Stony Brook Medicine



Stony Brook Pediatrics Primary Care Clinic CurriculumNutrition INovember 2018Materials developed by Susan Walker, MDGoals and Objectives: Understand the various types of infant formula choices and the indications for feeding eachUnderstand the role of DHA/ARA and pre/probiotic supplementation of formulasDiscuss the recommended timing for solid food introductionUnderstand the new recommendations for prevention of peanut allergy in high risk infantsABP content specs:Infant feeding:-Breast-feedinga. Understand the qualitative and quantitative differences between human milk and various infantformulasb. Recognize the presence and importance of various antibodies (including secretory IgA) in humanmilk and colostrumc. Understand factors that could interfere with breast-feedingd. Understand the significance of colitis in a breast-fed infante. Recognize the effects of maternal ingestion of drugs on breast-fed infantsf. Know the normal pattern of feeding and stool frequency in breast-fed infants-Formula-feedinga. Know the content of various infant formulas and milk sources, the indications for their use, andpossible side effectsb. Differentiate milk protein allergy from lactose intolerancec. Understand the nutritional supplements that can be used to increase caloric density of formulasand their risksd. Know the normal pattern of feeding and stool frequency in formula-fed infants-Introduction of cow milk and solid fooda. Understand the qualitative and quantitative differences between human milk and cow milkb. Understand the appropriate age at which cow milk should be introduced into the dietc. Know the appropriate age and sequence for introducing solid food into an infant’s dietd. Understand the consequences of introducing solid food prematurely during solid food prematurelyAllergies:-Understand and apply current recommendations for feeding infants who are at riskfor the development of food allergy Note: This module only briefly touches on breastfeeding, which is the recommended type of feeding for infants. Learners are referred to the breastfeeding module in the newborn nursery curriculum for detailed information regarding breastfeeding.Before attending the session1.Read the following articles:Updates in Infant Nutrition Pediatrics in Review 2017;38;10 Infant Formula and Formula Feeding–Cow Milk Protein Formulas Pediatrics in Review 2017 2017;38;5 Infant Formulas Pediatrics in Review 2017;38;5 four (4) things you have learned from the articles you read.List two (2) things about this topic you would like to research further.List one (1) ‘pearl’ you consider essential knowledge regarding this topic.3.Answer the following questions:You are seeing a two-week-old child in your office for a weight check. His mother reports that he is having many watery stools per day, and that she thinks she saw blood in the most recent one or two. She is feeding him cow milk based formula. On exam, you note that he has regained birth weight. Physical exam is otherwise unremarkable. Guaiac of the stool is positive. Based on your history and physical examination, you recommend the following: Change to soy-based formulaChange to an extensively hydrolyzed formula (such as alimentum or nutramigen)Change to an amino-acid-based formula (such as neocate or elecare)Continue current formulaRefer to gastroenterologyHis mother has heard that these types of formulas are expensive and is wondering why she can’t try soy instead. What is the indication for soy formula?The same infant returns for his one month well check. The mother reports that his stools are less frequent and there is no more blood. You confirm that his stools are now guaiac negative. She asks you if her son will be allergic to milk for the rest of his life. You respond:He will likely outgrow his milk allergy by six months of ageHe will likely outgrow his milk allergy by age one, and can try cow’s milk at that timeHe will likely out grow his milk allergy, but will always be sensitive to lactose He is unlikely to ever outgrow his milk allergyThe same infant returns for his fifteen month well check and is tolerating milk products well. You confirm that his stool guaiac is still negative. The mother reports that she is expecting another baby and would like to “do something” while she is pregnant to prevent the occurrence of milk allergy in her next baby. Of the following choices, your best response is:She should avoid milk, eggs, and peanuts while pregnant, but may eat them during breastfeeding.She should avoid milk, eggs, and peanuts while pregnant and lactating.She should avoid milk only while pregnant and lactatingShe may continue her normal diet while pregnant and lactatingShe may continue her normal diet while pregnant, but should restrict milk while lactating.Then mom returns with her new infant for her first visit. She is currently breastfeeding, but is “very tired” and is considering switching to formula. She wants to know what formula to feed her new infant to help prevent allergies in her baby. After discussing the protective effect of exclusive breastfeeding in the first four to six months of life in helping reduce the risk of milk allergy, you reply:There is some evidence that partially or extensively hydrolyzed formulas may prevent the development of milk allergy in those at risk.There is some evidence that soy formula may prevent the development of milk allergy in those at risk.There is some evidence that late (after age 6 months) introduction of solid foods may prevent the development of milk allergy in those at risk.Introduction of fish, eggs, and peanuts should be delayed until after age 1.The new infant returns for her four month well visit. Although still tired, her mother has continued to exclusively breastfeed this baby. She now seeks your advice on how to begin complimentary food introduction. The advice that you give this mother may include all of the following EXCEPT:A. She may offer highly allergic foods before the age of 1 year.B. Highly allergic foods may be introduced before other complementary foodsC. Whole nuts should be avoided, but nut butters may be introduced.D. Cow’s milk products should be avoided until age 1E. Allergists should be consulted for advice about starting solid foods for those infants with moderate to severe atopic dermatitis or for infants who have had a reaction to any solid food.The same infant returns with her mother for her 6 month well visit. Her mother tells you that she has tolerated several grains, fruits, and vegetables without incident. She is interested in giving her some peanut butter, but is concerned that early introduction of peanut might increase her risk of peanut allergy. What advice do you give her regarding giving this 6 month old peanut products?A. She should avoid introducing peanut until age 1 to reduce his risk of developing peanut allergyB. She can begin introducing peanut nowC. She can begin introducing peanut now as long as there is not family history of peanut allergy.D. Peanut can be introduced after the baby is seen by an allergist and skin tested for peanut allergy.E. Peanut can be introduced after he has blood testing for peanut-specific IgE.Nutrition I Board Review:1. During a routine health supervision visit, the mother of a 2? month-old male infant tells you that the baby has been experiencing bloating and flatulence. His diet consists of 5 to 6 oz of a cow milk-based formula given five times per 24 hours. Because of frequent spitting-up, his mother recently added rice cereal to each bottle. He has two to three seedy stools per day. On physical examination, the baby is alert and vigorous. His length and weight are tracking between the 50th and 75th percentiles. The infant’s mother asks you whether switching to a soy protein-based formula will help her baby’s "gassiness."Of the following, the MOST likely the cause of this infant’s symptoms isA. cow milk protein allergyB. excessive energy intakeC. incomplete starch digestionD. lactose malabsorptionE. sucrase-isomaltase deficiency2. You are addressing a group of new mothers regarding infant feeding. One asks you when an infant can be switched from formula to whole cow milk.Of the following, you are MOST likely to respond that whole cow milkA. can be introduced at 6 months of age if an infant has significant gastroesophageal refluxB. can be given at 9 months of age if the infant is also taking a wide variety of supplemental foodsC. may be given as a supplement at any age as long as the infant also receives human milkD. should be avoided until 12 months of age because its iron content is absorbed poorlyE. should be avoided until 2 years of age because its caloric content is inadequate for optimal growth ................
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