Case Three: Carlos

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Carlos

Carlos  is a healthy, developmentally appropriate baby who was born at 40 weeks gestation to a 41 year old mother, Antoinette, and 49 year old father, Francisco. Carlos has a sister who is 6 and a brother who is 8 years old. The family is Mexican American.  Antoinette is a clinical nurse at a large hospital.  Francisco  is a counselor at a local high school. Both Antoinette and Francisco and are active in their church and community. Francisco's mother lives with the family. She works part time during the days, but she often joins the family for meals and frequently takes care of Carlos on evenings and weekends when his parents have other responsibilities.

During  her pregnancy with Carlos Antoinette developed gestational diabetes and she required insulin to control her blood glucose levels. Two of Antoinette's older siblings have developed type 2 diabetes.  Antoinette gained 40 pounds during her pregnancy with Carlos.  Antoinette now weighs 150 pounds and is 5 tall.  Francisco  is 5'5" tall and weighs 180 pounds. At his birth on July 1, Carlos weighed 4600 g and was 54 cm in length.

Carlos's growth history:

Carlos is breastfed when he is with his mother.  Antoinette is a strong advocate for breastfeeding in her community. She breastfed all of her children and plans to nurse Carlos at least until he is one year old. She reports no problems or concerns about breastfeeding. When she first went back to work she used the "pump room" at the hospital to express milk to be fed to Carolos the next day.  Recently, the nursing coverage on her floor has been reduced and  finds that she doesn't have time to express milk during her work day.  Carlos nurses once during the night, once before his mother leaves for work, and twice in the evening. While his mother is at work Carlos is cared for in a family day care home that is run by the wife of their pastor who is also a close friend of the family and Antoinette. Although Carlos is the only infant in the home, the child care provider has several other children under her care. At the child care, home Carlos spends most of his time in a crib. He cries a lot, and the provider tries to feed him whenever he cries by propping a bottle in his crib. When he is well, Carlos usually takes about 3 - 8 ounce bottles of Similac with iron.  Occasionally he is also given whole cows milk since the child care provider doesn't always have time to mix the powdered formula and just puts milk in Carlos's bottle when she fills up the older children's cups.   Several days out of the month, especially when he seems to be teething, Carlos will be congested or irritable, and he has had two recent ear infections. When this happens the day care provider gives him juice or sweetened lemon tea as she was taught to do by her mother. 

Carlos shows a strong interest in food. When the family eats, Carlos reaches out for the foods they are eating. He has been given "bits and pieces" of family foods, mostly by his maternal grandmother, since he was about 3 months old. These are primarily things like tortillas, soft cooked meats, and ice cream.  Antoinette has tried to give Carlos pureed vegetables, but he rejected them.  She states, "I guess he's just like his dad and older brother.  They don't eat any vegetables either."  At child care Carlos seems to want the foods the other children are eating, and the child care provider occasionally will give him some grapes or hot dog rounds to "suck" on when she feeds the other children. 

Antoinette is concerned about the family history of diabetes and how that might affect Carlos. She would like  to change the family's  eating patterns and to "count"  carbohydrates as she was taught to do when she developed gestational diabetes.  She is are reluctant to start giving Carlos baby cereal, and would like to start giving him ground chicken and fish on a regular basis. Their pediatrician recommends that they give baby cereal now and start meats at 8 or 9 months.  She would also like to start substituting low fat milk for the Similac or whole milk.

Neither Antoinette nor Francisco feel that they have time to including exercise in their busy daily lives, and Antoinette confesses that she often feels bad about leaving her children to watch TV in the evenings as she goes out to her meetings.  She states that Carlos is a blessing because he happily spends this time resting in his play pen.

Antoinette and Francisco have been taking several nutritional supplements that are being sold by someone at their church. They are asking you today about the value of  "B vitamin" and vitamin D, fluoride and ASD-plex (Hypoallergenic Nutrition Powder Complete with Vitamins, Minerals, Amino Acids, and Antioxidants) supplements for Carlos.   This family takes their water from the Seattle water system.

QUESTIONS

1. What are your priority concerns for this visit?
2. What are the positive aspects of Carlos’s nutritional status?
3. How many kilocalories would the RDA suggest that Carlos might need?
4. How many kilocalories are being provided by formula?
5. What might be going on with Carlos’s length growth pattern?
6. What might be going on with Carlos’s weight growth pattern?
7. Plot Carlos's weight on both the CDC (http://www.cdc.gov/growthcharts/) and WHO (http://www.who.int/childgrowth/en/) growth grids.  What are the differences in the interpretation of her growth?
8. What concerns do you have about the introduction of non-milk feedings?
9. What might you counsel about the relationship between Carlos’s positioning for feedings at day care and his frequent ear infections?
10. What might you counsel Carlos's parents about his iron intake?
11. What would you say about the need for a vitamin mineral supplement with or without fluoride?
12. What guidance would you give in terms of early childhood caries?
13. What guidance would you give to the family about preventing obesity and chronic disease?
14. What kind of feeding plan would you like to be able to work out with Carlos’s family and day care provider? How would you approach the family to suggest changes and help them make changes? What referrals and resources might you use?

References

CDC Growth Charts:  http://www.cdc.gov/growthcharts/

Bright Futures in Practice:  Nutrition:  http://www.brightfutures.org/nutrition/index.html

Bright Futures In Practice:  Oral Health:  http://www.brightfutures.org/oralhealth/about.html

Bright Futures in Practice:  Physical Activity: http://www.brightfutures.org/physicalactivity/about.htm

The Use and Misuse of Fruit Juice in Pediatrics: http://aappolicy.aappublications.org/cgi/content/full/pediatrics;107/5/1210

Bright Ideas Nutrition Education Skills Module:  http://www.nal.usda.gov/wicworks/Sharing_Center/CO/certprogram_brightideas.htm

Prevention of Pediatric Overweight and Obesity:  http://aappolicy.aappublications.org/cgi/content/full/pediatrics;112/2/424

The Start Healthy Feeding Guidelines for Infants and Toddlers:
http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B758G-4C6JPHJ-X&_coverDate=03%2F31%

AAP Statement:  Breastfeeding and the use of Human Milk: 2005 http://pediatrics.aappublications.org/cgi/content/abstract/115/2/496

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