Why Feeding Your Child With A Spoon Is Better For Her Development

Written by Jesse Hackell MD

messy face2

Growing up in the sixties, outer space was truly the final frontier. We greedily devoured all sorts of arcane facts about the nascent space program, from the rigors of pre-flight training to the seemingly more mundane details of how, exactly, one managed to eat and drink in the zero-gravity confines of outer space.

We knew that the astronauts drank Tang, which no self-respecting parent today would ever mistake for fresh-squeezed, locally sourced, organic and pesticide-free orange juice.

And astronaut foods were freeze-dried, and provided in pouches. When water was added to the pouches, the food was rehydrated and reconstituted, and the space explorers “ate” by sucking the resulting slurry out of the mouthpiece of the pouch.

Fast forward fifty years, and pouches aren’t just for astronauts any more. All sorts of fruits, vegetables and combinations thereof, in flavors which would certainly have thrilled early spacemen, are now seemingly the food deliver mechanism of choice for today’s on the move infants and toddlers.

No longer does feeding your baby on the go require a high chair, bib, bowl, spoon and yards of paper towels for clean-up.

Just pop off the top (don’t hand the top to the baby, although the caps are ingeniously designed to prevent choking should the little one happen to get hold of it and have it lodge in the airway), hand the pouch to your child, and–slurp–4 ounces of highest quality, organic produce goes down the hatch.

That’s progress, no? One prediction of the future made in the sixties actually coming true in the twenty-first century!

But I am not so sure that this new feeding mechanism actually represents progress for babies. They are born knowing how to suck nutrition out of a “container”–breast or bottle.

Progress in feeding, for an infant, comes not only in learning about new tastes and textures, but also in learning about new, more mature means of getting their comestibles out of the container and into their mouths.

These pouches (along with so called “sippy cups” with spouts) are really just bottles in disguise. (They are also a whole lot more expensive than either store-bought jars or homemade baby foods.) We do not generally recommend putting puréed foods in baby’s bottle, so why create a new bottle substitute?

Let me make a plea for a return to the older, admittedly messier, mealtime, with the baby sitting upright, wearing a bib, and being fed with a spoon. It will encourage the baby to learn new mouth movements and new positions for eating. And it will provide lots of opportunities for those adorable, messy face baby photographs!

Dr. Hackell is a founding member of Pomona Pediatrics PC, a division of Children’s and Women’s Physicians of Westchester. He practices in the lower Hudson River Valley just north of New York City.

Ten Tips to Help Prevent Childhood Obesity

Written by Dr. Jennifer Shaer MD., FAAP., IBCLC

There is a lot of attention these days on childhood obesity. How do cute chubby babies grow into unhealthy overweight children? It’s very easy. Weight management is an uphill battle for everyone. It is only successful for adults when they have the desire and determination to make a change. The problem for kids is that they want what they want, when they want it. Children cannot understand the consequences of overeating and lack of exercise. They cannot be expected to make healthy food choices on their own. It is up to parents to instill healthy eating habits in their kids. Here are a few tips.

Be a role model

Eating healthy is a family affair and children learn by example. It is unreasonable to expect one person in the family to be on a “diet”. Set the house up properly and think of healthy eating and exercise as a lifestyle change instead of a diet. Fill the cabinets and refrigerator with healthy snacks, fruits and vegetables. If the chips and junk food are not there, then they are not an option. If a child is whining that he wants the cookies, it is easy to say “no” if there are none in the house.

Watch portion sizes

There is an absolute distortion of what a portion size is these days. Read labels and measure your food just to get a sense of what a portion size is.

Recognize appetite as opposed to hunger

There is a big difference between appetite and hunger. Offer anyone an ice cream sundae and he will have an appetite. Just because your child will eat an entire plate of cookies, does not mean he is hungry.

Stop making your child clean his plate

It is really important to let your child decide how much he wants to eat. Young children have the ability to actually eat when they are hungry and stop when they are full. Your job as a parent is to choose what foods to offer and when to offer them. Your child’s hunger should determine how much of the meal he eats. If he chooses to eat very little at one meal, he will eat more at the next. Mealtime should not be stressful.

Do not use food as a reward

There are better ways to reward good behavior than giving junk food. Everyone should be allowed to eat junk food on occasion. The key is to limit unhealthy foods and limit the portions. Good behavior is an expectation aside from food.

Don’t drink your calories

An easy way to watch calorie intake is to drink more water. Kids can absorb a lot of calories by drinking juice, soda and even milk. When drinking milk, choose fat free.

Slow down. It takes time for the brain to realize that the stomach is actually full. If your child eats slower and drinks water while eating then he will get full faster. Do not allow second portions unless he is truly still hungry. Keep the serving platters off the table to make it more inconvenient to reach for a second serving.

Avoid emotional eating

If your kids are bored or happy or sad, then help them find something else to do.

Do not allow your kids to eat in front of the television or computer

Lots of calories can be eaten without even realizing it when you eat in front of the TV.

Be active as a family

Take a walk or go for a bike ride. Get off the couch and get moving.

Dr. Shaer is a pediatrician and a board certified lactation consultant (IBCLC). She is director of the Breastfeeding Medicine Center of Allied Pediatrics of New York. Dr. Shaer is dedicated to helping nursing mothers achieve their breastfeeding goals.


Why would a six-month old infant still need to be fed every four hours through the middle of the night?

Written by Jesse Hackell MD

Ah, yes, one of the most vexing new-parent questions, brought on by, yes, six months of interrupted sleep, daytime drowsiness and increasing irritability.

Why, indeed?

The answer is that it is usually a habit engendered in the infant, learned by the repeated feedings that he or she has received at all hours of the night. But how, and when, can this habit be broken?

Remember, first, that no one—not the parent, not the doctor not the grandmother—can determine when and how much a baby needs to eat.

Only the baby knows that for sure, based on the body’s need for growth and maintenance. And worst of all, those needs are not the same every day—a baby’s growth is not the same from day to day, nor is his energy expenditure.

But nature built in a wonderful system for appetite control—if given access to food throughout the day, an infant will eat what he needs, and then stop. Healthy babies do not starve themselves; neither do they overeat, unless they have been taught to do so by repeatedly being fed when they are not asking to be.

Think of a baby’s nutrition needs—for protein and calories, mainly– in terms of a 24 hour day.

Based on internal signals, the baby will require a certain amount of nutrients during each 24 hour period. If you feed the baby every four hours by the clock, the baby will essentially divide these needs into six portions, and eat one portion at each feeding time—which might well lead to one or more middle-of-the-night feedings.

But if the baby gets larger feedings during the daylight hours, her needs will have been met by bedtime, and there will not be the same signals prompting eating during the wee hours.

This will not occur instantly, however. In order to prompt the baby to eat more during the day, he needs to be hungrier than usual for those daytime feedings. So the first step should be to begin skipping the early morning feeding, and allowing the child to cry himself back to sleep. Then when he wakes a few hours later, he will be ravenous, and eat more than usual—which in turn will lead to a longer break before the next feed, a hungrier baby again, and greater intake through the day.

Then on the following night, secure in the knowledge that your child has taken more food than usual that day, the tired and sleep-deprived parent can be comfortable forgoing the nighttime feeding yet again. And with a small amount of manipulation, voila—your baby has given up the middle-of-the-night chowdowns.

Dr. Hackell is a founding member of Pomona Pediatrics PC, a division of Children’s and Women’s Physicians of Westchester. He practices in the lower Hudson River Valley just north of New York City.


When The Joy Goes Out of Eating, Nutrition Suffers

The title of this post is a partial quote from pediatric nutritionist Ellyn Satter. Here is the entire quote:

“The secret to feeding a healthy family is to love good food, trust yourself, and share that love and trust with your child. When the joy goes out of eating, nutrition suffers.”

The quote comes from a blog post titled Constructing Snacks into Mini-Meals on Dr. Wendy Sue Swanson’s blog, seattlemamadoc.com.

I found the article very interesting. Particularly because in our house, snacking is a bit of an issue. In fact, for my kids, snacks seem to be more important than the actual meal.

I’ve come to the conclusion that the only reason my kids eat regular meals, is because otherwise, they won’t be able to have a snack or dessert. It is like they view it as a means to and end. This is what I assume goes through their heads:

“The only way I’m gonna get the snack, is if I eat my lunch. Might as well eat the lunch, so I can get to my snack.”

And apparently, my family is the not the only one with this issue. It is a growing trend in the US.

Over the past 20 years, the amount of calories consumed by children from snacks has increased by 30%. Kids eat a third more calories everyday from snacks! What kids snack on certainly can reflect how their diet is shaped and how they grow. Plain and simple: snacks make us fatter by packing in lots of calories in relatively small bits of food, the definition of “calorie dense” foods. They also discourage our eating of things like fruit and veggies because they fill us all up. One recent study found it was our over-consumption of snacks more than our under-consumption of fruits and veggies that is getting us into trouble.

Dr. Swanson says that there has a huge shift in the way children eat and get their nutrition in the US. She highlights some examples, such as:

  • The introduction of processed foods in the 1970’s transformed what we eat from fresh to packaged food
  • TV advertising of snacks directed at kids increases their desire for snack foods
  • The challenge for busy families to find time to sit down and eat meals together
  • Watching TV during meals in households
  • Ubiquitous availability (they are everywhere!) and easy access to snack foods
  • It is okay to be a little hungry. Dr Grow says, “Teaching kids it’s okay to get a little bit hungry (not ravenous) and work up an appetite for a regular meal” is a healthy way to learn to eat right.
  • It’s our worst fear that our kids will starve. It’s almost an instinct to offer and offer and offer food all day. Our kids won’t starve, especially if we offer 3 meals and 2 healthy snacks daily.
  • Red/Orange/Yellow packaging is dangerous. These colors are known to make you hungry and eat more. Advertisers know this! Think about leading fast-food chains, junk food, candy bars and soda containers. Red/Orange/Yellow is threat level alert for high-calorie foods that often have little nutritive value.

We’ve written about snacking before on Survivor Pediatrics. In the this post, Dr. Hackell ask: with the national alarm increasing about the rate of obesity in our children (and adults as well), what message are we giving our children about eating when we provide them with a continuous stream of things entering their mouth throughout the day?

Dr. Swanson does offer a possible solution. She mentions the idea of switching the snack for a mini-meal. So, anything that we would feel comfortable eating during a normal meal, but in smaller portions.

I like this idea. Except the part about preparing yet another meal, even if it is mini. Snacks in little packages are just so convenient. But I guess I’ll give it a try and see.

To read the rest of Dr. Swason’s post, click on the link.


How to get your child to eat vegetables

Written by Jesse Hackell MD

Let me start by saying that I am not of the belief that the job of a parent is to FORCE a child to eat any particular food. Attempts to do so usually result in mealtimes which are unpleasant and stressful for both parents and children, and negate any attempts to have family meal times as a time of sharing and interaction.

That said, we all know that children are often picky in their accepted food choices, and that they do not always cooperate in eating the variety and selection of foods which we, as parents and physicians, would like. There is no dispute that a child’s diet should include fruits and vegetables, for many reasons: These foods provide vitamins lacking in other foods, they contain fiber which is needed for normal intestinal function, and they are generally lower in calories than processed foods, while still providing the same feelings of fullness, and thus may help to change the continuing trend towards childhood obesity.

Getting your child to accept and eat vegetables is a lifelong process, starting when the very first foods other than breast milk or formula are presented (it could even be suggested that breast-fed infants are introduced to vegetables through the maternal diet, knowing as we do that maternal intake does contribute to the taste and quality of the milk, but that is a different topic.)

There has recently been a change in what is recommended as first foods for infants. In the past, processed single grain cereals were the starting food, followed by the addition of vegetables and fruits. Now, however, researchers believe that the order in which foods are introduced to an infant makes little difference in eventual food tolerance. Thus it would make sense to introduce a child to foods such as vegetables which are both less processed and less sweet than other foods, and to let the child learn that these tastes (and some vegetables certainly do have strong flavors!) are just a natural part of eating. Adding whole grain baby cereals, as opposed to processed white cereals, further introduces stronger flavors, and makes them a part of the child’s diet from the start, and might well lead to better acceptance in the future.

As your child gets older, individual preferences become stronger. We can hope that early exposure might make this transition a non-issue, but that is not always the case. So we need to have techniques to make vegetables more palatable to toddlers and older children as well.

Many vegetables benefit from brief cooking, which softens them and make them more readily manageable by toddlers. Offering cooked or frozen and reheated pieces of many vegetables, such as carrots, will make them easy to handle for your children from their first attempts at self-feeding. And the nutritional value of these vegetables is far greater than the ubiquitous “puffs” of carbohydrates so often given to young children. Later, cooked and cooled broccoli spears, asparagus and carrots can be offered as a snack. Some children like to “dip” their vegetables in some sort of sauce, and I would suggest the use of plain balsamic vinegar as opposed to the common ranch dressing, which has far more fat and calories. For a child who will not eat a traditional tossed salad, vegetables and dip is a good prelude to dinner, and often can satisfy a hungry child home from school or play for long enough to enable the entire family to eat dinner together.

I do not believe that we need to “trick” our children, or disguise vegetables so they do not know that they are eating them, as so many people (such as “The Sneaky Chef”) are advocating. Nonetheless, common foods can and should be made with added vegetables, to benefit every member of the family. One favorite includes the use of vegetables in any dish made from ground meat—meat loaf, burgers, tacos or meatballs, for example. Using one pound of any ground meat (beef, veal, pork or turkey), take one cup of shredded carrots, one cup of shredded broccoli stalks (having steamed and cooled the florets for use with a dip), and one cup of shredded onion. Saute these in a little olive oil til soft, and mix with the meat, adding an egg if desired to hold things together. Add some bread crumbs, or even better, some rolled oats (not the instant variety), to add soluble fiber and beta glucans, which are thought to help control cholesterol, and form into a loaf, patties or balls, and cook as usual. The vegetables add moisture to the meat, as well as fiber to the diet, and they make the meat stretch further. You can also use chopped spinach or chopped artichoke hearts, which do not even need sautéing. Top with a tomato sauce, also prepared with added vegetables, for even more benefits.

I think the key here is to start doing this from the very first time your child eats these foods. Get them used to the fact that meatloaf simply has these flecks of orange and green in it, and they will not question the presence of the vegetables when they find them. If it becomes second nature for you to incorporate vegetables in everything you prepare, it will become second nature for your children to eat them as well.


She has a fever, her temperature is 99.2. Is It Normal?

By Jesse Hackell, MD

Photo Credit: Gary Ellis

It is Normal?

Every day, parents bring their children to the pediatrician’s office with complaints that something about the child is not “normal,” whether in terms of temperature, sleep patterns, appetite and food intake, elimination of urine and stool, and a whole host of other bodily functions. I spend a good part of many visits helping parents understand just what is, and should be, meant by the word “normal.”

Body Temperature

We have all grown up with the concept that the “normal” body temperature is 98.6 degrees Fahrenheit, right? Heck, it even says so on the old style glass thermometers, with a nice little arrow pointing right at 98.6—not that many of us use those glass thermometers any more (and no one should be using ones which contain silver-colored mercury) since ear and temporal thermometers have become so much more available and affordable in recent years.

In fact, the normal body temperature is not one number, but a range, generally felt to vary between 97 and 100.4 degrees. And it varies predictably with the time of day as well. Called a diurnal (from the Latin for day) variation, we reach our lowest temperature in the early pre-dawn hours, and our temperature peaks about twelve hours later, in the late afternoon. This variation is hormonally controlled, and while the times of the peaks and valleys can be altered (by changing sleep patterns, for example), this variation, and range of normal temperatures is characteristic of all humans.

So not only (as my colleagues have previously discussed) is fever not something to be feared, it is also something to be careful about even diagnosing. Consider that the temperature of a healthy, “normal” child might vary as much as three degrees Fahrenheit from the daily low to the daily high. And remember that, much more relevant that the number on the thermometer is the way that your child looks and acts.

What about sleeping patterns?

Is it “normal” for a baby to sleep eighteen hours out of twenty-four? Or for a toddler to seem as if he can get by on eight hours at night plus a couple of power naps during the day? The same answer applies to sleep as it does to fever—there is a wide range of what “normal” children require in order to function normally.

And therein lies the true answer: A child is getting enough sleep if he or she is able to be awake and functioning normally for blocks of time during the day, if he or she is not always yawning or drowsing off during activities, and if the mornings are not a struggle to get the child awake and moving in order to get the day started. Look at your child’s general alertness—that will give the best clue as to whether or not the amount of sheep he or she is getting is adequate.

Normal Food Intake

It is very hard to define a “normal” amount of food and nutrition intake. Different children have different metabolic rates and activity levels, and children do not grow at the same rate every day. No one—not the doctor, not the parent, not the grandmother—knows better than a child just how much nutrition a given child needs on a given day. And normal children will not starve themselves—they will choose and eat the foods that their bodies tell them are needed for growth.

Of course, they might naturally choose sweets or “junk” food, but I presume that, as parents, we will offer our children choices consistent with good nutrition, and allow then to choose types and amounts of foods from that selection. A parent’s job is NOT to get a child to eat; rather, it is to provide nutritionally sound choices from which the child can select those foods which his or her body needs at any given time.

Once again, the same thing holds for bowel movements, especially in the newborn and infant period.

There is no single “normal” frequency for an infant to have a bowel movement.

The pattern will depend on age, feeding and the infant’s own physiology, but, in general, as long as there are bowel movements at least every two to three days (although it can be longer in an exclusively breast fed infant), and most importantly, as long as they are soft and do not cause the baby discomfort when being passed, a baby will move his or her bowels when it becomes necessary. (This is not necessarily true as a child gets older, when some may hold their stools for prolonged periods, often out of fear of discomfort or out of hesitation to use a toilet; any signs of difficulty in defecation in an older child should be discussed with your child’s pediatrician.)

As in so much of pediatrics, what is “normal” can often best be defined by what is working for a particular child, and not by comparison to what other children are doing or experiencing. I cannot emphasize strongly enough that if your baby or child is happy, thriving, comfortable and growing, and is able to function normally, the chances are good that whatever he or she is doing with regard to temperature, sleeping, eating or eliminating is “normal” for him or her.

Listen to and watch your child—they are really good at letting you know if things are going well or not.

Dr. Hackell is a founding member of Pomona Pediatrics PC, a division of Children’s and Women’s Physicians of Westchester. He practices in the lower Hudson River Valley just north of New York City.


Is Providing Food Snacks To Children Contributing To Obesity?

Written by Dr. Jesse Hackell

I recently had a call from a local child psychologist, one to whom I regularly refer patients. After the usual pleasantries, and her report on her findings about, and treatment plan for, the most recent patient, she hit me with a question that I had never been asked before. “Why,” she inquired, “do so many patients seem to think that my waiting room is a picnic area?” When I inquired about what she meant, she went on to describe a recent family who brought a child in for an appointment, and while sitting in the waiting room, proceeded to spread out a cloth on the floor, and actually start giving the three year old child a variety of snacks. This was not, she was careful to inform me, at a normal lunch hour.

I had no good answer, but it did set me to observing my own office. I quickly came to realize that not a day goes by that the exam rooms and waiting area are not littered with candy wrappers, discarded juice boxes, raisins and crumbs of all descriptions. And while I have not found chewing gum stuck to the underside of the exam tables (yet!), many surfaces in the office end the day with unidentifiable sticky patches on them. But maybe worst of all is asking a child to open his or her mouth and finding the mushy remains of a chocolate cookie, pretzel or bagel coating the tissues one is trying to assess.

We do a pretty good job of running on time most days, getting patients out of the office within a half-hour or so of their arrival (see Dr. Lessin’s recent post), so most of the time patients are not sitting around waiting for more than a few minutes, either in the waiting room or the exam room. Are our children so nutritionally deprived that they cannot go thirty or even sixty minutes without some sort of food or drink, lest they starve?

But it goes further than the crumbs underfoot in the exam rooms (where we do expect our patients to be barefoot during some examinations) or the sticky patches on the waiting room chairs. Children in pre-school and all the way through elementary school seem to have snack time, sometimes twice a day, with cookies and juice provided two hours after breakfast and two hours after lunch.

With the national alarm increasing about the rate of obesity in our children (and adults as well), what message are we giving our children about eating when we provide them with a continuous stream of things entering their mouth throughout the day? We know that eating habits and relationships with food which are developed and reinforced in childhood will persist readily into adolescence and adult life. I fear that we may be creating problems for a whole new generation of people when we make food and snacks available at every waking moment of a young child’s day.

Signs in the office requesting patients and family members to refrain from eating and drinking have some effect, at least on our office cleaning bills. But I think we need to carefully think about the messages we give to parents about feeding their children. Breast feeding, even on demand, is fine, but even feeding an infant too frequently can develop a “snacking” habit, where the baby never learns to take a full feeding which will last a few hours until the next feeding time. But once the child moves on to beikost (German for foods other than milk or formula), we need to help parents develop a schedule where times for meals are separate and distinct from times where food and drink is not offered.

There are a whole host of potential benefits to this pattern, not the least of which might be less of a focus on food and drink as a continuous feast, and, just possibly, a reduction in a child’s total daily calorie intake. But teaching our children that the times when we eat are discreet and separate moments might also go some way to returning eating to a social, and not just refueling, activity.

Dr. Hackell is a founding member of Pomona Pediatrics PC, a division of Children’s and Women’s Physicians of Westchester. He practices in the lower Hudson River Valley just north of New York City.