2. FEEDING PRACTICES
Try these questions (detailed answers at the bottom):
Q1. The following parental feeding practices provoke excessive weight gain in childhood EXCEPT:
A. Strict parental restriction of childhood eating
B. Giving large portion sizes at meals and snacks
C. Increased frequency of fast food meals
D. All of the above contribute to excess gain
Q2. True or False. Vitamin D supplementation is not required if the breast-feeding mother is white and enjoys sun-bathing.
Q3. What is "Beikost" and why?
Q4. True or False. A 6 month old LGA infant (9 kg) is being fed 46 oz/day formula; is this appropriate?
A. Yes
B. No
And these techniques:
1. Practice taking a diet history on family members and friends addressing their child's nutrition. The first person to ask is your mother. Pick an age for yourself.
2. While in your seminar group, go around the table and let people describe the foods given to them as children. This works really well in an ethically diverse group. Imagine the progression of food from breast milk to formulae to a starch of some sort to a new food. Imagine the world around. What are the foods given?
2a. Feeding Practices---Taking a nutritional history
There are several methods for evaluating a child's diet including 3 day written diaries, food frequency checklists and kitchen inventories. In clinical practice, the 24-hour recall history is most commonly used. Be sure to consider night feedings as part of a day.
The clinic chart should be reviewed and the growth measurements plotted and BMI calculated. Is the child growing? Is the child anemic? Before taking a diet history, give an introductory comment. For example, "To help me take better care of your child, I need some information about what they are eating and drinking." Use the answers in the contex of the child's growth, development and nutritional status. Be careful not to judge cultural variable affecting the types of foods fed to children. Reserve judgements for practices that are documented to be harmful.
Here is a standard form for taking a diet history addressing essential information in healthy children past 6 months of age in a well child evaluation. In some practices, using a form the parent fills out and then you review together is helpful for efficiency.
1. Milk drinking
1a. Ask, "How many bottles/cups of milk does [use name] have each 24 hour day?
Approximate volume each day gets written down __________.
1b. Ask, "What kind of milk?" (whole, 1 or 2%, skim, chocolate)
2. Juice drinking/sweetened beverages:
Ask, "How many bottles/cups of juice does [use name] have each 24-hour day?
Approximate volume each day gets written down __________.
3. Food variety:
3a. Does [use name] have milk, meat, fruit, vegetable, and cereal or bread each day? Varied ____ or restricted _____.
Varied or restricted is written down. If restricted, ask an open ended question such as "tell me about the way you choose to eat at home." Follow with specific questions.
3b. Does your family limit or restrict certain kinds of food?
(vegetarian? Vegan? Kosher? Macrobiotic?)
Be sure to explore answer.
4. "Junk food" use" and fast food:
4a. Ask "Does [use name] have soda or "chips?"
If yes, ask "Is that most days _____, several times a week_____,
once a week_____, special occasions_____, or never_____?"
4b. Do you go out for fast food? No___; if yes, ask:
once a week___, 3-4 times a week___, once or twice a
week____.
5. Do you give [use name] a vitamin?
If yes, what kind _______________.
6. Do you ever worry that you won't be able to afford the food you want for ___?
If the answer is yes, explore with the complete USDA Food insecurity questionnaire. - see Part 2 Section 2 of the Teacher's Guide
7. Are there any questions or concerns? ___
8. Conclude with "I will check weight gain" _______ [Children need CBC and lead check at 9 months of age.
Assessing quality of diet. First check weight, length, BMI curves and red cell indices. If these are OK, one would want to see the infant taking between 16 and 24 ounces of formulae or milk, limiting juice to 6 ounces a day, having a varied diet or not having excess diet restrictions. Occasional use of chips and soda and trips out for fast food are expected. Of note, excessive resitrictions are associated with obesity! See Part III S 6 for discussion.
Feeding Practices-- Evaluation of diet quality and suggestions to parents
Suggestions must relate to foods and behaviors and not to nutrients. We know that the baby's intake has been adequate because the baby is growing. Formulae intake is quantified mostly to determine the proportion of nutrient needs coming from breast milk.
The education of the mother begins with a specific complement, like "I see from the history that you make an effort to prepare food for Johnny." Then you can suggest that she use more fruits and vegetables and make substitutions of low fat for full fat milk and other dairy products (after two years of age) and fruit for chips. Analyses of quantity of constituents would require more detail as to the amounts of food consumed. Referral to a registered dietitian may be needed. See the introduction to section 3 (macronutrients) for details.
2b. Feeding Practices – Infants
In almost every instance, comparing breast with bottle feeding gives advantage to the breast-fed infant -- less infection, fewer allergic responses, closer relationship with the mother, and improved development. Where breast milk is the sole food, there is enhanced absorption of iron. Most breast-fed infants, however, receive supplemental feedings that may inhibit iron absorption, and iron must be provided separately.
BREAST-FEEDING -- Why "breast is best" for human infants.
** Better bonding between mother and infant. Breast-feeding alone does not create a special mother-child bond, but the choice to breast-feed may introduce and enhance a better relationship between the mother and her infant.
** Fewer infections. There are anti-infective elements in human milk that are not present in formula including lacto-ferrin, lysozyme, and immune globulins IgG and secretory IgA.
** Less potential for allergic response for infants with a strong family history of allergy related illnesses. There are diminished levels of IgE in breast milk suggesting that infants are challenged less by substances seen as foreign.
** Water conservation. Breast-fed infants have a lower renal solute load because there is less protein, sodium and phosphate in human milk. This characteristic of human milk, in prehistoric times and in developing countries today, may be a significant contribution of infant feeding to human survival.
** Possible improved developmental outcome. In several studies of low-birth-weight infants, a small advance in developmental score was found among breast-fed infants after adjusting for demographic and perinatal factors. It cannot be determined from the data, however, if social rather than biologic influences were of more importance. In all studies of nutritional supplementation it is necessary to adjust the data for differences in measures of socioeconomic status and parent-child interaction.
Breast-fed babies are more likely to grow to the mean and less likely to either become obese or fail to thrive.
** Additional advantages. These include the convenience of breast-feeding, population control device for the community (not individuals), and maternal use of body fat gained during pregnancy for milk production, and appetite-control mechanism for the infant.
REQUIREMENTS TO BREAST-FEED
Primary failure is very rare. Most reasonably nourished motivated women can breast-feed. The survival of the human species is testimony to this fact. Mothers do require support including the following:
WHAT MOTHERS NEED TO BREAST-FEED:
1) A supportive attitude by the physician, family and
community-at-large,
2) Advice on positioning of the baby and proper placement of
lips on the nipple,
3) Timing of sucking, emptying of breast and their relationship
to milk let down,
4) Proper advice on the common problems of breast-feeding, and
5) Nutritional advice for the mother. Teen mothers are still growing
and require calcium and Vitamin D supplementation.
All breast-fed babies must receive a Vitamin D supplement.
- See Sections 4b & 5c
Iron is given to children at high risk for iron deficiency once solid feeding begins at 4 months of age. Fluoride is needed where the water supply is not fluoridated. Growth must be monitored closely as weight gain is the principal indicator of effective breast-feeding.
There are few absolute contraindications to breast-feeding. Mothers receiving chemotherapy, anti-thyroid drugs, and those with active tuberculosis should not breast-feed. HIV infected women should not breast-feed unless they live in places where bottle feeding is not possible.
The advisability of breast-feeding with prescription drug use follows the model for drug use in pregnancy although the data are less available. Consult an appropriate guide when asked. Categories A and B (no adverse information) always permit breast-feeding. Category C (inconclusive, adverse data in animals) may permit breast-feeding. Category D is generally prohibitive and category X is an absolute contraindication.
BOTTLE FEEDING
Successful manufacture of milk substitutes has allowed fathers to feed their infants, mothers to leave the home for work, and the adoption of infants. Bottle feeding, however, requires more than a chemically acceptable substitute for human milk.
Bottle-fed infants will fail-to-thrive unless the following conditions are met.
** Clean water is readily available.
** Prepared formulae can be refrigerated.
** Nipples and bottles are cleaned between uses.
** The child is nurtured.
** The formula is not watered down.
Caloric requirements for the first four months are provided by the formulae. In early infancy, there are six to ten feedings a day with two to three ounces each feeding. The frequency decreases and volume increases so that by four months of age, most babies are taking four 6 or 7 oz bottles a day. Usually mothers make 26 ounces of formulae by mixing one 13-ounce can of concentrate with equal parts of water. A powdered preparation is available. Here, one scoop of powder is mixed with each 2 ounces of water. A ready-to-feed preparation is available at an unnecessary expense. Most importantly, have the mother specify exactly how she makes it. Over dilution is a common cause for failure-to-thrive in infancy.
Older Pediatric text-books recommend (and grandparents remember) a mixture of one can of evaporated milk with one and a half cans of water and two tablespoons of corn syrup. The syrup is needed to raise the carbohydrate content and lower the protein and solute load. The water restores the concentration of the formulae to 20 calories per ounce -- the energy density of both breast milk and formulae. This preparation is discouraged because it had an excess solute load and produces iron deficiency. All low-income families should be sent to the W.I.C. program to get iron-fortified formulae or support for breast-feeding.
Moreover, health care providers have an advocacy role to play to ensure availability of quality food at affordable cost to the poor in society.
The most effective feeding practice: Iron-fortified formulas should always be used. The cow-milk based iron-fortified formulas used for healthy infants have been sufficiently similar that one could be substituted for another without regard to brand name. Certification by the American Academy of Pediatrics Committee on Nutrition is important as a guarantee of quality of the formulae.
Specialty formulas, however, differ greatly, and care must be taken to provide the proper formulae for each clinical situation (e.g., very low birth-weight, inborn errors of metabolism, and chronic illnesses with absorption difficulties or organ failure).
There is a common, but false, belief that iron-fortified formulae cause constipation. Infants fed approved manufactured formulae do not require vitamin and iron supplementation. Fluoride recommendations are the same as for breast-fed infants. Formulas do not contain fluoride, and supplementation may be needed depending on the water supply.
MATCH THE NUMBERED ITEMS WITH THE CORRECT LETTER
Similarities and differences for cow milk and human milk:
a. human > cow
b. human < cow cover this side of page, then look
c. human = cow
Q. Are human and cow milk the same or different with respect to the elements listed below? If they are different, which has more?
Both cow and human breast milk provide 50% of calories from fat. Human milk, with an 8% of calries from protein and 42% from carbohydrate differs substantially from the high protein (15% of calries) and low carbohydrate (35%) concentrations of cow milk.
2c. Feeding Practices -- The transition to solid feedings
THE USE OF "BEIKOST"
In the third world, nutritionists emphasize the importance of foods specifically reserved for infants during weaning. These weanling foods are referred to as beikost. The concept is as important as the food itself. In developing countries, within large families, the younger children may display kwashiorkor - meaning "the illness of infants when an older child is born" -- translated directly, because the older children take the protein and calorie rich foods needed by the infants. By reserving a food for weanling children, older children do not take infants' food.
The introduction of beikost is not recommended before 4 months of age. The AAP Committee on Nutrition now suggest holding off on beikost to 6 months of age.
In the United States, beikost is provided commercially. Thus, within reasonable limits, purchasing supplemental foods is recommended. Alternatively, if the family has the resources to prepare clean nutritious food, a home beikost can be made with a clear statement to older children that this is food for babies. There are disadvantages with home-prepared beikost.
** Parents adding salt and sugar to suit adult taste,
** Over-boiling thus destroying water-soluble and heat labile vitamins,
** The chance for bacterial contamination with the large volumes of food prepared, the long "cool-down" period after preparation, and the attempts to keep the food for too long a period of time.
With commercial beikost, powdered infant cereals are iron and vitamin enriched, jarred foods are prepared with minimal salt and sugar, and foods likely to promote allergy are restricted. Introduction of beikost is not recommended before 4 months of age. Early introduction of beikost is a form of forced- feeding increasing the chance of choking or over-feeding. Since one 13 oz. can of infant formulae contains 520 calories, the maximum that should be given to infants, it is reasonable to expect that an infant will consume:
** 30% of its calories as beikost by 6 months of age, and
** 50% of calories from beikost and "real food" by one year of age.
Foods should be introduced one at a time for several days in order to see if allergic symptoms develop. Foods likely to promote allergy (i.e., egg white and wheat) or that can obstruct the trachea (i.e., grapes, nuts, bread, hot dogs or peanut butter in a spoon) should be restricted. These foods should not be a part of the infant diet. Egg white and wheat may be introduced at or near one year of age with the others over age four years.
2d. Feeding Practices---Older children and adolescents
Implementing a "prudent" diet begins past two years of age.
Changing a person's diet is a very difficult process that includes the constant repetition of simple facts, rebuttal of faddist theories and slow steps to change. What people choose to eat is influenced by taste, flavor, palatability and culture as well as other factors such as convenience and cost. Even those individuals aware of the impact of diet on their health often seek solution by excess -- finding a singular miracle component, which will purge the body of unwanted toxins. Publicity given to a few isolated studies resulted in stampedes to the supermarket and drug stores for grapefruit pectin, oat bran, and fish oil.
The Characteristics of a Prudent Diet
DIETARY RECOMMENDATIONS FROM U.S.D.A.
The food pyramid
For historical purposes, it is worth noting that through the 1970s, families were taught to consume items from the 4 or 5 food groups (fruit/vegetables, meat, cereal grains, and dairy) in equal proportions. Even today, some parents and grandparents still follow this model. The United States Department of Agriculture (USDA) “food pyramid” was developed by the USDA in response to its two-fold responsibility - to protect the health and nutritional status of all Americans and to ensure the sale and distribution of the products of American agriculture. This creates an obvious conflict of interest in a country that is hip deep in corn and its byproducts -- corn oil and corn syrup. Nevertheless, the pyramid has become an important educational tool. Some comments:
** Suggested caloric intake should be sufficient to maintain a healthy weight for length or height.
** For children, the recommended intake of fat -- 30% of calories -- is a minimum, rather than a mean, intake. The decrease in fat intake can be implemented by decreasing the consumption of high fat animal products -- whole milk and full-fat cheese, butter, beef, pork, and lard. Low-fat dairy products are suggested with use of liquid oils high in monounsaturates – olive and canola oils.
** If more calories are needed for growth, the deficit can be made up by increasing sources of complex carbohydrates such as vegetables, legumes and fruits from an average of 46% to 55%.
** For many children and adults, a caloric deficit promotes health by helping achieve lean body weight. Complex carbohydrates from whole grain cereals and bulky vegetables increase the intake of dietary fiber.
** Encourage lower fat sources of protein, such as fish, poultry, legumes, low-fat dairy products and lean cuts of meat. Americans derive 12% of their total calories from protein. Mothers, however, think of protein containing foods, as "good nutrition" because they are expensive. Excess protein intake is associated with atherogenesis and hypertension.
** A substantial body of epidemiological data suggests that the two lower levels should be switched to emphasize consumption of fruits, vegetables, and oils high in monounsaturates and--omega-3 fatty acids-- "the Mediterranean Food Pyramid".
Food costs do matter
Early versions of prudent diets stressed the consumption of rice, beans, and small amounts of meat. They were inexpensive. The new versions, with calls for five to nine servings of fresh fruits and vegetables a day are costly. Supplemental food programs -- W.I.C., Food Stamps, and School Feeding Programs -- are essential to maintain the nutritional status of poor children. They work in two ways.
** First, they provide good food.
** Second, they reduce the cost to the family for the purchase of the remainder of the diet. Generally, poor families reserve the money saved to improve the quality of foods they purchase themselves. The data collected in the United States show that the major supplemental programs have been extremely effective.
Here are some examples of common problems poor families might have in maintaining a nutritious diet.
** The false idea that protein-containing foods are "better" than carbohydrates increases the cost of food .
** Olive oil, rich in monounsaturated fat, is substantially more expensive than other liquid fats. Canola oil is a less expensive substitute for olive oil.
** Lean cuts of beef and pork, when considered on a per calorie basis, are more expensive than fatty ones, but the use of smaller portions of lean meat provides better nutrition at no additional cost.
** Urban poor families are unlikely to have an inexpensive source of fresh vegetables or fruit.
The figures below show 1) An appropriate and affordable diet for poor families with children, 2) A sample food table, and 3) A “Home Plate”-- a pyramid modified by the suggestions listed above and applicable for the many food cultures of Americans in the year 2007.
FOOD GUIDE PYRAMID
USDA Low Cost Menu
1.25 Cup Cheerios
.5 Cup orange juice
1 baked chicken drum stick
1 tbs mayonnaise
2 slices whole wheat bread
.5 Cup applesauce
.5 Cup vanilla pudding
.5 Cup rice
.75 Cup beans with sausage
.33 Cup broccoli
.5 Cup juicey juice
.5 Cup jello with fruit
3 Oreo cookies
1 Cup milk
$3.32 or 0.18/100 Cal in an inner city
supermarket. The cost is 10% less in
the suburbs.
Food Labels
The new food labels must be on all
prepackaged foods excluding meats,
fish and poultry (these foods will also
face mandatory labeling in the future).
By law, the labels must include the
serving size, in standardized portions;
the number of servings per container;
and the amount per serving of the
following: calories, calories from fat,
total fat, cholesterol, sodium,
carbohydrates (including sugar),
protein and dietary fiber. The labels
should also include the % daily value
of the above nutrients based on a
2,000 calorie diet. Calories per gram
of carbohydrate, fat and protein are
also included. The % daily value of
selected vitamins and minerals can
also be included.
Caloric intake is based on energy expenditure and biologic need.
Recommendations are in accordance with those of the American Heart Association, American Diabetic Association and the American Dietetic Association. (See painter J, Rah J, Lee Y. Comparison of international food guide pictorial representations. Journal of the American Dietetic Association. 2002: 102(4): 483-489)
Answers
A1. D is correct. Overfeeding fast foods is obvious as it contains too much fat, sugar, and fiber-free polysaccharides. Excessive restriction, however, has also associated with excess weight gain by prohibiting self-regulation.
A2. The answer is false. Sub-clinical Vitamin D deficiency is rampant, even in the white population of northern cities. Few people voluntarily go in the sun without sunscreen given the risk of skin cancer. No one should put a baby in the sun without protection. Breast milk does not contain sufficient or secure amount of Vitamin D to meet RDA.
A3. What is Beikost and why? Beikost are foods fed to children at weaning that older children will not want. Use of beikost protects infants from protein-energy malnutrition. Older children will not "steal" their siblings' beikost foods.
A4. The answer is B. It is likely that the infant was overfed from birth. (See Part III, Sections 1 and 2.) At 6 months of age for a formulae fed infant, one should limit to 26 oz (780ml) providing about 500 kcal each day. We begin Beikost feeding to provide the remainder of nutritional needs. At one year of age, at the change to cow milk feeding, the infant should receive 1/2 of feeding from non dairy foods with further additions provided from a variety of food groups.
