INTRODUCTION OF COMPLEMENTARY FOODS

Category

Child Nutrition

 

 

1. INTRODUCTION OF COMPLEMENTARY FOODS. Practice exclusive breastfeeding from birth to 6 months of age, and introduce complementary foods at 6 months of age while continuing to breastfeed.

 

2. MAINTENANCE OF BREASTFEEDING. Continue frequent, on-demand breastfeeding until 2 years of age or beyond.

 

3. RESPONSIVE FEEDING. Practice responsive feeding, applying the principles of psychosocial care. Specifically: a) feed infants directly and assist older children when they feed themselves, being sensitive to their hunger and satiety cues; b) feed slowly and patiently, and encourage children to eat, but do not force them; c) if children refuse many foods, experiment with different food combinations, tastes, textures and methods of encouragement; e) minimize distractions during meals if the child loses interest easily; f) remember that feeding times are periods of learning and love - talk to children during feeding, with eye

to eye contact.

 

4. SAFE PREPARATION AND STORAGE. Practice good hygiene and proper food handling by a) washing caregivers’ and children’s hands before food preparation and eating, b) storing foods safely and serving foods immediately after preparation, c) using clean utensils to prepare and serve food, d) using clean cups and bowls when feeding children, and e) avoiding the use of feeding bottles, which are difficult to keep clean.

 

5. AMOUNT OF COMPLEMENTARY FOOD NEEDED. Start at 6 months of age with small amounts of food and increase the quantity as the child gets older, while maintaining frequent breastfeeding. The energy needs from complementary foods for infants with "average" breast milk intake in developing countries are approximately 200 kcal per day at 6-8 months of age, 300 kcal per day at 9-11 months of age, and 550 kcal per day at 12-23 months of age. In industrialized countries these estimates differ somewhat (130, 310 and 580 kcal/d at 6-8, 9-11 and 12-23 months, respectively) because of differences in average breast milk intake.

 

6. FOOD CONSISTENCY. Gradually increase food consistency and variety as the infant gets older, adapting to the infant’s requirements and abilities. Infants can eat pureed, mashed and semi-solid foods beginning at six months. By 8 months most infants can also eat "finger foods" (snacks that can be eaten by children alone). By 12 months, most children can eat the same types of foods as consumed by the rest of the family (keeping in mind the need for nutrient-dense foods, as explained in #8 below). Avoid foods that may cause choking (i.e., items that have a shape and/or consistency that may cause them to become lodged in the trachea, such as nuts, grapes, raw carrots).

 

7. MEAL FREQUENCY AND ENERGY DENSITY. Increase the number of times that the child is fed complementary foods as he/she gets older. The appropriate number of feedings depends on the energy density of the local foods and the usual amounts consumed at each feeding. For the average healthy breastfed infant, meals of complementary foods should be provided 2-3 times per day at 6-8 months of age and 3-4 times per day at 9-11 and 12-24 months of age, with additional nutritious snacks (such as a piece of fruit or bread or chapatti with nut paste) offered 1-2 times per day, as desired. Snacks are defined as foods eaten between meals-usually self-fed, convenient and easy to prepare. If energy density or amount of food per meal is low, or the child is no longer breastfed, more frequent meals may be required.

 

8. NUTRIENT CONTENT OF COMPLEMENTARY FOODS. Feed a variety of foods to ensure that nutrient needs are met. Meat, poultry, fish or eggs should be eaten daily, or as often as possible. Vegetarian diets cannot meet nutrient needs at this age unless nutrient supplements or fortified products are used (see #9 below). Vitamin A-rich fruits and vegetables should be eaten daily. Provide diets with adequate fat content. Avoid giving drinks with low nutrient value, such as tea, coffee and sugary drinks such as soda. Limit the amount of juice offered so as to avoid displacing more nutrient-rich foods.

 

9. USE OF VITAMIN-MINERAL SUPPLEMENTS. Usually fortified complementary foods or vitamin-mineral supplements for the infant are not required. In some populations, breastfeeding mothers may need vitamin mineral supplements or fortified products, both for their own health and to ensure normal concentrations of certain nutrients (particularly vitamins) in their breast milk. [Such products may also be beneficial for pre-pregnant and pregnant women].

 

10. FEEDING DURING AND AFTER ILLNESS. Increase fluid intake during illness, including more frequent breastfeeding, and encourage the child to eat soft, varied, appetizing, favorite foods. After illness, give food more often than usual and encourage the child to eat more.

Nighttime Feedings: Phasing Them Out

The first weeks with a newborn are extremely demanding. You need to feed your baby every 1 and 1/2 to 3 hours. Her voracious appetite makes any schedule impossible. You'll be up for feedings at least twice each night. However, when your baby is 1 month old, you can start to shape her feeding behaviors.

How can I help my baby give up middle-of-the-night feedings?

• After your baby is 2 weeks old and your milk supply is in, don't feed your baby more often than every 2 hours. More frequent daytime feedings (such as hourly) lead to frequent awakenings at night. For every time you nurse your baby, there should be 4 or 5 times that you snuggle your baby without nursing. Don't let her get into the bad habit of nursing every time she fusses (called comfort nursing).
• Put your baby in the crib drowsy but partially awake. Her last waking memory needs to be of the crib, not of the breast or bottle. If she learns how to put herself back to sleep, she will not cry after normal awakenings. She will cry at night only if she's hungry, sick, or uncomfortable.
• Make middle-of-the-night feedings brief and boring. Don't turn on the lights or talk to your baby. Feed your child quickly and quietly. During the day you can provide extra rocking and playtime.
• Take naps during the day when your baby is napping. This will help you survive the nighttime demands. You may need to lower your housekeeping standards.

With this approach and a little luck, your bottle-fed baby will give up middle-of-the-night feedings between 2 and 4 months of age. Your breast-fed baby will do the same between 4 and 6 months of age.

Weaning from Breast to Bottle

When should I begin weaning?

If you need to or want to stop breast-feeding, it is best to wait until your baby is at least 4 weeks old. If you are going to use breast milk in the bottles instead of formula, it is best to wait until your baby is at least 4 weeks so that your milk supply is well established and you can effectively pump your breast milk.

If your baby is older than 9 months, he or she is probably ready to wean straight to a cup rather than to a bottle.

How much and how often should I feed my baby?

The amount of formula or breast milk that most babies take per feeding (in ounces) can be calculated by dividing your baby's weight (in pounds) in half. For example, if your baby weighs 8 pounds, your baby will probably drink 4 ounces of milk per feeding. No baby should drink more than 32 ounces of milk a day. If your baby needs more than 32 ounces and is not overweight, consider starting solid foods. Overfeeding can cause vomiting, diarrhea, or excessive weight gain.

Babies generally need:

• 5 to 6 feedings per day for 1 to 3 month old babies
• 4 to 5 feedings per day for 3 to 7 months old babies
• 3 to 4 feedings per day from 7 to 9 month old babies

If your baby is not hungry at some feedings, increase the time between feedings.

If you are using formula:

• Be sure to watch carefully how your baby tolerates the formula. Look for rashes, spitting up, and/or bowel problems. If any appear, you should ask your doctor and ask if you need to change formulas.
• Use iron-fortified formula until the baby is at least 1 year old to avoid iron-deficiency anemia.

If you are using breast milk:

• Make sure you have enough breast milk pumped for each bottle feeding and that you store and warm the milk properly.
• Pump your breasts around the time you would have nursed your baby. That way you can maintain a good supply of milk.

How do I wean my baby?

• Take your time: Plan ahead and give yourself and your baby plenty of time. Gradual weaning gives your baby time to adjust. It also allows your milk supply to diminish gradually and saves you from engorged breasts. Some mothers experience a mild depression when weaning as a result of changes in hormones related to their milk production. This is especially likely to happen if the weaning is done too quickly.
• Hold your baby: Hold and cuddle your baby while giving him a bottle. Try to make bottle feeding as warm and comfortable as nursing was. Don't prop your baby up with a bottle in an infant seat and leave. Bottle feeding also gives the fathers, brothers, and sisters a chance to feed and relate to the baby and it spreads out the work!
• Eliminate 1 feeding at a time: The speed of weaning will depend on your baby. In general, however, it is best to substitute the bottle for one nursing session at a time. After you have replaced a nursing session with a bottle, wait 5 to 7 days. Then, if the baby is adjusting well, substitute a bottle for another nursing session. The early morning and late evening nursing sessions are usually the most difficult for your baby to give up. Wean the baby from these last. You will soon learn which feedings are your baby's least favorite and when his appetite is generally lowest. Replace these nursings first.

If your baby is taking a daily total of 16 to 20 oz. of milk by cup, in addition to 3 meals of solid food, he can be considered successfully weaned.

What if my breasts become engorged?

If your breasts become engorged because you are not nursing as much, allow your baby to suck 15 to 30 seconds from each breast to relieve your discomfort. Make sure that you don't nurse any longer, however, or you will trigger your breasts to produce more milk and the engorgement will get worse.

What if my baby resists the bottle?

Your baby will probably resist at first. Stay calm and go slow. Touch the baby's lips with the nipple. Do not force the nipple into her mouth. Let your baby draw the nipple in. If your baby is not upset by the bottle, you can move the nipple into the mouth further.

You may want to try putting breast milk in the bottle at first before trying formula. Your baby may not be as resistant to a familiar drink.

Choose a time to introduce the bottle when your baby is slightly hungry and will be more willing to try. Do not try the bottle when your baby is very hungry because he is likely to become upset and frustrated.

Do not spend more than 10 minutes at a time trying the bottle so you and your baby do not get too frustrated.

What if I have problems with weaning?

Setbacks in weaning can be caused by many things, including stress, major changes in meal or bed times, or illness. If such setbacks occur, wait until the situation improves or the illness is over, and then continue the weaning process. Call your baby's doctor if you have any questions or concerns.

Weaning from Breast to Cup

When should I begin weaning?

Weaning from breast to cup is dependent on your baby's need to suck and his ability to drink from a cup. A baby is usually receptive to weaning between 9 and 18 months. If your baby is less than 9 months old, you should wean him to a bottle first. When your baby is 6 months old, you can start introducing the cup, but wait to completely wean your baby until he is about 9 months old.

What kind of milk should I use?

You can put breast milk that you have pumped and stored in the cup. You can also use formula in the cup. If your baby is over 12 months you can start using regular whole milk.

If you use formula:

• watch carefully how your baby tolerates the formula. Look for rashes, spitting up, and/or bowel problems. If any appear, you should consult your doctor and ask if you need to change formulas.
• use iron-fortified formula until the baby is at least 1 year old to avoid iron-deficiency anemia.

How do I wean my baby?

• Take your time. Give your baby a chance to get used to the idea of a cup. At about 6 months old (or older), you can begin offering an occasional cup of breast milk, formula, or juice just to introduce the concept that drinks can come in another container. Plan ahead and give yourself and your baby plenty of time. Gradual weaning gives your baby time to adjust. It also allows your milk supply to diminish gradually and saves you from engorged breasts. Some mothers experience a mild depression when weaning as a result of changes in hormones related to their milk production. This is especially likely to happen if the weaning is done quickly.
• Start small and increase the amount of milk. When you are ready to wean, you can start offering your baby a cup with 1/2 oz. of milk or formula at every meal. After the meal, nurse your baby. Juice should not be used as a replacement for milk at feedings. Gradually increase the proportion of milk your baby takes from the cup. When your baby is taking 3 to 4 oz. of milk from the cup, you can eliminate a breast-feeding session (usually breakfast or lunch).
• Eliminate 1 feeding at a time: After eliminating one nursing session, wait 5 to 7 days before eliminating another to give your baby a chance to adjust. The early morning and late evening nursing sessions are usually the most difficult for your baby to give up. Wean the baby from these last. You will soon learn which feedings are your baby's least favorite and when his appetite is generally lowest. Replace these nursings first.

If your baby is taking a daily total of 16 to 20 oz. of milk by cup, in addition to 3 meals of solid food, he can be considered successfully weaned.

What if my breasts become engorged?

If your breasts become engorged because you are no nursing as much, allow your baby to suck 15 to 30 seconds from each breast to relieve your discomfort. Make sure that you don't nurse any longer, however, or you will trigger your breasts to produce more milk--and the engorgement will get worse.

What if I have problems with weaning?

Setbacks in weaning can be caused by many things, including stress, major changes in meal or bed times, or illness. If such setbacks occur, wait until the situation improves or the illness is over, and then continue the weaning process. Call your baby's doctor if you have any questions or concerns.

Weaning: How to Prevent Problems

Weaning is the replacement of bottle or breast-feedings with drinking from a cup and eating solid foods. Weaning occurs easily and smoothly unless the breast or bottle has become overly important to the child.

If you have a choice, it is best to wait until your baby is at least 6 months old before you wean from the breast. Your baby's digestive system is better able to tolerate a change in food after this age.

If you stop breast-feeding before 9 months of age, switch to bottle-feeding first. You should still introduce your child to a cup at about 6 months of age, but wait to fully wean your baby to a cup until he is at least 9 months old. If you stop breast-feeding after 9 months, you may be able to wean your baby directly to a cup.

Preventing Problems

Children normally show less interest in breast and bottle feedings between 6 and 12 months of age if they are also taking cup and spoon feedings. Many children start weaning themselves by 12 months. After the age of 12 to 18 months, the parent often has to start the weaning, but the child will be receptive. After 18 months of age, the child usually resists weaning because she has become overly attached to the breast or bottle.

If your child shows a lack of interest in the breast or bottle at any time after 6 months of age, start to phase out these nipple feedings. You can tell that your baby is ready to begin weaning when she throws the bottle down, takes only a few ounces of milk and then stops, chews on the nipple rather than sucking it, refuses the breast, or nurses for only a few minutes and then wants to play.

The following steps encourage early natural weaning at 9 to 12 months:

1. Keep bottle feedings to 4 times a day or less after your child reaches 6 months of age. Some breast-fed babies may need 5 feedings a day until 9 months of age.
2. Give older infants their daytime feedings at mealtime with solids. Once your child is having just 4 formula or breast-feedings a day, be sure 3 of them are given at mealtime with solids rather than as part of the ritual before naps. Your child can have the fourth feeding before he goes to bed at night.
3. After your baby is 4 weeks old and breast-feeding is well established, offer him a bottle of expressed breast milk or water once a day. This experience will help your baby get used to a bottle so you can occasionally leave him with a baby sitter. This step is especially important if you will be returning to work or school. The longer you wait to introduce the bottle after your baby is 2 months old, the more strongly your infant will initially reject it. If you wait until 4 months of age, it may take up to 1 week for your baby to accept the bottle. Once your baby accepts bottle feedings, continue to offer them 3 times a week so your baby will continue to accept them.
4. Hold your child for discomfort or stress instead of nursing her. You can comfort your child and foster a strong sense of security and trust without nursing every time she is upset and not hungry. If you always nurse your child in such situations, your child may learn to eat whenever she is upset. She may also be unable to separate being held from nursing, and you may become an "indispensable mother."
5. Don't let the bottle or breast substitute for a pacifier. Learn to recognize when your baby just needs to suck. At these times, instead of offering your child food, encourage him to suck on a pacifier or thumb. Feeding your baby every time he needs to suck can lead to obesity.
6. Don't let the bottle or breast become a security object at bedtime. Your child should be able to go to sleep at night without having a breast or bottle in her mouth. She needs to learn how to put herself to sleep. If she doesn't, she will develop sleep problems that require the parents' presence during the night.
7. Don't let a bottle become a daytime toy. Don't let your child carry a bottle around as a companion during the day. This habit may keep him from engaging in more stimulating activities.
8. Don't let your child hold the bottle or take it to bed. Your child should think of the bottle as something that belongs to you; hence, she won't protest giving it up because it never belonged to her in the first place.
9. Offer your child formula or breast milk in a cup by 6 months of age. For the first few months your child will probably accept the cup only after he has drunk some from the bottle or breast. However, by 9 months of age your child should be offered some formula or breast milk from a cup before breast or bottle feedings. Wean a baby younger than 6 months to a bottle and not to a cup. Babies cannot drink well enough from a cup at this age to get enough nourishment.
10. Help your baby become interested in foods other than formula or breast milk. Introduce solids with a spoon by 4 months of age to formula-fed babies and by 6 months to breast-fed infants. Finger foods can be introduced between 9 and 10 months of age or whenever your child develops a pincer grasp. As soon as your child can use finger foods, include her at the table with the family during mealtime. She will probably become interested in the foods that she sees you eating and will ask for them. As a result, she will become more interested in having other foods as well as formula or breast milk.

Weaning Reluctance or Resistance

When is weaning a problem?

Breast or bottle feeding can be considered prolonged after about 18 months of age. The older toddler who only occasionally nurses or drinks from a bottle may not need to be pressured into giving up the bottle or breast. Delayed weaning should be considered a problem only if it is causing one or more of the following types of harm:

• refusal to eat any solids after the age of 6 months
• anemia confirmed by a routine screening test at the age of 1 year
• tooth decay or baby-bottle cavities
• obesity from overeating
• withdrawal from other children and lack of interest in play because the child is always carrying a bottle around
• frequent awakening at night for refills of a bottle
• inability to stay with a baby sitter because the child is exclusively breast-fed and refuses a bottle or cup.

If your baby has any of these problems, read the next section. Otherwise, continue to breast or bottle feed your baby when she wants to (but no more than three times a day) and don't worry about complete weaning.

How do I eliminate excessive breast or bottle feedings?

To decrease breast or bottle feedings to a level that won't cause any of the problems described above, take the following steps:

• Reduce the number of milk feedings your child receives to 3 or 4 a day. When your child comes to you for additional feedings, give him extra holding and attention instead. Get your child on a schedule of three main meals a day plus two or three nutritious snacks.
• Introduce feeding from a cup if this was not done at 6 months of age. Cup feedings are needed as substitutes for breast or bottle feedings regardless of the age at which weaning occurs. The longer the infant goes without using a cup, the less willing he will be to try it. Starting daily cup feedings by 5 or 6 months of age is a natural way to keep breast or bottle feedings from becoming overly important.
• Immediately stop letting your child carry a bottle around during the day. The companion bottle can interfere with normal development that requires speech or two-handed play. It can also contribute to problems with tooth decay. You can explain to your child, "It's not good for you to carry a bottle around" or "You're too old for that."
• Immediately stop letting your child take a bottle to bed. In addition to causing sleep problems, taking a bottle of formula or milk to bed may cause severe tooth decay. You can offer the explanations suggested above.

Once you have made these changes, you do not need to do anything more unless you want to stop breast or bottle feedings completely. Attempt total weaning only if your family is not under stress (such as might be caused by moving or some other major change) and your child is not in crisis (such as being sick or learning to use the toilet). Weaning from the breast or bottle to the cup should always be done gradually and with love. The "cold turkey" or abrupt withdrawal approach will only make your child angry, clingy, and miserable. While there is no consensus about the best time to wean, there is agreement about the appropriate technique.

How do I eliminate breast-feeding completely?

• Offer formula in a cup before each breast-feeding. If your child refuses formula in a cup, offer expressed breast milk in a cup. If that fails, add some flavoring he likes to the formula. If your child is older than 12 months, you can use whole milk. Some infants won't accept a cup until after they have nursed for several minutes.
• Gradually eliminate breast feedings. First, eliminate the feeding that is least important to your child (usually the midday one). Replace it with a cup feeding. About once a week drop out one more breast feeding. The bedtime nursing is usually the last to be given up. There's no reason why you can't continue bedtime nursing for months if that's what you and your child want. Some mothers prefer to wean by decreasing the length of feedings. Shorten all feedings by 2 minutes each week until they are 5 minutes long. Then eliminate them one at a time.
• Relieve breast engorgement. Because the breast operates on the principle of supply and demand, the reduced amount of sucking time eventually reduces the amount of milk your breasts produce. In the meantime, express just enough milk to relieve breast pain resulting from engorgement. (This is better than putting your baby to the breast for a minute, because she probably won't want to stop nursing.) Remember that complete emptying of the breast increases milk production. An acetaminophen product also may help relieve discomfort.
• If your child asks to nurse after you have finished weaning, respond by holding her instead. Explain to your child that the milk is all gone from your breasts. If your child has a strong desire to suck, a pacifier may help.

How do I eliminate bottle-feeding completely?

• Offer formula in a cup before each bottle feeding. Use whole milk if your child is 1 year of age or older.
• Make the weaning process gradual. Eliminate one bottle feeding every 3 to 4 days, depending on your child's reaction. Replace each bottle feeding with a cup feeding and extra holding.
• Eliminate bottle feedings in the following order: midday, late afternoon, morning, and finally bedtime. The last feeding of the day is usually the most important one to the child. When it is time to give up this feeding, gradually reduce the amount of milk in the bottle each day for a week.
• After you have completed the weaning process, respond to requests for a bottle by holding your child. You can explain that bottles are for little babies. You may even want to have your child help you carry the bottles to a neighbor's house. If your child has a strong need to suck, offer a pacifier.

When should I call my child's health care provider?

Call during office hours if:

• Your child is over 6 months of age and won't eat any food except milk and won't drink from a cup.
• Your child has tooth decay.
• You think your child has anemia.
• This approach to weaning has not been successful after you have tried it for 1 month.
• Your child is over 3 years old.
• You have other questions or concerns.

Picky Eaters

What is a picky eater?

The peak time for picky eating is the toddler or preschool years. A picky eater:

• complains about or refuses specific foods, especially vegetables and meats
• pushes foods around the plate
• hides foods or gives them to a pet under the table
• eats enough total foods and calories per day.

What causes it?

Children of all ages (and adults) commonly have a few food dislikes. A picky eater is a child with many food dislikes. At age 2 or 3, up to 20 percent of children are picky eaters. It is normal for most young children to dislike foods with a bitter or spicy taste. Sometimes children dislike foods because of their color, but more often it's because they are difficult to chew. Children accept tender meats better than tough ones, and well-cooked vegetables better than raw. Occasionally a child who gags on large pieces of all foods has large tonsils that make it difficult to swallow.

How long does it last?

Most children who are picky eaters will grow out of it. They start trying new foods during the early school years because of peer pressure. The voracious appetite during the teen years also increases the willingness to experiment. If you try to force your child to eat a food he doesn't like, he may gag or even vomit. Forced feedings always interfere with the normal pleasure of eating and eventually decreases the appetite. Learning to accept new foods should not be expected before the teenage years.

How can I help my child?

• Try to prepare a main dish that everyone likes. Try to avoid any unusual main dish that your child strongly dislikes. Some children don't like foods that are mixed together, such as casseroles. Try reintroducing such dishes when your child is older.
• Allow occasional substitutes for the main dish. If your child refuses to eat the main dish and this is an unusual request, you may allow a substitute dish. An acceptable substitute would be breakfast cereal or a simple sandwich the child prepares for himself. Never become a short-order cook and prepare any extra foods for mealtime. The child should know that you expect him to learn to eat the main dish that has been prepared for the family.
• Respect any strong food dislikes. If your child has a few strong food dislikes (especially any food that makes her gag), do not serve that food to her when it's prepared as part of the family meal.
• Don't worry about vegetables, just encourage more fruits. Because vegetables tend to be hard to chew and some of them are bitter, they are commonly rejected by children and even by many adults. Keep in mind that fruits and vegetables are from the same food group. There are no essential vegetables. Vegetables can be entirely replaced by fruits without any nutritional harm to your child. This is not a health issue. Don't make your child feel guilty about avoiding some vegetables.
• Don't allow complaining about food at mealtimes. Have a rule that it's okay to decline a serving of a particular food or to push it to the side of the plate. But complaining about it is unacceptable.
• Encourage your child to taste new foods. Many tastes are acquired. Your child may eventually learn that she likes a food she initially refuses. Research shows, it may take seeing other people eat a new food 10 times before they're even willing to taste it, and another 10 times of tasting it before they develop a liking for it. Don't try to rush this normal process of adapting to new foods. Trying to force a child to eat one bite of a food per year of age is not helpful with most picky eaters. Instead, it's better to simply serve it repeatedly, ask your child to taste it, then trust your child when they say they have tasted the food.
• Avoid pressure or punishment at mealtime. Never pressure your child to eat all foods. Never punish your child for refusing to take one bite of a new food. It will only lead to liking that food less over time, gagging or even vomiting. If your child has a stubborn, strong-willed nature, pressure around eating can progress to a power struggle which in turn prolongs the picky eating.
• Don't argue about dessert. An unnecessary area of friction for picky eaters is a rule that if you don't clean your plate, you can't have any dessert. Since desserts are not necessarily harmful, a better approach is to allow your child one serving of desert regardless of what she eats. However, there are no seconds on dessert for children who don't eat an adequate amount of the main course. Desserts don't have to be sweets, they can be nutritious desserts such as fruit.
• Don't extend mealtime. Don't keep your child sitting at the dinner table after the rest of the family is done. This will only cause your child to develop unpleasant associations with mealtime.
• Keep the mealtime atmosphere pleasant. Make it an important family event. Draw your children into friendly conversation. Tell them what's happened to you today and ask about their day. Talk about fun subjects unrelated to food. Avoid making it a time for criticism or struggle over control.
• Avoid conversation about eating at any time. Don't discuss what your child eats in your child's presence. Trust your child's appetite to look after your child's caloric needs. Also don't give praise for appropriate eating. Don't give bribes or rewards for meeting your eating expectations. Children should eat to satisfy their appetite, not to please the parent. Occasionally you might praise your child for trying a new food that he does not like the taste or texture of.
• Consider giving your child a daily vitamin-mineral supplement. If your child is not eating at least 1 serving or meat per day, give a multivitamin with iron to prevent iron deficiency anemia. Although vitamins are probably unnecessary for most of us, they are not harmful in normal amounts and may allow you to be less concerned about your child's eating patterns.

When should I call my child's health care provider?

Call during office hours if:

• Your child is losing weight.
• Your child gags on or vomits certain foods.
• Your child has heartburn.

You have other questions or concerns.

Formula (Bottle) Feeding

Should I use formula?

Breast milk is best for babies, but breast-feeding isn't always possible. You will need to use a baby formula if:

• You decide not to breast-feed.
• You need to stop breast-feeding and your baby is less than 1 year old.
• You need to occasionally supplement breast-feeding with formula (after breast-feeding is well established).

If you want to breast-feed but you think you are not making enough milk, don't stop breast-feeding. Talk to your health care provider or lactation nurse before you stop. Any bottle feeding, before breast-feeding has been well established, could reduce your supply of breast milk and make it difficult to continue breast-feeding.

What type of formula should I use?

If your child is less than 1 year old, discuss which formula to use with your health care provider.

Baby formulas are designed to give your baby all known essential nutrients in their proper amounts. Most formulas are made from cow's milk. A few are made from soybeans. Soy formula is used for babies who may be allergic to or have difficulty digesting the type of protein in cow's milk. The American Academy for Pediatrics recommends you use iron-fortified (not low-iron) formula to prevent anemia.

Most formulas are available in three forms: powder, concentrated liquid, and ready-to-serve liquid. Powder and ready-to-serve liquid are best if you are using it to supplement breast milk. Powder and concentrated liquid formulas are less expensive per feeding than ready-to-serve formulas.

When can I give my baby regular milk?

Regular, whole cow's milk should not be given to babies before 12 months of age. This is because of increased risks of iron deficiency anemia and allergies. Skim or low-fat milk should not be given to babies before they are 2 years old because the fat in whole milk is needed for rapid brain growth.

How do I prepare formula?

Mix concentrated liquid formula with water in a ratio of one to one. Mix each level scoop of powdered formula with 2 ounces of water. Never make the formula for your baby more concentrated by adding extra concentrated liquid or extra powder. Never dilute the formula by adding extra water. Careful measuring and mixing ensure that your baby receives the proper mix of formula.

Do I need to boil the water first?

Most city water supplies are quite safe. If you make one bottle at a time, you don't need to use boiled water. When using tap water for preparing formula, use only water from the cold water tap. Let the water run for 2 minutes before you use it. (Old water pipes may contain lead-based solder and lead dissolves more in warm water or standing water.) Fresh, cold water is safe. After you prepare the formula with the cold water, you can heat the bottle to the right temperature. Ask your health care provider if you are not sure whether your water supply is safe for your baby.

If you have well water, you need to boil your water for 10 minutes (plus 1 minute for each 1000 feet of elevation above sea level) or use distilled water until your child is 6 months old.

If you prefer to prepare a batch of formula, you must use boiled or distilled water and closely follow the directions printed on the side of the formula can. This prepared formula should be stored in the refrigerator and must be used within 48 hours.

Can I make my own formula?

If necessary, you can make your own formula temporarily from evaporated milk. (Evaporated milk formulas have some of the same risks as whole cow's milk, namely, iron deficiency anemia and allergies.) Mix 13 ounces of evaporated milk with 19 ounces of boiled water and 2 tablespoons of corn syrup. Place this mixture in sterilized bottles and keep the bottles refrigerated until use (up to 48 hours).

What temperature does the formula need to be?

In the summertime, many children prefer cold formula. In the wintertime, most prefer warm formula. By trying formula at various temperatures you can probably find out what your child prefers. If you do warm the formula, check the temperature of the formula before you give it to your baby. If it is too hot it will burn your baby's mouth. Be especially careful if you heat the formula in a microwave because the formula can get too hot very quickly.

How often should I feed my baby?

Your health care provider will tell you when and how often to feed your baby. In general, your baby will probably need:

• 6 to 8 formula feedings per day for the first month
• 5 to 6 formula feedings per day from 1 to 3 months
• 4 to 5 formula feedings per day from 3 to 7 months
• 3 to 4 formula feedings per day from 7 to 12 months

If your baby is not hungry at some feedings, increase the time between feedings.

How much formula should I give my baby?

Newborns usually start with 1 ounce per feeding, but by 7 days they can take 3 ounces. The amount of formula that most babies take per feeding (in ounces) can be calculated by dividing your baby's weight (in pounds) in half. For example, if your baby weighs 8 pounds, your baby will probably drink 4 ounces of formula per feeding. No baby should drink more than 32 ounces of formula a day. If your baby needs more than 32 ounces and is not overweight, consider starting solid foods. Overfeeding can cause vomiting, diarrhea, or excessive weight gain.

How should I hold the baby during feedings?

Feeding should be a relaxing time -- a time for you to provide both food and comfort for your baby. Make sure that both you and the baby are comfortable:

• Your arm supported by a pillow.
• Baby in a semi-upright feeding position supported in the crook of your arm. This position reduces choking and the flow of milk into the middle ear.
• The bottle tilted so that the nipple and the neck of the bottle are always filled with formula. (This prevents your baby from taking in too much air.)

How long should I feed my baby?

Gently remove the bottle from time to time to let your baby rest. A feeding shouldn't take more than 20 minutes. If it does, you are overfeeding your baby or the nipple is clogged. A clean nipple should drip about 1 drop per second when the bottle of formula is turned upside-down.

Do I need to burp my baby?

Burping is optional. It doesn't decrease crying. Burping helps your baby spit up less. Air in the stomach does not cause pain. If you burp your baby, be sure to wait until your baby reaches a natural pause in the feeding process. Burping two times during feeding and for about a minute is plenty. More burping may be needed if your baby spits up a lot.

How long can I store formula?

Prepared formula should be stored in the refrigerator. It must be used within 48 hours. Prepared formula left at room temperature for more than 1 hour should be thrown away. At the end of each feeding, throw away any formula left in the bottle.

Does my baby need to drink water?

Babies do not routinely need extra water. However, when they have a fever or the weather is hot they should be offered a bottle of water twice a day. Run the water from the tap for 2 minutes before you use it for drinking. Keep some of this water in your refrigerator.

Do I need to give my baby vitamins?

No. Baby formulas contain all the vitamins and minerals your baby will need.

Do I need to give my baby fluoride?

From 6 months to 16 years of age, children need fluoride to prevent cavities. If the water supply where you live contains fluoride and your child drinks at least 1 pint of formula made with water each day, this should be enough. Otherwise, fluoride drops or tablets should be given separately. You can get a prescription for fluoride drops from your child's health care provider.

Another way you can help your baby's teeth is by making sure your baby does not sleep with a bottle. Milk, juice, or any sweetened liquid in the mouth can cause severe decay of your baby's first teeth. Liquids tend to pool in the mouth during sleep. The sugar in these drinks is changed to acid by bacteria in the mouth. The acid then etches the tooth enamel and causes decay.

Prevent tooth decay by not using the bottle as a daytime or nighttime pacifier. If you cannot stop the nighttime bottle or replace it with a pacifier, fill the bottle with water.

Solid (Strained) Foods

When should I start feeding my child solid foods?

The best time to begin using a spoon to feed your child is when your baby can sit with some support and move his head to participate in the feeding process. This time is usually between 4 and 6 months of age. Breast milk and commercial formulas meet all of your baby's nutritional needs until 4 to 6 months of age. Introducing strained foods earlier just makes feeding more complicated. Research has shown that in most cases solid foods won't help your baby sleep through the night. The only exceptions are those few breast-fed babies who are not getting enough calories or gaining enough weight.

What types of foods should I feed my child?

• Cereals Cereals are usually the first solid food added to your baby's diet. Generally these are introduced to infants between 4 and 6 months of age. Cereals should be fed with a small spoon and should not be given in the baby's bottle. This is because an infant should be taught to differentiate between what he eats and what he drinks. Start with rice cereal, which is less likely to cause allergies than other cereals. Barley and oatmeal may be tried 2 or 3 weeks later. A mixed cereal should be added to your baby's diet only after each kind of cereal in the mixed cereal has been separately introduced.
• Vegetables and fruit Strained or pureed vegetables and fruits are the next solid foods introduced to your baby. The order in which you add vegetables and fruits to your baby's diet is not important. However, you should introduce only one new food at a time and no more than 3 new foods per week.
• Meat and protein alternatives By 7 to 8 months of age your baby should be ready for strained or pureed meats and protein alternatives (such as beans, peas, lentils, cottage cheese, and yogurt). Babies who are only getting breast milk and no other solids can develop a zinc and iron deficiency. This can be prevented by starting pureed red meats between 6 and 8 months.

Are there foods I should not feed my child?

Egg whites, wheat, peanut butter, fish, and orange juice may be more likely to cause allergies than other solid foods, but this is controversial. Avoid adding these foods to your baby's diet until 1 year of age, especially if your infant has other allergies. Also, avoid giving your child honey during the first year of life.

How do I spoon feed my child?

Place food on the middle of the tongue. If you place it in front, your child will probably push it back at you. Some infants get off to a better start if you place the spoon between their lips and let them suck off the food.

Some children constantly bat at the spoon or try to hold it while you are trying to feed them. These children need to be distracted with finger foods or given another spoon to hold.

By the time they are 1 year old, most children want to try to feed themselves and can do so with finger foods. By 15 to 18 months of age, most children can feed themselves with a spoon and no longer need a parent's help to eat.

When can my child have finger foods?

Finger foods are small, bite-size pieces of soft foods. They can be introduced between 9 and 10 months of age or whenever your child develops a pincer grip.

Most babies love to feed themselves. Since most babies will not be able to feed themselves with a spoon until 15 months of age, finger foods keep them actively involved in the feeding process.

Good finger foods are dry cereals (Cheerios, Rice Krispies, etc.), slices of cheese, pieces of scrambled eggs, slices of canned fruit (peaches, pears, or pineapple), slices of soft fresh fruits (especially bananas), crackers, cookies, and breads.

Should I give my child snacks?

Once your baby goes to 3 meals a day, or eats at 5-hour intervals, he may need small snacks to tide him over between meals. Most babies begin this pattern between 6 and 9 months of age. The midmorning and midafternoon snack should be a nutritious, nonmilk food. Fruits and dry cereals are recommended. If your child is not hungry at mealtime, cut back on the snacks or eliminate them.

Can my child eat table food?

Your child should be eating the same meals you eat by approximately 1 year of age. This assumes that your diet is well balanced and that you carefully dice any foods that would be difficult for your baby to chew. Avoid foods that he could choke on such as raw carrots, candy, peanuts or other nuts, and popcorn.

What foods contain iron?

Throughout our lives we need iron in our diet to prevent anemia. Certain foods are especially good sources of iron. Red meats, fish, and poultry are best. Some young children will only eat lunch meats, and the low-fat ones are fine. Adequate iron is also found in iron-enriched cereals, beans of all types, egg yolks, peanut butter, raisins, prune juice, sweet potatoes, and spinach.

Does my child need vitamins?

If your child is between 2 and 12 months old and you are breast-feeding, you will need to give your child a vitamin D supplement. Formula fed infants get all the vitamins they need from the formula. After your child is 1 year old and is eating a balanced diet, added vitamins are not necessary. If your child is a picky eater, give him 1 chewable vitamin pill twice a week.

Healthy Diet

Health Problems Related to Diet

At least 7 health problems have been proven to relate to diet. The first 4 problems occur in children as well as in adults. The last 3 occur primarily in adults.

1. Iron deficiency anemia This type of anemia usually occurs between 6 months and 2 years of age. The main symptoms are fatigue, pale skin, becoming tired easily, and delayed motor development. Iron deficiency anemia can also cause behavioral symptoms such as restlessness, irritability, and poor attention span.
2. Overweight Obesity is one of the most common nutritional problems in this country. Obesity is also one of the most important contributing factors in heart disease, hypertension, type 2 diabetes, and some cancers.
3. Tooth decay Tooth decay is more likely if a child has a lot of sugar in his diet. (Poor toothbrushing habits also contribute to tooth decay.)
4. Intestinal symptoms Too little fiber in the diet can cause intestinal problems such as constipation, abdominal discomfort, appendicitis, gallstones, and some intestinal cancers.
5. Osteoporosis Soft bones (osteoporosis) in later adulthood causes curvature of the spine and increased fractures (especially hip fractures). Most of the calcium that gives strong bone density is laid down between 9 and 18 years of age.
6. Coronary artery disease A lot of animal fat (especially cholesterol) in the diet contributes to coronary artery disease. This disease hardly exists in poor countries where the population subsists on low-fat, high-carbohydrate diets. It is also less common among vegetarians.
7. High blood pressure High blood pressure has been associated with an increased amount of salt or a decreased amount of calcium in the diet of some susceptible persons. Most people, however, get rid of extra salt through their kidneys and don't develop high blood pressure.

Recommendations for a Healthy Diet

• Learn the 5 basic food groups:
  • milk products (milk, cheese, yogurt, ice cream) 2 to 3 servings per day
  • meat/eggs (red meats, poultry, fish, and eggs) 2 to 3 servings per day
  • grains (breads, cereals, rice, pasta) 6 to 11 servings per day
  • fruits (juice or solid fruit): 2 to 4 servings per day
  • vegetables (juice or vegetables): 3 to 5 servings per day

20% of a healthy diet should consist of milk, meat and eggs, and 80% should be vegetables, fruits, and grains. (Fiber is found in grains, fruits, and vegetables.) Another similar recommendation is that children should get 55% of their calories from carbohydrates, 30% from fats, and 15% from proteins.

• Eat 3 meals a day. Breakfast is essential for children. Research has shown that missing breakfast interferes with alertness, attention span, thinking, and memory. For dieters, skipping breakfast usually doesn't lead to weight loss. All meals should contain fruits or vegetables, as well as grains. Meat or milk should be included in 2 of the meals. Eating snacks is largely a habit. Snacks are unnecessary for good nutrition but harmless unless your child is overweight. If your child likes snacks (and most children do), encourage fruits, vegetables, and grains. Only allow 1 snack between meals and don't give it close to mealtime.
• Decrease the amount of fat (meat and milk products) in the diet. Americans eat excessive amounts of meat and dairy products. Although cholesterol is important for rapid growth, children over age 2 should consume it in moderation (not eliminate it). To decrease the amount of fat in the diet, follow these guidelines:
  • Remember that 1 serving of meat per day is adequate for normal growth and development. (Don't serve meat more than twice a day.)
  • Serve more fish and poultry and fewer red meats, since the latter have the highest cholesterol levels. Lean red meats are lean ground beef, pork loin, veal, and lamb.
  • Trim fat off meats and the skin from poultry.
  • Don't serve bacon, sausages, spareribs, pastrami, and other meats that have a high fat content. Cut back on hot dogs, lunch meats, and corned beef.
  • Limit the number of eggs to 3 or 4 per week. (Eggs have the highest cholesterol content of any of the commonly eaten foods. The cholesterol in 1 egg is equivalent to the cholesterol in 14 ounces of beef, 1-and-1/2 quarts of whole milk, or 1 quart of ice cream.)
  • Serve 1% or 2% milk instead of whole milk for children over 2 years of age.
  • Decrease the amount of milk your child drinks to 2 or 3 cups per day. (Encourage your child to drink water to satisfy thirst.) On the other hand, some teenage girls may need to be reminded to consume adequate milk products (the equivalent of 3 glasses of milk) to lay down the bone mass required to prevent osteoporosis later in life.
  • Buy margarine instead of butter.
  • Keep in mind that red meat may be hard to give up because of the widespread misconception that red meat helps to build muscle mass and strength.
• Increase the amount of fruits, vegetables, and grains in the diet. Follow these guidelines:
  • Children should consume at least 5 servings of fruits and vegetables per day. (50% of American children eat only 1 fruit or vegetable per day.)
  • Try to serve a fruit at every meal.
  • Offer fruits as dessert and snacks.
  • Start every day with a glass of fruit juice. Avoid excessive fruit juice which can cause diarrhea or decrease your child's appetite for other foods. The American Academy of Pediatrics recommends the following limits for fruit juice per day: 6 ounces for children age 6 months to 6 years and 12 ounces for children 7 to 18 years. Serve 100% fruit juices, not fruit drinks. Fruit drinks mainly contain water and sugars. They don't count as a serving of fruit.
  • From a practical stand point, fruits and vegetables are interchangeable. Don't force children to eat vegetables they don't like. Offer ones they do like or substitute a fruit.
  • When making casseroles, increase the amount of vegetables and decrease the amount of meat.
  • Serve more soups.
  • Encourage more cereals for breakfast.
  • Use more whole-grain bread in making sandwiches.
• Include an adequate amount of iron in the diet. Throughout our lives we need adequate iron in our diets to prevent anemia. Everyone should know which foods are good sources of iron. Red meats, fish, poultry, and eggs are best. One serving per day of these foods will provide adequate iron. Although liver is a good source of iron, it contains 16 times more cholesterol than beef and should be avoided. For young children who refuse meats in general, use some low-fat luncheon meats as a meat source. Adequate iron is also found in iron-enriched cereals, beans of all types, peanut butter, raisins, prune juice, sweet potatoes, spinach, and egg yolks. The iron in these foods is better absorbed if the meal also contains fruit juice or meat.
• Maintain an adequate calcium intake. Calcium is important for building strong bones, thereby preventing fractures in teens and soft bones (osteoporosis) in later adulthood. Most of the calcium that gives healthy bone density is laid down between ages 9 and 18 years. During this time calcium intake should be 1200 mg per day. A cup (8 ounces) of milk contains 300 mg, so optimal intake is 4 servings of milk products per day. One cup of milk is equivalent to 8 ounces of yogurt, 1.5 ounces of cheese (approximately 2 slices) or 1 cup of calcium-fortified fruit juice. Whole, 2%, 1% and skim milk all contain the same amount of calcium per cup. Children age 1 to 4 years need 2 servings of calcium per day and those 4 to 9 years need 3 servings per day. If a child of any age doesn't like the taste of milk, intake can easily be improved by serving flavored milk.
• Avoid excessive salt. Salt is not usually harmful for people without high blood pressure. However, to discourage a taste for excessive salt in infants do not add it to their foods. Remove the salt shaker from the dinner table. Use other herbs and spices instead of salt. Purchase salty foods such as potato chips and pretzels sparingly.
• Avoid excessive pure sugars. Sweets are not bad, but they should be eaten in moderation. Most humans are born with a "sweet tooth." They seek out and enjoy candy, soft drinks, and desserts. The main side effect of eating candy is tooth decay if the teeth are not brushed afterward. Eating food with a lot of sugar ("a sugar binge") can cause jitters, sweating, dizziness, sleepiness, and intense hunger 2 to 3 hours later. This temporary reaction is not harmful and can be relieved by eating some food. A love of sweets is not related to obesity (if the total calories per day are normal) or hyperactivity. A high amount of sugar in the diet has not been correlated with coronary artery disease or cancer.

Know what to eat before exercise. Eating meat does not improve athletic performance. The best foods to eat before prolonged exercise are complex carbohydrates. These include bread, pasta (noodles), potatoes, and rice. These should be eaten 3 to 4 hours before the athletic event so they have passed out of the stomach. Drinking water continues to be important up to the time of the activity and every 20 to 30 minutes during the activity.

Healthy Meal Planning

How can I get my children to eat healthy foods?

Many parents are realizing that rushed schedules and too many dinners from fast food restaurants are affecting the way their children eat and view foods. The best way to get your kids to eat well is to be a role model and to get them involved in meal planning. Eating healthy is always a family affair. Whether your children are very young and you are looking to start them out "right" or already in the habit of eating too many high fat, high sugar foods, you can use these tips to help your family eat healthy meals.

Where do I start?

Children should be offered a variety of foods from all food groups including whole grains, fresh fruits and vegetables, low-fat or skim dairy products, lean meats, fish, poultry, and beans. A good rule of thumb in choosing the healthiest versions of these foods is "the less processed, the better."

• Go shopping. Take an inventory of your cupboards. If you typically buy high-fat, high-sugar snacks, sodas, sugary fruit drinks, and baked goods, you'll need to change your shopping habits. Children get used to having these foods available and will choose them over fresh fruits, yogurt or other healthier snacks. Writing out a shopping list really helps. Let your kids help write the "new" list.
• Change cereals. Switch from high-sugar cereals to those that are only lightly sweetened and are high in fiber. If your children really complain, dress them up with fresh fruit or allowing a "mix." A mix is a healthy cereal with a small handful of sweet cereal on top.
• Serve low-fat milk. If your children are over 2 years of age, switch to low-fat or skim dairy products. Children should get used to lean milk products early. Encourage 2 to 3 servings a day. Offering cold cereal or making oatmeal with milk can add an additional serving of milk for those children that don't care for drinking milk. Water and low-fat milk should be offered more frequently than juice. While 100% juice is nutritious, it is also very high in calories and can become a problem for children at risk for being overweight.
• Serve less meat and make it lean. Prepare only the leanest cuts of meats, pork, and poultry without skin. Fish is also a great choice. Try having a meatless lunch or dinner a few times a week, using beans or soy products.
• Serve fruit and vegetables. Most children don't eat enough fruits and vegetables. Take every opportunity to serve them. Breakfast and snack time is perfect for fruit. All lunch and dinner meals should be served with vegetables. Always have a full fresh fruit bowl on the counter and baby carrots in the refrigerator for snacking. Offer vegetables to dip in low-fat dressing. Vegetables soups and colorful salads are good appetizers. Try making a salad with baby spinach, mandarin oranges, crushed nuts and fruit-based dressing. Include the kids in making up new salad combinations.
• Don't eat out as much. Try to eat at fast food restaurants less often. If you are just picking up food to take home, try ordering the entrée only. Skip the fries, high- fat side dishes, and soda. Serve burgers with fresh fruit, leftover corn on the cob, and milk or juice. Be creative.
• Limit fats. Avoid offering too much saturated fat such as butter, sour cream and cream cheese. Cook with canola or olive oils and use only very soft or tub margarines (look for those without trans-fats). Choose low-fat dressings and light mayonnaise.
• Give kids a chance to get used to new foods. When trying new foods, realize that children are not small adults. They experience textures and flavors differently, and some foods, like certain strong smelling vegetables and rough grains will not appeal to them until they are older. Many kids won't try a new food until it is offered many times. Continue to offer a variety of food but try not to become frustrated or force them to eat new foods.
• Let your kids control the amount. Even if you spend a lot of time making a dish, don't make your children clean their plate when they tell you they're full. Serve small portions. If your child is still hungry, he or she will ask for more. The key to promoting a healthy relationship with food is for you to offer a nutritious selection and let your child have control over how much is eaten.
• Have scheduled meals and snack times. Children, especially younger ones, like to know what to expect. Family dinners are very important and often the only time where the whole family can be together.

How do I fit a healthy diet into our busy schedule?

If you have a busy schedule, go shopping and stock your cupboards with quick, healthy choices for the week. Always have basic foods available to prepare fast, simple and nutritious meals.

Basics for your shopping list:

• Low-sugar, high-fiber cereals
• Whole wheat bread, rice (brown is best), pasta, other whole grains
• Fresh or canned fruit (in own juice or light syrup)
• Fresh, frozen, or low salt canned vegetables
• Leafy vegetables for salads
• Fresh or frozen lean meats like skinless chicken or turkey breasts, pork tenderloin, sirloin or round steak, and fish (tuna is convenient)
• Eggs or egg substitute
• Low-fat or skim milk, yogurt, lean cheese (such as string cheese)
• Tofu or