Infant & Toddler Feeding Flashcards Preview

SPRING16 N833 Adv Pedi > Infant & Toddler Feeding > Flashcards

Flashcards in Infant & Toddler Feeding Deck (101):
1

What were the millenium developmental goals?

UN Initiative 2000-2015

 

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2

When do we use WHO vs CDC growth charts?

WHO <24 months

CDC >24 months

3

Why use the WHO growth charts?

  • for <24mo
  • Growth of BF infant is standard
  • Better description of physiological growth in infancy
  • Based on high quality study aimed at developing growth charts

4

What is stunting?

Low height for age (2 SD)

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5

When does stunting start?

•before birth ( poor maternal nutrition)

6

Why does stunting occur?

  • Before birth: poor maternal nutrition
  • Poor feeding practices
  • Poor food quality
  • Frequent infection (--> slowed growth)

7

What is wasting?

Low Weight for Height
by 2 SD

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8

Definition of underweight

Low Weight for Age

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9

Major contributor to under-five deaths?

Undernutrition

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10

Interventions to prevent undernutrition?

•Breast feeding within one hour of birth

•Exclusive breast feeding through 6 mos

•Adequate complementary feeding

•Micronutrient supplements 

11

Why is breastfeeding recommended?

•Bonding

•Nutritional value

•Availability

•Different effects on metabolism

•Self regulation

•More open to variety of tastes (formula always tastes the same, BM flavor varies w/mom's diet)

12

Why is formula used?

As a substitute for human milk

13

How is formula regulated in the U.S.?

  • •Carefully controlled by FDA
    • –Nutrients (sugar, fat and protein)
    • –Safety

14

Preparations of formula on the market

Ready to feed

Powder

Concentrate

make sure you ask how they prepare their formula - ensure doing correctly

15

Why is iron fortification recommended in formula?

•Rationale
–Meet hgb needs after maternal stores depleted (RBCs last 120 days - after 4 months needs restoring)
–Increase stores prior to whole cow's milk:  Prevent IDA
–Improve alertness, ability to interact and learn
 

16

Iron absorption from breast milk vs formula?

•50% of iron absorbed from breast milk
•12% of iron absorbed from formula
 

17

How much iron in iron fortified formulas?

•Iron fortified formulas contain 10-12 mg/l
•Low iron formulas discontinued (were used for fussy babies - no evidence and deprives of needed Fe)

18

Formula recommendations for non-breast fed term healthy babies?

–Start on CM formula at 20cal/oz

–Iron-fortified formula

–0-12 mos

19

What is DHA/ARA and why is it being added to formulas?

newer ingredients

•DHA(Omega-3)/ARA (Arachidonic acid)

–Structural fats found in brain and retina

–Better cognitive and visual development (until 18 months)

–Now all formulas fortified

20

Why are prebiotics being added to formula?

to help develop the immune system

21

Rationale for avoiding palm oil in formula?

Improved calcium absorption w/o palm oil

22

What are the various types of formula on the market?

•Cow’s milk

•Soy protein

•Partially hydrolyzed

•Elemental

•Lactose free

•AR

•DF

•Preterm

•Specialty

•Follow-up

23

Contents of Cow's Milk Formulas

•Sugar – lactose

•Protein– cow’s milk

•Minor differences in whey/casein ratios

•Non-nursing babies started on CM formula

24

Brands of Cow's Milk Formula available? Position of AAP?

•Similac, Enfamil, Good Start, store brands

•AAP – no statement supporting brand

25

What is different about Similac Organic formula?

•Meets USDA criteria: 95% free

–Hormones

–Antibiotics

–Other chemicals

26

How is does Similac organic compare to non-organic similac?

•Same nutrition as other Similac

•DHA, ARA supplements

•AAP – no benefit to organic BUT:

–Lower exposure to pesticides

–Meats not treated with antibiotics

27

2012 Position of AAP on organic foods?

•no benefit to organic BUT:

–Lower exposure to pesticides

–Meats not treated with antibiotics ( resistance)

–No large studies to prove better

–Higher costs to families

28

What age group os Similac Newborn intended for?

Birth to 3 months

29

Benefits of Similac Newborn?

–27 oz. provides all Vit D (vs 32 oz)

• no need for supplement

–Whey-casein (60-40) ratio more similar to BM in first 6 mos

30

When and why was soy-based formula introduced?

•1929- intolerance to CM formula

31

Brands of soy-based formula?

•All brands equivalent

–Prosobee

–Isomil

–Alsoy

32

Is soy formula iron fortified?

yes

33

Calories /nutrition in soy based formula vs cow's milk formula?

Same calories

BUT recent studies call into question nutritional adequacy and safety

34

Composition of soy'based formula?

•CHO sources
–Sucrose
–Corn syrup solids
–Maltodextrin
•Protein:  soy
•Fats from vegetable oil
•Iron fortified, zinc fortified
•Meet vitamin, mineral, -lyte specs

35

What are phytoestrogens?

•Non-steroidal estrogens (isoflavones)

found in soy

36

What are potential negative effects for kids of phytoestrogens?

–Sexual development and reproduction

–Neurobehavioral development

–Immune and thyroid function

•No conclusive data re kids or adults

37

What are potential benefits of phytoestrogens to adults?

–Coronary artery disease

–Some cancers

 

•No conclusive data re kids or adults

38

Why was soy based formula previously used in diarrhea?

If diarrhea, gp off formula, use a kind of ORS, then titrate up on soy. Theory had washed lactase out of system w/diarrhea and thus not give lactose. Recent info does not hold this up.

 

•Similac Soy Expert Care DF: plays on this belief

39

Should soy based formula be used for recovery from AGE?

•Most infants OK with breast or CM formula during recovery from AGE

40

Should soy based formula be used in preterm infants?

NO.

•Serum phosphorous lower

•Alkaline phosphatase higher

•Degree of osteopenia increased even with Ca and D supplements

41

Relationship between soy formula and cow's milk sensitivity

•Cross reactivity to soy protein if enterocolitis from CM formulas
–Bloody diarrhea

 

•High incidence of sensitivity  to CM AND soy
–25% < 6mos
–5% 6-12 mos

42

Indications for Soy Formula

•Disorders of carbohydrate metabolism

–Galactosemia ( newborn screening)

–Primary lactase deficiency ( very rare)

•Family’s desire to avoid animal products

43

Benefit of soy formula in colic?

•10-20% of 0-3month old infants with “colic”

•Calming attributed to sucrose and fiber in soy

•Controlled studies – no differences in soy or CM

44

What formulas are marketed for colic?

•CM protein partially broken down = partially hydrolyzed

–Similac Sensitive

–Carnation Good Start

–Enfamil GentleEase

•Reduced lactose

•Marketed for fussiness and gas

45

Rule of 3s for colic

“3 weeks old, 3 hours a day, 3 months”- normal!

Doesn’t mean they need treatment, have gerd, etc

46

What percentage of infants have a CM protein allergy?

2-3%

47

Types of CM protein allergy reactions

•IgE mediated reactions (antibody-mediated)

•Non IgE mediated (cell- mediated)

48

Immediate response (IgE) to CM protein allergy?

–Urticaria

–Angioedema

–Vomiting

–Acute flare of eczema

–Severe GI symptoms

•Bloody mucousy stools

49

Delayed response to CM protein allergy

–Irritability

–GER

–Atopic dermatitis

–Enteropathy

50

Diagnosis of CM protein allergy

–Positive skin prick

–Positive serum specific IgE

51

Prognosis for CM protein allergy

•75% outgrow by 3 yrs

•90% outgrow by 6 yrs

52

MGMT recommendations for CM protein allergy, BF and non

•Anaphylaxis rare

•Breast feeding encouraged

•Management if symptoms con’t with BF:

–Mom to avoid all milk products

–Read labels!!

–Try for 2-4 weeks

53

When to use elemental formulas? 

•If

–careful nursing

–CM or (?) soy formula tried

•And

–still severe symptoms

54

Brands of elemental formulas?

•Alimentum

•Nutramigen

•Pregestimil

–Fat malabsorption and protein allergy

55

When should you see improvement on elemental formulas?

2-4 weeks

 

56

How long to use elemental formulas

Continue at least until 12 months

57

What is a super hypoallergenic formula?

•Neocate /Elecare

–100% free amino acids

–No intact proteins

–Lactose free

58

When to use a super hypoallergenic formula?

 

•Multiple food protein intolerances

•Soy and protein hydrolysate not helpful

–Previously only available by prescription, now OTC.

59

What is a lactose free formula?

•Cow’s milk formula

–No lactose – corn syrup solids for CHO

–Promoted for “non-specific formula intolerance”

– Same calories/oz as standard formulas

60

Why is a lactose free formula questionably necessary?

LI is not usually present at birth

61

Why do preterm infants need special formulas?

–low body stores of nutrients

–deficient bone mineralization

–accumulated energy deficit

62

Formulas available for preterm infants?

–Enfacare Lipil 
–Neosure

63

How many calories per ounce in preterm infant formulas?

–22 calories/oz

 

64

How long should preterm infant formulas be used?

–Recommended until 9 months, often stopped earlier

65

What spit-up formulas are available and why are they used?

•Enfamil A.R. Lipil and Similac Spit Up
• - full-term infants who spit up frequently or who need a thickened formula
can thicken your own formula w/a spoonful of rice cereal

66

How does spit-up formula compare to other formulas?

–Nutrients same

–Rice starch for thickening

–Viscosity 10 X routine formula

–Flows through standard nipple

–Milk–based fatty acid pattern similar to breast milk

–Iron fortified

–Easier preparation than adding rice to formula

–Contains DHA and ARA

67

What are follow up formulas?

•Marketed for 9 months through toddler

•Increased iron and calcium

–Similac 2

–Enfamil Next Step

–Carnation Good Start Supreme 2

•V/M of 2-3 servings of F/V in sippy cup!!!

•NOT needed if good variety of solids

68

Examples of when specialty formulas may be used

Inborn errors of metabolism:

  -PKU

  -Maple syrup urine disease

  -Homocystenuria

   -Methylmalonic acidemia

   -Organic acid disorders

69

Problems with goat milk formula

•Not the best alternative

•Low

– Vitamin D

– Iron

– Vitamin B12

–Folate

•may lead to IDA or megaloblastic anemia

70

Recommendations for patients using goat milk formula

–Chose

•Pasteurized, supplemented with Vitamin D and Folic Acid

–Supplement

•additional carbohydrate, such as sugar or corn syrup.

–Need vitamin supplements with iron

71

Recommendation for Almond Milk Formula?

Just don't 

can lead to scurvy, FTT, etc

72

Usefulness of differently shaped bottles

One option to try for fussy babies - before "flipping formulas"

73

Why is Vit D important to G&D?

•Essential for calcium absorption( bones)

•Maintains healthy immune system

•May help prevent

–Autoimmune disease

–Some cancers

–Type 2 DM

 

74

Consequences of inadequate Vit D?

can lead to rickets and low calcium

75

76

How much Vit D supplementation is recommended (BF vs FF)

•Supplementation
–Breast fed infants:   400 IU
•TVS, PVS, D-VS*
–Formula fed < 32 oz/day:  400 IU
•*Vitamin D-Only:  care with administration- risk of toxicity

77

What are AAP's 2014 fluoride recommendations?

•Toothpaste –

–When teeth emerge ( grain of rice am’t)

–At three years of age ( pea-sized am’t)

•Fluoride varnish

–At tooth emergence and every 3-6 mos

•Community water fluoridation – YES

•Dietary supplements

–If drinking water not fluoridated

•Fluoride rinse - ≥ 6 yrs old

78

Considerations when introducing eggs, nuts, peanuts, shellfish - when and special considerations?

•Previously eggs delayed until 12 months; Nuts, peanuts, shellfish until 2-3 yrs

•Now: Solids held until 4-6* mos; above foods can be given unless

–Positive family history of food allergy (1 first degree relative-parent or sib), then wait until ~ 2 yrs

–Also controversial in literature

79

Percent of 6 mo olds who are obese?

7%

80

Overweight 5yo are __x more likey to be obese w/in 9 years

4

**obesity at 5y is a strong indicator for obesity as an adult

81

Infant interventions to prevent obesity

•Recognize hunger and satiety cues

•Engage infant in other ways than feeding

•No need to “finish the feeding”

•Variety of foods after (4) 6 months

•May need to introduce new foods (5-10x)

•Avoid “kid foods” with ↑fat/calories

82

Duration of infant feeding patterns

Last longer than previously thought!

Early taste preferences for F/V, sugary bevs last

 

83

According to 2014 pediatrics study, when is the best time to set infant feeding patterns?

10-12 months - start early

Again, patterns last

84

What is WIC?

Women, Infants, Children

•1970’s - nutrition program for low-income pregnant, breast feeding and non-breast feeding moms, infants and children <5yrs.

85

Obesity and WIC

More obesity

86

Where is WIC available?

•50 state health departments

•34 Indian Tribal Organizations

•DC

•5 territories

–Puerto Rico

–Guam

–America Samoa

–Northern Mariana

–Virgin Islands

87

WIC eligibility

•Nutritional risk

–Medical ( LBW, anemia)

–Diet

•Inappropriate feeding habits

•Does not meet current guidelines for Americans

Income

–185% of federal poverty guidelines

•Family size and income ( family of 4; 44,123)

–Medicaid and/or SNAP

88

WIC services

•Nutrition risk assessment

•Nutrition education

•Breast feeding education

•Health, social and welfare referrals

89

Outcomes associated with WIC services

Success:

•Lower Medicaid costs for mom and baby

•Longer gestations

•Higher birth weights

•Lower infant mortality

90

How does WIC support breastfeeding?

•Incentives

–If fully breast feeding mom

•More foods

•More fruits and vegetables

–If fully breast fed baby

•More fruits and vegetable

•More baby meats

•Less formula

91

Recent revisions to WIC for infants (2009)

–No cereal until 5 months

–Decrease in amount of formula > 6 months

–Baby foods added

–No juice

92

Recent revisions to WIC for children (2009)

–Juice limited
–Voucher for fruits/vegs @ FM
–Less milk and more calcium substitutions but not yogurt or rice milk in  CT
–Whole wheat/grain bread
–Fewer eggs

93

WIC Foods: Federal vs State decisions

•Feds determine nutritional values

•States determine specific foods

–Some allow organic milk, eggs, cheese

–All allow organic fruits and vegetables

–Food packages adapted to needs of family

•Allergy, intolerance, medical conditions

94

APRN role in r/t WIC

•Collaborate/communicate with WIC colleagues

•Make both roles more effective in helping children to be healthy weight

•Complete forms with essential information

95

Immediate risks to obesity

•Shame

•Low self esteem

•Negative body image

•Depression

•Lack of friends

•Inability to play

•Behavior problems

•Poor academics

96

Long term risks to obesity

•Hypertension

•dyslipidemia

•Diabetes

•Respiratory

•Orthopedic

•Hepatic

97

Obstacles to healthy nutrition

•Lack of knowledge/information from PCPs
•Heavily marketed toddler foods
•Resources
•Parenting styles:
–Authoritarian:  Rigid, controlling--> decreased intake of healthy
–Avoidance of conflict--> poor eating habits
–Flexible yet firm--> healthy eating habits

98

High risk populations for obesity

•Low SES

•Southern region of US

•African-American

•Hispanic

•American Indian

•Difficult to separate SES and racial/cultural factors

99

Challenge of feeding with Toddlers?

Developmentally: exploring, saying no

Erickson’s stages: independence. --> picky eating

Tricky to give healthy food! 

100

Approaches with Toddlers/Preschoolers

•Self feed
•Healthy choices and reasonable quantities
–Colorful, fun
•Limit milk ( 20-24 oz/day)
–WCM 12-24 months;  Low fat or skim >24 months
–If significant family history – low fat milk @ 12 mos
•Do not force to eat if not hungry or food averse
•Avoid juices, sweetened drinks, cereals, candy, fast food

101

Nutrition resources

•CDC.gov

•who.int/en

•myplate.gov

•AAP.org

•nhlbi.nih.gov/health/public/heart/obesity/wecan

•healthykids.org

•nationaldairycouncil.org