Infant Feeding, Immunizations,
and Patient (parent) Education
To understand the benefits, risks, contraindications, and schedules for
routine childhood immunization.
To provide a guide for infant feeding for the student's use in his/her
To learn the definition of anticipatory guidance.
To discuss safety and emphasize this so that the student will include it
in his/her practice.
The role of the physician in infant nutrition is largely one of "educator"
The body of knowledge that surrounds infant and childhood nutrition is
a growing and changing one. If one looks at the history of this area over
the past 50 years, it becomes apparent that we have revolved back to the
practices of the 1920s and before, at least in the areas of introduction
of solid foods and breast feeding. This trend is the result of several
Increased knowledge of specific immunologic, hormonal, nutritional and,
possibly, behavioral advantages of breast milk.
Awareness that long-term nutritional practices contribute to some of the
serious diseases of society (obesity, hypertension, atherosclerosis).
A better look at correlating infant development and readiness with types
of food offered.
As a result, you will sometimes find yourself advocating a particular feeding
regime against a wall of resistance from grandparents, mothers-in-law,
aunts and, at times, physicians. It then becomes necessary for you to provide
sufficient information and support to enable parents to understand
why and how your plan is preferrable. This can be accomplished by the information
you supply plus involvement of the parent in the patient education
classes available in the Clinic.
More public awareness of the importance of nutrition.
The scope of information on infant nutrition that applies to this Clinic
will cover two areas: Prenatal Nutrition and Infant Feeding Periods.
As you follow OB patients, it is important to consider that, over the
past 15 years, we have learned that smoking, alcohol consumption,
drug ingestion, and excess caffeine, as well as the nutrition of the
mother before and during preg-nancy, all affect fetal growth
and development. Expectant mothers should be apprised of these dangers.
Certain specific deficiencies in pregnant women can affect the fetus.
The most common is iron, but zinc, calcium, and vitamin deficiencies may
also adversely affect fetal growth. Similarly, inadequate intake of calories
and protein, especially in females underweight at the beginning of pregnancy,
can produce small-for-date babies.
The view that the fetus is relatively protected from nutritional deficiencies
of the mother by its ability to "parasitize" maternal stores is no longer
the predominant one. Your patients can benefit from dietary counsel
the course of their prenatal follow-up.
This is also a good time to discuss breast or formula feeding. The many advantages
of breast feeding were referred to earlier in this discussion, and the tables
and reference readings in your handout will give you additional information.
It is important to recognize that this is the parents' decision - the
information we supply enables them to make an informed decision.
This second area becomes important as you follow infants for "well-baby
care." The feeding guide in this section provides specific recommendations.
In order to understand the rationale behind these recommendations, it is
best to consider infant feeding periods in 3 overlapping stages: (1) the
nursing period, (2) the transitional period, and (3) the modified adult
During the nursing period, lasting usually 4-6 months, most babies are
mechanically best able to swallow liquids, so breast milk or formula is
the exclusive source of nutrients. Correlating well with the neuro-muscular
development of this stage is lack of developmental maturity of the intestine
and kidney. The intestinal tract at this stage does not cope well with
foreign protein and is best equipped to digest the protein, fat, and carbohydrates
in breast milk. Similarly, the immature kidneys do not handle large osmolar
loads of protein and electrolytes.
The transitional period follows at about 4-6 months to 1 year. The dietary
changes (addition of strained or soft foods) in this period fit well with
the baby's improved ability to recognize a spoon, chew and swallow non-
liquids, and appreciate variations in taste of food. The intestine is developing
immunologically, with defense mechanisms to protect against foreign protein,
and the kidneys are more able to handle the osmolar load of more solids
and less water.
It is possible to recommend feeding schedules that are tailored to the
individual baby, if one considers all of these areas.
The onset of the modified adult period is a little more a matter of individual
preference, but it generally begins after 1 year. By this age most of the
physiologic mechanisms have matured to near-adult proficiency. The infant
is learning to feed himself, and his ability to digest and absorb a variety
of foods has matured. The majority of his nutrients can come from the table
with only minimal alteration (cutting into small pieces, etc.).
The importance of immunizations in children has been adequately reviewed.
The current schedule is included in this section for your review and reference.
Two points are worth emphasizing for your work in this Clinic:
The significance that parents place on these immunizations is related to
the degree of importance accorded them by the physician (by your
consistent inquiries and recommendations).
Contraindications to Pertussis Vaccine
Explaining to parents that low-grade fever, irritability, and minor, localized
reactions are not uncommon following immunization will save a lot
of grief (yours and mother's). Also, recommending Tylenol in a prophylactic
sense is helpful.
Contraindications to MMR
Allergic hypersensitivity to a prior dose.
Fever of 105øF within 48 hours of a prior dose.
Hypotonic-hyporesponsive reaction to a prior dose.
Inconsolable crying of 3-hour
duration within 48 hours of a prior dose.
Convulsions within 3 days of a prior dose.
Encephalopathy within 7 days of a prior dose.
Contraindications to Varicella Vaccine
Pediatric Annals, Vol. 10, No. 11, November 1981,
Pediatrics, Vol. 65, No. 6, June 1980, "Feeding
Supplemental Foods to Infants."
Clinical Pediatrics, Vol. 21, No. 6, June 1982,
"Fetal Alcohol Syndrome."
Family Physician, Vol. 24, No. 1, July 1981, "Human
Milk and Breast Feeding."
1991 American Academy of Pediatrics Red Book.
T. Davis, MD