Revised June 2011
American College of Emergency Physicians Section of Pediatric Emergency Medicine
b. The American Academy of Pediatrics (AAP) recommends that the introduction of solids be delayed until 4 to 6 months of age. The reason for that is to allow infants to develop the motor skills necessary to clearly indicate hunger or satiety. There is some evidence that spooning food into infants who lacks the skills to show if he or she is no longer hungry may increase the likelihood that the child will learn to overeat. This becomes more important issue in light of the increasing prevalence of obesity in childhood. In addition, early introduction of solids, particularly rice cereal, can lead to constipation. Rice is rich in complex carbohydrates with slow release of glucose from its complex form leading to improved sodium and water absorption without exerting an osmotic penalty. Rice has also been shown to have an inhibitory effect on the chloride channels. The net result of all these properties is significant reduction of stool volumes in patients with diarrhea who are given rice-based oral rehydration solutions. These effects of rice may be seen even in normal intestinal epithelium leading to thickening in stool consistency thus making the stools difficult to pass. Parents should be educated regarding the change of stool patterns when introducing solids in the infant's diet.
e. A relatively high fat intake should continue throughout infancy to ensure adequate caloric intake and to provide substrate for central nervous system growth. Because of its low caloric density and high protein and electrolyte load, low-fat milk is not recommended by the AAP until age 2 years in normal weight toddlers. Children aged from 12 months to 2 years who are overweight, obese, or have a family history of obesity, dyslipidemia, or cardiovascular disease, should consume reduced-fat milk per recent AAP guidelines on obesity prevention.
a. Most of food aspiration occurs in children 3 years of age and younger. Two-thirds of the recovered food items are clearly inappropriate food for infants and young children (such as nuts, popcorn, and candy), but one fourth of the items are vegetables and fruits, suggesting a continued need for supervision to prevent choking.
d. The AAP recommends delaying the introduction of fresh milk until 12 months of age. Early use of cow's milk increase the risk of iron deficiency because of the low concentration and bio-availability of iron in milk, and because fresh cow's milk induces occult fecal blood loss in young infants.
c. Breast milk is low in vitamin K. Prior to the widespread use of vitamin K prophylaxis in hospitals, classic hemorrhagic disease of the newborn affected 0.25% to 1.7% of term infants. This has been almost eliminated by parenteral administration of vitamin K at birth. This form of hemorrhagic disease most often presents with intracranial bleeding and causes severe morbidity and mortality. Factors contributing to the development of the late bleeding include diarrhea and antibiotic administration. Breast-fed infants are at risk for iron deficiency anemia because the iron in breast milk, although well absorbed, is inadequate. Some breast-fed infants deplete their iron stores by 4 to 6 months of age and could develop biochemical evidence of iron deficiency anemia by 9 months of age. Iron fortification of formulas has resulted in significant decrease in the prevalence of childhood anemia.
c. Please refer to Table 1. The explanation for this question: 1000cc (for the first 10 Kg) + 50 cc x 2= 1100 cc. For IVF calculation, you can use the rule 4, 2, 1 which is 4cc/kg/hr for the first 10 kg, 2 cc/kg /hr for (11-20 kg) and 1 cc/kg /hr for (21 kg and above). Therefore, the IVF rate for this 12 Kg infant is (4cc x10 kg) + (2ccx 2 kg)= 44cc/hr.
|Maintenance Fluid Requirements for Children|
|Weight (kg)||Volume (per day)|
|Preterm||(<1,000) 140-150 cc/kg|
|11-20||1,000 cc + 50 cc/kg for each kg above 10 kg|
|20-50||1,500 cc + 20 cc/kg for each kg above 20 kg|
For infants younger than 1 year of age, special elemental formulas are available in which the source of protein is a hydrolyzed case in or amino acids. The fat blend is a mixture of medium-chain and long-chain triglycerides, whereas the carbohydrate content is mostly corn syrup solids. These formulas are commonly used in situations where the gastrointestinal tract is compromised, as in the case of postgastroenteritis malabsorption syndrome (partial villus atrophy causing decrease in the ability to digest and absorb nutrients). On the other hand, patients with fat malabsorption and cholestatic liver disease require formula, which contains high amount of medium-chain triglycerides.
c. Portagen is a formula that contains the highest amount of medium-chain triglyceride oil (85%), and is most commonly used for patients with fat malabsorption and cholestatic liver disease (see Table 2).
|Composition of Special Infant Formulas|
|Alimentum||Casein hydrolysate||MCT (50%)/LCFA|
|Pregestimil||Casein hydrolysate||MCT (55%)/LCFA|
|Portagen||Na+ hydrolysafe||MCT (8%)/LCFA|
|Neocate Infant||Amino acids||LCFA/MCT|
MCT = medium-chain triglyceride; LCF = long-chain fatty acid; SHS = Scientific Hospital, Inc.
d. The best indicator for appropriate feeding is adequate weight gain. Infants typically gain 1 oz per day for the first few months of life (this is after the first 10days of life when they could loose up to 10% of their birth weight). Urine output (about 6-7 wet diapers per day) is a good measurement of adequate fluid intake. Calories count could be used to assure adequate nutrition by comparing the calories required versus the calories taken by the infant (see Table 3.)
|Caloric Requirements for Parenteral Nutrition for Children|
Clinical Tip: Quick assessment of appropriate amount of formula for an infant:
The number of oz given every 4 hours = Weight in kg
Example: A 3 kg baby should be given 3 oz of formula every 4 hours.
Calories count=3 kg x 120 cal per day=360 calories
360 calories/20 cal per oz=18 oz
18 oz/6 (feeding every 4 hours)=3 oz
10. c. Smaller volume thickened feeds with rice cereal usually comprise the initial treatment of uncomplicated gastro-esophageal reflux (GER) in thriving infants. Though the clinical symptoms of GER improve with intervention, a high incidence of constipation and straining during defecation occur. On the other hand, oatmeal cereal, has a lower carbohydrate content (10g per 15g serving of oatmeal versus 12 g of carbohydrate and 1g of sugar in an equivalent amount of rice cereal), which probably gives it less ability to enhance sodium and water absorption and hence less liability to cause more solid stools. Additionally, oatmeal has 1g of fiber per 15g serving and rice cereal has none. This may further explain the ability of oatmeal to keep the stools at a softer consistency as compared to rice cereal, but still able to thicken the formula to decrease the GER symptoms.
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