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Starting Solids: The Old and the New and the Myths

Written by Kristen Stuppy MD

Many parents are excited yet apprehensive to start foods with their infants. So many questions, so many fears. So much food introduction guidance has changed in recent years, that what you did with your older kids might not be current. Change takes time, so not everyone agrees on the “new” rules. Talk to your own pediatrician to see their take on it all!

The older “rules” for starting foods were so confusing… different sources will vary on these rules.

  • don’t feed before 6 months is now ok to feed at 4 months if baby’s ready
  • don’t give nuts, eggs, and other “allergy” foods until ____ (2/3/5 years, varying by expert) is now it is okay to give allergy foods unless there is a family history of food allergy
  • don’t start more than one food every 3-5 days is now introducing multiple foods at one time is ok
  • start with rice, then add vegetables, then meat., wait until last for fruit is now begin with any foods, but try to make nutritious choices, such as meat which is high in iron and protein

Variations of this were plenty, depending on the provider’s preferences. No wonder there is so much confusion!!!!

New rules are much easier. I like easier.

  • Start new foods between 4 and 6 months, when your baby shows interest and is able to sit with minimal support and hold the head up.
  • Don’t give honey until 1 year of age.
  • Don’t give any textures your baby will choke on.

Done.

That’s it. Nothing fancy. Any foods in any order. Multiple new foods on the same day are okay. Common sense will hopefully guide types of foods. Nothing too salted. Try nutritious foods, not junk.

These minimal rules can make parents weary.

What about food allergies if foods are given too early?

Research does not support the thought that starting foods earlier lead to allergies. In fact, there is research to support that starting foods earlier might prevent food allergies. A full 180 degree change!

Pregnant women and breastfeeding mothers no longer have to avoid nuts or other allergy foods in most cases. If there is a close family member with a food allergy, it might still be beneficial to wait to introduce that food. Talk with your pediatrician in that case.

I admit that I was initially nervous about telling parents it was okay to give nut products in infancy. Not just the allergy aspect, but also choking risks. ~ Back to the no textures your baby will choke on… nuts are hard and round– two no-nos, peanut butter is thick and sticky– another choking risk.

Any of the more allergy prone foods should first be offered in small amounts at home. These foods include nuts, egg, and fish. Do this only if there is no one in your house who is allergic to that food.

Have diphenhydramine allergy syrup around just in case, but remember most kids are NOT allergic, and starting younger seems to prevent (not cause) allergy. In the case of nuts, since there is also a choking risk, you can try a food cooked with nuts or nut oil.

What about saving the fruit for last so they don’t get a sweet tooth?

Babies who have had breast milk have had sweet all along! Breast milk is very sweet, yet babies who are graduating to foods often love the new flavors and textures with foods.

Formula babies haven’t had the sweet milk, but they can still develop a healthy appreciation of flavors with addition of new foods. Saving fruit for last simply doesn’t seem to make a difference.

Adding fruits alone is not very nutritious though, so fruits should be added along with other more nutritious foods. The more colors on our plates, the healthier the meal probably is!

I thought they couldn’t have cow’s milk until after a year?

Cow’s milk is not a meal in itself (like breast milk or formula). It is missing many vitamins and minerals, so babies need to continue breast milk or formula until at least a year. Cow’s milk may lead to allergies or eczema, including formulas made with cow’s milk.

Milk products, such as cheese and yogurt can be given to babies as part of an otherwise well rounded diet as long as they don’t show any allergy risks to milk. Regardless of dairy intake, it is recommended for infants under 6 months to have 400 IU Vitamin D/day and those over 6 months to take 600 IU Vitamin D/day as a supplement.

I thought they should have cereal first…

Rice cereal has been the first food for generations, probably because grandma said so. There has never been any research supporting giving it first. With white rice and other “white” carbohydrates under attack now, it is no wonder the “rice first” rule is being debated. Despite being fortified with vitamins and iron, it is relatively nutrient poor, so choosing a meat or vegetable as first foods will offer more nutrition.

Shouldn’t we wait on meat?

Waiting on meat due to protein load was once recommended, but no longer felt to be needed. Pureed meats (preferably from your refrigerator… baby food meats are not very palatable!) are a great source of nutrition for baby! Some experts recommend meat as the first food due to its high nutritional value and low allergy risk.

How do we know what they’re allergic to if we start several new things at once?

First, most kids are not allergic.

Second, if they are allergic to a food, it is often days/weeks/months before the allergy is recognized. Waiting 3 days between food introduction simply doesn’t allow recognition unless it is hives or anaphylaxis, and there are a small number of foods that account for most of these reactions.

If your child has one of these reactions we can test to see what the offender was. This is recommended with severe allergies since people with one allergy might have other allergies, and identification for avoidance is important.

Allergy symptoms can be broad and often are not specific: dry skin (eczema), runny nose, hives, swelling of lips, difficulty breathing, vomiting, diarrhea, or blood in the stool. If you think your child is allergic to a food, discuss with your doctor. Severe symptoms (anaphylaxis) demand immediate attention!

How do we know when to start foods? I wanted to start to help baby sleep through the night, but I heard starting too soon increased obesity and diabetes.

When babies are able to sit with minimal support and hold their head up and when thye show interest in food by reaching for it they might be ready. They can wait until 6 months to start foods, but some studies show poor weight gain and nutritional balance as well as resistance to foods if started after 6 months.

In formula fed babies it has been shown to increase the risk of obesity at 3 years (6x!) if foods are started before 4 months of age. That risk is not seen in exclusively breast fed infants or those who begin foods after 4 months of age.

It is still an old wive’s tale that starting solids will help baby sleep through the night. Babies tend to sleep longer stretches at this age, so it is no wonder that this myth perpetuates. Start foods because you see signs that baby is ready, not because you want longer sleep patterns!

How do I know how much to feed my baby?

Babies will let you know when they are full by turning away, pursing their lips, spitting out food, or throwing foods. As they eat more food, they will need less breast milk or formula. In general a baby who is gaining weight normally will self regulate volumes.

What’s better: baby foods bought at the store or home made foods?

Marketing and ease of preparation has made pre-prepared foods for us all common place. It does not mean they are any better. They cost more than home made foods. I didn’t make baby foods when my kids were babies because I thought it would be too hard, but now I puree foods to put into recipes (my kids are like many who aren’t fans of veggies and I want to improve their nutrition). It really isn’t hard. You can take whatever you are cooking for your family and put it in a food processor or some blenders and with a little water to get it to a texture baby can eat: voila! Home made food. There are of course many baby food cook books and ideas of how to freeze meal-sized portions so you can make multiple meals at one sitting. There is help for parents who want to safely prepare baby food at home at the USDA website.

My baby only wants table foods. Is that okay? Don’t they need pureed foods first? He doesn’t have many teeth!

Pureed foods are what most babies start with due to the easy texture, but some babies quickly develop the ability to pick up small pieces of food with the pincher grasp (finger/thumb) and want to feed themselves. If they are able to get the food in their mouth, move it to the back safely with their tongue, and swallow without choking, they are ready to feed table foods… at least with some textures. Beware of chewy or hard foods as well as round foods ~ these all increase the risk of choking.

Most babies will be able to eat table foods between 9 and 12 months. They tend to not have molars until after 12 months, so they grind with their gums and use all their saliva to help break down food. They need foods broken into small enough pieces until they can bite off a safe bite themselves.

Don’t put the whole meal on their tray at once… they will shove it all in and choke! Put a few bites down at a time and let them swallow before putting more down. Rotate food groups to give them a balance, or feed the least favorite first when they are most hungry, saving the best for last!

This is a great time for parents, sitters, and other caregivers to take a refresher course on CPR in case baby does choke. Infants and young children are more likely to choke on foods and small objects, so it is always good to be prepared!

How much juice should my baby drink?

In general I think babies don’t need juice at all. They can practice drinking from a cup with water. Juice adds little nutritional value and a lot of sugar. Eating fruit and drinking water is preferable. If they do drink juice, it should be 100% fruit or vegetable juice, not a fruit flavored drink! No more than 4 ounces/day of fruit juice is recommended.

What about organic?

There is not enough evidence to recommend organic food, since the nutritional components of the foods are similar regardless of how they were farmed.

Organically grown foods do have lower pesticide residues than conventionally farmed produce, but it is debated if this is significant or not to overall health. Conventionally farmed produce have the pesticide levels monitored, and they fall within levels that are felt to be safe.

Organic farming rules also dictate no food additives or added hormones, which is also an area of study for health risks and benefits, but not enough data is available to give an educated opinion yet.

Organic farming is generally felt to be better for the environment, but the sustainability of that is questioned.

Many argue that the taste of organic foods is superior.

Organic farming might increase the risk of bacterial and fungal contamination or heavy metal content, so it is very important to wash fresh fruits and vegetables well prior to cutting or eating (as you should with all fresh foods).

For more information, see the USDA site.

A backyard garden can be inexpensive, organic, and a great way for your kids to learn about growing and preparing healthy foods!

 

Dr. Stuppy is a practicing pediatrician in Kansas. I feels privileged to be able to help families keep their children healthy and she loves watching entire families grow!  Dr Stuppy is active on Facebook and puts a more personal touch to pediatric topics on her blog.  

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Excessive milk can cause anemia? How?

Written by Kristen Stuppy MD

Photo Credit: Gawker

A recent facebook posting recommending limiting milk intake prompted questions from followers about iron deficiency anemia from milk. Nutrition and iron balance is actually a relatively lengthy discussion, so I will try to explain it here.

Short answer: Cow’s milk has little iron. When kids drink a lot of milk, they don’t eat iron-containing foods in sufficient volumes. Cow’s milk also has big proteins that can cause microscopic bleeding in the gut. The more milk consumed, the more bleeding (though usually still not seen in the stools).

More milk = more blood loss from the gut, but less blood produced because less iron in the diet = anemia

Iron is used to build healthy red blood cells that carry oxygen throughout our bodies. Too few red blood cells in the body is called anemia. Red blood cells are made in our bone marrow and they live for about 3 months. It is important for the body to continually make new red blood cells as it breaks down and removes old ones.

In general anemia can be caused from several factors:

  • too little blood produced (iron deficiency being a major risk for this)
  • increased blood loss (ie excessive bleeding)
  • increased destruction of blood cells in the body (typically from abnormal blood cells or infection)
  • Iron deficiency can be due to several factors:
  • poor iron absorption due to disease (some studies show milk inhibits iron absorption)
  • poor iron in the diet (the most common cause)
  • long term slow blood losses (such as heavy monthly periods or GI bleeding)
  • increased iron need (such as a growth spurt or pregnancy)

Why does preventing iron deficiency anemia matter?

Because the most common symptom of anemia is no symptoms. It can go unnoticed for quite a while in some kids, yet cause long term problems with growth and development.

Symptoms develop when the anemia becomes more severe and include tiredness, looking pale, irritability, decreased appetite, slowed development, weakness, immune dysfunction, and pica (eating non food substances- such as dirt).

Newborns are designed to drink their mother’s milk. Humans have learned to make formulas that can nourish babies if they aren’t able to drink their mother’s milk for whatever reason.

Cow’s milk, soy milk, and goat’s milk are not acceptable for infants due to the nutritional voids they have (not just iron). After about 1 year of age babies tend to wean from mother’s milk and/or formula onto whole milk. (Newer recommendations allow weaning onto low fat milk–another topic entirely.) Unfortified non-human milks contain very little iron.

The iron in human milk is better absorbed and iron is supplemented into formula. If toddlers and children drink too much milk, they fill up on it and don’t eat a variety of other food groups that include iron and other important nutrients missing in their milk.

Foods that are good sources of iron:

  • meats and poultry (especially organ meats, such as liver)
  • lentils, peas, and dried beans
  • eggs
  • oysters, clams, and fish
  • molasses
  • peanut butter
  • soy
  • pumpkin or sesame seeds
  • fruits such as prunes, apricots, and raisins
  • vegetables such as spinach, kale, broccoli, and other greens
  • whole grain fortified breads and cereals
  • Vitamin C increases iron absorption, so eat foods with iron and Vitamin C at the same meal!

Confused Which Vitamin To Give To Your Child?

Written by Sandra Graba, MD

With so many vitamin options available, choosing the right vitamin for your child can be a daunting task.

Not all vitamins are all the same! The age and health history of your child are important factors to consider. A premature infant will have different requirements than a healthy 2 year old.

My goal here is to give a sense of direction in the vitamin isle, but it is important to discuss individual needs with your doctor.

Often doctors will prescribe vitamins for your newborn, so that makes it much easier! Other times, they tell you the name of the vitamin to choose in the isle. The vitamins your pediatrician recommends at this age is a little different depending on whether your breastfeeding your child or not.

Vitamins For Newborns

Vitamin K is very important in the newborn period but thankfully all babies get a vitamin K shot right at birth and the subsequent needs are met by breastmilk and formula. Breast-fed babies need extra vitamin D: 400 IU and iron supplement of ~ 11mg daily starting at 6 months.

Six Month Old

Typically, pediatricians will give D-visol (vitamin D) through 6 months of age, then switch to poly-vi-sol (multivitamin) with iron starting at 6 months, but some pediatricians opt to start the multivitamin from the start. Either choice is fine. All formulas are iron and vitamin fortified to contain at least the recommended daily amounts for the first year of life.

12 Month Old

After the 1st birthday, life is completely different! Your little baby is turning into a toddler and with it comes a whole new challenge: feeding. We switch them from their vitamin fortified breastmilk or formula to whole milk and table foods.

Toddlers

The tricky part is that toddlers are inherently picky! They manage to get enough calories through all of the “picking” of their food, but do they get enough vitamins and minerals?

Consider this: One cup of whole milk (about 8 oz) has only ¼ of the recommended daily allowance of vitamin D, ½ to 1/3 of the amount of calcium, and no iron. This means that your child will need to drink 16- 32 oz (2-4 glasses) of milk to get all the vitamin D and calcium they need – but you would still need to consider their iron needs.

Also, high volume of milk intake (more than 16 oz a day) can lead to anemia. Translation: your mom was right that milk is good for you but there is too much of a good thing.

So, what to do? In general, all vitamins and minerals are important, but some are easier to get them to eat than others. We can focus on a few important ones: vitamin D, calcium, iron, B vitamins, and folate.

Iron is important in red blood cell formation and neurologic development among other things. It is plentiful in meat, dark leafy green vegetables, beans, tofu, cereal and bread. 1-3 year olds need about 7mg per day, 4-18 year olds about 10-12 mg per day except for menstruating adolescent girls who need about 15mg daily.

B vitamins are important for production of oxygen carrying cells and can be found in fish, poultry, meat, eggs, dairy, leafy green vegetables, beans/peas, breads and cereals. B6 and B12 are fairly easy to get in the diet. 1-8 year olds need about 0.5 – 0.6 mg per day and teenagers need about 1.0-1.3 mg/day.

Calcium is very important for growing bones. Some sources of calcium include cheese, yogurt, orange juice, fortified breads and cereals, spinach, and salmon. 1-3 year olds need ~ 500 mg a day, 4-8 yo need ~ 800 mg a day. and 9-18 year olds need ~ 1,300 mg a day.

Vitamin D is a tough one! The best source is the sun…but we spend most of our year bundled in sweaters, coats, scarves…you get the idea. There are a few natural food sources: cod liver oil, salmon, mackerel, tuna, liver, and egg yolk. My 3 year old definitely won’t eat liver. Thankfully, cereals and dairy are fortified. The current recommendation for all age groups is a minimum of 400 IU daily.

After sorting through the vitamin isle, it seems that either Flintstones’ Complete – it is ½ tablet for 2-3 year olds and a full tablet for older than 4 years or Centrum Kids Complete Multivitamin are the best bet for toddlers and school age kids.

Even still, they don’t provide 100% of the calcium and vitamin D in 2-3 year olds but they are pretty good for iron, B vitamins, and folate.

There are so many character and flavor choices available but the nutrition guide for these two vitamin types can at least provide a guide to compare the other vitamins to while your head is spinning in the isle. Overall, remember that vitamin supplements are just that – supplements to a healthy diet. Children with any special needs will have different requirements.

A few words on Gummy vitamins…

Though they taste good and are probably easier to get your children to take, the vast majority I have seen fall short in providing the necessary daily nutrients. Many contain ¼ to ½ the amount of vitamin D and 10% or less of the needed calcium;No gummies contain iron. Many have the minimum amount of B vitamins but less than the recommended folate. Each gummy does, however, contain about 3g of sugar. If the serving size for your child is 2 gummies, giving them their vitamins is about the same as giving them a ¼ cup of soda!

 

Dr. Graba is a practicing pediatrician at Salud Pediatrics.

Making Healthy Food Choices For Your Children

Written by: Joanna E. Betancourt MD., FAAP

I have many parents that come to our clinic with concerns about their children’s weight. They complain that the children only snack on unhealthy things like chips and cookies and they don’t like to drink water or milk but rather drink sugar drinks.

I often ask parents, where do they get all this junk food and drinks? And they grin or smile back with a little bit of culpability because they know where I’m going with the question. Parents are the ones buying all this stuff and putting it in the pantry. So, it isn’t a big surprise that the child prefers the junk food over the healthy foods.

You don’t have to be a doctor to know that if you give a child a choice between an apple and a chocolate chip cookie, most kids are going to prefer the cookie.

A big part of living lifestyle is making the right food choices. And the responsibility lies within the parents, not the children, because the parents are the ones that make the food buying decisions.

The HealthyChildren.org provides excellent guiding principles to keep in mind when planning and preparing meals for your family. Below are just a few:

  • Vegetables: 3-5 servings per day. A serving may consist of 1 cup of raw leafy vegetables, 3/4 cup of vegetable juice, or 1/2 cup of other vegetables, chopped raw or cooked.
  • Fruits: 2-4 servings per day. A serving may consist of 1/2 cup of sliced fruit, 3/4 cup of fruit juice, or a medium-size whole fruit, like an apple, banana, or pear.
  • Bread, cereal, or pasta: 6-11 servings per day. Each serving should equal 1 slice of bread, 1/2 cup of rice or pasta, or 1 ounce of cereal.
  • Protein foods: 2-3 servings of 2-3 ounces of cooked lean meat, poultry, or fish per day. A serving in this group may also consist of 1/2 cup of cooked dry beans, one egg, or 2 tablespoons of peanut butter for each ounce of lean meat.
  • Dairy products: 2-3 servings per day of 1 cup of low-fat milk or yogurt, or l’/2 ounces of natural cheese.

Of course, the idea is not to overwhelm your children with drastic changes. However, little by little you can make a difference. For example, if your child wants chicken, it is better to “choose” baked or grilled chicken instead of a fried piece of chicken. Or when giving them a snack, consider pretzels or plain popcorn instead of potato chips.

Keep this in-mind when going to the grocery store next time. And remember, making healthy food choices is part of raising a healthy child.

Dr. Betancourt is a practicing physician. She is a mother of 3 young children (12, 8 and 5). She practices in the western suburbs of Chicago. 

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New Year’s Resolutions in October?

Written by Jennifer Gruen MD

Most people make resolutions on New Year’s, but I find winter too depressing to embark on ambitious, life changing projects. Instead, I view October as a chance to work on change. It is a good time for kids to try a new sport or set goals for school, and for parents to resolve to change the way they approach the new school year.

Resolutions are notoriously hard to stick to. Remember to make your goals POSITIVE. State what you WILL do, not what you won’t do… “I will eat fruit for dessert 5 days a week,” instead of “I will eat less candy.” Make your goals specific, as in “I will run 30 minutes a day, 5 days a week,” instead of “I will exercise more.” And make goals measurable- “I will do an outdoor activity with the kids 20 minutes a day,” instead of “I will get the kids outside more.” Set end dates when possible- “I will organize my closet by next Saturday.” This approach works better for children too: they can make a chart and visually document their progress in areas such as reading, exercise, or eating more fruits and vegetables. Build in positive rewards such as special trips or choosing a meal.

Perhaps your family has overindulged on ice cream at the beach this summer. Fall is a good time to reassess your children’s eating habits and make simple, step-wise changes in what they consume. Make a single change at a time. First, cut out juices and sweetened drinks. The next week introduce whole grain breads and pastas. The third week show your kids how to fill half their plates with fruits and vegetables at each meal. Resolve to pack a healthy lunch for school or work once a week. Then twice. Swap out the potato chips for dried fruit chips. Allow your kids chocolate milk once a week rather than everyday. Change your family’s milk jug from whole milk, to 2%, to 1%, and then skim- do it over time, cover the label, and they won’t notice the change.

Is your child spending too much time inside playing video games? Brainstorm ways to get them outside and moving. Be creative- if your child doesn’t want to do a team sport (or you would rather not spend a lot of money on classes or time driving there) challenge her to run around the house a few times, and see how many more rounds she can do each day. How many continuous jumps can he do with a jump-rope? How many hoops can she shoot without missing? The more interesting the activity, the more it will engage and challenge your child. My son hates playing soccer, but will do the same running around outside pretending to be Harry Potter playing Quidditch with his friends. A few hoops on sticks and we had a field!

The key to making all these resolutions work is making changes small and steady. How many pledges to lose 25 pounds in the New Year work? Aiming for a 5 (or even 1) pound weight loss is much more achievable, and avoids the feeling of failure that dooms many a diet. These small changes are also more likely to persist, and your whole family will feel a sense of accomplishment long before 2012 rolls around!

Dr. Gruen opened her practice, Village Pediatrics, in 2009, but prefers spending time creating fantastic kids birthday parties.