Mgr. Martin Krobot Mgr. Kamila Jančeková Mgr. Sylva Šmídová Department of Public Health Public Health II – spring 2018 CHILDHOOD HYGIENE breastfeeding support • infant and toddler nutrition • growth charts • social pediatrics Breastfeeding support Not only milk drinking! •exclusive breastfeeding: •childhood and adolescence obesity prevention •decrease in infant mortality •lower incidence – atopic dermatitis, otitis media, URT infection, GIT infection •mothers – lower risk of postpartum depression, mammal and ovarial tu, T2DM, osteoporosis, rheumatoid arthritis •contraceptional effect •relationship between child and mother Childhood hygiene •Breastfeeding support Mutual look The child smells the mother The child tastes the milk The child touches mother‘s skin The child feels mother‘s touch on its back The child moves with its mother The child listens to mother‘s voice Author: Nils Bergman Skin-to-skin contact Mother provides warmth Stimuli for child‘s brain •Breastfeeding support Childhood hygiene Breast milk composition •specific for animal species •appropriate with lifestyle, genetics and individual needs •milk of bats low in water, milk of sea mammals higher in fat, milk of primates higher in carbohydrates •composition variable in time due to change in needs •transfer of information about child‘s needs during BF • •standard sample of BM doesn‘t exist due to variability 6 •Breastfeeding support Childhood hygiene Breast milk composition •colostrum •yellowish liquid •# protein (Ig), # minerals (Mg – peristalsis) •$ carbohydrates, fats •transient milk •mature milk • •composition isn‘t constant – according to child‘s needs 7 •Breastfeeding support Childhood hygiene Breast milk composition •energy: 280–290 kJ/100 ml •P : F : CH = 7–10 : 50 : 40 •protein: 0,9–1,3 g/100 ml •whey/casein ratio – digestibility •fats: 4 g/100 ml •lipase – easier digestion, rich in PUFA (DHA), cholesterole •carbohydrates: 7 g/100 ml •Lac (absorption of Ca, Fe), Fru, Gal (galactolipids for CNS development) •oligosaccharides – microbiota support 8 •Breastfeeding support Childhood hygiene Breast milk composition •minerals •less then in cow‘s milk (kidneys), suitable proportion •Ca:P = 2:1 •Fe absorbable up to 70 %, Zn, Cu, Co, Se well absorbed •low content of Fe and Zn – antenatal stores •protective factors •Ig, lactoferrin, lysozyme, macrophages, complement, interferons aj. •harmful substances •weight reduction during BF – lipophilic xenobiotics (PCB etc.) •medicaments, alcohol, drug etc. 9 •Breastfeeding support Childhood hygiene Proteins in breast milk 10 25 % np-N 8 % 2 % 8 % Breast milk Cow‘s milk 67 % Whey 8 % 8 % Casein 90 % 25 % np-N 2 % •Breastfeeding support Childhood hygiene Fats in breast milk •mature milk – small droplets •milk contains lipase – better digestion •SFA : UFA = 42–48 : 52–57 •rich in PUFA (linolic acid, linolenic acid, arachidonic acid, DHA – CNS and retina growth and development) •cholesterole (5x the amount in cow‘s milk, cell membrane development) • 11 •Breastfeeding support Childhood hygiene Imunologically active compounds 12 •Breastfeeding support Childhood hygiene DHA cholesterole substances supporting microbiota WHO recommendation •up to term. 6th month of age exclusive breastfeeding • • •up to 2 years of age and beyond introducing local nutritious food while breastfeeding 14 •Breastfeeding support Childhood hygiene Other recommendations •European Code Against Cancer (2014) •Breastfeeding lowers the risk of cancer in mothers. Breastfeed your child, if possible. •WHO •Breastfeeding is the most effective way for child health protection and support. •opinion of alergologists* •The most effective prevention of food allergies is exclusive breastfeeding for 4–6 months. 16 •Breastfeeding support *Pracovní skupina dětské gastroenterologie a výživy. Doporučení pracovní skupiny gastroenterologie a výživy ČPS pro výživu kojenců a batolat. Česko-slovenská pediatrie. 2014, roč. 69, č. S1, s. 12-13. ISSN 0069-2328. Childhood hygiene Risks rise when not breastfeeding •child •otitis media •gastroenteritis •atopic dermatitis •severe infection of LRT •necrotic enterocolitis •SIDS •obesity •T1 and T2 diabetes mellitus •asthma •leukaemia 17 • •mother •postpartum depression •T2 diabetes mellitus •mammal and ovarial tu Source: International Code of Marketing of Breast-Milk Substitutes •Breastfeeding support Childhood hygiene higher expenses for healthcare negative environmental impact Source: International Code of Marketing of Breast-Milk Substitutes Official breastfeeding support •WHO, UNICEF: •1981 – International Code of Marketing of BM Substitutes •1991 – Baby-friendly Hospital Initiative •1991 – Ten Steps to Successful Breastfeeding (WHO, UNICEF) • •CZ: •2007 – Standard practical instructions for BF in CZ (upgr. 2015) 19 •Breastfeeding support Childhood hygiene International Code of Marketing of BM Substitutes 20 „(...) if you decide to feed from the bottle, you will have two main advantages against breastfeeding mothers. First, you don‘t have to feed the child alone (…) second, you will know how much milk has your child drunk.“ „(…) bottle for breastfed children. Preserves natural way of suckling as in breastfeeding (…) facilitates switching from the breast to the bottle and back (…)“ „(…) first choice, closest to natural breastfeeding.“ •Breastfeeding support Childhood hygiene Situation before the Code •children were always BF – those who weren‘t didn‘t survive for long •if the mother couldn‘t breastfeed, she hired a wet nurse •for children, who couldn‘t be breastfed, the substitute was other mammal‘s milk •1867 – Henri Nestlé – „Farine Lactée“ – artificial nutrition for children who couldn‘t be breastfed (expansion until 1970s) •in developed countries breastfeeding started to rise thanks to support •artificial nutrition producers – developing countries, aggressive marketing (presents for healthcare workers, promotion aimed to mothers, samples) •Breastfeeding support Childhood hygiene International Code of Marketing of BM Substitutes •1979 – congress of WHO, UNICEF, government delegates and producers of BM substitutes – approved 1981 •recommended to incorporate into legislation • •aim – to contribute to adequate and safe infant nutrition through support and protection of BF against inappropriate marketing of BM substitutes, bottles and pacifiers • •in CZ it‘s not a part of legislation (not obligatory) 22 •Breastfeeding support Childhood hygiene Arrangements of the Code •No public promotion of these products •No free samples for mothers •No promotion in healthcare facilities •No consultants employed by the producers consulting mothers •No presents or free samples for healthcare providers •No text or images idealizing artificial nutrition, including images of children on the packaging 23 •Breastfeeding support Childhood hygiene Arrangements of the Code •Information for healthcare providers should be evidence-based and true •All information about infant formula including labels, should point to the benefits of breastfeeding, the cost of infant formula and its risks •Inappropriate products, eg. sweetened condensed milk, should not be promoted as appropriate for children •All products should be in high quality and take into account climatic and storage conditions of the country 25 •Breastfeeding support Childhood hygiene Remember: •Breast milk substitutes should always be used as the last alternative! • •Optimally in indicated cases only. 26 •Breastfeeding support Childhood hygiene Baby-friendly Hospital Initiative (BFHI) •initiative of WHO and UNICEF (1991) •worldwide effort to protect, support and promote breastfeeding •in CZ 65 out of 96 maternity hospitals •recertification every 5 years • •facility has to meet the criteria: •„10 steps to successful breastfeeding“ 27 Seznam BFHI nemocnic v ČR: http://www.kojeni.cz/maminkam/bfh/seznam-bfh-nemocnic/ •Breastfeeding support ! rev. 2017 ! Childhood hygiene The developement of the percentage of exclusively breastfed newborns after maternity hospital discharge (BFH and other maternity hospitals), Czech Republic The developement of the percentage of exclusively breastfed newborns and breastfed with formula supplementation after discharge by the type of hospital (BFH and other maternity hospitals), Czech Republic Breastfeeding until 6 months Long-term breastfeeding in CZ 2013 (in %) 6 weeks 80,3 3 months 63,7 6 months 38,6 Exclusive breastfeeding 6 weeks 27,5 3 months 15,3 6 months Not observed 30 •Breastfeeding support Childhood hygiene 10 steps to successful breastfeeding •? 31 •Breastfeeding support Childhood hygiene 10 steps to successful BF – 2017 •key clinical practices 1.Where facilities provide antenatal care, pregnant women and their families should be counselled about the benefits and management of breastfeeding. 2.Early and uninterrupted skin-to-skin contact between mothers and infants should be facilitated and encouraged as soon as possible after birth, and all mothers should be supported to initiate breastfeeding as soon as possible after birth, within the first hour after delivery. 3.Mothers should receive practical support to enable them to initiate and maintain breastfeeding and manage common breastfeeding difficulties. 4.Mothers should be discouraged from giving any food or fluids other than breast milk, unless medically indicated. 5.Facilities providing maternity and newborn services should enable mothers and their infants to remain together and to practise rooming-in throughout the day and night. 6.As part of protecting, promoting and supporting breastfeeding, discharge from facilities providing maternity and newborn services should be planned for and coordinated, so that parents and their infants receive the appropriate care and have access to supportive resources. 34 •Breastfeeding support Childhood hygiene 10 steps to successful BF – 2017 •critical management procedures 7.Facilities providing maternity and newborn services should have a clearly written breastfeeding policy that is routinely communicated to staff and parents. 8.Facilities providing maternity and newborn services should fully comply with the International Code of Marketing of Breast-milk Substitutes and relevant World Health Assembly resolutions. 9.Health-facility staff who provide infant feeding services, including breastfeeding, should have sufficient knowledge, competence and skills to support women to breastfeed. 10.Facilities providing maternity and newborn services should establish ongoing monitoring and data-management systems to monitor compliance with the clinical practices above. 35 •Breastfeeding support Childhood hygiene Skin-to-skin •immediately after the birth skin-to-skin contact of the child and its mother for at least one hour •for all mothers after vaginal labour or section without anaesthesia (except medicaly argued cases) •give enough time to the mother and child •support mothers to learn the signals of their child showing to be ready to be breastfed and offer help to mothers in case of need. •not force the child to the breast but help when the child is ready •Breastfeeding support Childhood hygiene •relationship between mother and child •it‘s not the result of nursing – its an instinctive system of the behaviour, expected by the child •it needs: •a closenes of the mother •carying by the mother •breastfeeding •expected mother‘s reaction to baby‘s crying images 2 •Breastfeeding support Skin-to-skin Childhood hygiene You could see… •the newborn can start sucking optimally on its own, if it has enough time (in the 55th minute on average) •the newborn is situated on the mother‘s belly only wiped dry •the hands aren‘t dried and no cap is given to the child •most of the newborn examinations can be carried out on the mother‘s body •skin-to-skin contact is ideal for managing normal body temperature, it controls breathing and heart rate, the child is calm and usually doesn‘t cry •uniterrupted contact between the mother and the child, rooming-in, begins right at the delivery room •Breastfeeding support Childhood hygiene You could see… •mothers after the section or total anesthesia can be skin-to-skin immediately after waking up •meanwhile, the child can be skin-to-skin e.g. with the father •children in need of special care should also have the possibility of skin-to-skin contact (otherwise the medical reason should be explained) •mother‘s body is better than an incubator •children after strenuous deliveries need more time (if the sucking couldn‘t start right after delivery, it can be compensated when possible) •Breastfeeding support Childhood hygiene •pay attention to the mothers, who faced breastfeeding problems in the past •teach the mothers: •breastfeeding positions •how to latch on the child (describe it, demonstrate it) •how to express the milk •help with the breastfeeding during first 6 hours after the labour (position, latching on, drinking...) •it‘s necessary to breastfeed or express the milk at least 8 times within 24 hours for good milk production • •Breastfeeding support Support of the mothers Childhood hygiene •teach the mothers how to identify their child is showing its will to be breastfed •the mothers should know at least 2 signals (turning head, opening mouths, the effort to suck the hand od finger etc. , sucking movements, dissatisfaction, the face pointing to crying... • •advise mothers to breastfeed as often and as long as the child wishes •Breastfeeding support Support of the mothers Childhood hygiene Lactation physiology The essential unit of glandular tissue is lobulus – racemous structure comprising of secretory cells (alveoli) and milk ducts. Alveols create milk from the nutrients coming through mother‘s blood. One breast contains cca 7–10 lobuli. Secretory cells are surrounded by myoepithelial cells. These cells, with their ability to contract, enable the milk to move from the alveolus to branched outlet system towards the nipple, where the nipple can suck it. Myoepithelial cells are present also in the walls of the ducts. •Breastfeeding support Childhood hygiene Stimulation of nerves in the nipple and areola by effective suckling Hypophysis stimulation Posterior pituitary oxytocin Myoepithelial cells milk expression Anterior pituitary prolactin Alveolar cells milk creation Engorged breasts Hypothalamus – prolactin inhibiting hormone (PIH) Lactation inhibition Lactation physiology •Breastfeeding support Childhood hygiene It follows that… Milk creation is affected by the amount of milk taken away by the child! If the milk isn‘t taken away, it‘s production decreases. • It is necessary to: 1. Effective suckling – monitoring and adjustment of suckling (position and swallowing, pause in the chin) 2. Unlimited access to the breast (length and frequency of breastfeeding = breastfeeding according to child‘s needs) → effective stimulation and emptying of the breast→ milk creation → the more milk is taken away from the breast, the more milk is created Every child has different capability of effective suckling and every mother produces and expresses the milk differently. Thus, every child needs different length and frequency of breastfeeding! •Breastfeeding support Childhood hygiene Four points for breastfeeding support •right position •right suckling •pause in the chin •breast pressing •Breastfeeding support Childhood hygiene Right position •Mother is pulling the child towards the breast with the whole forearm •Mother should feel comfortable – no back or shoulder pains •Transversal position (position of the dancer) is the easiest for most mothers and it provides the child with most milk •Breastfeeding support Childhood hygiene Right position •Breastfeeding support Childhood hygiene Right position •mother pushes the child with her forearm (the child is on the forearm) •palm of the hand is under the cheek of the child •mother touches the upper lip of the child with her nipple, from one side of the mouth to the other •she waits for the child opening its mouth wide and pulls it right to the breast •she encloses the child with the whole arm •elbow pushes the buttocks, wrist pushes between the scapulae – the child slightly tilts the head back (chin touches the breast, the nose not) •there is no obstacle between mother and child •Breastfeeding support Childhood hygiene Right position •sedentary position •mother should be comfortable •she shouldn‘t sit at the edge of hospital bed – it‘s too high without a chance to rest neither the legs, arms, nor the back •seat with well-supported straight back •trunk is directed slightly forward, pelvis is flat •Breastfeeding support Childhood hygiene Right position •child‘s head and body are very close to mother‘s body •child‘s whole body is supported and legs are winded around mother‘s body •child‘s buttocks are pushed to mother‘s body by her forearm – the nipple will be automatically directed towards the child‘s upper lip •it‘s not a belly-to-belly position, but the child is facing the breast from below and there is an eye contact •child‘s body keeps a line (ear, shoulder, hip) •Breastfeeding support Childhood hygiene Right position •palm of the hand under the child‘s cheek •Breastfeeding support Childhood hygiene Right position •tilting upwards •Breastfeeding support Childhood hygiene Right transversal position - child is on the forearm - child is tilted upwards - body keeps a line - mother‘s fingers are under the child‘s cheek - mother pushes the child‘s buttocks with her elbow - mother pushes the child‘s scapulae with her wrist •Breastfeeding support Childhood hygiene Wrong positions •Breastfeeding support Childhood hygiene Right suckling the child only holds the nipple with its lips the child is suckling right •Breastfeeding support Childhood hygiene Right suckling •mouth is open wide •tongue reaches at least the lower lip •chin is touching the breast •nose isn‘t touching the breast •child covers more of the areola with its lower lip than with the upper – areola is more visible above the upper lip •cheeks don‘t collapse inside while breastfeeding • •Breastfeeding support Childhood hygiene Right suckling •Breastfeeding support Childhood hygiene Wrong suckling •Breastfeeding support Childhood hygiene Pause in the chin •monitoring of the suckling •checking if the child gets the milk •nutritive and non-nutritive suckling • •https://www.youtube.com/watch?v=-erpc0vLbm4 • • •Breastfeeding support Childhood hygiene How big is baby‘s stomach? •Breastfeeding support Childhood hygiene Breast pressing •prevents the baby from falling asleep by getting the milk to it – the milk is pouring faster •Breastfeeding support Childhood hygiene Why is it important •for the mother – prevention of sore nipples •breastfeeding doesn‘t hurt – if so, then it has to be treated • •in case of problems •check the „four points“ •check the frenulum •don‘t use nipple shields •contact lactation counsellor •Breastfeeding support Childhood hygiene Only breast milk •exclusive breastfeeding or feeding with breast milk (from the mother or bank) since delivery until dismissal •mother‘s shouldn‘t be provided with brochures promoting substitutes of breast milk •Breastfeeding support Childhood hygiene Reminder – arrangements of the Code •No public promotion of these products •No free samples for mothers •No promotion in healthcare facilities •No consultants employed by the producers consulting mothers •No presents or free samples for healthcare providers •No text or images idealizing artificial nutrition, including images of children on the packaging 65 •Breastfeeding support Childhood hygiene Reminder – arrangements of the Code •Information for healthcare providers should be evidence-based and true •All information about infant formula including labels, should point to the benefits of breastfeeding, the cost of infant formula and its risks •Inappropriate products, eg. sweetened condensed milk, should not be promoted as appropriate for children •All products should be in high quality and take into account climatic and storage conditions of the country 66 •Breastfeeding support Childhood hygiene What if the child has to be fed? The child is still breastfed. The child learns to be BF by being BF. Mothers learn to BF by BF. The child won‘t refuse the breast. For the child, breastfeeding is more than milk intake! •Breastfeeding support Childhood hygiene •if the child can‘t start suckling •pokud se dítě nepřisává na prs, krmíme pohárkem •stačí obyčejná léková odměrka nebo malá sklenička What if the child has to be fed? •Breastfeeding support Childhood hygiene •The child is in the same room and bed with its mother •No separation (only from excusable reason) • „Mother needs to rest after the labour.“ yes, but with her child •If there is not a medicaly indicated reason, start with rooming-in immediatelly after the labout •Breastfeeding support Rooming-in Childhood hygiene •Before the discharge from the hospital the mother should be given information, where to find help (pressed info, contact for lactation consultants, supporting groups etc.) •The hospital should support and coordinate the •estabilishment of such supporting groups •The staff suport mothers and enable acces •of a person who is well experienced in breastfeeding •support and can judge the qualitty of breastfeeding •technique and provide help soon after the labour •Breastfeeding support The care after the labour Childhood hygiene •do not give the children substitutes, bottles, comforters •the mother must be informed of the risks involved •"Baby confused by a pacifier„ • • Children learn to breastfeed by breastfeeding. " " Give the baby artificial substitution of the breast is not physiological! This is the intervention technique! Dr. Jack Newman •Breastfeeding support According to the Code Childhood hygiene Contraindications of breastfeeding •health conditions •galactosemia •children of mothers with HTLV I and HTLV II (human T-lymphotropic virus) •children of mothers with HIV/AIDS •children with PKU can be partially breastfed •temporary contraindications (solution: regular squirting) •squirted milk can be given to child, e.g. active TBC •radioactive isotope treatment – interruption of BF for 5 times the t1/2 of the isotope •incorrect contraindications •hepatitis B and C of the mother, allergies of the child, diarrhoea of the child, fever and cold of the mother, diarrhoea of the mother •medicaments – almost everything can be treated with drugs compatible with breastfeeding •Breastfeeding support Childhood hygiene •three groups •management of BFH •hospitalized women 3rd day postpartum •medical staff of BFH The view of lay people and professionals on lactation counselling (Pokorná, Kameníková, Dvořáková, 2016) •Breastfeeding support Childhood hygiene The view of mothers and medical staff on information about BF (Likert‘s scale: 5 – most important, 1 – least important) •mothers (241 mother in total) 4,75 – the importance of breastfeeding 4,6 – effective suckling recognition 4,5 – treatment of sore breasts, sore nipples, position during breastfeeding 4,4 – frequency and length of breastfeeding 4,0 – pause in the chin observing (20 women didn‘t mark) 16,2 % of mothers weren‘t educated about the breastfeeding effectivity recognition 25,3 % weren‘t allowed for postpartum skin-to-skin contact •medical staff (141 workers) 4,8 – treatment of sore nipples 4,7 – BF frequency, treatment of sore breasts 4,4 – breastfeeding length lowest value – pause in the chin observing (20 workers didn‘t mark) Most addressed issues: 65,8 % start of suckling 43,9 % effective suckling 24,6 % sore breasts 21,9 % sore nipples •Recommendations 68,4 % BF frequency according to child‘s needs 46,5 % BF length accorfing to child‘s needs Source: Pediatrie pro praxi, 2016, 17(5) - http://www.pediatriepropraxi.cz/artkey/ped-201605-0009_Moznosti_podpory_kojeni_laktacniho_poradenst vi_z_pohledu_laicke_i_odborne_verejnosti.php •Breastfeeding support Childhood hygiene What you as doctors should know (suitable for self-study) •How to treat aching nipples? •How to treat failure to thrive? •How to treat mastitis or blocked milk ducts? •How to treat candidosis? •How to treat failure to thrive following after previous thrift? •How to treat milk refusal in a child? • • •Breastfeeding support Childhood hygiene PAUSE 5 min 78 Obsah obrázku osoba, interiér, zeď, jezení Popis vygenerován s velmi vysokou mírou spolehlivosti Infant and toddler nutrition Complementary food • • • • When to start with complementary feeding? • Is it necessary to terminate breastfeeding? • • • 80 •Infant and toddler nutrition Childhood hygiene WHO recommendation •up to term. 6th month of age exclusive breastfeeding • • •up to 2 years of age and beyond introducing local nutritious food while breastfeeding 81 •Infant and toddler nutrition Childhood hygiene When to start? •the child is mature enough to eat •breast milk is no longer sufficient to cover the child‘s needs • •WHO recommendation is always the priority. • •if the child fails to thrive before compl. 6th month – lactation support " non-milk complementary food " breast milk substitute •not before completed 4th month •children born prematurely (before 35th week) •not before completed 3rd month of adjusted age 82 •Infant and toddler nutrition Childhood hygiene Introduction of complementary food •diversity – gradually add new tastes •let the child use its hands, feed „on its own“, but w/o force •gradually soft bites – rather cut than mashed •deeper heavier bowl, working with a spoon •after 10th month liquids in a cup •regular dietary regimen •autonomy, but not without supervision •collective dining – habits • • 83 Childhood hygiene •Infant and toddler nutrition Potential allergens introduction (MZ ČR) •in children with high risk of allergy only one new type of food at a time •gradual introduction, observing the reaction •together with breastfeeding, higher antigen tolerance •not before compl. 6th month – early contact with the allergen doesn‘t overcome the benefits of exclusive breastfeeding •concerning allergies, gluten no later than in 7th month together with BF •ESPGHAN – timing has no effect on the incidence of coeliac disease • •Ministry of Health recommendation vs. opinion of allergologists •The most effective prevention of food allergies is exclusive breastfeeding for 4–6 months. 84 •Infant and toddler nutrition Childhood hygiene Beware •insoluble small bits of food •milk shouldn‘t be given as a drink, proteins shouldn‘t be covered only from dairy sources (Fe) •low-fat products shouldn‘t be given – the child needs food of high energy density and low volume (fats make 45 % of energy) •sweets, snacks •not to add sugar or salt • 85 Childhood hygiene •Infant and toddler nutrition Role of the parents •feed the child slowly and patiently •react to the signs of hunger and satiety •various combinations, tastes, textures •help the child to learn – beware of negative examples • •feeding – relationship 86 •Infant and toddler nutrition Childhood hygiene Nutrition after 2 years of age 87 •Infant and toddler nutrition Childhood hygiene Risk nutrient – iron •often insufficient intake •other sources of protein than dairy products shouldn‘t be omitted • •iron in different food groups •cereals – e.g. porridge (mainly oats) •meat – red meat, intestines (liver) – meat factor •seeds, legumes (appropriately processed) •fruits and vegetables – vitamin C • 88 •Infant and toddler nutrition Childhood hygiene Recommendation on complementary food introduction in toddlers (Ministry of Health, CZ) •It is necessary to consider exclusive breastfeeding until completed 6th month followed by breastfeeding with complementary food according to child‘s needs until 2 years and beyond an optimal nutrition standard for the child, which corresponds with the recommendations of World Health Organization (WHO), European Society for Peadiatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) and Scientific Advisory Committee on Nutrition (SCAN). •Complementary food should be introduced in both breastfed and not breastfed children no later than after completed 6th month of age, 180 days (in 26th week), but not before completed 4th month of age (17 weeks). 89 Childhood hygiene •Infant and toddler nutrition Recommendation on complementary food introduction in toddlers (Ministry of Health, CZ) •Complementary food is introduced when breast milk or milk substitute no longer covers the nutrient requirements of the child. If the breastfed child fails to thrive, it is recommended tu support the mother in breastfeeding and introduce a non-milk complementary food. If the lactation doesn‘t improve, breast milk substitute is introduced. •The process of introducing the complementary food in prematurely born children (born before the 37th week) is as follows: In children born after completed 35th week, it is recommended to act as in children born in term. In children born before completed 35th week, complementary food can be introduced 5–8 months since birth date, but not before completed 3rd month of adjusted age (calculated delivery date). Complementary food introduction is always assessed individually according to clinical state of the child (health, psychomotoric maturity, thrift etc.) 90 Childhood hygiene •Infant and toddler nutrition Recommendation on complementary food introduction in toddlers (Ministry of Health, CZ) •Developmental maturity is important when introducing complementary food, i.e. keeping the head in a stable position, coordinating eyes, hands and mouth when looking for food, holding it and putting it into mouth, swallowing and tolerance of solid food. •In both breastfed and not breastfed children the complementary food is introduced in accordance with present recommendations. Food containing gluten should be introduced until completed 7th of the child‘s life at the latest, optimally together with breastfeeding. 91 Childhood hygiene •Infant and toddler nutrition Recommendation on complementary food introduction in toddlers (Ministry of Health, CZ) •In children with high risk of allergies, the process of complementary food introduction is similar to other children, but only one new type of food is introduced at a time, while potential reaction is observed. By introducing complementary food together with breastfeeding, the imunoprotective tolerance of the organism of the infant towards the antigens in food rises. •So far, decrease of incidence of allergies or coeliac disease by early sensibilization with allergens in food hasn‘t been proven . There is no reason to recommend contact with food allergens and food containing gluten before completed 6th month to thriving children. 92 Childhood hygiene •Infant and toddler nutrition Further information •Recommendation on complementary food introduction in toddlers (Ministry of Health, Czech rep.) •http://www.mzcr.cz/Odbornik/dokumenty/doporuceni-k-zavadeni-komplementarni-vyzivyprikrmu-u-kojencu _7542_1154_3.html •Dietary guidelines for the inhabitants of Czech rep. (SPV, 2012) •http://www.vyzivaspol.cz/rubrika-dokumenty/konecne-zneni-vyzivovych-doporuceni.html •diploma thesis: •Jana Kráľová: Iron deficiency anemia in infants and toddlers • • 93 •Infant and toddler nutrition Childhood hygiene Growth charts What are they for? •growth examination by GP •underweight/overweight classification in children •alert that „something is happening“ • •charts available in CZ •height, weight, weight/height ratio, BMI •circumferences – hips, waist, head, arm •skinfolds – biceps, triceps, thigh, subscapular, suprailiacal, 2-skinfold sum, 4-skinfold sum 96 •Growth charts Childhood hygiene How are they made? •nationwide anthropometric survey (CAV) •CAV 2001 – most up-to-date data •CAV 1991 – charts regarding weight • • • • • Why do we use weight and BMI charts from 1991? 97 •Growth charts Childhood hygiene •malnutrition •celiac disease •endocrine disorders •cancer •… •familial low stature •constitutional delay of •growth and puberty (CDGP) •other minor disorders Good utility, not a pattern! •think when you use the charts • •a child high for his age – weight will be higher •assess rather weight/height or BMI (in older children) •a child with family history of low statures – will be smaller •keep other factors in mind • 100 •Growth charts Childhood hygiene What do we know from only one point on the chart? Exclusively breastfed children •exclusively BF children slightly „delayed“ in Czech charts •physiologically slower growth and weight gain •graphs created according to the data of breastfed children + children fed breast milk substitutes • • •Complementary food or substitutes shouldn‘t be given only because of slight delay of exclusively breastfed children against the growth chart! Childhood hygiene 101 •Growth charts Assessment of the weight of a child Percentile area Assessment > 97 obese 90–97 overweight 75–90 stocky 25–75 proportional 10–25 lean < 10 underweight 102 •Growth charts Childhood hygiene Exercise •boy, 12 y.o., 156 cm •girl, 10 y.o., 140 cm, 44 kg •girl, 10 y.o., 156 cm, 44 kg •boy, 13 m.o., 73 cm, 9 kg •boy, 13 m.o., 79 cm, 10 kg • • In CZ, does GP have to monitor weight and height of a child? • In CZ, does GP have to use growth charts for this monitoring? • If the child is proportional, does it mean its nutrition is alright? 103 •Growth charts Childhood hygiene Further information •webpage of National Health Institue + RustCZ •http://www.szu.cz/publikace/data/program-rustove-grafy-ke-stazeni • •growth charts for download •http://www.szu.cz/publikace/data/seznam-rustovych-grafu-ke-stazeni 104 •Growth charts Childhood hygiene Obsah obrázku osoba, exteriér, strom, žena Popis vygenerován s velmi vysokou mírou spolehlivosti Introduction to social pediatrics Social pediatrics •social aspects of health •healthy development, child‘s needs •promoting the best interests and right of the child • •Declaration of the Rights of the Child (1989) •World Declaration on the Survival, Protection and Development of Children (1990) 106 •Social pediatrics Childhood hygiene Focus of social pediatrics •chronically ill children •children with a handicap •family environment quality and its impact on child‘s health •abandoned, orphaned children, spare family care •toxicomania, childhood criminality, socially maladaptive children •social impacts of illness and health impairment for the child, family and society •threatened children, CAN sy, criminal acts commited on children 107 •Social pediatrics Childhood hygiene Risk groups of children 108 •? •Social pediatrics Childhood hygiene Risk groups of children •children born prematurely, with inborn errors of development, with complications •unwanted children – lack of interest, negligence, abuse, killing •dispensarized children – sense impairment, chronic illness •adolescents – mainly behavioral problems •children from socially/culturally disadvantaged environment •environment preventing the child from full development of its potential, capabilities and skills 109 •Social pediatrics Childhood hygiene Risk groups of children •socially/culturally disadvantaged environment •parents too young (mainly underage mother) •incomplete primary education of one of the parents •chronic or psychiatric illness of one of the parents •insufficient social integration of the parents (language etc.) •home violence •addictive substances in the family •legitimate investigation of the child protection authority 110 •Social pediatrics Childhood hygiene Why are they at risk? •factors with an impact on health: •genetics •environment •healthcare system •lifestyle •social aspects •social differences and inequalities in health •social disadvantage and cultural differences •unemployment, poverty • •Social aspects can have a huge impact on child‘s health! • 111 •Social pediatrics Childhood hygiene Think about it… 112 •what is the role of a pediatrician in social pediatrics? •Social pediatrics Childhood hygiene Mgr. Martin Krobot Mgr. Kamila Jančeková krobot@med.muni.cz jancekova@med.muni.cz Contact for a case of need: