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Childhood Nutrition – Some Specifics (Part 2 of 2)

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!


Food Fights (Second Edition) by Laura Jana, MD, FAAP, and Jennifer Shu, MD, FAAP

Center for Disease Control website (

American Academy of Pediatrics website (

2015-2020 Dietary Guidelines for Americans (

8 To Live By (

Childhood Nutrition – A Healthy Start (Part 1 of 2)

March is National Nutrition Month in the United States. I realize that every month has a number of designations such as this, and most people pay little attention to them, myself included. However, as it relates to child health, I can think of few topics of greater importance. In fact, the way we eat as a nation is contributing to the fact that generational life expectancy is actually decreasing for the first time. This is a tragedy that can be avoided.

The Extent of the Problem

It’s no secret that we have a very serious problem in this country with overweight and obesity. Although awareness of the problem has increased, there has not been any significant improvement in national statistics. In fact, they continue to get worse.

It is estimated that 35 to 40 percent of adults in the United States are obese. Overweight accounts for another 30 to 35 percent. These rates represent a threefold increase since the 1970s, and the rates of childhood obesity parallel those of the adult population. About 20%of children in the U.S. are obese. That’s 1 out of every 5! The lifelong health consequences of this problem are well documented.

It’s impossible to fully cover such a broad topic in a single article (or a thousand-page book for that matter!), so I wanted to offer a few important ideas about helping our children develop and maintain healthy eating habits. This article will focus on the broad issue of intuitive eating and how to cultivate this in our children (and ourselves). The next will offer more specific advice.

But First, a Disclaimer

I will not address physical activity in this article, simply due to the fact that it is also an incredibly expansive topic. However, its absence does not suggest a lack of importance. Indeed, physical activity is a vitally important part of a healthy lifestyle and should not be overlooked. But it will have to be the subject of another article.

Intuitive Eating

Most of us are born with the natural instinct to eat when we’re hungry and stop when we’re full. But somewhere along the way many of us develop habits of eating which have nothing to do with the basic reason for food consumption. Add in access to bottles for too long, foods that are for pleasure only, treats given as a reward for good behavior, as well as many other contributing factors, and it’s easy to see how caloric excesses may arise.

The assault on our natural intuition toward eating starts early on. As a toddler or preschooler, most of us were told by proud parents, “You’re such a good girl (or boy) for finishing all of the food on your plate!” We beamed with pride as we learned that eating a lot of food pleased our parents and equated to us being “good.” How many of us have said similar things to our children?

It’s best if we try to leave value judgment out of eating. Instead of using the above phrases, or similar ones, with our children, we might consider saying things like; “It looks like you’re really hungry today. Would you like some more vegetables?” or, “I see that you don’t feel like eating right now. I’ll save your food for later when you’re hungry.” If we try to state our observations rather than make value judgments about our children’s eating, mealtime will be more enjoyable for all.

We should remember that one of our jobs as parents is to provide healthy foods for our children to eat, several times per day. The child will then decide what she eats and how much. This applies to the vast majority of children, with rare exceptions. I know that sounds too easy, but most of the complicating factors in this arena are created by us, the parents. Anxiety, feelings of rejection, power struggles, age-related behavioral issues, and many other factors, contribute to making the feeding relationship seem overly complex. We will do better if we try to leave our own emotions out of it, and encourage the feeding intuition our children come equipped with from the start.

The following topics are related to intuitive eating, including some exceptions to the rule:

“…but she doesn’t eat anything!”

On occasion, this can be a concern. But only when a child is not growing well and not gaining enough weight to stay consistent on the growth curve. Fortunately, this is typically not the case. The vast majority of children who go on hunger strike altogether (or hold out for only their favorite foods) are healthy and growing fine. Let’s face it… it doesn’t take many calories to keep a little 2-year-old going. Even older grade school kids don’t need as much as we might think. As I have told the parents of some overweight and obese children who expressed this concern, sometimes we have to adjust our expectations.

“He has what you might call a narrow diet”

If your child will eat only chicken nuggets and french fries, then it might be appropriate for those foods to disappear from the house (and the car, and grandma’s house, etc.) for a little while. Until he or she discovers that there are other edible substances available, there may be some whining and dramatic displays of deprivation, but survival is very likely (for all involved parties). Keep in mind that it may take up to a dozen tries before a new food is accepted, but if the child is hungry, that number is likely to decrease.

A tried and true technique on this front is the “one bite method” or the idea of “no thank you bites.” It’s essential that we respect the child’s tastes in this process. One bite means one bite. If they don’t like it or say, “No, thank you,” to more, then that’s it. Don’t try to cajole your child into eating “just 5 more bites” of something he obviously doesn’t like. It’s exceedingly rare for a child to be so picky and stubborn that he will actually stop growing, lose weight, or become malnourished. So once again, offer the healthy foods you would like your child to eat, and eventually things will work out.

The Forrest Gump Eater – “You never know what you’re gonna get”

Toddlers and preschoolers are often known for their inconsistency regarding different foods. As parents, this can drive us crazy! I remember saying to my sons when they would refuse to eat something they had devoured the day before, “But you just ate this yesterday! What’s going on?” We tend to worry about those “not hungry” days, and fear that our child will be unable to make it through the week. But as long as some “hungry” days are in the mix, and we take full advantage by allowing them to eat their fill on those days, everything should be okay. Inconsistency is aggravating, but I, for one, am still working to overcome this tendency in my parenting style. So we should probably cut our kids a little slack here, too.

“She’s a good little eater!”

On the other end of the spectrum is the child who never met a food she didn’t like, and lots of them. This brings delight to the parents of an eight-month-old… less so for those of an eight-year-old. It all depends on where the child is on the growth curve. There are some children who seem to be able to eat more than their parents and maintain an appropriate weight, but this is not generally the case. If the child is in the overweight or obese category, something has likely gone wrong with the eating intuition, and appropriate interventions should be made. It’s essential that a child who likes everything is offered healthy foods for both meals and snacks, and that portions are appropriate, both in size and number. “Only fruits and vegetables as snacks” is a good rule for these children (and basically everyone). There will be more specifics about this in the next article.

“Do as I say, not as I do” vs. “Let’s do this together!”

As with almost everything regarding our children’s behaviors, we should also consider our own. Here are a few potentially revealing questions we can ask ourselves about how well we are modeling the intuitive eating behaviors we encourage in our children:

Have I ever eaten a meal and then realized that I wasn’t hungry before I ate?

Have I bought into the “clean your plate” mentality?

Do I often eat until feeling overfull?

How many of my calories come from foods or drinks which offer no nutritional value?

How much time do I spend thinking about food?

Are there foods in my house that are off-limits to the children?

Do I follow the recommendations for fruits and vegetables and limit my sugar intake?

Some of the most powerful influences in our children’s lives are the things they see us do, much more so than what we say. This is rarely truer than in the realm of nutrition. Remember with regard to our food choices, if it’s in the house, it’s fair game, for everyone! If the eating expectations we have for our children are far afield from our own habits, our words will often fall on deaf ears. However, if we set specific goals as a family, and encourage each other along the way, there is a much greater likelihood of success.

[…to be continued later this month]


Food Fights (Second Edition) by Laura Jana, MD, FAAP, and Jennifer Shu, MD, FAAP

Center for Disease Control website (

American Academy of Pediatrics website (

2015-2020 Dietary Guidelines for Americans (

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