Robert Karp, MD
SUNY-Downstate Medical Center
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PRE-TEST (detailed explanations at the bottom):
True or False:
Q1. Vitamin D supplementation is not necessary for a Caucasian infant living in the continental United States.
Q2. By 2 to 4 months of age, infants give different cry signals for hunger, wetness, need for comforting, etc.
Q3. Infants in day care should, if possible, be fed human breast milk obtained from pumping.
Q4. Supplementation with an appropriate Beikost, such as infant rice cereal does not increase the risk for obesity later in childhood.
OBJECTIVES
Residents and pediatricians will be able to:
1. Encourage continued breast-feeding
2. prevent early introduction of solid foods
FACILITATOR PREPARATION
Pediatric Nutrition Notes address issues of too-early feeding and the importance of breast-feeding.
The references used in Section 1 of the obesity cycle are appropriate for use here.
See also: Morgan JB, Lucas A, and Fewtrell MS. Does weaning influence growth and health up to 18 months? Arch Dis Child. 2004 Aug;89(8):728-33
The case history from Section 1 continues [Section 1, the family at high risk for having an obese child.] The Case is that of an infant, Sharon S, with two overweight parents and whose birth weight was 4,080 grams. The first part of the case describes the ways in which the parents are informed of risk for obesity and encouraged to breast feed exclusively and appropriately.
Case 1 Continues:
Sharon is brought for her 2-week visit. At this visit, your measurements show good growth– a regain to birth weight plus 100 grams to a total of 4,180 grams. Her length and head circumference are also appropriately larger. Her mother is making plans to return to work before her next visit. She asks, “how will I feed Sharon when I go back part time in 2 weeks.”
Q 1 What options are available? We begin each of the pieces of the case history with an opportunity for the residents and others to play out the roles of the parents and the pediatrician.
SUGGSTIONS: You begin by asking Mrs. S what her part time schedule is and how Sharon will be taken care of while Mrs. S works. You keep in mind that each family is unique and that there are many options for continuing to encourage optimum nutrition in the newborn. While keeping the following options in mind you are listening carefully to the individual circumstances of Sharon’s family.
A1. Possible choices for feeding are:
1. To continue breast-feeding entirely. This would be possible only if Mrs. S is one of the few women in the United States working near her infant in a setting that provides for nursing mothers with an appropriate day care and time allotted to feed.
2. You want to maximize the opportunity for Mrs. S to continue to breast-feed. Given the likely restrictions, the preferred option, is for Mrs. S to pump her breast and have the day-care or individual that cares for Sharon bottle-feed breast milk. This can be done effectively as breast milk can be frozen. Mothers who choose this must instructed on how to defrost the breast milk.
A tepid water bath is best. Mothers must be informed, never to put milk or other food for an infant in a microwave to heat. Because microwaves heat from the inside of the container, the container itself may feel neutral to the wrist or even cool while the contents are excessively hot. Liquids may be heated to above the boiling point.
3. To chose a formulae for use. Day-care settings generally have formulae available. It is important to be sure that they use an AAP approved formulae especially if a parent insists on a cow-milk free formulae. Cow milk should not be used before 12 months of age. [Hyperlink to Pediatric nutrition notes]
For any child using formulae, the criteria provided in Nutrition Notes apply:
[Again, see Nutrition Notes]
- there is an approved formulae. These all contain sufficent Vitamin D.
- it is properly constituted – watch out for over dilution
- there is adequate refrigeration
- there is clean, hot water available for cleaning bottles and nipples
The Case Continues
Mrs. S says that she has a day-care and they will provide a standard formulae and have the proper support system to feed Sharon. She is concerned about whether they will feed her properly
Q2. What instructions should Mrs. S give the day-care or home-care person who feeds Sharon?
A2. Given, the risks for obesity, guidance for use of formulae should include careful monitoring of amount. Neither over-restriction – a “fear of fatness” that could lead to protein-energy malnutrition, nor satisfying needs for oral gratification with bottle-feeding is appropriate. The day-care should look for satiety cues that are often associated with non-nutritive sucking
TABLE 1. Satiety Clues
TEACHING CAPTION: The most difficult task for the bottle-feeding mother is to recognize non-nutrititive sucking.
These all signal that Sharon has had enough to eat that would indicate satiety. Moreover, they need to be informed that infant crying does not necessarily indicate hunger . Mothers can distinguish the meaning of a cry. Suggest that they attend to the difference between a pre-feed (hunger) cry and those that follow. Go over causes of crying such as need to be changes, burped, comforting as well as hunger and encourage the day-care to think of this “list’ when responding to an infant’s cry. If possible, ask Mrs. S to describe any possible satiety cues she has observed while feeding Sharon.
Q3. Many parents do not have the luxury of a day-care setting with a well-trained staff. What should a parent do when the day-care person is the grandmother, a or family member?
A3. Mrs. S should review the satiety cues she has noticed while feeding Sharon. Also helpful is to give Mrs. S. a copy of the growth and weight for height chart to share with family members, with the comment that Sharon is growing well. Comforting with food needs to be discussed as are gentle reminders that “food is not love”. These are important for family members who may be certain that “a crying baby is a hungry baby,” or that feeding an infant is an expression of affection. The custom of putting cereal in the bottle adds calories and, after the nipple is slit to accommodate the thicker feedings, alters the flow of formula, too.
Q4. Is there anything else you, the pediatrician, should check with respect to the completely breast-fed infant?
A4. Don’t forget supplementation with a source of Vitamin D [see Nutrition Notes] The AAP no longer distinguishes between white children and children of color in requiring supplementation.
The Case continues:
Sharon is brought for her 2-month visit. Sharon is maintaining her weight at 5,400 grams -- about the 80th percentile for weight for age and sex. These are the same percentiles for length and head circumference. Mrs. S tells you that she would like to feed Sharon solid foods now and wonders when and how she should begin. She asks about cereal in the bottle.
Q5. Can you explain introduction of solid feeding to Mrs. S?
A5. Begin by supporting Mrs. S’s ability to maintain Sharon’s feeding so that her weight gain is stable. Also, be sure to integrate the nutrition issues in with other elements of well baby care such as Sharon’s developing motor skills, family nutrition and activity habits and routine well-child care. Counseling about obesity prevention should be an integral part of the well visit but needs further exploration if Mrs. S is becoming preoccupied with weight only. [See warning boxes in module on Failure to Thrive Part IV, Section 2]
With respect to Mrs. S’s desire to start supplemental feedings early, review the normal infant development and explain the fact that it really isn’t safe to offer the infant solid foods on a spoon until she loses her “tongue thrust” (a reflex pushing out of food which lasts almost to 4 months of age). An infant who is primarily breast-fed can be kept on breast milk alone until 6 months of age. Growth curves were developed using measurements from a bottle-fed population of children. The `fall-off’ seen with some breast fed infants may be an artifact of the monitoring system used. As for cereal in the bottle, “We strongly discourage this for healthy babies as it just adds calories and disrupts the careful science that went into the creation of infant formulae.”
The data provided by the Lucas group (see above) suggest that early weaning leads to increased weight to age 18 months. By that age, these children’s growth converges with growth of late supplemented children. One should, however, defer supplementation especially for high-risk children living in high-risk communities and defer supplemental feeding.
There is further discussion of this in the Introduction to Section 3 part 2 by Drs. Kjolhede and Scranton [Link to Intro Sect 3 part 2]
The Case Continues:
It is in the four-month visit that the issue of supplemental feeding begins. Infants that delay supplementation until six months of life are less likely to “over-gain.” However, there may be a dip in the growth curve because the standard NCHC curves were created with a bottle-fed population. The first feeding is of a pulverized starch. Rice is a gluten free grain and is suggested as the first starch. Oats and barley do have some gluten. They are also used though with caution if there is a family history of celiac syndrome.
Sharon continues to grow as a larger child with percentiles between 75th and 85th for weight. You continue your support into weaning and toddlerhood.
SUMMARY
These two sections (#’s 1 and 2) modules provide a heath start for an infant ”at-risk” for obesity. The principles described apply to all infants.
ANNOTATED ANSWERS
A1. The answer is False. Yes, white infant in the lower latitudes exposed to sunlight without sunscreen will convert UV light to cholecalciferol, but this is not done because of concern for early exposure to sunlight. When exposed both mother and infant after six months of age should be shaded and wearing sunscreen. All infants need a source of vitamin D provided orally..
A2. The answer is True. Fairly early, infants provide different signals for different circumstances. Mothers learn that pre-feeding cries differ from post-feeding ones. Hearing the other cries should lead to non-nutritive (change, cuddle, rock, etc.) responses
A3. The answer is True. Mothers can pump their breast and bottle safely. Breast milk can be stored in the freezer. Unfrozen, unused milk, however, must be discarded.
A4 The answer is False. Pardon the double negative. Early supplementation, even with appropriate supplementary foods does increase risk of obesity. The AAP has moved the recommendation for introduction of Beikost from 4 to 6 months of age.
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