) formulas in paediatric and allergological practice 227

um-chain triglycerides (MCT) [3, 4]. The latter ones, in the other hand, fatty acids are located in the first and
a natural form, occur in a very limited quantity, mainly third position and are therefore more difficult to absorb.
in coconut oil [5]. Use of the coconut oil is however lim- The chemical structure of triglycerides in human milk
ited due to its high content of lauric and myristic acid, provides better absorption than in the case of cow’s
which have atherogenic properties [1]. milk. This is because these triglycerides have optimal
Dietary fats are divided according to the source of assimilability, which is provided by a species-specific es-
origin. Saturated fatty acids are the most prevalent an- terification of the palmitic acid (in the second position
imal fats. Vegetable and fish fats mainly include mono- of glycerol) [2, 8, 11].
and polyunsaturated fatty acids. When feeding an infant Once they are absorbed into an enterocyte, fatty
one has to remember to provide it with fats of a prop- acids and monoglycerides undergo resynthesis to tri-
er composition. Thus, formulas fed to an artificially fed glycerides, in the presence of ligase, co-enzyme A, and
baby should be maximally similar to human milk. This is ATP. Chylomicrons are formed. They get to the lymph
because there are some significant differences between and only then can they be transported to blood and
human milk and cow’s milk as regards the total content destination organs [10, 12]. Thus, shortly after a fatty
and proportions of mono- and polysaturated fatty acids, meal, a significant increase in the quantity of chylomi-
the proportion of long-chain polyunsaturated fatty acids crons is observed in blood (lipaemia). The peak of this
(LC-PUFA – C > 20), cholesterol, and the stereoisometric phenomenon is observed 2–4 h after a meal and may
structure of triglycerides [6, 7]. Fats contained in hu- last for up to 36 h. Release of fats from chylomicrons re-
man milk provide 50% of energy. Long-chain fatty acids quires the presence of plasmatic lipases, and only then
constitute about 95% of all fatty acids. Medium-chain can they be metabolised or stored as a reserve in the
triglycerides constitute up to 10% (usually about 2%) fatty tissue [12].
of the total fat. Among saturated fatty acids, as well as Hydrolysis of MCT (which is faster than LCT hydro-
mono- and polyunsaturated fatty acids, palmitic, oleic, lysis anyway) does not require bile and lipase. Without
and linoleic acids are prevalent, respectively [1, 8]. Use of hydrolysis, they may also be absorbed by the entero-
vegetable oils in particular proportions in modified milk cytes and they do not require re-esterification [4, 8].
formulas allows us to obtain a profile of fatty acids that From enterocytes they are directly absorbed into the
is similar to natural human milk [1, 9]. portal vein and then transported mainly to the liver.
The diversity of lipid structures is associated with Thus, absorption of MCT is faster than that of LCTs.
the multitude of their biological and biophysical fea- Their metabolism is facilitated as well because they
tures, such as easiness of lipolysis, way of absorption, are metabolised by the liver almost completely (only
metabolism, and biological functions. Absorption of when the liver’s metabolic abilities are exceeded the
the larger part of lipids (LCT) requires special process- process is taken over by peripheral tissues) with energy
ing in the digestive tract, i.e. emulsification with bile. release, regardless of the presence of carnitine (which
This process is aimed at obtaining maximum surface is necessary for the transport of long-chain fatty acids
for digestion (lipolysis with breakage of ester bonds of through the mitochondrial membrane). Thanks to this
triglycerides and with release of monoglycerides, free the availability of medium-chain fatty acids for mito-
fatty acids, and glycerol). Fats of short carbon chains chondrial oxidation is better [12]. This means that MCT
and unsaturated bonds are digested more easily than are an easy and quick source of energy [3, 10]. Howev-
the saturated long-chain fatty acids [3, 10]. The process er, it should be borne in mind that quantities of MCT
of digestion of fats mainly takes place in the duode- exceeding the abilities of the liver are metabolised pe-
num and the initial segment of the jejunum. Lipases ripherally in a carnitine-dependent mechanism, which
are found in the pancreatic juice and the brush border. can increase the demand for it. On the other hand, it
At infantile age gastric lipase is also significant. This is has been observed that on the enterohormonal path-
because the activity of the pancreatic lipase in children way (an important element of which is a MCT-induced
during the first few months of life is low. increase of the YY peptide concentration and a decrease
The degree of absorption of a given fatty acid de- in cholecystokinin release) MCT cause a decrease of
pends on its location in the molecule [11]. Fatty acids appetite and consequently a decrease in energy in-
located in the central position are easily absorbed be- take [3, 13]. They also interfere with the metabolism of
cause lipases are very efficient at breaking the bond the fatty tissue, by hindering the creation of a deposit
between glycerol and the residue of a fatty acid. This from long chain acids [12]. It has been proven that an
is why butter is an easily absorbed dietary fat, in which MCT-enriched diet modulates metabolism of fats, which
80% of the saturated fatty acids bound with glycerol are is manifested as a decrease in the concentration of tri-
in the central position. In ripening and blue cheeses, on glycerides and cholesterol [14].

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228 Ewa Łoś-Rycharska, Zuzanna Kieraszewicz, Mieczysława Czerwionka-Szaflarska

The properties of fats contained in food, include the MCT formula, as well as, for example, a lactose-free or
length of fatty acids, modulate the motor function of low-lactose formula applied at the initial stage of treat-
the digestive tract, secretion of enterohormones, and ment, can determine effective dietetic therapy [40]. The
even the mesenteric flow [15–17]. Unlike LCT, MCT do time period between the beginning of the diet and the
not affect the release of cholecystokinin or the empty- subsidence of symptoms is longer in the case of en-
ing of the gallbladder and they do not increase the se- teropathy (up to approximately 6 weeks) [41].
cretion of pancreatic enzymes [13, 18]. They can speed Iacono et al. [39] treated 9 infants with severe
up the intestinal passage by affecting the release of symptoms of food polyallergy, which did not subside
the YY peptide, but only in the distal sections of the after treatment with hydrolysates and soya-based for-
intestine [13]. Moreover, it has been found that MCT mula. After a short period of parenteral nutrition, they
facilitate absorption of calcium [10, 19, 20]. applied donkey’s milk with an additive of MCT (40 ml/l
Due to these features, increased supply of MCT is of milk), which lead to good tolerance of this food and
particularly important in patients with disturbances of an increase in the infants’ body mass. However, tak-
digestion and absorption, who suffer from energy defi- ing other studies into consideration, it seems that it is
ciency and disturbed absorption of fats [21]. These are not the addition of MCT that was crucial, but rather the
patients with disturbed bile secretion (cholestasis, dis- type of the protein used. Verwimp et al. [42] compared
turbances in hepatic-intestinal circulation of bile acids, the use of two elimination formulas in 79 young (be-
intestinal dysbacteriosis), or pancreatic lipase secretion low the age of 3 months) babies with allergy to cow’s
(for example, in pancreatic failure in the course of cys- milk protein. Whey hydrolysate was used, which con-
tic fibrosis), since MCT do not have to be emulsified in tained a standard composition of fats and lactose or
the digestive tract or undergo the process of lipolysis a lactose-free whey hydrolysate containing 50% of MCT.
[21–23]. Preparations containing MCT are also used in After 10 weeks it was found that in both groups the
patients with disturbed absorption and energy defi- diet turned out to be an effective means of treatment
ciencies associated with, for example, classical coeliac in 80% of cases.
disease, short bowel syndrome, or status post bowel Medium-chain triglycerides are also used in nutri-
transplantation [24–26]. tion of prematurely born infants, due to the immaturity
A supply of MCT is also recommended in aggravated of their digestive tract and high demand for energy [3,
Crohn’s disease [27]. What is more, studies conducted 5, 19, 43–45]. It has been shown that the activity of
on animals showed that a diet based on elementary for- gastric lipase in premature infants is insufficient, which
mula containing MCT (unlike LCTs) has an anti-inflam- negatively affects the hydrolysis of fats [46]. However, it
matory effect in inflammatory diseases of the intestines has also been found that stimulation of the activity of
[28]. Medium-chain triglycerides are also recommend- gastric lipase is higher for the LCT formula, compared to
ed in Fabry disease (disturbances in resynthesis of tri- the MCT formula [47].
glycerides in enterocytes) and in disturbances of lymph Therapeutic formulas contain such proportions of
outflow (for example after cardiosurgical surgeries or fats that 48% of the energy is obtained from the fat,
due to intestinal lymphangiectasia) [29, 30]. Some met- out of which 55% is obtained from MCT, which allows
abolic conditions, including (but not only) the ones as- for appropriate proportion of EFA [21]. However, in the
sociated with disturbances of mitochondrial β-oxidation nutrition of patients requiring significant elimination
of fatty acids, can also be treated with an MCT-enriched of long-chain fatty acids, pure MCT oil constitutes the
diet [31, 32], and early application of an MCT formula is main source of fat. Milk formulas for premature infants
usually significantly beneficial for the treatment. are also enriched with MCT, but the quantity of MCT
Supply of MCT is indicated in enteropathy in the should not exceed 40% of total fat content [1]. High
course of food allergy, including severe symptoms of content of MCT increases the osmolality of the prepara-
allergy to cow’s milk protein in infants [33–37]. Alter- tion, which should also be taken into account.
ations in the structure of intestinal villi can take place. The use of preparations containing an additive of
Clinical signs include chronic diarrhoea, disturbed MCT has its limitations, especially if they are to be
growth, and poor appetite. Impaired digestion and ab- used for a longer period of time. It should be borne in
sorption, whose symptoms are dominant in the clini- mind that necessary unsaturated fatty acids belong to
cal picture of the disease, lead to anaemia, hypoalbu- the LCT fraction, which means that we may be dealing
minaemia, and other deficiencies [36–38]. Frequently, with a risk of their deficiency when the content of MCT
symptoms do not subside after application of potent in a diet is too high [10, 48]. It is recommended that
hydrolysates of a non-modified composition of fats [39]. preparations with a high proportion of MCT should be
In such a situation, the hydrolysate or an elementary used for a maximum time of several weeks and that

Gastroenterology Review 2016; 11 (4)

Medium chain triglycerides (MCT) formulas in paediatric and allergological practice 229

patients should be provided with supplementation of been found that feeding prematurely born infants with
essential unsaturated fatty acids [21]. MCT formulas is more beneficial, also due to its effect
In studies conducted on infants with cholestasis, on temperature regulation, compared to feeding with
deficiencies of essential unsaturated fatty acids were standard formulas. Sulkers et al. [52] showed that in
found in the group fed with a preparation in which the prematurely born infants fed with a formula with in-
content of MCT was 87% of total fat and the content creased content of MCT the increase of body mass was
of linoleic acid was 3.4% of energy, while in the group higher (which was associated with deposition of fatty
fed with a preparation with the content of MCT of 40% tissue), compared to prematurely born infants fed with
(the content of linoleic acid – 7% of energy) no such a formula of only a small quantity of MCT (38% vs. 6%).
deficiencies were detected [49]. Improvement in the increase of body mass and increase
The proportion of MCT is undoubtedly crucial for po- of the skin fold thickness in infants born with low body
tential deficiencies. It has been shown that in infants mass, induced by MCT formula, was observed by Vaidya
fed with a MCT formula (40% of total fat), oxidation of et al. [53].
long-chain unsaturated fatty acids was lower than in Even though no significant benefits for the course
prematurely born infants fed with a standard formula. of disease was found in infants with allergy to cow’s
Rodriguez et al. [5] studied prematurely born infants milk protein compared to hydrolysed formula of tra-
fed with MCT or standard formulas. They administered ditional fat composition, no negative effect on the in-
marked linolenic acid and tested the concentration of crease of body mass was found during 10 weeks of
marked CO2 in the exhaled air and the concentration of observation [42].
polyunsaturated fatty acids in serum. They found lower Higher osmolality of the formulas containing MCT
concentration of marked CO2 and even higher concen- should not be underestimated, since it is associat-
tration of fatty acids. ed with higher risk of osmotic diarrhoea. Therefore,
In the case of formulas containing MCT a decrease the dose of MCT should be increased gradually and
in the concentration of some fat-soluble vitamins was the osmolality of the preparation should not exceed
observed (especially vitamin E) [48, 50]. 400 mOsm/kg [54].
We should also take into account the lower caloric- Other adverse effects of formulas containing high
ity of MCT, compared to LCT (approximately 8.3 kcal/g proportion of MCT described in literature include de-
and 9.1 kcal/g, respectively). It has been suggested in ficiency of carnitine resulting in damage of the liver
studies conducted on adult patients that the supply of and kidneys due to long-lasting feeding of a prema-
MCT increases energy expenditure and the burning of turely born infant (24 Hbd) with extremely low body
fatty tissue, and consequently reduces body mass [15, mass [55]. It has also been found that MCT can en-
51]. Observations of the increase of body mass in pre- gage carnitine in the course of their metabolism and
maturely born infants fed with MCT formulas do not ex- carnitine reserves in infants are low. Therefore, in
plicitly confirm improvement of increase in body mass, such cases supplementation with carnitine should be
compared to infants fed with formulas of a standard considered.
fat content [43, 45, 47]. There have been no differences Interesting observations were recently described
detected in the increase of body mass between children by Li et al. [56], who carried out a study on mice and
fed with formulas containing different proportions of showed that dietary MCT can promote allergy to food
MCT [45]. allergens simultaneously eaten with it, by hindering
However, other observations indicate that there is absorption of the allergen into blood and increasing
a positive effect of MCT formulas on the growth of pre- its absorption in Peyer’s patches, where stimulation of
maturely born children with low body mass. Another Th2 response takes place. Medium-chain triglycerides
study examined the potential effect of MCT on hinder- can also cause an increase in allergic response after an
ing appetite and decreasing fat deposition as fatty tis- oral attempt at food provocation. The study was not
sue in prematurely born infants (which had been sug- conducted on a human population; however, it clearly
gested in studies conducted on adults). Telliez et al. [3] indicates that MCT should be used sensibly.
gave their patients a formula containing 37% of MCT Medium-chain triglycerides are therefore not recom-
or a formula containing 100% of LCT, for 3 days. Then mended as an additive to standard formulas for healthy
they found that absorption of food and energy in the children. Their use should be limited to strictly specified
group fed with MCT formula was higher compared to medical indications [9].
the group fed with a formula containing LCT only. Chil-
dren from this group also presented with higher use Conflict of interest
of oxygen, higher temperature, and longer sleep. It has The authors declare no conflict of interest.

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230 Ewa Łoś-Rycharska, Zuzanna Kieraszewicz, Mieczysława Czerwionka-Szaflarska

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