There are days, when as a parent, you feel on the top of the world! You cherish the smiles and funny faces of your kids in your photos and home movies. You pour your heart out, and perhaps your wallet, as you try to pick a gift for them during the Holidays. And you love their cute comments which seem to come out of nowhere at just the right time.

Then there are days, when nothing seem to go right. Your kids refuse to eat what you prepare for them. When all you hear is a big NO out of their mouth for everything you ask them to do. When you have to deal with a terrible tantrum in a public place with everyone else looking at you as if you are the worst parent on the face of the earth!

“Children don’t come with an instruction manual”, writes Dr Kathleen Cuneo in her new workbook for parents of toddlers and preschoolers called Empowered Parenting. She was kind enough to send a copy for me to review. Kathleen is the founder of Dinner Together, a website devoted to helping parents build healthy families one meal at a time. She has successfully used the power of family meals for raising kids with healthy eating habits.

Parenting is not easy, yet it often appears that everyone but you have figured it out! Parenting is also one of those topics you are likely to get a lot of unsolicited advice. Everyone but you seem to know how to raise your kids these days. This workbook will definitely empower you make your own game plan so you can simply smile off these unsolicited tips!

This is a workbook, which means you need to do some work! I am only half-joking because this is exactly why I like it so much. She does not offer a cookie-cutter formula or a set of “rules” which will magically solve your parenting problems. Rather, she walks you through 3 simple principles using worksheets, questionnaires and practical tips. The 3 focus areas for you to work through are:

1. Knowing yourself
2. Knowing your child
3. Communicating effectively

The exercises under the first point of “Knowing yourself” will help you figure out your parenting style,  help you articulate your expectations and make you aware of your hot buttons. You will learn how to become more aware of yourself, your strengths and blind spots. If you do it right, you will feel more confident in your approach to parenting and not get distracted by others.

Knowing your child is equally important because each child is unique and develops at his or her own pace. Quite often, parents feel the anxiety of missing the so called standard growth milestones. They compare their child with others in the park and begin to wonder if they should be doing something else. Unless there are medical issues, it is important to accept your child’s growth pattern as completely “normal”. The exercises in this section will help you identify your child’s individual strengths, emotional responses and reactions to new environments. They will also help you understand the triggers for bad behavior and motivators for good behavior. Again, if you do it right, you will be able to brush off outside advice about how you should handle your child’s behaviors.

The final section will help you  match your style to your child’s temperament and personality so you can communicate effectively. The keyword is “effectively”, because the goal should be to motivate your child to develop the positive behavior you desire. Dr Cuneo provides many examples of specific situations where you can exercise the tools of effective communication. It is not just what is spoken, it is also the body language and emotional expressions that matter. She also addresses the subject of rewards and how you should use them to motivate these behaviors.

In the final chapter, she offers tips for promoting healthy sibling relations and managing conflicts.

One thing I wish Dr Cuneo had emphasized in this workbook is that parenting is a team sport. Traditionally moms have done the heavy lifting when it comes to raising young kids. However, the times are changing and dads are beginning to get more involved. Naturally dads have a different approach, which at times, may seem at odds with a mom’s approach. It is important to have a good understanding, and acceptance of these differences in parenting styles so you don’t find yourself playing the good cop/bad cop with your kids. Having said that, there is no rule that you should do the exercises in this workbook alone.

A suggestion for the next update of this workbook would be to include a few specific exercises aimed at understanding your partner’s style and developing a common plan of action.

Overall, this workbook is worth the investment of your time. The good news is that Dr Cuneo is offering a huge discount for a limited time. Check out the offer for the workbook and other products on her website.

©2011 Littlestomaks.com

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.

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.

Wall Street Journal reported last week that sales of children’s supplements in 2008 were around $1.1 billion and growing at 4-6% each year. This is the first time data is available for kids supplements, although there is little doubt that multivitamins and mineral supplements are a big business. Just look at the amount of space they occupy on the shelf at a typical supermarket!

I am sure the question has come to your mind – should you give your child a supplement?

The position of the American Dietetic Association, which I agree with completely, is that food should be the primary source of vitamins and minerals your child needs. In general, it is very unlikely that your child has a strong need for additional supplementation even if he is a picky eater or does not seem to eat enough fruits and veggies! The Wall Street Journal article cites a study of 1847 pre-schoolers in Belgium which suggested that both supplement users and those who did not take them were often meeting their nutritional needs through food alone with the exception of vitamin D.

Having said that, there are situations where you do want to discuss the subject of supplements with your pediatrician. In 5 Reasons To Consider A Multivitamin Supplement, I wrote about a few of these situations:

1. If you are exclusively breastfeeding (0-24 months)
2. If your child’s diet is primarily vegetarian (2-5  years)
3. If your child does not eat enough fruits and veggies (2-5 years)
4. If you have a picky eater (2-5 years)
5. If your child’s growth profile is slower than normal (2-5 years)

The keyword here is consider - which means you should research this option and bring it up for discussion with your pediatrician or dietitian. Some experts believe that a majority of children today need some kind of supplementation, most frequently vitamin D, probiotics and omega-3, to fully optimize their nutrient intake. That may or may not apply to your child. It is very important to look at your child’s health history and growth profile over a long period of time. Just because he has become a picky eater over the last few weeks and does not eat any fruits and veggies is not enough of a reason to jump on the supplements bandwagon!

There is another aspect to supplement use. I wrote about another study of over 10,000 children 2-17 years old which concluded that kids who really need vitamins don’t get them. The point was that children from affluent households with a fairly good health profile were the biggest consumers of supplements.

In other words, parents are giving supplements to their children just in case and that they do not think there is any risk. Clearly, supplement makers focus on this behavior with their marketing and product mix. The problem is that there can be a downside if you are not careful. Here are a few possibilities -

1. Risk of overdose, particularly vitamin A which can cause liver problems and lower bone density
2. Overdose of iron can be fatal
3. Zinc overdose causes copper deficiency which can cause anemia (low red blood cells)
4. Poorly balanced formulation with respect to your child’s needs
5. One product containing high amount of selenium caused vomiting and diarrhea
6. Unknown impurities, sugar, artificial colors

The fact remains that unlike pharmaceuticals, nutritional supplements are not rigorously regulated by the FDA. Some rules do exist and the FDA has the power to force product recalls, but it is only when there is a reported problem. As a result, a few bad products actually manage to slip through the cracks.

Bottom line: Treat vitamins and other supplements like drugs and use them only after consulting with your doctor. Choose a quality product with high purity ingredients (look for the USP seal).

Are you using a supplement with your child? Share your reasons and the type of supplement in comments 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.

This week, Registered Dietitian Nour El-Zibdeh offers tips for getting enough iron from a vegetarian diet without relying on supplements.

Question: How can I ensure enough iron if my child is on a strict vegetarian diet?

Answer:

Iron is important for health. It is part of hemoglobin, a protein found in red blood cells, and its main role is to transfer oxygen to body tissues and cells.

Too little iron causes fatigue, decreased immunity, and may impair psychomotor development in infants.  Iron deficiency occurs due to three general reasons:

1. increased needs of iron (growth),
2. decreased absorption (iron in the diet comes from sources that are not easily absorbed, such as plant foods),
3. decreased iron intake (low total food intake).

The prevalence of iron deficiency in the United States is low. However, toddlers are at a high risk because they don’t drink or eat iron-fortified formula or cereal anymore, and their intake of iron-containing foods may still be low. Toddlers who are on vegetarian diets, drink more than 24 ounces of milk a day, or suffer from decreased availability of food are at an increased risk.

Type of iron in the diet

There are two types of iron in the diet, heme and non-heme. Heme iron comes from animal sources and is the most easily absorbed. Non-heme iron is the most prevalent in food, found in both animal and plant sources, but its absorption is less efficient and can be influenced by many factors.

When discussing plant sources of iron, two points must be distinguished. First, the amount of iron in plant foods, and second, the amount that is actually absorbed. For example, half cup of soybeans has 4.5 mg of iron, but the fiber and protein in soybeans prevent its absorption. Half cup of tomatoes, on the other hand, has 1 to 2 mg of iron but is easier to absorb.  Vitamin C improves the absorption of iron, while phytates (in bran and whole grains), oxalates (in spinach, rhubarb, strawberries, nuts, chocolate, and wheat bran), polyphenols (in coffee and tea), calcium, and fiber prevent its absorption.

Tips for vegetarian toddlers

1. Offer a variety of plant foods, especially those high in vitamin C. These include guava, lemon, orange, papaya, tomatoes, beetroot, broccoli, cabbage, cauliflower, pumpkin, and turnips.
2. Choose iron-fortified cereals and grains when possible.
3. If you are interested in numbers, toddlers one to three years old need 7 mg or iron a day, and toddlers over four years old need 10 mg a day. Since iron in plant foods is not absorbed entirely, aim for more than the recommended amount from plant foods, not supplements. Here are some foods rich in iron.
4. Don’t give your toddler more than 24 ounces of milk (cow, goat, or soy) a day. Milk is low in iron and high in calcium (prevents iron absorption), and too much can be filling causing your child to be uninterested in other iron-containing foods. Too much cow’s milk can also irritate the gastrointestinal tract and cause bleeding, which will lead to iron losses.
5. Don’t stress about iron deficiency unless your child shows symptoms, which include fatigue and weakness, pale skin, mucous membranes, rapid heartbeat, irritability, decreased appetite, dizziness, or feeling lightheaded.
6. Consult with your pediatrician if you suspect deficiency, and don’t give your child iron supplements on your own. The human body doesn’t have a way to get rid of excess iron, so too much can be toxic and cause organ damage.

©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.

This is a guest post by Jan Gambino, author of Reflux 101 and an expert in infant/toddler acid reflux, feeding disorders, special needs and parents education. She writes at RefluxMom.

Picky eating is common and often occurs during the toddler years. After the intense growth and the seemingly easy going attitude about eating and drinking during the first year, the average toddler will often have a slower rate of growth and become more opinionated about what she eats and when.

Picky Eating May Include

• Eating a limited variety of foods.
• Avoiding one or more food groups such as: dairy, vegetables or fruits.
• Craving Carbohydrates such as crackers, bread, pasta.
• Requesting a particular type of food (for example: a child who will only eat French Fries from the local fast food restaurant or Brand X frozen chicken nuggets from the food store).
• Showing displeasure or having a tantrum when a new food is presented.
• Crying or refusing to eat when the favored foods are not available.

For more information about this normal stage, read my previous post about coping with picky eating.

Beyond Picky

A few children have significant difficulty eating a variety of foods and these worrisome symptoms needs to be discussed with the doctor. If your child has many or all of the symptoms of picky eating plus any of the concerns listed below, it is time to schedule an appointment with the doctor.

Worrisome symptoms that need to be discussed with the doctor

• Slow weight gain.
• Weight loss.
• Extremely limited diet that may lack key nutrients.
• Tantrums, fussiness or crying at meals or when food is presented.
• Fearful about eating or when food is presented.
• Choking, coughing or gagging when food is presented or when eating.
• Immature feeding skills (for example: eating pureed food only beyond infancy).

A toddler may be picky or beyond picky like my daughter due to a medical condition such as gastroesophageal reflux disease (GERD). A food allergy, food intolerance or a digestive condition such as GERD, Celiac Disease, Lactose Intolerance or another condition may cause eating and digestion to feel uncomfortable or painful. A child may try to “fix” this problem by avoiding foods or food groups or even limiting intake. Other causes of extremely picky eating include: sensory issues (textures, temperatures and flavors cause discomfort) or an oral motor problem such as a swallowing disorder, aspiration or poor muscle tone. In addition, a learned pattern of eating or adapting to digestive discomfort may lead to behavioral issues. Sometimes a behavioral reaction to eating (turning away, crying) may occur due to an undiagnosed medical condition. It is always best to work with your child’s doctor to look at medical and behavioral causes of picky eating and developing a treatment plan together.

©2010 Littlestomaks.com

Eating too many sugary foods is now believed to be one of the main reasons behind our obesity problem. But can it also weaken your immune system?

Some experts such as Dr Sears believe that excess sugar decreases immunity. I was intrigued by this notion so I decided to research if there was any scientific basis for it. One commonly cited study was published way back in 1973 in the American Journal of Clinical Nutrition. In this study, researchers found that when volunteers took about 100 g of sugar, the infection fighting cells in their blood were less effective in killing bacteria. Not much has been published on this topic since then, but this belief about the role of sugar in compromised immunity still persists.

No doubt, there are many harmful effects of excess sugar. It may be that poor immunity results from overall poor health, not simply because of consuming too much sugar. If you want to make sure your child develops a good resistance to infectious diseases, follow these time-tested advice:

• Balanced diet, rich in fruits and veggies (see tips)
• Play-nutrition-rest
• Reduce meat consumption
• Multivitamins if needed (see when to consider a multivitamin)

And if you are struggling with a sugar problem, here are a few tips on how to shake off a sweet addiction!

©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.

This week, Registered Dietitian Victoria Retelny explains why omega-3 is important for growing children and suggests a few food sources of these essential fatty acids.

Question: Is Omega 3 proven to be helpful for children? Can you recommend a few good sources and brands of Omega 3?

Answer:

Yes, omega-3 fatty acids, particularly docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA), which are found in breast milk, are beneficial for children’s normal growth and development.  For infants, DHA has been found to be vital for visual and brain function and development.  Some research has shown these essential fats to help children with attention deficit & hyperactivity disorder (ADHD). As children grow into adults, there is evidence that omega-3s are a great way to keep the heart healthy, too.

As always, food sources should be the first choice for your child’s diet.  Omega-3 fatty acids come from two sources: plant foods like walnuts, flaxseeds, tofu, soybeans, and canola oil, which contain alpha-linolenic acid (ALA) and fatty fish, which contain both DHA and EPA.  Some of the best fish sources of omega-3s are salmon, albacore tuna, lake trout, mackerel, and herring.  Since some fish can be high in mercury and other contaminants, there are limits to how much children (and adults) should eat.  According to the U.S. Food and Drug Administration (FDA) and the Environmental Protection Agency, up to two average fish meals or 12 oz per week – is safe for children.  Since albacore tuna is higher in mercury than chunk light tuna, limit the serving to 6 oz. per week.

The types of fish that children (and adults) should avoid due to high mercury levels:

• Shark
• Swordfish
• King mackerel
• Tilefish (Golden bass)

The Dietary Guidelines for Americans 2005, advise people to check local advisories to learn about the safety of fish caught in nearby local lakes, rivers, and coastal areas. Advisories may recommend that people limit or avoid eating some types of fish caught in certain places. If no advice is available, young children may eat up to 1 meal per week of fish from local waters, but no other fish during that week.

The U.S. dietary supplement market is exploding with omega-3 capsules. Use caution, particularly with young children, when giving supplements – of any type.  Dietary supplements are not regulated by the federal government.  According to the FDA’s Web site, supplements ingredients may be reviewed for safety, but not effectiveness.  The ultimate responsibility for product safety is on the manufacturers and distributors before the supplements reach store shelves. The FDA will step in if products are found to be unsafe or if they contain false or misleading claims.

So what are good sources of omega-3s for children?  The best sources are fish and “designer” foods like omega-3 fortified cereal, yogurt and eggs.  Although, a recent article in Journal of the American Dietetic Association states that there is no specific recommendation for EPA and DHA individually right now, the need to get a balanced diet that includes essential fatty acids like omega-3s is important, particularly for growing children.  As always, consult a physician before giving fish oil capsules to children under 18 years old.

References:
Kris-Etherton P, Hill AM.  n-3 fatty acids: food or supplements?  J Am Diet Assoc (2008):108(7);1125-1130.

US Food and Drug Administration, Dietary Supplements: What You Need to Know.

Omega-3 fatty acids, fish oil, alpha-linolenic.  The National Institutes of Health, Medline Plus.

Dietary Guidelines for Americans. MyPyramid for Preschoolers.

©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.

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.