photo credit: DesertNana aka majamom

Chances are you have not had a whole lot of opportunity to ask your family physician or pediatrician about a few rules of thumb for your child’s nutrition. After all, there is hardly any time to talk about nutrition even on a routine wellness visit. Our experience has been no different as the doctor always seems to be in such a big rush to get you out of there!

That is why, I read with great interest an article written by a physician and a registered dietitian published in the American Family Physician, which is a peer reviewed journal of the American Academy of Family Physicians. The title of this article is Nutrition in Toddlers and it contains a nice table of 7 consensus recommendations you can use to manage your child’s nutrition. I wanted to share them with you in this article.

A toddler diet should include 2-3 servings of milk or other dairy products  per day

Not a problem in most cases unless your child has a milk allergy or intolerance. Milk is a great way to meet your growing child’s calcium and vitamin D needs.

Toddlers older than 2 years old should get 30% of daily calories from fat

Not all fat is bad, even though we live in a world where low fat seems to be the golden rule. What you need to limit is saturated fat or trans fat and watch dietary cholesterol. Very easy to do if you reduce processed foods and rely more on home-cooked meals. Polyunsaturated or monounsaturated fats and fatty acids are among the healthy fats you must include in your child’s diet.

Limit fruit juices to no more than 4-6 oz per day and emphasize whole fruits and veggies

It is easy to get comfortable with the no-sugar 100% pure fruit juice label on the box, but fruit juices are no replacement for real fruit. Getting your child to love fruits and veggies takes effort and patience, but don’t give up!

Vitamin supplementation is unnecessary except in undernourished or chronically ill children

I could not agree more! It is natural to worry as a parent, and sometimes feel the pressure to start using a vitamin supplement just to be safe. There days we hear so much about vitamin D deficiency but a supplement is not needed unless your child doesn’t get enough sun exposure or if he does not or cannot drink at least 2 cups of milk. There are situations where you may consider a multivitamin for your toddler, but the general advice is to manage your child’s vitamins and minerals needs through diet and healthy lifestyle.

Good nutritional habits should be fostered by sitting at the table, turning off the television and interacting socially

Sometimes we get so focused on the what of eating, that we forget about the how of feeding! Having a family meal without the distraction of TV or video games is a very powerful way of building lifelong healthy eating habits. Dr Kathleen Cuneo of Dinner Together is an expert in this matter whose opinion I respect a lot. I really like her approach and belief that feeding is parenting. That is what matters in the long run, not the nutritional facts on the label!

Parents should offer children a variety of foods, expose them repeatedly to healthy foods and model healthy eating behaviors

Like it or not, you are a role model for your young child. And when it comes to building lifelong healthy eating habits, your attitude towards food and eating is the most important factor. Being a role model is not difficult; just be consistent and completely natural with your child.

To reassure parents and detect undernourished children, physicians should monitor growth patterns including body mass index

While it is natural to worry if your child falls below the 50th percentile on weight and height growth charts, body mass index is a better tool to assess if your child is overweight or underweight. Body mass index uses both height and weight. It is very easy and you can use an online calculator if you don’t want to wait until your next wellness check appointment.

I think these recommendations pretty much sum up the latest thinking in child nutrition. They are based on sound evidence and practical experience of doctors and dietitians. You don’t have to try to follow all of them on a daily basis. You can try to make them a part of your child’s overall eating habits in the long run. It is also a good idea to tailor your approach to your child’s individual personality without getting hung up on a certain best way to practice them.

Good luck!

©2010 Littlestomaks.com

Ask The Expert is a weekly column on Littlestomaks.com. The idea is to have a reader-submitted question answered by a nutrition expert or a pediatrician. Feel free to submit your question in the comments section below.

Kids love Mac’ n Cheese! Sometimes, so much that they don’t want to eat anything else! This is challenging for toddler parents who try hard to provide a healthy, balanced nutrition. This week, registered dietitian  Lindsey Walder tackles this issue and advises parents to shift their focus from nutrient intake to establishing and maintaining a healthy eating environment.

Question: My child eats only cereal and mac & cheese. How can I improve his nutrition?

Young children commonly go through phases during which a few foods are accepted and everything else refused.  One reason these food jags occur is that young eaters are neophobic—in other words, they fear new foods and tastes.  Interestingly, toddlers’ taste buds become much more perceptive around the time they start walking, making them increasingly selective about what they eat.  Researchers believe that the sudden change around age two from eating a wide variety of foods to eating a limited number actually may have a genetic link that could have served to protect our prehistoric baby ancestors as they first toddled out of the cave.  What exacerbates children’s innate reluctance to try new foods at this age is the pure delight most toddlers take in attempting to, for the first time, exert control over some aspect of their lives.

While having a picky eater is extremely frustrating for parents, the good news is that nutritional deficiencies in the United States are rare.  If your children are growing normally according to your pediatrician, rest assured that they are more than likely adequately well-nourished.  So, take a deep breath and present your child with broccoli for the tenth time.  Even if you are turned away – again – take comfort in knowing that this stage usually only lasts until age four or five.  That said, the malleable years of early childhood are still crucial for establishing good eating habits, and parents should make the most of it.  It’s not as difficult as you may think.

First, to avoid driving yourself crazy worrying if your toddler is getting the right nutrition while also trying to accommodate his seemingly undying yearnings for macaroni and cheese, I recommend shifting your focus from nutrient intake to establishing and maintaining a healthy eating environment.  Doing so will lay the foundation for an appreciation of a wide variety of healthy foods.   In my practice, parents who fret and stress about their child’s eating (or lack thereof) during meal time are the ones who usually face the most resistance from their child.  In addition to not worrying so much, there are five simple things parents can do now to foster good eating habits and encourage venturing beyond mac & cheese.

Expose your toddler repeatedly to new foods

Offering the same new food every day for 5-14 days can be effective.  Including these unfamiliar or previously-rejected items at meal times without forcing your child to eat them helps him to become more comfortable with the food item and may increase his willingness to try it.  Remember, meals should be eaten together as a family (without any short-order cooking), so your child can see you enjoying a wide variety of foods.

Give 2-3 choices of healthy foods

One mother told me she successfully employs this tactic with her four-year old: for snacks, she asks her son if he would like an apple or a banana.  This is a win-win approach to avoid a power-struggle since both parent and child are part of the decision.

Avoid forging a connection between eating and good or bad behavior

Too often we use food to assist with parenting responsibilities—down the road this practice can lead to an unhealthy food relationship.  Consequently, do not bribe your child with food.  Instead of offering food for rewards or comfort, give your child stickers or a hug.  And, try not to put any food or food group on a pedestal; simply teach your child that some foods are healthier than others.

Keep the highly-processed, sodium and sugar-heavy, refined foods like packaged frozen meals, chips, high-fat meats, cookies, cakes, and sugary drinks out of the house

Your three-year old can’t take the car and go pick up a box of sugary cereal at the grocery store.  Take advantage of the fact that you are the food gatekeeper and have control over what foods get offered.  Go ahead–cross the hot dogs off your shopping list!

And finally, stock your kitchen with healthy, delicious foods such as fruits, vegetables, whole grains, nuts, beans, fish, lean protein, and reduced-fat dairy products

Not immediately, but over time, your youngsters will learn to prefer healthy types of foods if that is what they’re accustomed to.

©2010 Littlestomaks.com. All Rights Reserved

Disclaimer – Information provided in Ask The Expert column on Littlestomaks.com is intended to give you general guidance on a question related to toddler nutrition. It is not meant to be treated as medical advice. You are welcome to contact this expert for a detailed consultation on your specific situation to determine what actions, if any, you should take regarding nutrition and health of your toddlers. We do not recommend you to take any action based solely on the information presented in this column. Experts have agreed to provide their professional opinion on toddler nutrition related questions on a voluntary basis and no compensation is offered to them by Littlestomaks.com.

Ask The Expert is a weekly column on Littlestomaks.com. The idea is to have a reader-submitted question answered by a nutrition expert or a pediatrician. Feel free to submit your question in the comments section below.

There are so many handy snacks around these days. No wonder kids get hooked on them at an early age, so much that they don’t eat anything else. This week, registered dietitian and exercise physiologist  Susan Dopart advises parents to get their kids involved in shopping and cooking as they try to introduce them to vegetables and other healthy foods.

Question: My 5 1/2 yo prefers not to eat! She will “snack” on muffins, goldfish crackers if you let her, but will only eat a handful of other things, none that include vegetables. She weighs 34 lbs and is almost 6 years old; 25% percentile on weight since she was 1 or 2. What should I do?

Children will eat what you feed them.  If you offer your daughter a variety of healthy choices (and not the muffins, goldfish or other) eventually she will give up and pick one of those.

Involve her in the shopping and cooking process.  Bring her grocery shopping and have her pick out 2-3 favorite fruits and vegetables each week.  Educate her at the store about what vitamins and minerals are in each one so she knows why they are important to eat.  For example, a strawberry has vitamin C which is important for healing when you scrape your knee.

In my office I show children the list of multiple ingredients in snack or processed foods.  I then tell them it take their bodies longer to process and digest those foods rather than foods without a label, like fruits and vegetables.

Taking the snack foods out of house will eliminate temptation and keep the environment clean.  If those foods are not around or accessible, and nutritious foods are in their place it will encourage healthy eating.

There are ways to make vegetables more kid-friendly.  I have a vegetable casserole that combines vegetables with eggs and cheese in tomato sauce that kids love.

To encourage new foods have your daughter try a no thank you serving.  Since many children have aversions to vegetables due to their strong flavors, their taste buds need conditioning over time.  A “no thank you” serving is having her try a bite or two (one or two teaspoons) of something she does not like each time it is served.  Research shows a child may need to eat a new food 10 times before they start to like it and ask for it.

One of the most important aspects of feeding your child is being a healthy role model.  If a child sees you eating vegetables each day, it is one of the best ways to encourage healthy eating.

With respect to your daughter’s size that may be what is normal for her. There is not a concern about her size unless she falls below the 10% percentile for height or weight.

Good luck.

©2010 Littlestomaks.com. All Rights Reserved

Disclaimer – Information provided in Ask The Expert column on Littlestomaks.com is intended to give you general guidance on a question related to toddler nutrition. It is not meant to be treated as medical advice. You are welcome to contact this expert for a detailed consultation on your specific situation to determine what actions, if any, you should take regarding nutrition and health of your toddlers. We do not recommend you to take any action based solely on the information presented in this column. Experts have agreed to provide their professional opinion on toddler nutrition related questions on a voluntary basis and no compensation is offered to them by Littlestomaks.com.

News about childhood obesity is everywhere these days. Hardly a day goes by without a screaming headline in the media about this issue. Jamie Oliver has further popularized it by his TV show and even Mrs Obama has taken up this cause via her Let’s Move campaign. There is no doubt that we must address childhood obesity, but what about the problem of underweight and short stature? How worried should a parent be if their toddler falls under the 5th percentile in weight and height?

Recently, registered dietitian Teresa Wagner tackled a reader question in our Ask the Expert column about a toddler not gaining weight. I received a follow up email from another reader who was worried that her 8 month old child was below the 5th percentile and not eating much. The tone of her message reflected her extreme worry and frustration at not knowing what to do.

There is a reason why our media does not focus on this problem. The numbers, when taken as a whole nationwide are not that high. See below a chart based on the 2008 data CDC’s Pediatric Nutrition Surveillance System (PedNSS) on growth indicators. The PedNSS system is a public health surveillance system which monitors the nutritional status of children from low income families under Federal programs. Data comes from public health clinics where these children are seen for routine care, nutrition education and supplemental food.

Percentage of children 2-5 years old who are underweight or of short stature is between 3-5% for Whites, Blacks and Hispanics. These numbers are even smaller for American Indians and Alaskan Natives. Compared to the 20-30% obesity rates, these numbers are too low to capture the attention of mainstream media and policy makers. Besides, the media loves to show extreme images of either very fat kids or severely malnourished starving kids from the third world countries. Anything else does not make the cut for prime time!

As a parent, it is natural to worry. It becomes a personal issue and fancy nationwide statistics do not make a difference. The frustrating part is that it is not always possible to get enough credible information to make informed decisions. The result is that each day becomes a battle to force feed a child in the hope that she will put on some weight. Since children have a natural ability to regulate their food intake based on their current needs, it may seem like they are not eating enough. Anger, frustration and despair are the emotions most parents feel under these circumstances.

Here are 5 questions you can consider to assess the situation and take appropriate actions

Is there a trend in my child’s growth chart numbers?

A single data point on the growth chart, although important, should not cause concern. Take time to understand growth charts and their limitations so you can use them to evaluate the general growth pattern of your child. Another thing to keep in mind is that your child may not be in the normal range for both weight and height. For example, our twins are tall for their age group but lag behind in weight. From this perspective, I like the BMI for age chart because it takes into account both weight and height at the same time. You can use this online calculator for BMI chart or ask your doctor about it.

Is there a medical reason for slow growth?

This is where keeping a close eye on your child’s growth pattern will help you find medical issues that may be affecting her growth. There may be known birth defects or undiagnosed metabolic or digestive disorders. Severe case of reflux like GERD is also a concern. Detecting them early and working with a specialist for corrective action is very important.

Is there a specific reason for poor appetite?

Nearly all toddlers are picky eaters and it is natural for them to frequently show poor appetite. But if it persists over a long period of time, you will need to be extra vigilant so you can find the root cause. Are there food allergies? Special environmental or seasonal triggers? Does a change in menu or feeding schedule help? The important thing is to pay attention to the unique needs of your child so each feeding is most effective. Siblings around the same age, twins or multiples need different treatments based on their individual personalities. Clearly a challenge for most parents, but there is no perfect answer. Practicing the principles of attachment parenting and nutrition can help.

Does my child seem different than his siblings or other family members?

Although it is not always a good idea to compare your children, you have to take into account your family history and genetic makeup. In some ways, a consideration of these factors is probably more important than the growth charts which are based on population averages. If your family ethnicity is not one of mainstream population, it is unlikely that the growth chart standards will be accurate for your child. Evaluate your child’s height, weight and BMI through the lens of your family’s history to determine if there are differences you should be concerned about.

Are there any special circumstances in my family?

Every family goes through ups and downs – financial, emotional or health-related – often over an extended period of time. Assess if you have certain stresses in your personal life or your family situation at the moment. Even toddlers pick on them easily even if they cannot articulate it. If these problems persists over a long period, there may be slow weight gain or even a loss in weight. Recognize these problems early and seek help from family, friends or your doctor to manage them.

One last thing to remember – early childhood height and weight is often a poor predictor of adult height and weight, except in the case of overweight or obesity. You may be surprised how fast your child can grow upon reaching puberty. Keep a close eye on the growth charts, spot the problems early and take appropriate action. No need for excessive worry just because of a couple of low points on the charts!

Most importantly, focus on building healthy eating habits. Offer a variety of foods in healthy balance and moderation.

Are you concerned about an underweight child? Please share your personal story in a comment below.

©2010 Littlestomaks.com

Ask The Expert is a weekly column on Littlestomaks.com. The idea is to have a reader-submitted question answered by a nutrition expert or a pediatrician. Feel free to submit your question in the comments section below.

It is natural for parents to be concerned about slow weight gain in their children when they see the weight percentile number on the growth charts. They try to then force feed their child in the hope that he will gain more weight. In this article, registered dietitian Teresa Wagner explains why this approach may not work in the long run. Instead, she suggests you try to implement the notion of division of responsibility in feeding.

Question:I am worried that my 4 year old is not gaining enough weight although he is growing tall. What should I be feeding him so he can put on some weight?

Answer:

As a registered dietitian who worked for almost 10 years with pediatric clients, I have met many parents who are concerned with their children’s either abundance of or lack of weight gain. Weight status is a result of many factors including but not limited to heredity, metabolism, growth, environment and activity level.

Healthy children are born with an innate ability to regulate their own food intake due to hormones in the body that control the rise and fall of blood glucose levels and appetite. When left to one’s own devices, children will naturally eat when they are hungry and stop when they are full. Take for example, my own daughter who has surpassed me in height at the age of 14. When she was a child, she hovered around the 25th% for weight vs. height and was so tiny that you could have wrapped your fingers around her legs. However, when she was eating, she might stop in the middle of a bowl of ice cream, a baggie of grapes or a slice of pizza and be done. Once she went through puberty, she blossomed out into a curvy teen, now hovering around the 50th% of weight for height and still enjoys the foods she eats but innately monitors her own appetite.

The main concepts we should be concentrating on as parents to teach our children involving eating are balance, variety and moderation. Enjoying a variety of nutrient rich foods that will maximize the nutrients we obtain while moderating our calories and balancing those calories with appropriate physical activity or active play. When I taught college, the first statement I would make to my students was that if they learned nothing in my class but the definition and application of the three words balance, variety and moderation, I would be happy.

As a young dietitian, I learned all of my basic information on child feeding and actually worked for years in eating therapy for children who were born without the innate ability to either eat by mouth or sense hunger, fullness and satiety. The guru of child feeding in my book has always been Ellyn Satter.

Ellyn’s division of responsibility in eating tells us that parents are responsible for serving nutritious foods in a positive and supportive atmosphere while the child is responsible for how much and whether or not they will eat. In doing so on both parts, the child can develop successful skills in balance, variety and moderation and carry forth these skills into adulthood in developing a healthy lifestyle that includes physical activity, adequate sleep and weight maintenance. Teaching these concepts at a young age decreases your child’s risk of developing chronic disease as an adult. By becoming overly concerned or forceful with children’s eating and weight, we disrupt this natural balance by creating a negative atmosphere or forcing unneeded calories and our child may lose  that inborn ability, as many of us have, to balance their own weight and monitor their own food intake. In the mean time, they will grow normally based on their own unique make-up of weight status factors. Thus, Ellyn says don’t try to control the amount of food or calories that your child eats; that is the child’s job.

Instead:

• Maintain a division of responsibility in feeding; you providing/child monitoring.
• Do family-friendly feeding and maintain a supportive atmosphere.
• Offer nutrient rich snacks between meals and encourage active play.
• Let your child grow up to get the strong, healthy body that is right for them.

©2010 Littlestomaks.com. All Rights Reserved

Disclaimer – Information provided in Ask The Expert column on Littlestomaks.com is intended to give you general guidance on a question related to toddler nutrition. It is not meant to be treated as medical advice. You are welcome to contact this expert for a detailed consultation on your specific situation to determine what actions, if any, you should take regarding nutrition and health of your toddlers. We do not recommend you to take any action based solely on the information presented in this column. Experts have agreed to provide their professional opinion on toddler nutrition related questions on a voluntary basis and no compensation is offered to them by Littlestomaks.com.

Ask The Expert is a weekly column on Littlestomaks.com. The idea is to have a reader-submitted question answered by a nutrition expert or a pediatrician. Feel free to submit your question in the comments section below.

This week, Registered Dietitian Liz Marr offers a few tips for ensuring a complete nutrition of a 4 year old child.

Question: How much fat and protein is my 4 year old supposed to get? If he doesn’t get enough, should he be taking a vitamin?

Answer:

Despite concerns of many parents, it’s natural for preschoolers’ appetites to decline and for them to hyperfocus on specific foods to the exclusion of others (food jags). That’s because their growth rate slows compared to infancy and they are testing their independence through foods. As long as a variety of nutritious foods are presented to children and the child is otherwise healthy, most parents need not worry about whether a child is obtaining too little or too much nutrition. Following MyPyramid will help ensure that children eat appropriate amounts of protein and fat as well as balance intake of other important nutrients. Here is a quick guideline that will help you gauge your 4-year-old’s food intake compared to recommendations:

Another way to evaluate children’s longer-range nutritional status (versus day-to-day eating) is through height and weight measurements and growth charts used by pediatricians. These growth charts are very closely correlated with nutritional status. Therefore, if your child is considered within a normal range for height and weight, particularly as it tracks over time, it’s likely their nutritional intake is not compromised.
As far as vitamin and mineral supplements go, major scientific groups, such as the American Dietetic Association and the American Academy of Pediatrics, indicated that vitamin and mineral supplements are generally unnecessary for healthy children and that it’s better to emphasize healthy eating patterns.

©2009 Littlestomaks.com. All Rights Reserved
Disclaimer – Information provided in Ask The Expert column on Littlestomaks.com is intended to give you general guidance on a question related to toddler nutrition. It is not meant to be treated as medical advice. You are welcome to contact this expert for a detailed consultation on your specific situation to determine what actions, if any, you should take regarding nutrition and health of your toddlers. We do not recommend you to take any action based solely on the information presented in this column. Experts have agreed to provide their professional opinion on toddler nutrition related questions on a voluntary basis and no compensation is offered to them by Littlestomaks.com.

Ask The Expert is a weekly column on Littlestomaks.com. The idea is to have a reader-submitted question answered by a nutrition expert or a pediatrician. Feel free to submit your question in the comments section below.

This week, Registered Dietitian Preethi Rahul explains why it is important to know and track the general growth pattern of your toddler using growth charts.

Question: Why is it important to know the general growth pattern of toddlers?

Answer:

To understand the importance of growth pattern of toddlers it is very important to understand what growth is.

Growth is defined as increase in the size of an organism or part of an organism, usually as a result of an increase in the number of cells. Growth is a physical aspect which can be quantified. A child’s physical growth refers to the increases in height and weight and other body changes that occur as a child matures. Hair grows; teeth come in, come out, and come in again; and eventually puberty hits. It’s all part of the growth process.

How do you judge your child’s growth pattern?
There are various tools that can help parents understand their child’s growth pattern. Two most widely used ones are:

Growth charts
The National Center for Health Statistics has developed growth charts that are used to compare a child’s measurements with those of other children the same age. By plotting a child’s measurements on these charts, doctors are able to compare individual growth patterns with data collected on thousands of children. This helps to determine whether a child’s growth is normal compared with others the same age. The charts are a series of percentile curves that show the distribution of growth measurements of children from across the country.

BMI charts
Designed to measure body mass, BMI charts can help to determine whether a child’s weight is appropriate for their height. To get a quick picture of a child’s weight status, the health care professional enters the height, weight, age, and gender. The resulting number is then compared to other children of the same age to see if the child’s weight falls within the normal boundaries.

Here is a good article which tells you 5 things you need to know about growth charts.

Now why is it important to understand your child’s growth pattern?
Children are constantly growing and changing and periodic assessment of their progress allows any problems to be detected and treated early. Most children are assessed by health care professionals only when they are ill, at which time growth and development is not focus of care.

Growth measurements must be recorded at regular intervals to indicate growth patterns. Height and weight when taken only once do not lend themselves as interpretation of growth status. Children generally maintain their height and weight in the same growth channels during preschool and early childhood years, although these channels are not well established until after 2 years of age. Individual children sometimes grow at faster or slower rates; nonetheless; they should follow along their same growth channel.

Regular monitoring of growth enables trends to be identified early and intervention or education to be initiated so that long-term growth is not compromised. Weight that increases at a rapid rate and crosses growth channels suggests the development of obesity. A child who appears to be overweight may be advised to boost their physical activity a bit since overweight children have a higher risk of becoming overweight adults than their lighter peers. With early intervention, a small problem need not become a lifelong struggle.

Lack of weight gain or loss of weight over a period of months may be a result of under nutrition , an acute illness, an undiagnosed chronic disease, or significant emotional or family problems.So health care professionals and parents can work together to determine the best way to get the child back on track. Vitamin and mineral deficiencies can also be identified and if they are in the initial stages diet alone would be sufficient to bridge the gaps.
Thus as a responsible parent you need to constantly monitor your child’s growth and take necessary action as and when needed!

©2009 Littlestomaks.com. All Rights Reserved
Disclaimer – Information provided in Ask The Expert column on Littlestomaks.com is intended to give you general guidance on a question related to toddler nutrition. It is not meant to be treated as medical advice. You are welcome to contact this expert for a detailed consultation on your specific situation to determine what actions, if any, you should take regarding nutrition and health of your toddlers. We do not recommend you to take any action based solely on the information presented in this column. Experts have agreed to provide their professional opinion on toddler nutrition related questions on a voluntary basis and no compensation is offered to them by Littlestomaks.com.

Recently, I published a post highlighting some of the great comments I have received from all of you. I got very good feedback so I decided to compile a few more interesting comments from the archives.

I am constantly inspired by your comments and I learn a lot from them. I want to say thanks to those who spend time reading my posts – some on a very regular basis – and leave a comment behind with some advice, helpful tips or a question for further research. Some of them have their own blogs, which I highly recommend you to visit whenever you get a chance.

Enjoy, and feel free to leave a comment of your own.

1. In response to my post 5 things you need to know about growth charts, Jenna of Kidappeal wrote:

Thanks for the research on growth charts. my pedi has never mentioned BMI for my kids at visits. perhaps that’s because it’s not a concern?? I do recall the nurse said the pedi likes weight % to be less than height %. it is good that you point out parents should look at data over time, my boys were not at the same percentiles at birth, 2y and for my oldest 4y. if you have any concerns at all about your child being overweight, the best thing to do is let them eat as much fruit, veggies, whole grains, legumes and lean protein as they want, but limit juice, other calorie drinks besides low fat milk (after age 2), refined grains and convenience/packaged food.

2. When Kathy asked for advice on the Global Toddlers survey about how to “move on” from the milk bottle for her 2 yo son, TwinToddlersMom replied

Kathy,
We had similar problem with twins not giving up their bottle especially at night before they sleep. They were 22 months old and our pediatrician told us to go ” cold turkey ” about it. At that age, doctor believed that it is not good for teeth, even causes speech problems because of sucking habit. They were also asking more milk at the middle of the night. We did not have much sleep. Anyways, We had to do in 1 night, I first bought Elmo sippy cups and I asked them to throw their regular bottles in the trash can. They were both so excited about trying Elmo sippy cups they put their bottles to the garbage right away. First morning was Ok with Elmo sippy cups but then the night was very difficult, they cried about 20 min about asking bottles back. But bottles were gone
( well, not really, mommy kept them in storage, it is harder for mom than anyone else to accept that they are not babies anymore!) But we did not give in.

After 3-4 night crying before sleep, they realized that bottles are not coming back. But they rejected milk afterwards, doctor told me it could happen but I could substitute with yogurt and cheese instead of milk. I think it was almost 1 or 2 months , I tried a few alternatives, because whenever I gave milk in sippy cups they said NO. Finally I found about liquid yogurts, I mixed them with milk (50:50), they like the shape of bottles and start drinking those with straws. Slowly, they were back to regular milk again. I did not give any chocolate milk but I tried the strawberry one. I tried to avoid the ones with a lot of sugar. Anyways, since summer, they are now 2.5, we do not use sippy cups anymore, they love colorful regular plastic cups that we bought from IKEA and they drink at least 1-2 cups of milk every day and some times we give orange juice with Ca and Vitamin D added (Tropicana Healthy Kids).

3. When Dr. Ayala of Herbal Water offered useful tips in Help! My Kids Don’t Eat Enough Fruits and Vegetables, Nile shared her experience:

I guess I had a good example when I was brought up, but for some reason my son did not pick up the same habit as both his father (my ex husband) and I bought a lot of fresh produce, even things from South and Latin America. However, we supplemented it with vitamins. Luis and I have been consistent despite no longer being married as we agree on a lot of things for Angel’s upbringing. We now ask him to at least try a bite of new foods before deciding to rule them out. So far that has been a success and he even asks for things like corn and apples.

So, I guess I can say that your suggestions are a must do.

4. Natalie of A Little of This, A Little of That shared her son’s favorite vitamin in response to my post 5 Reasons to Consider a Multivitamin Supplement:

I have been giving my son a “gummy” vitamin for the past year and a half. He LOVES them. But he also loves fruit and vegetables. I have noticed a marked improvement in his health since starting the vitamins however. Other than well child check ups he has not had to visit a Dr in about a years time. We used to be there at least every other month or so for a cold or infection of some kind. He uses a chewable gummy vitamin, I am really not sure what brand, but it is Transformers shapes. the shape is VERY important to him.

5. Half Pint Pixie shared this in response to Annie’s guest post Attachment Parenting and Toddler Nutrition:

Thanks for this! We are very slowly starting to wean, my daughter is 2 years & 3 months now, up until now I have been very confident knowing she is getting lots of goodness from nursing, but I find now that it is so easy to get caught up in the “what are they eating” hysteria which seems to get worse the more online (non-AP) info you read!

I found Carlos Gonzales’ book to be so reassuring and yes, I agree with watch your child, not the plate. I just have to stop eating her leftovers now

Photo source: regalzam0ra on Flickr
©2009 Littlestomaks.com

Source: noe** on Flickr

According to a recent study that looked at data for over 10,000 children between the ages of 2 – 17 years old, you are more likely to give a vitamin and mineral supplement to your child if:

• your child is between 2 – 4 years old
• your child is underweight (BMI < 5th percentile)
• your child is in overall good health and has an active lifestyle
• you have good access to healthcare
• your household income is high
• you are a non-Hispanic White

On the other hand, you are less likely to give a vitamin and mineral supplement to your child if:

• your child is overweight (BMI >85h percentile)
• your child’s overall health is generally poor
• you do not have health insurance
• your child rarely drinks milk
• your household income is at or below poverty level
• you are a Mexican American,  or non-Hispanic African American

It is quite easy to draw a conclusion that children who do not really need supplements are actually more likely to be getting them, while those who may benefit from taking supplements are less likely to take them mainly because they are poor and come from a certain racial background. Here is a headline from a recent article “Kids who need vitamin not getting them while those who get them do not need them” which seems to echo the editorial commentary in the journal Archives of Pediatrics & Adolescent Medicine where the original article is published.

In my opinion, this is an over-simplification of the real situation. This study was based on the 1994-2004 National Health and Nutrition Examination Survey (NHANES) which is claimed to contain nationally representative data on comprehensive dietary supplement use in the United States. Intake of vitamin and mineral supplements in the NHANES database was measured by figuring out if the child had used any of these supplements in the 30 days prior to the interview. Looking at the pattern of vitamin use (or non-use) over just 30 days is not enough to draw a relationship between “health” and “need” of such supplements. The effect of diet and nutritional supplements on health is slow and takes place over the long term. If a child is “healthy” at the time of the interview, and taking supplements, it does not mean that he does not need them. On the same note, if the child is not “healthy” and not taking vitamin supplements, it does not mean that the family cannot afford them. In this regard, I do not agree with the authors of this study on the implications of race and poverty.

While it may be true that if a child is growing up in an affluent family with access to good health care, the parents are well-informed and are able to afford vitamin supplements. However, it is also possible that the child is overweight or not in good health despite the use of multivitamins and regular doctor visits.

In contrast, it may be true that a child growing up in a poor family may not be getting vitamins because they cannot afford them. However, it is also possible that the parents do not simply have the right information to make an informed decision regarding the nutrition and supplements for their children.

Does it mean that you should immediately stop using your current vitamin supplement for your child? Before you jump to such conclusions based on this study, you may want to consider the following -

• While it is always recommended that your child should get all the necessary minerals and vitamins from a balanced diet which includes plenty of fruits and veggies, you should consider using supplements – and continue using them – in certain situations. I have written about them previously in my post 5 Reasons To Consider A Multivitamin Supplement.
• Consult with your doctor, especially if your child is underweight or might be at risk of vitamin deficiency either due to eating habits or a health condition. You may need to switch brands or get a prescription for a pharmaceutical grade multivitamin.
• Continue introducing more fruits and veggies in your child’s diet while keeping him on a good multivitamin supplement.  As long as you do not exceed the recommended dose, or use a mega-vitamin, this should not do any harm. Encourage a good amount of physical activity every day and reduce TV watching and computer games. Keep an eye on his growth pattern and BMI by using a growth chart. Your doctor may advise you to stop or reduce the use of supplements based on the right changes in eating habits, lifestyle and growth patterns.

What is your opinion? Would you do anything differently as a result of this report?

Photo Source Inmagine.com

I have heard a variety of opinions from Moms through my Global Toddlers survey on the topic of nutritional supplements. Some are using them for their toddlers, while others are skeptical about their effectiveness. Personally, we have not used any multivitamin supplements for our twins so far, but we also think about it sometimes. So I decided to research this subject and thought about 5 reasons you may consider giving your child a daily dose of a multivitamin. I have relied heavily on two books, which I strongly recommend to all of you:

1. Dr. Spock’s Baby and Child Care, 8th Edition – The One Essential Parenting Book (Find on Amazon here)
2. Disease Proof Your Child by Joel Fuhrman, M.D. (Find on Amazon here)

If you are exclusively breastfeeding your child (0-24 months)

Breast is certainly the best and if you have made the decision to breastfeed your child, you should be congratulated. Breast milk provides all the necessary nutrients for your baby’s physical growth and brain development. It also builds a strong immune system which protects your child from disease later in life. However the actual amount of vitamins, minerals and other nutrients a child will get from breast milk depends on Mom’s diet and nutrition during pregnancy and while breastfeeding.

Breast milk contains very little vitamin D, and although you can compensate for it by supplementing your own diet or by having your child get some exposure to sunlight, it might be a good idea to consider a vitamin D supplement for your child. In fact, the American Academy of Pediatrics recommends that all exclusively breastfed infants and toddlers be given 200 IU vitamin D supplement beginning within the first 2 months after birth. Good nutrition and outdoor play is critical for avoiding vitamin D deficiency, which has recently been reported to be on the rise in infants and children.

If your diet is primarily vegetarian, you may also consider a vitamin B12 supplement for your child. Vitamin B12 is one of the 8 B vitamins needed for normal functioning of the nervous system and the brain, and for the formation of blood. It is only available from animal products such as meats, dairy and eggs.

Although breast milk contains a highly absorbable type of iron, the overall amount is low. If your diet is iron-deficient and if your child is not eating iron-fortified complementary foods (formula, cereals, baby foods), you may consider an iron supplement. Iron is very important for maintaining blood oxygen levels and brain development.

If your child’s diet is mainly vegetarian (2-5 years)

Raising your child on a meatless, low fat and mainly plant-based diet is now highly recommended by many nutrition experts and pediatricians. Such a diet has many positive health benefits over the long term. It is indeed possible to get all of the major nutrients from fruits and vegetables. Having said that, we realize that it is not easy to develop a 100% meat-free diet, nor do we think it is necessary. We do believe in reducing the overall meat consumption, particularly red meats. We try to eat only chicken and fish as much as possible, although sometimes we do make a few dishes with lean beef, and once in a while, we do relish some of our lamb recipes.

Vitamin B12 deficiency is a major risk for children on a vegetarian diet. Another risk could arise if they are eating only a limited range of veggies and not including lentils, beans and nuts in their diets. If this is the case, you should consider a multivitamin supplement for your child.

If your child is not eating enough fruits and vegetables (2-5 years)

By far, this is a major concern of most parents! Eating a variety of fruits and vegetables is absolutely essential for healthy nutrition. However, most parents struggle with their children as they try to encourage them to eat more fruits and vegetables. Why this is so, I do not know right now. I do intend to research this problem and think about it some more for future posts.

While you can try to make up for it by selecting so-called “healthy” (vitamin and mineral fortified) processed foods for your child, it is not really a good alternative. Be really careful about sugar, fat (particularly trans and saturated fat), cholesterol and sodium, which may be lost in the fine print on the carefully designed package. But most importantly, even though the processed food may contain all the right ingredients, usually their absorption by our body is not very good. Our digestive system has evolved over a very very long time to extract energy and critical nutrients from natural foods such as fruits and vegetables without overloading any of its critical organs. It is indeed a complex machinery! The science of food – even though great advances have been made in recent years – still is in its infancy. We can add minerals and vitamins to processed foods, but do we really understand how they interact with each other or what happens to them inside the human body? I do not think so.

If you find yourself in this situation, you can consider a multivitamin supplement. Driven by research, these supplements now are formulated to maximize absorption. Since these supplements are not yet regulated by the FDA, there may be huge differences in quality and risks of different brands. Always do your research and consult with your doctor for recommendations.

If you have a picky eater (2-5 years)

Having a picky eater on your hands is another common problem. Although in most cases, it is a behavioral and communication issue, it is possible that your child may have a strong aversion, or even allergies to certain foods. In most cases, the advice I have heard is to be patient and offer different foods to your child at different times. I like to call it a 5-times-5-ways approach, which involves introducing new foods (including fruits and veggies) slowly and in different forms so your child can begin to develop a taste for them on his own and at his own choosing.

The risk in this case is that your child does not get a balanced nutrition and she may develop a deficiency for certain essential nutrients. In fact research has shown that 65% of those who did not use supplements, and even 9% of those who used supplements, had vitamin E intakes of less than the Estimated Average Requirement (5 mg/day). And recently, there have been many reports of vitamin D deficiency in infants and toddlers.

A multivitamin supplement may be considered in this case. In the words of Dr. Spock, “one vitamin pill a day is preferable to fighting with your child to finish his vegetables or eat more raw food“.

If your child’s growth profile is slower-than-normal (2-5 years)

Sometimes you may feel that your child is too thin, or too short in comparison to other children of his age. Whatever you do, he just does not seem to be growing that much. It is a very natural for a parent to feel this way; however this is a very complex issue and you should not take any drastic steps without consulting with your Pediatrician.

Tracking your child’s height, weight and BMI (Body Mass Index) using growth charts is a good way to understand his growth pattern in comparison to a normal growth profile for children of his age. As I have written in my post 5 Things You Need to Know About Growth Charts, these charts are based on a large amount of data collected from various national surveys. You should not worry about a single data point on these charts if it happens to fall below the “50th percentile”, but you should look at the trend over a period of time to see how it looks in relation to the norm. With online tools, you don’t have to wait for your next doctor visit. Resist the urge to check it every week; a quick check every 5-6 months should be sufficient.

If after tracking the growth chart for your child you find that his growth is slower than normal, your doctor may suggest an appropriate diet and a nutritional supplement.

So you have decided to give your child a multivitamin supplement, now what?

Here are few things to keep in mind once you have made a decision to use vitamin supplements:

• Research the brand for quality; not all vitamin supplements are created equal!
• Read the label carefully and do not exceed the recommended dose. There can be dangerous side effects due to vitamin toxicity.
• Look for one without vitamin A – it can lead to loss of calcium in the urine. Instead rely on yellow/orange colored fruits and veggies which provide beta carotenes so that our body can make vitamin A at its own rhythm.
• It should not have more than 2500 IU of beta-carotenes; studies have linked high does beta-carotene supplementation to higher rates of cancer and heart disease.
• It should have the full spectrum of minerals, most importantly calcium, iron and zinc.
• No artificial colors, sweetners or flavors.
• Taste and form acceptable to your child. No use picking a fight over the multivitamin!

Do you use a multivitamin supplement for your child? Why? And what kind? Please share in your comments.

Do you find yourself wondering if your child is growing “normally”? Do you find yourself comparing your child’s height or weight with other children when you take her out to play in the park? Do you begin to make plans about how you will change her diet when your doctor informs you that she is below 50th percentile in weight for her age?

If so, you are not alone. It is a natural instinct for any parent to worry about the growth of their child. In my post on Take a Step on the MyPyramid for Preschoolers, I introduced you to how you could make a growth chart for your toddler based on his height and weight. In this post, I provide you more details and suggest a few actions for you to consider as you think about your child’s growth.

Growth charts are based on national population statistics

Data on physical measurements (weight, head circumference, length, standing height etc.) for children of different ages is collected from national surveys and analyzed using statistical methods to prepare the growth charts. These charts show lines for various percentiles, which are used as a reference for comparing the actual measurements. There are two limitations of this method that you should be aware of:

1. Just like the census, national health surveys are not done every year. In fact, the last National Health and Nutritional Examination Survey (NHANES III) was done during 1988 – 1994. This led to a revision of the 1977 growth charts in the year 2000. Amazing, isn’t it, that today’s growth charts are based on data that is 15 years old! Surely, a lot has changed since then.
2. Data is collected based on a “statistical sample”, which is supposed to represent the true nature of the whole population. Although there are some rules for estimating this “statistical sample”, no one can say with 100% confidence that it really represents everybody. In the interest of creating a “normal” growth profile, the researchers have to make some trade-offs and not include various special cases. It is important for you to be aware of what those special cases are. Your pediatrician should be able to advise you if you happen to be one of them.

Having said that, the current growth charts are still a very useful tool to evaluate the general growth pattern your child in relation  to what is normally expected. Recognize that the researchers do a very good job planning for a national survey to really “fill the gaps” in their current data and understanding. For example, in the NHANES III, they over-sampled infants and toddlers 2 months – 5 years old to properly account for the growth patterns in this age group. They also included a higher number of breastfed children to reflect the rising rates of breastfeeding compared to previous years. They utilized advanced statistical methods to create a better and smooth transition between infants/pre-schoolers and adolescents.

Growth charts are age and sex specific

Different measurements are made on infants (less than 36 months) and toddlers/adolescents (2 – 20 years). For infants, weight, head circumference and head-to-toe height is measured in a lying down position. The measured data is evaluated on these 4 types of growth charts:

1. Length for age
2. Weight for age
3. Head circumference for age
4. Weight for length

In most cases your pediatrician will show you the first two charts; usually blue for a boy and pink for a girl.

For toddlers/adolescents, weight and height is measured in a standing position. The measured data is evaluated on these 3 types of growth charts:

1. Weight for age
2. Stature (height) for age
3. BMI (Body Mass Index) for age

Again, your pediatrician will most likely show you the first two charts. However, the BMI for age is the most important chart in my opinion (see below)

Growth charts do not apply to preemies and other special cases

Data from very low birth weight (VLBW) is  not included in the infant growth charts since their growth patterns are known to be very different from higher weight, full-term infants. If this applies to you, there are other specialized growth rate charts you can ask your pediatrician about. The best general growth charts in this case are based on the the Infant Health and Development Program (IHDP) data, which can be used from 40 weeks to 36 months. It is not, however, without its limitations; so you should have a good discussion with your doctor.

Other special cases include health conditions such as Down syndrome, cerebral palsy and Turner syndrome. Special growth charts are available but again, they have many limitations.

Although, I did not find any discussion on the topic of multiples (twins, triplets etc.) I think that these too are special cases. Usually, multiples have low birth weight and do not go to full-term. Even though, the NHANES III data included low birth weight infants, I did not find any reference of categorizing data for multiples. Multiples may also show different growth patterns, where one of the child grows “normally” but the other(s) lag behind. It is my (selfish) hope that the next national survey will try to account for this gap.

Pay special attention to the BMI for age growth chart

Body Mass Index (BMI) is calculated using both weight and height. It is very easy, and you can use this online calculator simply by entering the age, weight and height. BMI is known to track very well with age, first increasing from birth to 8 months of age, then falling until age 6 and finally rising with age. There are two important things you can learn from the BMI chart with age for your child -

1. Percentile – Your child is at high risk of being overweight if the BMI is between 85th and 95th percentile for his age. If the BMI is over 95th percentile, then the child is considered overweight.
2. Trend in BMI for age chart – the sooner your child’s BMI hits its lowest number, the more likely he  is going to have a higher BMI percentile when he grows up, and greater is his risk of being overweight. Watch the trend in BMI for age over time closely and take action sooner than later.

BMI-for-age chart, Boys, >2 years old

Growth charts are used only as a screening tool

It is important to understand that growth charts are used only as a screening tool and not to diagnose a medical condition. The 5th percentile cut-off is useful to identify infants at risk of overall health and growth problems. The 95th percentile cut-off, especially on the BMI for age chart, is useful for early identification of childhood obesity. However, resist the instinct to be alarmed by a single point on these charts. You should look at a series of points over several visits to understand the overall pattern and assess if there is any unexpected change. If you have a concern, consider making these charts more frequently. With online tools, you don’t have to wait for your next doctor visit.

Take action

Here are 5 actions you can take:

1. Use information to manage your concerns and anxiety over what is a “normal” growth pattern for your child. Hopefully, this article is helpful; however there are a few more resources you can use to learn more about growth charts:
   • CDC’s growth chart website
   • Use and interpretation of growth charts – an instructional guide
   • Recommendations for growth references for VLBW infants
2. Resist the urge to make nutritional changes or goals based on a single data point on a growth chart.
3. If a single data point causes concern, track more often and then make a plan in consultation with your pediatrician.
4. Resist the urge to compare your child with others, or even with his own brothers/sisters. For example, two children with the same BMI could have very different risks based on their age.
5. Take a long term view to your child’s growth.

Feel free to share your personal experience and advice regarding growth charts.

You probably already know about the Food Pyramid from the USDA. What you may not know is that now there is a new version just for pre-schoolers (2-5 years old) called MyPyramid for Preschoolers. On this website, you can get a lot of useful information, all in one place. Check it out.

• You can make a customized MyPyramid plan for your toddler based on age, sex and level of physical activity. One problem is that the age selection is only in whole years, so if your toddler is say 2 and a half years old (like ours), you probably want to pick 3 years. Here is how it looks for our boy (Armaan) and our girl (Asya). It gives you details of how many calories and how much from each food group you should be feeding each day. Click the thumbnail for full size image.

• In the Grow Up Healthy section, you can prepare a growth chart for your toddler based on height and weight. This is what you get when you visit your Pediatrician. Now, you don’t need to wait the whole year before the next physical check-up to get this information. A growth chart can help you monitor the growth of your toddler and compare it to other children of the same age and sex. One word of caution – don’t get carried away by what you see on the chart. In my opinion, you should pay more attention to the overall growth pattern over time rather than a single point on this chart. Check out the What Influences Growth section that describes the factors that affect the growth patterns of preschoolers. Notice the value of nutrition and sleep! I would also add physical activity level in this section if I had my way. But then there is a separate section on that (see below).
• Under Healthy Eating Habits and Picky Eaters sections, you would find useful tips for developing good feeding habits at an early age. I was familiar with most of their advice on this section; one thing that caught my eye was their advice on how to cope with marketing and advertising on TV. It is a good read and I recommend it.
• Under Physical Activity there is good information on how much (60 minutes per day, does not need to be all at once), outdoor and indoor activities, and safety. The most important thing to remember is that you are a role model for them; therefore if you maintain an active lifestyle, they will learn to do so too.
• Very good tips for Food Safety regarding general hygiene, snacking, choking hazards, food handling and food preparation.
• There are also ideas for Sample Meals and Snacks (based on the recommended calorie level – first make the customized MyPyramid Plan) and More Information on food groups with examples of different types of foods and the serving size in each group.

Check it out and let me know what you think. Did you find anything new that you did not know before? Would you recommend it to your friends?