20 - Infant Care Flashcards
Describe a normal umbilicus
- Clean and dry
- Slightly moist/sticky with slight mucoid discharge and odor
- Falls off 5-15 days after birth
- Small amount of blood on separation
- Small amount of mucoid material on separation
Describe a umbilical cord with signs of infection (Omphalitis)
- Erythema, edema & tenderness
- Extending beyond 5 mm
- If accompanied by: fever, lethargy, and/or poor feeding
Describe umbilical cord care
Keep cord clean & dry:
- Wash hands with soap & water before and after touching it
- Clean around base of cord with water on cotton tipped applicator or with a soft washcloth after bathing & at diaper changes
- Fold diaper below cord stump
- Expose to air or cover with loose clothing
- Avoid buttons and bandages over naval
Should we use alcohol or antimicrobials on the umbilical cord?
No - delays healing, dries out cord
Describe the care of a circumcised penis
- Ensure effective pain relief: topical or local anesthesia during procedure, consider acetaminophen for 24-48 hours post-procedure
- After circumcision gauze is applied. Remove and replace with every diaper change for 24 hours (use non-stick gauze and apply petrolatum to prevent sticking)
- Gently wash with warm water (+/- mild soap) 1-2 times a day
- Continue to apply petrolatum for 3-5 days (no gauze)
What is the normal progression of a circumcised penis?
- small amount of blood
- redness & swelling for a few days
- yellow discharge/scab develops and then decreases with healing
- complete healing in 7-10 days
Red flags of a circumcised penis
- bleeding > quarter size on diaper
- worsening redness/swelling (not starting to decrease within 48 hours)
- fever
- lethargy/poor feeding
- no urination within 12 hours of procedure
Describe the care of an uncircumcised penis
- Foreskin gradually separates
- Not fully retractable until 3-5
- Foreskin should not be forced back
- Penis should be washed regularly during bathing, mild soap may be used
- As the foreskin naturally retracts, cleaning and drying underneath the foreskin can be performed
- As for the foreskin retracts skin cells are shed which may appear as white, cheesy lumps (smegma)
Breastfeeding:
Always preferred method of nutrition for the first ______ and beyond
6 months
Breastfeeding:
Vitamin __ supplementation recommended
D
Describe cow’s milk allergy (CMA)
- develops in 2-4% of infants, generally occurs in first few months of life
- Sx: vomiting, wheezing, hives, rash, bloody diarrhea, skin rashes
- this is NOT lactose intolerance (lactase deficiency) as this develops later in life
Lactose-free cow milk based formula:
Any advantages?
No
Lactose-free cow milk based formula:
Not recommended for ____ __________
acute gastroenteritis
Lactose-free cow milk based formula:
Not appropriate for which conditions
- galactosemia
- congenital lactase deficiency
Lactose-free cow milk based formula:
Effective for colic?
No
Lactose-free cow milk based formula:
Why should we not give this unless we have to?
Because lactose is important for mineral absorption and maintenance of normal gut flora
Soy-based formula:
Who is it indicated for?
- Vegan diets
- Galactosemia or congenital lactase deficiency
- People who cannot consume dairy-based products for cultural or religious reasons
Partially Hydrolyzed Protein Formula:
Benefit over other products?
little evidence for any benefit
Extensively Hydrolyzed Protein Formula:
Who is it indicated for?
- Physician-confirmed food allergies
- Those that cannot tolerate cow milk or soy protein
- Malabsorption syndromes (short bowel syndrome, liver disease, cystic fibrosis)
Amino Acid Based Formula:
Who is it indicated for?
for those with severe allergies and malabsorption disorders that do not tolerate extensively hydrolyzed formulas
Describe Modified Formulas
-what they contain/benefits
Thickened formula:
- Reduce regurgitation by 0.6 episodes/day
- Associated with weight gain issues
Addition of essential fatty acids (EFA’s):
-Evidence lacking for benefit
Nucleotides:
-No evidence for benefit
Pre/Probiotics:
-Evidence lacking for benefit
Describe therapeutic formulas
- High MCT (medium chain triglycerides) and higher energy for pre-term infants
- Low PRSL (potential renal solute load) formula for renal insufficiency
- Human milk fortifiers (HMF): Added to mother’s milk in premature infants
Recommended pediatric daily dose for Vitamin D?
400 IU/day
Recommended pediatric daily dose for Vitamin D between October and April for those:
- North of the 55th parallel
- North of the 40th parallel in those with deficiency risk factors (ex. non-white race, anti epileptic therapy, malabsorption conditions)
800 IU/day
What is the current recommended upper intake level for infants up to 12 months?
1000 IU/day
How much Vitamin D is in breast milk?
<25-78 IU/L in women supplemented with 400 IU daily
How much Vitamin D is in infant formula?
400 IU/L or more
How much Vitamin D is in supplements?
400 IU/mL in D-Vi-Sol & others
400 IU/drop Kids D drops & others
1 oz = ___ mL
30
A Filipino father approaches you at the pharmacy counter. He has heard that some babies need Vitamin D drops and he is wondering if he should be giving them to his child. He has a 2 month old healthy, full-term daughter who is exclusively bottle fed using Similac Advance formula. She drinks about 6, 5 oz bottles of formula a day.
Does she need vitamin D?
If so, how much?
30 oz of formula/day = 900 mL of formula/day
400 IU/ L
x IU / .9 L
x = 360 IU daily
*Filipino race so she needs 800 IU daily
I would recommend giving one D-drop, that way she is at 760 IU/day which is probably enough.
Or you could do 1.1 mL of the D-Vi-Sol (440 IU) to equal exactly 800 IU, but that would be difficult to measure.
_____ = most common nutrient deficiency in children
Iron
What is an iron deficiency associated with?
diminished mental, motor, and behavioural functioning (these effects are long-lasting despite correction of deficiency)
What are some symptoms of iron deficiency?
pallor (pale appearance)
irritability
poor appetite
delayed growth/development
Iron stores accumulated during _____
gestation
How long is the iron stores accumulated during gestation sufficient for?
up to 4 months in healthy full-term infants
*often lacking in pre-term infants
How much iron does breast milk contain?
0.3-1.0 mg/L
Bioavailability of iron in breast milk?
50%
*high bioavailability
How much iron does infant formula contain?
4-13 mg/L
Bioavailability of iron in infant formula?
4-6%
*a lot lower than breast milk
List some strategies for preventing iron deficiency
Breastfeeding is preferred
Use iron-fortified formulas:
-No difference between low and standard-iron formulas in the frequency of fussiness, cramping, colic, regurgitation, flatus, or stool characteristics (except a darker color)
Start iron-rich foods @ 6 months (iron-fortified cereals, meats)
Do not introduce cows milk until after 1 years of age
Breastfed pre-term & low birth weight and infants with certain medical conditions may require supplementation
Infant ____ = benign, self-limiting condition
colic
When does infant colic resolve?
Resolves in 60% of infants by 3 months, 80-90% by 4 months
Describe Wessel’s “rule of three” - crying for no apparent reason
- Lasts > 3 hours per day
- Occurs on > 3 days per week
- Persists for > 3 weeks (this point is often excluded)
Differential diagnosis for infant colic
Distinguishing from normal crying:
- Paroxysmal (not a sudden attack)
- Qualitative - louder, higher, more variable pitch, more turbulent (distressed/urgent)
- Hypertonia (increase in muscle tension, unable to release muscles)
- Difficulty consoling
Otitis media, thrush, constipation
When would you refer infant colic?
- Breathing difficulties (wheezing, cyanotic episodes)
- Watery stools/blood in stools
- Fever
- Poor weight gain
- Signs of dehydration
- Excessive vomiting:
- “Happy” spitter - normal, generally outgrow by 18 months
- Warning signs: spitting up blood/coffee grounds, green or yellow spit up, breathing difficulties, poor weight gain, fever, diarrhea, signs of dehydration
Goals of therapy for infant colic
- Decrease crying
- Minimize parental stress/frustration & strengthen coping skills
- Minimize impact on infant-family relationship
What is the first-line management for infant colic?
1) Parental support
2) Feeding techniques
3) Soothing techniques
Describe feeding techniques
2) Feeding techniques:
- feed baby in a vertical position
- use the correct bottle and nipple size for the baby’s age
- curved bottles allow infant to be fed while sitting up
- bottles with a collapsible bag may decrease air swallowing
- changing the nipple to one with a smaller hole or anti colic design may decrease colic attacks
- burp baby in an upright position, with baby being held over the shoulder in a gentle chin grasp
- burping should be encouraged after every 30-60 mL of formula ingested or after every 5-10 mins of breastfeeding
Describe soothing techniques (physical)
Massage the baby
-could do just the belly or whole body
Gently push the baby’s legs back and forth in a bicycle motion if they demonstrate gastric distress by pulling their legs up and arching their backs.
Warm baths may relieve GI spasm
Describe soothing techniques (behavioural)
A colic diary that document’s the crying patterns throughout the day
A routine schedule for feeding, holding, and playtime
Caregiver must take rest breaks to relieve frustration
Describe soothing techniques (environmental)
Providing white noise is a possibility (not shown to work for everyone)
Increased carrying, car rides or baby swings are NOT effective for managing colic
Describe parenteral support that pharmacists can provide
Acknowledge: difficulty of situation, they are doing their best
Reassure: not a sign of rejection, common condition not caused by the caregiver
Take breaks and have a “rescue plan” if overwhelmed
Feelings of frustration, anger, exhaustion, guilt and helplessness are normal
Educate that colic is common and resolves on it’s own by 3-4 months of age
Are pharmacological agents effective for managing colic?
No good evidence for any given agent.
Consider placebo effect and risk vs. benefit:
- Probiotics: studies show possible benefits with lactobacillus reuteri (BioGaia), more studies needed, requires 2-4 weeks of continuous treatment to show effect
- Concentrated sucrose: short-acting pain relief?
- Simethicone: antiflatulent?
- Gripe water (various formulations: herbs, fennel, bicarbonate, ginger, chamomile, dill) - make sure does not contain alcohol !!
When is dietary management indicated?
Only indicated in cases of confirmed allergies, should see physician for assessment
What type of symptoms would appear for you to suspect allergies?
- severe symptoms
- positive family history
- additional atopic symptoms (eczema, wheezing, allergic rhinitis)
- additional GI symptoms (vomiting, diarrhea)
When should breastfed infants have a consult with a dietician?
when they’re old enough to talk, LOL, JUST JOKES
*when there is maternal avoidance/hypoallergenic diet (no eggs, milk, nuts or wheat)
How long do dietary managements need to be trifled for to see effectiveness?
7-14 days
