2019-20 TOW #6: Formula feeding

As a companion topic to last week’s review on breastfeeding, we are taking some time to learn about formula feeding. While breastfeeding is recommended as the optimal nutrition for babies, there are families for whom this is not an option (see commentary below from a pediatrician who was not able to breastfeed her baby); parents rely on us to have expertise on formula feeding as well.

Teaching materials for this week:

Take-home points about formula feeding:

  1. How much formula to provide? after the first few weeks of life, for every 1 kg (or 2 pounds) babies drink ~1 ounce of formula, up to about 7-8 ounces (I usually say closer to 6 ounces is optimal), every 3-4 hours. This amount approximates the baby’s stomach capacity and will meet metabolic needs of an otherwise healthy infant (which is ~100kcal/kg/day in babies <10 kg). Babies should be gaining 25-30g/day through 3 months, then 15-20g/day from 3-6 months (see helpful table in case discussion). Total intake in the day should be no more than 32oz. There is some evidence that using larger bottles (>=6 oz) at 2 months may be associated with feeding too much at one time, and with more rapid weight gain/overweight at 6 months.
  2. Parents often ask about how to choose a formula-what should we say?: Although claiming unique properties, all of the major standard formulas commercially available are essentially similar and contain enough vitamins and minerals to meet babies’ needs. If fully formula-fed, vitamin D should be adequate to meet 400 IU daily. There should never be an indication to use “low-iron” formulations. There is mixed evidence on whether adding long-chain fatty acids DHA and ARA to formulas has benefit for vision and cognition; nonetheless, these are now routinely added to most formulas in the US. Check out info for parents on choosing a formula from the AAP healthychildren website on choosing a formula
  3. What are recommendations for preparing formula? This is important to know and families should follow labels carefully. (I will always remember a baby brought to us at clinic seizing and hypoxic from hyponatremia due to inproperly mixed formula.) For powdered formula, it is typically 1 scoop for every 2 ounces. Fill the water first, then add the powder. In places with safe drinking water, standard tap water can be used without boiling (heavy boiling may increase concentrations of lead, in fact). Be cautious about well water – this should be tested for lead and other heavy metals. There is some concern about mild fluorosis if formula is mixed with fluoride-containing water – in which case you can sometimes mix with bottled water. At room temperature, discard formula not used within 2 hours. Refrigerated formula should be discarded after 24 hours.
  4. When should we consider switching formulas? Most infants tolerate standard formulas and do not require switching. Parents often ask about switching formulas when babies have irritability and colic, which are unlikely to improve because of a formula change. Infants with specific GI symptoms, such as diarrhea, constipation, blood in the stool, and excessive gas are more likely to benefit from a formula switch.
  5. When should infants have special formulas? Soy-based formulas can treat some cow-milk formula intolerance, whether from lactose intolerance or cow milk protein allergy. Infants that have an IgE-mediated cow milk allergy may switch to soy-based formula, though up to half of infants allergic to cow’s milk may also not tolerate soy. In these cases, hydrolyzed formulas are required (such as Alimentum, Nutramigen, Pregestamil, and Neocate). These formulas are 3-4 times more expensive and may require prescriptions to be covered by insurance/WIC, though most are available over the counter. (See the helpful table to review these in the article above).

2019-20 TOW #5: Breastfeeding

Promoting breastfeeding in infants represents our earliest opportunities to influence nutrition and health for the lifetime. Among the many reasons to promote breastfeeding, the emerging data on how breastfeeding affects the microbiome for infants is pretty amazing. This data may help us better understand why breastfed babies get fewer infections and have other health benefits. Another benefit of breastfeeding: babies get exposed to flavors of healthy foods, and are more likely to eat them later.

Take-home points on breastfeeding challenges:

  1. What are the indicators of successful lactation to assess at initial well visits? Mother: milk is in, not too engorged, minimal nipple soreness with latching (should be improving, get better after first few sucks each feeding); starting to adjust to her newborn and has social support; Baby: feeding on both breasts 8-12 times in 24 hours, satisfied after 30-40 minutes of nursing; gaining 25-30 grams a day.
  2. What are the main problems with breastfeeding that often lead to early cessation? Primary breastfeeding challenges include poor latch, nipple pain, and problems with milk supply. While nearly all mothers try breastfeeding, almost half stop after a few weeks due to these challenges (and many others due to having to return to work without adequate support for breastfeeding). Most challenges are treatable with support from us, lactation specialists, and family/social support. Only about 5% of moms actually have physiologic problems that lead to inadequate supply.
  3. How can we help with these challenges? We need to know a few basics: observe feeds so we can help with latch in different positions, assess nipple pain (should improve with better latch and with time. but if not think of fungal and bacterial infections and vasospasm as causes), and help with milk supply. If milk supply is an issue, recommended strategies include rest, hydration, breast compression, and increased stimulation through feeding and pumping, and galactogogues including Reglan, fenugreek and oxytocin nasal spray.
  4. Why are late preterm infants at special risk for difficulty breastfeeding? Some appear large (6-7 pounds) but can be breastfeeding “imposters”; appear to be feeding well but are not transferring enough milk and not gaining weight well. They need extra attention, clear feeding plan, and benefit from early and ongoing lactation support to help them get there.
  5. How do we decide if a mom’s medication is compatible with breastfeeding? Look it up on LactMed, the NIH sponsored website to provide information about drugs and other chemicals while breastfeeding.

2018-19 TOW #39: Nutrition and picky eating

This is a topic close to my heart, and it’s really a rich, packed one. Please try to digest (pun intended!) whatever element is most helpful for you to learn/review.

Materials for this week:

Take-home points:

  1. What should we recommend for children to eat? The American Heart Association and AAP say diets should focus on fruits and vegetables, whole grains, low-fat dairy, beans, fish, and lean meat. (I like Michael Pollen’s 7-word summary: “Eat food, not too much, mostly plants.”) Biggest dietary room for improvement for all ages (kids to adults): cutting down on added sugars (in everything from bread to yogurt to drinks), and eating less processed foods. As the daughter of a cardiologist, I’ve watched with interest the debates over fat and animal fats in our diets. As in many health-related issues, the answer seems to be “it depends”: some people are more susceptible to lipid changes with animal fats, even when maintaining a healthy weight, but for others, animal fats in moderation may be okay, and is certainly preferable to added sugars.
  2. How we eat not just what we eat matters. There’s certainly some truth to the adage “we are what we eat,” (best dramatized by the movie Super Size Me), but it’s also “we are HOW we eat.” Our society has emphasized food on the go, and there’s been a growing interest in teaching children a more balanced message: mindful eating (which our own amazing Dr. Lenna Liu teaches about), raising our own food through gardening, and creating a positive environment for eating without distractions.
  3. Review with families the Division of Responsibility for feeding, especially for picky eaters (“parent is responsible for what, where, when and child is responsible for how much”). Ellyn Satter, a child dietitian who developed this model, reminds us of key elements: make eating times pleasant (no pressuring, battles, cajoling, etc.), only offer water between snacks and meals, be aware of lack of food experience while not catering to likes and dislikes. When giving new foods, offer along with ones kids already know. Children can self-regulate and recognize when they are full or hungry. It’s typical to taper off food intake between 15 months and 3 years as growth rate slows, termed “physiologic anorexia.” I like to show parents how the BMI chart goes DOWN during these times, and that it is expected they will look skinnier (and will seem much pickier!)
  4. Portion size matters as a cue to eating/hunger, with more evidence for effects in toddlers/preschoolers and up, but some evidence this may even be true for infants. One study found that 2 month old babies who were formula fed using large bottles (holding >=6 oz.) gained more weight by 6 months than babies fed with bottles <6 oz.
  5. Promote interaction not distraction during meals. Media has a pervasive influence on children’s food choices and even young children are heavily marketed to by the food industry. Watching TV during meals is associated with kids’ poorer food choices in multiple studies. Sitting together for meals has many positive effects, and doesn’t just have to be at dinner, but can be any meal. To spur interaction, we have found it helpful to start our family dinners with a gratitude practice.

TOW #33: Eating disorders

This week’s topic is Eating Disorders, in recognition of National Eating Disorders Awareness week. This is a tough diagnosis for multiple reasons. Thankfully we have our wonderful adolescent medicine colleagues locally to provide expert guidance on this topic, so help is close by.

Materials for this week:

Take home points to review about Eating Disorders:

  1. Epidemiology: Once thought of as primarily a problem for white upper middle class females, unfortunately, the number of males and minority tweens/teens of both genders with disordered eating has increased in recent years, with up to 14% meeting criteria for disordered eating NOS. About 0.5% of female adolescents are diagnosed with anorexia and 1.5% with bulimia. Teens are particularly high risk during times of transition, and also in highly competitive athletics.
  2. Clinical definition: Eating disorders involve dysfunctional eating habits (may include restrictive eating and binge/purging), weight changes, and body image distortion with intense fear of gaining wt. Suspect in patients who fail to maintain weight in adolescence (especially concerning if <85% of ideal body wt, IBW), or who have amenorrhea, cold intolerance, constipation, headaches, fainting or dizziness. Ask about satisfaction with weight, efforts to control weight, exercise, and changes in diet. The female athlete triad is defined by low energy with or without eating disorder, hypothalamic amenorrhea, and osteoporosis. (DSM-5 criteria are in Tables 1 & 6 in the Peds in Review article).
  3. Physical exam: Some patients have normal exams, and patients with bulimia may have normal weight. Vital sign changes are important including bradycardia, hypothermia, and orthostatic changes. Skin findings may include acrocyanosis, lanugo, peripheral edema, and muscle atrophy. “Russell sign” is callus/abrasion over the MCP/PIP joints from tooth scraping while inducing vomiting. Also look for worn tooth enamel and salivary gland enlargement from purging.
  4. Work-up: Review wt trajectories/changes, and compare weight to median BMI (50th percentile BMI for age on growth chart, which is the ideal body wt). The current weight is divided by the IBW. In primary care it is more important to diagnose medical complications of eating disorders and refer for psychological management. Labs to consider initially are BMP (electrolyte, BUN, glucose abnormalities), ESR (to rule out systemic inflammation), and CBC (assess for malignancy/anemia).
  5. Management: Eating disorders represent complex physical and mental health disorders with high mortality rates. Refer to adolescent medicine for multidisciplinary care. If acutely ill/worsening, determine if patient meets criteria for inpatient admission in consultation with adolescent specialists (see AAP guidelines for hospitalization in Table 4 of this review). Provide regular follow-up as PCP for overall health/support and encouragement to engage in treatment. SSRIs may be considered for concurrent depression/anxiety, especially with bulimia.

TOW #12: Iron deficiency anemia

One of the major nutritional deficiencies worldwide is iron deficiency (ID) and iron deficiency anemia (IDA), so it’s an important area of pediatric nutrition for us to review and understand.

Materials for this week:

Take-home points:

  1. Epidemiology: Since the 1970s we have made significant progress identifying and screening for iron deficiency, but it remains the most common nutrient deficiency worldwide. In the US it is estimated that about 8% of infants and toddlers have iron deficiency. Some believe this may be underestimated (see Magge et al).
  2. What are the effects of iron deficiency? Iron deficiency is associated with poorer cognitive and social-emotional outcomes and has  persistent effects, but treatment can improve outcomes. Unfortunately, most of that data is from developing countries; in a systematic review for the USPSTF, data were lacking in developed countries, and no RCTs were available for routine screening to prevent IDA.
  3. Who should we screen? Iron deficiency screening is recommended by the AAP for all children between 9-12 months: labs recommended vary. At a minimum Hct/Hgb identifies anemia and adding Zinc Protoporphyrin to Heme ratio (ZPPH) (an inexpensive and widely available test) can help identify iron deficiency that precedes anemia (but note ZPPH is also elevated from lead and anemia of chronic disease).
  4. What are important risk factors for iron deficiency? Risk factors include prematurity, cow milk consumption before 1 year of age, drinking more than 24 oz/day of cow’s milk per day after 1 year, low income status, and restricted diets for any reason.
  5. What is the recommended treatment? Treat iron deficient children with 3-6 mg/kg of elemental iron daily until sufficient and then 2-3 months after to ensure adequate iron stores. Typically we repeat blood tests 1-3 months after starting therapy (some test at 1 month, others wait until further in) to ensure response and compliance and/or do additional work-up if not improving.

TOW #38: Nutrition and picky eating

We continue National Nutrition Month with another nutrition-related topic: nutrition guidance and picky eating. This is a topic close to my heart, and it's really a rich, packed one. Please try to digest (pun intended!) whatever element is most helpful for you to learn/review. 

Materials for this week:

Take-home points:

  1. What should we recommend for >2 year olds to eat? For those age 2 years and older, the AHA recommends a diet that relies on fruits and vegetables, whole grains, low-fat dairy, beans, fish, and lean meat (frankly, that mostly applies to under 2, just in different forms). Biggest dietary room for improvement for all ages (kids to adults): cutting down on added sugars, which are in everything from bread to yogurt to beverages, and eating less processed foods. As the daughter of a cardiologist, I've been watching with interest the debates over fat and animal fats in our diets. As in many health-related issues, the answer seems to be "it depends": some people are more susceptible to lipid changes with animal fats, even when maintaining a healthy weight, but for others, animal fats in moderation may be okay, and is certainly preferable to added sugars.
  2. How we eat not just what we eat matters. There's certainly some truth to the adage "we are what we eat," (best dramatized by the movie Super Size Me showing the effects of a purely fast food diet), but it's also "we are HOW we eat." Our society has emphasized food on the go, and there's been a growing interest in teaching children a more balanced message: mindful eating (which our own amazing Dr. Lenna Liu has been teaching residents about), raising our own food through gardening, and creating a positive environment for eating without distractions.
  3. Review with families the Division of Responsibility for feeding, especially for picky eaters ("parent is responsible for what, where, when and child is responsible for how much"). Ellyn Satter, a child dietitian who developed this model, reminds us of key elements: make eating times pleasant (no pressuring, battles, cajoling, etc.), only offer water between snacks and meals, be aware of lack of food experience while not catering to likes and dislikes. When giving new foods, offer along with ones kids already know. Children can self-regulate and recognize when they are full or hungry. It's typical to taper off food intake between 15 months and 3 years as growth rate slows, termed "physiologic anorexia." I like to show parents how the BMI chart goes DOWN during these times, and that it is expected they will look skinnier (and will seem much pickier!)
  4. Promote interaction not distraction during meals. Media has a pervasive influence on children's food choices and even young children are heavily marketed to by the food industry. Watching television during meals is associated with kids' poorer food choices in multiple studies. Sitting down at a table for meals with others is preferred. It doesn't have to be at dinner, if that doesn't work for families, but find meals they can eat and enjoy together regularly. We have found one way to do this is to start our family dinners with a gratitude practice.
  5. Portion size matters as a cue to eating/hunger, with more evidence for effects in toddlers/preschoolers and up, but some emerging evidence this may even be true for infants. A study published in Pediatrics in 2016 found that 2 month old babies who were formula fed using large bottles (holding >=6 oz.) gained more weight by 6 months than babies fed with bottles <6 oz.

TOW #37: Failure to thrive

It's national nutrition month, so we are going to focus on a couple of nutrition-related topics this month. Next up in TOW-land: failure to thrive. Some of the approach to this topic has evolved, including starting with less medicalization/work-up and reserving hospitalization to limited situations. Great clinical pearl from the astute R3 Dr. Caleb Stokes MD PhD: "someone in Canada (where everyone is nicer) gave me the suggestion of calling it "slow to thrive" so new parents don't feel like they or their child is failing." 

Materials for next week:

Failure to Thrive (FTT) take-home points to review:

  1. Diagnosis of FTT starts with appropriate growth measurement and correct data input on the growth chart/EMR. Re-measure when a child plots below the 5th percentile (or any measurement not tracking) to ensure accuracy. FTT can be missed or misdiagnosed due to incorrect measurement/ data input. In children less than 2 years of age, we use recumbent length (not height). Measure head circumference until age 3.
  2. Plot the growth trajectory on the appropriate chart. Use the World Health Organization (WHO) charts for children aged 0 to 2, Centers for Disease Control and Prevention (CDC) charts for children over 2, or a need-specific growth curve (e.g., premature infants, Down syndrome) available from the CDC.
  3. FTT is not considered a syndrome but is a physical sign of inadequate nutrition to maintain growth. It has several definitions: most common being less than 3rd percentile weight-for-age on more than one occasion OR crossing two major percentiles (90th, 75th, 50th, 25th, 10th, and 5th) downward. Shifts in percentiles can be normal in healthy developing children. In one study, between birth and 6 months of age, 39% of healthy children crossed two major percentile lines (up or down), as did 6% to 15% of children between 6 and 24 months of age.
  4. Use the history and physical to help differentiate FTT etiology: 1) inadequate caloric intake, 2) inadequate absorption, 3) excess demand or 4) inadequate utilization (or some combination). There are no routine lab tests for FTT and only 1-2% of diagnostic tests ordered in the hospital for FTT evaluation help to establish an etiology. If no obvious concerns on history or physical suggest medical disease, we can start nutritional and social therapy before obtaining more work-up (which might inlude CBC, urinalysis and lead levels). FTT due to low caloric intake will result in decreased weight followed by decreased height (stunting), and finally, if severe, decreased head circumference. Head circumference tends to be spared from , so think about congenital abnormalities if there is a pattern of more symmetric decrease across all three growth parameters.
  5. Hospitalization for FTT should be limited to more severe cases not responding to intervention or for short stay where coordinating multidisciplinary care is considered most helpful. Note that in-hospital weight gain has been studied, and has not been shown to be sensitive or specific indicator for non-organic FTT.