This article is meant to provide some specific advice about childhood nutrition and feeding issues. Although various sources were used (see References), many of these ideas can be found in an excellent book titled “Food Fights,” which is recommended reading for all parents of young, and even not-so-young, children. Before getting to a potpourri of ideas, I’d like to mention the importance of making sure our sources of information in this arena are reliable.
“That’s not what I read on Facebook”
We’ve long been in the so-called “Information Age.” Unfortunately, this has become a problem in the sense that much of what we read on the internet has not been properly vetted, and may or may not be true. Some information is known to be false by those who post it and is intended to mislead, while other times people unknowingly post or “like” or “retweet” things that are false and misleading. That’s why some now refer to our time as the “Misinformation Age” or the “Disinformation Age.” Fun fact – the New Webster’s Dictionary word of the year for 2016 was “post-truth” – a sad commentary on the current state of affairs.
The subject of nutrition and healthy eating tends to particularly attract speculation, myth, misinformation, and outright falsehoods. The ideas I will present are well studied and evidence-based. While this is certainly not an exhaustive list, it is meant to provide some highlights to help us make changes that will positively impact our children’s health (and ours as well).
Remember to encourage intuitive eating
If you haven’t yet read part 1 of this article, posted earlier this month, please do so. Many of the “big picture” concepts are discussed there, and it’s important to keep those in mind as you read this installment. I’ll proceed in a somewhat age-based order, starting with infants.
Breast, bottle, cup – liquid nutrition for babies
It’s been well established that breast milk is best for babies in the first year of life. However, only a small minority of children have been offered only breast milk to drink by their first birthday. So while the goal is to get your baby as much breastmilk as possible, those who are formula-fed do just fine. Keep in mind, however, that it is easier to overfeed a bottle-fed baby, and formula-fed infants tend to have higher rates of overweight and obesity in childhood, although this is highly dependent on other factors as well.
Probably even more important is to remember that breast milk and formula are the only liquids infants need in the first year of life. No water or juice required. Water alone is largely unnecessary in the first year due to the fact that it’s easy to meet liquid intake requirements without it. I often refer to juice as “liquid candy” due to its high sugar content and limited nutritional value. If juice is to be given, only 100% fruit juice is acceptable, and it should be limited to 2-3 oz per day in this age group. Better still, use it as an occasional treat, or not at all.
It is recommended that babies start to learn how to drink from a cup starting at about 6 months of age. This can be from any of the various devices, like sippy cups, straws, and regular cups. Putting breast milk or formula in these is preferable over juice or water. This will aid in the transition away from the bottle between 12 and 15 months, and help our toddlers to not reject cow’s milk at a year because it’s in something other than their beloved bottle.
Can my baby have a protein shake?
While there’s no recommendation for babies to drink Muscle Milk, there is an increased emphasis on making sure our babies get enough protein. When babies are introduced to foods at 4-6 months of age, pureed meat should be on the menu, in addition to the cereal, fruits, and vegetables we all think of. Other good sources of protein should also be considered as our babies learn to eat by spoon.
Many parents ask questions about what their babies can and can’t eat, and our advice as pediatricians has evolved in this area. Currently, the restricted foods in the first year of life are honey and choking hazards. Also, babies are not to drink cow’s milk, but other dairy products, such as yogurt and cheese, are fine for most babies to eat. So the long lists of restricted foods have largely gone away. There’s even evidence that giving babies highly allergenic foods such as creamy peanut butter and scrambled eggs before 9 months of age may reduce the risk of allergy. Still, it’s most important to consider the nutritional value of the foods we offer most often.
Grazing vs. Dining
It’s important that around their first birthday, our toddlers make the transition from the grazing pattern of the first year to the meal based pattern which should persist from then on. We should try to feed these little mess makers in the high chair or booster seat for both meals and snacks. This typically helps us to offer healthier food choices, teaches that eating should happen as its own event and not while doing something else, and also limits the mess to a confined space. We should not allow our toddlers to carry around sippy cups, which provide a continuous infusion of liquid to both bathe the teeth and increase calories. It’s a good habit to offer both food and drink in the high chair or booster, and avoid routinely offering food in other settings (in the car, while watching TV, before bed, etc.).
“If you eat your [enter healthy food here] you’ll get a [enter unhealthy food here]!”
We’ve all done it. Whether it’s to encourage toilet use, incentivize completion of chores, or get your preschooler to finally eat broccoli, using food as a reward is almost epidemic in our culture. Even some experts have promoted this method of providing positive feedback (one M&M for going pee on the toilet and two for going poop). I have occasionally found myself suggesting similar reward systems to parents, but this is probably not the best idea for long term success. How many times have we heard someone say (or thought ourselves), “That piece of cake is my reward,” or, “I’ll celebrate by eating a tub of ice cream!” Food as a reward is pervasive, but not very healthy.
It’s better to use “the one bite rule” or “no thank you bites” to help children try new foods. And this should be done in a relatively low pressure, relaxed way. Studies have shown that when we make a big deal about our children eating or trying food, the natural reflex becomes one of caution on the part of the child. The child’s thought bubble might read, “If mom wants me to eat this so bad, it must be healthy, and healthy is gross!” Keep in mind that it may take 10-15 tries of a food before it is accepted, so don’t give up.
Milk is not the enemy
In some ways, it seems like there’s been an all-out assault on milk in recent years. It’s included in the lists of “foods to avoid” (usually from questionable sources) for everything from nasal congestion to allergy concerns to behavior problems. While some adults may have increased difficulty dealing with a lot of dairy as they get older, the same is typically not true for our children. For the vast majority of children, cow’s milk is helpful and healthful food. For children in the second year of life, whole milk is the recommended beverage and should be consumed at a rate of 16-24 oz per day (from a cup, not a bottle). After 2 years of age, the amount stays about the same, but the recommended type of milk becomes 2%, 1% or skim. There’s still some controversy about milk fat, with some finding that it’s beneficial and others not. More specific recommendations may be issued in the future. Bottom line – “Got milk?” is still a question worth asking.
Break the fast, every day
The benefits of eating a healthy breakfast have been well established. In many ways, it really is the most important meal of the day. Kids do better in school, adults perform better at work, and toddlers tend to be more manageable all day if a healthy, substantial breakfast is eaten. But many families struggle to make healthy eating part of the morning routine. As parents, we should set the tone in our families by providing a good breakfast for the kids, and also by eating a good breakfast ourselves on a daily basis. It’s good to consider protein sources in making our breakfast choices, and also make sure all food groups are well represented. This can prove challenging but will be well worth the effort as we make breakfast a priority in our homes.
Sugary beverages – “So yummy!” (but not so good)
There is a veritable flood of sugary drink varieties all around us. It’s no wonder they are so popular because they taste so good! The reason they taste good, however, is plain and simple… sugar. The latest dietary guidelines call for relatively modest amounts of simple sugars and added sugars in our daily diet. Just one soda, sports or energy drink, or serving of juice, will often exceed that recommendation. For 2-3 years olds, the recommended added sugar intake is 2-3 tsp per day. For adults, it’s only about 10 tsp daily. Coincidently, 10 tsp of sugar is the amount you’ll find in the average 12-ounce soda. For our kids (and us) milk and water are the best drinks around.
Hungry for a snack? Eat an apple!
There’s one suggested rule from which nearly all families will benefit if it is implemented by the whole family. I call it the “only-fruits-and-vegetables-as-snacks” rule. Rather than reaching for chips or candy or a million other packaged foods when we’re hungry between meals, we will be better off if we instead choose vegetables or fruits in virtually any form, with fresh being preferred. This does not include fruit snacks (not actually fruit), ketchup (no need to explain), or juice (already covered).
Families who decide to make this one of their guidelines will derive several benefits. It will be easier to achieve the 5-9 helpings of fruits and veggies recommended on a daily basis. Total calorie consumption will decrease significantly (without feeling hungry). Those calories consumed will be far healthier ones. And it becomes something family members can encourage each other to do, creating more family unity in purpose, and more purposeful eating as well.
Restrictive diets are, well… restrictive!
I’m a firm believer that (almost) all foods are fair game, but some should be consumed often and others only rarely. The “almost” is in there for things like deep-fried Twinkies and the like, which really should not be for human consumption. The fact is, any diet that calls for eating severely limited calories, or only very specific foods and food types are unsustainable and unlikely to lead to long term success. Starvation diets, in particular, are harmful because they typically result in loss of muscle mass and decreased basal metabolic rate (the number of calories we burn just by living). That will ultimately lead to weight gain, not sustainable weight loss.
Why do I mention this with regard to pediatric nutrition? Kids are fast learners. If we are always talking about and starting and stopping one diet after another, they will come to consider diet fads as normal eating patterns. But if the emphasis is on healthy food choices (eating more of the healthy foods and less of the unhealthy ones) this issue will be properly framed in the minds of our children.
If it’s in the house, somebody is going to eat it (probably the kids)
It’s important to carefully consider what we put in the cart when grocery shopping. And I think it’s good advice to not go to the grocery store when hungry. We may find that we are in the habit of buying foods that are “off-limits” to the kids, but okay for us as parents. We may need to rethink some of those choices and make healthier eating a family affair. Children are more likely to learn from what we do than what we say. If there’s an abundance of unhealthy food in the house, how can our children be expected to make healthy choices? On the other hand, if fresh fruits and vegetables, whole grains, dairy, and other healthy options dominate our refrigerator and pantry, this will become the norm for the whole family. If we want to make improving our children’s nutrition an attainable goal, it must be done as a family.
Ring the dinner bell!
Many organizations concerned with health and nutrition in recent years have called for a return to the family table. Families who regularly eat meals together have been shown to have lower rates of obesity, juvenile delinquency, and substance abuse in children and teens. This can be a difficult thing to achieve in our busy world but is well worth the effort in rearranging schedules and setting this expectation. Much more goes on at the table than eating, and this is felt to be part of the explanation for the many benefits of dining together. It’s also important to turn off the television and be present as a family whenever we’re able to break bread together. This allows the family to connect, and also allows parents to keep an eye on those who may be inclined to have too much of a good thing. The family can get up from the table together after everyone has eaten and clean up, reducing the chances of eating past full. There are many other benefits of making family meals the norm in our homes.
One thing at a time, but let’s get started!
These are only a small sampling of the many great ideas to be found in the references at the end of this article. But don’t get overwhelmed thinking we have to do everything at once. We tend to be far more effective if we focus our efforts more narrowly until we’ve achieved the desired goal. Then we can move on to the next. Little changes like these can make a tremendous difference over time. We can all improve our eating habits and overall nutrition. It is imperative that we do so. In this way, we might reverse the current trend toward overweight and obesity which threatens to affect our children’s generation more than any other in history. It can be done, and we have to start!
References
Food Fights (Second Edition) by Laura Jana, MD, FAAP, and Jennifer Shu, MD, FAAP
Center for Disease Control website (www.cdc.gov)
American Academy of Pediatrics website (www.aap.org)
2015-2020 Dietary Guidelines for Americans (https://health.gov/dietaryguidelines/2015)
8 To Live By (https://intermountainhealthcare.org/ext/Dcmnt?ncid=520289779)
