Primary Care Final

Infant growth and nutrition fast facts

Infants DOUBLE their birth weight between 4-6 months

Infants TRIPLE their birth weight by one year

Infant length (height) increases by 50% in the first year of life… Maximal growth velocity for length is observed in the first 6 months of life, with rate slowing in the

subsequent 6 months

Infant Nutrition: Middle Infancy (6-9 months)

• Human milk fed infants have a more marked slowing in length/weight gain than their formula fed peers; this is a normal variation

• Using WHO growth charts is recommended, as they reflect the typical growth trajectory of human milk fed infants

• Complementary (solid) food introduction recommended at around 6 months of age (and no sooner than 4 months of age) based on infant readiness (breastfeeding in combo with foods through 24 months or longer)

Middle Infancy: Ready for Complementary Foods?

• Diminished extrusion (tongue thrust) reflex

• Able to sit with support

• Good head/neck control

• Early introduction of complementary foods (<4 months of age) associated with increased rates of adiposity

• Thickened feedings (human milk or formula mixed with infant cereal)→ choking risk

• Timing coincides with need for increased iron intake in the infant’s diet

Food Introduction

• There is no evidence that any one food group should be introduced first, with the exception of foods with high allergenic potential

• Offer 1 new food at a time over at least 3 days, watching for signs of allergy

• Feed soft purees via spoon with infant secured/supported in a highchair with straps

• Include iron rich foods in the diet daily

• Offer new foods with high allergenic potential at home, one new ingredient at a time

• CONTINUE to offer human milk or formula along with solids through 12 months

Baby Led weaning

• Based on theory that infants 6+ months are more developmentally advanced and do not require to be spoon fed purees

• Baby is offered graspable pieces of soft textured food

• Must always be closely observed by a caregiver to prevent choking

• Must make efforts to include iron rich foods in the diet

• Baby is to continue to be offered breast/chest feedings on demand, thus facilitating the self-weaning process

Complementary Foods and Food Allergy

Once a few complementary foods considered to be low allergenic risk have been introduced foods with higher allergy potential may be introduced one at a time, in small amounts at home at home

If no apparent reaction, re-introduce the same food in gradually increasing amounts

In children with a strong family history of atopy (sibling or parent with food allergy) but no personal history of atopy: may proceed as above

EXCEPTION: For infants with a personal history of moderate-severe atopic dermatitis OR history of immediate or severe reaction to ANY previously introduced food/human milk exposure to food: Refer to allergist for evaluation +/- testing prior to home introduction of highly allergenic foods

Calcium and Vitamin D requirements late infancy

7-12 Months:

11 mg Iron

260 mg Calcium

400 IU Vitamin D: Continue supplementation until child is over 1 year and drinking up to 1 L Vitamin D fortified cow’s milk QD plus dietary sources of Vit D –OR-- Child under one year old taking at least 1 L (approx. 32 oz) per day of Vit D containing infant formula

Infant nutrition late infancy

Typically prefer to eat 3 meals per day plus snack

Offering a cup for practice of self-feeding skills may begin

NO fruit juice or sweetened beverages in the diet

Water is not necessary before 12 months of age, though it is not dangerous to allow small quantities (an ounce or two) in order for the child to practice use of a sippy cup

KEEP IN MIND: May take multiple (10+) exposures to a given food before infant will accept it

Toddler growth stats

Quadruple BW by age 2

4.5-6.5 lb per year

2.5-3.5” per year

Rate of gain then slows significantly and associated decrease in appetite

Three meals per day, plus 2-3 healthy snacks

Toddler Nutrition Anticipatory Guidance

Bottle weaning should take place at 12-14 months

Avoid using soft spout cups that mimic bottle use; using a spoutless sippy cup (360 degree cup) or cup with a straw is recommended until child can use an open cup

Offer foods rich in iron; pair with vitamin C rich foods to improve absorption

Limit cow’s milk intake to UNDER 24 OZ daily (Ideal: 16-20 oz daily)

The toddler should be offered finger foods and utensils to practice self-feeding skills

Normal to observe days with low interest in eating; appropriate to view energy intake as an average over a few days

Struggles surrounding meals are common; Children frequently go through “food jags” where they only request/accept certain foods

Meals should be seated…not on-the-go

Review avoidance of choking hazards

Any tube-shaped foods should be cut into quarters before serving until age 6 year

Growth and feeding patterns in prek

4.5-6.5 lb per year

2.5-3.5” per year

3 meals plus 2-3 small snacks per day

May still prefer finger feeding, but should always be offered/encouraged to use utensils to promote fine motor skills

Practical Portion Recommendations for Children

Recommended portion sizes for children 4+ years:

• ½ c. fruit or veg per meal

• 1 slice whole grain bread or other whole grain per meal

• 2-3 oz lean meat or fish per meal (deck of cards size)

• 2 8 oz servings milk daily (whole milk from 12-24 months, may continue whole milk or switch to 2% milk in children 2+ years)

*Children 2-3 years old require portions about 2/3 of that noted above at meals

Early childhood calcium and vitamin D

Children 1-3 years old require 700 mg calcium and 600 IU Vit D daily

Children 4-8 years old require 1000 mg calcium and 600 IU Vitamin D daily

Recommended daily intake of 16 oz milk per day (max 24 oz)

For children who cannot tolerate cow’s milk, soy milk is also calcium fortified and a good protein source

Early childhood iron/IDA

•1-3 years: 7 mg daily

•4-8 years: 10 mg daily

•9-13 years: 8 mg daily

•IDA diagnosis: hemoglobin > 2 SD below the age-appropriate mean- i.e.. Hgb < 11.0 at 12-35 months

•PREVENTION: Including iron rich foods in the diet daily starting in middle infancy

AAP recommends iron deficiency screening for all children at 12 months, with

follow up screening between 12 months and 5 years for at-risk children

middle childhood growth patterns

5-7 lbs per year

2.5” per year

Require 3 meals plus 1-2 snacks daily; about 1/3 of calories typically from snacks

Caloric needs vary– minimum 1600 per day, more if active (2000)

• Preadolescent growth spurt onset:

• Females (Tanner II-III): 9-11 years

• Males (Tanner III-IV): 10-12 years

middle childhood dietary recs

Water should be offered throughout the day for thirst, Avoid sweetened beverages or 100% fruit juice

Dairy intake to meet adequate calcium/Vitamin D levels:

Ages 4-8 years recommended daily calcium intake: 1000 mg/600 IU Vitamin D

Try to include 16 oz Vitamin D fortified milk (or equivalent from cheese, yogurt plus foods rich in vitamin D and calcium) daily

Ages 9 +: 24 oz milk QD or equivalent from other sources; Recommended daily calcium intake: 1300 mg/ 600 IU Vitamin D

Iron intake: Age 9-13 years: 8 mg dietary iron/day

middle childhood cholesterol screening

The AAP recommends that children without risk factors for hyperlipidemia have initial non-fasting total cholesterol and HDL screening between the ages of 9-11 years

For children with known risk factors: initial cholesterol testing is recommended between the ages of 2 and 10

Healthy Total <170, LDL <110

Infant Voiding Patterns

Neonatal bladder capacity= < 30 ml

1-2 weeks old: Infants void every 1-3 hours or with each feeding

This frequency persists through the first few months of life

Bladder emptying occurs reflexively; there is no discernable pattern

Advise parents to expect changing at least 6 -8 wet diapers/24 hours

Toddler Voiding Patterns

Bladder control milestone: The ability to hold urine emerges in the toddler age group in concert with complete myelinization of pyramidal tracts in the spinal cord and the development of voluntary sphincter control

Toddlers can stay dry for up to 2 hours

Frequency= 8-14x/24 hours (Richardson, 2020)

Bladder volume= 120 ml (4 ounces) in a 2-year-old

Bladder capacity by age

Age in Years + 2 = Bladder Capacity (in ounces)

or

(AGE IN YEARS + 2) 30 = Bladder Capacity (in milliliters/cubic centimeters)

Preschool Voiding Patterns

98% of 4-year-olds have attained daytime bladder continence

Nocturnal bladder control shows more variability in this age group

Advise caregivers that nocturnal enuresis, at least occasional, is WNL through age FIVE

Voiding Patterns in School Aged Children

At age 6 years

Normal urine volume: 400-600 ml

Normal voiding frequency: 5-6x daily

Majority of typically developing children are continent overnight

ENURESIS: Key Definitions

Enuresis= a condition involving the involuntary passage of urine

Primary enuresis= involuntary voiding episodes in a child for whom urinary continence has never been attained

Secondary enuresis= enuresis that recurs after a 6 month or longer interval without enuresis

Monosymptomatic nocturnal enuresis (MNE): intermittent incontinence that occurs overnight during sleep

Non-monosymptomatic nocturnal enuresis (NMNE): nocturnal urinary incontinence with additional features including:

Diurnal enuresis= daytime involuntary urine loss

Urgency =sudden, unexpected, and imperative urge to void

Voiding difficulties= weak stream, hesitancy, and/or need to strain to void

Abnormally low or high daytime voiding frequency (voiding <4 or >7 times per day)

ENURESIS HAS EFFECTIVE TREATMENTS… IF YOU KNOW TO TREAT IT

Current understanding is that MNE is due to a mismatch between nocturnal urine production, nocturnal bladder storage capacity, and the ability to arouse from sleep

Active therapy is recommended for symptomatic children from the age of 6 years.

Enuresis: Key History Features

CONSTIPATION, SNORING, AND STRESSORS

Bowel movements in neonates

Meconium stool is passed in the first 48 hours of life

If not passed in this timeframe, consider (meconium ileus/CF, Hirschsprung’s)

Transitional stool (green, brown) follows on DOL 3-4

Normal infant stool after the first few days of life varies:

Human milk fed infant stool: yellow, pasty to runny; may appear “seedy”, may see milk curd in stool

Formula fed infant stool: yellow to light brown, pasty

For infants > 48 hours old, expect 1-6 BMs/day through the first month of life

If less than this, suspect inadequate milk/formula intake

Infant Stool Patterns

4-month-old HUMAN MILK FED infants range from one per day to one per WEEK

4-month-old FORMULA fed infants 1+ BM daily

As solids are introduced at around 6 months, it is normal for stool consistency

and odor to change (firmer stools common)

By 9 months, stools tend towards firmer consistency and darker color

By 9- 12 months, the infant typically begins to have more predictable stool patterns

Infant dyschezia– infant straining/crying for at least 10 min prior to passing BM;

seen in infants UNDER 6 months; stool produced is soft; NOT constipation and

is does not require intervention

toddler BM

BMS TEND TO BE PREDICTABLE/SOFT TO FORMED STOOL

FREQUENCY: ANYWHERE RANGING FROM1- 2XPER DAY TO QOD IS CONSIDERED NORMAL

INTEREST IN ELIMINATION PROCESSES EMERGES IN CHILDREN AT 18-24

MONTHS

TYPICALLY, DAYTIME POTTY TRAINED BY AGE THREE

Signs of toilet training readiness

1) Child is dry for at least 2 hours per day or wakes dry from naps

2) BMs become regular/predictable

3) Facial expression, posture or words make it clear that child is about to void/BM

4) Child asks for underwear

5) Asks to use potty

6) Uncomfortable in soiled diaper and wants to be changed

7) Able to follow simple directions

8) Able to undress (pull pants up and down), able to walk to and from bathroom

school aged kids BM

Most typically developing school aged children are fully day/night toilet trained, though may have occasional accidents (engrossed in play)– these tend almost always to be wetting accidents

Fecal incontinence (encopresis) effects 1.5% school aged children

Normal BMs pattern ranges from QD-TID to QOD

Rome criteria for functional constipation children <4

Must include 2 or more of the following occurring at least once per week for a

minimum of 1 month--

•≤2 defecations/week•

At least one incontinence per week after the acquisition of toileting skills

• History of excessive stool retention

• History of painful or hard bowel movements

• Presence of a large fecal mass in the rectum

• History of large-diameter stools that may obstruct the toilet

rome criteria constipation >4

Must include 2 or more of the following occurring at least once per week for

a minimum of 1 month--

•≤2 defecations in the toilet per week

• At least one episode of fecal incontinence per week

• History of retentive posturing or excessive volitional stool retention

• History of painful or hard bowel movements

• Presence of a large fecal mass in the rectum

• History of large-diameter stools that may obstruct the toilet

the leading causes of fatal injuries in minors are

<1 year of age: suffocation (*2/3 of all infant injury fatalities)

•1 - 4 years of age: drowning

•5 -19 years of age: motor vehicle crash (as occupant)

From birth to 14 years of age, the most common injury type requiring ED care

falls

Injury Prevention Model

Primary Prevention: modification with the goal of preventing an initial injury causing event. Can include both advice and actions. Examples:

◦ Advice: Targeted safety advice such as the anticipatory guidance provided at well child visits (e.g. safe storage of household cleaners)

◦ Action: Storing household cleaning products high out of the reach of children to prevent ingestions

Secondary Prevention: modification with the goal of reducing severity of injuries that occur. Examples:

◦ Use of properly installed rear-facing infant car seat

◦ Installation of smoke detectors and sprinkler systems

Tertiary Prevention: modification aimed at minimizing the long-term impact of injuries that have already occurred. Examples:

◦ Access to immediate on-site medical care for an existing injury (school health services, EMS)

◦ Rehabilitation services to minimize long-term disability secondary to injury

active injury prevention

behavioral strategies to prevent injury

◦ Involve individuals playing an active role in risk reduction for those under their care

◦ Requires individual adherence to risk reduction guidance and is more subject to

failure due to caregiver inattention or fatigue

passive injury prevention

structural interventions to prevent injury

◦ Involve structural/environmental changes aimed at risk reduction

Car seat guidelines

2 and 30* (Must remain in a rear facing car seat until at least 2 yr AND 30 lb.)… and per AAP, most children should and can remain in a weight/height appropriate rear facing seat up until age 4 years

5 and 40* (Must remain in a 5-point harness car seat until at least 5 yr AND 40 lb.)

8 and 60* (Must remain in a lap positioning booster seat until at least 8 yr AND 60lb.)

13 years old to ride in front passenger seat

Children and teens who routinely sleep too little are at higher risk of:

Obesity

Type 2 diabetes

Poor mental health

Injuries

Attention and behavior problems

Poorer school performance

BSATED Sleep Questions

Behavior: Routines, how the child falls asleep, caffeine, and screens before and during bedtime.

Satisfaction: Young children can't self-report; parents' ratings reflect their own mood,

views, and culture.

Alertness: Sleepy children may look wired, not tired. Napping norms vary by culture.

Timing: Bedtime before about 9 pm.

Efficiency: Night wakings are normal in infants; “sleeping through the night” has no

standard definition.

Duration: Total sleep in 24 hours, compared with age-based recommendations.

Standard sleep duration guidelines

Infants 4–12 months 12–16 h (incl. naps)

Toddlers 1–2 years 11–14 h (incl. naps)

Preschool 3–5 years 10–13 h (incl. naps)

School-age 6–12 years 9–12 h

Teens 13–18 years 8–10 h

Two processes controlling sleep

Sleep pressure: Builds the longer we're awake; discharges during sleep. Builds faster in young children, so they need naps.

Circadian clock: The SCN's alerting signal peaks in the evening and withdraws at night. Light sets the clock.

Sleep comes easily when pressure is high and the alerting signal falls (the “sleep gate”).

Development of sleep clock

Birth: No circadian rhythm yet. Sleep is driven by feeding and arousal, around the clock.

6–8 weeks: Day–night differences in sleep and body temperature start to appear.

8–12 weeks: Cortisol rhythm, then a melatonin rhythm about a week later. Night sleep starts to consolidate.

By 12 months Circadian system is well established.

NREM sleep

Three stages: N1 (light), N2, and N3 (deep, slow-wave)

Brain waves, heart rate, and breathing slowdown

Physical restoration, immune function, and growth

Sleepwalking and night terrors happen here (N3)

REM sleep

Brain activity resembles wakefulness; vivid dreams

Muscle atonia: temporary paralysis of the body

Memory consolidation, learning, and emotional processing

Nightmares happen here

sleep architecture changes with age

Newborn (0–2 mo) ~50 min About 50% active (REM) sleep; enters REM first; sleep spread around the clock

Infant (3–12 mo) 50–60 min Circadian rhythm emerging; longer night-time blocks

Toddler/preschool (1–5 y) 60–70 min Fewer night wakings; naps drop off; REM falls toward the adult ~25% by age 3–5

School-age (6–12 y) 80–90 min Most deep N3 sleep of the lifespan; stable rhythm; very alert by day

Adolescent (13–18 y) ~90 min N3 declines; circadian phase delay; REM concentrated toward morning

BEARS sleep screen

Bedtime problems

Excessive daytime sleepiness

Awakenings at night

Regularity and duration
Snoring

What’s normal for newborn/infant sleep

Newborns sleep about 14–17 hours in short bouts spread across day and night,

with wide variability

Two states, about half each: active (REM-like) and quiet (NREM-like) sleep

Breastfed babies wake more often because breast milk is digested quickly

Night sleep consolidates around 2–3 months; self-soothing emerges around 3

months.

By 9 months, 50–80% sleep through the night

Night wakings for feeding and comfort are normal

Normal toddler sleep

11–14 h per 24 hours, including naps

2 → 1 naps by about 18 months; ~ half stop napping by age 3

Exploration and limit-testing begin, and with them bedtime “curtain calls”

Sleep begets sleep: cutting naps won't improve night sleep. Keep naps before

about 4 pm.

Night feedings are no longer nutritionally needed

Crib to toddler bed: no rush. Many families wait until the child climbs out or is 3.

Comfort objects are fine after 12 months

Behavioral treatments for sleep issues

1. Parent education and prevention: Routines, drowsy-but-awake, realistic expectations

2. Positive routines and faded bedtime; Start bedtime when the child is sleepy; move it earlier 15 min at a time

3. Parental presence (“camping out”): Parent stays in the room, moving the chair out over several nights

4. Graduated extinction: Brief, boring check-ins at lengthening intervals

5. Extinction: Put to bed and no response until morning

Warn families about the extinction burst: crying often gets worse for a few nights before it improves.

Matching sleep strategies to complaints:

Night wakings

• Calm, brief, boring responses: no lights, no play

• Timed check-ins for older infants and toddlers

• After ~6 months, stop feeding to sleep (if ready)

Early rising

• Move bedtime earlier: counterintuitive, but it works

• Keep a regular morning wake time

• Outdoor light soon after waking

Bedtime resistance

• Offer structured choices (which pajamas, which book)

• Bedtime pass: one free trip out of bed per night

• Bedtime fading, then move earlier 15 minutes at a time

Naps

• One consistent midday nap for toddlers

• Preschoolers: avoid naps over 90 min or after ~3 pm

• Daytime activity and outdoor light consolidate night sleep

Normal preschool sleep

10–13 hr including naps

Naps fade between 3 and 5; about 15% of 5-year-olds still nap

Imagination and nighttime fears grow; bedtime resistance is common

Ask about snoring: OSA peaks at ages 2 to 8

Normal school age sleep

9–12 h, no naps

Daytime sleepiness is not normal at this age; look for a cause

Parents often don't know about night wakings or late-night screens

Parasomnias peak; use a bedtime pass and relaxation skills for fears

New daytime sleepiness? Think short sleep, OSA or narcolepsy

Sleep terrors, sleepwalking

Deep NREM

First third, 1–3 hours after falling asleep

During the episode Confused, inconsolable, may not recognize parent

Memory next day None

Sleepwalking: up to 40% of children ages 3–7

What parents do: Don't wake or restrain; keep the home safe; protect sleep

Nightmares

REM

Last third, toward morning

During the episode Wakes fully, frightened, seeks comfort

Memory next day: Vivid recall of the dream

Up to 75% of children

Comfort and reassure; limit scary media; address stress

Bedwetting

Not a diagnosis before age 5

Ask about daytime symptoms, constipation, snoring, thirst and

frequent urination, and stressors

Never punish

Treat (age 5+): Enuresis alarm; Most durable cure; needs 2–3 months

and a motivated family

Desmopressin: Works quickly (sleepovers, camp); relapse is common when stopped.

Limit evening fluids.

Delayed sleep-wake phase disorder

Normal sleep, wrong timing

Can't fall asleep until 1–2 am; can't wake for school

Sleepiest in the morning; feels fine when allowed to sleep on their own schedule

Weekday sleep debt plus weekend sleep-in creates “social jet lag”

1 Education and motivation: the teen has to want the shift

2 Same schedule 7 days a week (weekend wake no more than 1–2 h later)

3 Bright light right after waking; dim light and no screens in the evening

4 Low-dose melatonin in the early evening, several hours before current sleep onset, to shift the clock earlier

OSA

Habitual snoring (3+ nights/week), gasps or pauses, labored breathing, restless sleep, mouth breathing, sweating, new bedwetting

Inattention, hyperactivity, behavior or learning problems, morning headaches.

Ask about snoring at every well visit

Snoring plus symptoms: polysomnography (gold standard) or refer to a sleep specialist or ENT

First-line treatment: adenotonsillectomy

CPAP if surgery isn't an option or OSA persists

RLS and PLM

Restless legs syndrome (clinical diagnosis)

• Urge to move the legs with uncomfortable sensations

• Worse at rest and in the evening; relieved by movement

• Often mislabeled as “growing pains”; affects 1–6% of children

Periodic limb movement disorder (PSG diagnosis)

• Repetitive limb movements on PSG, more than 5 per hour in children,

not explained by OSA

• Plus disturbed sleep or daytime symptoms

Iron and RLS

1 Check Ferritin, iron, and TIBC

2 Treat Ferritin under 50 ng/mL: oral elemental iron 3–6 mg/kg/day

3 Take on an empty stomach with vitamin C

4 Repeat labs in about 6 weeks; improvement can take 3 months

Narcolepsy

Excessive daytime sleepiness: In children it may look like irritability, hyperactivity, falling grades, or naps returning

Cataplexy: Sudden weakness with laughter or emotion; in kids, facial slackness or tongue protrusion

Sleep paralysis and hallucinations: At sleep onset or on waking

Disrupted night sleep: Frequent awakenings despite sleepiness by day

• Overnight PSG followed by a multiple

sleep latency test (MSLT)

• Stop stimulants, antidepressants, and

hypnotics about 2 weeks before

• Type 1 (cataplexy or low hypocretin) vs. type 2

• Refer to a pediatric sleep specialist

melatonin dosing, timing, safety

Toddlers 0.5–1 mg 2 mg 30–60 min before bed

Children 1–3 mg 5 mg 30–60 min before bed

Adolescents1–5 mg 10 mg 1–2 h before bed

• Sleep onset (hypnotic): 30–60 min before bedtime

• Clock shift (chronobiotic): low dose, 3–6 h before DLMO, i.e., early evening

• Immediate-release for sleep onset; extended-release for staying asleep

• Give it consistently, with a routine and dim evening light

• Common: morning grogginess, headache, vivid dreams

• Rare: enuresis, dizziness, GI upset

• Avoid under age 2 unless specialist-managed