Pediatric Clinical Practice Guidelines for Nurses in Primary Care

Chapter 7 - Nutrition

Nutritional Principles

• General
• Types of Nutrients

Infant Feeding Principles

• General
• Adequacy of Intake

Feeding Choices

• Breast-Feeding
• Formula Feeding
• Vitamin and Mineral Supplements
• Solid Foods

Nutritional Deficiency Disorders

Common Nutritional Problems

• Obesity
• Nutritional Rickets
• Iron Deficiency Anemia in Infancy

Nutritional Principles

General

For normal growth, a child's nutritional intake must include protein, fat, carbohydrate, water, vitamins, minerals and trace elements in adequate amounts. For many nutrients, deficiency states can occur if intake is inadequate. Similarly, a variety of diseases are associated with excess intake of specified nutrients.

Types of Nutrients

• Energy (expressed as kilocalories [kcal]): needed for metabolic functions and growth; available from protein, carbohydrate and fat
• Protein: contributes to energy intake and supplies amino acids for tissue growth and replacement
• Carbohydrates: provide caloric energy and thus help limit the need for protein and fat
• Fats: contribute substantially to energy needs because of high caloric density (9 kcal/g); some essential fatty acids are important for growth of the infant's nervous system
• Water: necessary to sustain life and growth
• Vitamins: essential cofactors in metabolic processes
• Minerals: necessary in small quantities for growth and metabolism; deficiency states are clinically recognized for only a few minerals

Infant Feeding Principles

General

Healthy infants obtain nutrition in a pattern that encourages social interaction with parents and caregivers. Thus, infant feeding provides both nutrition for growth and an opportunity for social interaction, both of which are crucial to the infant's well-being. Infants should always be held while being fed in an effort to prevent nursing bottle caries of the teeth.

Adequacy of Intake

Adequacy of intake is best determined by observing weight gain. Expected gain is as follows:

• 30 g/day in the first 3 months
• 15-20 g/day in the second 3 months

Six well-soaked diapers and yellowish stool daily are also indicators of adequate nutritional intake.

Average daily energy requirement is 115 kcal/kg during the first year of life, although there is some variation from one child to another. The average caloric content of formulas and breast milk is 20 kcal/oz or 67 kcal/100 mL (1 oz = 30 mL).

Feeding Choices

Breast-Feeding

In the first 6 months of life, an infant's requirements for water, energy and major nutrients can best be met by human milk. For this reason, as well as for the emotional benefits to the child and the immunologic benefits in terms of protective effects against infection (especially in populations where refrigeration is lacking or water supplies are suspect), breast milk is considered the best choice for feeding infants.

Advantages

• Fewer respiratory, GI and otitis media infections
• Ideal food: easily digestible, nutrients well absorbed, less constipation
• Increased contact between mother and baby and, perhaps, added self-esteem for mother
• Economical, portable, affords ease of meeting infant's feeding needs quickly
• May decrease occurrence of allergies in childhood
• Mothers often like it more than bottle-feeding
• More rapid and complete reversion of mother's pelvis and uterus to pre-puerperal state

Contraindications

• HIV infection or active TB
• Substances of abuse will pass into human milk; see Table 7-1, below, this chapter, for information about drugs that are passed into milk

Physiology

• Stimulation of areola causes secretion of oxytocin
• Oxytocin is responsible for let-down reflex, whereby milk is ejected from cells into milk ducts
• Sucking stimulates secretion of prolactin, which in turn triggers milk production
• Milk is therefore created in response to nursing, i.e., nursing increases the supply of milk

Technique

• Mother should be in a comfortable position, usually sitting or reclining with baby's head in crook of her arm (side-lying position is often useful following delivery by cesarean section)
• Bring baby to mother (to minimize stress on mother's back)
• Baby's belly and mother's belly should face each other or touch (belly-to-belly position)
• Initiate the rooting reflex by tickling baby's lips with nipple or finger; as baby's mouth opens wide, mother guides her nipple to back of the baby's mouth while pulling the baby closer; this maneuver will ensure that the baby's gums are sucking on the areola, not the nipple
• It is important that the baby be allowed to nurse within the first hour after birth

Positioning and Latching On

Source: Baby & Parent Health Program, Community Health Services, Halton Regional Health Department

Fig. 7-1: Cradle Position for Breast-Feeding

1. Breast-feed in a sitting position, with good back support, as soon as possible.
2. Place a pillow on your lap to bring baby to breast height.
3. Position baby with his or her head resting on your forearm, facing you (belly to belly), with your hand supporting the diaper area.
4. Baby's face should be across from the breast, the mouth across from the nipple and the head tilted slightly back.
5. Place four fingers under breast and thumb on top, well back from nipple and areola.
6. Lightly tickle baby's lower lip with nipple. Have patience.
7. When mouth opens wide (as big as a yawn) quickly point nipple at opening and pull baby onto breast.
8. If baby is positioned correctly, the nose should be resting on top of breast and not buried in breast tissue. Do not press on breast to make "breathing space."
9. If there is pain, take baby away from breast and repeat.
10. Check "latch." Mouth should be big with lips turned back. Chin should be well underneath breast, and nose should be resting on top.
11. Listen for baby swallowing. If baby is feeding well, you will see short bursts of sucking and swallowing with pauses between. The jaw movement goes past the ears, sometimes making the ears wriggle.
12. Let baby feed at first breast until he or she pushes nipple out of mouth; offer a burp and continue on other breast. The baby may not suck for as long on the second breast. Start on that side during the next feeding session.
13. If baby starts wriggling during the feeding, he or she may need to burp. Take the baby off the breast, offer a burp and then latch on again.
14. Each baby is different and each will take a different period of time to feed. If a feeding is taking an hour or more, the baby is probably not latched on properly. Contact someone to watch you nurse and check the latch.

Fig. 7-2: Football Hold for Breast-Feeding

If you have difficulty feeding your baby in the cradle position, try the football hold. This hold can work well in the following situations:

• Cesarean birth
• Small baby
• Mother experiencing more difficulty with one side than the other
• Mother with flat nipples

1. Sit in upright position with good back support.
2. Place one or two pillows at your side.
3. Lie baby on pillows at your side.
4. Support the back of the neck with your hand. This allows the baby's head to tilt back a little.
5. Hold your breast as described for the cradle position.
6. Tickle baby's lower lip. Wait for his or her mouth to open and pull the baby onto the breast.

Fig. 7-3: Alternative Position for Breast-Feeding

1. Sit in upright position with good back support.
2. Place a pillow in front of you.
3. Lie baby across your body facing you.
4. Hold breast with hand on same side (right breast, right hand).
5. Support back of baby's neck and shoulders with other hand.
6. Tickle baby's lower lip. Wait for the baby's mouth to open wide and pull the baby onto the breast.
7. When baby is feeding well, try taking hand from breast and putting it around the baby for support.

Mother's Diet While Nursing

• Adequate caloric and protein intake
• Plenty of fluids
• Prenatal vitamins

Signs of Adequate Nursing

• Breasts become hard before and soft after feeding (noted in the first few weeks after the birth)
• Six or more wet diapers in 24 hours
• Baby satisfied and weight gain appropriate (average 1 oz or 28 g per day in the first few months)
• Growth spurts should be anticipated around 10 days, 6 weeks, 3 months and 4-6 months
• During growth spurts, baby will nurse more often over a period of several days, which will increase milk production to allow for further adequate growth

Client Education

Antepartum

Promote advantages of breast-feeding early and regularly during the course of the pregnancy.

Postpartum

Counsel women on the following aspects of breast-feeding:

• Technique
• Natural history
• Colostrum present in breast at birth but may not be seen
• If baby is feeding well, he or she will be adequately nourished
• Milk will not come in before third day postpartum
• Frequent nursing (at least 9 times/24 hours) will lead to milk coming in sooner and in greater quantities
• Mother should allow baby to determine duration of each nursing session
• Baby will lose weight over the first few days and may not regain birth weight until 7 days
• Supplemental vitamins are unnecessary unless the baby has very limited exposure to sun (in which case vitamin D should be given); see "Vitamin and Mineral Supplements," below, this chapter
• Breast milk alone is adequate for first 6 months
• Solids may be introduced at 4-6 months

Mothers who are planning to return to work should start switching the baby to bottle-feeding about a week ahead of time, for the hours of the day when the mother will be away. This can be done by omitting a breast-feeding session every few days and substituting pumped breast milk or formula, preferably given to the baby by another caregiver. To increase the likelihood that the baby will take a bottle occasionally, introduce bottle-feeding at 3-4 weeks (once breast-feeding has been well established). Give milk by bottle once or twice a week.

Breast Care

• Porous breast shields collect any milk that drips; shields should be changed when wet to prevent skin maceration
• Correct positioning, with nipple and areola well into the infant's mouth, helps prevent nipple soreness and cracked nipples
• For cracked nipples, express some milk, and allow the milk to air dry on the nipples; ensure the infant is latching on correctly
• When one nipple is sore, feedings should be started on the side that is not sore; it may be helpful to change the feeding position (e.g., from sitting to lying) when nipples are sore

Possible Complications

Plugged Milk Ducts

Mother is well except for sore lumps in one or both breasts, without fever.

Apply moist hot packs to lump(s) before and during nursing. The mother should nurse more frequently on the affected side. Ensure good technique.

Mastitis

Woman has a sore lump in one or both breasts, accompanied by fever or redness of the skin overlying the lump. She may be quite ill. Other possible sources of fever should be ruled out (in particular, endometritis and pyelonephritis).

Apply moist hot packs to the lump(s) before and during nursing. The mother should nurse more frequently on the affected side. Administer antibiotics (e.g., cloxacillin) for Staphylococcus aureus (the most common organism) for at least 7 days. The mother should get more rest and use acetaminophen (Tylenol) as necessary. The fever should resolve within 48 hours; otherwise, consider changing the antibiotic. The lump should also resolve. A persistent lump may be an abscess, which must be drained surgically.

Engorgement

Engorgement usually develops just after milk first comes in (day 3 or 4). It is characterized by warm, hard, sore breasts.

To resolve, offer baby more frequent nursing. The mother may have to hand-express a little milk to soften the areola enough to let baby latch on. The baby should be allowed to nurse long enough to empty the breasts. The problem usually resolves within a day or two.

Flat or Inverted Nipples

When stimulated, inverted nipples will retract inward, whereas flat nipples remain flat. Check for either of these conditions during the initial prenatal physical.

Nipple shells (doughnut-shaped inserts) can be worn inside the bra during the last month of pregnancy to gently force the nipple through the center opening of the shell. The baby can nurse successfully even if the shell does not correct the problem before birth. A lactation consultant or a member of the La Leche League may be a good resource in this situation.

Problems of Lactation

Source: Baby & Parent Health Program, Community Health Services, Halton Regional Health Department

Insufficient Lactation

This problem is almost always due to improper feeding techniques, which can be remedied. Occasionally, it is due to problems other than technique.

Signs

• Insufficient weight gain in an infant who is receiving food only by breast-feeding
• Infant may latch on poorly
• Infant may suck inconsistently
• Let-down reflex may be inconsistent
• Some infants appear hungry (indicated by crying soon after feedings), whereas others are content, but gain poorly

Risk Factors

• Mother has previous experience with this problem
• Physical abnormality of the breast
• No breast enlargement during pregnancy
• History of breast surgery

Management

Goal is to preserve breast-feeding, if possible.

• Frequent feeding sessions
  
  • Breast pumping (with an electric pump, if available) after each feeding
  • Increase maternal fluid intake
  • Ensure mother gets adequate rest
  • Offer water to infant in small amounts as necessary after breast-feeding sessions
  • Monitor the infant's well-being

If signs of failure to thrive or dehydration appear, consult a lactation specialist and a physician. It may be necessary to give formula supplements after breast-feeding sessions, or a switch to formula feeding may be indicated.

Breast Milk Toxicology

Most maternal medications are secreted in some quantity into breast milk (Table 7-1). The risks of discontinuing the mother's medication must be weighed against the risks to the baby. Sometimes the medication can be replaced, and sometimes the effect on the baby is not sufficient for concern.

Any medication marked with an asterisk in Table 7-1 is an absolute contraindication to breast-feeding.

*Do not breast-feed.
†Use alternative medication.

Formula Feeding

General Information

Commercially prepared formulas closely resemble breast milk in composition, except for the immunologic components. Commercial infant formula that is fortified with iron is now the standard recommendation for all infants who are fed formula from birth. Infants weaned from the breast before 9 months of age should receive an iron-fortified formula. Evaporated milk formulas provide adequate energy and nutrient content and are less expensive, provided they are mixed correctly. They lack an adequate supply of iron and may interfere with absorption of iron from other sources. The composition of whole cow's milk is inappropriate for infants and promotes blood loss from the gut. It should not be used in the first 9 or 10 months of life. Partly skimmed and skimmed milk should never be used in the first year of life, because the lack of fat can be difficult for the kidneys to handle. See Table 7-2 for volume and frequency of formula feeding.

When refrigeration is lacking, it is suggested that bottles be boiled before formula is prepared.

Where mothers are forced by circumstances to use evaporated milk formula, appropriate mixing is essential (see below), and daily ferrous sulfate supplements (2 mg elemental iron per kilogram body weight) are recommended. For the at-risk infant (e.g., low birth weight and premature infants, extremes of poverty or a history of iron deficiency in siblings), provision from birth of daily supplemental iron through formula or Fer-In-Sol is especially important.

Recipes for Formula

Commercial Infant Formulas

• Ready to feed: give as is, without dilution
  
  • Concentrate: mix 1:1 with water
  • Powdered: follow instructions; over-dilution of powdered formula can be dangerous

Evaporated Milk

3 oz milk + 5 oz water + 1 tbsp sugar = one 8-oz bottle (30 mL = 1 oz)

After 6 months, use 4 oz milk + 4 oz water (no added sugar)

Vitamin and Mineral Supplements

Children in some First Nations and Inuit communities may require fluoride supplementation, except if the community has high levels of natural fluoride in the water supply. The regional dental officer can provide information on the situation in your community.

Recommended dose of fluoride is as follows (Canadian Paediatric Society 1996):

• 6 months to 2 years: 0.25 mg/day
• 3-4 years: 0.50 mg/day
• >5 years: 1 mg/day

Multiple vitamins are generally not recommended, but Tri-Vi-Sol with fluoride is an adequate preparation for children 0-2 years of age.

It is preferable to give vitamin D (e.g., D-Vi-Sol) separately from fluoride (e.g., Pedi-Dent or Karidium).

Table 7-3 indicates requirement for vitamin D in relation to type of feeding. For infants living in northern communitites, the recommended dose of vitamin D is 800 IU/day.

Solid Foods

Iron-fortified infant cereal should be added to the diet as a first supplement at age 4-6 months (one grain type at a time). Prepared baby foods, if used, should be added initially in small quantities, one at a time, after cereals have been started. Vegetables or meats should be started before fruits.

Nutritional Deficiency Disorders

Nutritional deficiencies can present clinically as symptoms and signs in multiple body systems. Common body parts and systems affected include the skin, hair, nails, eyes, mouth, neck, and cardiovascular, musculoskeletal and neurologic systems. See Table 7-4 for information on the clinical manifestations of common nutritional deficiencies.

Common Nutritional Problems

Obesity

Definition

An excess in weight of 20% or more relative to the calculated ideal weight for age, sex and height, determined from standard pediatric growth charts. Many Aboriginal children have a high weight-to-height ratio on standard growth charts. Rapid increases in weight-to-height ratios are of concern, as is obesity in older children.

Causes

• Most commonly exogenous, due to excessive caloric intake for basal needs and low energy output.
  
• Genetic influences: Obese children <3 years old without obese parents are at low risk for obesity in adulthood, but among older children, obesity is an increasingly important predictor of adult obesity, regardless of whether the parents are obese. Parental obesity more than doubles the risk of adult obesity among both obese and non-obese children <10 years old.

Risk factors influencing the development of obesity in children:

• Parental overweight
• Overweight at birth
• Physical inactivity
• Irregular snacking
• Poor food choices
• Lack of availability of variety of nutritious foods

History

• Child's birth weight
• Early feeding history
• Age at onset of obesity
• Dietary history (during the week and on weekends)
• Caloric intake beyond calculated norms for age
• Food preferences, snacks, where are meals eaten and with whom, moods associated with food
• Child and family feeding patterns
• Use of food as reward or part of social function
• Family history of obesity, hypertension, cardiovascular disease, diabetes mellitus, cerebrovascular accident
• Past medical history, including illnesses, surgeries, admissions to hospital
• Physical activity pattern
• Older child: school performance, peer relationships, parental relationships, child's perception of his or her body

Physical Findings

• Overall appearance
• Blood pressure
• Weight and height (with exogenous obesity, linear growth is usually accelerated; with endocrine or metabolic disorders, linear growth is usually retarded)
• Hypoventilation (may suggest Pickwickian syndrome)
• Fat distribution
• Increased subcutaneous tissue
• Increased triceps skin-fold thickness
• Skin: striae, irritations (intertrigo)
• Stage of sexual maturation
• Presence of orthopedic problems (e.g., scoliosis, genu valgum, slipped femoral epiphyses)
• Other causes of obesity associated with signs relevant to underlying cause (e.g., hirsutism, acne, striae, hypertension, mental deficiency)

To rule out a congenital syndrome, check for hypogonadism, short stature, dysmorphic features, small extremities and mental retardation.

Differential Diagnosis

• Diabetes mellitus
• Hypothyroidism
• Cushing's disease
• CNS diseases (e.g., meningitis, brain tumors, cerebrovascular accident or head trauma may be associated with onset of obesity due to hyperphagia and decreased activity)
• Genetic or congenital disorders (e.g., Down's syndrome)

Complications

• Accelerated bone growth and skeletal maturation
• Accelerated maturation, with early menarche and decreased final height, often seen in girls
• Hyperinsulinemia
• Decreased levels of growth hormone
• Decreased levels of prolactin in girls
• Decreased levels of testosterone in boys
• Increased rates of amenorrhea and dysfunctional uterine bleeding in girls
• Hyperlipidemia
• Hypertension
• Choledocholithiasis
• Slipped capital femoral epiphyses
• Legge-Calvé-Perthes disease and genu valgum
• Increased respiratory illness in toddlers <2 years old
• Pickwickian syndrome (increased daytime sleepiness and hypoventilation)
• Obstructive sleep apnea
• Psychosocial sequelae (e.g., low self-esteem, abnormal body image, difficulty developing peer relationships, social withdrawal and isolation)
• Adult obesity

With more children becoming overweight, the prevalence of insulin-resistance causing type 2 diabetes in children is rising. The earlier diabetes begins, the earlier in life the complications tend to occur. The development of diabetes in children is a serious public health threat. See "Diabetes Mellitus in Aboriginal Children," in chapter 17, "Hematology, Endocrinology, Metabolism and Immunology."

Diagnostic Tests

• Random blood glucose by glucometry
• TSH and T₄ levels (if child is of short stature)
• Urinalysis (for glucose)
• Lipid profile (in adolescents)
• Pelvic ultrasonography to rule out polycystic ovaries in adolescent girls with amenorrhea or dysfunctional uterine bleeding (this test must be ordered by a physician)

Management

Goals of Treatment

Change behavior so that more energy is used by the child for growth, activity and metabolic processes than is consumed.

The whole family must be included in the management of this problem.

Appropriate Consultation

• Consult a physician if you suspect an underlying physiologic, metabolic or psychologic disorder as the cause of obesity
• In infants and toddlers, treatment should be cautious; consult a physician before any investigation or treatment is begun

Nonpharmacologic Interventions

Prevention

• Early preventive measures, with emphasis on families in which one or both parents are overweight
• Promotion of prolonged breast-feeding may help decrease the prevalence of obesity in childhood
• Because obese children have a high risk of becoming obese adults, such preventive measures may eventually result in a reduction in the prevalence of cardiovascular diseases and other related diseases
• For obesity due to other causes, underlying disorders must be treated

Older Children with Exogenous Obesity

• Program of decreased caloric intake and increased exercise over a long period
• Reducing television, videotape and video game use may be a promising, population-based approach to prevent childhood obesity

Monitoring and Follow-Up

Follow up monthly to monitor height and weight until optimal weight has been achieved.

Nutritional Rickets

Definition

A disorder characterized by failure of growing bone matrix to become mineralized. Under-mineralized bones are less rigid than normal, and bone deformities result.

Causes

• Vitamin D deficiency
• Calcium deficiency
• Phosphorus deficiency

Children at Risk

• Small, premature infants
• Breast-fed infants who do not receive vitamin D supplementation
• Children whose diet is lacking in vitamin D or who have insufficient exposure to sunlight
• Children with chronic renal insufficiency
• Children with biliary atresia or chronic liver disease
• Children with inflammatory bowel disease

History

• Diet containing little vitamin D (breast milk, tea, juices as primary fluid sources)
• Low exposure to sun because of pigmented skin or winter season
• Low vitamin D intake by mother during pregnancy
• Bone pain
• Delayed standing or walking
• Anorexia
• Seizures (due to low calcium)
• Pathologic fractures
• Family history of rickets

Physical Findings

• Bossing deformity of the head
• Craniotabes
• Premature fusion of sutures
• Bowing of legs
• Thickening of costochondral junction (rachitic rosary)
• Prominence of wrists and knees
• Muscle weakness
• Awkward gait
• Dental caries
• Hepatic or renal enlargement (only if rickets is related to liver or renal disease)
• Seizures (due to low calcium) may be presenting complaint

Differential Diagnosis

• Chronic renal insufficiency
• Biliary atresia
• Chronic liver disease
• Inflammatory bowel disease

Complications

• Permanent leg bowing, occasionally requiring corrective surgery
• Contractures of the pelvis may cause difficulty with labor and delivery

Diagnostic Tests

Discuss any diagnostic tests with a physician.

• Knee and wrist x-ray, if available (one view only, as rickets is a symmetric condition)
  
  
• X-ray will show irregular cortices and bony margins, widened mataphyses, widened growth plates and osteopenia

Management

Nonpharmacologic Interventions

Preventive: encourage vitamin supplementation during pregnancy.

In communities where rickets is common, encourage nutrition education and consider vitamin D supplementation for all children <2 years old.

Pharmacologic Interventions

Prevention: Recommendations of the Canadian Paediatric Society

Source:Indian and Inuit Health Committee, Canadian Paediatric Society (1988; reaffirmed April 2000)

Infants who are entirely breast-fed should be given 400 IU/day of vitamin D. This amount may be increased to 800 IU/day during the winter for children living in the Far North. The administration of 800 IU/day should be limited to children <2 years old, who are at greatest risk for rickets.

Infants who are bottle-fed with formulas made from fortified whole or canned milk have sufficient amounts of vitamin D during the summer but should receive a supplement of 400 IU/day of vitamin D during the winter.

Pregnant women and nursing mothers in the North should take 400 IU/day of vitamin D either as fortified milk or in addition to their vitamin and mineral supplementation, which provides 400 IU/day of vitamin D.

Children >2 years old who do not drink adequate amounts of milk enriched with vitamin D should be given 400 IU/day of vitamin D during the winter. The long days during the summer should provide enough sunlight to produce adequate amounts of endogenous vitamin D.

Treatment

Discuss with a physician the initial vitamin D dose for treating rickets.

vitamin D (D-Vi-Sol) (A class drug), 400 units/mL; 5000 to 10 000 units/day for 5 weeks, followed by 400 units/day (curative dose) is a common regimen

Monitoring and Follow-Up

• Blood and urinary calcium levels should be monitored if vitamin D therapy is used
• Discuss frequency of monitoring with a physician

Referral

Refer all cases of suspected rickets to a physician for evaluation as soon as possible.

Iron Deficiency Anemia in Infancy

See "Iron Deficiency Anemia in Infancy," in chapter 17, "Hematology, Endocrinology, Metabolism and Immunology."