To calculate the correct quantity of milk feed for an infant who is full-term, and developing within normal parameters, it is important to consider expected weight gains and losses. Weight gain is expected to be in the region of 200 g per week during the first 3 months of life, although, as the infant first adapts to the environment, there is an expected weight loss within the first 2 weeks of life. This usually constitutes a loss of approximately 10% of body weight, i.e. if an infant weighs 3.5 kg at birth, there will be an estimated loss of 350 g.

To achieve weight gain, the infant is offered 150 mL/kg of body weight every 24 hours, i.e. if the infant weighs 3.5 kg:

It is then necessary to divide this overall quantity into a set number of feeds. Under normal circumstances, an infant in the first month of life will be offered feeds approximately every 4 hours, which equates to six feeds in 24 hours:

Therefore one needs to prepare 90 mL of feed in each bottle (Hubbard & Trigg 2000).

Weaning should start when the infant reaches 6 months of age (Department of Health, 2003 and Department of Health, 2008). Many parents according to Foote et al (2003), Hamlyn et al (2000) and Fewtrell (2003) choose to give solid foods before 6 months. However, parents should be encouraged to continue milk feeds until at least 4 months (17 weeks). Weaning should not commence before 4 months because the immature digestive and renal systems cannot cope with solid foods (DoH 1994, Scientific Advisory Committee on Nutrition 2003). Parents should be encouraged to view 4 months (17 weeks) as the earliest time to commence weaning.

It is imperative that individual circumstances are considered when health professionals are giving advice on the age for the introduction of solid foods. At 6 months of age infants reach a transition period. By this time the gastrointestinal tract has matured sufficiently to handle more complex nutrients and is less sensitive to potentially allergenic foods. Tooth eruption is beginning, which facilitates biting and chewing (DoH 1994, Hockenberry 2003).

Eating a weaning diet requires the infant to have a level of neuromuscular coordination that may not be achieved prior to 6 months, e.g. holding the head in an upright position, sitting up. Around 6 months of age, the tongue-thrust reflex, which causes food to be pushed out of the mouth, is reducing. Chewing motions and the ability to move food to the back of the mouth and swallow are developing (Department of Health (DoH), 1994 and Department of Health, 2003, Hockenberry 2003). Therefore, developmentally, the infant becomes ready to move into the weaning stage.

The weaning diet should consist of foods from all main food groups: carbohydrates, proteins, fats and oils, and sugars as well as fruit and vegetables (Table 40.2). However, when preparing foods for the infant, additional salt and sugar should be avoided due to the immaturity of kidneys and liver (DoH 1994).

New foods should be added to the infant diet one at a time. Infant cereal may be given mixed with modified formula milk in a bowl. If the infant is breast fed the cereal can be mixed with expressed breast milk or water. Fruit juices can be mixed with the dry cereal – the vitamin C content of the juice enhances the absorption of iron. Vitamin C is destroyed by heat and juice should therefore not be warmed. Offer fruit juice from a cup rather than a bottle to prevent the development of dental caries.

Common foods such as milk, eggs, soya, wheat, peanuts, tree nuts (e.g. hazelnuts), sesame seeds and, in older children, fish and shellfish, which form about 90% of cases of food allergy should be avoided.

According to Fiocchi et al (2003), cow’s milk intolerance is a multifaceted disorder representing adverse systemic and local gastrointestinal reactions to cow’s milk protein. The hypersensitivity may be manifest through a variety of signs and symptoms. These may appear within 45 minutes of milk ingestion or after a period of several days, e.g. cow’s milk intolerance may be manifest as colic or sleeplessness in an otherwise healthy infant. The diagnosis is made after careful history taking.

Allergy to cow’s milk affects 2–7% of infants under 1 year old. It is the most common food allergy in childhood (Department for Education and Skills (DfES), 2006 and Wakefield et al., 1998). Children usually grow out of milk allergy by the age of 3, but about 20% of these children will still be allergic to milk as adults.

Cow’s milk allergy is caused by a reaction to a number of allergens in cow’s milk. The protein in milk can be broken down into curds (casein), which form when milk sours. Whey is the watery part that is left when the curd is removed. A reaction can also be triggered by small amounts of milk received through the mother’s breast milk from dairy products she has eaten, or, from feeding cow’s milk to the infant.

The symptoms of milk allergy are often mild and can affect any part of the body. In more severe episodes symptoms can include rashes, diarrhoea, vomiting, stomach cramps and difficulty in breathing. In a very few cases, milk allergy can cause anaphylaxis.

The differences between food allergy and food intolerance are shown in Table 40.4.

The principle nursing objectives are assessment and identification of potential milk allergy and appropriate health education advice and counselling of parents regarding substitute milk feeds.

The protein-hydrolysed formulae are less palatable than milk-based formulae. Consequently, reluctance to accept the new formula by the infant may be a problem. This can be overcome by introducing the formula gradually over a period of days. Parents also need to be reassured that the infant will receive complete nutrition from the new formula and will suffer no ill effects from the absence of cow’s milk.

Once solid foods are started, parents require guidance in avoiding all associated milk products during weaning. This requires carefully reading all food labels to avoid potential addition of milk products to the prepared food.

There is no medical treatment (Food Standards Agency (FSA) 2003) for lactose intolerance but the symptoms can be avoided by controlling the amount of lactose in the diet. This requires elimination of dairy products in the diet. In infants, a soya-based formula can be substituted for cow’s milk formula or human milk. As dairy products are a major source of calcium and vitamin D, supplementation of these nutrients is needed to prevent any deficiency.

Identification of sources of lactose is required, e.g. especially hidden sources such as bulk agents in certain medications. Check with the pharmacist regarding this possibility when ordering medications of any sort.

To ensure sufficient protein in the vegetarian diet, foods with incomplete proteins (those that do not have all of the essential amino acids) must be eaten at the same meal with other foods that supply the missing amino acids. The three basic combinations of foods consumed by vegetarians that generally provide the appropriate amounts of essential amino acids are:

The best assurance of nutritional adequacy is to eat a variety of foods. Families need guidelines for selecting foods that provide essential nutrients without exceeding energy requirements. Nurses and health visitors involved in the care of infants play an important part in the health education process. By understanding the factors such as cultural and religious dietary needs that may influence the decisions parents make concerning weaning, health professionals can adapt recommended weaning guidelines appropriately for individual families (Shaw & Pal 2002).

Growth measurements alone are not used to diagnose children with failure to thrive. The finding of persistent deviation from an established growth curve is cause for concern. Percentile charts should be used for all infants. If weight and height measurements fall off the percentile indicated by birth weight for that percentile then failure to thrive should be considered.

The above factors require assessment and the infant may require hospitalisation for an assessment of physiological status. The needs of the family will also need to be assessed. The multidisciplinary team, including social workers, health visitors, dietitians, will play an important role in the assessment and planning of appropriate interventions to support the family in providing for the nutritional needs of the infant.

When atopic eczema occurs during infancy it affects each infant differently in terms of both onset and severity of signs and symptoms. A rash may first appear in patches around the cheeks and chin, combined with local vasodilation, which gives the rash a red appearance. This can progress to spongiosis (the breakdown of the dermal skin cells and the development of intradermal vesicles) (Spagnola & Korb 2002). This can be seen as red, scaling, oozing skin. Scratching can eventually produce a weeping skin. The skin may then become infected. Chronic scratching produces lichenification or coarsening of the skin folds. Aycliffe (2009) in a comprehensive review of the management of eczema confirms that more girls than boys are affected by the disease.

Once the infant becomes more mobile and begins crawling, exposed areas, such as the inner and outer parts of the arms and legs, may also be affected. Atopic eczema may also affect the skin around the eyes, the eyelids, and the eyebrows and lashes. Scratching and rubbing the eye area can cause the skin to redden and swell. Rubbing also causes patchy loss of eyebrows and eyelashes. Over time, atopic eczema may lead to development of an extra fold of skin under the eyes.

An infant with atopic eczema may be restless and irritable because of the itching and discomfort of the disease (Table 40.6). Difficulty in sleeping can occur due to the nature of pruritus.

Researchers including Cork (1997) have observed differences in the skin of those with atopic eczema that may contribute to the symptoms of the disease.

The outer layer of skin, the epidermal layer, is divided into two parts: an inner part containing moist, living cells, and an outer part, known as the horny layer or stratum corneum, containing dry, flattened, dead cells. Under normal conditions, the stratum corneum acts as a barrier, keeping the rest of the skin from drying out and protecting other layers of skin from damage caused by irritants and infections. When this barrier is damaged, irritants act more intensely on the skin.

The skin of an infant with atopic eczema loses moisture from the epidermal layer, allowing the skin to become very dry and reducing its protective abilities. Thus, when combined with the abnormal skin immune system, the infant’s skin is more likely to become infected by viruses (e.g. herpes simplex) or bacteria (e.g. Staphylococcus and Streptococcus spp.).

Immunoglobulin E (IgE) is a type of antibody that controls the immune system’s allergic response. An antibody is a protein produced by the immune system that recognises and helps fight and destroy viruses, bacteria, and other foreign substances that invade the body. Normally, IgE is present in very small amounts but levels are high in 80–90% of people with atopic eczema (Hanifin and Rajka, 1980 and Hockenberry, 2003).

Atopic eczema can present with a variety of symptoms. The symptoms can vary in intensity and also over time. Assessment of general health, past medical history, familial history plus specific assessment of skin should be carried out. In infancy, lesions are located on the:

Lesions can also be generalised, i.e. they can cover the entire body. The signs and symptoms of atopic eczema are shown in Box 40.1.

Exploration of any family history of allergies is necessary. Although atopic eczema runs in families, the role of genetics or inheritance is still not clear. It does appear that more than one gene is involved in the disease. Studies suggest that genetics play an important part in the inheritance of the disease (Spagnola & Korb 2002). Infants and children are at increased risk for developing the eczema if there is a family history of other atopic disease, such as hay fever or asthma. The risk is significantly higher if both parents have an atopic disease. In addition, studies of identical twins, who have the same genes, show that in an estimated 80–90% of cases, atopic disease appears in both twins. Fraternal (non-identical) twins are no more likely than two non-related people in a general population to both have an atopic eczema.

Aycliffe (2009) has discussed the use of scoring tools to ascertain the presence of eczema in an affected child. The National Eczema Society provides information on the optimum method of doing this: www.eczema.org/professionals.html.

A preliminary diagnosis of atopic eczema can be made if the patient has three or more features from each of two categories: major features and minor features (Hanifin and Rajka, 1980 and National Eczema Society, 2003).

The most common allergenic (allergy-causing) foods are eggs, milk, peanuts, wheat, soy and fish. A recent analysis (Spagnola & Korb 2002) of a large number of studies on allergies and breastfeeding indicated that breastfeeding an infant for at least 4 months may protect the infant from developing allergies. Mothers with a family history of atopic conditions should be advised to avoid eating common allergenic foods during late pregnancy and breastfeeding.

A basic diet of hypoallergenic food is given to the infant initially. One new food at a time is added to determine the infant’s reaction to it:

When an infant has atopic eczema, the family may have to cope with the stress and frustration associated with the disease and nurses undertaking an assessment should ascertain how the condition is impacting the family; for example, if it is adversely affecting the child’s ability to form and sustain friendships (Aycliffe 2009). The infant may be fussy and irritable and unable to keep from scratching and rubbing the skin. Sleepless nights also cause irritation to both infant and family. Distracting the child and providing activities that keep the hands busy are helpful but require much effort on the part of the parents or caregivers. Another issue family’s face is the social and emotional stress associated with changes in appearance caused by atopic eczema.

Soaps and detergents are drying because they remove natural lipids from the skin surface. Emollients provide a barrier to prevent water evaporating from the skin and also foreign irritants from entering. Emollients can be applied in liberal amounts twice a day and whenever the skin feels dry and itchy.

Emollients are available in various forms, including creams, ointments, lotions, soap substitutes and bath additives. Twitchen & Lowe (1998) describe the action of emollients as hydrating, soothing and smoothing of the scales on the skin.

Hoare et al (2000), in a systematic review of research into atopic eczema treatments, found there was insufficient evidence to make recommendations on treatments such as Chinese herbs, homeopathy, massage therapy, hypnotherapy and evening primrose oil.