Pediatric Primary Care Case Studies (28 page)

1. Obesity results when there is an imbalance between energy intake from food and energy expenditure from physical activity. Therefore, healthful nutrition practices and behaviors such as improved nutrition quality, appropriate portions, daily breakfast, and a daily plan of physical activity are key elements in the prevention and treatment of childhood obesity.

2. Heritability is a critical correlate regarding the prevalence and severity of obesity, with ethnic minorities at higher risk for overweight.

3. An obesogenic environment starting during prenatal development has a significant impact on the development of childhood obesity.

4. The primary care provider should address nutrition and physical activity at every well child visit by consistently monitoring growth parameters (height and weight percentiles) starting at birth and charting BMI beginning at age 2 years.

5. Childhood overweight and obesity typically do not occur as a single family member issue, but rather also as a health issue for other family members. Thus, a family-centered approach is needed as part of the management plan.

6. Motivational interviewing is a technique that establishes a collaborative relationship in the prevention, treatment, and management of a health problem. Offering management options and involving the caregiver and older child with decisions related to types of physical activity to engage in and adopting more healthful food choices encourages the practice of self-care management of the child’s overweight problem.

7.
Excessive screen time and food portions, lack of daily physical activity, fast food consumption, and using food as a reward are unhealthful behaviors that should be discussed with parents.

8. The emotional toll of childhood overweight and obesity, such as poor self-esteem and victimization by bullying, should also be addressed.

9. Some parents do not believe their child is overweight or at risk for comorbidities that they erroneously believe are adult onset problems.

10. Because of the increased prevalence of childhood overweight and obesity, primary care providers must assume an active role in the prevention and management of childhood obesity.

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Chapter 8

The Breastfed Infant Who Is Not Gaining

Pamela J. Hellings

Breastfeeding is a learned skill. Not infrequently, mothers encounter feeding difficulties that may result in slow weight gain for the baby. The challenge is to separate the common problems from the more complex issues. Slow weight gain cannot be dismissed as simply poor feeding technique in the early post-partum days. The provider must consider and eliminate other possibilities through a knowledgeable and thoughtful history and physical examination process.

Educational Objectives

1.   Recognize issues associated with slow weight gain in a newborn infant.

2.   Manage the feeding issues to maintain breastfeeding whenever possible.

3.   Provide appropriate follow-up to assure adequate nutrition and weight gain in the infant and to support the family.

   Case Presentation and Discussion

You pick up a message that Mrs. Jackson called one hour ago. She gave birth 8 days ago to her first child, a male infant, Peter. She did not keep her 3-day follow-up appointment at the clinic because she was “too exhausted” after delivery. She is breastfeeding but is worried that he is not getting enough to eat.

What further information would be helpful at this point?

In order to make the decision regarding the need for follow-up, a description of the feeding frequency and duration as well as a wet diaper and stool count would be helpful.