avoiding foods that may be choking hazards. 16 Topic Guiding principle summary—for breastfed children Modifications for non-breastfed children Meal frequency and energy density Increase the number of times that the child is fed complementary foods as he or she gets older: for the ‘average’ child, 2–3 times/day at 6–8 months and 3–4 times/day at 9–11 months and 12–23 months. Additional nutritious snacks may be offered 1–2 times/day. Frequency is directly related to caloric density of the meal: 0.65 kcal/g is the lowest (child needs more meals), and 1.0 kcal/g the highest (child needs fewer meals). Increase the number of times that the child is fed complementary foods as he or she gets older: for the ‘average’ child, 3 times/day at 6–8 months, 4 times/day at 9– 11 months, and 4–5 times/day at 12–23 months. Additional nutritious snacks may be offered 1–2 times/day. Nutrient content of complementary foods Feed a variety of foods to ensure that nutrient needs are met: meat, poultry, fish, or eggs should be eaten daily; vitamin A–rich fruits and vegetables daily; diets should have adequate fat content; and avoid giving drinks with low nutritive value. In addition to recommendations for the breastfed child: If the child receives animalsource foods, give 200–400 ml/day of milk; if not, 300–500 ml/day; avoid raw milk. Vitamin-mineral supplements or fortified products Use fortified complementary foods or vitamin-mineral supplements (preferably mixed with or fed with the food) for the infant, as needed. Feeding during and after illness Increase fluid intake during illness, including more frequent breastfeeding, and encourage the child to eat soft, varied, appetizing, favorite foods. After illness, give food more often than usual and encourage the child to eat more. Increase fluid intake during illness, and encourage the child to eat soft, varied, appetizing, favorite foods. After illness, give food more often than usual and encourage the child to eat more. Sources: World Health Organization/Pan American Health Organization, Guiding Principles for Complementary Feeding of the Breastfed Child, 2003. World Health Organization, Guiding Principles for Feeding Non-Breastfed Children 6–24 Months of Age, 2005. World Health Organization, Guidelines on HIV and Infant Feeding, 2010. 17 Annex B. Core infant and young child feeding indicators Category Indicator Early initiation of breastfeeding Proportion of children born in the last 24 months who were put to the breast within one hour of birth. Exclusive breastfeeding under 6months Proportion of infants 0–5 months of age who are fed exclusively with breastmilk. Continued breastfeeding at 1 year Proportion of children 12–15 months of age who are fed breastmilk. Introduction of solid, semisolid, or soft foods Proportion of infants 6–8 months of age who receive solid, semi-solid, or soft foods. Minimum dietary diversity Proportion of children 6–23 months of age who receive foods from four or more food groups. Minimum* meal frequency Proportion of breastfed and non-breastfed children 6–23 months of age who receive solid, semi-solid, or soft foods (including milk feeds for non-breastfed children) the minimum number of times or more. Minimum* acceptable diet Proportion of children 6–23 months of age who receive a minimum acceptable diet (apart from breastmilk) [composite indicator based on minimum dietary diversity and minimum meal frequency]. Consumption of iron-rich or iron-fortified foods Proportion of children 6–23 months of age who receive an iron-rich food or iron-fortified food that is specifically designed for infants and young children, or that is fortified at home. *Minimum is defined for breastfed and non-breastfed children and dependent on age. Source: World Health Organization, Indicators for Assessing Infant and Young Child Feeding Practices, Parts 1–3, 2010. Neonatal Antibiotic Use: What Are We Doing and Where Shall We Go? Dustin D. Flannery, DO,*† Karen M. Puopolo, MD, PhD*† *Division of Neonatology, The Children’s Hospital of Philadelphia/University of Pennsylvania, Philadelphia, PA † Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, PA Education Gap To properly assess the scope of the problem of unnecessary antibiotic use and monitor the impact of such efforts, there is a need to consistently characterize antibiotic usage in NICUs and nurseries, as well as among centers. Abstract Antibiotic stewardship aims to ensure that clinicians administer the right antibiotics, to the right patients, for the right reasons. These principles are being widely applied in medical care, but have been particularly challenging in the NICU. Infectious risk factors and clinical instability are common among neonatal patients, and lead to significant cumulative antibiotic exposures in the NICU setting. Both the frequency with which antibiotics are administered and the potential unintended consequences of antibiotic administration differ between preterm and term infants. Multiple metrics are available to measure antibiotic use, yet no single measure is universally applied to neonatal stewardship. Objectives After completing this article, readers should be able to: 1. Review current rates of neonatal antibiotic use among preterm and term infants. 2. Recognize the potential risks of antibiotic therapy in preterm and term infants. 3. Describe measures of antimicrobial stewardship and identify advantages and limitations of applying these to the neonatal population. INTRODUCTION Antibiotic therapy is a mainstay of neonatal care, and antibiotics are the most commonly prescribed class of medications in the NICU. (1)(2) Antibiotics have AUTHOR DISCLOSURE Dr Flannery has disclosed that he is supported by the Eunice Kennedy Shriver National Institute of Child Health & Human Development of the National Institutes of Health (award no. T32HD060550). Dr Puopolo is a member of the NeoReviews editorial board. This commentary does not contain a discussion of an unapproved/ investigative use of a commercial product/ device. ABBREVIATIONS AAP American Academy of Pediatrics