Nutritional Health Pediatrics

Notes from Chap 10: Nutrition

The AAP recommends exclusive breastfeeding until 4-6 months and continued breastfeeding supplemented with foods for infants until at least 12 months old. AAP also redo giving 400 IU of vitamin D to all breastfed infants until 1 year of age and to all children and adolescents with diets deficient in vitamin D.and unfortified formula until they are 1 years USPSTF redo that children 6 and older be screened for obesity and are given comprehensive intensive behavioral interventions to improve weight. foods should come from plants: whole grains, fruits, vegetables, legumes, nuts iron rich foods are essential for infants and adolescents extra calcium, iron, and folic acid are important in adolescent girls' diets growth is greatest in infancy and adolescence and is a second source of energy consumption. sodium: 1-3y: 1000mg/day, 4-8: 1200, 9-18: 1500 sodium requirements vary with the rate of extracellular fluid expansion, which is most rapid in infants and very young children. potassium: requirements increase as lean body mass increases and are higher during the rapid growth of infancy and adolescence than during middle childhood. Fruits, vegetables, and fresh meat have high potassium content. chloride: no RDA, adequate amounts ingested with normal diet protein: children should receive 5-30% of daily calories from protein. growth needs of the premature infant require higher levels of protein than those of infants born at term. carbohydrates: 45-65% of children's body energy requirements should be supplied by carbs. most should be in complex form. fats: 1-3 be 30% to 40% of total caloric intake, children more then 3 should get 25-35% of total calories from fat, with less than 10% of total calories in the form of saturated fat. picky eaters can get vitamins because trends towards eating fewer fruits and veggies as adolescence progresses and school aged children are at high risk for vitamin and mineral deficits not a substitute for food child's intake should be assessed over 3 day period and strategies to encourage child to eat a healthful, varied diet put in place if after assessment, the provider concludes that child is at risk for nutritional deficit, multivitamins can be given preterm or low birth weight babies and children with chronic illness may need supplements, all pregnant teenagers should receive prenatal vitamins History nutritional status of mother during pre food and fluid intake of child and family: type of feeding method used during infancy, breastfed, formula name and preparation, problems, weaned, solids started, allergies, intolerances current nutritional intake, frequency and amounts of feedings in 24hr period types of foods and fluids amts eaten (24hr recall, 3 day diet history, length of time and frequency child is at breast) additional intake is childs intake different from family eating pattens: -frequency -bottle feeding: propped? does child take bottle to bed at night or nap time? who feeds child? -breastfeeding: on demand or scheduled? how flexible is mother to demand of infant? is mother working? is breast milk frozen and fed by someone other than mother? -feeding patterns or behaviors -describe mealtime: does family sit down together? are meals prepared at home? does child eat at school? how often are fast foods eaten? what amount of time is spent eating? how long does it take to feed child? -does family eat out frequently? how many times per week? reactions to and attidues about food: -any reaction to particular foods (vomiting, diarrhea, rash) -food preferences or dislikes -cultural factors: beliefs or attitudes family has about how and what child should eat or how family should eat? -what is child's attitude about foods and eating? -feeding ability of child: does child choke, gag, vomit, have suck or swallow difficulties, refuse certain foods? -parents' and child's knowledge of foods and nutritional needs mgmt of foods in family: -who plans, purchases, and prepares foods and meals for family? -economic and environmental factors - are finances adequate to supply nutritious food? is there a refrigerator? does family have car to carry larger amounts of food from store? is there a full-service grocery store in neighborhood? what is socioeconomic status of family? is food shopping budgeted? are food stamps or other supplemental programs used? health status affected by nutrition: -chronic condition, special diet formula or device for feeding, any medications -elimination patterns -dental status and care of teeth -change in hair, nails, skin or mucous membranes -tolerance for hot or cold weather -growth, activity, exercise patterns: has child been growing as parents expect, has there been a history of unusual weight gain or loss, does child have energy to play, is the child engaged in strenuous activity such as athletic training program -fam hx: HTN, DM, hyperlipidemia, obesity, heart disease, allergies, eating disorders PE: body temp, height weight, head circumference, arm circumference and triceps and sub scapular skin fold caliper measurements for children at risk for obesity or malnutririon, BMI, skin (clear smooth firm with good turgor), muscle tone, posture, skeletal development, hair (smooth, full, shiny; no dryness, broken ends, bare patches, or discoloration), mucous membranes, eyes (moist, shiny, no dark circles, conjunctiva pink), teeth (eruption approp to age, gums healthy, no bleeding), neck (thyroid, parotid glands of normal size), abdomen (flat, soft), cardiovascular (no patholgic murmur, normal heart size, skin warm pink less then 3 sec cap refill, peripheral pulses equal, strong), neuro and behavior (alert, active, reflexes present, no complaints of headache, neuritis) diagnostic test: CBC - hct, hgb iron ferritin serum albumin, nitrogen, minerals lipids bone radiographs, bone age (height age - age at which 50% of children reach the patients height) newborns and infants: during the 2nd year of life cows milk can be included in children diets. AAP recommends whole milk for children 12-24 months, reduced fat or 2% is reco if concern of overweight or obesity or a fam hx of obesity or cardiovascular dz. reduced fat milk contributes to adequate fat intake and has no negative effect on growth or body composition. fat free milk is not reco for children less than 2. bottle feeding beyond 12 months old appears to be a risk factor for overweight and formula-fed infants introduced to solid foods before 4 months are 6x as likely to be obese at age 3 toddlers and preschoolers: the growth rate is slower than that of infants, resulting in decreased energy needs. increased size and activity - require increased number of total calories, addition of muscle mass demands high protein intake many foods are fortified with vits and mins school aged children: protein needs increase as they gain more muscle mass. active boys 10-18 need 2200-3200 calories a day, girls need 1800-2400. adolescents: children never seem to stop eating. high levels of energy are needed to support rapid growth esp if children participate in sports or other exercise programs. adolescent girls are at risk for iron deficit when menstruation begins an children who eat a legal diet will need B12 supplementation. pregnancy in adolescence: 1300-1500mg of calcium, daily folic acid of 0.4mg is reco for all girls capable of becoming pregnant, increased to 0.6mg during pregnancy. for adol who are 4 years past menarche, gestational weight gain is similar to adults. portions: 1 tbsp of food per year of age. for children younger than 5 years old, one serving is about 1/4 to 1/3 of an adults serving. for older children 1/4 to 1/2 of an adults serving. children may reject a food up to 15-20 times before they become accustomed to it and enjoy eating it. food should be removed without comment and then offered again at another meal. don't become childs short order cook, preparing a special dish if child rejects what has been fixed for family. if child chooses not to eat much at particular meal, they will be hungrier at next. children should be offering snacks between meals, but not substitute for meals, no graziing or eating whatever food is available -offer the food when children are hungry -allow children to taste a little of food rather than eating a full portion -expose children to food by preparing and serving without expecting them to eat it -provide an example of parents eating and enjoying the food -prepare the food the way children prefer: few spices, lukewarm, recognizable -associate food with pleasant experience -never force food on children physical activity: reco children and adolescents engage in 60 minutes of physical activity every day, moderate to vigorous intensity aerobic (exercise that makes them breath hard); they should do vigorous activity at least 3 days a week and muscle- and bone-strengthening at least 3 days a week

13. Discuss the recommendations for progressing to solid foods in the first year.

see card 1 & 2

4. List several risk factors.

see causes slide

14. List the principles and guidelines for fluoride, vitamin, and mineral supplementation.

see questions 6&7, card 3

What components of a physical examination are necessary when attempting to determine an infant or child's nutritional status?

• Body temperature • Height, weight, and head circumference measurements; arm circumference and triceps and subscapular skinfold caliper measurements for children at risk for obesity or malnutrition • BMI • Skin condition (clear, smooth, firm, with good turgor) • Muscle tone, posture, skeletal development (body erect, tone good) • Hair (smooth, full, shiny; no dryness, broken ends, bare patches, or discoloration) • Mucous membranes, eyes (moist, shiny, no dark circles, conjunctiva, pink) • Teeth (eruption appropriate to age, gums healthy, no bleeding, no cleft palate) • Neck (thyroid ( goiter - iodine deficiency), parotid glands of normal size) • Abdomen (flat, soft) • Cardiovascular (no pathologic murmur; no CHF; normal heart size; skin warm, pink, less than 3-second capillary refill; peripheral pulses equal, strong) Musculoskeletal for bone growth and development Elimination: Number of wet and stooled diapers and frequency • Neurologic and behavior (alert, active, reflexes present, no complaints of headache, neuritis)

1. List eight important components of a feeding history for infants, children, and adolescents.

• Nutritional status of mother during pregnancy • Food and fluid intake of child and of family: Type of feeding method used during infancy: If not breastfed, formula name and preparation. Any problems? When weaned? When solids started? Any allergies or intolerances noted? Current nutritional intake of child (if child is still an infant, ask more specifically about frequency and amounts of feedings in a 24-hour period) Type of foods and fluids Amounts eaten (may use 24-hour recall, 3-day diet history, or length of time and frequency that child is at breast) Additional intake (e.g., vitamin, fluoride, or iron supplements) Is child's intake different from the rest of the family? How? • Eating patterns: Frequency of eating (nursing, meals, snacks) Bottle feeding: Is bottle propped? Does child take bottle to bed at night or at naptime? Who feeds child? Breastfeeding: On demand or scheduled? How flexible is mother to demands of infant? Is mother working? Is breast milk frozen and fed by someone other than the mother? Feeding patterns or behaviors for both child and family Describe mealtimes: Does family sit down together? Are meals prepared at home? Does child eat at school? How often are "fast foods" eaten? What amount of time is spent eating? How long does it take to feed child? Does family eat out frequently? How many times per week? • Reactions to and attitudes about foods: Any reaction to particular foods (e.g., vomiting, diarrhea, rash)? Food preferences or dislikes Cultural factors: What beliefs or attitudes does family have about how and what child should eat or how family should eat? What is child's attitude about foods and eating? Feeding abilities of child: For example, does child choke, gag, vomit, have suck or swallow difficulties, or refuse certain foods, perhaps because of texture or smell? Parents' and child's knowledge of foods and nutritional needs • Management of foods in the family: Who plans, purchases, and prepares food and meals for family? Economic and environmental factors that influence how food is managed: For example, are finances adequate to supply nutritious foods? Is there a refrigerator? Does family have a car to carry larger amounts of food from store? Is there a full- service grocery store in the neighborhood? What is the socioeconomic status of family? Is food shopping budgeted? Are food stamps or other supplemental programs used? • Health status affected by nutrition: Special considerations for children or family related to food: For example, does child have a chronic condition that requires a special diet, formula, or device for feeding? Are any medications being taken? Elimination patterns Dental status and care of teeth Patterns of wound healing, infections, colds, and mild illnesses Any change in hair, nails, skin, or mucous membranes? Tolerance for hot or cold weather? Growth, activity, and exercise pattern: For example, has child been growing as parent expects? Has there been a history of unusual weight gain or loss? Does child have energy to play? Is the child engaged in strenuous activity such as an athletic training program? Family history: Hypertension, diabetes, hyperlipidemia, obesity, heart disease, allergies, eating disorders? Nutrition for growth Food and fluid intake of child and of family Eating patterns and habits Reactions to and attitudes about foods Management of foods in the family Health status affected by nutrition Food security Culture and food

10. Describe the various methods for preparing formulas. 11. Review the nutritional formulation of the various formulas.

• Premature transitional formulas: Higher caloric content more nutrient dense than regular cow's milk-based formulas; 24 kcal/oz Protein source: nonfat cow's milk, whey • Cow's milk-based formulas: Standard formula for healthy term infants; 20 kcal/oz • Nutrient-dense cow's milk-based formulas Similar to premature formula, but with less phosphorus and calcium; some preparations have up to 27 kcal/oz • Hypoallergenic formulas: Partially hydrolyzed whey-based formulas, Soy-based formulas (protein source: soy protein isolate with L- methionine), Extensively hydrolyzed casein-or whey-based formulas Amino acid-based formulas (elemental) • Formulas with long-chain polyunsaturated fatty acids, More closely approximates human milk with content of docosahexaenoic acid (DHA, an omega-3 fatty acid) and arachidonic acid (ARA, an omega-6 fatty acid) May enhance visual and mental development, especially in preterm infants • Formulas for feeding beyond 6 months of age (Step-2 formulas), usually calcium fortified, must be supplemented with solids • Nutrient-dense formulas for older child Caloric content up to 30 kcal/oz; other nutrients increased over regular infant formula • Specialized formulas Higher caloric content (24-30 kcal/oz); nutrient dense; free amino acid and peptide-based formulas; lactose-free • Protein supplements • Nitrogen-free calorie supplements • Oral electrolyte solutions Occasionally infants demonstrate intolerance to formula, showing irritability, weight loss or slow gain, vomiting, diarrhea, constipation, other gastrointestinal problems, or atopic dermatitis. The provider must work closely with parents to identify a formula tolerated by the infant, being careful to allow sufficient time for the baby to respond to a new formula as it is introduced. This can be a time- and energy-consuming process in which parents need support, reassurance, and encouragement. Referral to a registered dietician can be helpful. For commercially prepared, ready to feed should not be diluted. Mix formulas with bottled water for first month. Store in refrigerator if open no longer than 24 hrs. Serve formula at room temp. Do not microwave to heat. Do not let formula sit out at room temp. Carefully read the instructions on the formula can to know how to mix the formula and store the formula. Do not fix old unused leftover prior-fed formula with new mixed formula.

Mrs. Smith, mother of 5-month old Elizabeth, has noted a change in her eating pattern. Recently she has begun to require extra nursings in addition to the 8-12 breast-feedings she was already having. Her birth weight was 7.3 lb. Her weight today is 15.5 lb. Her elimination patterns are entirely normal. She has begun to awaken one additional time during the night to breastfeed. Mrs. Smith feels that Elizabeth may be ready for solid foods. 1. What demands do the rapid growth of infancy place on nutritional requirements? 2. List the importnat points to consider when evaluating an infant's readiness for solid foods. 3. What is the traditional age guideline for the introduction of solid foods? What is the rationale?

1. Potassium requirements increase as lean body mass increases and are higher during the rapid growth of infancy and adolescence than during middle childhood. Rapid infant growth requires high caloric intake. Adequate intake of breast milk or infant formula meets all energy needs for infants until 4-6 months old. Children younger than 2 years can require more than 30% dietary fat for neural development. Vitamin D supplement (400 IU daily) is reco for all breastfed infants and infants who receive an unfortified formula until they are 1 year old. Infants should have an adequate source of vitamin C after 4-6 months old. Daily Estimated Energy Requirements (EER) for Infants and Toddlers in Kilocalories Age, Calculation of Daily Kilocalorie Needs, Estimate Based on, 50th Percentile of Weight 0-3 months - EER = (89 × weight of infant [kg] - 100) + 175 (kcal for energy deposition) - 100 kilocalories/kg/day 4-6 months - EER = (89 × weight of infant [kg] - 100) + 56 (kcal for energy deposition) - 85 kilocalories/kg/day 7-12 months - EER = (89 × weight of infant [kg] - 100) + 22 (kcal for energy deposition) - 80 kilocalories/kg/day 13- 35 months - EER = (89 × weight of child [kg] - 100) + 20 (kcal for energy deposition) - 83 kilocalories/kg/day 2 & 3. 6 months - introduce solids into the infant's diet: • Infants' sucking patterns have changed sufficiently to allow mastery of chewing and swallowing. • Infants can sit with some support, and they are able to purposefully move their heads. • Infants are able to grasp, pick up, and bring objects to their mouths. • Iron stores present at birth are being depleted. • Growth demands require nutrients other than those provided in milk alone. • Developmental needs (cognitive, sensory, and motor) are stimulated by new foods, textures, smells, tastes, and use of utensils. Solids can be introduced in whatever sequence the family desires - nonallergenic cereals are usually the first infant foods. Dense proteins should be introduced later to allow for maturation of the renal system. Home-prepared foods, such as grains, mashed bananas, applesauce, pureed squash, cooked vegetables, and blenderized meats, can meet all the child's nutritional needs. Although not necessary, commercial baby foods can provide adequate nutrition, but labels should be examined to determine their content, especially for calories, fats, additives, salt, and sugar. Principles for the Introduction of Solids into the Infant's Diet • Introduce one food at a time, waiting 3 to 5 days before offering another to assess for adverse reaction. • Offer rice cereal, the least allergenic of cereal grains, as the first food. • Introduce fruits, vegetables, and other cereals in any sequence desired. • Feed only iron-fortified cereals. • Prepare food appropriate to child's developmental abilities (e.g., strained, mashed, or finger foods). • Use home-prepared or commercially prepared foods. • Provide a variety of foods. • Help child develop healthy patterns of eating: Be alert and responsive to child's cues when eating. Use a spoon to feed solids. Offer about 1 Tbsp per year of age as a serving for infants; for older children, about one fourth to one half an adult serving. Never force a child to eat. Include the child in family mealtimes.

You note at today's visit that Elizabeth is able to sit with support, will intentionally mouth a toy, and has doubled her birth weight. 4. What do you recommend to Elizabeth's mother regarding the introduction of solid foods? 5. If appropriate to introduce solid foods, what guidelines would you give Mrs. Smith regarding the introduction of solid foods?

4. She can start solid foods. 5. Start with cereal. see above. Offer solid foods at least 2 to 3 times per day Have the infant become accustom to different and new textures and tastes Introduce solid foods with a spoon; do not put cereal in a bottle Begin with iron-fortified rice cereal which can be prepared with either breast milk or formula Add new foods one at a time and start with 1-2 teaspoons, waiting 2-5 days between introduction of new foods Limit juices to 4-6 oz per day and offer in a cup or avoid altogether Avoid feeding as a comfort measure use fluoridated water Avoid foods with high allergy potential (strawberries, eggs, peanut butter, cow's milk, soy, wheat) until the end of the first year; avoid honey until after the 1st year Position infant in high chair or infant seat to eat Avoid foods that can cause choking such as popcorn, grapes, raw carrots, nuts, hard candies, and hot dogs

Elizabeth's older brother, age 3 years, has been a "fussy eater" since 18 months of age and takes a children's multivitamin plus mineral supplement. Mrs. Smith fears the same will happen to Elizabeth. She wants to know whether to give her a vitamin supplement. They live in a town with fluoridated water and do not receive fluoride supplementation. 6. What advice would you give Mrs. Smith at this time regarding vitamin and mineral supplementation? 7. What would you advise regarding fluoride supplementation?

6. Vitamin supplements, except vitamin D, are usually not necessary for healthy term breastfed or formula-fed infants who eat a variety of cereal, fruits, vegetables, and proteins after 4 to 6 months old. Vitamin D supplement (400 International Units daily) is recommended for all breastfed infants and infants who receive an unfortified formula until they are 1 year old. Infants should have an adequate source of vitamin C after 4 to 6 months old. A multivitamin supplement is recommended for infants at nutritional risk. Iron deficiency is the leading cause of anemia in children, and iron supplementation is appropriate in some cases. Term infants who are breastfed usually have adequate iron supplies until 4 to 6 months old. Premature or low-birth-weight infants, infants who are exclusively breastfed beyond 4 to 6 months old, and infants who are fed cow's milk before they are 12 months old are at high risk for iron deficiency anemia. Iron-fortified cereals and iron-fortified formulas are excellent sources of dietary iron supplements for infants 6 to 12 months old. Earlier supplementation may be necessary for premature infants, especially those that are breastfed. Administration of oral iron drops 1mg/kg/day would need to be given until iron and zinc-rich fortified foods are introduced such as pureed meats. Other vitamins and supplements that can be given are 200mg of calcium per day at the age of 6 months and then increased to 260 mg per day for age 7 to 12 months; 400 IU of vitamin D can be given per day until 1 years old. 7. The American Dental Association (ADA) recommends fluoride treatment starting at 6 months old. The fluoride level of water used to mix formula should be measured to ensure that infants do not receive excess fluoride. If the water supply is fluoridated, formula-fed infants younger than 6 months old can be given ready-to-feed formula, or nonfluoridated bottled water can be used to prepare formula. Use fluoridated water or bottled water that contains a concentration of 0.8 to 1.0 mg/L (ppm) of fluoride. The USPSTF recommends "that primary care clinicians prescribe oral fluoride supplementation starting at 6 months of age for children whose water supply is deficient in fluoride". The AAP recommends the application of fluoride varnish from the time of primary tooth eruption until age 5, at least once every 6 months and every 3 months for those at increased risk of dental caries, and until the establishment of a dental home.

15. What is a prudent diet? For what age groups and populations is it recommended?

A diet to protect against heart disease, stroke, and other common diseases. It consists of fruits, vegetables, whole grains, legumes, nuts, fish, and low-fat dairy products rather than refined or processed foods, red meats, high concentrated sweets, eggs, and butter. A multistep approach decreases fat, cholesterol, and protein.

7. Under what conditions would you refer the infant/child to a physician.

Bariatric surgery (roux-en-Y gastric bypass; laparoscopic adjustable gastric binding; sleeve gastrectomy) has not been widely used as a therapy for adolescents and children, but can be effective in treating morbidly obese adolescents with comorbidities It has been recommended that adolescents be selected for bariatric surgery using criteria set by the National Institutes of Health (NIH) for adult eligibility. The Endocrine Society states that adolescents who are morbidly obese (BMI >50) or who have a BMI greater than 40 with comorbidities are candidates for bariatric surgery Some providers believe that having surgery during adolescence (rather than waiting until adulthood) may be more beneficial for individuals with childhood-onset obesity. But the surgery has potentially serious side effects and adolescents must be carefully monitored because long-term effects are still unknown complications: hypertension, impaired glucose tolerance, sleep apnea, orthopedic problems (slipped capital femoral epiphysis), social rejection, lowered self-esteem, depression, suicide

12. List common feeding concerns and describe anticipatory guidance strategies for dealing with them.

Breast milk provides ideal nutrition and supports optimal growth and physical development. (Exclusive breastfeeding [only breast milk] is recommended for a minimum of 4 months, but preferably for 6 months.) ■ Feeding their infant, until age 12 months, breast milk or iron-fortified infant formula and avoiding low-iron milk (cow's, goat's, soy), even in infant cereal. ■ Feeding their infant until he is full. ■ For younger infant (up to age 3 months), signs of hunger include putting the hand to the mouth, sucking, rooting, pre-cry facial grimaces, and fussing. ■ For older infant (ages 4-6 months), signs of hunger include moving the head forward to reach the spoon and swiping food toward the mouth. ■ Spitting up a little breast milk or formula at each feeding is normal. Food Safety ■ Following food safety practices for storage of expressed breast milk or open containers of ready-to-feed or concentrated formula. Dangers of warming expressed breast milk, formula, or food in containers or jars in the microwave. ■ Warming bottles by holding them under hot running water or placing them in a bowl of hot water for a few minutes. ■ Testing warmed fluids to make sure that they aren't too warm by sprinkling drops on wrist (the fluid should feel lukewarm; if too warm, cool down and test again). ■ Avoiding foods that may cause choking (small or slippery foods, such as hard candy, whole grapes, hot dogs; dry and difficult-to-chew foods, such as popcorn, raw carrots, nuts; sticky or tough foods, such as peanut butter, large chunks of meat). ■ Following food safety practices to reduce their infant's risk of food-borne illness. Giving breastfed and partially breastfed infants a vitamin D supplement beginning during the first few days of life. (Supplementation should continue unless the infant is weaned and is consuming at least 1 L per day or 1 qt per day of vitamin D-fortified formula or whole milk. Cow's milk should not be given to infants younger than 12 months.) ■ Giving infants ingesting less than 1 L per day or 1 qt per day of vitamin D-fortified formula a vitamin D supplement beginning during the first few days of life. ■ Giving breastfed infants vitamin B12 before age 6 months if the mother is vitamin B12 deficient (vegan [eats no animal products], is undernourished, does not take vitamin B12 supplements) Feeding Practices ■ Continuing breastfeeding for 12 months or as long as the mother and child wish to continue. ■ Feeding their infant on demand stimulates the lactation process (the longer the infant sucks, the more breast milk the mother's body makes). ■ Allowing their infant to finish feeding at one breast before offering the other breast (20-45 minutes per feeding provides adequate intake and allows the mother rest time between feedings). ■ Feeding their infant when she is hungry, typically 10 to 12 times per day during the initial weeks of life, 8 to 12 times per day for the next several months, and 6 to 12 times per day thereafter. ■ Feeding their infant more often during periods of rapid growth. (Frequent feedings help establish the milk supply and prevent the breasts from getting too full.) Maternal Eating Behaviors ■ Eating a variety of healthy foods helps the mother stay healthy and helps the infant grow. ■ Drinking beverages such as milk or juice when thirsty and drinking a glass of water at each feeding. ■ Limiting the consumption of beverages containing caffeine (coffee, tea, soft drinks) to 2 servings per day. ■ Avoiding alcoholic beverages 2 hours before breastfeeding. (If the mother drinks alcoholic beverages, no more than 8 oz wine, 12 oz beer, or 2 oz hard liquor should be consumed per day [less for small women].) Support ■ Encouraging the father to help care for their infant (bringing the infant to the mother at breastfeeding time; cuddling the infant; helping with burping, diapering, and bathing). ■ Mothers breastfeeding multiples require more food, additional nutrition counseling, and extra help at home. Feeding their infant immediately after birth, preferably in the delivery room. ■ Feeding their infant when she is hungry, usually every 2 to 3 hours, about 8 to 12 feedings in 24 hours. ■ Their infant is getting enough milk if there are 6 to 8 wet diapers and 3 or 4 stools in 24 hours and the infant is gaining weight as expected. ■ Avoiding artificial nipples (pacifiers, bottles) and supplements (unless medically indicated) until breastfeeding is well established; this occurs at around age 4 to 6 weeks. (Some infants never use pacifiers or bottles.) Waiting until breastfeeding is well established before introducing infant formula (for mothers combining breastfeeding and formula-feeding). Their infant settling into typical breastfeeding routine of every 2 to 3 hours in the daytime and every 3 hours at night, with 4- to 5-hour stretches between feedings; total of 10 to 12 feedings in 24 hours. ■ After the mother's milk comes in, infants should have about 6 to 8 wet diapers in 24 hours. (Infants may have stools [typically loose] after every feeding or as infrequently as every several days.)

Define obesity. What is the incidence of obesity in the pediatric population?

Excessive adipose tissue may be due to an increase either in the size of fat cells (hypertrophy) or in the number of fat cells (hyperplasia). Childhood-onset that is hyperplastic is difficult to control because fat cells can be reduced in size but not in number. BMI and weight-for-height are used to define parameters. In adults, normal BMI ranges from 18.5 to 24.9, and an individual is defined as obese if BMI is 30 or greater. In children, the definition of obesity and overweight is less specific. Children are compared with a normative group of peers, and percentiles specific for their age and gender are a more valid indicator of underweight, normal weight, overweight, or obesity than is an absolute BMI. The Expert Committee on the Assessment, Prevention, and Treatment of Child and Adolescent Overweight and Obesity recommends that children 2 to 18 years old with a BMI greater than or equal to the 95th percentile for age and sex, or those with a BMI greater than or equal to 30 (whichever is lower) be considered obese, not "overweight." Children with a BMI between the 85th and 95th percentiles for age and sex are overweight, not "at risk for overweight." There are no BMI parameters for children younger than 2 years; those with a weight-to-height ratio of greater than or equal to the 95th percentile are categorized as overweight. BMI measurements must be used cautiously to assess individual children because some children have a body weight or BMI in excess of the norm for their age, gender, and height without having excess fat. Children who are genetically large-boned may weigh more than their peers or athletic adolescents may have a higher BMI as a result of heavier muscle mass. Epidemiology Nearly one third of U.S. children are overweight or obese. NHANES data from 2007 to 2008 indicate that 9.5% of children younger than 2 years old are overweight and data from the Early Childhood Longitudinal Study found 31.9% of 9 month olds and over 34% of 2 yr olds either at risk or obese Nearly 12% of children 2 to 19 years old have BMIs greater than or equal to the 97th percentile, 16.9% have BMIs greater than or equal to the 95th percentile, and 31.7% have a BMI greater than or equal to the 85th percentile The rapid rise in overweight and obesity in the U.S. occurred between the 1960s and 2000, with about 5% of all children 2 to 19 years old being obese in the 1971-1974 NHANES study, and 13.9% in 1999-2000. Since 1999, NHANES data have been collected annually and there appears to be no significant upward trend, except among 6- to 19- year-old boys. There is a significant difference in obesity prevalence by race and gender, with 29.2% of 12- to 19-year-old non- Hispanic black girls and 26.8% of 12- to 19-year-old Mexican-American boys having BMIs greater than or equal to the 95th percentile

9. Discuss the components of parent education and counseling for the mother of an infant who is formula feeding.

Formula preparation and storage Formula safety Infant holding Infant burping iron-fortified infant formula until 12 months Spitting up a little breast milk or formula at each feeding is normal Dangers of warming expressed breast milk, formula, or food in containers or jars in the microwave. Feeding Practices ■ Holding their infant close when feeding, in a semi-upright position. ■ Feeding their infant when he is hungry, typically every 3 to 4 hours (6-8 times in 24 hours) until complementary foods are added. ■ Preparing and offering more formula as their infant's appetite increases. ■ Offering their infant water on hot days between feedings (infants don't usually need water). ■ Checking for causes if their infant is crying more than usual or seems hungry all the time (uncomfortable feeding position, formula prepared incorrectly, bottle nipple too firm or hole too big, unheeded hunger cues, distracting feeding environment). ■ Not enlarging the hole in the bottle nipple to make infant formula come out faster. ■ Seeking consultation with a health professional if their infant is not feeding enough. Food Safety ■ Preparing formula as instructed, and following sanitary procedures (washing hands before preparing formula; cleaning area where formula is prepared; cleaning and disinfecting reusable bottles, caps, and nipples before each use; washing and drying top of formula container before opening). ■ Not adding cereal or other foods to infant formula. ■ Discarding infant formula left in the bottle when their infant has finished eating; not reusing a bottle that has been started. ■ Covering and refrigerating open containers of ready-to-feed or concentrated formula. ■ Storing powdered formula at room temperature.

3. What specific laboratory tests may be necessary when assessing nutritional status?

Hemoglobin or hematocrit Iron and/or ferritin levels Serum levels for various elements: albumin, nitrogen balance, minerals, lipids, vitamin D Bone radiographs for suspected iodine, vitamins C and D, or copper deficiency or to compare bone age with height age (age at which 50% of children reach the patient's height) TSH and T4 to rule out obesity secondary to hypothyroidism Blood glucose - starting at age 4 Hgb A1C Lipid panel - starting at age 4 Liver function tests - starting at age 4

3. How is a diagnosis of obesity established?

In adults, normal BMI ranges from 18.5 to 24.9, and an individual is defined as obese if BMI is 30 or greater. In children, the definition of obesity and overweight is less specific. Children are compared with a normative group of peers, and percentiles specific for their age and gender are a more valid indicator of underweight, normal weight, overweight, or obesity than is an absolute BMI. The Expert Committee on the Assessment, Prevention, and Treatment of Child and Adolescent Overweight and Obesity recommends that children 2 to 18 years old with a BMI greater than or equal to the 95th percentile for age and sex, or those with a BMI greater than or equal to 30 (whichever is lower) be considered obese, not "overweight." Children with a BMI between the 85th and 95th percentiles for age and sex are overweight, not "at risk for overweight." There are no BMI parameters for children younger than 2 years; those with a weight-to-height ratio of greater than or equal to the 95th percentile are categorized as overweight. BMI measurements must be used cautiously to assess individual children because some children have a body weight or BMI in excess of the norm for their age, gender, and height without having excess fat. Children who are genetically large-boned may weigh more than their peers or athletic adolescents may have a higher BMI as a result of heavier muscle mass.

6. Describe the health benefits of breastfeeding.

It is rich in vitamins, minerals, fat, proteins (including immunoglobulins and antibodies), and carbohydrates (especially lactose). It contains enzymes and cellular components, including macrophages and lymphocytes, in addition to many other constituents that offer ideal support for growth and maturation of the human infant. The sequence of colostrum, transitional milk, and mature milk meets the changing nutritional needs of the newborn and infant. Thus the milk of a mother of a 9-month-old has different concentrations of fat, protein, and carbohydrate and different physical properties, such as pH, when compared with the milk of the mother of a newborn or 1-month-old. lower risk of nonspecific gastroenteritis, necrotizing enterocolitis, acute otitis media, severe lower respiratory tract infections, asthma, atopic dermatitis, type 1 and type 2 diabetes, obesity, sudden infant death syndrome (SIDS), and childhood leukemia in breastfed infants protection against bacterial, viral, and protozoal illnesses during infancy. Human-milk glycans and immunoglobulins appear to inhibit pathogens from adhering to intestinal mucosa, replicating, and causing disease. Oligosaccharides in breast milk also support the growth of the infantis strain of Bifidobacterium longum in the intestine of the breastfed infant, while suppressing pathological bacteria such as Escherichia coli, Clostridium, and Enterococcus reduce the incidence of fever after immunization The long-term benefits of breastfeeding for 6 months may include a decreased incidence of atopic diseases and an association with lower rates of asthma in young children. protective against obesity, has been associated with lower cholesterol in adults and may be protective against type 1 and type 2 diabetes in youth infants who are breastfed for 6 months have less risk for infection than those breastfed for 4 months exclusive, prolonged breastfeeding may actually contribute to health problems. infants exclusively breastfed for 9 months or longer had an increased incidence of atopic dermatitis and food hypersensitivity in childhood Complementary foods should be added to the infant diet by 6 months of age. There are also benefits for the mother that include more rapid return to her nonpregnant state; establishment of the strong bond associated with successful nursing; decreased risk for breast cancer and ovarian cancer, especially if the lastborn child is breastfed; decreased risk for metabolic syndrome; Breastfeeding also provides an economic incentive as a free and plentiful source of excellent infant nutrition. The cost of formula and other necessary supplies easily exceeds $1000 to $1200 each year.

4. List 20 clinical signs indicating a malnourished state in an infant and/or child.

Persistent open fontanelles - not closing at the times when they should Thin, sparse, brittle hair; hair is easily plucked out Pale or dry conjunctiva Oral changes such as cheilosis (redness and swelling mouth and lips), angular fissures at the corners of the mouth Tooth decay, missing teeth, cavities, fluorosis (gray and black spots on teeth Spongy, receding gums that bleed easily Fissured or ridged nails; spoon shaped nails Xerosis (dry skin), follicular hyperkeratosis (sandpaper feeling to skin) Decreases subcutaneous fat and muscle wasting appearance Increased weight loss Poor weight gain Behavioral changes: Irritability, confusion, lethargy, fatigue, excessive crying Abdominal distention Hepatomegaly Splenomegaly Growth stunting edema - severe water retention in the tissues Poor immune function Rapid heart rate Elevated blood pressure maintains or begins losing weight child's linear growth slows or ceases head circumference levels off anemia pallor fatigue vulnerability to infections delayed healing behavior problems inactivity irritability poor academic performance, poor vocabulary perceptual difficulties

8. How would you manage a child with obesity?

Prevention of overweight and assertive treatment of children who are already overweight should be priorities for care. counseled on healthful nutrition and exercise; the primary goal of weight management is to normalize, not necessarily reduce weight. focus on slowing the rate of weight gain, thereby allowing children to grow into their weight. Restricting fat intake for infants is not recommended because of the rapid neurologic development occurring at this age. If the child is beyond a weight into which he or she will reasonably "grow," weight reduction becomes the treatment goal. misperceptions by parents may hinder treatment, especially if the intervention plan requires family lifestyle changes, and may need to be addressed by the provider as a part of treatment. Lifestyle Changes If a child's body is able to signal to the brain that it has reached satiety before the child overeats, and if the child responds to the body's cues of satiety, caloric intake will decrease. Research indicates that young infants are highly sensitive to satiety and stop eating when full, but it appears that this natural regulator can be overridden by overfeeding the infant or providing high-calorie foods that are quickly absorbed as glucose (e.g., juice or juice drinks) In essence, the child no longer knows when he or she is full—when the body has received enough calories. Parents should be encouraged to respond to their infant's cues of satiety by stopping the feeding. Preliminary research suggests that decreasing the protein content of formula in early infancy can bring children back into line with normal growth patterns Nutrient intake for infants must not be compromised, however. Breastfed infants tend to gain weight more slowly than formula-fed infants, and breastfeeding should be encouraged as a way to prevent overweight. Children must be monitored for height and weight on a regular basis, but progress should be measured by other parameters as well. Improved dietary habits; increased physical activity, fitness, and strength; and enhanced self-esteem are significant endpoints that should be acknowledged and praised by the family and health care team alike. Motivational interviewing may be a helpful strategy when working with adolescents and parents of overweight children. The National Association of Pediatric Nurse Practitioners (NAPNAP) Healthy Eating and Activity Together (HEAT) Initiative (2006) guidelines are consistent with recommendations for developing healthy eating habits and include: • Educate parents about: Children's growth patterns and nutritional needs Ways children communicate hunger and satiety Strategies for developing healthy eating habits Strategies to encourage physical activity in children Risk factors for overweight Early indicators of overweight • Implement behavioral change interventions including: Early intervention (in infancy if necessary) Family-centered treatment, with counseling regarding communication and eating habits Increased activity Decreased intake of high-fat, high-glycemic, and high-calorie foods Increased intake of fiber (AAP recommends 0.5 g/kg/day for children older than 2 years Appropriate portion sizes • Provide ongoing support to families In addition, depending on the child's age, baseline BMI, presence of medical complications, and weight status of parents, treatment can include either weight-loss or weight-maintenance strategies that focus on the following: • Modify diet to increase fruits and vegetables to five or more per day and eliminate sugared drinks • Decrease "screen time" to less than 2 hours per day • Remove television from child's bedroom (if present) • Emphasize "mindful viewing" of television; TV is never on without attention and thought, never as "background" • Exercise 1 hour or more per day • Eat a daily breakfast • Decrease meals eaten outside home • Have a family meal at least five or six times a week • Allow child to self-regulate meals; avoid being overly restrictive. This does not, however, mean the child can eat whatever he or she wants —the parent must provide healthful foods to choose from The Expert Committee on the Assessment, Prevention, and Treatment of Child and Adolescent Overweight and Obesity recommends these strategies in a staged management approach with active monitoring by the primary care provider and involvement of the entire family. If initial efforts are unsuccessful, more rigorous management that may include behavior modification, highly structured monitoring and control, multidisciplinary interventions, medication, or surgery is recommended. Overeating, overweight, and obesity are complex phenomena involving social cues and expectations and physiological dynamics, and their management requires that both the child and family change lifestyle patterns. It may be that a family-based behavior modification approach, using cognitive-behavioral and family therapy will be necessary in most cases for successful weight loss. When the entire family is involved, the overweight child has a much greater chance to normalize weight. Do not put child on a diet. Instead, gradually modify the entire family's eating habits. For example, serve fruit as a substitute for dessert, switch to nonfat or 1% milk, experiment with low-fat recipes and methods of food preparation, and use reduced-fat margarine, salad dressings, and other low-fat condiments. Serve nutritionally dense foods that reflect recommendations of MyPlate, including whole grains, fruits, vegetables, lean-protein foods, and low-fat dairy products. • Do not force children to clean their plates. They should eat only until they are full. • Serve age-appropriate portions (e.g., 1⁄4 to 1⁄3 adult portion for young children). • Schedule and enforce regular times for meals and snacks. Do not skip meals. Do not allow children to "graze" throughout the day. • Structure mealtimes to be a family time, eating, sharing, and enjoying food together. • Have low-calorie, nutritious snacks readily available, such as air- popped popcorn, pretzels, low-fat yogurt, frozen fruit juice bars, skim milk, low-sugar cereals, fresh fruit, and raw vegetables. • Do not have high-calorie snacks readily available (e.g., potato chips, cookies, cakes, pies, ice cream, candy, soda pop, and doughnuts). • Promote physical activity. Start slowly, with low-weight-bearing exercise. Set reasonable goals and celebrate achieving them. Make daily exercise a priority. Encourage family participation, individual exercise, and team sports and structured activities with peers as appropriate. • Limit television viewing to 1 to 2 hours a day or less. Replace television viewing time with family activities, hobbies, chores. Children who watch 4 or more hours of television per day are twice as likely as other children to become obese. Children are more sedentary when they watch television, and frequent food advertising is linked to increased snacking. • Praise and reward children for the progress they make in reaching nutrition, activity, physical fitness, self-esteem, or weight goals. • Emphasize the uniqueness of each child, pointing out special talents, abilities, and positive qualities. • Do not overly restrict children's diets or demand children eat when they are not hungry. This approach actually leads to overeating and subsequent overweight. Community Changes Individual and family interventions may not be sufficient to deal with the causes of obesity. If children cannot safely play outside, for example, it may be impossible for them to get the recommended 60 minutes of moderate to vigorous daily exercise they need. Community change is imperative to support individual and family efforts to lose weight. The CDC recommends community action in six different areas (CDC, 2009): • Increasing access to affordable healthy foods • Supporting healthy food choices • Promoting breastfeeding • Encouraging physical activity • Providing safe communities in which to exercise • Organizing at the grass roots to create and continue health-supportive change Primary care providers can provide community policymakers with the detailed recommendations presented in the CDC Guidebook, give them information about obesity as a public health problem, and support public policy that creates positive change. Medications Lifestyle changes should be the primary treatment for obesity in children and adolescents Medications should only be used after an intensive, formal trial of lifestyle change has proven ineffective and the child is excessively obese (>95th percentile), or overweight (>85th percentile) with comorbidities present Several medications are used to control weight in adults and adolescents. Orlistat (decreases fat absorption) is the only FDA-approved medication for pediatric use, for children 12 and older. Orlistat is available over the counter and by prescription, so providers should be sure to determine if the family or child is self-medicating. Sibutramine and several appetite suppressants (phentermine, rimonabant, and metformin) are used to treat obesity in adults. Metformin does not have FDA approval for use in treatment of obesity, but has been used experimentally. All these medications have potential side effects and it is recommended that, other than orlistat, they not be used with children and adolescents; fiber supplements (e.g., glucomannan) can be used to prevent side effects (e.g., fatty stools) of orlistat.

5. Discuss the components of parent education and counseling for the mother of an infant who is breastfeeding.

Recommendation Benefits of breast-feeding Contraindications Components of breast milk Positions for breast-feeding Frequency and duration of breast-feeding Pumping Collection and storage of breast milk Infant weight gain Urine and stool output Maternal nutrition during breast-feeding Safe and unsafe medications during breast-feeding Returning to work Breastfeeding issues and complications: sore nipples, severe engorgement, mastitis, thrush, poor weight gain, jaundice Weaning

Breastfeeding Part 3

Severe Engorgement: extremely full, sore, and swollen breasts, beyond normal fullness experience as milk comes in. Caused by milk stasis in breast from inadequate emptying. Clinical Findings: painful, hard, lumpy swollen breasts, usually warm to touch, nipples flattened by swelling, bruising or trauma to nipples and areolae. diff dx: bilateral mastitis mgmt: take a hot shower or wrap breasts with warm, wet compresses for 5-10 minutes before nursing, Disposable diapers can be wet with hot water and then wrapped around each breast and "tabbed" to hold them in place. Plastic liner holds heat in longer than washcloth or towel gently massage entire breast or use an electric pump with intermittent suction on minimal setting for several minutes after using wet heat manually express milk before feeding to soften areola and make it easier for infant to latch on properly nurse frequently and make certain that latch on and position are correct and audible swallowing is heard avoid long stretches bw feedings in early weeks as milk supply is being established. pump breasts if feeding will be missed. Mastitis: rarely seen, infection of breast that can occur anytime during lactation. occasionally identified during 3rd trimester. S. aureus, streptococci and Corynebacteria are most commonly associated. predisposing factors include: stress, fatigue, cracked nipples, plugged ducts, constricting, improperly fitting bras, inadequate emptying of breast, sudden weaning or a significant decrease in number of feedings, using a manual pump clinical findings: malaise, breast tenderness or pain, reddened, warm lump in any quadrant, sometimes associated with red streaking, flu-like sx, fever, chills, body aches. "flu" in breastfeeding woman is mastitis until proven otherwise. mgmt: empty breast. nurse frequently or if pain is severe, pump milk carefully from affected breast. breast milk is not infected and is fine for infant. use analgesics as necessary antibiotic tx is mainstay of tx. PO abx such as penicillinase-resistant penicillin or a cephalosporin that covers S. aureus. 10-14 days. Dicloxacillin often used, augmented and cefuroxime have been found to be effective with few adverse effects -oral Lactobacillus fermentum CECT5716 or L. salivarius CECT5713 probiotics isolated from human milk, as effective as abx therapy. Rest (extremely important) -do not wean abruptly bc of possibility of mastitis progressing into abscess -take warm showers or use warm wet compresses -increase fluids comp: abscess and septicemia Nipple Confusion: when infant is accustomed to nursing form a bottle and is introduced to the breast. when offered the breast, the babies use the same sucking pattern as with a bottle, which makes it difficult to obtain adequate nourishment and may continuer to maternal sore nipples. infants may cry fuss or push away with their arms during attempts to nurse. infants may have been given a bottle or pacifier during breastfeeding. unless absolutely necessary early bottle feeding and pacifier should be avoided in breastfeeding infant findings: ineffective suckling at breast, breast refusal, sore, red, or bruised maternal nipples diff dx: other causes of fussiness and refusal to feed mgmt: avoid all baby bottle nipples and pacifiers for first 4-6 weeks or until infant is breastfeeding correctly -retrain infant to suck correctly at breast by correct positioning, proper latch on technique, suck training to repattern tongue movements, supplementation via alternative methods -consult with lactation specialist -if supplements are medically indicated, give with eye dropper, spoon, syringe, or cup through 5 french feeding tube (attached to a 20 or 30ml syringe) taped to areola or breast. The end of the tubing protrudes slightly past the end of the nipple so that the tube, nipple and areola are in the infants mouth -use of a thin silicone nipple shield may help infant successfully latch on and suckle, esp with preterm infant and using nipple shields can encourage continued bfing. cleansing and drying both the shields and breast after feeding are important to prevent skin breakdown. comp: failure to thrive, hyperbilirubinemia, colic and crying, prolonged feedings, sore and cracked nipples, plugged ducts, mastitis, frustration Breast Milk Jaundice: late onset, elevated serum indirect bilirubin conctration with peak level occurring on or after 7-10 day of life in infant drinking adequate amount of breast milk with no other signs of liver abnormality exact cause unknown. enzyme may be present in some mothers' milk that inhibits the action of glucuronyl transferase and increases intestinal absorption of bilirubin. more common in Asian and Native Americans. Siblings with same mother are often affected. True is uncommon, less than 1 in 200 births. clinical findings: PE: healthy and thriving infant, adequate stooling and voiding, appropriate weight gain, appearance of elevated bilirubin levels bw 7 and 10 day of life, bilirubin peaks around day 10-15, persistence into 3 month of life diagnostic studies: serum bilirubin, urine and other cultures to r/o infection diff dx: pathological jaundice mgmt: continue being unless clinical signs of pathologic jaundice are observed. breast milk jaundice is not harmful thrush: oral candidiasis, in infant or found on nipple or areolae of nursing mother, both members should be treated. poor weight gain: 2 diff times, during newborn period initiation of bfing may not proceed normally and infant may actually continue to lose weight or gain very slowly. after newborn period, infants may gain weight more slowly than expected given normal parameters for age. -infrequent or inadequate feeding bc of poorly managed bfing or environmental or social circumstances in family system -inadequate milk production -infection -organic disease -physical anomaly that prevents good suckling or swallowing clinical findings: infant factors: -continued weight loss after 5-7 days old -failure to regain birthweight by 2-3 weeks old -failure to maintain an ongoing weight gain of 0.5-1oz per day -weight below the 3rd % for age (this finding can be a pattern over time or a sudden change) -lethargic, sleepy, inactive, unresponsive infant -newborn or young infant sleeping longer than 4 hours bw feedings, although 1 5hr stretch at night can be normal dry mucous membranes poor skin turgor technique factors: -ineffective latch on or suckling -short time at breast (infant is removed before nursing is finished, thus reducing access to hind milk and total consumption) -infant kept on a preset schedule despite cues for more feeding -infant given water between feedings to get through to next feeding -infant encouraged or allowed to sleep through the night before 8-12 weeks old -fewer than 8 feedings in 24 hours -infant fed in a distracting enviroment -in older infants, bfing offered after solids are given -infant in daycare setting that doesn't facilitate bfing maternal factors -does not initially respond to infants cues for feeding or doesn't recognize that waking is needed to establish feeding -hectic schedule with limited time for bfing -recent illness or significant weight loss -uses oral contraceptives or other hormones diff dx: pattern of slower but normal weight gain in healthy breastfed infants and failure to thrive mgmt: complete history, thorough assessment of techniques, provide instruction, encouragement, reinforcement for correct techniques, refer for tx of physical or organic causes be alert for any infant who has lost too much weight and is unable to feed with vigor at the breast; such infants require immediate infusion of calories for energy -use supplemental system at breast if supplementation is required -encourage and assure comp: developmental delay, poor bonding, severe dehydration early failure to establish bfing, some infants may appear to be in a septic state and require hospitalization for rehydration

8. Describe the components of basic breast feeding education.

Space - finding a quiet and private space and location to breast feed the infant Positions - knowing and understanding the principles of correct positioning for breast feeding and the different types of positions; correct latching by the infant Frequency and duration of feedings - After the first 24 hours, the infant should be breast fed 8 to 12 times per day (every 2 to 3 hours) for at least 20 to 45 minutes at each feeding Breastfeeding - Try to nurse on both sides of breasts at each feeding for approximately 15 minutes on each breast. Consider hand expressing or pumping a few drops of milk to soften the nipple if the breast is too firm and sore and tender for the baby to latch on. Signs of a healthy breast fed infant: active and alert state, contented and satisfied behavior after feedings, sufficient output of at least 6 wet diapers and several stools per day, good skin turgor and color, developmentally appropriate progress, and age-appropriate height and head circumference Additional community resources for breast feeding support and assistance

What are some concerns mothers may have about breastfeeding and which strategies may assist them in overcoming their difficulties?

What about the pain? - There shouldn't be any pain when breast feeding. Only mild nipple soreness and/or tenderness or dry cracked nipples. Pain is a warning sign that means something is wrong. To manage sore nipples, nurse from the least sore side first, use short frequent feedings, expose the nipples to air for short periods several times per day, and pump the affected breast if pain is too severe to allow nursing Is the baby getting enough milk? - Feed the baby when he or she is hungry which is evidence by signs of sucking, rooting, putting their hands to their mouths, and fussing. Crying is a late sign of hunger. In the first few days of life, newborn should be breastfed between 8 to 12 times per day and should have 1-3 soiled diapers within a 24 hour period. By day 3 the infant should have 4 or more wet diapers in 24 hours and stools should be 2 to 3 stools in 24 hours. At about 1 week of age, the newborn should feed every 1 to 3 hours in the daytime and every 3 hours at night with one longer 4 to 5 hour stretch between feedings. During this time the newborn should have about 6 to 8 wet diapers in a 24 hour period. What about returning to work - Provide education on pumping, storing, and feeding of breast milk, education on proper hygiene and cleansing of the breast pump, pumping times and breast accessibility What can I eat or what shouldn't I eat or drink when breast-feeding? - A minimum of 1800 calories per day that includes fruits, vegetables, whole grain breads and cereals, calcium-rich dairy products, and protein rich fish, meats, and legumes are a good source of nutritional food intake while breast feeding. Large amounts of caffeine from coffee, soda, or chocolate should be discouraged because caffeine is transmitted via breast milk to the infant and can cause jitteriness in the infant. Alcohol intake in the amount of 2 cans of beer, 8 ox of wine, or 2 to 2.5 oz of liquor can impair milk ejection reflex

What are the most common causes of obesity in children?

a complex relationship of genetics, environment, and the body's response to environmental factors the specific moderators of excess weight gain vary and the relationship among variables is complex. New discoveries of the factors (e.g., hormones, brown fat, microbes, brain activity) involved in the dynamics of satiety, insulin sensitivity, and weight regulation are being made daily. It may be that most obesity is a function of a genetic predisposition combined with environmental stimuli Rapid weight gain in infants from birth to 5 or 6 months old is a strong predictor of overweight in children and puts children at risk for subsequent obesity and metabolic syndrome. "Fat babies" are not necessarily healthy babies; prevention of overweight from birth and early intervention for children at risk for overweight is essential. A biological imbalance of hormones, peptides, proteins, and other factors may lead to obesity; Insulin and leptin are two major hormones that normally serve to control satiety and influence weight. Resistance to insulin and to leptin, seen in some racial and ethnic groups, and often found in obese individuals, may contribute to the body's failure to register satiety. chronic hyperinsulinemia may be the source of insulin and leptin resistance. Leptin normally stimulates the ventromedial hypothalamus (VMH), sending the message that the body has adequate energy stores. Insulin and leptin share the same "signaling cascade" in the VMH, however, and if insulin levels are high, leptin is prevented from signaling its message of satiety. Hyperinsulinemia thus prevents the message that the body is satiated from getting through; overeating to satisfy hunger can result. Hyperinsulinemia in children has three sources: genetics, epigenetics (small- and large-for-gestational-age infants experience hyperinsulinemia and insulin resistance), and environment. Environmental dynamics contributing to hyperinsulinemia are threefold: • Increased stress leads to increased cortisol production, which can lead to insulin resistance. • Decreased physical activity contributes to insulin resistance. • Diet, especially high levels of fructose and decreased fiber, leads to excess insulin secretion. "High-glycemic" foods (such as soda, sweetened juices, processed breads, pastries, and crackers) are more quickly converted to serum glucose, and stimulate a sharp rise in insulin production. With the high insulin level, glucose is moved quickly into cells, the extra insulin stays in the blood and the resulting hypoglycemia stimulates hormone release that further increases appetite. The end result is overeating and increased fat storage Increasing physical activity and changing diet (eating more low- glycemic foods, such as whole grains, vegetables, and fruits) can help decrease excess insulin production and restore the body's natural feedback system. people may be "addicted" to certain foods, genes and neural pathways characteristic of alcohol dependence may be shared by certain foods, especially sugars, carbohydrates, fats, and possibly processed salty foods Decreased physical activity results in decreased energy consumption and weight gain if dietary intake remains stable; whereas increased physical activity leads to weight loss. increased time spent on sedentary activities (e.g., "screen time"), many schools have discontinued physical education classes, that many children are driven to school rather than walking or riding bicycles, and that many neighborhoods are unsafe for outdoor play—all environmental factors that contribute to the problem of excess weight gain. AAP recommends no television for children younger than 2 years old and 1 to 2 hours per day for older children, about 63% of 0- to- 2-year-olds, 82% of 3- to 4-year-olds, and 78% of 5- to 6-year-olds watch television each day. Older children watch about 4.5 hours of television per day, and, with media multitasking, have approximately 10 hours and 45 minutes of media contact in a typical day. most children do not get the amount of exercise recommended by the Centers for Disease Control and Prevention (CDC). Changes in eating habits, rather than a decrease in physical activity may be more important. Watching television replaces active play but it also exposes children to snack-food advertising and increases the likelihood that children will overeat and eat more empty calories . Temperament may be a risk factor for obesity; in one study, 12- month-old male infants with shorter attention spans and female infants with greater soothability or negative reaction to food were more likely than their counterparts to be overweight at 6 years of age A number of environmental factors put children at risk for being overweight, including having obese parents, maternal smoking during pregnancy, bottle feeding, family stressors, and middle and low socioeconomic status. Research suggests that prenatal exposure to endocrine disruptors, such as bisphenol-A or estrogen, may predispose to overweight and obesity Psychosocial factors also contribute to the increased incidence of obesity, including family stressors, using food to regulate emotions or to cope with stress, overeating in response to inappropriate body image perceptions, social pressure to be thin, depression, and low self-esteem. Children who suffer neglect or abuse or have an overcontrolling parent may turn to food for comfort and solace, with overeating as a result.

Chap 11 Notes Part 1: Breastfeeding

containdications to breastfeeding: -infections and many drugs can be passed to infant via breast milk -contraindications are rare -herpetic lesions on nipples, areolas or breast -maternal diagnosis and treatment of cancer -maternal HIV -infant with galactosemia special consideration: -significant maternal or infant illness affecting the ability to feed -maternal illness such as TB, chickenpox, or hep B -invasive breast surgery, breast reduction where areola is removed and reattached -documented hx of milk supply problems characteristics of human milk components: colostrum: production begins at 20 weeks of gestation. pregnant women has small amt of yellow dc on her nipple or clothing. after delivery, production increases. thick rich yellowish fluid has fewer calories than mature milk and is lower in fat. rich in immunoglobulins esp IgA and other antibodies. higher in Na, Cl, protein, fat-soluble vitamins and cholesterol than mature milk, facilities the passage of meconium. Infants first immunization. meets all nutritional needs of a normal term newborn in the first few days of life. no supplementation is necessary. transitional milk: several days after delivery. more lactose, calories and fat and less total protein than colostrum mature milk: second week after delivery, provides 20kcal/oz. water: 90% of human milk, meets all the fluid needs of infant lipid content: 3.8%, contibutes to 30-55% of kilocalories in human milk. fat content is higher at the end of feeding (hind milk) than at beginning (foremilk). breastfed infants have higher plasma cholesterol levels than do formula fed infants, however breastfeeding has protective effect against cardiovascular disease. DHA has beneficial effect on infant's neurobehavioral function, esp preterm infants. if infants are not breastfed, formula should be supplemented with DHA. protein: 0.9% of human milk. 60-70% of protein is whey and 30-40% is casein. carbohydrates: lactose, essential for growth of human infant, enhances absorption of calcium. vitamins and minerals: more than adequate amounts of A, E, K C, B1, B2, and B6. the level of vit D intake may not be adequate in breastfed infants who lack exposure to sunlight. 30 min per week of unprotected exposure to the sun while dressed in a diaper only or 2 hours per week clothes (as long as head is not covered) provides adequate vit D for a Caucasian breastfed infant. iron is found in low levels in human milk, iron absorption is highly efficient, with 49% of the available iron absorbed in contrast to 4% from formula. actual production of breast milk is triggered by the fall in progesterone concentration after both of the baby. Placental retention inhibits milk production. suckling by the infant is essential to establish and maintain lactation. the amt of milk produced depends on stimulation of the breast, removal of milk, and release of hormone. supply and demand. suckling stimulates hypothalamus to decreases prolactin-inhibiting factor and permits release of of prolactin by the anterior pituatiry, which leads to rise in the level of prolactin. directly proportional to the level of suckling by infant and more important to initiating than maintaining lactation. hypothalamus also stimulates synthesis and release of oxytocin by posterior pituitary. oxytocin reacts with receptors in the myoepithelial cells of the milk ducts to initiate a contracting action that results in forcing milk down the ducts. increases milk pressure - letdown reflex or milk ejection reflex. oxytocin also aids in maternal uterine involution mammary gland increase in size and rapid growth of lobuloalveolar tissue. alveoli sites of milk production and combine in numbers of 10-100 to form lobule: 20-40 lobule combine into lobes and 15-25 lobes empty into a lactiferous duct. insufficient glandular tissues - absence of breast changes associated with pregnancy, a unilaterally underdeveloped breast or conical shaped breasts nipple may be everted (protuberant from the breast), flat or inverted. the pinch test may be needed to identify nipples that invert with tactile stimulation to arela. place thumb and forefinger on opposite sides of areola about 1-1.5 inches back from nipple-areolar junction. gently compress as though bringing the two fingers together. prenatal assessment; maternal expectations for breastfeeding, knowledge about breastfeeding, techniques for getting off to a good start, identification of any contraindications. nipple evaluation. early postpartum: transition to breastfeeding, close observation of feeding, signs of progress for successful breastfeeding. maternal hx: -overall health, chronic illnesses or allergies -previous breastfeeding experience -cultural expectations -routine use of OTC, prescribed, recreational or street drugs, tobacco, alcohol, herbal supplements -surgery esp to breast or thoracic -nutiritonal status -family and community support -preg hx, complications or need for meds -L&D hx, medications, procedures or complications infant hx: -overall health -congential conditions cardiac resp or orofacial -trauma or complications during delivery -medications received during L&D or in early postpartum period -activities or procedures including circumcision, use of bilirubin lights, or use of bottle, cup or tube feeding -gestational age -early response to feeding attempt maternal exam: -type of nipple -presence of surgical scars on breast or thoracic area -nipple brusiing or bleeding infant exam: -oral-motor skills and structure -finger inserted beyond gum line to soft palaate - infant should be able to suck smoothly and evenly in a wave like motion of tongue as finger is drawn in for suckling. -hard and soft palates intact without palpable clefts or submucosal clefts -extend tongue over lower gum with no evidence of tight frenulum -state of alertness and readiness for feeding positioning: infant should be positioned face on at nipple height so that no head turning or tilting is required. nipple should be directed toward center of infants mouth -infant should be lying on side not back -infant body in good alignment - straight line from ear to shoulder to hips -intants top and bottom lips should be flanged out -infents tongue should extend forward over lower gumline and cup around nipple and areola -quiet feedings - no clicking or popping, audible swallowing such as plug or air blowing out babies nose should be heard cradle position: mother sitting upright or leaning slightly forward with her feet on floor or stool or her legs crossed in front of her. infant is held with mouth at nipple height and mother and infant are in a tummy to tummy arrangement. mother uses freehand to support the breast while keeping fingers well back found areola so she doesn't interfere with latch on. don't pinch breast tissue. regular cradle: baby head is supported in the crook of elbow on same side as breast being suckled. cross cradle: the opposite hand supports the babies head and shoulders - works well for premature infant after positioning, mother should touch babys lower lip with nipple to stimulate mouth opening, mother should bring baby close that lips come up and over the nipple and back on areolar tissue and nipple rests on top of baby tongue. mother can check lips for flanged, open placement. tip of nose touching breast. if baby appears to be pushed into breast, infants butt should be brought closer to tummy. can usually remove hand that was supporting breast and use it to cradle baby in arms. relax back. side lying: when mother in uncomfortable sitting up or wishes to nap or sleep with baby. early days - not easy to use bc can't see breast and nipple. mother lies on side, cradles infant in elbow, supports infants back and neck. arrange one or two pillows under mothers head and shoulders and rolled towel or blanket along infants back to keep infant in side lying position. prevents pressure on episiotomy or abdominal incisions. football hold: infant is supported off to side of bother. often used by mother who had c-section bc it doesn't require that infant be positioned along her abdomen or by mother of multiples when she would like to feed two babies at once. mothers with flat or inverted nipples are able to achieve latch on more easily in this position. 1-2 firm pillows place at mothers side to help support infant. baby is in side lying position and flexed at hip with buttocks back against chair or couch. esp helpful for mothers with heavy breast. early feedings: first BF should take place as soon after birth as possible. full term neonates often have an alert period for 30-60 min after delivery that is ideal for first feeding practice. infant foes into deep sleep after initial alertness and is difficult to wake for feeding practice. parents instructed to watch for any awakening behavior, opening eyes or movement in bed. newborns won't cry. full term infants born with stores of fluid and energy to carry them through early transition. not necessary to provide any supplement, including water, to healthy full term neonate. feeding with rubber or silcone nipple may lead to nipple confusion. the infant should be encouraged to go to each breast for at least 10-15 minutes of active suckling, some may spend up to 30 minutes. an infant who falls sleep in 5 min should be stimulated to continue active suckling. a mother is unlikely to get sore or cracked nipple when her infant is latched on correctly. frequency and duration: after first 24 hours the infant should go to the breast 8-12 times (or every 2-3 hours) in 24 hours for approximately 20-45 minutes at each feeding. parents need to be alert for an infant who sleeps for mother 4 hours at a time or who goes to sleep at the breast in 5 minutes. urine and stool output guidelines urine: first 2 days of life, infant may urinate only 1-3 times in 24h. By day 3, the infant should have 4 or more wet diapers in 24 hours and by day 4 4-6 wet diapers per 24 hours. Over time, the infant should have a minimum of 6-8 wet diapers in a 24 hours period. urine should b light yellow with no strong odor. diary of wet diapers can aid in accurate assessment of progress. stool: first 24 hours after delivery, baby should have at least one meconium stool followed by another on the 2nd day of life. day 3 - stools make transition to loose, yellow, seedy stools of breastfeeding, infant should have 2-3 stools in 24 hrs. may increase first few weeks of life. some stool with every feeding. first month - some infants stool less frequently and may go several days to a week between stools. infrequent stopping, esp in first month, should stimulate a feeding hx and weight check to make sure infant is getting enough breast milk. pumping: if mother and infant are separated for more than 1 or 2 feedings, pumping should be part of the plan to assist with milk production. if separated right after brith, pumping should being asap within first 24 hours. mother should pump 6-8 times in 24 hours for 15 minutes if she is using double pump or 10 min per breast if sing pump. save even the smallest amounts of colostrum to give to infant. hospital grade piston style pump that permits both breasts at same time is ideal. collection and storage of milk: wash hands will before pumping, use clean containers for collection and storage. pump parts should be thoroughly cleaned after each use. milk stored in clean plastic bottles or disposable milk bags. store in small amounts so that only amount that is needed is defrosted and used. milk that has been defrosted and not used within 24hrs should be discarded. refrigerate asap and can be stored for up to 8 days. stores on blue ice in cooler for 24 hours. if not used in that time, should be frozen. can be freezes for 3 months or 12 months in a freezer where 0 F is maintained. label bags/bottles with date of collection. placed in ice or on blue ice unit when transporting.

5. What are the differential diagnoses for an infant/child presenting with obesity?

hypothyroidism, polycystic ovary disease, Down syndrome, and Prader-Willi syndrome

6. Discuss the management for each of the differential diagnoses.

hypothyroidism: treated with replacement doses of levothyroxine sodium. Ongoing laboratory monitoring and follow-up are age-dependent. Because normal thyroid function in the first 3 years of life is critical for normal cognitive development, more frequent monitoring is necessary for infants and young children. In general, an elevated TSH (in primary hypothyroidism) or depression of the free T4 (in central hypothyroidism) indicates the need to increase the dose of medication. Following an adjustment in thyroid hormone replacement, thyroid function testing should be repeated in 4 to 6 weeks to be sure the new dose is adequate. Age - LThyroxine (mcg/kg/day) 0-6 months: 10-15 6-12 months: 6-8 1-5 years: 5-6 6-12 years: 4-5 >12 years: 2-3 PCOS: not desiring current fertility with hyperandrogenic features alone: 1st oral contraceptive pill or antiandrogen adjunct metformin, mechanical hair removal or topical therapy 2nd: antiandrogen plus oral contraceptive pill 3rd: long-acting GnRH analog plus oral contraceptive pill with oligoamenorrhea alone 1st: weight loss 2nd: oral contraceptive pill 2nd: metformin 3rd: cyclic progestin with hyperandrogenic features plus oligoamenorrhea 1st: weight loss plus oral contraceptive pill adjunct: metformin or mechanical hair removal or topical therapy 2nd: antiandrogen plus oral contraceptive pill 3rd: long-acting GnRH analog plus oral contraceptive pill Down syndrome: Early intervention begins in infancy and continues throughout childhood. Education in integrated classrooms in a neighborhood school has been shown to be successful. Immunizations are important because these children are more susceptible to infections. Cardiac care, hearing screening, growth monitoring, and prevention of overweight are important roles for providers. Thyroid screening; gastrointestinal care for disorders such as pyloric stenosis, duodenal atresia, Hirschsprung disease, or imperforate anus; atlantoaxial instability screening for those involved in sports; and awareness that leukemia may emerge as a problem are further issues that the provider should monitor . Thyroid screening from 1 to 18 years has led to increased rates of thyroid disease management in these children, but in some regions of the U.S. only 14% of children are being screened despite the fact that thyroid screening is part of the guidelines for care of children with DS Prader-Willi: monitoring and management of comorbid conditions include sleep apnea, diabetes mellitus, and gastric distension and rupture. Other comorbid conditions associated with obesity are common. treatment with growth hormone (GH) in all children and adolescents with PWS who have clinical evidence of growth failure. GH therapy improves linear growth and also body composition, including fat-free mass and bone density abnormalities. Contraindications include severe obesity, severe sleep apnea, or respiratory compromise, as there may be an increased risk of death in these patients. Patients should be closely monitored for the development of respiratory obstruction, particularly during the first few months of GH treatment. ●The optimal duration of GH treatment has not been established. The most rapid improvements are seen during the first 12 months of therapy, and more modest improvements are seen for up to five years of treatment if sufficient doses of GH are given. ●Management of feeding and obesity is a critical part of care for patients with PWS. We recommend designing a highly structured living environment in which access to food is strictly limited through close supervision and physical barriers ●No pharmacological agent, including phentermine, topiramate, or SSRIs, has been shown to be helpful in controlling appetite or binge eating and we suggest NOT using these agents for this purpose (Grade 2C). Psychotropic drugs are often used for behavior control. ●Weight loss surgery for patients with PWS has been reported, but not well-studied. There are concerns about both efficacy and safety of the procedure in these patients. Until better information is available, we suggest NOT performing weight loss surgery for patients with PWS unless it is in the context of a disease-specific research protocol (Grade 2C). (See 'Surgical weight loss procedures' above.)

Breastfeeding Part 2

infant weight gain normal newborn infants lose 5-8% of their birthweight in the first few days of life. once maternal milk volume increases, infant begins to gain weight in the range of 0.5-1oz per day or 4-7 oz per week. Most breastfed infants have regained their birth weight by 2 weeks. One criterion for failure to thrive is lack of return to birth weight by 3 weeks. Breastfed infants usually double their birth weight by 5-6 months old and triple it by 1 year old. characteristics of a healthy breastfed infant include: -active and alert state -developmentally appropriate progress -age-appropriate height and HC -good skin turgor and color -sufficient output of at least 6 wet diapers per day -contented and satisfied behavior after feeding Growth Spurts when baby's growth demands exceed the breast milk supply at that moment for 2-4 days the infant seems to be hungry all the time and demands to be fed more frequently. increase the number of feeding because increased stimulation of the breast will increase milk production to the amount needed. once the level of milk production has risen, the infant returns to the normal feeding pattern. supplementation can lead to a decrease in milk production. growth spurts occur every 3-4 weeks weaning: natural process typically occurs as other foods become a part of the infant's diet and the infant begins to participate in self-feeding. ideal time for weaning depends on: beliefs and desires of individual family members, developmental readiness of the infant, nutritional replacements for breast milk, and social and environmental issues affecting the decision implement it gradually, breast pump to gradually decrease milk production and prevent breast engorgement, blocked ducts, and discomfort. Pump when uncomfortable and to pump only to comfort, not to empty. factors associated with early weaning include: young mothers, low socioeconomic status, low maternal education, maternal smoking, formula feeding or short duration of breastfeeding sessions, lack of information or support from health professionals early to return to work, lack of support from family, advice from other female family members to wean, and being from a non-hispanic black cultural group can influence intro of solids or weaning earlier than recommended maternal nutritional needs during breastfeeding: -a minimum of 1800 calories -an additional 500 calories more than the nonpregnant diet -generous intake of fruits and vegetables, whole grain breads and cereals, calcium-rich dairy products, and protein-rich meats, fish, legumes -rich sources of calcium, zinc, folate, magnesium, and vitamin B6 -culturally appropriate foods -supplementation with calcium or prenatal vitamins or both only if diet is poor adequate fluid intake: maternal urine that is light yellow and has no strong odor. even with a diet that is adequate in nutrients and calories, a gradual maternal weight loss of 1-2lbs per month usually occurs. breastfeeding is the ideal way for a mother to return to her pre pregnancy weight exclude or decrease foods from diet if particular food bothers infant or infant appears to be allergic to it. for infants with colic, it might be helpful to reduce allergenic foods (cow's milk, eggs, peanuts, tree nuts, soy, fish, wheat) in mothers diet. intake of alcohol more than 0.5g/kg of maternal body weight (2 cans of beer, 8 oz of wine, 2-2.5 oz liquor) can impair the milk ejection reflex. The occasional use of small amounts of alcohol need not be avoided, but regular use should be discouraged. large amounts of caffeine from coffee, soda or chocolate should be discouraged bc caffeine is transmitted via breast milk to infant and can be associated with jitteriness in the infant and may have a negative effect on the iron content of breast milk. 1-2 cups of coffee per day should pose no problem returning to work: the ideal work environment provides: -breaks or lunchtime (or both) in which the mother can pump or go to infant -a private, convenient location for pumping with access to a sink for washing up and a refrigerator for storage -supportive colleagues and supervisors before delivery: discuss plans with employer before maternity leave. provide employer with info to help in planning. discuss options with other employees have continue to breastfeed after returning to work. gain support of coworkers. investigate pumps including rental or purchase. identify a place to pump and store breast milk at work. during maternity leave: practice method of breast milk expression that will be used at work. begin freezing milk, introduce the bottle after breastfeeding is well established (around 3-4 weeks) after return to work: if available use on-site or nearby childcare, so you can go to infant during the day. ask employer if caregiver for child may bring infant on site once a day to nurse. if possible arrange work hours to maximize time to nurse infant (arrive at work at 830 instead of 8). have a picture of your baby at the pump. plan on 15-30 minutes to complete pumping. wear clothes for easy access to breasts and to hide leaks. feeding breast milk: warm or thaw milk in warm water. do not use microwave because milk heats unevenly and presents a risk for burns. refrigerate thawed milk for no more than 24 hours; do not refreeze. do not add milk to a bottle that has already been used. -wash hands before and after pumping. rinse pump parts with cool water, then was with dish detergent and rinse well after each use. 24 states including DC and PR currently have laws specifically related to work and breastfeeding. Medications for Breastfeeding Mothers -give drugs that are normally safe for infants or have been tested in infants -avoid long acting forms of a drug -schedule feeding at times when the drug level is lowest. often immediately after taking drug is safest time -observe infant for changes in feeding pattern, fussiness, vomiting or diarrhea, or rash -consider all appropriate options and select the drug with lowest level in breast milk -avoid drugs that inhibit prolactin release, estrogen, antihistamines, and ergot compounds -be cautious about the use of herbal preparations flat or inverted nipples: make it more difficult for infant to latch on in the early days bc it is harder to pull nipple into mouth for suckling. as baby continues to breastfeed, nipple tissue elongates; with time problem becomes less severe and successful breastfeeding is possible. flat nipples do not change over time, but infant develops style to latch on successfully. adhesions cause retraction or inversion. flat nipples found in women with larger breasts. prenatal: if pt is not at risk for preterm labor, breast shells can be used during third trimester for inverted nipples. plastic dome shaped devices with small holes for ventilation, an opening in the portion that lies against skin fits over nipple and gentle suction during use helps stretch the nipple tissue. helps stretch out adhesions. post partum: provider should stay with mother during early feeding attempts. football hold position and have mother lean slightly forward as baby latches on. -wear breast shells between feedings, manually pull or roll the nipple immediately before latch on, use a breast pump for 1-2 min before latch on, put a cold cloth or ice on nipple for a few seconds before latch in, avoid pacifiers and bottle nipples until infant is 4-6 weeks old. if supplementation is medically indicated, use syringe, dropper, feeding tube or supplemental nutrition system. complications: frustration, loss of self-confidence, inadequate infant nutrition and its sequelae, severe maternal engorgement, plugged ducts, or mastitis, discontinued breastfeeding sore nipples: pain caused by irritation or trauma to nipples and areola, breakdown in skin integrity. caused by: improper latch-on and positioning at breast, prolonged negative pressure, inappropriate suction release from the breast, use of or sensitivity to nipple creams and oils, incorrect use of breastfeeding supplies (pumps, shells, shields), thrust (candidiasis), leaking nipple that are not properly air-dried clinical findings: tender, bruised, raw, cracked, bleeding, blistered, discolored, swollen, or traumatized mild tenderness is sometimes described by new mothers as they are getting used to infants suckling other diffs: breast or nipple trauma, thrush, mastitis, access, milk plugs at nipple mores management: assess BFing at early feeding. prevent problem by demonstrating and reinforcing proper latch on technique and positioning. counsel mothers to seek early help for more than mild tenderness. nipples can be damaged by constant high negative pressure and do not toughen up as breastfeeding progresses. cracking and bleeding are not normal. rub a few drops of colostrum or hind milk onto the nipples and areola after every feeding and let is air dry expose nipples to ear for short periods several times a day use breast shells to prevent bra or clothing from rubbing against nipples nurse from least sore side use short frequent feedings pump affect breast if pain to see severe to allow nursing use mild analgesics as necessary refer to lactation specialist as approp