The Infant
Case 2.1 Nutrition and Weight
Clinical Case Studies for the Family Nurse Practitioner, First Edition. Edited by Leslie Neal-Boylan.
© 2011 John Wiley & Sons, Inc. Published 2011 by John Wiley & Sons, Inc.
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SUBJECTIVE
Nelson, a 12 - month - old infant, presents to the offi ce for a well - baby visit. He is accompanied by his mother, Kylie. Kylie states that Nelson has been healthy since his last well - baby visit at 9 months of age. He has had no visits to the urgent care clinic or to the emergency room in the interim. Kylie is concerned that Nelson ’ s appetite has diminished. She states that he is not eating as much lately as he had been.
Diet: Nelson ’ s nutrition history reveals that he has successfully transitioned to a diet with whole milk. He drinks fi ve 8 - oz bottles of whole milk daily. Nelson is a “ picky eater. ” He rarely eats foods that are offered to him and, instead, prefers to drink from the bottle. He is not currently taking any multivitamins.
Elimination: Kylie states that Nelson has 4 – 6 wet diapers daily. He does not have any diarrhea but does have occasional constipation that is relieved with prune juice.
Sleep: Nelson sleeps 13 hours nightly but does not take any naps during the day. He does not have any problems falling asleep or staying asleep. His nighttime bedtime routine includes a bath and bedtime story read to him by Kylie.
Developmental: Nelson is able to walk while holding onto furniture. He can also stand unassisted for about 5 seconds. Nelson says “ dada ” and “ mama ” and has words for bottle and milk.
Birth h istory: Nelson was the product of a 37 - week gestation. He was delivered vaginally with the assistance of a vacuum. During the pregnancy, Kylie had no falls or infections. She did not drink alcohol, take over - the - counter or prescription medications (other than prenatal vitamins), use tobacco products, or use illicit drugs. Nelson ’ s birth weight was 3000 g, and his Apgar scores were 8 at 1 minute and 9 at 5 minutes. Past medical history reveals that Nelson has had 3 episodes of acute otitis media since birth. He has had no injuries or illnesses requiring visits to the emergency department.
Social h istory: Nelson was born to a 20 - year - old mother. He has a 2 - month - old younger sibling. He lives at home with his mother and his paternal grandmother. Nelson ’ s father is currently incarcerated.
Nelson ’ s mother does not currently work outside the home. The family receives rent subsidy from Section 8 and food subsidy from the Women, Infants, and Children ( WIC ) program and food stamps.
By Mikki Meadows - Oliver , PhD, RN
28 The Infant
The family also receives monthly cash assistance from the Temporary Aid to Needy Families ( TANF ) program. The family has no pets and there are no smokers in the home.
Family m edical h istory: Nelson ’ s mother has no health problems. His father is 32 years old and has no history of chronic medical conditions. His maternal grandmother has a history of breast cancer.
His maternal grandfather has high blood pressure. His paternal grandmother (48 years of age) is healthy with no health problems. The health history of his paternal grandfather is unknown.
Nelson is not currently taking any over - the - counter, prescription, or herbal medications. He has no known allergies to food, medications, or the environment. He is up to date on required immunizations.
OBJECTIVE
Nelson ’ s vital signs were taken in the offi ce. His weight is 6.4 kg, and his length is 66 cm. His tem- perature is within the normal range at 36.8 ° C (temporal). When observing Nelson ’ s general appear- ance, he is alert, active, and playful. He appears well hydrated and well nourished.
Skin: Clear of lesions; no cyanosis of his skin, lips, or nails; no diaphoresis noted. Nelson has good skin turgor on examination.
HEENT : Nelson ’ s head is normocephalic. His anterior fontanel is open and fl at (0.5 cm × 0.5 cm). Red refl ex is present bilaterally; and his pupils are equal, round, and reactive to light. There is no discharge noted. Pinnae are normal, and the tympanic membranes are gray bilaterally with positive light refl exes. Bony landmarks are visible, and there is no fl uid noted behind the tympanic membrane.
Both nostrils are patent. There is no nasal discharge; and there is no nasal fl aring. Nelson ’ s mucous membranes are noted to be moist when examining his oropharynx. He has 8 teeth present with white spots present on both upper central incisors. There are no lesions present in the oral cavity.
Neck: Supple and able to move in all directions without resistance; shotty nodes present in the pos- terior cervical region.
Respiratory: Respiratory rate is 20 breaths per minute, and his lungs are clear to auscultation in all lobes. There is good air entry, and no retractions or grunting are noted on examination. No deformi- ties of the thoracic cage noted.
Cardiovascular: Heart rate is 106 beats per minute with a regular rhythm. There is no murmur noted upon auscultation; brachial and femoral pulses are present and 2 + bilaterally.
Abdomen: Normoactive bowel sounds are present throughout; soft and nontender. There is no evi- dence of hepatosplenomegaly.
Genitourinary: Normal male genitalia. Nelson is circumcised and his testes are descended bilaterally.
Neuromusculoskeletal: Good tone in all extremities; full range of motion in all extremities.
His extremities are warm and well perfused. Capillary refi ll is less than 2 seconds, and his spine is straight.
CRITICAL THINKING
Which laboratory tests should be ordered as part of a 12 - month, well - child visit?
Other than “ well child, ” what additional diagnoses should be considered for Nelson?
What is your plan of treatment, referral, and follow - up care?
Nutrition and Weight 29
Does this patient ’ s psychosocial history affect how you might treat this case?
What if the patient lived in a rural setting?
Are there any demographic characteristics that might affect this case?
Are there any standardized guidelines that you should use to assess or treat this case?
RESOLUTION
Diagnostic t ests: According to the American Academy of Pediatrics ( AAP ) Recommendations for Preventive Pediatric Health Care guidelines, there are several tests that are recommended for the 12 - month well - child visit. A hemoglobin or hematocrit is recommended at the well - child visit to screen for iron defi ciency anemia. A blood lead test is also recommended to screen for an elevated blood lead level. A tuberculin test is recommended if the child has risk factors for contracting tuberculosis, such as travel to an endemic area, residing in a homeless shelter, or visiting someone in jail. Nelson ’ s father is incarcerated. If he visits in father in jail, he should receive a screening for tuberculosis.
Other than “ well child, ” what additional diagnoses should be considered for Nelson?
Based on the information gathered during his history and on his physical examination, there are several additional diagnoses that may be considered. Related to Nelson ’ s nutrition, there are 2 poten- tial diagnoses: at risk for constipation and at risk for iron defi ciency anemia. Nelson is drinking nearly 40 oz of cow ’ s milk daily. This amount of milk is excessive for his age (recommended amount is 20 – 24 oz daily). Excessive milk intake is associated with iron - defi ciency anemia, as well as constipation.
Regarding his weight, Nelson is currently in the age range to develop physiologic anorexia of the toddler. Because the rate of growth decreases during the second year of life (between 1 – 2 years of age), this diagnosis signifi es that the child needs fewer calories and therefore may be more likely to eat less. Another consideration is that Nelson is becoming full from his excessive milk intake and may be less likely to be hungry for solid foods.
What is your plan of treatment, referral, and follow - up care?
The plan of treatment for this visit would be to discuss the excessive milk intake, discuss iron rich foods, and discuss the decreased caloric needs of the young toddler compared to the young infant.
Kylie should be advised to feed Nelson solid foods before offering him milk. She would also be advised to wean Nelson off the bottle and to feed him liquids from a cup only, limiting juice to 4 oz and cow ’ s milk to 24 oz per day. A daily pediatric multivitamin may also be prescribed for Nelson.
Since Kylie already receives TANF and WIC services, she can be referred to the SNAP Food Stamp Assistance Program for additional help in acquiring nutritious foods for Nelson. If further nutritional concerns arise, the family can be referred to a nutritionist. Nelson should return to the offi ce for a well - child visit in 3 months for his 15 - month checkup. He should return sooner if there are signs and symptoms of illness.
Does this patient ’ s psychosocial history affect how you might treat this case?
Nelson ’ s family is likely to be of a lower socioeconomic status ( SES ) based on their eligibility for governmental subsidies such as WIC, TANF, and Section 8. Because of their SES, the family may be less likely to be able to afford nutritious foods. This could affect Nelson ’ s weight and growth patterns.
What if the patient lived in a rural setting?
Living in a rural setting might further limit access to nutritious foods since there may be fewer local facilities where nutritious foods can be readily purchased.
Are there any demographic characteristics that might affect this case?
The family ’ s low income status is the demographic factor in this case. Other demographic character- istics such as gender and ethnicity are not likely to affect this case.
30 The Infant
Are there any standardized guidelines that you should use to assess or treat this case?
Refer to the American Dietetic Association (2007) and American Heart Association (2005) resources in the References and Resources below for standardized guidelines on nutrition and weight that might be used to assess or treat this case.
REFERENCES AND RESOURCES
American Dietetic Association . ( 2007 ). Pediatric weight management evidence - based nutrition practice guideline . American Dietetic Association.
American Heart Association . ( 2005 ). Dietary recommendations for children and adolescents: A guideline for practitio- ners: Consensus statement from the American Heart Association . American Heart Association.
Daher , S. , Tahan , S. , Sole , D. , Naspitz , C. , Da Silva - Patricio , R. , Neto , U. , & De Morais , M. ( 2001 ). Cow ’ s milk protein intolerance and chronic constipation in children . Pediatric Allergy and Immunology , 12 , 339 – 342 . Food Stamp Assistance . http://foodstamp - assistance.com
Oliveira , M. , & Osorio , M. ( 2005 ). Cow ’ s milk consumption and iron defi ciency anemia in children. (Portuguese — English Abstract) . Jornal de Pediatria , 81 , 361 – 367 .
Supplemental Nutrition Assistance Program ( 2010 ). Food stamp assistance .