Health Problems of Infants

VITAMIN IMBALANCES

Although true vitamin deficiencies are rare in the United States, subclinical deficiencies are commonly seen in population subgroups in which either maternal or child dietary intake of foods containing adequate amounts of vitamins is imbalanced. Vitamin D–deficiency rickets, once rarely seen because of the widespread commercial availability of vitamin D–fortified milk, increased before the turn of the century. Populations at risk include:

The American Academy of Pediatrics (2003c) now recommends that infants who are exclusively breast-fed begin to receive 200 IU of vitamin D by age 2 months. Furthermore, children who have minimal sun exposure, do not consume at least 500 ml of vitamin D–fortified milk, or are not taking a vitamin supplement with vitamin D should take vitamin D supplements daily to prevent rickets and vitamin D deficiency. The 200 IU of vitamin D may be obtained by taking a multivitamin supplement containing 400 IU vitamin D per ml or per tablet (American Academy of Pediatrics, 2003c). Inadequate maternal ingestion of cobalamin (vitamin B₁₂) may contribute to infant neurologic impairment when exclusive breastfeeding (past 6 months) is the only source of the infant’s nutrition (Centers for Disease Control and Prevention, 2003).

Children may also be at risk secondary to disorders or their treatment. For example, vitamin deficiencies of the fat-soluble vitamins A and D may occur in malabsorptive disorders. Preterm infants may develop rickets in the second month of life as a result of inadequate intake of vitamin D, calcium, and phosphorus. Children receiving high doses of salicylates may have impaired vitamin C storage. Environmental tobacco smoke exposure has been implicated in decreased concentrations of ascorbate in children; therefore increased intake of sources of vitamin C should be encouraged even in children minimally exposed to environmental tobacco smoke (Preston, Rodriguez, and Rivera, 2006; Preston, Rodriguez, Rivera, and others, 2003). Children with chronic illnesses resulting in anorexia, decreased food intake, or possible nutrient malabsorption as a result of multiple medications should be carefully evaluated for adequate vitamin and mineral intake in some form (parenteral or enteral).

Children with sickle cell disease are reported to have suboptimal intakes (according to DRI recommendations) of vitamins E and D, folate, calcium, and fiber, which decrease significantly with increasing age. Poor dietary intake was a significant factor in the study’s findings (Kawchak, Schall, Zemel, and others, 2007).

Vitamin A deficiency has been reported with increased morbidity and mortality in children with measles. However, a Cochrane review of studies wherein a single dose of vitamin A was administered to children with measles found no decrease in mortality. Children with measles under the age of 2 years who received two doses of vitamin A (200,000 IU) on consecutive days did have decreased mortality rates and a reduced rate of pneumonia-specific mortality (Huiming, Chaomin, and Meng, 2005). Complications from diarrhea and infections are often increased in infants and children with vitamin A deficiency. The American Academy of Pediatrics (2006b) recommends that vitamin A supplementation be considered in children hospitalized with measles and associated complications (diarrhea, croup, pneumonia), especially children between the ages of 6 months and 2 years. Although scurvy (caused by a deficiency of vitamin C) is rare in developed countries, cases have been reported in children who were fed an organic diet deficient in vegetables and fruits (Burk and Molodow, 2007).

An excessive dose of a vitamin is generally defined as 10 or more times the recommended dietary allowance (RDA), although the fat-soluble vitamins, especially A and D, tend to cause toxic reactions at lower doses. With the addition of vitamins to commercially prepared foods, the potential for hypervitaminosis has increased, especially when combined with the excessive use of vitamin supplements. Hypervitaminosis of A and D presents the greatest problems, since these fat-soluble vitamins are stored in the body. High intakes of vitamin A have been linked to physeal growth arrest, which can lead to osteoporosis, fracture, and metaphyseal irregularity (Saltzman and King, 2007). Vitamin D is the most likely of all vitamins to cause toxic reactions in relatively small overdoses. The water-soluble vitamins, primarily niacin, B₆, and C, can also cause toxicity. Poor outcomes in infants, namely a fatal hypermagnesemia, have been associated with megavitamin therapy with high doses of magnesium oxide (McGuire, Kulkarni, and Baden, 2000), and severe anemia and thrombocytopenia have resulted from megadoses of vitamin A (Perrotta, Nobili, Rossi, and others, 2002).

One vitamin supplement that is recommended for all women of childbearing age is a daily dose of 0.4 mg of folic acid, the usual RDA. Folic acid taken before conception and during early pregnancy can reduce the risk of neural tube defects such as spina bifida by as much as 70%. Drugs such as oral contraceptives and antidepressants may decrease folic acid absorption; thus adolescent females taking such medications should consider supplementation.

Deficiencies and excesses of vitamins A, B complex, C, D, E, and K are summarized in Table 11-1, and the RDAs and DRIs are listed in Appendix G. General nursing care management is discussed below, and specific interventions are presented in Table 11-1.

COMPLEMENTARY AND ALTERNATIVE MEDICINE

The misuse or overuse of vitamins as a part of complementary and alternative medicine (CAM) places some children at risk for health problems. One survey found that a relatively small group of parents routinely gave their children megavitamin therapy; however, the researcher recommends further research to ascertain a more realistic number of children using multivitamin preparations (Loman, 2003). Sawni, Ragothaman, Thomas, and others (2007) noted that of persons reportedly using CAM, the most common CAM remedies used in children seen in the emergency department were home or folk remedies (59%), herbs (41%), prayer for healing (14%), and massage therapy (10%). A survey in a WIC (Women, Infants, and Children) clinic found that child herbal use was common, especially among Hispanic children attending the clinic. Some of the herbs used by the children in the survey (St. John’s wort, dong quai, and kava) have questionable safety (Lohse, Stotts, and Priebe, 2006).

There is concern among health care workers that terms often used to market supplements such as megavitamins may mislead parents regarding the actual benefits (or harm) of such therapies. The intention herein is not to discredit the use of CAM such as vitamin supplements; rather, it is to ensure safety and efficacy in children who may experience inadvertent harm. The use of various herbal therapies, or intake of herbs, is also becoming more popular; many of these have been a part of medicine since early days and are beneficial in some cases.

There are reports of an increase in the use of herbs by lactating mothers to increase breast milk supply. The galactogogues fenugreek, blessed thistle, fennel, and chaste tree have been purported to increase maternal milk supply, yet few studies support the efficacy or the safety of these herbs in breastfeeding infants; fenugreek has been the most widely studied, yet it may have adverse effects such as colic and diarrhea in breastfeeding infants (Conover and Buehler, 2004; Lawrence and Lawrence, 2005). For a discussion of galactogogues, including those mentioned above, see Appendix P in Lawrence and Lawrence (2005).

Herbs known to have adverse effects in children include ephedra, comfrey, and pennyroyal; some herbs may not be harmful taken alone but may counteract or potentiate prescription medications when taken together (Loman, 2003). Parents should be fully informed of the use of herbs to ensure that there is more benefit than potential harm in the ingredient being used. Health care workers also need to be knowledgeable of the benefits or potential harm in herbs to appropriately counsel parents and address their concerns. Little research has been performed in children on many over-the-counter herbal medicines, yet some herbs are known to cause harm in children (Kemper and Gardiner, 2004; Lanski, Greenwald, Perkins, and others, 2003; Loman, 2003). Parents should be cautioned not to exceed the upper limits of vitamin intake according to the new DRI (see p. 380 and Appendix G).^*

MINERAL IMBALANCES

A number of minerals are essential nutrients. The macrominerals refer to those with daily requirements greater than 100 mg and include calcium, phosphorus, magnesium, sodium, potassium, chloride, and sulfur. Microminerals, or trace elements, have daily requirements of less than 100 mg and include several essential minerals and those whose exact role in nutrition is still unclear. The greatest concern with minerals is deficiency, especially of iron, calcium, phosphorus, magnesium, and zinc. Low levels of zinc can cause nutritional failure to thrive.

The regulation of mineral balance in the body is a complex process. Dietary extremes of mineral intake can cause a number of mineral-mineral interactions that could result in unexpected deficiencies or excesses. For example, excessive amounts of one mineral, such as zinc, can result in a deficiency of another mineral, such as copper, even if sufficient amounts of copper are ingested. Thus megadose intake of one mineral may cause an inadvertent deficiency of another essential mineral by blocking its absorption in the blood or intestinal wall, or by competing with binding sites on protein carriers needed for metabolism.

Deficiencies can also occur when various substances in the diet interact with minerals. For example, iron, zinc, and calcium can form insoluble complexes with phytates or oxalates (substances found in plant proteins), which impair the bioavailability of the mineral. This type of interaction is important in vegetarian diets because plant foods such as soy are high in phytates. Contrary to popular opinion, spinach is not an ideal source of iron or calcium because of its high oxalate content.

Children with certain illnesses are at greater risk for growth failure, especially in relation to bone mineral deficiency as a result of the treatment of the disease, decreased nutrient intake, or decreased absorption of necessary minerals. Those at risk for such deficiencies include children who are receiving or have received radiation and chemotherapy for cancer; children with human immunodeficiency virus (HIV), sickle cell disease, cystic fibrosis, gastrointestinal malabsorption, or nephrosis; and very low–birth-weight preterm infants.

Deficiencies and excesses of the essential macrominerals and microminerals are summarized in Table 11-2. General nursing care management is discussed on p. 380, and specific interventions are discussed in the table.

VEGETARIAN DIETS

Vegetarian diets have become increasingly popular in the United States because people are concerned about hypertension; cholesterol; obesity; cardiovascular disease; cancer of the stomach, intestine, and colon; and the influence of the animal rights movement. In one survey, adolescent vegetarians were more likely than nonvegetarians to meet the Healthy People 2010 objectives for overall nutrient consumption (Perry, McGuire, Neumark-Sztainer and others, 2002). The American Dietetic Association and Dietitians of Canada (2003) issued a statement endorsing vegetarian diets for adults and children; the statement further notes that well-planned vegetarian diets are adequate for all stages of the life cycle and promote normal growth. Children and adolescents on vegetarian diets have the potential for lifelong healthy diets and have been shown to have lower intakes of cholesterol, saturated fat, and total fat and higher intakes of fruits, fiber, and vegetables than nonvegetarians (American Dietetic Association and Dietitians of Canada, 2003).

The major types of vegetarianism are:

Lacto-ovo vegetarians, who exclude meat from their diet but consume dairy products and rarely fish.

Lactovegetarians, who exclude meat and eggs but drink milk.

Pure vegetarians (vegans), who eliminate any food of animal origin, including milk and eggs.

Macrobiotics, who are even more restrictive than pure vegetarians, allowing only a few types of fruits, vegetables, and legumes.

Semi-vegetarians, who consume a lacto-ovo vegetarian diet with some fish and poultry. This is an increasingly popular form of vegetarianism and poses little or no nutritional risk to infants unless dietary fat and cholesterol intake is severely restricted.

Many individuals who are concerned about healthy diets subscribe to vegetarian diets that may not be typified by the above categories. Therefore during nutritional assessment it is necessary to clearly list exactly what the diet includes and excludes.^*.

The major deficiencies that may occur in the stricter vegan diets are inadequate protein for growth; inadequate calories for energy and growth; poor digestibility of many of the bulky natural, unprocessed foods, especially for infants; and deficiencies of vitamin B₆, niacin, riboflavin, vitamin D, iron, calcium, and zinc. Strict vegan diets also require supplements of vitamin B₁₂ and vitamin D. Vitamin D is essential if exposure to sunlight is inadequate (<5 to 15 min/day on the hands, arms, and face of light-skinned persons; slightly more in darker pigmented individuals) or in persons who are dark-skinned or who live in northern latitudes or cloudy or smoky areas. Many of these deficiencies can be avoided in children who are not consuming 100% of the RDA of vitamins and minerals with a multivitamin-mineral supplement (Dunham and Kollar, 2006).

Evaluate for iron deficiency anemia and rickets in children on strict vegetarian and macrobiotic diets; this may occur as a result of consuming plant foods such as unrefined cereals, which impair the absorption of iron, calcium, and zinc. Other factors that affect iron absorption are listed in Box 11-1.

NURSING CARE MANAGEMENT

Identification of adequacy of nutrient intake is the initial nursing goal and requires assessment based on a dietary history and physical examination for signs of deficiency or excess (see Nutritional Assessment, Chapter 6). After assessment data are collected, this information is evaluated against standard intakes to identify areas of concern. The Institute of Medicine (IOM) (2000) has developed guidelines for nutritional intake that encompass the RDAs yet extend their scope to include additional parameters related to nutritional intake. The DRIs^* are composed of four categories. These include estimated average requirements (EARs) for age and gender categories, tolerable upper-limit (UL) nutrient intakes that are associated with a low risk of adverse effects, adequate intakes (AIs) of nutrients, and new standard RDAs. The new guidelines present information about lifestyle factors that may affect nutrient function, such as caffeine intake and exercise, and about how the nutrient may be related to chronic disease. An important factor in the development of the DRIs that affects children, particularly infants 0 to 6 months, is that the AIs are based on the nutrient intake of full-term, healthy, breast-fed infants (by well-nourished mothers), which now represents the gold standard for infant nutrition in this age-group.

The American Heart Association (AHA) (2005) (see also Gidding, Dennison, Birch, and others, 2005) Dietary Guidelines, patterned after the 2005 Dietary Guidelines for Americans, may also be used to encourage healthy dietary intakes designed to decrease obesity and cardiovascular risk factors and subsequent cardiovascular disease, which is now known to occur in young children as well as adults. The AHA Guidelines have been endorsed by the American Academy of Pediatrics (2006a), yet it is important to note that these guidelines are for children ages 2 years and older. The guidelines encourage a variety of fruits, vegetables, whole grains, and low-fat dairy and nonfat dairy products, in addition to fish, beans, and lean meat.

MyPyramid, developed by the U.S. Department of Agriculture, replaces the Food Guide Pyramid as a guide for adult and childhood nutrition. This interactive dietary guide aims to simplify food choices designed to decrease fat and empty calorie intake and increase consumption of grains and vegetables. The MyPyramid for Kids (Fig. 11-1) incorporates examples of exercise for children as well as suggested serving sizes. The Internet version of MyPyramid for Kids^* offers an interactive game for children (Blast Off). Suggested serving sizes for the five food groups are listed in Box 11-2.

A vegetarian food guide pyramid (rainbow for Canadian vegetarians) developed by the American Dietetic Association and Dietitians of Canada includes guidelines for meeting the minimum recommendations for nutrients, including protein, iron, zinc, calcium, vitamin D, riboflavin, and iodine. The new food guide can be adapted to different types of vegetarian diets according to specific needs (American Dietetic Association and Dietitians of Canada, 2003; Messina, Melina, and Mangels, 2003).

Achieving a nutritionally adequate vegetarian diet is not difficult (except with the strictest diets), but it requires careful planning and knowledge of nutrient sources. For children the lacto-ovo vegetarian diet is nutritionally adequate; however, the vegan diet requires supplementation with vitamins D and B₁₂ for children ages 2 to 12 years. Infants should be breast-fed for the first 6 months and preferably for 1 year, be introduced to some solid foods after about 4 to 6 months, and receive iron-fortified cereal for at least 18 months. Vitamin B₁₂ supplementation is recommended if the breastfeeding mother’s intake of the vitamin is inadequate or if she is not on vitamin supplements (Dunham and Kollar, 2006). The introduction of solids for vegetarian infants may occur using the same guidelines as for other children (see p. 346). The American Dietetic Association and Dietitians of Canada (2003) recommend iron supplementation in infants exclusively breast-fed after 4 to 6 months by vegetarian mothers and no dietary fat restrictions in vegetarian children younger than 2 years. The use of vitamin C juices (in moderate amounts, not as a milk substitute) with foods high in iron will further improve iron absorption. Breast milk from vegetarian mothers can be deficient in vitamin B₁₂; supplementation of both mother and child is advisable. If cow’s or human milk or commercial infant formula is not given, fortified soy formula is recommended. A variety of foods should be introduced during the early years to ensure a well-balanced intake.

To ensure sufficient protein in the diet, foods with incomplete proteins (those that do not have all the essential amino acids) must be eaten at the same meal with other foods that supply the missing amino acids. The three basic combinations of foods consumed by vegetarians that generally provide the appropriate amounts of essential amino acids are:

Additional dietary considerations for young children are found in Chapters 12 and 14.

PROTEIN-ENERGY MALNUTRITION

Malnutrition continues to be a major health problem in the world today, particularly in children under 5 years of age. Lack of food, however, is not always the primary cause for malnutrition. In many developing and underdeveloped nations, diarrhea (gastroenteritis) is a major factor in malnutrition. Additional factors are bottle-feeding (in poor sanitary conditions), inadequate knowledge of proper child care practices, parental illiteracy, economic and political factors, climate conditions, cultural and religious food preferences, and simply the lack of adequate food. Müller and Krawinkel (2005) point out that poverty is the underlying cause of malnutrition. The most extreme forms of malnutrition, or protein-energy malnutrition (PEM), are kwashiorkor and marasmus.

In the United States milder forms of PEM are seen as a result of primary malnutrition, although the classic cases of marasmus and kwashiorkor may also occur. Unlike developing countries, where the main reason for PEM is inadequate food, in the United States PEM occurs despite ample dietary supplies (see Growth Failure [Failure to Thrive], p. 396). PEM may also be seen in persons with chronic health problems such as cystic fibrosis, renal dialysis, and gastrointestinal malabsorption; in the elderly who have chronic malnutrition; or in persons with acute illnesses such as prolonged, untreated anorexia nervosa. Kwashiorkor has been reported in the United States in children fed only a rice beverage diet (Rice Dream) and few solid foods (Katz, Mahlberg, Honig, and others, 2005). The rice drink contains 0.13 g of protein per ounce (compared with the 0.5 g found in human milk and infant formulas) and is an inadequate source of nutrition for children. Other reported cases of kwashiorkor in developed countries involved infants who were fed nonstandard infant diets such as flour water, corn porridge, molasses, and nondairy creamer (Katz, Mahlberg, Honig, and others, 2005). Kwashiorkor has also been reported in the United States when infants have been fed inappropriate food as a result of parental (caretaker) nutritional ignorance, a perceived cow milk–based formula intolerance, family social chaos, or cow’s milk intolerance (Liu, Howard, Mancini, and others, 2001). It is therefore important that health care workers not assume that PEM cannot occur in developed countries; a comprehensive dietary history should be obtained in any child with clinical features resembling PEM.

FOOD SENSITIVITY

Food sensitivity is a general term that includes any type of adverse reaction to food or food additives. Food sensitivities can be divided into two broad categories:

This classification is not universally accepted, however; therefore the terms food sensitivity, hypersensitivity, allergy, and intolerance are often used interchangeably. The American Academy of Allergy, Asthma, and Immunology further suggests defining food-induced reactions according to the following: adverse food reactions, food hypersensitivity (allergy), food anaphylaxis, food intolerance, food idiosyncrasy, food toxicity or poisoning, anaphylactoid reaction to food, pharmacologic food reaction, and metabolic food reaction (American Academy of Pediatrics, 2004).

The clinical manifestations of food hypersensitivity may be divided as follows (American Academy of Pediatrics, 2004):

Systemic—Anaphylactic, failure to thrive

Gastrointestinal—Abdominal pain, vomiting, cramping, diarrhea

Respiratory—Cough, wheezing, rhinitis, infiltrates

Cutaneous—Urticaria, rash, atopic dermatitis

Food hypersensitivities usually occur either as an immunoglobulin E (IgE)–mediated or non-IgE-mediated immune response; some toxic reactions may occur as a result of a toxin found within the food (Sampson, 2004). Food allergy is caused by exposure to allergens, usually proteins (but not the smaller amino acids) that are capable of inducing IgE antibody formation (sensitization) when ingested. Sensitization refers to the initial exposure of an individual to an allergen, resulting in an immune response; subsequent exposure induces a much stronger response that is clinically apparent. Consequently, food hypersensitivity typically occurs after the food has been ingested one or more times. The most common food allergens are listed in Box 11-3.

Allergies in general demonstrate a genetic component: children who have one parent with allergy have a 50% or greater risk of developing allergy; children who have both parents with allergy have up to a 100% risk of developing allergy. Allergy with a hereditary tendency is referred to as atopy. Some infants with atopy can be identified at birth from elevated levels of IgE in cord blood.

Deaths have been reported in children who suffered an anaphylactic reaction to food. Onset of the reactions occurred shortly after ingestion (5 to 30 minutes). In most of the children the reactions did not begin with skin signs, such as hives, red rash, and flushing, but rather mimicked an acute asthma attack (wheezing, decreased air movement in airways, dyspnea). Children with food anaphylaxis should be watched closely because a biphasic response has been recorded in a number of cases in which there is an immediate response, apparent recovery, then acute recurrence of symptoms (Sampson, 2003). Parents, teachers, and child daycare workers should be educated regarding signs and symptoms of food hypersensitivity reactions. People with food sensitivity should avoid unfamiliar foods and restaurants that do not disclose food ingredients. New labeling guidelines require that food additives such as spices and flavoring be clearly labeled on commercially sold, store-bought foods. Hidden ingredients in prepared foods have been implicated as a potential source of food hypersensitivity.

Other symptoms of anaphylaxis to food allergens include wheezing, cough, dyspnea, urticaria, abdominal cramps, vomiting, diarrhea, a drop in systemic blood pressure or shock, and, in small preverbal children, restlessness, urticaria, irritability, listlessness, and unresponsiveness. Oral allergy syndrome occurs when a food allergen is ingested (commonly fruits and vegetables) and there is subsequent edema and pruritus involving the lips, tongue, palate, and throat; recovery from symptoms is usually rapid. Immediate gastrointestinal hypersensitivity is an IgE-mediated reaction to a food allergen, and reactions include nausea, abdominal pain, cramping, diarrhea, vomiting, anaphylaxis, or all of these. Additional food hypersensitivities seen in young children include allergic eosinophilic gastritis, allergic eosinophilic gastroenterocolitis, dietary protein enterocolitis (or milk protein intolerance), and dietary protein proctitis.

Although the reason is unknown, many children “outgrow” their food allergies; children may outgrow milk and egg allergies, but peanut allergies may persist. Children who are allergic to more than one food may develop tolerance to each food at different times. Because of the tendency to lose the hypersensitivity, allergic foods should be reintroduced into the diet after a period of abstinence (usually a year or more) to evaluate whether the food can be safely added to the diet. However, foods that are associated with severe anaphylactic reactions will continue to present a lifelong risk and must be avoided. Because children with food allergies (usually two or more) are at risk for inadequate nutrient intake and growth failure, it is recommended that they have an annual nutritional assessment to prevent such problems (Christie, Hine, Parker, and others, 2002).

Breastfeeding is now considered to be a primary strategy for avoiding atopy in families with known food sensitivities; however, there is some evidence that cow’s milk protein is transferred via breast milk. The breastfeeding mother is encouraged to avoid foods such as peanuts, tree nuts, fish, and shellfish during the first 6 months of breastfeeding. In addition, supplementation, if required, is best with hydrolysated or amino acid formulas, not soy formulas. Additional recommendations to decrease the incidence of food allergies in children at higher risk for allergies is to avoid introduction of selected complementary and solid foods: dairy products should not be introduced until 12 months of age; hen’s eggs at 24 months; and peanut, tree nuts, fish, and seafood at 36 months (Fiocchi, Assaad, Bahna and others, 2006). The strategies listed in the Nursing Care Guidelines box are those recommended by most authorities for infants with a family history of atopy.^*

Children with extremely sensitive food allergies should wear medical identification such as a bracelet and have an injectable epinephrine cartridge (EpiPen) readily available and know how to use it. It is also helpful for the child to have a copy of the individualized written treatment plan on hand for prompt diagnosis and treatment (such plans can be downloaded from http://www.foodallergy.org and completed by the practitioner).

REGURGITATION AND “SPITTING UP”

The return of small amounts of food after a feeding is a common occurrence during infancy. It should not be confused with vomiting, which can be associated with a number of disturbances that may be insignificant or serious. Regurgitation is usually benign, although persistent regurgitation necessitates medical evaluation to rule out gastroesophageal reflux (see Chapter 24). For clarification the terms are defined as:

Regurgitation—Return of undigested food from the stomach, usually accompanied by burping

Spitting up—Dribbling of unswallowed formula from the infant’s mouth immediately after a feeding

The normal occurrence of regurgitation or spitting up should be explained to parents, especially to those who are unduly concerned about it. Regurgitation can be reduced by some simple measures, such as frequent burping during and after feeding, minimum handling during and after feeding, and positioning the child on the right side with the head slightly elevated after feeding. The inconvenience of spitting up can be managed with the use of absorbent bibs on the infant and protective cloths on the parent.

Sometimes frequent dribbling of formula causes excoriation of the corners of the mouth, chin, and neck. Keeping the area dry promotes healing but can be difficult to maintain. Helpful suggestions include applying a thin film of petrolatum or A&D ointment to the affected areas after cleansing and using absorbent nonplastic-lined terry-cloth bibs, which are changed frequently.

PAROXYSMAL ABDOMINAL PAIN (COLIC)

Colic is reported to occur in 5% to 30% of all infants (Neu and Robinson, 2003), yet has no particular affinity in regard to the gender, race, or socioeconomic status of the infant and family (Ellett, 2003). The condition is generally described as paroxysmal abdominal pain or cramping that is manifested by loud crying and drawing the legs up to the abdomen. Other definitions include variables such as duration of cry greater than 3 hours a day, occurring more than 3 days per week, and parental dissatisfaction with the child’s behavior. Some studies report an increase in symptoms (fussiness and crying) in the late afternoon or evening; however, in some infants the onset of symptoms occurs at another time. Colic is more common in young infants under the age of 3 months than in older infants, and infants with “difficult” temperaments are more likely to be colicky. Despite the obvious behavioral indications of pain, the child tolerates breast milk or some type of infant formula well, gains weight, and usually thrives. There is no evidence of a residual effect of colic on older children, except perhaps a strained parent-child relationship in some cases; in other words, infants who are colicky grow up to be normal children and adults.

Among the theories that have been investigated as potential causes are too rapid feeding, overeating, swallowing excessive air, improper feeding technique (especially in positioning and burping), and emotional stress or tension between parent and child. Although all of these may occur, there is no evidence that one factor is consistently present. In some infants colic may be a sign of CMA or cow’s milk intolerance, and eliminating cow’s milk products from the infant’s diet and the diet of lactating mothers can reduce the symptoms; in some infants soy milk may cause the same discomfort as cow’s milk. Parental smoking, strained parent-infant interaction, lactase deficiency, difficult infant temperament, difficulty regulating emotions, central nervous system immaturity, and neurochemical dysregulation in the brain have also been proposed as potential causes of colic (Ellett, 2003; Neu and Robinson, 2003). A positive association between consumption of fruit juices (carbohydrate malabsorption) and colic has been demonstrated in some cases (Duro, Rising, Cedillo, and others, 2002). The final consensus of most experts who study colic is that it is multifactorial in nature and that no single treatment for every colicky infant will be effective in alleviating the symptoms.

GROWTH FAILURE (FAILURE TO THRIVE)

Growth failure, or failure to thrive (FTT), is a sign of inadequate growth resulting from inability to obtain or use calories required for growth. FTT has no universal definition, although one of the more common parameters is a weight (and sometimes height) that falls below the 5th percentile for the child’s age. Another definition of FTT includes a weight for age (height) z value of less than −2.0 (a z value is a standard deviation value that represents anthropometric data normalizing for sex and age with greater precision than growth percentile curves [Markowitz and Duggan, 2003]). A third way to define FTT is a weight curve that crosses more than 2 percentile lines on the National Center for Health Statistics growth charts after previous achievement of a stable growth pattern. Growth measurements alone are not used to diagnose children with FTT. Rather, the finding of a pattern of persistent deviation from established growth parameters is cause for concern. In addition to lack of consensus on the precise definition of FTT, there are those who advocate for a change in terminology; thus, terms such as growth failure and pediatric undernutrition are used in the literature for failure to thrive (Locklin, 2005).

Traditionally the three general categories of failure to thrive have been as follows:

Some experts, however, suggest that the above classifications are too simplistic because most cases of growth failure have mixed causes; they suggest that FTT be classified according to pathophysiology for the following categories: (1) inadequate caloric intake—incorrect formula preparation, neglect, food fads, excessive juice consumption, poverty, behavioral problems affecting eating, or central nervous system problems affecting intake; (2) inadequate absorption—cystic fibrosis, celiac disease, vitamin or mineral deficiencies, biliary atresia, or hepatic disease; (3) increased metabolism–hyperthyroidism, congenital heart defects, or chronic immunodeficiency; and (4) defective utilization—genetic anomaly such as trisomy 21 or 18, congenital infection, or metabolic storage diseases (Krugman and Dubowitz, 2003). The etiology of growth failure is often multifactorial and involves a combination of infant organic disease, dysfunctional parenting behaviors, subtle neurologic or behavioral problems, and disturbed parent-child interactions (Block, Krebs, and American Academy of Pediatrics Committee on Child Abuse and Neglect and Committee on Nutrition, 2005).

Other factors that can lead to inadequate infant caloric intake include:

Poverty—Lack of funds to buy sufficient food; diluting formula to extend available supply

Health or childrearing beliefs—Fad diets; excessive concern with preventing conditions such as obesity, hypercholesterolemia, or nursing caries; strict use of scheduled feedings

Inadequate nutritional knowledge—Cultural confusion of newly arrived immigrants who are unaware of appropriate food selections in American markets; parents with cognitive impairment

Family stress—Overwhelming involvement with another chronically ill child; any number of other stresses (financial, marital, excessive parenting and employment responsibilities, depression, chemical abuse, acute grief)

Feeding resistance—Result of nonoral nutritional therapy early in life

Insufficient breast milk—Result of a number of different causes (fatigue, illness, poor release of milk, insufficient glandular tissue, lack of maternal confidence)

In the following discussion, FTT is used to describe any child with growth failure, whether it be organic, nonorganic, a combination of both, or of unknown etiology.

SUDDEN INFANT DEATH SYNDROME

Sudden infant death syndrome (SIDS) is defined as the sudden death of an infant younger than 1 year of age that remains unexplained after a complete postmortem examination, including an investigation of the death scene and a review of the case history. Since 1992, the incidence of SIDS in the United States has decreased by 53% to an all-time low of 0.57 per 1000 live births in 2002 (American Academy of Pediatrics, 2005). The dramatic decrease is attributed to the Back to Sleep campaign.^* SIDS is the third leading cause of infant deaths (birth to 12 months) and the first leading cause of postneonatal (between 1 month and 12 months) deaths. SIDS claimed the lives of 2162 infants in 2003 (Heron and Smith, 2007). Table 11-3 summarizes the major epidemiologic characteristics of SIDS.

APNEA AND APPARENT LIFE-THREATENING EVENT

Apnea is defined as a cessation of breathing for 20 seconds. Apnea of infancy is defined as an unexplained respiratory pause of 20 seconds or more, or pauses of less than 20 seconds that are accompanied by pallor, cyanosis, bradycardia, or hypotension in the term infant. The latter is a distinct entity from apnea of prematurity (see Chapter 9). An apparent life-threatening event (ALTE), formerly referred to as aborted SIDS death or near-miss SIDS, generally refers to an event that is sudden and frightening to the observer, in which the infant exhibits a combination of apnea, change in color (pallor, cyanosis, redness), change in muscle tone (usually hypotonia), choking, gagging, or coughing, and which usually involves a significant intervention and even cardiopulmonary resuscitation (CPR) by the caregiver who witnesses the event (National Institutes of Health Consensus Development Conference, 1987). The definition of ALTE may include apnea, but ALTE may occur without apnea (Silvestri and Weese-Mayer, 2003).

Apnea during infancy can be a symptom of any one of many disorders, including sepsis, seizures or other neurologic disorder, upper or lower airway infection or abnormality, gastroesophageal reflux, hypoglycemia or other metabolic problems, impaired regulation of breathing during sleep or feeding, or a result of intentional harm by an adult caregiver. Delayed ventilatory responses to hypercapnia and hypoxia were observed in one study of 69 infants with apnea of infancy (Katz-Salamon, 2004). Abusive head injury has been reported in a small percentage (2.5%) of children with ALTE (Altman, Brand, Forman, and others, 2003). Intentional suffocation and Munchausen syndrome by proxy cases have also been reported with ALTE (Hall and Zalman, 2005). However, in about half the cases no cause is identified.

Infants with a history of ALTEs may be at increased risk for SIDS, but these children constitute only approximately 7% to 12% of all SIDS victims. Most infants with ALTE are less than 6 months of age, and although there has been a significant decrease in SIDS since 1992, the incidence of ALTE has not changed (Hall and Zalman, 2005). A diagnosis of apnea of infancy or idiopathic ALTE is often made when no cause is found.

Results from the Collaborative Home Infant Monitoring Evaluation study found that apnea and bradycardia occurred at conventional and extreme alarm thresholds in all groups of infants studied: siblings of SIDS infants, infants with ALTEs, symptomatic (of apnea and bradycardia) and asymptomatic preterm infants weighing less than 1750 g (3.8 pounds) at birth, and healthy term infants. The researchers concluded that many infants experience apnea and bradycardia in each of these groups yet do not die (Jobe, 2001; Ramanathan, Corwin, Hunt, and others, 2001). Furthermore, it was reported that apnea does not appear to be an immediate precursor to SIDS and that cardiorespiratory monitoring is not an effective tool for identifying infants at greater risk for SIDS (American Academy of Pediatrics, 2003a).

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