Health promotion and anticipatory guidance are particu- larly important in infant and child health. Parents need to have an understanding of nutritional needs, including selection of healthy snacks. Proper dental care is also important in maintaining a child’s health. Since infants and children are developing cognitively and physically during this time, there are specifi c considerations that must be given to safety needs. Immunizations provide protection from and prevention of disease and selection of appropriate toys encourages developmental play that meets safety requirements and facilitates development of social roles. Sexual development and sexual education promote healthy sexual behavior in later years.
NUTRITIONAL GUIDANCE Infant Feeding
The fi rst decision that parents make regarding infant nutrition is the decision to breast feed or bottle feed their newborn. Although the composition of infant formula is similar to that of breast milk, and many babies thrive on proprietary formula, breast milk is still considered to be the best option for optimal health promotion and disease prevention in the newborn. One of the primary benefi ts of breastfeeding is the decreased incidence of bacterial and viral infections as a result of passive immunity, acquired via the transfer of maternal antibodies. According to the U.S. Department of Health and Human Services’ Offi ce on Women’s Health (2005), breastfed infants are less likely to develop allergies, gastrointestinal tract diseases, respira- tory tract diseases, ear infections, and childhood obesity.
They also have fewer systemic bacterial infections, urinary tract infections, and bacterial and viral infections of the respiratory tract.
Since an infant’s immune system does not become fully mature until 2 years of age, the maternal transfer of antibodies and immune factors enhances development of the immune system and facilitates the neonate’s immune system response. The longer the time that an infant is breastfed, the stronger the protection against infection and the earlier the maturation of the infant’s immune system. In addition, some studies have indicated that breastfed infants experience lower rates of diabetes, lym- phoma, leukemia, Hodgkin’s disease, and sudden infant death syndrome (SIDS) (American Academy of Pediatrics [AAP], 2005).
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74 unit one Foundations in Maternal, Family, and Child Care
Human breast milk contains more carbohydrates, less protein, and less casein than cow’s milk or infant formulas.
This difference in chemical composition facilitates diges- tion of breast milk and enables the infant to more readily utilize the nutrients provided. At 1 year of age, breastfed
infants are leaner than their formula-fed counterparts. In addition, breastfed infants tend to gain less weight during childhood, a factor that may lead to reduced overweight and obesity in later life.
While breastfeeding and breast milk are associated with many benefi ts, commercially prepared formula, based on cow’s milk, also provides the essential nutrients for infant growth and development. Soy-based formulas are available for infants who have an intolerance to formulas based on cow’s milk. Sucrose and corn syrup, the carbohydrates in soy formulas, tend to be more easily digested than lactose, the carbohydrate in cow’s milk-based formula. However, cow’s milk formulas provide a better source of protein than the soy formulas. Hydrolyzed-protein formulas are also available for infants with intolerance to cow’s milk-based formula. Because the protein has already been broken down, the likelihood of an allergic response is diminished.
Whole milk should be introduced into the infant’s diet at 1 year of age. By this time, the infant’s digestive system has developed enough to provide the enzymes necessary for appropriate absorption and use. The use of whole milk is important in ensuring that the child receives enough fat and calories to meet nutritional and developmental needs (Table 4-2).
Table 4-1 Preventive Services Delivery Schedule: High-Priority Services
Service 19–39 Years 40–64 Years 65⫹ Years
Aspirin Prophylaxis Discuss with women post-menopause, men over age 40, and younger individuals at increased risk for coronary heart disease
Breast Cancer Screening Annual mammogram for women
with risk factors; every 1–2 years for women 50 to 64 years of age with no risk factors
Annual mammogram for women with risk factors; every 1–2 years for women 65 and older with no risk factors
Cervical Cancer Screening First Pap smear at age 21 or 3 years after fi rst sexual intercourse, whichever is earlier; every 3 years after 3 consecutive normal results
Every 3 years after 3 consecutive normal results
Pap smear with new sexual partner
Chlamydia and Gonorrhea Screening
All sexually active females, including asymptomatic women aged 25 years and younger
Colon Cancer Screening All persons 50–79 years of age
Hypertension Screening Blood pressure screening every 2 years if less than 120/80 mm Hg; annual blood pressure screening if 120–139/80–89 mm Hg
Infl uenza Vaccine Annually between October and March for individuals aged 50 and above, those with chronic illnesses, members of the health care team, and others at high risk
Pneumococcal Vaccine Immunize individuals at high risk once; re-immunize once after 5 years if at risk for losing immunity
Immunize at age 65 if not done previously; re-immunize once if fi rst vaccination received greater than 5 years ago and before age 65 Problem Drinking Screening Screen for problem drinking among all adults and provide brief counseling
Tobacco Cessation Counseling
Assess all adults for tobacco use and provide ongoing cessation services for those who smoke or are at risk for smoking relapse
Total Cholesterol and HDL Cholesterol Screening
Fasting fractionated lipid screening for men older than age 34 every 5 years
Fasting fractionated lipid screening for men older than age 34 and for women older than age 44 every 5 years
Vision Screening Asymptomatic elderly adults
Sources: American College of Obstetricians and Gynecologists (2007); U.S. Preventive Services Task Force (2007); Institute for Clinical Systems Improvement (ICSI, 2005).
Box 4-1 Components of Health Promotion Screening
Beginning in adolescence, screening should include:
• Height, weight, and body mass index (BMI)
• Risk evaluation and counseling: Nutrition, obesity, physical activity, dental health, tobacco use, immunizations, human immunodefi ciency virus (HIV) prevention, sexually transmitted diseases prevention and sexual health, sexual abuse, preconception counseling for all women of childbearing age, medication use, and sun exposure
• Safety: Domestic violence, seat belt use, use of helmets, fi rearm safety, and use of smoke and carbon dioxide detectors in the home
• Behavior assessment: Depression, suicide threats, alcohol and drug use, anxiety, stress reduction, and coping skills
Data from Michigan Quality Improvement Consortium. (2005, July). Adult preven- tive services (ages 18–49). Southfi eld, MI: Author.
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chapter 4 Caring for Women, Families, and Children in Contemporary Society 75
Ethnocultural Considerations—
Infant feedingCulture plays an important role in infant feeding. For many new immigrants and members of ethnic minorities, the tra- ditions of their homeland, the consumption of traditional foods, and maintaining traditional food preparations pro- vide comfort in an environment that is new and unknown, and is a way of sustaining cultural identity. Some cultural practices include breastfeeding on demand and early intro- duction of solid foods, where others feel that exposure of the breast is indecent–a view that decreases the mother’s comfort with breastfeeding. It is imperative for nurses to recognize biases that the Western view of health and nutri- tion is the only appropriate method to feeding an infant.
Nurses need to evaluate the effect of the cultural practices objectively and intervene only if the mother or baby is at risk for harm.
Introduction of Solid Foods
As a child moves from infancy to toddlerhood, parents should introduce solid foods into the diet, including fi n- ger foods. The foods that should be introduced are based on the developmental stage and nutritional need. Solid food should not be introduced until the infant is at least 4 months of age since the digestive tract is still developing until this point. In addition, solid food should not be put
in an infant’s bottle. Instead, the child needs to learn that food is to be eaten and taken from a spoon.
Between 4 and 6 months of age, infants begin to exhibit signs of readiness for the introduction of solid foods. These signs include the ability to hold up the head, sit in a high chair, and move the tongue around the mouth without pushing food out of the mouth (as the extrusion refl ex disappears). In addition, the infant should be teething, gaining weight (should be doubled from the birth weight), and remain hungry after 8 to 10 breast feedings or after consuming 40 ounces of for- mula per day. The fi rst solid food offered to the infant should consist of an iron-fortifi ed rice cereal prepared by mixing one teaspoon of cereal with 4 to 5 teaspoons of breast milk or formula. Over the following weeks, the cereal mixture consistency should be thickened, and the amount gradually increased to 1 tablespoon of cereal per day. New cereals, such as those containing oats and bar- ley, may be added, but parents should wait at least 1 week before adding each new food in order to identify signs of potential allergy.
Between the ages of 6 and 8 months, the infant’s cereal intake should increase to 3 to 9 tablespoons per serving, given two to three times per day. In addition, parents should introduce pureed or strained fruits, such as bananas, pears, apples, and peaches, into the diet, beginning with 1 teaspoon and increasing to one- fourth to one-half cup in two to three feedings. At 1-week intervals, pureed or strained vegetables such as carrots, squash, sweet potatoes, avocado, green beans, and peas should also be introduced in the same form as the fruit.
Finger foods can be introduced once the infant reaches 8 to 12 months of age. Signs of readiness for fi nger foods include the ability to pick up objects with the thumb and forefi nger (known as development of the pincer grasp), the ability to transfer items from one hand to the other, and the tendency to put everything into the mouth.
Examples of appropriate fi nger foods include small pieces of lightly toasted bagels, small pieces of ripe bananas, well-cooked spiral pasta, teething crackers, and low-sugar
“O”-shaped cereal. During this age, mixed cereals may also be introduced, along with small amounts of yogurt and cottage cheese, small amounts of protein (e.g., egg yolk, pureed meats and poultry, mashed beans with soft skins), and apple and pear juice. Citrus juices should not be introduced, as the digestive system has not developed enough to utilize the nutrients.
From 1 year to 18 months of age, the toddler should begin to use a spoon and eat some of the same foods (mashed or chopped into bite-size pieces) as the older family members. Whole milk, eggs, full-fat yogurt, and cottage cheese, and citrus juices can be introduced at this time. New vegetables, such as broccoli and caulifl ower can also be introduced.
New foods are then introduced over the next 18 months as the infant begins to feed himself more and make his own choices. Fruit, cut up into bite-size pieces, and diced vegetables may be added to the diet. As the toddler develops his own taste, combination foods such as macaroni and cheese and spaghetti may also be introduced.
Table 4-2 Infant Feeding Patterns Birth–1 month Breast every 2–3 hours
Bottle every 3–4 hours 2–3 oz. per feeding
2–4 months Breast or bottle every 3–4 hours 3–4 oz. per feeding
4-6 months Breast or bottle 4-6 times per day 4-5 oz. per feeding
6–8 months Iron-fortifi ed rice cereal Breast or bottle 4 times per day 6–8 oz. per feeding
8–10 months Finger foods
Chopped or mashed foods
Sippy cup with formula, breast milk, juice or water Breast or bottle 4 times per day
6–8 oz. per feeding
10–12 months Self-feeds with fi ngers and spoon Most table foods are allowed Breast or bottle 4 times per day 6–8 oz. per feeding
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76 unit one Foundations in Maternal, Family, and Child Care
Now Can You— Discuss infant and child nutrition?
1. Discuss the benefi ts of breastfeeding when compared to bottle feeding?
2. Describe the recommended process for introducing solid foods into an infant’s diet?
3. Identify at least four safe, nutritious fi nger foods for infants and toddlers?
Childhood Nutrition
Once the child reaches 3 years of age, parents should be introduced to the Food Pyramid for Kids (U.S. Department of Agriculture, 2005). As with the Food Pyramid devel- oped for adults, the servings per day are calculated based on weight and activity. Specifi c suggestions are included, such as limiting the intake of juice, ensuring that all juices are 100% natural, and incorporating whole grains to com- prise half of the daily grain intake (Fig. 4-1).
Snacks for children are often the most diffi cult aspect of planning meals. Parents need to be taught that snacks should be nutritious, and that any food item that is appro- priate for a meal is appropriate for a snack. Children typi- cally need to eat every 3 to 4 hours to maintain energy needs. Thus, parents must consider portion sizes when pro- viding snacks for their children. Nutritious snacks include grain products, fruit and vegetable juices, fresh fruits and vegetables, dried fruit, nuts, and seeds (Box 4-2).
DENTAL CARE
Teething typically begins between 4 and 7 months of age.
The fi rst teeth to erupt are usually the bottom central inci- sors followed by the upper central and lateral incisors. The next to erupt are the bottom lateral incisors followed by the fi rst molars. An infant may have any range from no teeth to eight or more teeth by her fi rst birthday. Most children will have all 20 of their primary teeth by their third birthday.
Signs of teething include increased drooling, irritability, desire to chew on objects, crying episodes, disrupted sleep- ing, and eating patterns. Caregivers can be encouraged to give teething infants a cool wet washcloth, teething rings that have been cooled in the refrigerator, or a clean fi nger rubbed on the gums to help ease the discomfort.
The American Dental Association (ADA) recommends that a dentist examine a child within 6 months of the eruption of the fi rst tooth and no later than the fi rst birth- day. Daily dental care can begin even before the fi rst tooth emerges. Gums can be gently wiped with a damp wash- cloth or gauze, and when the fi rst tooth emerges, a soft toothbrush and water can be used. Toothpaste cannot be used until age two.
SLEEP AND REST
Newborns sleep approximately 15 to 20 hours per day in 2- to 3-hour increments. By 3 months of age, infants sleep approximately 15 hours in a 24-hour period. At 6 months, the infant may have two naps of 2 hours each during the day and sleep 9 to 14 hours per night. From 9 months to 1 year, the length of naps may decrease slightly, with nighttime sleep remaining in the 9- to 14-hour range.
Infants are not born knowing how to put themselves to sleep. To help the infant learn to fall asleep on his own, caregivers can put the infant to bed drowsy but awake, rather than breastfeeding or rocking the infant to sleep. By training the infant to fall asleep independently, if he wakens in the night, he is more likely to self-soothe back to sleep.
Dr. T. Berry Brazelton describes six states of behavior in the newborn: quiet sleep, active sleep, drowsiness, quite alert, active awake, and crying. These states include body activity, eye movements, facial movements, breathing pat- terns, and response to external and internal stimuli. The nurse can provide anticipatory guidance by educating Family Teaching Guidelines...
Introducing Solid Foods to Infants The baby is ready for the introduction of solid foods at approximately 6 months of age. To help determine if the baby is ready for solid foods, look for developmental cues such as the ability to sit well with support and the decrease or disappearance of the extrusion refl ex. The baby may watch very intently as you eat, and may seem hungry between bottles or breastfeeding.
◆ Iron-fortifi ed rice cereal is recommended as baby’s fi rst solid food for a couple of reasons. Rice is the least allergenic of the grains and the iron helps the baby replenish the iron needed for growth and develop- ment. When introducing the rice cereal to the baby, you can mix it with formula, breast milk, or boiled and cooled water until it is very soupy. As the baby becomes accustomed to solid foods, the consistency of the cereal can be gradually adjusted to create a less soupy texture.
◆ When the baby is eating about 4 tablespoons of cereal twice a day, introduce vegetables and fruits. It is rec- ommended to start with vegetables and then expose the baby to the sweet taste of fruits, as babies are typi- cally more accepting of the sweet tastes.
◆ Introduce one food at a time, waiting 3–5 days between new foods so you will be able to identify any reactions to particular foods.
◆ Introduce food before formula or breastfeeding when the infant is hungry, and follow each solid food meal with breast milk or formula.
Seeking Additional Help:
◆ If the infant is not growing or gaining weight, if he is unable to suck or swallow or shows any signs of an allergic reaction, it is important to promptly seek help from the primary health care provider, nearby clinic, or emergency room.
Essential Information:
◆ Keep salt, sugar, and additives to a minimum or avoid them altogether. If you make your baby’s food, do not add salt or sugar.
◆ Never put food in bottles or mix food with formula because it can cause choking.
◆ Offer only small bites of food to prevent choking and pay close attention to your baby when feeding.
Data from American Academy of Pediatrics. (2005). Policy statement: Breastfeeding and the use of human milk. Pediatrics, 115(2), 496–506.
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chapter 4 Caring for Women, Families, and Children in Contemporary Society 77
caregivers about how to recognize these states in the new- born. Often caregivers think the infant is waking, when the infant is actually in a period of active sleep and if left for a few minutes, he will settle back into a quiet sleep state.
In 1992, the American Academy of Pediatrics recom- mended that infants be placed on their backs to sleep to reduce the risk of sudden infant death syndrome (SIDS).
According to the Centers for Disease Control and Preven- tion (CDC), SIDS rates have declined up to 50% in recent years. Premature infants and infants with certain illnesses may be required to sleep in a prone or side lying position.
Toddlers and preschoolers require the same amount of sleep per day as do infants. Toddlers and preschoolers sleep approximately 14 hours in a 24-hour period, 11 of those hours at night. One 1.5- to 3-hour afternoon nap provides the additional needed rest. Bedtime resistance is likely to appear in this developmental stage. The nurse can provide anticipatory guidance by recommending sleep strategies for caregivers to implement with toddlers.
School-age children require about 10 to 12 hours of sleep per night. Depending on activity level, some children may require a little more or a little less. The nurse can edu- cate the caregiver to assess their child’s mood, tempera- ment, and energy levels throughout the day to determine if the amount of sleep they are getting is suffi cient.
Figure 4-1 MyPyramid for Kids.
Box 4-2 Snacks for Children
• Grain products
• Bread products: Yeast breads and quick breads, made from whole wheat, rye, oatmeal, mixed grains, and bran; rye crisps; whole- grain crackers. Serve with crackers and cheese, peanut butter, or milk.
• Cereals: Dry cereals with less than 5 grams of sugar. Serve with milk.
Add dried fruits.
• Popcorn: Top with grated cheese instead of butter and salt.
• Cookies: Use whole-wheat fl our for baking. Try oatmeal or peanut butter cookies. Serve with milk.
• Beverages: Fruit juices and vegetable juices. Serve milk with breads, cereals, and cookies. Blend fruit with milk in a blender.
• Vegetables: Cut up raw vegetables. Serve with peanut butter, cheese, or milk. Include broccoli, carrots, celery, green beans, zucchini, and others.
• Fresh fruit: Serve with peanut butter, yogurt, or milk. Include apples, bananas, grapes, melons, oranges, and peaches.
• Nuts and seeds: Include almonds, cashews, and peanuts
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