Unit 4
3 year milestones
- Copies adults and friends - Shows affection for friends without prompting - Takes turns in games video icon - Shows concern for crying friend Understands the idea of "mine" and "his" or "hers" - Shows a wide range of emotions - Separates easily from mom and dad - May get upset with major changes in routine - Dresses and undresses self - Follows instructions with 2 or 3 steps - Can name most familiar things - Understands words like "in," "on," and "under" - Says first name, age, and sex - Names a friend - Says words like "I," "me," "we," and "you" and some plurals (cars, dogs, cats) - Talks well enough for strangers to understand most of the time - Carries on a conversation using 2 to 3 sentences - Can work toys with buttons, levers, and moving parts - Plays make-believe with dolls, animals, and people - Does puzzles with 3 or 4 pieces - Understands what "two" means - Copies a circle with pencil or crayon - Turns book pages one at a time - Builds towers of more than 6 blocks - Screws and unscrews jar lids or turns door handle - Climbs well - Runs easily - Pedals a tricycle (3-wheel bike) - Walks up and down stairs, one foot on each step
2 year milestones
- Copies others, especially adults and older children - Gets excited when with other children - Shows more and more independence - Shows defiant behavior (doing what he has been told not to) - Plays mainly beside other children - Points to things or pictures when they are named - Knows names of familiar people and body parts - Says sentences with 2 to 4 words - Follows simple instructions - Repeats words overheard in conversation - Points to things in a book - Finds things even when hidden under two or three covers - Begins to sort shapes and colors - Completes sentences and rhymes in familiar books - Plays simple make-believe games - Builds towers of 4 or more blocks - Might use one hand more than the other - Follows two-step instructions such as "Pick up your shoes and put them in the closet." - Names items in a picture book such as a cat, bird, or dog - Stands on tiptoe - Kicks a ball - Begins to run - Climbs onto and down from furniture without help - Walks up and down stairs holding on - Throws ball overhand - Makes or copies straight lines and circles
4 year milestones
- Enjoys doing new things - Plays "Mom" and "Dad" - Is more and more creative with make-believe play - Would rather play with other children than by himself - Cooperates with other children - Often can't tell what's real and what's make-believe - Talks about what she likes and what she is interested in - Knows some basic rules of grammar, such as correctly using "he" and "she" - Sings a song or says a poem from memory - Tells stories - Can say first and last name - Names some colors and some numbers - Understands the idea of counting - Starts to understand time - Remembers parts of a story - Understands the idea of "same" and "different" - Draws a person with 2 to 4 body parts - Uses scissors - Starts to copy some capital letters - Plays board or card games - Tells you what he thinks is going to happen next in a book - Hops and stands on one foot up to 2 seconds - Catches a bounced ball most of the time - Pours, cuts with supervision, and mashes own food
1 year milestones
- Is shy or nervous with strangers - Cries when mom or dad leaves - Has favorite things and people - Shows fear in some situations - Hands you a book when he wants to hear a story - Repeats sounds or actions to get attention - Puts out arm or leg to help with dressing - Plays games such as "peek-a-boo" and "pat-a-cake" - Responds to simple spoken requests - Uses simple gestures, like shaking head "no" or waving "bye-bye" - Makes sounds with changes in tone (sounds more like speech) - Says "mama" and "dada" and exclamations like "uh-oh!" - Tries to say words you say - Explores things in different ways, like shaking, banging, throwing - Finds hidden things easily - Looks at the right picture or thing when it's named - Copies gestures - Starts to use things correctly - Bangs two things together - Puts things in a container, takes things out of a container - Lets things go without help - Pokes with index (pointer) finger - Follows simple directions like "pick up the toy" - Gets to a sitting position without help - Pulls up to stand, walks holding on to furniture ("cruising") - May take a few steps without holding on - May stand alone
special nutrition
- benefit of human milk for preterm infants - provides different quality and quantity of proteins - lipid profile (cholesterol, DHA, ARA) - carbs designed for human infants - antioxidants - other bioactive factors
appropriate for gestational age (AGA)
- weight at birth falls between 5 lb 12 oz (2.5kg) and 8lb 12oz (4kg) - average is around 7lbs
large for gestational age (LGA)
- weight at birth is above 90th percentile - plump extremities, torso, and full cheeks - much more glycogen at birth than SGA, but can still be hypoglycemic (mothers usually diabetic) - polycythemia may also be present
There are many disagreements on whether or not preterm infants should grow rapidly in the first few months of life or not. Even though it seems that the faster the baby gains weight during the first few months and the quicker the "catch-up" growth the faster the preterm infant will become healthy, the data on this topic may suggest otherwise. From the chart providing "bone mineral content catch-up by 2 yr", it appears that if the baby's growth and weight gain is more gradual at the beginning instead of rapid, the weight and height will meet or exceed that of a formula fed preterm infant. Data from "Effect of randomly assigned dietary supplement on growth at 5 years" also shows similar findings. If you only look at the first few months of life, it does look like a human milk fed preterm is growing insufficiently compared to a formula fed preterm, but if you look beyond to ages 2 or 5 years, you can see that the preterm does eventually catch-up to other babies of similar ages in a healthy way. In addition to this data, it is suggested that rapid catch-up growth in early infancy may have metabolic programming effects that increase the long-term risk of obesity, insulin resistance, diabetes, hypertension, CVD, and cerebrovascular disease.
Explain whether or not premature infants need to grow rapidly in the first few months of life in order to achieve adequate anthropometric measures and bone mineralization later in life. Back up your explanation with data.
- nutritional screening assessment 1 week and 4-6 weeks after discharge - if infant growing slowly or assessment is abnormal, provide nutritional supplementation - continue breastfeeding with the addition of the supplement - continue to monitor
how is the nutritional status of the premature infant monitored?
- fatigue - low tolerance of volume - disorganized feeding
what are some challenges in feeding VLBW and ELBW infants?
- choking hazards: items that have a shape and/or consistency that may cause them to become lodged in the trachea, such as nuts, grapes, raw carrot - honey: botulism spores that can harm baby's immature digestive system
what are some foods to avoid when introducing solids to a baby?
1. families of infants with special health care needs should be considered - emotional impact of having a sick newborn may be overwhelming to parents - healthcare providers must be sensitive to parents' emotional needs 2. severe preterm birth survival rate is about ~90% - nutrition support is generally required - high metabolic rates
what are some nutritional concerns in infants with special health care needs?
- spina bifida - down syndrome - diseases with slower metabolic rate
what are some reasons why the energy needs may be decreased for premature infants?
- sustained pattern of weight gain of sufficient duration - competent oral feeding (breast or bottle) - nutritional risks assessed and treated - ability to maintain body temperature - mature cardiopulmonary function - medical conditions ID and treated - screening completed (metabolic, hearing and eyes, immunizations) - parents and home environment assessed as capable of safe and adequate infant care - appropriate follow-up arranged
what are the criteria for hospital discharge of the high risk infant?
- meta-analysis concluded that formulas with higher energy and protein content had limited benefits for growth - lack of data on what to feed the preterm infant after discharge - how fast catch-up growth should occur is unknown - need more information regarding breastfed infants
what are the dilemmas and lack of knowledge related to post-discharge nutrition?
- AAP suggests 120 cal/kg for preterm infants - the european society for gastroenterology and nutrition gives a caloric range of 95- 165 cal/kg - recovering infants may need as much as 180 cal/kg
what are the energy/calorie needs for premature infants?
- provide up to 55% calories from fat - low-fat diet rarely required - essential FAs and DHA/AA are important
what are the fat needs for premature infants?
- hydrolyzed protein or single amino acid formulas - specific amino acid formulas such as for PKU - 3-3.5 g/kg required for preterm infants
what are the protein needs for premature infants?
- advances in health care have reduced infant mortality - advances in neonatal health care have increased survival of infants who were preterm, low birth weight and/or with chronic conditions - result is that there are more infants requiring specialized nutritional services - improved survival: weight at 50% survival
why is the age of viability getting younger?
jaundice
yellowing of the skin and the whites of the eyes caused by an accumulation of bile pigment (bilirubin) in the blood
- has doubled birth weight - is no longer satisfied with breast milk or formula - wants to eat more frequently - sits up and holds head up - drools when hungry - takes in interest in what you are eating
what are signals a baby is ready for solids?
- host defense - GI development - special nutrition - neurodevelopmental outcomes - physically and psychologically healthier mother - economic and enivronmental
what are some benefits of human milk for preterm infants?
- difficulty breathing - infections - temp regulation - fever - recovery from surgery
what are some reasons why the energy needs may be increased for premature infants?
- preventing illness - maintaining health - treating conditions in infancy
what are some roles nutrition has for infants with special health care needs?
- reduced permeability faster - induces lactase activity - multiple factors to stimulate growth, motility, and maturation of the intestine - human milk empties from the stomach faster than artificial milks - less residuals and faster realization of full enteral feedings
what are some ways in which human milk helps GI development?
- familial support - community support (WIC) - proper breastfeeding education and equipment
what are some ways to support the breastfeeding mother-baby dyad post-discharge?
- inadequate nutrients to support in utero growth standard - significant decreases in protein and Na content over first month - Ca. P, and Vit. D content inadequate to support in utero bone mineralization standard - fortified human milk and preterm formulas give consistently faster growth parameters
what are the concerns around using human milk for premature infants in the hospital specifically?
1. availability: - establishing and maintaining maternal milk supply to discharge and beyond 2. restricted milk intake: - limits nutritional intake 3. nutritional: - insufficient proline, Ca, P, Na, & vitamins - variability of composition (especially fat) - loss of nutrients due to storage and feeding 4. infectious: - bacterial contamination during expression, storage, & feeding - viral transmission (CMV and HIV)
what are the concerns around using human milk for premature infants?
- ten guiding principles - evidence based - pan american health organization - world health organization - similar document for non-breastfed child
what are the guiding principles for complementary feeding of the breastfed child?
- pre-discharging rooming in - individualized plan for transition to full breastfeeding (mother's goals, social & financial concerns) - equipment (breast pump, home scale,etc.) - outpatient lactation follow-up and support (support groups, lactation, RD, WIC)
what are the steps of breastfeeding discharge planning for high risk infants?
- pre-growth nutritional assessment (growth and lab) - mother-infant dyad breastfeeding assessment - cardiorespiratory stability - adequate volume is transferred in a reasonable time - nutritional follow-up plan (primary MD, lactation, RD)
what are the steps of nutrition discharge planning for high risk infants?
- human-milk - human-milk fortifier - preterm infant formulas (vary in caloric content, MCT oil, whey protein)
what are the various types of nutrition that premature infants could receive?
- any milk not taken at the breast could be fortified - single nutrient supplement not ideal - human milk fortifier not practical or appropriate for most infants - enriched formula or preterm formula - term formula not indicated
what are the various ways in which human milk can be fortified?
- may need additional vitamins and minerals to support catch-up growth or during recovery from illness - human-milk fortifiers provide additional calories and nutrients - preterm infant formulas may have higher amounts of vitamins and minerals
what are the vitamin/mineral needs for premature infants?
parenteral and enteral feeding
what are two ways preterm infants are fed by nutrition support?
Based on the data provided in graphs, human milk seems to have overall better health outcomes compared to formula. The data shows that human milk has a better impact on upper respiratory symptoms and infectious morbidity in preterm infants compared to formula.
what does the data related to human milk and health outcomes of premature infants say?
- infants with an appropriate weight for postconceptional age should be breastfed when possible - infants with subnormal weight for postconceptional age at discharge should have fortified human milk - at least until 40 weeks corrected age (probably until 52 weeks CA)
when should a breastfed infant be fed fortified human milk or special formula post-discharge?
- infants with an appropriate weight for postconceptional age should receive standard infant formula with LCPUFA - infants with subnormal weight for postconceptional age at discharge should have a special post-discharge formula with LCPUFA - at least until 40 weeks corrected age (probably until 52 weeks CA)
when should a formula fed infant be fed fortified human milk or special formula post-discharge?
- medium-chain triglycerides (MCT) are beneficial to VLBW and ELBW infants because of low pancreatic and liver enzymes - essential fatty acids and DHA and AA are important
which types of fats would be most beneficial to feed preterm infants?
moro reflex
- aka the "startle reflex" - reflex that is easily elicited in a newborn by pulling up gently on the arms and then suddenly letting go - the infant will extend the fingers and arms out and around and then cry - this reflex is produced by the suddenness of the stimulus, not the distance of the fall - if this reflex is absent, this is a concern (brachial plexus or upper extremity injury or underlying CNS pathology should be considered)
6 month milestones
- Knows familiar faces and begins to know if someone is a stranger - Likes to play with others, especially parents - Responds to other people's emotions and often seems happy - Likes to look at self in a mirror - Responds to sounds by making sounds - Strings vowels together when babbling ("ah," "eh," "oh") and likes taking turns with parent while making sounds - Responds to own name - Makes sounds to show joy and displeasure - Begins to say consonant sounds (jabbering with "m," "b") - Looks around at things nearby - Brings things to mouth - Shows curiosity about things and tries to get things that are out of reach - Begins to pass things from one hand to the other - Rolls over in both directions (front to back, back to front) - Begins to sit without support - When standing, supports weight on legs and might bounce - Rocks back and forth, sometimes crawling backward before moving forward
18 month milestones
- Likes to hand things to others as play - May have temper tantrums - May be afraid of strangers - Shows affection to familiar people - Plays simple pretend, such as feeding a doll - May cling to caregivers in new situations - Points to show others something interesting - Explores alone but with parent close by - Says several single words - Says and shakes head "no" - Points to show someone what he wants - Knows what ordinary things are for - Points to get the attention of others - Shows interest in a doll or stuffed animal by pretending to feed - Points to one body part - Scribbles on his own - Can follow 1-step verbal commands without any gestures - Walks alone - May walk up steps and run - Pulls toys while walking - Can help undress herself - Drinks from a cup - Eats with a spoon
5 year milestones
- Wants to please friends - Wants to be like friends - More likely to agree with rules - Likes to sing, dance, and act - Is aware of gender - Can tell what's real and what's make-believe - Shows more independence - Is sometimes demanding and sometimes very cooperative - Speaks very clearly - Tells a simple story using full sentences - Uses future tense - Says name and address - Counts 10 or more things - Can draw a person with at least 6 body parts - Can print some letters or numbers video icon - Copies a triangle and other geometric shapes - Knows about things used every day, like money and food - Stands on one foot for 10 seconds or longer - Hops; may be able to skip - Can do a somersault - Uses a fork and spoon and sometimes a table knife - Can use the toilet on her own - Swings and climbs
2 month milestones
- begins to smile at people - can briefly calm herself by sucking reflex - tries to look at parent - coos, making gurgling sounds - turns head toward sounds - pays attention to faces - begins to follow things with eyes and recognize people at a distance - begins to act bored if activity doesn't chagne - can hold head up and begins to push up when lying on tummy - makes smoother movements with arms and legs
neurodevelopmental outcomes
- benefit of human milk for preterm infants - higher IQ scores (especially for males) - improved visual development - less and less severe ROP - development of taste and smell
snacks
- defined as foods eaten between meals - usually self-fed, convient, and easy to prepare
digested blood
- during the process of delivery, a newborn will occasionally swallow small amounts of maternal blood - this is usually spit back up after delivery within 24 hours
meconium staining
- evidence of this condition in utero may be a clue to an infant who was stressed before birth - staining on the fingernails (normally white, but stained yellow) - staining may also be present on the umbilical cord and skin
human milk
- food for nutritional management - a therapeutic agent that protects from and reduces incidence and severity of various morbidities - a programming agent for genetic and biologic pathways - a mechanism to involve mothers and families in NICU care
duration of exclusive breastfeeding and age of introduction of complementary foods
- guiding principle #1 - breastfeeding should start early (within one hour of birth) - practice exclusive breastfeeding from birth to 6 months of age, and introduce complementary foods at 6 months of age while continuing to breastfeed
feeding during illness and after illness
- guiding principle #10 - increase fluid intake during illness, including more frequent breastfeeding and encourage the child to eat soft, varied, appetizing, favorite foods - after illness, give food more often than usual and encourage the child to eat more
maintenance of breastfeeding
- guiding principle #2 - continue frequent, on-demand breastfeeding until 2 years of age or beyond
responsive feeding
- guiding principle #3 - feed infants directly and assist older children when they feed themselves, being sensistive to their hunger and satiety cues - feed slowly and patiently, and encourace children to eat, but do not force them - experiment with different food combos, textures, and methods of encouragement - minimize distractions - remember that feeding times are periods of learning and love (talk to children during feeding with eye to eye contact)
food consistency
- guiding principle #6 - gradually increase food consistency and variety as the infant gets older, adapting to the infant's requirements and abilities - infants can eat pureed, mashed, and semi-solid food beginning at 6 months - by 8 months most infants can aslo eat "finger foods" - by 12 months most children can eat the same types of foods as consumed by the rest of the family
amount of complementary food needed
- guiding principle #6 - start with small amounts and increase quantity as child gets older, while maintaining frequent breastfeeding - energy needs from complementary foods for infants with "average" breast milk intake in developing countries are approximately 200kcal/day at 6-8 months, 300 kcal/day at 9-11 months, and 550kcal/day at 12-23 months of age - industrialized countries differ somewhat (130,310, and 580 kcal/day at 6-8, 9-11, and 12-23 months)
meal frequency and energy density
- guiding principle #7 - for the average healthy breastfed infant, meals of complementary foods should be provided - 2-3 times per day at 6-8 months of age - 3-4 times per day at 9-11 and 12-24 months of age, with additional nutritious snacks offered 1-2 times per day - if energy density or amount of food per meal is low, or the child is no longer breastfed, more frequent meals may be required
nutrient content of complementary foods
- guiding principle #8 - feed a variety of foods to ensure that nutrient needs are met - meat, poultry, fish or eggs should be eaten daily, or as often as possible - vegetarian diets cannot meet nutrient needs at this age unless nutrient supplements or foritified products are used - vitamin A-rich fruits and veggies should be eaten daily - provide diets with adequate fat content - avoid giving drinks with low nutrient value - limit the amount of juice offered
use of vitamin-mineral supplements or fortified products for infant and mother
- guiding principle #9 - use fortified complementary foods or vitamin-mineral supplements for the infant, as needed. - in some populations, breastfeeding mothers may also need vitamin-mineral supplements or fortified products, both for their own health and to ensure normal concentrations of certain nutrients (particularly vitamins) in their breast milk - such products may also be beneficial for pre-pregnant and pregnant women
safe preparation and storage of complementary foods
- guidining principle #4 - wash caregivers' and children's hands before food prep and eating - store foods safely and serving foods immediately after preparation - use clean utensils to prepare and serve food - use clean cups and bowls when feeding children - avoid the use of feeding bottles, which are difficult to keep clean
small for gestational age (SGA)
- low birth weight and relatively thin extremities and torso - babies have decreased glycogen and fat stores - particuarly prone to hypoglycemia after birth - polycythemia is also common due to increasced erythropoetin levels from a hypotoxic uterine environment
9 month milestones
- may be afraid of strangers - may be clingly - has favorite toys - understands "no" - makes different sounds - copies sounds and gestures of others - uses fingers to point at things - watches the path of something as it falls - looks for things she sees you hide - plays peek-a-boo - puts things in his mouth - movies things smoothly from one hand to the other - picks up things like ceral between thumb and index finger - stands, holding on - can get into sitting position - sits without support - pulls to stand - crawls
rooting reflex
- reflex that can be elicited by stroking the cheek with a finger - the newborn responds by turning the head towards the side being stroked and by opening the mouth, as if ready to eat - it may seem difficult to elicit this reflex is the first few days, but it becomes stronger over the first week or two
protective reflex
- reflex that occurs when the eyes and nose are gently covered with a cloth and the infant arches and makes efforts to push the item away with their hands - babies will respond to objects that obstruct nasal breathing in a similar way - this reflex prevents the mouth and nose from being covered by the breast during breastfeeding because and infant who cannot breathe will pull away
stepping reflex
- reflex that occurs when the infant is suspended upright, with feet touching the table, and then is brought to a forward-leaning position - one foot will lift up and then step forward in an apparant walking motion
sucking reflex
- reflex where as soon as the infant feels his thumb at his lips, he begins sucking - sucking is a self-soothing manuever for infants - an examiner can take advantage of this reflex (and its ability to soothe a fussy baby) by allowing the infant to suck on a finger or pacifier during the examination
acrocyanosis
- shortly after birth, cyanosis of the hands, feet , and perioral area are common - typically resolves in 24-48 hours
4 month milestones
- smiles spontaneously - likes to play with people and might cry if playing stops - copies some movements and facial expressions - begins to babble - cries in different ways to show hunger, pain, or tiredness - lets you know if he is happy or sad - responds to affection - reaches for toy with one hand - uses hands and eyes together - follows moving things with eyes from side to side - watches faces closely - recognizes familiar people and things at a distance - holds head steady - pushes down on legs - may be able to roll over - can hold a toy and shake it
transitional stool
- stool that represents that change from meconium to the normal yellow, seedy stools that characterize infants feeding on milk only - the dark color of meconium is still visible, but lighter, yellowish curds can also be seen - exclusively breastfed infants should have transitional stools by day 4 if feedings are adequate
meconium
- stools that are characterized by their dark (almost black) color, stick consistency and odorless nature - normal passage should include at least one stool in the first 48 hours after birth and traditional stools should start by day 4
yellow stool
- the normal appearance of stool in an infant who is exclusively breastfed - bright yellow color and seedy texture - this stool should be present by day 5 after birth
galant reflex
- this reflex is elicited by suspending the infant in a prone position (the feet should not be touching the bed) - the side of the back is then stroked in a cephalocaudal direction - the infant will respond by moving the hips towards the side that was stimulated
grasp reflex of the foot
- this reflex is strongly present in the feet of a newborn - stroking up the middle of the foot will elicit the reflex - the toes curl under and seem to grasp onto the thumb of the examiner - this is not the same as a negative babinski reflex - this reflex is present until 2-3 months of age
enteral
- type of feeding where nutrients are delivered directly to GI tract - types include oral gastric and transpyloric (gastrostomy & jejunostomy)
parenteral
- type of feeding where nutrients are delivered directly to the bloodstream - used for GI problems that may interfere with oral feeding - used for damage or inflammation to GI tract from necrotizing enterocolitis (NEC)
- makes her feel like she is contributing to her baby's health - she can try to hand express some colostrum - involving the parents as much as possible is important
how does human milk serve as a mechanism to involve mothers in NICU care?
1. growth - weight gain goal = 15-30 g/day - length goal > 0.5cm/week - head circumference >0.5cm/week 2. chemical parameters - phosphorus. alkaline phosphatase, BUN prealbumin 3. bone mineral content 4. long term health & development
how is nutritional adequacy monitored in the premature infant?
- 2.2 g/kg adequate if growth or digestion are not affected - 3-3.5 g/kg required for preterm or recovery from illness - 4 g/kg may be needed for ELBW
how may protein needs vary based on the health status of the infant?
