Are Tongue and Lip Ties Being Overdiagnosed and Overtreated?

Written by Robin Kaplan, M.Ed, IBCLC, Owner of San Diego Breastfeeding Center

That has been the million dollar question of the week.  Since Rachel Cautero published her article in the Atlantic last week about this topic, conversations about tethered oral tissue (TOTs) have had a resurgence of epic proportion.  To discuss this topic, I was interviewed by Meghna Chakrabarti on NPR’s On Point this week. Her interview, entitled To Improve Breastfeeding, Babies Get Their Tongues Clipped.  Is it necessary?, included the Atlantic journalist (Rachel Cautero), a pediatric ENT from John Hopkins (Dr. Jonathan Walsh), and me, an IBCLC from San Diego.  

I encourage you to listen to this interview, as there were many important issues brought up that parents need to hear.  I also encourage you to consider listening through an unbiased lens, as the first 30 minutes are fairly skewed due to the sharing of personal breastfeeding experiences by Meghna and Rachel.  They talk about being informed of their infants’ tongue ties during a very vulnerable early postpartum period and how upsetting this information was to them. They shared how they both decided to stick with breastfeeding, despite significant pain for weeks and months, instead of considering a tongue tie release.  And they both ended up finding that breastfeeding eventually got better and that they felt frustrated with all of the discussions online about tongue tie and upper lip tie releases, which they feel is being sold as the ‘cure-all’ to lactation woes.

Keep in mind….these are just two individuals’ stories out of many.  We all have our personal stories of parenthood/breastfeeding/labor, etc that skew the way we view a situation because they evoke an emotional response in us.  These emotional reactions are normal, but are that person’s point of view.

What I would like to share are the most pertinent points about tethered oral tissue (TOTs) that were shared in this interview, as well as a few more that weren’t shared due to time constraints.

4 Main Take-Aways about Tethered Oral Tissue (TOTs)

Tethered oral tissue can restrict range of motion in the tongue, lips, and cheeks

• All people have frenulums, but to have tethered oral tissue (TOTs) means that the frenulum is restricting range of motion and impacting function.  Here is a handout that includes many of the symptoms that can be related to TOTs.

• These TOTs do not stretch over time, but some children/adults learn to compensate despite the tightness.  This is why some children and adults don’t show or feel that they have long-term complications.

• Releasing restricted frenula can have a profoundly positive effect on both parent and baby and their ability to meet their breastfeeding goals, but is not always necessary.

International Board Certified Lactation Consultants (IBCLCs) identify tethered oral tissue at a higher rate than pediatricians/ENTs because they are the professionals completing full oral/feeding assessments.  

• IBCLC assessments are not 15 minute well-baby checks.  They are extensive assessments, lasting 1-3 hours, using research-supported evaluation tools.  

• TOTs cannot be evaluated just by looking in the mouth or at a photo of the mouth, tongue, and lip.  Function must be taken into account.

• Parents should be walked through each part of the oral/feeding assessment so that they can make an informed decision about what is best for their child.

• It is always necessary to go back to basics (positioning and latch) first, before blaming a tongue or lip tie. If the symptoms for the breastfeeding parent or baby are not relieved with the basics, then further assessment is necessary.

• Parents should be presented with a menu of options: bodywork (CST/PT/OT/Chiro, etc); oral exercises; tummy time; supplementing; exclusive pumping, etc. - everyone deserves to be supported regardless of their decisions.

There has been an increase of identification of and recommendation to release tethered oral tissue in the past two decades, with good reason

• Increased research and ultrasound investigation on how the tongue and lips function while feeding have shown what is necessary to achieve comfortable, effective breastfeeding and milk removal.  This information was not available until the past two decades.

• There has been a shift in the international culture to be more pro-breastfeeding than it was during the 1900s.  It is unfortunate that some families feel ‘pressured to breastfeed’, as Rachel mentioned in the interview. Personally, I think this shift in societal views towards breastfeeding has more to do with current research identifying the vast health-promoting and immunological benefits to mom and baby when breastfeeding, rather than parents feeling pressured to breastfeed.

• TOTs are nothing new.  Tongue ties and frenotomy descriptions can be found in early Japanese writings, other historical documents, and even the bible.  In the 1600s, frenotomy was widely known and there is documentation that describes that midwives would keep one fingernail long and sharp so that she could release the tight frenulum without the use of an instrument.

• In the early 1900s, formula was advertised as better than breastmilk and breastfeeding was considered as something that only impoverished people do.  Up until then, if a mother could not breastfeed her baby, the family hired a wet nurse or the baby would die due to lack of nourishment. Formula changed the way we looked at infant nutrition and breastfeeding, which meant tethered oral tissue wasn’t viewed as important to address.  With this pendulum shift to positive views about breastfeeding, parents want answers when challenges arise. And many of these challenges can be attributed to TOTs.

There is a lack of evidence specifically studying the long term effects of tethered oral tissue (TOTs)

• There are several case studies and randomized control studies on how frenotomies improve breastfeeding outcome.

• There are some correlations between TOTs and challenges eating solid foods, speech and change in oral/dental structure, but there is only a small amount of research to back this up.   We clearly need more research.

• What we do know is that children with TOTs often mouth breathe, which is widely recognized as pathological and may lead to:

  • open-mouth posture, which can block the airway when sleeping, leading to bruxism, snoring, sleep apnea

  • impaired swallowing, which can lead to a palate that doesn’t naturally expand and Eustchian tubes not opening and equalizing pressure in the middle ear

So, what’s the overall take away message?

When a family has breastfeeding challenges and doesn’t receive a comprehensive oral/feeding assessment that evaluates tongue and lip function, then we run the risk of tongue/lip ties being overdiagnosed and overtreated.   

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For more information about tethered oral tissue, check out these resources:

Dr. Ghaheri’s website

SOS for TOTs by Lawrence Kotlow, DDS

Tongue-Tied by Richard Baxter, DMD, MS

Kellymom: Breastfeeding a Baby with a Tongue Tie or Lip Tie (Resources)

Tongue tie articles on SDBFC’s website

Breastfeeding After Exclusive Pumping

A few months ago, we sent out a Call for Breastfeeding Stories.  Our desire was to flood the Internet with beautiful breastfeeding and pumping stories of triumph, overcoming challenges and struggles, and positive outcomes, regardless of the total amount of milk a mom was producing.  We are thrilled to share these stories with you, our readers, and hope that they offer support and inspiration for you, wherever you are in your breastfeeding or pumping journey. 

Thank you to all of the mothers who submitted their stories!  If after you read these memoirs you are inspired to submit your story, feel free to send it to RobinKaplan@sdbfc.com.    

This memoir is from Amanda, from https://exclusivepumping.com/

When I was pregnant with my second child, I was planning to breastfeed her. I was also really nervous about it because of my experience with my first child.

After my son was born, we struggled with nursing while we were in the hospital. Each nurse suggested that I hold him a different way, and it always worked when they were standing right there. However, after they left and I tried to nurse again on my own, I could never get him to latch. I remember being so sleep deprived from labor that I couldn't really listen to what they were telling me and have it sink in.

Additionally, the hospital had a lactation consultant, but there had a been a huge snowstorm a few days earlier, and she "hadn't been seen since the blizzard." So that form of assistance wasn't available, unfortunately.

(After my nurse told me that, I had this mental image of the lactation consultant getting lost on her way to the hospital in a sleigh or something. Hopefully, she eventually made it back.)

After three weeks of struggling and my son still not being back up to his birth weight, I ended up deciding to exclusively pump for him. I had a lot of complicated emotions around this - guilt for not trying harder to nurse, inadequacy for not being able to make nursing work, pride in myself for managing to breastfeed by pumping only. As a Type A person, I became pretty obsessed with it - how much I was pumping, how much he was eating, how much my stash was, etc. Exclusively pumping became such a big part of my identity as a new mom that I started an entire website about it. 

So, when I was pregnant with my daughter, I wanted to make sure that she got breast milk, too, just like my son did. At the same time, I knew how hard it was to exclusively pump, and I was already terrified of having two kids under two years old. Exclusively pumping with a toddler and baby seemed impossible to me, and I wasn't sure if I could manage it again.

As soon as she was born, though, it was obvious that this baby had a completely different temperament than my son. While he had screamed for his entire first hour of life outside the womb, she just cried a little and then latched on like a champ.

There were definitely some bumps in the road over the first few days - again, I struggled a bit with latch in the hospital - but we moved past them pretty quickly, and she was back up to her birth weight after a little over week.

I have such great memories of nursing my daughter while on maternity leave. Some days (instead of going to Stroller Strides or trying to run errands) I would just decide to be lazy and spend the whole day on the couch with her - snuggling, switching to the other breast from time to time, and watching entire seasons of Game of Thrones.

I ended up nursing my daughter until she was 18 months old. I don't think I had much milk left at that point, and it was just part of her bedtime routine. When I ended up needing to go on a trip without her, my husband to put her to bed, and that was the end. I was sad to be done with nursing her, but it also felt like it was time.

Being able to nurse my daughter really helped me heal from the feelings of guilt and inadequacy I had felt after not being able to with my son. I'm so grateful for both breastfeeding relationships, though, because they taught me different things - my son taught me that I could figure things out as a mom even when things didn't go the way I'd planned, while my daughter taught me the importance of being in the moment and savoring time together.

Robin Wrote a Breastfeeding Book!

One thing that many people don’t know about me is that I have always had a passion for writing. Before becoming a lactation consultant, I wrote curriculum for local museums and websites and wrote two unpublished children’s books.  So when I was approached to write this breastfeeding book I knew that there was no way I could pass up this amazing opportunity.

Supporting new families through their breastfeeding journeys has truly been my calling.  I love my job and the adrenaline rush I feel when I have empowered a family and helped them to meet their breastfeeding goals.  There is so much more to breastfeeding than just latching a baby to a breast.  There are nuances, both simple and challenging, that help make this process enjoyable and seamless.  We, as lactation consultants, have the honor to facilitate this breastfeeding process, when needed, and this book is just one step in that journey.  Latch: A Handbook to Breastfeeding with Confidence at Every Stage provides families with the supportive and educational basics they need while breastfeeding their children, from pregnancy to weaning.

Over the next few weeks, I will be sharing some content you will find in Latch.  This book is a great baby shower gift, for even the most seasoned-breastfeeding parent, as well as something you will want to buy even if you have already started breastfeeding.  Latch is already available for presale on Amazon at: bit.ly/LatchBook and can be in your hands as early as March 13, 2018!

Thank you for following along and I look forward to sharing more details about Latch over the next few weeks!

Iron Rich Foods for Infants and Toddlers

Rachel is a pediatric dietitian and mom to an infant and toddler.  She is the instructor of the “Introduction to Solids” at the San Diego Breastfeeding Center.  Join us for the next Introduction to Solids class on February 17th at 10:00am.  More information and registration can be found here.

At your baby’s 4 or 6 month checkup, your doctor may discuss starting your baby on solid foods.  It is an exciting time – up until this point your baby has been taking in all of his nutrition from breast milk or formula, and you get to shape his palate with new flavors and textures over the next 6 months and beyond. Your doctor may have talked to you about introducing iron rich foods early on. This is because iron stores in your baby typically start to become depleted around 6 months of age. I typically recommend families wait until 6 months of age to start solids (although I have heard pediatricians recommend between 4-6 months). 

It is common to hear that infant fortified cereals are a good first food.  Why?  Infant cereals are typically fortified with iron and lots of other vitamins and minerals, which is why foods like rice cereal have historically been discussed as a good first food. BUT now we know that iron fortified cereals are not the only option, and many parents skip them altogether to start on solid foods. Another benefit of skipping these cereals is that early exposure to more tastes and flavors has been shown to increase baby’s interest in the tastes and textures of new foods in the future.  Here are some great iron rich foods to offer right from the start:

Meats: meats can be a great food to introduce early on. Try stewing meats or using a slow cooker to allow for a softer texture.  If you are introducing pureed foods, you may need to add a bit of water with meats to allow the food to blend or try blending with other great first foods like avocado and sweet potato. If you are using a baby led weaning approach, try soft meatballs with minced chicken or beef.  Make chili and soup with chicken, beef, turkey and lamb. 

Lentils and beans:  I love these as dips, added to a sauce or as finger foods for a bit older baby.  Beans and lentils are super easy to make. Mash on their own or add to a sauce.  And if you take my introduction to solids class, I always bring in a sample that’s parent and baby approved, such as my green pea hummus or lentils - you can use these interchangeably as a puree for baby or a great dip for a slightly older toddler or an adult.  

Greens: spinach, chard and kale are a few food sources of iron. Saute them with other vegetables or combine them in a puree with meats. As your baby learns to drink out of a straw or an open cup add greens to a fruit smoothie for some added nutrition.

Eggs: Eggs are a good source of iron. An egg scramble with veggies is a great way to get in some iron, and lots of vitamins and minerals.

Grains: Often overlooked, but some grains are high in iron.  Some of my favorites include teff, amaranth, quinoa and millet.  Make cereals with these grains, use in chili or stew, or make muffins or bread.

These are only a few great sources of iron. Although breastmilk is typically thought of as a poor iron source, the iron in breastmilk is absorbed very well by baby and is still an excellent source of iron for your growing child.

And one more tip – iron is better absorbed with a source of vitamin C.  So for better absorption of iron pair an iron rich food with something like citrus fruits, berries, broccoli, apples or tomatoes. Also- breastmilk is an excellent source of vitamin C!

And remember that providing a balance of nutrients is important – iron is one of several important nutrients once baby starts solids. 

Want to learn more?  Join me at my upcoming Introduction to Solids class at The San Diego Breastfeeding Center on February 17th. Click here to register and for more information.

Breastfeeding Truly Takes a Village!

A few months ago, we sent out a Call for Breastfeeding Stories.  Our desire was to flood the Internet with beautiful breastfeeding stories of triumph, overcoming challenges and struggles, and positive outcomes, regardless of the total amount of milk a mom was producing.  We are thrilled to share these stories with you, our readers, and hope that they offer support and inspiration for you, wherever you are in your breastfeeding journey. 

Thank you to all of the mothers who submitted their stories!  If after you read these memoirs you are inspired to submit your story, feel free to send it to RobinKaplan@sdbfc.com.    

This Breastfeeding Memoir is from Natalie

Before my son was even born, I knew I wanted to breastfeed him. I attended multiple classes on breastfeeding, stocked up on nursing pads, nipple butter, and felt as prepared as I could be prior to his arrival. After a precipitous labor/delivery, he ended up being born in front of the hospital! One benefit was that I got to hold him immediately, so we had lots of skin to skin time which was emphasized in the classes. We tried breastfeeding within one hour of his birth, and he immediately latched! We had a lactation consultant visit at the hospital, and she said everything looked great! I even scheduled my first lactation appointment at SD Breastfeeding Center when my son was 4 days old. We weren't having issues, but I quickly learned that breastfeeding my son was way different than the practice doll we used in the class! During that visit, I learned my son had lip and tongue ties. Nobody else evaluated him for these, but being tongue tied myself it didn't come as much of a surprise. Fortunately, he was transferring well and the ties did not seem to be interfering with his feeding.

Fast forward 2 weeks, and my son was not at his birth weight. He was feeding for over an hour, falling asleep, and seemed very irritable and unhappy. As a new mom, I assumed this was normal. I pushed on for another week and then decided to schedule another visit with the LC for an evaluation. There, I did a weighted feed and learned that he wasn't transferring effectively. The LC explained how he was being restricted by his lip and tongue ties, and this could potentially decrease my supply. She recommended I consider a release of his ties, so I immediately called a provider and had them addressed the next day.

I read how many mothers noticed instant results and symptom relief post release. I didn't notice immediate results, but was confident that things would improve over the next few weeks. When they didn't, I followed up with Melanie, our LC. She assessed him and noticed that he still seemed restricted, wasn't transferring adequately, and recommended we take him for body work. Due to his poor weight gain (6 oz in 2 weeks) she taught me how to use my breast pump and implement an SNS (supplemental nursing system). She also recommended a galactagogue supplement. Things weren't moving in the direction I wanted, but I was committed to do everything I could to continue breastfeeding.

At this point, I was feeling very defeated and inadequate. I felt like I was doing everything I could, and was so sad that my little baby was not growing at the rate he should. My pregnancy and delivery were so natural and without issue that I naively thought breastfeeding would follow. I called my sister in law, who happens to be a breastfeeding mother.  She immediately came over with galactagogue-rich foods and tea, and even pumped for my son while I built up my supply!

After additional LC visits, support groups, and the implementation of bodywork, I made the decision to have a second release for my son. Even though we are still post op and performing stretches, I already am seeing results. My son is happier, and I no longer have to use the SNS system. I have a nice freezer stash of my milk, and he is thriving with weight gain. He's not even three months old, so I don't know how this journey will end. I do know, however, that I'll do everything I can to preserve our nursing relationship. Without the help of multiple providers, I'm not sure where we would be. "It takes a village" is such an appropriate phrase for this season of my life. I am so thankful to live in a community that has SO much support for breastfeeding mothers.

Breastfeeding After Breast Reduction - A Memoir

A few months ago, we sent out a Call for Breastfeeding Stories.  Our desire was to flood the Internet with beautiful breastfeeding stories of triumph, overcoming challenges and struggles, and positive outcomes, regardless of the total amount of milk a mom was producing.  We are thrilled to share these stories with you, our readers, and hope that they offer support and inspiration for you, wherever you are in your breastfeeding journey. 

Thank you to all of the mothers who submitted their stories!  If after you read these memoirs you are inspired to submit your story, feel free to send it to RobinKaplan@sdbfc.com.    

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This breastfeeding memoir is from Jenna

Ten years ago, eighteen-year-old Jenna was bouncing between San Diego and Los Angeles counties looking for a plastic surgeon. They had to be willing to do a keyhole incision and leave my nipple attached while they performed a bilateral breast reduction. I was a senior in high school and had my breast reduction surgery during spring break. 

Fast forward six years. I find out I'm pregnant the day my boyfriend gets to Djibouti, Africa, where he'll be deployed for the next 7 months. I sought out a natural birth provider in my network after reading the book, Defining your Own Success: Breastfeeding After Breast Reduction Surgery by Diana West. In this book, it encouraged mothers to birth as naturally as possible for the best chance at breastfeeding after a reduction and this book had become like a Bible for me, so I followed its every recommendation. After finding midwives, a doula and a baby-friendly hospital, I looked for an IBCLC and a Breastfeeding 101 class. I knew I needed to be prepared or I would succumb to all of the "boobie traps" within the first few days. My daughter was born on the much later end of normal, well past 42 weeks, was 9lbs 11oz at birth, and was born with a tongue tie and upper lip tie. I was given hell at the hospital for not wanting to give her formula, after requesting several times to be seen by the in-house IBCLC. The nurses and pediatricians said they'd never seen a mother be able to exclusively breastfeed after a reduction and feared that I wouldn't feed my baby because of my determination to nurse. 

At 6 weeks old, my daughter was diagnosed with life-threatening food allergies making even allergen-free, prescription-only formula not an option. The first six weeks I pumped after every feeding.  My husband spoon-fed, finger-fed, syringe-fed, cup-fed, & I used an SNS. At our 2 month pediatrician appointment, our doctor told me to quit trying and that what we were doing wasn't sustainable. I sought out chiropractic care, craniosacral therapy, multiple tongue tie revisions, continuous IBCLC care, breastfeeding support groups, homeopathic remedies, acupuncture, removed all allergens from my diet, quit my job, and somehow decided, breastfeeding was worth it all. From eight weeks old, we exclusively nursed through recurring tongue ties, vasospasms, low milk supply, mastitis, severe food allergies, thrush, and an abscess, for over 3 years, through a pregnancy and tandem nursing for a year and a half. Her younger sister is 28 months and we don't see an end in sight. 

We Were Not Meant to Mother Alone

A few months ago, we sent out a Call for Breastfeeding Stories.  Our desire was to flood the Internet with beautiful breastfeeding stories of triumph, overcoming challenges and struggles, and positive outcomes, regardless of the total amount of milk a mom was producing.  We are thrilled to share these stories with you, our readers, and hope that they offer support and inspiration for you, wherever you are in your breastfeeding journey. 

Thank you to all of the mothers who submitted their stories!  If after you read these memoirs you are inspired to submit your story, feel free to send it to RobinKaplan@sdbfc.com.    

_____

Our first breastfeeding memoir is from Michelle

I booked at least 2 vacations for my maternity leave, all on airplanes. I was going to wear my baby everywhere, nursing her as we went along. I had the organic breast pads purchased, all the nursing tanks, and the most breastfeeding-friendly bottles, but of course I wouldn’t need those for at least several months. I would see Mamas nursing their babes at the beach and I would find myself staring as I daydreamed about my nursling that was to come. December 2013, my sweet baby girl arrived.  She latched and we were a nursing team. 24hrs later I was told she was Coombs positive and her jaundice levels were high. She was sleepy, was losing too much weight and I needed to give her formula in a bottle. I cried lots of tears. "FORMULA? No way!", but I had no other options. Every time I fed her, and I wouldn’t let anyone else feed her.  I felt awful and felt like I was letting her down. 7 days later I was told, "your daughter is failure to thrive". Queue more tears, more formula, more guilt, and not a lot of milk being produced from me. 

Over the next month, my journey consisted of doctors’ visits, pumping 8x a day, a baby screaming at the breast due to bottle preference and low supply, tube feeding, domperidone, and yet my milk never fully came in. 5 weeks in, a friend asked me to go to a breastfeeding support group.  I went and hoped no one would notice me feeding formula to my sweet baby who wouldn't latch more than 5 minutes. Everyone noticed, yet no one judged me. 

3 months in, at the Breastfeeding Support group that I now attended weekly, a Mama who I hardly knew asked if I wanted her to pump for me, and then another offered to help, as well. This would begin my donor milk journey, and a mental shift in my head that allowed me to stop seeing what I wasn't capable of, and start enjoying the beauty that came from a community that would end up feeding both of my babes! I threw away my pumping and tube feeding schedule right along with the lies that told me I wasn't enough because I couldn't get my body to do what I needed to do to fully feed my baby. We kept nursing as much as possible until 10 months and she got half formula and half donor milk. 

A few months later, I was pregnant with my son. After my prenatal appointment at the San Diego Breastfeeding Center, I got permission from my doctor to start hand expressing at 37 weeks to collect colostrum to give my baby in the hospital through syringe feeding at the breast to help flush any jaundice he would have since he would be Coombs positive, as well. I started to collect donor milk and I had a community that donated enough breastmilk to supply him 9 full months as I only provided him about 30% of his needs with my own supply. He was born and I had a tiny bit more milk and a lot more confidence. I knew that no matter what, a nourished baby is a loved baby. I knew now that if I needed to give formula, I wasn't less of a mother.  If I fed my baby pumped milk, donated milk, only could nurse a few times a day, used a cover, didn't use a cover, nursed for 3 months or nursed for 3 years, no matter what, I WAS ENOUGH. Even after a 6 day stay in the hospital for his Coombs, a tongue and lip tie revision, and a micro supply, we nursed for 10 months with donor milk through the SNS tube feeding at the breast. We then fed formula in a bottle and nursed as often as he wanted. He nursed until 16 months. 

Today I am working towards my IBCLC, because of the non-judgmental support I received from the San Diego Breastfeeding Center community. They didn't sprinkle magic fairy breastfeeding dust on me that fixed all issues, but they gave me a plan that was doable. They gave me tools to accomplish the goals I set for myself.  They gave me hope and they provided me with a community that was there to cheer me on. When I think about my breastfeeding journey, it is less about feeding my children, and more about the discovery that we Mamas cannot mother alone; we were never intended to do so. It takes a village to raise a baby, and for me, it took a village to feed mine. I am forever grateful. 

Introducing the Top 8 Allergens to Infants

Written by Rachel Rothman, MS, RD, CLEC

A frequent question I encounter in my practice and in my Introduction to Solids classes, is how to introduce foods that may be allergenic to babies.  The last 15 years have brought significant attention to allergens, and most parents are now keenly aware of the risks.  However, a drumbeat of new research published on the causes of allergies and allergy prevention has brought new strategies to light and debunked old myths. Until 2008, the American Association of Pediatrics recommended that parents delay exposing infants to certain allergens until after one year of age. The guideline changed because after a review of research and patient outcomes, there was no evidence for waiting. I help many moms and dads make sense of this new world, as they are understandably cautious about what this all means for their child.

 

What are the top 8?

The “top eight allergens” are: cow’s milk, eggs, peanuts, tree nuts, fish, shellfish, soy and wheat.  These foods are associated with the eight most common food allergies, though it is possible for an allergy to occur with any food. 

So when can I introduce these foods?

Most pediatricians will tell you that you can begin to introduce these foods soon after starting solids. I usually recommend starting solids with foods not on the top 8 list, and getting 1-2 months of solids before introducing any of these more common allergens, just to note whether baby has any reactions to other foods.  That might mean you begin to offer the 'top 8' foods around 7-9 months of age.  And if your child is at a higher risk for food allergies, consult with your pediatrician.

When offering one of the top 8 allergens, it will be easiest if you only introduce one at a time, and that you observe and note any changes in baby in the first minutes, hours, or days.  If all goes well, wait a few days before offering another new food so you’ll be able to isolate any food that may be causing an issue.  If you’re concerned that something seems different, consult your pediatrician.

Let’s break down each of the allergens and discuss some ways to introduce:

Cow’s milk: Most of us have heard, no cow’s milk before one year of age.  This refers to the fact that cow’s milk should not be a replacement for breast milk or formula before the first year.  Why?  Cow’s milk has different nutrient properties than breast milk/ formula, primarily a higher proportion of protein and lower amount of fats and carbohydrates, including some differences in vitamins and minerals.  Breast milk contains the perfect proportion of all nutrients.  Cow’s milk should not be used as a replacement for breastmilk or formula. But, cow’s milk can be used in recipes, like soups, baked goods, or other foods before the first year.  Some families choose not to introduce cow’s milk, which is fine too.  This is a hot topic, so stay tuned for a post dedicated to the dairy debate!

Eggs:  Eggs are a staple in my house for my daughter, my husband, and myself.   It was previously thought to hold off on egg whites before one year of age, but like the recommendations for allergens, most pediatricians say you can introduce whole egg soon after starting solids- just be sure the egg is thoroughly cooked!  I love eggs as a finger food- they are so nutritious, and easy for baby to pick up and eat relatively early on.  Making an egg and vegetable scramble or frittata is a great way to include vegetables in baby’s breakfast as well.

Two-ingredient egg and banana pancakes: easy for baby to eat!
 

Peanuts and Tree nuts:  These are among the most highly allergenic foods, so be sure to monitor for reactions when introducing peanuts and tree nuts.  Keep in mind that whole nuts are a choking hazard for children until about 4 years of age.  When introducing nuts, try spreading a thin amount of nut butter on a piece of bread, mixing a bit of peanut butter into oatmeal or putting a very small amount of nut butter on a spoon (too large of a scoop can be a choking hazard, as well).  If your baby loves peanut butter as much as mine did, she’ll be well on her way to learning how to use a spoon!

Fish: Fish is great food for babies because of all of the nutrient benefits- just be sure fish is thoroughly cooked. Fatty fish is an excellent source of omega-3 fatty acids (specifically DHA) which baby needs for brain growth, especially under 2 years of age.  You will want to choose a fish type that is lower in mercury (some fish to avoid include King mackerel, marlin, orange roughy, shark, swordfish, tilefish, ahi tuna, and bigeye tuna).  The EPA has this great guide which lists the mercury content and sustainability level of many types of seafood. Flaked salmon can be a great finger food (or even mashed with avocado or sweet potato), or try making crab cakes or tilapia cakes.

A bit of flaked salmon, sautéed zucchini rounds and potato wedges – a perfect dinner for a 9 month old!
 

Soy: Some pediatricians do recommend waiting to introduce soy until baby is tolerating other foods.  If your baby has already been diagnosed with a soy allergy, you will want to speak with your pediatrician on it’s introduction, and keep in mind many packaged foods contain soy-based ingredients.  Baked or sautéed tofu can be a great finger food, or try adding tofu into lasagna in place of ricotta cheese.  You may want to wait until baby is about 9 or so months of age before introducing soy.

Wheat: Research and opinions are mixed on the introduction of wheat.  Many pediatricians recommend waiting on introducing wheat until other grains have been introduced (like oats, rice, or barley) to see if baby has any reaction to grains.  Wheat does contain gluten, and some babies might have a gluten intolerance or sensitivity, but note this will be different than a true wheat allergy. 

And again, always follow your pediatrician’s recommendations and speak with your pediatrician if food allergies run in your family, as the recommendations may be different.  Families of babies that have a history of an allergic condition, including a food allergy, asthma, allergic rhinitis or eczema, should absolutely speak with their pediatrician before offering any of these foods. 

Want to learn more about introducing solid food to your little one?  Join me at the San Diego Breastfeeding Center for my next introduction to solids class on January 28th at 10:00-11:30am. Learn more here

Rachel Rothman, MS, RD, CLEC is a mom, pediatric dietitian, and instructor at the San Diego Breastfeeding Center.  Rachel specializes in working with children and families.  She lives in San Diego with her husband, Ben, and daughter, Sydney.  You can contact Rachel here.

References:

Introduction of Solids and Allergic Reactions. (2009, December 7). Retrieved from https://www.aap.org/en-us/about-the-aap/aap-press-room/pages/Introduction-of-Solid-Foods-and-Allergic-Reactions.aspx

Fliescher, D. M. (2013, January 28). Early introduction of allergenic foods may prevent food allergy in children. Retrieved from https://www.aappublications.org/

Greer, F. R., Sicherer, S. H., & Burks, A. W. (2008, January). Effects of Early Nutritional Interventions on the Development of Atopic Disease in Infants and Children: The Role of Maternal Dietary Restriction, Breastfeeding, Timing of Introduction of Complementary Foods, and Hydrolyzed Formulas. Retrieved from http://pediatrics.aappublications.org/content/121/1/183

Age-appropriate Portions for Toddlers (and Moms)

This post is by Rachel Rothman, MS, RD, and is the third post in the three-part blog series about introducing solids to your little one.  Rachel is a mom to a toddler, a pediatric dietitian and instructor of “Introduction to Solids” and “Nutrition for Toddlers and Preschoolers” at the San Diego Breastfeeding Center.  Join us for the next Nutrition for Toddlers and Preschoolers class on October 29th at 10:00am.  More information and registration can be found here.

In case you missed it, I discussed the feeding relationship in my previous two posts, and these may be summarized using the division of responsibility. Parents are responsible for the “what, when, and where of feeding; children are responsible for the how much and whether of eating” [1].  In this third post we discuss age appropriate serving sizes – however, as with all nutrition advice, sustainably learning the behaviors associated with this division of responsibility will be as important, if not more influential, than simply choosing specific serving size, as all of our young ones progress at slightly different paces and individual ways.

Most of the food we eat- and the nutrient measurements we rely on – use the idea of serving sizes. But what does a serving look like?

Adults struggle with this because it’s hard to learn at home, and when we eat out, it’s nearly impossible to get consistent feedback.  As children, most parents did not learn to react this way, and an age of abundant and convenient food has limited the effects of our natural impulses.  

When we feed our children, many parents second-guess themselves and their children’s eating behaviors.  Is my child eating enough?  Is my child eating too much?  Here are some helpful guidelines when it comes to your children and serving sizes, starting from the beginning, when first introducing solids.

Tips and guidelines when thinking about the appropriate serving size for your infant and toddler:

- Around 6-7 months, as your baby is first starting solids, it’s important to remember serving sizes are very small.  If you are offering purees, you will want to start by offering 1-2 teaspoons, keeping in mind initially your baby may not take more than a small taste.  You will most likely be advancing to 1-3 tablespoons as your baby moves toward 7-8 months.

- From 6 months to around 1 year, breast milk or a breastmilk substitute should still make up the majority of your baby’s calorie intake.  Offer breast milk or a breastmilk substitute before solids, especially when starting out. 

- All babies are different.  Some babies love solids right off the bat and may take more than 2-3 tablespoons.  That’s okay!  It may take other babies some time to begin their solid intake and they may refuse for a while.  That’s okay, too! The important thing is to continue to offer solids, but let your child decide whether he/she wants to eat.

A typical toddler breakfast: 2-3 tablespoons of yogurt, 1/4 cup fruit and 2-3 small pancakes (and it’s okay if they don’t finish the whole thing!).

-Around 8-11 months your baby continues to grow, so does his/her appetite.  Solid intake may increase, but not by much.  A full day’s worth of solids might be: ¼ cup of fruit, ¼ cup vegetables, 1-3 tablespoons protein and ¼ cup whole grains.  A serving of vegetables, however, may still be closer to 2-3 tablespoons.  

- After one year of age, baby’s growth slows (most babies triple their birth weight over the first year!).  With a decrease in growth rate may also come a decrease in appetite.  Do not be alarmed if intake decreases after one year of age.  It’s most important to monitor your baby’s weight gain and growth. 

Snacks and lunch packed for daycare: 1/2 peanut butter and jelly sandwich, blueberries, oat and spinach muffin, string cheese and nectarine slices.

Additionally, after one year of age, your toddler may be eating more meals and snacks throughout the day.  When thinking about meals and snacks to serve, try to offer something from each food group.  Meals should consist of a fruit or vegetable, carbohydrate and protein, while a snack might consist of a fruit and vegetable and a carbohydrate. Don’t be afraid to think outside the box and try new things.   One of my daughter’s favorite on the go snacks is a mix of chick peas and green peas;  a combination of protein and carbohydrates with a healthy mix of vitamins and minerals.  

Stay positive! Picky eating behaviors often develop during this time and can persist as a phase many healthy kids go through.  If you stay positive and dedicated to offering a broad variety of healthy, whole foods, you have the best chance of continuing to nourish your little one while accommodating their tastes and preferences.

To learn more about introducing solids to your little one, join me at the SDBFC in one of my Introduction to Solidsor Nutrition for Toddlers and Preschoolers classes.  More information can be found here.

[1] Satter, Ellen M.,  Child of Mine: Feeding With Love and Good Sense, Bull Publishing Company; Revised edition (March 1, 2000) http://www.amazon.com/Child-Mine-Feeding-Revised-Updated/dp/0923521518 

Rachel Rothman, MS, RD is a mom, pediatric dietitian, and instructor at the San Diego Breastfeeding Center.  She lives in San Diego with her husband Ben and daughter Sydney. 

Understanding Infant Sleep - 6 weeks to 4 months

In our previous sleep article, we discussed normal sleep patterns and realistic sleep expectations for infants up to 6 weeks.  By the time we hit 6 weeks, our children have gone through so many developmental changes, including what shapes their sleep patterns.  What do these patterns look like now and when will you start to actually get some sleep?  

What does research tell us about sleep patterns for 6 week - 4 month old infants?

• Babies this age still receive about a ⅓ of their food during the middle of the night.

• Between 6 weeks and 4 months, babies begin ‘sleep consolidation’, which means that they start to combine 2 or more sleep cycles together without waking in between.

• Babies at the age tend to falls asleep more easily after eating in the middle of the night, which is a welcomed trend after the first 6 weeks of your child wanting to party after each meal in the middle of the night.

Take home message:  Your baby is still going to wake up in the middle of the night to feed, but he/she should be able to fall back asleep much more quickly after eating.  This means less walking around the house, singing lullabyes at 3am.  Whoo hoo!

What does science tell us about how babies sleep at this age?

• 6-12 week old babies still fall asleep in active sleep, i.e. dreaming, hence the eye movements, silly smiles, and sporadic arm movements. However, active sleep time becomes shorter and shorter at the beginning of the sleep cycle, which means you may only have to wait a few minutes before you can put your baby down without waking him/her.

• A baby’s circadian rhythm is settling in now, which means deeper sleep at night, with less jarring movements, allowing baby to stay asleep much more easily.

• 12-16 week old babies now fall asleep in quiet sleep, similar to adults. This means that your baby doesn’t fall asleep dreaming (REM), but rather begins to drift to sleep and stay asleep.

• Patterns vary from baby to baby, therefore it is not a lack of parenting skills if your baby is still waking every 2-3 hours in the middle of the night. It is important to remember that every baby is different and has different needs.

Take home message:  Your baby is going to start to fall asleep and stay asleep more easily.  His/her days and nights will no longer be mixed up and he/she will start to fall into a deeper sleep in the middle of the night.

What are common sleep patterns for a 6 week to 4 month old baby?

• Daytime naps are still sporadic and frequent. Some babies fall asleep right after eating, while others are awake after eating and then fall asleep after some alert time.

• Daytime naps can range from 20 minutes to several hours, while some of the longest naps can take place while you are out and about.

• Babies love to nap while being worn or out on a walk. The fresh air seems to lull them to sleep.

• Evening sleep will be all over the place, especially during the ‘witching hour.’ What this will most likely look like is eat, sleep for 20 minutes, eat, sleep for 20 minutes, and repeat for a few hours. Here are some great ways to survive the witching hour!

• Nighttime sleep is starting to get better. Your baby might have one longer chunk of sleep for the first half of the night (for example, like a 4-5 hour stretch between 8pm and 1am). Then your baby might continue to wake every 2-4 hours after that. Remember, your baby’s stomach is still really small and this frequent waking in the middle of the night is protective against SIDS.

Take home message: Babies at this age still have fairly unpredictable sleep patterns. Since your baby may start to sleep longer in the beginning of the night, you might consider going to bed earlier than usual, to take advantage of this long stretch of sleep.

What are some tips for parents to get more sleep?

• Mastering the sidelying position can be a game changer. Your baby is much sturdier than he/she used to be, therefore sidelying can be much easier and comfortable now, for both of you.

• Look into safe co-sleeping guidelines, as research has shown that families who safely co-sleep or bedshare get more sleep than those whose babies sleep in a different room.

• If you are uncomfortable with bedsharing for the whole night, consider setting your alarm for 20 minutes, while nursing in the sidelying position in bed. Then, if you end up falling asleep, your quiet alarm will wake you and then you can place your baby in his/her own bed, bassinet, or sidecar.

• Try what the authors of Sweet Sleep call ‘Front Loading:’ do more work early in the day and start to unwind earlier in the evening.  If you can unwind earlier, that means you can fall asleep earlier and easier, as well.  Check out this Huffington Post article about 15 Science-Backed Ways to Falls Asleep Faster

Resources for evidence-based info about normal infant sleep:

http://www.secretsofbabybehavior.com/2010/04/science-of-infant-sleep-part-ii-big.html

http://www.amazon.com/Sweet-Sleep-Nighttime-Strategies-Breastfeeding/dp/0345518470

https://www.psychologytoday.com/blog/moral-landscapes/201302/normal-human-infant-sleep-feeding-method-and-development