Peds, part 9: G&D - Infant Parental Guidance - Nutrition, Sleep Safety, Dental Health, Vaccines
by Meris Shuwarger BSN, RN, CEN, TCRN December 20, 2021 Updated: December 07, 2022 6 min read
In this article, we discuss parental guidance for those who are caring for infant children, that is, children from birth to one-year of age.
The Pediatric Nursing series follows along with our Pediatric Nursing Flashcards, which are intended to help nurses and nursing students learn and retain information about caring for pediatric patients. The flashcards are a clear, complete study tool and a helpful reference for practicing RNs, PNs, and other medical professionals.
When you see this Cool Chicken, that indicates one of Cathy's silly mnemonics to help you remember. The Cool Chicken hints in these articles are just a taste of what's available across our Level Up RN Flashcards for nursing students!
Parental nutrition guidance for infants (birth to one year)
The following are nutrition tips to teach to caregivers of infant children.
Breastmilk or formula
For the first 12 months of life, a child should receive breast milk or formula.
It is important not to prop up a bottle. The caregiver should hold the bottle or, when the child is able, allow the child to hold it on their own.
No supplemental water or other fluids without an order until 6 mos.
Children have a larger percentage of their body make-up composed of water than adults, which means that they are affected by fluid balance disturbances and electrolyte disturbances more than adults. So it is important to educate a new parent or caregiver not to give their infant supplemental water until the age of 6 months, unless advised to do so by a pediatrician.
When preparing formula, although water must be added to it, there is a specific ratio of formula to water. Typically, the ration is one scoop of powdered formula to two ounces of water. It is vitally important to mix water and formula in the correct ratio. If providing baby with liquid formula that is pre-mixed and ready to use after opening, do not add water to it. It is already mixed in the correct ratio.
No honey or cow’s milk until 12 mos.
Do not give honey or cow’s milk to a child until they are one year of age.
Honey should be avoided because of the risk for botulism. Although modern food preservation and preparation standards have essentially eliminated the risk of botulism in adults (whose immune systems are mature), an infant is in the process of building their immune system and might not be able to fend off an infection, which could be life-threatening.
Cow’s milk should be avoided due to the potential for irritation of the infant’s GI tract. Note that some children might need different or special type of formula that includes dairy milk, but this would be per their provider’s orders or instructions.
Introduce solids at 4 – 6 mos.
Solids can be introduced between 4 to 6 months, though, again, defer to any specific guidance of the child’s pediatrician.
Solid foods are introduced at this time when baby has good head control and can sit up with little or no support.
- Start the infant’s solid food diet with iron-fortified infant rice cereal, which is a good transition from a breastmilk or formula diet to solid foods.
- Introduce each new food one at a time, and wait 3 – 5 days between each new food to rule out allergies. Do not alternate between prepared baby foods, such as bananas for one meal, apples for the next, and pears for the next, because if the baby doesn’t tolerate one of these foods (if they have a bad GI reaction or an allergic reaction), it will not be clear which food has caused the issue. That means feeding baby one food at a time, over several days or longer, before moving on to another, different individual food.
- Provide mashed or pureed foods. Infants don’t have many teeth, so they do not yet have the ability to chew their food.
- Introduce common allergens, such as eggs and small tastes of peanut butter, after several foods have been successfully tolerated. There is a lot of guidance at present that allergens should be introduced sooner rather than later to help to prevent the possible development of allergies to a particular food. For example, a pediatrician may say to the parent of a 4-month old, “You don’t have to start feeding her solids, but I want you to take a little bit of peanut butter, put it on your finger, and put it on her lips or her tongue. Do this every day for a couple of weeks to help to prevent an allergy to that food.”
- Introduce soft finger foods at 9 – 10 mos. This is the time when the child is developing their pincer grasp, so they may want to hold their food in their fingers.
- Avoid choking hazards. It is important to avoid choking hazards, for example nuts, seeds, hot dogs, or grapes. Also avoid anything that requires a lot of chewing, like big chunks of meat or cheese.
Parental sleep safety guidance for infants (birth to one year)
Remember the ABCs of safe sleep: Alone, on their Back, in a Crib!
Sleep safety is another important thing for caregivers to understand. Parents of infant children should be taught to follow the Cool Chicken hint (ABC) when it comes to putting baby to bed:
- Baby should be alone. It’s okay to share a room with others, but not in the same bed
- Place baby on their back for all sleep, including naps
- Always put baby to bed in a crib, a designated space to sleep that is their own and meets certain safety criteria
Other teachings of sleep safety include the following.
Use a firm, tight-fitting mattress
The mattress in the crib should be firm and fit tightly in the crib frame. This is to prevent baby from getting stuck between the mattress and railing, which could be fatal.
The mattress should only be covered by a fitted sheet. Keep soft bedding such as blankets, pillows, bumper pads, and soft toys out of the baby’s sleep area.
Crib slat spacing
The slats in the crib need to be less than two and three-eighths inches apart from one another (6 cm).
Crib mattress height
Set the crib mattress at its lowest position before baby learns to stand. This will make it harder for them to climb over the rails as baby grows in size and strength.
Remove mobiles when the baby is able to get up on their hands and knees, or at 5 mos. old, whichever comes first.
Don’t place crib near a window or heat vent
People get concerned about their child being too cold at night. This leads caregivers to put the crib near a heating vent or window. But overheating is a bigger concern than the infant being too cold. To keep baby warm and not overheated, dress them in pajamas or put them in a sleep sack, which is a blanket that zips up around them. Do not tuck baby in with a blanket that may come loose, as this is a potential choking hazard.
Parental guidance for dental health for infants (birth to one year)
Even for an infant, dental health is important. This is to ensure the health of their teeth when they first erupt.
Schedule first dental appointment at 1 year old
A child should see the dentist at one-year of age or within 6 months of their first tooth erupting, whichever one comes first. For example, if an infant’s first tooth erupts at age 5 months, schedule the dentist appointment for age 11 months. A child whose first tooth doesn’t erupt until they are 9 months old would see the dentist around their first birthday.
Do not start brushing teeth right away
Wipe the baby’s teeth and gums with a damp washcloth before progressing to toothbrushing. This can feel good to the infant and help soothe the gums when baby is teething.
For difficulty with teething (e.g., crying, sleeping issues), offer safe teething toys or gently rub baby’s gums with a clean finger. The counterpressure can feel good, which is why babies chew on things when they are teething.
Parental guidance for scheduling infant vaccinations (birth to one year)
The following are guidelines for when to vaccinate infants during their first year.
Vaccinations at birth
“oKay, you’re Born!”
Vaccinations at 2 mos.
“B. DR. HIP”
This is a mnemonic for the Hep B. (administered between 1 and 2 mos) DTaP, RV, Hib, IPV, and PCV vaccines. RV stands for rotavirus (a virus that causes diarrheaand other intestinal symptoms). Hib is Haemophilus influenzae B. IPV is the polio vaccine. P is for PCV, the pneumonia vaccine.
Vaccinations at 4 mos.
At 4 months, it is time for another round of DTaP, RV, Hib, IPV, and PCV vaccines.
Vaccinations at 6 mos.
“B. DR. HIP”
At 6 months, it is time for the last round of DTaP, RV, Hib, IPV, and PCV vaccines. Note that it is also time for a round of hepatitis B vaccine (between 6 and 18 mos.). And, if seasonally appropriate, this is the age to start giving children their annual flu shot.
Hi. I'm Meris with Level Up RN, and in this video, I'm going to be talking to you about some important parental guidance for those who have children who are infants, meaning from birth to age one year. I'm going to be following along using our pediatrics flashcards. These are available on our website, leveluprn.com, if you want to get a set for yourself. And if you already have your own, I would invite you to follow along with me.
Okay. Let's get started. So first up, we are talking about nutritional guidance for the infant. You can see there's a lot of information on this card. And we do have some bold red text here, meaning that it's pretty important stuff to know to be able to teach to caregivers. So for the first 12 months of life, a child should be receiving breast milk or formula. We also don't want to prop up a bottle. So we would want to hold the bottle or allow the child to hold it when they are able to. But here's a really, really, really important part. Remember that children have a larger percentage of their body make-up composed of water than adults, and they are a lot more water than we are, which means that they are affected by fluid balance disturbances and things like electrolyte disturbances a lot more than we are. It affects them more strongly. For this reason, it is so desperately important that you educate a new parent or caregiver not to give their infant supplemental water until the age of 6 months. Now, obviously, if the pediatrician says something else based on a condition or an alteration in health that they may have, that's different. But when we're talking about just normal growth and development, no water until the age of 6 months.
When you're preparing something like formula, you do add water to it, but it's in a very specific ratio of formula to water. Typically, it's one scoop of powdered formula to two ounces of water, and it's crucial that that be the correct ratio. We don't want to do things like water down formula or add additional water to pre-prepared formula. You can buy that liquid formula that is ready to feed and you just keep it in the fridge after opening it. We don't want to add water to that. It is already in the correct ratio.
We also don't want to give honey or cow's milk until one year of age. Honey is because of the risk for botulism, which is crazy because you really don't hear about people having botulism, right? And it's because, for the most part, we have good food preserving and preparation standards now, and so we don't really get botulism that much. But adults are much more able to fend it off with a mature immune system versus an infant who is still building that immune system. Botulism would be deadly for them. No honey. Cow's milk has to do with irritation of the GI tract. So there are some children who will need different and special types of formula. And again, that would be per their provider's orders or instructions.
Solids can be introduced between 4 to 6 months. Again, defer to the specific guidance of the pediatrician. But there's a lot of guidance right now that allergens should actually be introduced sooner rather than later to help to prevent developing allergies. It's pretty interesting. So when my daughter was 4 months old, the pediatrician said, "You don't have to start feeding her solids, but I want you to take a little bit of peanut butter, put it on your finger, and just put it on her lips or her tongue. Just a little bit. And do it every day for a couple of weeks to help to prevent that allergy." Pretty interesting.
So what do we want to do when we feed an infant? First of all, we're going to introduce one food at a time. So this means we're not giving blends of things. We're not going to buy prepared baby food that's bananas, apples, and pears because if the baby doesn't tolerate it, has a bad GI reaction to it or has a true allergy, we're not going to know which one it is. So we're going to introduce foods one at a time, typically for several days in a row or maybe a week, and then we can move on to doing another different type of individual food. One of the first foods a child should get, per the education you receive in nursing school, is iron-fortified infant rice cereal. I am going to say defer to your pediatrician on that, but that is the guidance for your NCLEX and your nursing school exams and even some clinical practice. We're going to give mashed or pureed foods. Again, remember, we probably don't have many teeth, so we're not trying to chew it up. We want to give them pureed stuff already. And we, of course, want to avoid allergens. I'm sorry, not allergens. We want to avoid choking hazards. So those things we detailed in another video in this series, but things like nuts, seeds, round things like hot dogs, grapes, things that require a lot of chewing, big chunks of meat or cheese, we want to avoid that.
Okay. Moving on, let's talk about sleep safety. I mean, it's so important, right? We have so much information here on this card for you, and a lot of it is bold and red. The gist of it is this, right? This is our-- I even hesitate to say it's our Cool Chicken. This is the way to remember safe sleep kind of across the country, across the world. It's ABC. Alone. So the child needs to be alone, meaning not sharing a bed with another child or an adult. On their back. B for back. So we're going to place them on their backs to sleep. And C is for in a crib. So this means that they are in a designated space to sleep that is their own and meets certain criteria.
When it comes to a crib, we need to have-- the slats in the crib need to be less than two and three-eighths inches apart from one another, which is six centimeters. So that's one of the requirements there for crib. We also want the mattress to be firm. So not a soft mattress. A firm mattress. And if you buy a crib mattress, it should be firm. We want it to fit tightly into the crib. Very important there. And then we only want to put a fitted sheet over top of it. So we're not putting a fitted sheet and a flat sheet and a blanket. We don't have anything else in the crib. They are alone in the crib, meaning no blankets, no pillows, no crib bumpers, no stuffed animals. Nothing should be in that crib except for the mattress, the fitted sheet, and the baby.
People get really concerned about their child being too cold at night, and, actually, overheating is a bigger concern than being too cold. So people will try to put the crib near a heating vent or something along those lines, and you should not do that. That is also one of the guidelines of safe sleep. Instead, we can put the baby-- obviously, dress them in pajamas of some sort and put them in a sleep sack. So that's a blanket that zips up around them. They kind of wear it like a vest that goes all the way down to their feet. And it is enclosed, but it's not a loose blanket that is just floating around in that bed.
Okay. Now, moving on, we're talking about dental health guidance. It's funny to think about dental guidance for an infant, right? But the health of those teeth when they first erupt is very, very important. So we want a child to see the dentist at one year old or within 6 months of their first tooth erupting, whichever one comes first. So my son, he got his first tooth when he was 5 months old. So 6 months later was when he was 11 months old, and that's when we went to the dentist. My daughter didn't get her first tooth until she was 9 months old, but we still went to the dentist at a year old. So it's whichever one comes first. When the child is little, you can wipe the tooth or the gum with a damp washcloth, and that can actually also feel good for them when they are teething. But then you can progress to actually brushing their teeth. And another thing. Like I said, for that teething pain, you can rub on their gums gently with a clean finger. That counterpressure can feel really good, and that's why babies chew on things when they are teething.
Okay. Lastly, we're talking about vaccinations. So these are the guidelines here for vaccinations in the first year of life. I'm going to take you through them. We have age birth, 2 months, 4 months, and 6 months, okay? So within that first 12 months of life. We will talk about the actual 12-month, one-year checkup in the next version of this, in the next age, but this is in that infancy period. So birth, this is my favorite Cool Chicken of ours for this. It's okay, you're born. So K and B for born. So that's where we give vitamin K, which is not a vaccination. It is just an injection of a medication. But then we also give the hepatitis B vaccine. So Hep B, vitamin K. Okay, you're born.
Then at 2 months, we have B Dr. HIP. So B is for hepatitis B. Then we have doctor. So DR. That's for DTaP and rotavirus, which can be abbreviated RV. Then we have HIP. So the H is for HIB, Haemophilus influenzae B, the I is for IPV, which is the polio vaccine, and then the P is for PCV, which is the pneumonia vaccine. So B Dr. HIP. Then at 4 months, it's just Dr. HIP. There's no B. There's no hepatitis B. And then at 6 months, we're back to B Dr. HIP. However, if it is seasonally appropriate, the child should begin receiving their first seasonal flu vaccine at this age. So, for instance, my son, when he was 6 months old, it was April. It wasn't flu season. He didn't get a flu shot, right? But if he had been 6 months old in October or November, perhaps he would have gotten one then. So it's only if it's seasonally appropriate. So look for those cues in test questions and clinical practice.
All right. I'm going to ask you some quiz questions to test your knowledge of key facts I provided in this video. Let's see how you do. First up, I want you to tell me, at what age is a child allowed to have supplemental water? How should the nurse describe a mattress that is appropriate for an infant to use in a crib?
When should the nurse educate caregivers to schedule their child's first dental appointment? Give me the two milestones.
A child is at a checkup for their 6-month pediatric checkup during October. Tell me all of the vaccines that this child should receive.
All right. Let me know how you did in the comments. I'm sure you did great. If not, you can go back and rewatch for some more key points. Thanks so much and happy studying.
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