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 practice.
• 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" and "advocate." 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 factors:

• 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.

• 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 during 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 period.

• 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.

• 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).

• 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.

• 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.

• Egg allergy.
• Neomycin allergy.
• Pregnancy.

• HIV Positive.
• Immunocompromised..

Reference Reading

Pediatric Annals, Vol. 10, No. 11, November 1981, "Nutrition."

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.