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.

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. 

How to Help Your Little One Feel Full with Solids

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

In my previous post, I addressed a parent’s responsibilities for the “when” (setting meal time) and the “what” (the food to be served) of feeding.  This approach is generally referred to as the feeding relationship: Parents are responsible for the “what, when, and where of feeding; children are responsible for the how much and whether of eating” [1].   The relationship is between parent and child, and between the child and the food they eat.  Now that we’ve established the parent’s responsibilities, we can move to the child’s responsibilities – whether to eat, and how much to eat.  

By controlling the WHAT, parents introduce foods, and should be actively monitoring how children respond. Getting started is fairly simple: you offer the food, and your child decides how much and WHETHER they want to eat it.  Yep, that’s it.  

However, this will surely bring a challenge (and for some, the harder obstacle to overcome) to be okay with how much and whether your child accepts the food.  

 

Start Small

When introducing solids to your little ones, starting small is essential to help him learn to physically accept solid food and learn to taste, chew, and swallow effectively.  If you choose to start by offering purees, offer a small amount of a pureed food to your little one.  If the child opens his/her mouth toward the spoon, help guide the food into his/her mouth.  If the child turns away from the spoon, trust his/her instincts that he/she does not want that food or is simply not ready.   If you choose to use the baby led weaning approach, start by placing food in front of your child on his/her high chair tray or the table. Trust that your baby knows what he/she needs.  And keep in mind, especially when starting out, breast milk or a breastmilk substitute will make up the majority of your little one’s calories and nutrition until he/she is close to a year old.  Your job is to help them learn how to eat.  You are letting them know they can choose how much and whether they would like to eat.  

When you move beyond purees and toward more complex foods, offered more frequently, this approach can, and often will, get more challenging.   As your child gets older and enters toddlerhood less of his/her nutrition may come from breast milk or a breastmilk substitute.  However, this is when it is more important than ever to keep in mind your child’s ability to self regulate.  As you offer more food at a given meal, you’ll be looking for signs that your child feels hungry.  That feeling (rather than a specific amount of food) helps your child to learn appropriate eating habits.

 

Experiencing Hunger and Feeling Full

Allow your child to experience the physical and cognitive effects of being hungry before eating - his/her young body’s regulatory reflexes come from feeling hungry and then knowing when he/she full.  

Research shows that children who are taught in this manner develop positive food attitudes, interest in eating a variety of foods, an intuitive sense of how much to eat, and long term skills for healthy eating and meal planning.[2]

There are a few things you can do to encourage your child to feel hungry and full, such as only offering a meal or snack every 2-3 hours (allow your child to feel hunger and sensation of fullness) and only offering water in between meals (rather than juice or sugary beverages).  

Eat Meals Together

Sit and have meals with your child, as time allows, and eat the same foods as they eat.  Not only will you be in a better position to monitor your baby’s preferences, but you can encourage her choices and ease her frustrations through words and sounds.  When your child tries a new food or enjoys an old favorite, you can show him that his choices matter to you.  Another benefit is cognitive: take the opportunity to teach your child the names of the foods he’s eating!

Lots of Exposure to the Same Foods

Keep in mind it can take up to 20 exposures of a new food before a child accepts it.  This is true when introducing solids to an infant as well as more complex foods to a toddler.  Before you rule out a food and dismiss your child as disliking it, keep offering it.  Chances are, after enough exposures, your child may have a change of heart.   While some degree of pickiness is normal, if you feel concerned with your child’s feeding habits, consult your pediatrician or a registered dietitian.

With the principles above, you’ll be on your way to raising a healthy eater!  Stay tuned for our next post, “Age-appropriate portions”.  If you’d like to keep exploring this topic with us, we’d love to see you in our next  Introduction to Solids class.

[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

[2] Satter, “Eating Competence: Definition and Evidence for the Satter Eating Competence Model” Journal of Nutrition Education and Behavior ● Volume 39, Number 5S, September/October 2007  http://www.ellynsatterinstitute.org/cms-assets/documents/101150-596171.ecdefandev.pdf

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.  You can contact Rachel here.

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

Two Things More Important than Portion Sizes when Offering Solids to Infants

Join Rachel Rothman, MS, RD in our three-part blog series to learn more about introducing solids to your little one.  Rachel is a pediatric dietitian and the instructor of our Introduction to Solids classes here at the SDBFC. 

Introduction to Solids, Serving Sizes, Feeding Relationship

When babies are 4-6 months of age, many moms start thinking about how much solid food kids should eat.  It’s easy to get caught up in a race toward the “starting solids” milestone, but what comes next?  Many parents wonder, now that their little one has started eating solid foods, how much is enough?  Am I making him/her overeat?  Am I wasting food? Am I teaching poor habits? 

What might reassure you is that as long as your selections contain a balance of protein, carbohydrate, fats and vitamins and minerals, measuring “servings” of food consumed may not necessarily be the best way to ensure your baby’s success at adopting a solid diet.  

First, take a step back. Renowned feeding expert Ellyn Satter, MS, RDN, MSSW gives parents the helpful suggestion of a “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” (Satter).   Babies have the innate ability to self regulate.  They will let you know when they want more, such as opening their mouths when food is offered.  Conversely, will let you know when they are full, such as turning away from the spoon and sealing their lips tightly.  

Rather than a fixed “serving” - offer food to your child, but look for signs that they are full.  With that in mind, you have two things in your control: when is mealtime, and what are you serving.

When is mealtime?  

A general idea of how many meals you should offer each day depends on the age of your child:

Once you have an idea of when those mealtimes and snack times fit into your baby’s wake and sleep schedule, you’ll want to establish some strategies for how much to offer at each serving.  Start small: when first introducing solids, 1-2 teaspoons is enough for your little one.  And remember, up to one year of age breast milk or formula will continue to make up the majority of your baby’s calorie intake.  

Next, think about the overall composition of the meal:

Thinking about the composition of meals, know that all babies are different and some may progress through textures more quickly (or more slowly) than others. That’s okay.  As discussed above, you can only control the what and when.  Your child is in control of the how much and whether.

This process is bigger than serving size.  You’re trying not merely to nourish your little one; but to introduce your little one to a variety of new foods, textures, flavors, and nutrients.  This diversity is part of a journey you’re on, together with your young child, to ensure their healthy relationship with food.  These approaches will help your child to develop the tools to succeed when making food decisions on his/her own.

Stay tuned for my next post: “How To Help Your Little One Feel Full” to learn more about introducing new foods to your child.

Understanding Infant Sleep - The First 6 Weeks

“I slept like a baby”  

When I hear this saying, I immediately envision sleeping deeply, soundly, and for 10 hours straight.  Whoever came up with that saying clearly didn’t have children!  All of the babies I know definitely do not sleep soundly for an extended period of time until at least toddlerhood… and even then sleep can be disrupted by teething, colds, and just regular night waking. With current infant sleep recommendations stating that babies should learn to sleep on their own, all night, by 6 months, I have to wonder how much of this information is hearsay and old-wives’ tales and how much is evidence-based (using good research models). 

So, let’s break this down using the most current research.  

SOURCE: UNITED STATES BREASTFEEDING COMMITTEE

What does research tell us about infant sleep patterns?

Today I am going to discuss sleep patterns and behaviors for infants during the first 6 weeks.  I will continue to share information about sleep patterns for older babies throughout the next few weeks.

How much does a 0-6 week old newborn typically sleep in a 24 hour period?

• Newborns sleep in short spurts, both day and night.

• Most babies this age sleep between 9-19 hours over a 24 hour period (that’s a huge variation!)

• Newborns have extremely small stomachs, which means they need to eat small, frequent meals, at least 8-12 times per day (as a minimum).  These feeding sessions can take anywhere from 15 minutes to over an hour, on average.  

• Newborns eat about ⅓ of their food during the night.

• Some babies may take one longer stretch of sleep at the beginning of the night (maybe 4 hours), but then may spend more time eating throughout the rest of the night and day to make up for the food intake they missed while sleeping longer. 

Take home message: It is biologically and developmentally normal for your baby to sleep in only 1-3 hour increments during the first 6 weeks because they are unable to eat enough at a feeding session to go for longer.  

Why do newborns wake often?

• Besides having a small stomach capacity, newborns are hard-wired to wake frequently during the day and night.  This is one of the ways their bodies are protected from SIDS.

• Newborns’ sleep cycles are different than adults: when they fall asleep, they spend more time in active (REM) sleep rather than quiet sleep (which means they wake more easily), their temperature doesn’t drop in the middle of the night (which means that they cannot distinguish daytime from nighttime), and they have no circadian rhythm.

• Newborns are often unable to join multiple sleep cycles together.  This takes a few months for their bodies to figure out.  A newborn sleep cycle is 45 minutes long.  You might get two sleep cycles strung together for 90 minutes of uninterrupted sleep, but then they are right back up again.

Take home message: Babies are programmed to wake frequently and sleep lightly.  This is developmentally normal infant behavior.

What are realistic sleep expectations for your 0-6 week old newborn?

• Your baby’s sleep patterns are going to be all over the place.  Unpredictable. Some short spurts (20 minutes).  Some long spurts (3 hours).  This is normal and will become more predictable over time. 

• Your baby is going to wake frequently during the day and night until he/she develops a circadian rhythm around 3 months.  At 3 months, your baby may still wake frequently during the night, but will at least be able to fall back asleep fairly easily and quickly.

• Your baby is also going to eat all of the time.  This is what builds and maintains your milk supply.  This is also what helps your baby gain weight and grow.

• Sleep patterns will be disrupted during growth spurts.  Growth spurts happen around 2 weeks, 4 weeks, and 6 weeks.  What this means is that your baby will sleep less for a few days and want to eat more.  Once these growth spurts pass, your milk supply should be even more robust than before and your baby will slow back down to eating slightly less frequently.

What are some tips for parents feeling really overwhelmed and sleep deprived with baby’s frequent waking?

• Sometimes just knowing that these sleep patterns are normal and temporary makes the situation seem more manageable.  Remember, your baby will eventually start sleeping for longer chunks of time (which we will discuss in the next few articles)

• Have your baby sleep on someone’s chest while you take a nap.  Babies LOVE to sleep on an adult’s chest and usually sleep a bit more soundly and longer.  This is not spoiling your baby or creating a bad habit.  This is meeting your baby’s developmental need to be near others.

• 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. 

• 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

• Start filtering out the misinformation you receive from others about what they think your baby should be doing regarding sleeping and eating.  This will only create a situation where you think there is a sleeping problem, when in actuality your situation is most likely perfectly normal.

In our next article about infant sleep, we will discuss normal sleep patterns for babies 6 weeks to 4 months.

Resources for evidence-based info about normal infant sleep:

http://www.secretsofbabybehavior.com/2010/03/science-of-infant-sleep-part-i-first-6.html

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

https://www.isisonline.org.uk/hcp/how_babies_sleep/

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

Top Tips for Introducing Solids to Your Baby

Written by Rachel Rothman, MS, RD

At your baby’s four-month visit, your pediatrician may have talked to you about starting your baby on solid foods and probably recommended to start between 4-6 months.  It’s usually recommended that baby can start solids when he/she is sitting up mainly on his/her own, has a pincer grasp, seems interested in food, and opens his/her mouth when food is offered.  As a pediatric dietitian, I get asked many questions about infant nutrition and starting baby on solid foods.  

(Note - many pediatricians may suggest it’s okay to start a baby on solids as early as 4 months, but it is important to note that the American Academy of Pediatrics’ statement on breastfeeding is as follows: Exclusive breastfeeding for about 6 months, followed by continued breastfeeding as complementary foods are introduced, with continuation of breastfeeding for 1 year or longer as mutually desired by mother and infant.)

Here are just a few of the things to keep in mind when your baby is ready for solid foods: 

1. At the beginning it’s still just for fun.  Your baby will still be getting most of his nutrients from breast milk or formula, so your goal should be to help him learn these new feeding behaviors.  Eating should be a fun experience, and not stressful.  If you begin feeding solid food and your baby has a hard time with it – she’s gagging or fussy  - wait and try again at a later time.  You will not do any damage by waiting a bit.  
2. Consider some key nutrients and focus on variety.  Key nutrients for babies and toddlers include vitamins A, C, and D, iron, total fat and omega-3 fats, and calcium.  Each of these nutrients serves a specific purpose within the body; around 6 months of age, babies require these in other forms, above what is in breast milk or formula.  Don’t be afraid to be creative with the foods you are offering to meet baby’s needs for these nutrients.  Infant cereal may be what your grandmother recommends, and it’s no slouch – its high iron content is helpful.  However, variety is important for teaching your little one to appreciate different food tastes and textures, so try purees of spinach, beans or lentils.   To help baby intake of additional omega 3 fatty acids, try adding chia seeds, ground flax or ground walnuts to purees.
3. Some foods should be avoided at the beginning.  A few foods you will want to avoid until baby is 12 months include honey (because of the risk of botulism), cow’s milk (it contains too much protein), and small solids (small chunks of raw vegetables, grapes, sausages, whole nuts and seeds can all be choking hazards).  Allergens are another consideration.  Recommendations about the foods to avoid (in order to minimize risk from allergic reactions) have changed over the years.  A 2008 review of research by the AAP concluded that the top 8 allergenic foods (cow’s milk, eggs, peanuts, tree nuts, fish, shellfish, soy and wheat) need not be avoided unless you have a family history of food allergies.  In that case, it is best to speak with your pediatrician before proceeding.
4. Serving sizes are small.  I hear a lot from parents that their baby is not eating enough.  But how much is enough?  A typical serving size when starting solids is 1-2 tablespoons of a puree or soft food - it’s a small amount.   And you will want to start by offering one to two meals per day.  Remember, baby will still be getting a good portion of her nutrition from breastmilk or formula until age one.  As baby gets older the serving size will increase, after 12 months the amount of food per meal should be around ¾ to 1 cup.
5. Division of Responsibility.  Renowned feeding expert, Ellyn Satter, gives parents the helpful suggestion of 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” (Satter).  Do not force your child to eat more or stop eating if you feel they have had too much.  Babies have the amazing ability to self regulate (many of us adults have long since lost this ability). Eating is a behavior that does need to be learned, but does not need to be rewarded.
6. Milk feedings first.  Ashley Treadwell, IBCLC at the San Diego Breastfeeding Center offers these tips for protecting your mill supply when starting solids. "When it comes to maintaining your milk supply, this can be one of the most important rules to follow when offering your baby solids.  Be sure that baby is always offered the breast first, and then solids.  If baby is filling up on solids, she may not remove as much milk from the breast as she needs.  Over time, milk left in the breast tells your body to stop producing as much which will decrease your milk supply.  If you are sure that baby is taking all the milk he/she needs from the breast prior to offering him solids, you will help to maintain your supply to meet your baby’s needs."

When feeding baby don’t forget about mom and dad.   All too often I see mom and dad focused so much on baby’s health and wellness that the parents’ health and wellness falls by the way side.  Remember to practice good nutrition for yourself, this will not only help you to feel better, but to set a good example for your child.  Healthy and happy mom and dad lead toward a healthy and happy baby!

Want to learn more about starting baby on solids? 

Join me at the San Diego Breast Feeding Center on June 17th from 10-11:30 am for a class on introducing solids.  More information can be found here.

When Should I Introduce Solids While Breastfeeding?

Dear SDBFC,

Thanks for responding to this question on Facebook the other day, but I would love to hear more on this topic: does breast milk start losing its nutritional value after 6 months? If the pediatrician states solids (in particular enriched rice cereal) twice a day are needed, are there any alternate opinions? I'm curious if the WHO or LLL have any alternate evidence.

Sincerely,

Abby

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Dear Abby,

Thank you for your excellent questions.  Solids are a huge topic of discussion in our weekly breastfeeding support group and pretty much every pediatrician in town has a different philosophy.  Here’s what the official organizations recommend:

The World Health Organization: “Infants should be exclusively breastfed for the first six months of life to achieve optimal growth, development, and health.  Thereafter, to meet their evolving nutritional requirements, infants should receive nutritionally adequate and safe complementary foods while breastfeeding continues up to two years or beyond.

The American Academy of Pediatrics: “Introduction of complementary feedings before six months of age generally does not increase total caloric intake or rate of growth and only substitutes foods that lack the protective components of human milk.”

Based on these recommendations, it is not that the breast milk is losing nutritional value at 6 months, or even a year!  It is that your baby is beginning to need additional nutrition, which is supplied by complementary foods.  Plus, complementary foods start out as little bites, not full bowls of food.  It is a very slow process.

So why do these organizations recommend delaying solid foods until your baby is at least 6 months? 

Here’s what the research says.....

1. Your baby’s digestive tract is not fully ready to accept anything other than breast milk until she/he is at least 6 months old.  This is when your baby’s intestinal tract is finally sealed against allergens and will be able to digest a greater variety of foods.

2. As stated on Kellymom.com, the pancreatic enzyme amylase does not reach adequate levels for digestion of starches until around 6 months, and carbohydrate enzymes such as maltase, isomaltase, and sucrase do not reach adult levels until around 7 months. Young infants also have low levels of lipase and bile salts, so fat digestion does not reach adult levels until 6-9 months.  When foods aren’t digested well, babies can have negative reactions (eczema, gas, constipation, etc.) 

3. Most babies don’t need iron supplementation (see our article Do All Exclusively Breastfed Babies Really Need Iron Supplementation to see if your baby is one who is at risk for anemia), so the excess iron given through iron-fortified foods (cereals) actually DECREASES a baby’s efficiency in iron absorption when given before 6 months of age.  Most exclusively breastfed babies have enough iron stored in their bodies to last for at least 6-9 months.

4. Delaying solids helps to protect a mom’s milk supply and decreases her risk of early weaning.

So, do you have to start with iron-fortified rice cereal when your baby is ready for solids?  NO!  Iron-fortified white rice cereal is almost completely void of nutritional value.  I am completely guilty of starting this with my oldest child, as I didn’t know any better, yet it was such a waste. 

Go for the whole grains and foods! 

Choose REAL food! 

What are your options for those first solid foods? 

One of my favorite websites, Wholesome Baby Food, gives a fantastic list of foods to start with your infant.  La Leche League gives similar recommendations, as well.  How much better does this list sound than boring rice cereal?

Avocado

Banana

Whole grain cereal

Pear

Squash

Sweet potatoes

Lastly, do you have to start solids the minute your baby turns 6 months old?  No.  Wait until your baby is showing signs of being able to tolerate solid foods, such as sitting up unassisted, developing a ‘pincer’ grasp, and is willing to gnaw and chew food.  For a detailed article about solid food readiness, check out Kellymom.com’s article, Is My Baby Ready for Solid Foods?,  as well as The Womanly Art of Breastfeeding.

Sincerely,

SDBFC

Do you have a question you would like answered by our lactation consultant? Please post it in the comment section, on our Facebook page, or to our Twitter Account (@SanDiegoBFC). We would love to feature it in an upcoming Help A Breastfeeding Mama Out article!