Neobook — clinical reference

Referrals to Dietetic Department

Breastfeeding Babies Under 6 Months

If the dietician is not available

What to do if a child does not grow on breastfeeding

Factors that reduces milk production

How to increase breast milk production

Ordering of tube feeds and infant formula

Ordering of meals

HIV and infant feeding

Referrals to Dietetic Department

Written referrals can be done using the specific Dietetic Department referral form or memo. The Dietician, Mrs Marlize Gouws does a ward round in ward 3B1 and 2B2 at 11h00. Please refer patients as soon as possible, because Paarl Hospital only has one Dietician for all the wards. All malnourished children should be referred to the Dietician.

Children that were seen in POPD, needing a Dietician consultation, needs to be referred to the POPD clerk for an appointment with the Dietician. Out patients are only seen on Tuesdays. Please give the mother a copy of the discharge summary in case the child’s folder cannot be found. Only premature babies with failure to thrive (FTT) will be seen on the day of their POPD appointment.

Breastfeeding Babies Under 6 Months

NEVER TELL A MOTHER TO STOP BREASTFEEDING HER CHILD IF SHE HAS NOT CONSULTED THE DIETICIAN

IF THE DIETICIAN IS NOT AVAILABLE

Place baby on IV fluid
Talk to a consultant

WHAT TO DO IF A CHILD DOES NOT GROW ON BREASTFEEDING

Determine how regular the mother is breastfeeding her baby. Increase the frequency of breastfeeding to at least 2 hourly.
Evaluate the position and attachment of the baby during breastfeeding – correct technique.
Monitor HGT’s and rehydration.
Prescribe Metoclopramide 10mg po tds 14/7 to the mother to increase breast milk production
NEVER TELL A MOTHER THAT SHE IS PRODUCING TOO LITTLE BREAST MILK EVEN WHEN YOU FEEL THAT IS THE CASE – THE SUCCESS OF BREASTFEEDING IS DETERMINED BY THE MOTHER’S BELIEVE THAT SHE CAN PRODUCE ENOUGH MILK.

FACTORS THAT REDUCES MILK PRODUCTION

Infrequent breastfeeding (not feeding on demand)
Baby is given top up feeds of Infant formula, because the mother believes that she produces too little milk
Expressing of breast milk (if a mother is instructed to express over a period of days to determine the amount of breast milk production. It is impossible for her to express the amount that the baby is able to suck out of the breast.)

HOW TO INCREASE BREAST MILK PRODUCTION

Ask mother to express one feed at least 2 hours after she had breastfed the baby. This must be done under supervision of the nursing staff. She has to express both breasts until no more milk can be expressed. Do not tell her the baby’s needs at this stage. After expressing she must breastfeed the baby for extra stimulation to the breast.
Determine the baby’s needs (150ml/kg).
Determine the volume of the top up feeds. Needs – expressed EBM = top up feed
Reduce the volume of the top up feed daily while you are monitoring weight gain.
FM85 can be added to breast milk if weight gain is not sufficient.

ORDERING OF TUBE FEEDS AND INFANT FORMULA

All tube feed patients must be referred to the Dietician. All tube feeds and infant formula must be ordered on the milk list and sent to the milk kitchen.

The following infant formula and tubefeed products are available currently:

Category	Product
Babies < 6m	Infacare 1 at 150ml/kg
Babies 6m -1 year	Infacare 1 reduce milk from 150ml/kg at 6mnde to a total of 600ml/day at 1 year
Infant and children > 1 year	*Cow’s milk
Semi-elemental feed for babies < 1year	Similac Allimentum or Pepticate
Semi-elemental tube feed for children older than 1 year	Peptamin Junior Provide Xtra (clear fluid with semi-elemental characteristics for children older than 1 year)
Standard tube feed for children older than 1 year	Pediasure providing 30g protein per litre or Frebini Original Easy bag
Standard supplement for children older than 1 year	Pediasure or Frebini Energy drink
SAM	Initially F75 100 ml/kg(oedema) – 130ml/kg (without oedema) and F100 during the rehabilitation phase

*Cow’s milk is not prescribed for children that receive a meal. Every child that receives a meal from the kitchen will receive 600ml cow’s milk per day automatically. Children older than 1 year only needs 600ml of cow’s milk per day.

ORDERING OF MEALS

The following diets are available:
Baby soft	6 months to 1 year
Full diet	Children older than 1 year
Puree diet	Children with chew and swallowing difficulties
Clear fluid diet	Post-operative children
Full fluid diet	See products available above
Diabetic diet	6200kJ Preschool children 7600 kJ Young school children

HIV AND INFANT FEEDING

Premature babies in ward 2B2

Baby needs to receive breast milk.

If baby is unable to breastfeed, but the mother chose breastfeeding as her feeding choice at the clinic, baby can receive unpasteurised express breast milk until baby is able to breastfeed.
If baby is unable to breastfeed, but the mother chose infant formula as her feeding choice at the clinic, baby can receive pasteurised express breast milk until baby is discharge on infant formula. (Mother will not receive free infant formula at the clinic except if the mother or baby are classified as high risk).
If FM85 is added to express breast milk of HIV positive mothers the breast milk must be pasteurised.

Full term babies in ward 2B1

HIV positive mothers make their feeding choice at the anti natal clinic – DO NOT TRY TO CHANGE HER CHOICE WITHOUT A VERY GOOD REASON
HIV positive mother that choose infant formula must be informed that they will not receive free formula from the clinic and that it costs R500 per month to feed a baby on infant formula
Babies of mothers that choose to breastfeed should only receive breast milk. If the babies HGT is to low increase the frequency and duration of the breastfeed. DO NOT ADD INFANT FORMULA. Place baby on IV fluids until breastfeeding can sustain appropriate HGT’s.
Babies that are breastfed will continue to receive breast milk until they are able to eat sufficient amounts of food to grow. Breast milk should be stopped by 12 months for HIV exposed babies

	0-3 MONTHS	3-6 MONTHS	6-9 MONTHS	9-12 MONTHS	12-18 MONTHS	18-24 MONTHS
GROSS MOTOR	Moro reflec ATNR Grasp reflex Poor head control Flexed posture	Hands to midline Hands to feet Rolls to side	Primitive reflex absent Rolls to prone Sits with support Bounces when stood Rocks - creeping	No head lag Bear walks Uses both hands in play Pulls to stand Stand to sit Walks - hold one hand	Walks - stand - walk Pushes baby walker Crawls up steps, down backwards Climbs up onto chair	Walks - changes direction Push/pulls toys Squats in play Walks into ball - to kick it Throw ball - holds hands together
FINE MOTOR	Fixes and follows Eye.hand tracking to 90° Fingers feel objects Ulnar grasp at 3 months	Holds and plays with rattle Palmar grasp Reaches out for an object Mouthing begins	Uses more radial grasp Holds 2 objects in one hand Finger feeds	Pokes finger into holes Pincer grip and voluntary release throws objects	Puts block in cup Palmar grasp 2 block tower Scribbles Turns pages of carboard book	Draws horizontal line 6 block tower Turns pages of book Tears paper Screws lid off
SPEECH AND HEARING Receptive Lang. Expressive Lang.	Looks when spoken to Maintains eye contact Cooing and squeals/ giggles Differential cry	Turns head to sound Silenced by familiar voice Looks at face and mouth of mother Vocalise sounds Uses different pitch uses voice to attract attention	Responds to "no" and "hello" Listens to singing and speech Responds to "where's mommy" Babbles, gagga Imitates sounds jargon emerging Imitates actions - waving	Understands "where is" and "come here" Waves goodbye Understands simple gestures - up, come Responds to sounds Simple words for items "nonsense" talk Says "Mama, Daddy" Enjoys music	Name simple pictures - car, dog Follow simple command Identifies 3 objects when given choice Points to 1 body part 5-7 words Imitates words Same word for different meaning Says social word, "ta, yes"	Understands jump, run, walk Identifies 1/4 items Understands spatial concept "put in" Can ask for objects by name Asks for toiler Me/Mine /no/ more used 3 word sentences
PSYCHOSOCIAL	Sucking with lips seales around teat Rooting reflex present	Eats solids from spoon Gag reflex present Reflexes diminish Smiles at reflection in mirror	Holds bottle with hands Drinks from cup with help Finger feeds Laughs at faces/ peek-a-boo	Holds arms out for dressing Bites and chews Plays peek-a-boo Give and take game Stranger anxiety	Finger feeds Uses a spoon for feeding - messy Potty sits - not yet successful Pulls off socks Imitates house tasks	Takes off clothes Dry during day Bowel controlled Eats with spoon
CONCEPTS	Eye movements Responds to lights/blinks Turns head to light Watches hands Recognize bottle at 3m	Watches everything Moves head and eyes together Eyes move in unison, no squint Watches toy fall - forgets about it	Stretches hand when a toy is seen Looks for toy when dropped on the floor Finds partially hidden toy	Watch toy fall - looks for lost toy Points to wanted object Watched people, animals Finds hidden toy	Finger points to object wanted Points to 1 body part Matches objects from a choice of 2 Lift lids to find toys in box	Matches shapes Points to pictures in book Knows 3 body parts In/out Big/small

	18M - 2 YEARS	2 - 2 ½ YEARS	2½ - 3 YEARS	3 - 3½ YEARS	3½ - 4 YEARS	4 - 4½ YEARS	4½ - 5 YEARS
GROSS MOTOR	Walks - changes direction Push/pulls toys Squats in play Walks into ball to kick it Throw ball hands together	Walks backward Runs well, jumps Walks tiptoe Kicks ball Rides scooter	Leg stands 2 sec Climbs wet Carries object Pedals tricycle	Climbs alternating feet Catches big ball Walks tiptoe Climbs apparatus	Balances leg, 9 seconds Hops in place Ball over head when throwing	Balance 1 leg 10 sec Tiptoe runds Step and throw Uses racquet Jumps rope	Galloping Catches tennis ball with both hands
FINE MOTOR Hand function and vision	6 block tower Turns pages of book Tears paper Screws lid off Draws horizontal line	Digital pronate grip 8 block tower 4 beads Hand preference Draws dots	Folds paper Snips with scissors inaccurately Draws	9 block tower 6 beads Rolls clay Turns key Draws	Static tripod grip 8 beads Small peg onto board Draws	Letters of name Folds accurately 12 beads Thumb/finger opp. Draw	Dynamic tripod grip Cuts on line Writes name Draws
SPEECH AND HEARING Receptive Lang. Expressive Lang.	Understands jump, run, walk Identifies 1/4 items Understands spatial concept "put in" Can ask for objects by name Asks for toilet Me/mine used Says no/mine/more 3 words sentences Knows name, please	Understands me, you, who, where Echolalia Uses past tense Says simple rhymes Simple sentence structure	Understands long, short, wide, narrow, thick, thin, who, rough, smooth Says "I want, no" Articulation errors	Understands 2 part instruction Shows ages on fingers Gives name and surname Uses plurals	Comprehends well Uses "I am" correctly Says age Gives sex	Abstract reasoning begins Asks "why" with meaning Enjoy rhyming words	Understands when reasons are given Clear speech Complex speech sentences
ADL SKILLS	Takes off clothes Dry during day Bowel controlled	Uses spoon Verbalise toilet needs Pulls pants on Washes hands	Bladder and bowel control at night Assist dressing	Opens door Puts on jersey Pours into glass Wash and dry hands	Spreads butter with knife Uses fork Does large buttons	Does buckles Does buttons Brushes teeth Wash face Sets table	Cuts with a knige Uses knife and fork
CONCEPTS Form and space perception	In/out Big/small Matches shapes Points to pictures in book	Under/behind/ More Knows same and different Names	2 pice puzzle Up/down Top/bottom Matches 6 shapes Names	Knows L & R words Remember 3-10 obj. Names	Next to Between 5/6 piece puzzle Knows difference between square rectangle	Above/below Far/near 10 piece puzzle Sizes cups	Hidden pictires Knows L&R 15-20 piece puzzle Names
Colours and numbers		Matches 3 colour Names 1 colour One/many	Matches 6 colours Names 4 colours Shows age on fingers	Knows black and white Counts to 10	Matches all colours Names most colours	Counts to 20	Light/dark colours
Body parts and draw	Knows 3 body parts	Knows sex Recognises fine details in picture Recognises photo of family	Knows hair, nose, eyes, mouth Recognises photo of self	Knows fingers, hips, shoulders Draws head and legs	Knows eyes and thumbs Draws body/arms	Draws mouth, eyes, nose, body, arms, legs	Knows wrists, ankles Draws mouth, eyes, nose, body, arms, legs, hands

Infant & Paediatric Feeding within Paarl Hospital

Drugs mentioned