Assessment
1. Monitor nutritional intake for consistency with expert recommendations for age at each well child visit or at least annually, including:
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Assessment
1. Expert recommendations are provided by the AAP 2005 Breastfeeding Policy Statement and the ADA 2004 Start Healthy Guidelines for Feeding Infants and Toddlers (Birth to Age 2 Years) (Butte et al., 2004; Gartner & Greer, 2003). Nutrition supervision and assessment includes inquiries about intake volume, frequency, and duration as well as appropriateness of nutrient and nutritional patterns in order to identify changes that may be needed. Information regarding infant's exposure and transition to solid foods provides the foundation for identifying feeding practices and infant responses and the opportunity to individualize education and counseling (Baker et al., 1999; Bell & Wolfe, 2004; Gartner & Greer, 2003; Story, Holt, & Sofka, 2000).
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a. Breastfeeding for frequency, duration, latch, comfort, efficiency (8 to 12 times a day at birth, changing to 6 to 10 times a day when solids are introduced).
b. Iron-fortified formula intake based on 110 calories per kilogram (kg).
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a, b. Observing a feeding is often the best way to determine the source of identified problems with intake (Kleinman, 2004). |
2. Monitor and document barriers to healthful eating, such as lack of nutritious foods, financial barriers, and lack of knowledge about healthful food choices. |
2. To best assist parents, health care providers must be aware of barriers that families face in making appropriate food choices (Strauss & Knight, 1999). |
Education
3. Educate parents about recommended nutritional intake for age: |
Education |
a. Breastfeed exclusively from birth to 6 months of age and throughout the first year of life after complementary foods are added. |
a. The World Health Organization (WHO), AAP, and Maternal and Child Health Bureau of the U.S. Department of Health and Human Services (MCHB/DHHS) recommend breastfeeding exclusively in the first 6 months of life and throughout the first year. Breastfeeding is more likely to be successful when both practical information and social support are provided. The combination of maternal pre-pregnancy obesity (BMI >30) and lack of breastfeeding may be associated with greater risk of childhood overweight. Therefore, promotion of breastfeeding for mothers with pre-pregnancy obesity is particularly encouraged. Breastfeeding also has a protective effect for children whose mothers have a normal pre-pregnancy BMI (Gartner et al., 2005; Li et al., 2005; Story, Holt, & Sofka, 2000; von Kries et al., 1999). |
b. Offer iron-fortified formula to infants not breastfed until 12 months of age, not to exceed 32 ounces (oz) per day. |
b. A greater prevalence of iron-deficiency anemia has been found in infants who have not received iron-fortified formula (Kattelmann, Ho, & Specker, 2001). |
c. Wait to introduce appropriate types, amounts, and portion sizes of healthful complementary foods until the child is developmentally ready, between 4 to 6 months of age. |
c. Early introduction of mixed feeding is associated with early, excessive weight gain in infancy and overweight in childhood. Infants do not require foods other than breast milk or formula until 4 to 6 months of age (Kramer et al., 2004; Stettler et al., 2003; Stettler et al., 2002). No data exist to guide the sequence of offering new foods. The current, prudent recommendation is that single foods be offered one at a time and for several days to identify any adverse reactions. Food allergies will be promptly identified. More than one exposure to the food is necessary to sensitize the infant and provoke an allergic reaction (Butte et al., 2004; Story, Holt, & Sofka, 2000). |
d. Iron-fortified cereal: begin between 4 to 6 months and transition from 1 to 2 servings per day; decrease to 1 serving per day as other iron-rich foods are added to the diet.
e. Fruits: gradually increase from 1 to 3 servings per day.
f. Vegetables: gradually increase from 1 to 2 servings per day.
g. Protein-containing foods: gradually increase from 1 to 2 servings per day.
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d. A greater prevalence of iron-deficiency anemia has been found in infants who have not received iron-fortified formula or cereal. Correction of anemia does not reverse the adverse affects of anemia on the child's mental abilities (Kattelmann, Ho, & Specker, 2001; Kleinman, 2004; Story, Holt, & Sofka, 2000). |
h. Calcium-containing foods: Adequate Intake (AI) = 210 milligrams (mg) per day from 0 to 6 months; 270 mg per day from 7 to 12 months. |
h. Good scientific evidence is lacking regarding the actual calcium needs of infants. The recommended AIs presented here are taken from the IOM 2004 Daily Required Intake (DRI) report and are based on extrapolations from data on maternal breast milk, its content, bioavailability, and typical daily intake (Baker et al., 1999; Butte et al., 2004; Kleinman, 2004. |
i. Vitamin D: minimum requirement is 200 International Units (IU) per day. A supplement of 200 IU per day is recommended for breastfed infants who do not receive adequate sunlight exposure and formula-fed infants who are taking less than 500 milliliters (mL) per day of formula. |
i. (Gartner & Greer, 2003). |
j. Eliminate night-time bottle feedings by 6 months and plan to transition to cup feeding between 9 to 12 months of age. |
j. By 6 months of age, infants begin to consolidate their sleep cycles, gradually increasing sleep from 2 to 3 hours to 6 to 8 hours by 6 months of age. By 6 months of age, night feedings are no longer necessary for healthy babies who are getting adequate calories during the daytime. A transition to cup feeding between 9 and 12 months of age is usually developmentally appropriate. Additional feedings may lead to overfeeding and overweight. Prolonged use of the bottle is linked with greater risk of overweight in early childhood (Bonuck, Kahn, & Schechter, 2004; Kramer et al., 2004; Stettler et al., 2003; Stettler et al., 2002). |
k. Avoid calorie-dense, nutrient-poor foods. |
k. Recent research shows that many mothers introduce a variety of calorie-dense, nutrient-poor foods during infancy. Anticipatory guidance may reduce the frequency of their use and prevent excessive weight gain associated with intake of such foods (Kramer et al., 2004; Stettler et al., 2003; Stettler et al., 2002). |
l. Provide 3 meals and 2 to 3 healthy snacks daily for older infants and young children. |
l. Most 9-month-old infants are on the same eating schedule as their family, which is typically breakfast, lunch, and dinner with infant snacks mid-morning, afternoon, and bedtime. Infants' limited stomach capacity results in an inability to get all of the nutrition they need in fewer, larger meals. Frequent small meals helps to prevent infant distress and tantrums caused by hunger (Story, Holt, & Sofka, 2000). |
m. Limit 100% fruit juice to 4 to 6 oz per day and avoid consumption of fruit drinks and sodas. |
m. Excessive fruit juice intake is associated with excessive weight gain. Many parents confuse fruit drinks or fruit-flavored beverages with 100% fruit juice (Story, Holt, & Sofka, 2000). |
4. Educate parents about how to carry out promising feeding practices:
a. Accept that food intake varies from day to day as the infant balances energy intake from food with energy output in activity.
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4a. Parents benefit from understanding that it is normal for infants and young children to vary their intake each day to match their activity level, thus preventing overweight (Johnson & Fisher, 2004; Lederman et al., 2004). |
b. Respect the infant's innate ability to self-regulate intake based on satiety by recognizing and responding appropriately to infant hunger and satiation cues. |
b. Children from birth to 5 years of age demonstrate the ability to self-regulate the balance in intake of energy from food with their daily activity level. Teaching parents to recognize and respect hunger and satiation cues ensures that this innate regulatory ability is supported, preventing overfeeding (Johnson & Fisher, 2004; Lederman, 2004). |
c. Eat together as a family as often as possible to increase quality of nutrition and enhance family connectedness. |
c. When children eat regularly with families, they increase their intake of fruits, vegetables, fiber, and micronutrients from food; consume fewer fried foods, less soda, and less saturated and trans fat; and have a lower glycemic load. Family mealtime is a time that parents convey their cultural beliefs and values to their young children, and a "typical weekday family meal" is a potent way to shape an infant's learning about nutrition and eating (Gillman et al., 2000) |
d. Assist in the development of the infant's self-feeding skills through appropriate use of utensils, including juice and/or water in a sippy or open cup. |
d. The introduction of solid foods allows the infant to explore new textures, smells, colors, and tastes of foods. The infant's developing motor skills, vision and social behaviors, tongue movements, and head and trunk control allow the infant to sit and reach for food and objects. These experiences provide the foundation for self-feeding in which the child gains control over the types and amounts of food consumed through exploration and experimentation with new foods and self-feeding skills (Johnson & Fisher, 2004; Story, Holt, & Sofka, 2000). |
e. Support the importance of the infant's developing ability to self-regulate feeding. |
e. Learning about foods and eating during the transition to solid foods from an exclusive breast milk or iron-fortified formula diet is an important developmental task during infancy. Parental control over food types and portion sizes offered to the child has the potential to affect a child's feeding practices and energy balance by increasing the child's preference for high-fat, energy-dense foods and limiting the child's acceptance of a variety of foods and food textures (Johnson & Fisher, 2004; Story, Holt, & Sofka, 2000). |
f. Recognize parental responsibility to purchase and prepare only healthful foods and drinks. |
f. Advertising powerfully affects parents' purchasing decisions. By providing education on the importance of the parent's choices of foods, practitioners may provide needed support for positive nutritional practices in the home (Ritchie et al., 2005; Roberts, Blinkhorn, & Duxbury, 2003) |
5. Educate parents about how to avoid engaging in less optimal feeding practices and deal with common feeding difficulties:
a. Avoid use of the "clean bottle or plate" policy.
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5a. Parental feeding practices, particularly parental control over the child's eating, may be culturally based and reflect the parent's own body dissatisfaction rather than the child's actual weight. Sensitivity to these factors needs to be considered when counseling families (Duke et al., 2004). |
b. Avoid use of food as a bribe or reward; offer food only to satisfy hunger.
c. Encourage the infant to develop strategies for self-calming vs. caregiver's use of "comfort feeding" for calming.
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b., c. Feeding is a common parental response to infant distress. Parents need information about the breadth of reasons an infant cries, other than hunger, and ways to distinguish among these cries for help. Information about ways to support an infant's self calming efforts (flexed positioning, hands to face or mouth, non-nutritive sucking) also promotes the infant's overall development of self regulation (Dennison & Boyer, 2004; Story, Holt, & Sofka, 2000). |
d. Recognize neophobia (fear of new foods) as a typical developmental response to new foods that requires repeated exposures (up to 15 times) to new foods and opportunities to learn about food and eating. |
d. Providing nutrition and feeding information to parents about common challenges encountered with older infants enables them to become more effective problem solvers and decision makers regarding their infant and child's eating and feeding habits (Butte et al., 2004; Lee, Hoerr, & Schiffman, 2005; Vereecken, Keukelier & Maes, 2004). |
e. Recognize that overfeeding may be contributing to spitting up or gastroesophageal reflux disease (GERD). |
e. Spitting up and reflux are common parental concerns in infancy. Overfeeding should be included in the differentials evaluated as a possible cause (Bergmann et al., 2003; Wray & Levy-Milne, 2002).
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f. Provide positive verbal recognition of the child's efforts to try new foods. |
f. Feeding during the first year provides a social context for eating. The parent's presence with the infant during mealtimes and his/her social and verbal responses to the infant's cues allow for a positive feeding environment and interaction that "feeds" not only the infant's nutritional needs but emotional needs as well. This is an important way to set the stage for the importance of a child's emotional needs being met through social interactions, rather than through food (Story, Holt, & Sofka, 2000). |
6. Counsel with an emphasis on the positive health consequences of good nutrition rather than focusing on the infant's weight. |
6. Hispanics: In the Hispanic culture, thinness is often associated with poor health and there is often the perception that a little extra weight is necessary for children in order to help them recover from illness. (Crawford et al., 2001; McArthur, Anguiano & Gross, 2004).
African Americans: African Americans are more tolerant of larger body size, and caregivers seldom perceive their children as obese (American Obesity Association, 2005; Stettler et al., 2003). Practitioners may be more successful at establishing rapport with Hispanic and African American families if the discussion is initially focused on health not necessarily weight.
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