Happy New Year! Hope you all had a wonderful time with your loved ones over the Holidays.

I took a little break from blogging but now it feels great to be back! I am looking forward to continuing our journey in child nutrition in 2011, but first I would like to invite you to check out these top 10 posts of 2010 in terms of page views and comments. Some of them were written in 2009 and made the list then, but continued to attract interest in 2010. Science driven, yet practical, nutrition knowledge indeed can be timeless in some ways! Thank you for interest and support over these years.

Whether you are a brand new visitor – or a regular reader of this blog – I hope you will find them interesting and useful as you try to manage your growing child’s nutrition needs. Share your own experience, offer advice, or simply ask a question in your comments below. I would love to hear from you!

	Simple Recipes – Chicken with Quinoa   This is a very easy recipe to make! Quinoa, in my opinion, is the unrecognized superfood because it is a good source of protein and low glycemic index carbs. It also provides a good mix of vitamins and minerals.
	Milk Allergy and Ear Infections   Dairy allergy can be one of the underlying causes of recurring ear infections. This article by Jasmine Jafferali, MPH, explores this issue in a simple, yet practical, Q&A format.
	Ask the Expert – Sushi and Toddlers  If you are a sushi lover and you are thinking about introducing your toddler to sushi, you have got to read this informative piece from registered dietitian Janet Helm. She writes a great blog at Nutrition Unplugged with tons of excellent information about nutrition and food trends.
	All Natural Toddler Multivitamin   My review of Floradix Kinder Love Children’s Multivitamin Liquid Extract Formula attracted a lot of attention because it is based on herbal extracts and fruit juices. It claims to be easy on the child’s digestive system while providing vitamins A, B, C, D and E. It is not a good source of minerals.
	Looking for a Multivitamin Supplement?  This is a “mini” guide to toddler vitamin supplements on the market. If you are considering a supplement for your child, you can use a simple comparison chart in this post. Centrum Kids and Flintstones Complete offer a good balance of complete vitamins and minerals. But the most important advice is to rely on a balanced diet with plenty of fruits and vegetables.
	Product Reviews – Buddy Fruits  This is a simple fruit puree and makes a healthy snack when you are on the go. When we found it in our local supermarket early last year, it wasn’t as commonly available as it is now. Can be a little messy for small children, but overall not a bad choice for a quick snack.
	Basmati Rice: It is Very Easy to Cook and You Will Love It’s Flavor and Fragrance  We love basmati rice! It is an excellent source of low glycemic index carbohydrates. Try my simple recipe to cook it as a separate side dish. You can also try some of the links in this post for other great recipes.
	Simple Recipes – Pasta with Spinach and Mushrooms  This is a simple variation of our recipe Chicken with Pasta and Vegetables. It hardly takes any time to prepare and we save it for those hectic days when we have to quickly put something together for dinner.
	Traffic Light and Food Labeling  Clearly, consumers want simple and easy to understand front of the box food labels. FDA is worried about accuracy and manipulation by the food industry. A traffic light based food labeling system is gaining popularity in UK and Australia. It is not perfect, but clearly a step in the right direction.
	Milk Choices for Toddlers   Registered dietitian Jill Castle offers an overview of several different milk choices for toddlers in case cow’s milk is a concern. Jill blogs about child nutrition at Just the Right Byte.

Web statistics are surely important, but here are a few of my personal favorites. I hope you will check them out and leave me a comment with your opinion!

1. Surprising easy solution for preventing childhood obesity
2. How worried should you be about your underweight child?
3. Do children need more vitamin D?
4. Nutrition trivia – 10 facts to know about protein
5. Resting metabolic rate and weight management

©2011 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.

We often hear about overweight and obesity in children, but underweight, or slow weight gain can also be a cause for concern.  This week, Registered Dietitian Amy Braglia-Tarpey discusses the importance of including healthy fats in your child’s diet to manage the challenge of underweight.

Amy Braglia-Tarpey, MS RD B.A. in Psychology from the University of Arizona M.S. in Nutritional Science from California State University, Long Beach Registered Dietitian, Certified Nutrition Support Clinician,  and Board Certified Specialist in Renal Nutrition Worked as a clinical dietitian at Salinas Valley Memorial Hospital , with over 10 years of experience working in the field of nutrition Expert in nutrition support and nutrition for Chronic Kidney Disease Twitter: @RD4Change LinkedIn Profile Contact via email – ATarpeyRD@gmail.com

Question: I have a very underweight toddler. What are the best ways to add calories to food? I am often told to add cream, olive oil, or butter, but that just doesn’t seem healthy.

Answer:

Many parents are concerned about the quantities and amounts of fats their children are consuming.  Fear of fat has been instilled in us due to recommendations by the American Heart Association to reduce total fat, saturated fat, and cholesterol in our diets.  However, this advice is meant for adults, and is currently under scrutiny as research provides new information about the roles of different fats in our health.  Children require more fat in their diets than adults to support growth.  Moreover, the type of fat is more important than the overall quantity in most cases.  In pediatric underweight, adding calories for growth is extremely important.  Because fat provides more calories per gram than carbohydrate or protein, adding more to the diet is the most efficient strategy to promote weight gain.

In humans, fats are essential for building the membranes of cells.  In childhood, a balance of saturated, polyunsaturated, and monounsaturated fats is necessary to give new cells structure.  Without any one of these components, cell membranes can become too rigid or weak.  Therefore, some quantity of each of these types of fats should be provided by the child’s diet.

While it is true that the majority of calorie additions should come from monounsaturated and polyunsaturated fats, saturated fats in moderate quantities can add calories as well as palatability.  Monounsaturated fats are found primarily in plant oils, although meat fats contain some as well.  Olive and canola oils, avocado, and almond butter are good sources of monounsaturated fat.  Most polyunsaturated fats come from plant oils as well, and appear in the largest quantities in vegetable oils such as soybean oil.  Another type of polyunsaturated fat, Omega-3 fatty acids, are abundant in fish and marine oils, as well as flaxseed and walnuts.  Saturated fats in the diet come mostly from meats and dairy, although smaller amounts are present in vegetable oils.

Adding calories to aid in weight gain can be quite challenging.  Some calorie-dense foods are not well-tolerated by children, and some are rejected due to individual tastes.  If there is an underlying disease or condition that is preventing weight gain, it may be difficult to find calorie additions that adhere to the restrictions of the child’s diet.  Here are some suggestions for healthful calorie additions:

• Avocado- Add to sandwiches, wraps, and soups.  Spread on toast as you would butter, or make guacamole as a dip for veggies, crackers, and bread.
• Almond or peanut butter- Add to hot cereals such as oatmeal.  Use instead of butter when making cookies, spread on bread or crackers.  Freshly ground flaxseeds can also be mixed into cereals.
• Stir extra olive oil or canola oil into soups.  Canola oil has a neutral flavor and can be added to most cooked as well as baked goods.
• Drizzle olive oil over fish, chicken and pork.   Add olive oil to pastas, sweet potatoes, and other side dishes.  Make pesto, a calorie-dense blend of olive oil, nuts, and herbs (cheese optional).
• Cheese is a great source of protein, calcium, and phosphorus, as well as calories.  Kids love it!  Try string cheese for snacks, and stir cheese into casseroles and dips.  Melt it over eggs and vegetables.

Choose the majority of calorie additions each day from the above groups.  Cream may also be used, but with greater moderation.  ¼ cup of heavy cream supplies 200 calories, with one third of its total fat provided by mono- and poly-unsaturated types.  Use to add calories to cereals, soups, casseroles, and scrambled eggs.

What has worked for you? Share your experience in comments below.

©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.

In response to last week’s article How Worried Should You Be About Your Underweight Child, Cara shared her struggle with her son’s slow growth and weight gain due to gastroparesis. In her comment, she explained that it means delayed gastric emptying which keeps her son’s stomach full so he never feels hungry. This obviously leads to malnutrition and poor weight gain.

I did some research on this topic because I did not know anything about it. In this article I want to share a few facts and links to several good resources with you:

1. Gastroparesis results from damage to the vagus nerve which controls the movement of food from stomach to the intestines.
2. Typically, this condition is seen in people with Type 1 or Type 2 diabetes. However, there are many cases where the exact cause is not known. Cara’s son, unfortunately, happens to be in this situation where the cause cannot be determined even after extensive medical tests.
3. Gastroparesis can also be caused by surgery in the stomach area, viral infections, several medications, bulimia, gastroesophageal reflux disease (GERD), nervous system diseases and metabolic  disorders.
4. It can be acute or chronic. Symptoms include heartburn, nausea, vomiting, weight loss, pain in the abdomen, irregular blood glucose levels, lack of appetite, feeling of fullness and reflux. Lately, there is a recognition that the diagnosis of gastroparesis be reserved for patients where it is prolonged and grossly delayed. Symptoms in many cases are modest and temporary.
5. New techniques for evaluation of symptoms are now available, including the SmartPill GI Monitoring System. Medications are also available – talk to your doctor if you are concerned about these symptoms.
6. Other treatment options include dietary changes in terms of amount, frequency and type of food. Avoiding high fat and high fiber foods may help. Talk to your doctor or dietitian before making any changes.
7. In extreme, and very unfortunate, situations a feeding tube may need to be used. The feeding tube bypasses the stomach to deliver nutrients and medications directly to the small intestine. In some other cases, liquid nutrients may need to be directly injected into blood bypassing the digestive system entirely.

Here are a few good links for further reading:

Gastroparesis - a 6-page primer from the National Institute of Diabetes and Digestive and Kidney Diseases
Living with diabetes and gastroparesis – American Diabetes Association
gastroparesis-prevalence – article from Canadian Journal of Gastroenterology (warning: very technical!)
Overview and treatment options at the Mayo Clinic
Resource page on Cara’s blog

Please feel free to share your own experience if you or someone else in your family and friends is facing this unfortunate situation.

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 new 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 Milton Stokes offers his thoughts on a common concern of many parents who worry that their child is not eating enough.

Milton Stokes, MPH, RD BS in Nutrition and Dietetics Registered Dietitian,Yale Masters of Public Health, Hunter College 10 years in Clinical Nutrition Website:One Source Nutrition Twitter:@Miltonstokes LinkedIn Profile Contact: via website

Question: My child is underweight. How can I get him to eat more?

Answer:

Underweight could be related to medical problems or just to a restricted diet. Either way, I make sure each pediatric patient’s growth is charted on a growth chart.  We need to monitor trends and patterns. Sometimes underweight really isn’t a problem; trending positively in the right direction matters more.  Provided there are no medical abnormalities, then we can quite simply address diet.

What parent hasn’t experienced concern and frustration when a toddler doesn’t eat what we think they should eat.  But take note: A little one’s ability to regulate dietary intake is in fact as close to perfection as it’ll ever be for his entire life. Yes! They may not finish everything on their plate or eat their cruciferous veggies.  This is normal.  Children are true experts at regulating their intakes: one meal might be scant; another quite large. The result is ideal balance.  Overall intake is what matters most.  It’s not until well-intentioned adults (i.e., grandparents?) who interject insisting a child clean his plate that problems arise.  This teaches the child to override his inherent ability to regulate dietary intake.  In my practice, I insist families eliminate membership in the Clean Plate Club.  Eat when hungry; stop when full.

Another consideration for a child’s eating pattern is that introducing new, unfamiliar foods takes time and patience.  Research and my professional experience confirms that what a parent does—role modeling during meals—is the most important way to encourage healthful eating.  Avoid food fights and food struggles.  Gentle episodes of exposure to new foods—as many as ten or more separate occasions—may be required to successfully expand a child’s intake.

Happy eating!

©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.