Professional Documents
Culture Documents
Learning Objectives
9.1 Describe factors that make infants at risk and how nutritional assessment and
interventions address these risks.
9.2 Compare how energy and nutrition needs are interpreted for preterm infants and infants
with special health care needs in contrast to healthy full-term infants.
9.3 Identify how growth is tracked and interpreted within nutrition assessments for infants at
risk or with special health care needs.
9.4 Describe nutrition problems commonly addressed for preterm infants and infants with
special health care needs.
9.5 Identify the nutrition problems during infancy after sever preterm birth that are not
found in infants with full-term births.
9.6 Describe examples of nutrition assessment and interventions for infants with congenital
anomalies and chronic illness.
9.7 Identify infants with feeding problems and appropriate nutrition services for them.
9.8 Identify terminology used in providing high-quality nutrition services as part of health
care teams.
9.9 Describe how families access nutrition resources and services in their communities for
infants at risk or with special health care needs.
Key Terms
children with special health hypocalcemia jejunostomy feeding
care needs microcephaly early intervention program
low-birthweight infant (LBW) macrocephaly congenital anomaly
very low-birthweight infant developmental delay anencephaly
(VLBW) autism diaphragmatic hernia
extremely low-birthweight nutrition support tracheoesophageal atrasia
infant (ELBW) parenteral feeding cleft lip and palate
fetal death or stillbirth enteral feeding maple syrup urine disease
Down syndrome necrotizing enterocolitis (NEC) chromosome 22Q11.2
seizures oral-gastric (OG) feeding deletion syndrome or
MCT oil transpyloric feeding (TP) DiGeorge syndrome or
catch-up growth gastrostomy feeding 22q11 microdeletion
1revised by Nadine Kirkpatrick, Sacramento City College, and Carrie King, University of Alaska
at Anchorage; originally by U. Beate Krinke, University of Minnesota
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9-2
Lecture Launchers
• Brief Dialogue (3 minutes, students in pairs): Ask students to think of the most seriously
ill person they know. Then ask them to discuss, with the student next to them, the effects
of this person’s condition on her or his life. Tell students: “As you think of the person who
has/had the condition, answer these questions” (write questions on board):
Debrief (whole class): Take a poll to find out about the types of illnesses with which
students are familiar. Generate a list of restrictions. Do students think these are
manageable or not? Do students believe that serious illness affects one’s personality or
changes the person?
Worksheet 9-2: Calculating the Nutrition Needs of Infants with Special Health Care Needs
1. 5.5 pounds 1 pound/2.2 kg = 2.5 kg
2.5 kg 120 kcal/kg = 300 calories
2. 2.5 kg 110-135 calories/kg = 275-338 calories
3. The infant will gain approximately 15 grams per day (p. 255).
4. 7.25 pounds 1 pound/2.2 kg = 3.3 kg
DRI = 3.3 kg 108 kcal/kg = 356 calories
Down syndrome infant should receive < 356 kcal/day to avoid excessive weight gain
5. 5.3125 pounds 1 pound/2.2 kg = 2.4 kg
2.4 kg 3.0-3.5 grams protein/kg = 7.2-8.4 grams of protein
6. Head circumference growth (p. 257).
7. 300 calories 55% calories from fat = 165 calories 9 calories per gram of fat = 18.3 grams
of fat
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9-3
2. The developmental delay probably started early in pregnancy with the formation of the
brain being affected by alcohol and drugs, so nutrition was not directly involved.
3. Eric is getting all the best interventions available in a loving family and enriched early
education, but it is unlikely that he will outgrow his consequences of his early abnormal
brain development. He is still at risk for learning problems and mental retardation.
Chapter Outline
I. Introduction
“Most infants are born healthy” (p. 253) but some are “children with special health care
needs.” Chapter 9 has a clinical or medical nutrition focus and uses many terms specific to
medical conditions. Learning metric to English conversions for height and weight
measurements as well as the many clinical margin definitions will be useful for describing
and understanding conditions that can affect the growth and development of children.
Infants at Risk. More small preterm infants (501-600 grams, the typical weight at 23
weeks of gestation) are surviving to childhood than ever before. They often have chronic
conditions that affect feeding and nutritional status. Three main risk categories are:
1) infants born before 34 weeks of gestation, 2) infants born with consequences of abnormal
development during pregnancy such as Down syndrome, a genetic syndrome, and
3) infants at risk for chronic health problems such as a challenging home environment.
Just as for healthy infants, questions about growth, dietary adequacy, and feeding patterns
are used to assess nutritional status (p. 253). However, the standards for preterm infant
comparison are different.
III. Growth
The goal for a newborn’s first year is to maintain growth appropriate for age and gender.
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9-4
Slow growth may signal underlying conditions; monitoring helps to pinpoint problems. (Six
management approaches are bulleted on p. 257.) An important concept for infant nutrition
is “gestational age.” Correcting for gestational age in preterm infants is described on p. 257.
For an example of how such a correction is used, see Table 9.4. Intrauterine growth may or
may not predict outside growth, but catch-up growth (1-3 years post-delivery) eventually
allows use of standard growth charts. Growth charts allow each infant to serve as his or
her own “control.”
In textbook
• Science of Nutrition
• National Library of Medicine: www.ncbi.nlm.nih.gov/pubmed
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9-5
Additional sites
• The web site for the Division of Developmental Disabilities of the Centers for Disease
Control and Prevention oversee is at
http://www.cdc.gov/ncbddd/developmentaldisabilities/index.html. This site provides up-
to-date information on birth defects.
B. Search the web for growth charts for an infant with Down syndrome. Are they gender-
specific? What sets them apart from the CDC growth charts? List 3 benefits of disease-
specific growth charts and 2 reasons why all infants should use the same growth charts.
C. Select two special infant formula preparations and compare the macronutrients and
vitamins and minerals provided. What are the similarities? What are the differences?
Discussion Questions
A. What does it mean to be an infant at risk? Name some conditions that result in
classification as an at-risk infant. What do these conditions imply for nutritional health?
B. This chapter’s author states that Chapters 8 and 9 “model sensitive communications with
families by avoiding the word normal and, by implication, abnormal when referring to
children with special health care needs.” In your opinion, is “standard growth” a more
acceptable term than “normal growth” or “typical” growth? What do these terms mean to
you? Generate a few examples of “family-friendly” phrases to describe infants with
conditions that place them at nutritional risk (such as VLBW or Down syndrome).
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9-6
C. Parents of a child with special needs may grieve for the loss of their hoped-for perfect or
healthy child. Think of an occasion where you or someone you know grieved for a loss. How
did grief affect your (or the other person’s) eating habits?
D. Describe examples of required adjustments made in the assessment and intervention for an
infant with a special condition. [Specialized growth charts for Down syndrome, greater
caloric and protein density in diets for LBW (under 2500 grams) infants; a list is included in
Chapter 11.] Why is it (or not) in the public health interest to develop unique tools for
special needs infants?
E. “Body fat build-up is a late sign of recovery from preterm delivery” (p. 257). Why is this
true? How might you assess build-up of body fat in an infant?
F. The WIC program includes birthweight in its infant risk assessment. What makes
birthweight a useful contributor to a risk profile?
G. Discuss factors contributing to IU growth (p. 257) and how these affect subsequent growth
of an infant. What is typical catch-up growth for infants (p. 260)? What are factors that can
slow growth?
H. “The first goal of nutritional care is to maintain growth for age and gender” (p. 256). Pretend
that you are the parent of a child with special needs. Discuss the nutritional implications of
this statement for your household. For example, how might this philosophy affect your
feeding relationship with the infant? With siblings of this infant?
Classroom Activities
A. Homework and role playing: Pretend that you are the sales representative for a formula
manufacturer. Develop 3-5 talking points for promoting each of the formulas in Table 9.2
(p. 264). Based on the nutrient composition, who is the target market for the formula? Can
you identify whether formula manufacturers specifically target a cultural or ethnic minority
group? What is one question you might anticipate from potential users of each of the
formulas? Go online and find an online address for one of the formula manufacturers (i.e.,
Mead Johnson Nutrition, Abbott Nutrition, Novartis, Nestle). Do their marketing points
match the ones you developed? Answer the question that you thought would be asked by
potential users. In class: Team up to role-play sales rep and consumer or health
professional. (If time permits, have team members trade places.) Debrief the class to
summarize talking points for each formula and clarify areas that were inaccurate or
confusing.
B. Homework—MCT oil: The goal of the activity is to further students’ understanding on the
implications of “adding special products.” Locate the article, Hay WW, Jr. (2008) Strategies
for feeding the preterm infant. Neonatology 94(4): 245-254. Have the class comment on the
recommendations for adding products to foods. What would be the challenges as the infant
becomes a toddler and still needs extra calories? Of note, the estimated cost of MCT oil is
$20/quart. Calculate the cost of trying to add 1 ½ tsp MCT oil with food at meals three
times per day. [1 qt = 4 cups = 192 tsp; $20 192 tsp = $0.104/tsp 1.5 tsp 3/day =
$0.47/day.]
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9-7
Questions:
1. Why would Emma’s physician want to delay the introduction of solid foods until
she is eight months old?
2. How are Emma’s height and length for her age? (Hint: remember to account for
gestation-adjusted age!)
3. What signs of feeding problems should Emma’s foster mother monitor her for?
4. What are some examples of nutrition services that Emma would be eligible for?
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9-8
1. Calculate the calorie needs for a 5 pound, 8 ounce preterm infant according to the
American Academy of Pediatrics guideline.
3. How will you know if the estimated calorie level is appropriate for the infant?
4. Calculate the calorie needs for a 7 pound, 4 ounce infant with Down syndrome.
5. Calculate the protein needs for a 5 pound, 5 ounce LBW infant at birth.
7. For the infant in question #1, determine the maximum amount of fat that should
be provided.
© 2014 Cengage Learning. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part, except for use as permitted in a
license distributed with a certain product or service or otherwise on a password-protected website for classroom use.
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The Project Gutenberg eBook of
Henkivakuutusherroja
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Title: Henkivakuutusherroja
Romaani
Language: Finnish
Romaani
Kirj.
VEIKKO KORHONEN
— Ai perhana!
— Ka, sinä lempoko siinä. Kun kulkee kuin lehmä kadulla, alkoi
Varsala purkaa sisuaan.
— Älä.
— Vai pääsi poika ylenemään. No, nythän sinä saat tuntea, miten
ihanaa on olla henkivakuutusherrana. Useimmiten toiset tekevät
työn, ja me saamme niittää sadon, ainakin mitä tantiemiin tulee.
Meidän on tosin pidettävä huoli kilpailusta ja siitä, että asiamiehet,
joille varsinainen työnteko kuuluu, eivät pääse laiskottelemaan,
mutta sehän tehtävä onkin kaikkein helpoimpia. Ja ajatteles, ethän
sinä enemmän kuin minäkään, tullessani Leimausyhtiön
palvelukseen ole suorittanut mitään tutkintoja tällä alalla, ainoastaan
ovelasti päättänyt muutamia tukkikauppoja maalaisten kanssa. Niistä
minut napattiin tähän toimeen. Huomasivat kai, että minussa on
liikeneroa ja että osaan olla ovela. Ja hyvin minä olen
menestynytkin, osaan herättää ihmisissä, varsinkin maalaisissa
luottamusta. Sen vaikuttaa ulkoasuni. Minä näes en komeile
vaatteilla. Olen sattunut usein toisten yhtiöitten samaan luokkaan
kuuluvien virkamiesten kanssa samaan aikaan hankinnalle ja tullut
huomaamaan, että kovin koreaa herrasmiestä katsellaan kansan
seassa hiukan sekavin tuntein. Minulla on siitä tuoreita esimerkkejä.
Viime viikolla yövyin erääseen taloon, jossa hieroin kymmenen
tuhannen vakuutusta, jota oli samana päivänä kärttänyt sinullekin
hyvin tunnettu Rientoyhtiön Keikaus. Kuulin miten isäntä arveli
emännälleen: — Tuo näyttää oikealta mieheltä! Se Keikaus oli niin
hieno mies ja isovatsainen. Taitaa syödä vakuutettaviensa varoja.
Mitäs, jos ottaisimmekin vakuutuksen Leimaus yhtiössä. Ja aamulla
se vakuutus päätettiin.
— Jospa se lienee niin kuin sanot. Mutta mitä muuta sanoisit vielä
ihmisiä piinatessa tarvittavan?
Varsala naurahti.
— Häh?
— Häh?
— Nousenhan minä.
— Ei ole.
— Kyllä.