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Anticipatory Guidance
Principles and practice Anticipatory Guidance Adding Solids to the Infant’s Diet AiV2VE BIENVENU BROUSSARD, R N , MSN, ACCE Infant feeding practices have not always conformed to professional recommendations. Anticipatory guidance based on a careful assessment of the baby’s mother, use of Gestalt principles, and innovative teaching techniques is more likely to lead to appropriate infant feeding practices than fragmented and inconsistent attempts.
Customs and practices surrounding the addition of solids to infants’ diets have varied significantly in history and among different cultures and often are not in accord with current scientific knowledge. From the time of the ancient Greeks into the 18th century, for example, it was an accepted . practice to delay breastfeeding until the newborn was “purged” of meconium (by giving him oil, honey, almond oil, sugared wine, butter, senna, or castor oil) and then to feed the infant a mixture of bread and water or milk until the mother was rested and had stopped discharging any lochia.’ Even after Mariceau mentioned others’ observations of the purgative effect of colostrum in 1673, not until 1748, when Cadogan recommended only breastmilk for the first three months, did an actual change in practice occur.’ Similarly, though the American Academy of Pediatrics’ Committee on Nutrition recommended in 1958 and again in 1980 that supSubmitted: December 1982. Accepted with revisions: February 1983.
July/August 1984 JOGN Nursing
plemental foods not be introduced before four to six months of age, many mothers continue to do so. Nurses are in an excellent position, both prenatally and in the immediate and later postpartum period, to do anticipatory guidance on adding solids. The technique the nurse uses in approaching the mother may well affect that mother’s acceptance and implementation of the information she receives. T h e nurse’s technique is, in turn, affected by her philosophical belief system surrounding learning and the learner. In approaching anticipatory guidance, the first step is to consider the characteristics of and influences on the learner, who is in most cases the infant’s mother. The mother brings with her to the learning situation a background of experiences with and emotions and attitudes about foods and eating, a cultural background, and a set of relationships with family and friends. T h e mother’s mind is not a tabula rasa upon which the nurse can impress a set of facts and expect her to act accordingly. A woman for whom food has an emotional meaning
(food = love/security) may feel she is depriving her infant if she does not start the infant on solids at an early age. A woman who is still dependent on her own mother may be likely to accept her mother’s decisions about starting solids. A woman whose friends all started their babies on solids at one month of age may feel that her infant must also achieve the same milestone. The nurse can assess for these factors and, by acknowledging them to the mother, help her develop insight into her decisions about solids and develop strengths to facilitate modifications of these decisions. Another way to look at the variables in a mother’s background and her decisions about starting the infant on solids is to consider the health belief model (HBM), originated in the 1950s by Hochbaum et al. to “explain health-related behavior at the level of individual decision making.”3 T h e health belief model enumerates three factors that determine an individual’s decision regarding actions recommended by health professionals: 1) “psychological state of readiness to take that action,” determined by
239
“perceived susceptibility to the particular health condition” and by the “perceived severity of the consequences of contracting the condition”; 2) “perceived benefit of the action weighed against the perceived cost or barriers involved in the proposed action”; and 3) a stimulus or cue that triggers the recommended b e h a ~ i o r . ~ A mother will not be psychologically ready to delay giving solids to her two-month-old if she does not perceive that the infant will be susceptible to obesity and allergies or if she does not regard these consequences as severe. A mother will give cow’s milk to her six-monthold if she perceives that the cost of formula outweighs its benefits to her infant. Nurses can explore and attempt to manipulate these variables and can provide or interpret cues that will trigger appropriate action in the mother. Cues could include consistency among nurses doing anticipatory guidance in different settings, pamphlets given to the mother to read at home, and signs of allergy or obesity in the infant. After making an assessment of the mother’s learning needs and her background, the nurse can proceed with guidance on starting solids (Table 1). Realizing that the mere learning of facts without real understanding “is rigid, forgotten easily, and can be applied only to limited circumstance^,"^ the nurse could seek to use Gestalt principles in the learning situation. Learning based on an understanding of the problem at hand and the principles involved “is easily generalizable and . . . remembered for a long time.”4 For example, instead of beginning a guidance session by stating when and how solids should be introduced, a better approach would be to describe some of the results of early infant feeding-obesity, food sensitivities-and to help the mother begin to make her own conclusions.
240
Table 1. General Guide for Introduction of Solid Foods or Other Supplements Stages of Infant Feeding
Food or Supplement Added
Nursing period (birth to 4-6 months)
Breastmilk, or prepared commercial formula in appropriate amounts
Principles to Convey to Mother Meets all of baby’s nutritional nee~is.~,~.’~ Infant able to suck and swallow liquids only (extrusion reflex
persist^).^,^,'^ Gastrointestinaltract cannot cope with foreign protein^.^ Kidneys cannot handle large loads of proteins and electrolyte~.~-’~ Interference with radiation b y sunlight of vitamin D precursors in the baby’s skin.7
400 IU of vitamin D daily for breastfed infants exposed to little sunlight Water if weather is very hot
Transitional period (4-6 months to 1 year)
Increased insensible water 1 0 ~ s . ~ Fresh cow’s milk can cause occult blood loss from the intestine and consequent iron deficiency anemia.’,’0 Baby’s iron stores start to become depleted.’ Extrusion reflex disappears and baby becomes able to swallow nonliquid food^.^-'^ Baby becomes able to express desire for food, or ~atiation.~.’ Baby becomes able to sit with support and can control head and Baby becomes able to digest and absorb other proteins, fats, and
Continue breastmilk or formula
Single-grain, iron-fortified infant cereals
carbohydrate^.^ Baby’s intestines are developing defense mechanisms to protect baby from foreign p r o t e i n ~ . ~ Baby’s kidneys are becoming able to handle larger osmolar loads7 Introduces a variety of foods to set patterns for a varied diet7.” Avoid spinach, beets, turnips, and collard greens until later infancy (nitrates they contain can cause methemogl~binemia).~ Wheat products and eggs may be introduced after 6-9 months to decrease risk of developing allergies to these substance^.^ If food intolerance or allergy develops, offending food can be identified.7
Prepared vegetables, fruits and meats with no added salt or sugar
Bread, cheese, eggs
Foods are introduced one at a time, at 1 week or longer intervals Water
Renal osmolar load is high in highprotein or electrolyte foods (e.9.. meats and egg yolk^).^.^.'^ Given in a cup to prevent “bottlemouth syndrome” of dental caries?
Juices
(Continued next page) ~~~
~
~
July/August 1984 JOGN Nursing
Table 1. (Continued)
-
Stages of Infant Feeding
-
Food or Supplement Added Combination foods
Modified adult period (over 1 year)
Family table foods, with minimal alteration (cut into small pieces or mashed to a lumpy consistency) Cow’s milk (whole) or breastmilk
As Chute stated, “discovering some
of their own answers t o a problem adds personal meaning t o the new facts and ideas learned.”5 Markesbery a n d Wong’s motivational tool, based o n Gestalt principles, consists of four tables.5 O n e table is used t o evaluate the infant’s weight status (obese o r nonobese). A second table is used t o determine the infant’s caloric needs per pound, according t o age range (birth to three months, three to six months, etc.). A third table states caloric needs, according t o weight and age, in terms of ounces of 20 calories/ounce formula. A fourth table illustrates the “average calorie content of common infant foods.”6 Using this tool, t h e nurse can help the mother understand why adding solids might be inappropriate. She is- not simply told that the baby should not have solid food, but is helped t o understand why. T h e teaching method itself can enhance learner receptivity. Lecturing is usually not as well received o r as effective as methods that actively involve the learner, such as group discussion, role-playing, or pencil and paper exercises. For example, for a group of mothers, a nurse and a mother could role-play a situation in which a mother is being pressured by her mother-inlaw t o start giving her one-monthold infant cereal in an infant feeder. By having the “mother” (nurse) handle the situation successfully,
July/August 1984 JOCN Nursing
Principles to Convey to Mother May introduce these when there is tolerance to each of the foods in them.7 Baby is learning to feed self.7 Baby can digest and absorb many types of foods.7 Baby’s physiological mechanisms are near to adult pr~ficiency.~ Skim-milk or low-fat milk (2% milk) can cause depletion of the baby’s fat stores.’-’’
facts about use of an infant feeder and early feeding can be transmitted, as well as ideas for handling persistent but uninformed relatives. Instead of simply telling mothers that unsweetened frozen juices would be better than canned baby juices, the nurse could have the mothers read the labels for nutritional content and price and guide them t o their own conclusion^.^ T h e nurse should provide the mother with a general guide on introducing solids a n d other supplements t o the infant’s diet. O t h e r issues t o discuss with mothers in anticipatory guidance include homemade baby food; safety factors (e.g., to prevent spoiling of baby’s food); selection of nutritious snack foods; establishing a pleasant atmosphere for eating to help the infant develop a positive attitude about food; avoidance of using foods in an inappropriate way (e.g., cereal at one month “ t o help baby sleep through the night”); amounts of food appropriate at each stage; and appropriate ways of feeding baby (avoiding use of infant feeder, using spoon and cup for anything besides milk). Assessment of the mother a n d use of Gestalt principles and innovative teaching techniques should result in anticipatory guidance that is well planned a n d effective, leading to infant feeding practices that are in accord with current scientific knowledge. Consistent anticipatory guidance by each nurse involved in
the mother’s care (prenatal classes, obstetrician’s office nurse, postpartum nurse, postpartum discussion groups, pediatrician’s office nurse) is more likely to lead t o the mother’s compliance than fragmented and inconsistent attempts.
References 1. Fildes V. It’s a wonder babies ever survived. Nursing Mirror 1979;149(2)(suppl):viii-xix. 2. Rosenstock I M . Historical origins of the health belief model. In: Becker MH, ed. The health belief model and personal health behavior. Thorofare, NJ: Charles B. Slack, 1974. 3. Mikhail B. The health belief model: a review and critical evaluation of the model, research, and practice. Advances in Nursing Science 1981;4(1):65-82. 4. Hergenhahn BR. An introduction to theories of learning. Englewood Cliffs, NJ: Prentice-Hall, 1982:266. 5. Chute D. Creating a learning environment. Canadian Nurse 1979; 74(1):48-51. 6. Markesbery B, Wong W. Watching baby’s diet: a professional and parent guide. MCN 1979;4(3):17780. 7 American Academy of Pediatrics, Committee on Nutrition. O n the feeding of supplemental foods to infants. Pediatrics 1980;65(6): 1178-81. 8 Jensen M , Benson R, Boback I. Maternity care: the nurse and the family. St. Louis: C. V. Mosby, 1981:655-95. 9. Sage CR. Infancy: the neglected age i n nutrition: facts for change. Canadian Nurse 1979;74(1):45-7. 10. Woodruff CW. The science of infant nutrition and the art of infant feeding. JAMA 1978;240(7):65761.
Address for correspondence: Anne Bienvenu Broussard, RN, 126 Burdin Street, St. Martinville, LA 70582.
Anne Bienvenu Broussard is an instructor in the College of Nursing at the University of Southwestern Louisiana in Lafayetteand has a private practice in childbirth education. Ms. Broussardis a member of Sigma Theta Tau, ASPO, and NAACOG.
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Customs and practices surrounding the addition of solids to infants’ diets have varied significantly in history and among different cultures and often are not in accord with current scientific knowledge. From the time of the ancient Greeks into the 18th century, for example, it was an accepted . practice to delay breastfeeding until the newborn was “purged” of meconium (by giving him oil, honey, almond oil, sugared wine, butter, senna, or castor oil) and then to feed the infant a mixture of bread and water or milk until the mother was rested and had stopped discharging any lochia.’ Even after Mariceau mentioned others’ observations of the purgative effect of colostrum in 1673, not until 1748, when Cadogan recommended only breastmilk for the first three months, did an actual change in practice occur.’ Similarly, though the American Academy of Pediatrics’ Committee on Nutrition recommended in 1958 and again in 1980 that supSubmitted: December 1982. Accepted with revisions: February 1983.
July/August 1984 JOGN Nursing
plemental foods not be introduced before four to six months of age, many mothers continue to do so. Nurses are in an excellent position, both prenatally and in the immediate and later postpartum period, to do anticipatory guidance on adding solids. The technique the nurse uses in approaching the mother may well affect that mother’s acceptance and implementation of the information she receives. T h e nurse’s technique is, in turn, affected by her philosophical belief system surrounding learning and the learner. In approaching anticipatory guidance, the first step is to consider the characteristics of and influences on the learner, who is in most cases the infant’s mother. The mother brings with her to the learning situation a background of experiences with and emotions and attitudes about foods and eating, a cultural background, and a set of relationships with family and friends. T h e mother’s mind is not a tabula rasa upon which the nurse can impress a set of facts and expect her to act accordingly. A woman for whom food has an emotional meaning
(food = love/security) may feel she is depriving her infant if she does not start the infant on solids at an early age. A woman who is still dependent on her own mother may be likely to accept her mother’s decisions about starting solids. A woman whose friends all started their babies on solids at one month of age may feel that her infant must also achieve the same milestone. The nurse can assess for these factors and, by acknowledging them to the mother, help her develop insight into her decisions about solids and develop strengths to facilitate modifications of these decisions. Another way to look at the variables in a mother’s background and her decisions about starting the infant on solids is to consider the health belief model (HBM), originated in the 1950s by Hochbaum et al. to “explain health-related behavior at the level of individual decision making.”3 T h e health belief model enumerates three factors that determine an individual’s decision regarding actions recommended by health professionals: 1) “psychological state of readiness to take that action,” determined by
239
“perceived susceptibility to the particular health condition” and by the “perceived severity of the consequences of contracting the condition”; 2) “perceived benefit of the action weighed against the perceived cost or barriers involved in the proposed action”; and 3) a stimulus or cue that triggers the recommended b e h a ~ i o r . ~ A mother will not be psychologically ready to delay giving solids to her two-month-old if she does not perceive that the infant will be susceptible to obesity and allergies or if she does not regard these consequences as severe. A mother will give cow’s milk to her six-monthold if she perceives that the cost of formula outweighs its benefits to her infant. Nurses can explore and attempt to manipulate these variables and can provide or interpret cues that will trigger appropriate action in the mother. Cues could include consistency among nurses doing anticipatory guidance in different settings, pamphlets given to the mother to read at home, and signs of allergy or obesity in the infant. After making an assessment of the mother’s learning needs and her background, the nurse can proceed with guidance on starting solids (Table 1). Realizing that the mere learning of facts without real understanding “is rigid, forgotten easily, and can be applied only to limited circumstance^,"^ the nurse could seek to use Gestalt principles in the learning situation. Learning based on an understanding of the problem at hand and the principles involved “is easily generalizable and . . . remembered for a long time.”4 For example, instead of beginning a guidance session by stating when and how solids should be introduced, a better approach would be to describe some of the results of early infant feeding-obesity, food sensitivities-and to help the mother begin to make her own conclusions.
240
Table 1. General Guide for Introduction of Solid Foods or Other Supplements Stages of Infant Feeding
Food or Supplement Added
Nursing period (birth to 4-6 months)
Breastmilk, or prepared commercial formula in appropriate amounts
Principles to Convey to Mother Meets all of baby’s nutritional nee~is.~,~.’~ Infant able to suck and swallow liquids only (extrusion reflex
persist^).^,^,'^ Gastrointestinaltract cannot cope with foreign protein^.^ Kidneys cannot handle large loads of proteins and electrolyte~.~-’~ Interference with radiation b y sunlight of vitamin D precursors in the baby’s skin.7
400 IU of vitamin D daily for breastfed infants exposed to little sunlight Water if weather is very hot
Transitional period (4-6 months to 1 year)
Increased insensible water 1 0 ~ s . ~ Fresh cow’s milk can cause occult blood loss from the intestine and consequent iron deficiency anemia.’,’0 Baby’s iron stores start to become depleted.’ Extrusion reflex disappears and baby becomes able to swallow nonliquid food^.^-'^ Baby becomes able to express desire for food, or ~atiation.~.’ Baby becomes able to sit with support and can control head and Baby becomes able to digest and absorb other proteins, fats, and
Continue breastmilk or formula
Single-grain, iron-fortified infant cereals
carbohydrate^.^ Baby’s intestines are developing defense mechanisms to protect baby from foreign p r o t e i n ~ . ~ Baby’s kidneys are becoming able to handle larger osmolar loads7 Introduces a variety of foods to set patterns for a varied diet7.” Avoid spinach, beets, turnips, and collard greens until later infancy (nitrates they contain can cause methemogl~binemia).~ Wheat products and eggs may be introduced after 6-9 months to decrease risk of developing allergies to these substance^.^ If food intolerance or allergy develops, offending food can be identified.7
Prepared vegetables, fruits and meats with no added salt or sugar
Bread, cheese, eggs
Foods are introduced one at a time, at 1 week or longer intervals Water
Renal osmolar load is high in highprotein or electrolyte foods (e.9.. meats and egg yolk^).^.^.'^ Given in a cup to prevent “bottlemouth syndrome” of dental caries?
Juices
(Continued next page) ~~~
~
~
July/August 1984 JOGN Nursing
Table 1. (Continued)
-
Stages of Infant Feeding
-
Food or Supplement Added Combination foods
Modified adult period (over 1 year)
Family table foods, with minimal alteration (cut into small pieces or mashed to a lumpy consistency) Cow’s milk (whole) or breastmilk
As Chute stated, “discovering some
of their own answers t o a problem adds personal meaning t o the new facts and ideas learned.”5 Markesbery a n d Wong’s motivational tool, based o n Gestalt principles, consists of four tables.5 O n e table is used t o evaluate the infant’s weight status (obese o r nonobese). A second table is used t o determine the infant’s caloric needs per pound, according t o age range (birth to three months, three to six months, etc.). A third table states caloric needs, according t o weight and age, in terms of ounces of 20 calories/ounce formula. A fourth table illustrates the “average calorie content of common infant foods.”6 Using this tool, t h e nurse can help the mother understand why adding solids might be inappropriate. She is- not simply told that the baby should not have solid food, but is helped t o understand why. T h e teaching method itself can enhance learner receptivity. Lecturing is usually not as well received o r as effective as methods that actively involve the learner, such as group discussion, role-playing, or pencil and paper exercises. For example, for a group of mothers, a nurse and a mother could role-play a situation in which a mother is being pressured by her mother-inlaw t o start giving her one-monthold infant cereal in an infant feeder. By having the “mother” (nurse) handle the situation successfully,
July/August 1984 JOCN Nursing
Principles to Convey to Mother May introduce these when there is tolerance to each of the foods in them.7 Baby is learning to feed self.7 Baby can digest and absorb many types of foods.7 Baby’s physiological mechanisms are near to adult pr~ficiency.~ Skim-milk or low-fat milk (2% milk) can cause depletion of the baby’s fat stores.’-’’
facts about use of an infant feeder and early feeding can be transmitted, as well as ideas for handling persistent but uninformed relatives. Instead of simply telling mothers that unsweetened frozen juices would be better than canned baby juices, the nurse could have the mothers read the labels for nutritional content and price and guide them t o their own conclusion^.^ T h e nurse should provide the mother with a general guide on introducing solids a n d other supplements t o the infant’s diet. O t h e r issues t o discuss with mothers in anticipatory guidance include homemade baby food; safety factors (e.g., to prevent spoiling of baby’s food); selection of nutritious snack foods; establishing a pleasant atmosphere for eating to help the infant develop a positive attitude about food; avoidance of using foods in an inappropriate way (e.g., cereal at one month “ t o help baby sleep through the night”); amounts of food appropriate at each stage; and appropriate ways of feeding baby (avoiding use of infant feeder, using spoon and cup for anything besides milk). Assessment of the mother a n d use of Gestalt principles and innovative teaching techniques should result in anticipatory guidance that is well planned a n d effective, leading to infant feeding practices that are in accord with current scientific knowledge. Consistent anticipatory guidance by each nurse involved in
the mother’s care (prenatal classes, obstetrician’s office nurse, postpartum nurse, postpartum discussion groups, pediatrician’s office nurse) is more likely to lead t o the mother’s compliance than fragmented and inconsistent attempts.
References 1. Fildes V. It’s a wonder babies ever survived. Nursing Mirror 1979;149(2)(suppl):viii-xix. 2. Rosenstock I M . Historical origins of the health belief model. In: Becker MH, ed. The health belief model and personal health behavior. Thorofare, NJ: Charles B. Slack, 1974. 3. Mikhail B. The health belief model: a review and critical evaluation of the model, research, and practice. Advances in Nursing Science 1981;4(1):65-82. 4. Hergenhahn BR. An introduction to theories of learning. Englewood Cliffs, NJ: Prentice-Hall, 1982:266. 5. Chute D. Creating a learning environment. Canadian Nurse 1979; 74(1):48-51. 6. Markesbery B, Wong W. Watching baby’s diet: a professional and parent guide. MCN 1979;4(3):17780. 7 American Academy of Pediatrics, Committee on Nutrition. O n the feeding of supplemental foods to infants. Pediatrics 1980;65(6): 1178-81. 8 Jensen M , Benson R, Boback I. Maternity care: the nurse and the family. St. Louis: C. V. Mosby, 1981:655-95. 9. Sage CR. Infancy: the neglected age i n nutrition: facts for change. Canadian Nurse 1979;74(1):45-7. 10. Woodruff CW. The science of infant nutrition and the art of infant feeding. JAMA 1978;240(7):65761.
Address for correspondence: Anne Bienvenu Broussard, RN, 126 Burdin Street, St. Martinville, LA 70582.
Anne Bienvenu Broussard is an instructor in the College of Nursing at the University of Southwestern Louisiana in Lafayetteand has a private practice in childbirth education. Ms. Broussardis a member of Sigma Theta Tau, ASPO, and NAACOG.
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