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 9-1

Instructor’s Manual1 for Chapter 9 – Infant Nutrition:

Conditions and Interventions
Resources Included in This Document
1. Lists of chapter learning objectives and key terms
2. “Lecture launcher”: dialog about the effects of illness
3. Assignment worksheets with answer keys: preterm infant nutrition, nutrition calculations
4. Answer keys for textbook case studies 9.1 and 9.2
5. Chapter outline/summary
6. List of relevant websites organized by topic
7. Internet activities: (A) ECTA Center site evaluation, (B) Down syndrome growth charts,
(C) specialized formula comparison
8. Discussion questions
9. Classroom activities: (A) specialized formulas, (B) MCT oil

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

© 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.
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):

• What restrictions did the condition impose?

• Did the individual’s personality change?

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 Answer Key (worksheets appear at the end of this document)

Worksheet 9-1: Case Study—Tube Feeding Plus Oral Food Intake

1. Page 269: “Preterm infants who were VLBW or ELBW need infant feeding guidelines based
on their adjusted gestational age. As an example, the recommendation for adding food on a
spoon at 6 months would be adjusted to 8 months for an infant who was born at 32 weeks
of gestation.”
2. Based on a correction for gestational age, Emma is at the six-month measurements on the
growth charts. Her weight is at the ~45th% and her length is at the ~55th%.
3. See Table 9.5.
4. Federal disability programs, Individuals with Disabilities Education Act (IDEA) Part C, and
Early Head Start.

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

Textbook Case Study Answer Key2

Case Study 9.1: Premature Birth in an At-Risk Family

1. No, Eric had catch-up growth, and his small head size and possible diagnosis of fetal
alcohol syndrome better explain his growth pattern than his premature birth.

2 Contributed by Janet Sugarman Isaacs

© 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.
 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.

Case Study 9.2: Noah’s Cardiac and Genetic Condition

1. The same way that breastfeeding benefits any newborn. It cannot correct the unusual
growth or the genetic defect, but it was valuable in the family’s viewpoint, and may help
them accept their son’s special needs.
2. Growth recommendations are customized for the special needs of the child. There were
other indicators that Noah had sufficient nutrition in having good fat stores and gaining
consistently, even if at a slower rate than that of other children.
3. The parents did not agree that their baby needed any services. This coping style of denial is
very common and did not prevent them from enjoying being parents. Noah’s parents will
likely accept more services when they realize Noah needs them; but it may be several years,
especially for the learning problems that come with this diagnosis.

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.

II Energy and Nutrient Needs

The needs of each infant are unique. Needs are met through individualized, closely
monitored, and frequently modified approaches. Energy needs are given as adequate
calories to gain 15 grams per day, which is about 1 pound per month. Caloric needs range
from 110-135 cal/kg for a preterm infant, up to 180 cal/kg for an extremely-low-
birthweight infant. Fast-growing infants require protein-sparing diets, meaning the diet
supplies enough carbohydrate and fat to prevent amino acids from being used for energy.
For preterm infants, 3-3.5 g/kg and even up to 4 g/kg of protein (for ELBW or extremely
low birthweight) are not unusual. Amino acid mixtures may be used when infants are
unable to break down regular proteins. Fat intake may be as much as 55% of calories and
fat is generally not restricted until after two years of age. Medium-chain fatty acids provide
nutrition when the infant is unable to metabolize long-chain fatty acids in milk. Use of
vitamins, minerals, and human milk fortifiers is customized according to infant need.

III. Growth
The goal for a newborn’s first year is to maintain growth appropriate for age and gender.

© 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.
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.”

IV. Nutrition for Infants with Special Health Care Needs

Table 9.1 categorizes the nutritional concerns of infants with special health care needs (i.e.,
growth, nutritional adequacy, feeding). An example of a condition with developmental delay
affecting nutrition is Down syndrome (p. 261). Growth charts specific to Down syndrome
infants help each family track their infant’s unique progress.

V. Severe Preterm Birth and Nutrition

VLBW (very low-birth weight—near 1500 grams) and ELBW (<1500 g) infants require
intensive care at minimum and potentially nutrition support via parenteral or enteral
feedings. Infants born at 23 to 32 weeks of gestation have not had time to develop and face
life-long risk for increased health complications and developmental problems. The
nutritional focus centers on providing adequate calories for growth and food safety. Oral
feeding helps to keep the gut healthy, partly due to stimulation that helps to keep the small
intestine’s absorptive surface intact. However, nutrition support may be necessary.
Comparisons of nutritional composition of preterm and term formulas (Table 9.2) and
feeding differences (Table 9.3) highlight some of the special needs of sick infants.

VI. Infants with Congenital Anomalies and Chronic Illness

Individualizing treatment and tracking progress are especially important for high-risk
infants, such as those with congenital anomalies (e.g., cleft lip and palate) or genetic
disorders (e.g., DiGeorge syndrome). The CDC publishes data for states and hospitals
participating in voluntary surveillance programs for infant mortality attributable to birth
defects (p. 266). Since folic acid fortification in grain products began, rates of spina bifida
and related conditions have declined significantly.

VII. Feeding Problems

Feeding difficulties are common in families with VLBW infants who are less able to signal
their wants and needs than healthy infants. Feeding guidelines are usually based on the
infant’s ability to give recognizable hunger and thirst cues. Adjusting for gestational age
helps caretakers to predict expected behaviors and avoid overfeeding that can lead to GI
discomfort. Table 9.5 provides signs of feeding problems in infants.

VIII. Nutrition Interventions

Nutrition interventions are geared to specific problems; nine (bulleted, pp. 269-270)
approaches to potential interventions are listed. Examples of special formulas for specific
conditions (Table 9.6) indicate the range of potential interventions.

IX. Nutrition Services

Federal programs provide wide access to services that can help early on in a child’s life; five
are listed on page 270.

Internet Resources At-a-Glance

In textbook
• Science of Nutrition
• National Library of Medicine: [Link]/pubmed

© 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.
 9-5

• Institute of Medicine Food and Nutrition Board: [Link]/fnb

• Infant Nutrition—Conditions & Interventions

• Emory University, Department of Pediatrics: [Link]/PEDS
• Mead Johnson Nutrition: [Link]
• Nestle Corporation: [Link]
• Abbott Nutrition (select ”Categories,” then “Infant & New Mother”):
[Link]
• United Cerebral Palsy: [Link]
• Neonatology on the Web: [Link]

• Public Food & Nutrition Programs

• National Association of Councils on Developmental Disabilities: [Link]
• Early Childhood Technical Assistance Center: [Link]
• National Organization on Fetal Alcohol Syndrome (NOFAS): [Link]

Additional sites
• The web site for the Division of Developmental Disabilities of the Centers for Disease
Control and Prevention oversee is at
[Link] This site provides up-
to-date information on birth defects.

Exploring the Internet: E-Trips

A. Go to the Early Childhood Technical Assistance Center ([Link] and explore

the nutrition advice for one of the various conditions discussed in this chapter. Evaluate
the nutrition advice. Who is the target audience for this site? When was the site last
updated (i.e., is current nutrition advice being given)? Does it answer your questions (e.g.,
questions about medications, sleeping patterns)? Is the nutrition advice comprehensive and
supported by documentation? Is there a contact person for further questioning? Under
what circumstances could a parent use this site?

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).

© 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.
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.]

© 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.
 9-7

Worksheet 9-1: Case Study—

Tube Feeding Plus Oral Food Intake
Emma, eight months old, was born at 32 weeks gestation with fetal alcohol spectrum
disorder and a heart murmur due to maternal alcohol abuse. She has lived with a
foster mother, who would like to adopt her, since she was two months old. Emma has
had multiple complications from her premature birth (e.g., needing to be tube fed via a
nasogastric tube for the first eight weeks of life) that have necessitated the use of
tubes in her nose and throat. This has resulted in an aversion to having anything
placed in her mouth including a feeding tube or a spoon. Emma has been fed regular
infant formula through a gastrostomy tube since she was two months old. Her current
weight is 15 pounds 5 ounces and her length is 26”. Emma’s foster mother is looking
forward to starting solid foods with Emma this week per her pediatrician’s advice.

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?

© 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.
9-8

Worksheet 9-2: Calculating the Nutrition Needs of Infants with

Special Health Care Needs
Directions: Use the information in the “Energy and Nutrient Needs” section of
Chapter 9 to complete this worksheet.

1. Calculate the calorie needs for a 5 pound, 8 ounce preterm infant according to the
American Academy of Pediatrics guideline.

2. Compare the answer to question #2 with the calories recommended by the

European Society for Gastroenterology and Nutrition for the same infant.

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.

6. What physical sign is an indication of adequate protein intake?

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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