Nutrition

What Every Parent Needs to Know

By William H. Dietz, Loraine Stern

American Academy of Pediatrics

Copyright © 2012 American Academy of Pediatrics
All rights reserved.
ISBN: 978-1-58110-321-2

Contents

Please Note,
Foreword,
Introduction,
Chapter 1: What’s Best for My Newborn?,
Chapter 2: Expanding Your Baby’s Diet,
Chapter 3: The Toddler Years,
Chapter 4: Nutrition During the School Years,
Chapter 5: The Adolescent Years,
Chapter 6: Is My Child Overweight?,
Chapter 7: Is My Child Too Thin? Too Small? Too Tall?,
Chapter 8: Nutrition Basics,
Chapter 9: Spitting Up, Gagging, Vomiting, Diarrhea, and Constipation,
Chapter 10: Eating Disorders,
Chapter 11: What Do I Do About Outside Influences?,
Chapter 12: Can I Cut My Child’s Risk of …?,
Chapter 13: Food Safety,
Chapter 14: Food Additives,
Chapter 15: Alternative Diets and Supplements,
Chapter 16: Is My Child Allergic?,
Appendixes,
A: What Caregivers Need to Know: A Checklist,
B: Food-Medication Interactions,
C: Standard Growth Charts,
D: Body Mass Index Charts,
E: Food Substitutions,
F: Choking/CPR,
G: Dietary Reference Intakes,
H: The DASH (Dietary Approaches to Stop Hypertension) Diet,
I: Health and Nutrition Resources,
Index,

CHAPTER 1

What’s Best for My Newborn?

Like many new parents, you’re probably eager to do what’s “right.” We want to stress at the outset that you’re embarking on one of life’s greatest and most rewarding adventures — namely parenthood. Usually there is no right or wrong way; instead, it’s a matter of deciding what works best for you and your baby. So relax. Enjoy getting to know your new baby and trust your own sense of what’s right for you.

When Laura and Jim Hawkins brought baby Emily home from the hospital, they were overjoyed and overwhelmed. “We were absolutely delighted to finally have a baby,” Laura recalls, “but neither of us knew anything about infant care. Since I planned to breastfeed, I figured I’d instinctively know what to do. It didn’t take long for reality to set in!” Nurses at the hospital helped Laura start breastfeeding and showed her such baby care basics as diapering and bathing. But in just 2 days, the Hawkinses were on their own at home. “For weeks we called our pediatrician almost daily with questions,” Laura recounts.

Not surprisingly, many of these questions dealt with Emily’s feedings. “How often should I feed her?” “How can I tell whether she’s getting enough milk?” “Should I give her supplemental formula ‘just in case’?” “Does she need extra iron and vitamins?” “What about water?” “Her stools are runny and yellowish. Does she have diarrhea?” “I have a bad cold. Is it safe for me to breastfeed?” “What should I do if I’m unable to nurse for a few days?”

Common Concerns

Many if not most new parents have similar concerns. In fact, parents ask pediatricians more questions about how and what to feed their babies than about any other aspect of early child care. Although this book is intended to answer the most frequently asked questions, it’s important to remember that no 2 babies are exactly alike. What’s good for your baby isn’t necessarily good for your sister’s or your neighbor’s. Your pediatrician is your best source of advice about what’s best for your baby, and you should not hesitate to discuss any concerns with him or her.

Decisions, Decisions

Even before your baby’s birth, you need to decide how you want to feed her. Will you feed your baby breast milk or formula? The American Academy of Pediatrics (AAP), the American Dietetic Association, and other organizations concerned with health and nutrition of newborns, infants, and children advocate exclusive breastfeeding for a minimum of 4 months but preferably for 6 months (about the time your baby’s diet begins to include solid foods), and to continue breastfeeding until the baby is 12 months old or as long as baby and mother want to continue.

The AAP has always advocated breastfeeding as the best way to nourish babies. Breastfeeding is best for the health of babies and mothers alike. In addition to numerous benefits, it is economical and convenient.

Breastfeeding guidelines recommend that health insurers cover necessary services and supplies. They emphasize the importance of providing workplace facilities where working mothers can pump and store milk to save for their babies.

Even though breastfeeding is a natural function, most women need help getting started. Prenatal classes often include breastfeeding instruction. Some doctors’ offices and most maternity centers have lactation consultants — specially trained nurses or other health professionals — who teach the basics of breastfeeding. Maternity nurses and physicians also help teach new mothers.

In an ideal world, you should deliver your baby at a hospital whose staff can help you with breastfeeding. Unfortunately, the trend toward 24- to 48-hour hospital stays following delivery often doesn’t allow enough time to ensure that all is going smoothly before going home. If problems arise after you leave the hospital, don’t give up on breastfeeding and switch to bottle- feeding at the first sign of difficulty. Your pediatrician can give advice and may recommend a lactation consultant. Many of these lactation experts make home visits. There are also support groups and telephone hot lines for nursing mothers. Relatives and friends may be able to provide help as well. (See Appendix I).

Getting Started

The offspring of any mammal instinctively seeks out a nipple and begins sucking within minutes of being born. Similarly, most human babies are alert and eager to suckle shortly after birth, provided there are no medical problems. Mothers who breastfeed while still in the delivery room typically describe a deep sense of pleasure and satisfaction. The earlier breastfeeding starts, the easier it is for mother and baby. However, if the first attempt is delayed, breastfeeding can still be initiated successfully later. Olfactory bonding — through which a baby learns to recognize his own mother’s scent — develops while the mother holds her baby, even if he is not suckling. Mothers allowed to breastfeed their baby soon after delivery have their milk come in sooner than mothers who do not.

The first time you breastfeed your baby is a time when you can discover how the baby can find your nipple and start to breastfeed. One way to do this is to put the baby on your abdomen or chest using what is called skin to skin, where the baby’s skin is in direct contact with yours. You may find it helpful to open or remove your gown so that you have nothing in the way between you and your baby. With the baby facing you, you may notice that she will start to move her body and start sucking while moving toward your nipple. Once at your nipple, the baby will begin to breastfeed. Don’t worry if it takes a little time for your baby to find your nipple.

At some point, you may need help positioning your baby comfortably and getting him to latch on properly. To do this, with your baby in front of you, lying on his side, belly to belly, bring his head up to your breast until his nose is level with your nipple. Hold your baby with one arm and use the other hand to support the breast. Gently stroke his lips with your nipple to stimulate his rooting reflex and interest in nursing. Position the nipple toward the upper portion of the baby’s mouth (Figure 1–1). You also may try squeezing out a few drops of milk, then lightly brushing the nipple against your baby’s lower lip; this will further stimulate his desire to nurse and prompt him to open his mouth wide. When his mouth is fully open, quickly bring your baby to the breast with his lips around the areola and the nipple deep in his mouth (Figure 1–2). When Figure 1–2 your baby is ready, let him position his lips around the areola with the nipple deep in his mouth. Make sure your baby’s face is not at an angle to your nipple but facing straight on to your breast. Your baby’s chest and abdomen also should be facing directly toward your chest and abdomen. His neck should be straight and not turned.

Latching On

It’s important to position the nipple far back in your baby’s mouth so that it touches the roof of her mouth and she is able to compress the areola, which is the dark area around your nipple (Figure 1–3).

If she latches on to only the nipple, milk can dribble out the side of her mouth. In addition, sucking on the nipple Figure 1–3 alone can make it sore and cracked, leading to excessive pain during nursing. You’ll soon be able to feel whether your baby is suckling properly; in the beginning, check that the nipple and most of the areola are inside your baby’s mouth, with her nose and chin just touching the breast and the lips looking like her mouth is wide open. Her jaws should move up and down, and she should swallow after every few sucks. If you have continuing pain, take your baby off the breast and reposition her. If your breasts are large and your baby’s nose is buried, draw her bottom and legs closer to your midsection and lift your breast up a bit from underneath to let your baby breathe from the sides of her nose as she nurses.

When your baby stops nursing, gently break the suction by inserting a finger in the corner of her mouth. This lets in some air and encourages your baby to let go. To prevent injury to the nipple, do not pull your baby off the breast while she is still suckling and tightly attached.

Finding the Right Position

Almost all nursing mothers describe breastfeeding as a highly pleasurable experience, but to make it so, you need to find a position that is comfortable for you and your baby. Experiment with the following positions until you find what works best for you at various times:

Lying Down (Figure 1–4)

You and your baby lie on your sides facing each other. Bring the baby toward your breast and allow her to latch on. Place a pillow under your head and another behind your back so you can be comfortable. A pillow between your knees is also comfortable. Women recovering from a cesarean delivery often find this the most comfortable position; it’s also good for night feedings. After the feedings, put your baby back in his crib. It’s the safest place for him to sleep. Keep your baby’s crib as close to your bed as possible. This will make it easier to breastfeed during the night.

Cradle Hold (Figure 1–5)

Sit in a comfortable chair or in bed with pillows tucked behind your back, under your arm on the nursing side, and on your lap to support your baby. Position your baby on his side with his tummy close to yours, his head cradled in the crook of your arm with his face next to your breast, his back resting along your forearm, and his bottom supported by your hand. In this and other positions, he should be able to latch on without turning his head. If your baby is very small or has a weak sucking reflex, try supporting the back of his head with your other hand rather than placing it in the crook of your elbow. (This is sometimes called the modified cradle or transitional hold.)

Clutch, Side, or Football Hold (Figure 1–6)

Sit in a comfortable chair (a roomy rocker is ideal) with a pillow on your lap to bring your baby up level with your breast. Position him with his legs under your arm and his head resting on your hand. If your arm gets tired, support it on a pillow or your thigh (bend your knee and place your foot on a stool or low table). The side position works especially well if you have large breasts or flat nipples, or after a cesarean delivery.

Breastfeeding and Intelligence

Several studies of children’s development reveal some intriguing findings about the relationship between breastfeeding and intelligence. Children who had been nourished on human milk did slightly but consistently better on standard tests in school than those who were fed formula. The longer they were breastfed, the better they did. What’s more, the advantages persisted well beyond early childhood. The breastfed children were more likely to complete high school irrespective of their family income, education, and standard of living, among other factors. Thus, breastfed babies appear not only to be healthier but also to do better in school.

Breast milk’s nutritional factors, its effect on lower rate of illnesses, and its psychological effects may also help explain breastfed children’s better performance in school.

Vitamins for Breastfed Babies

Human milk provides sufficient amounts of vitamins, except for vitamin D. Vitamin D helps absorb calcium and is needed to build healthy bones and teeth. Although human milk contains small amounts of vitamin D, it is not enough to prevent rickets (softening of the bones). Your pediatrician should prescribe a vitamin D supplement for your breastfed baby; in fact, the AAP recommends that all breastfed babies receive 400 IU of oral vitamin D drops, starting during the first few days of life and continuing until they are drinking vitamin D-fortified formula or milk (500 mL or about 17 oz). Most commercial formulas are fortified with vitamin D and other vitamins to ensure that babies get enough of these essential nutrients.

A mother who follows a vegan diet, which excludes all foods of animal origin, should talk to her pediatrician about her baby’s vitamin needs. A vegan diet lacks vitamins D and B. A vitamin B deficiency in an baby’s diet can lead to anemia and nervous system abnormalities.

For many years, some doctors have told parents that babies in highly allergic families may react to certain foods the mother eats that then pass into the breast milk, such as the protein from cow’s milk or cheese, or from eggs, seafood, and nuts. However, the AAP has concluded that at this time, there is no evidence that dietary restrictions in a nursing mother can play a significant role in preventing allergic diseases such as eczema, food allergy, or asthma. In rare cases, such as certain metabolic diseases, a baby may not be able to tolerate human milk and will need a special formula. A physical abnormality that makes it difficult for a baby to suckle normally, such as a cleft palate, may make breastfeeding impossible (see “Cleft Lip” and “Cleft Palate” on page 22). Mothers should remember that their pumped milk should be the first choice for any baby that needs a supplemental feed.

Formula Feeding

Breastfeeding has many advantages (see “The Special Health Benefits of Breastfeeding” on page 3), but there are instances in which it is not possible (for example, when a baby has a condition such as classic galactosemia, also known as GALT deficiency, which is a rare, inborn inability to digest a type of sugar [lactose] in milk). A mother may also be advised not to breastfeed when she is HIV positive or has a serious disorder, such as hepatitis B or tuberculosis, that could be passed in the breast milk, or takes medication that might harm her baby (see “Why Some Women Should Not Breastfeed” on page 15). Personal factors may make nursing impossible, and some women or their partners are not comfortable with the idea or harbor mistaken notions about what it entails (see “Common Myths About Breastfeeding” on page 24). At any rate, learn as much as possible about breastfeeding well before your due date and talk over the pros and cons with your obstetrician and pediatrician to make the best decision for your baby and yourself.

There are many kinds of infant formulas; most are based on cow’s milk, but there are also several formulas available for babies who cannot tolerate cow’s milk. Regular cow’s and goat’s milk, as well as canned condensed or evaporated milk, should not be given during the first year of life. Young babies cannot digest the protein in cow’s milk. Regular cow’s milk also doesn’t have enough iron and other vitamins or the right amounts of the minerals that are essential for proper growth and development. A child may lose blood through the stools because cow’s milk can damage the intestine.

A baby may have a problem that requires a special formula as the primary food or as a supplement to human milk. For example, premature or low birth weight babies may need special formulas to supply the extra energy and nutrients they need for growth. In these small babies the sucking reflex may not be fully developed, in which case they will be fed with a special tube or by bottle. Still, a premature baby can benefit from the antibodies and other unique components of human milk. Mothers of premature and other high-risk babies are usually encouraged to express their breast milk, which may be fortified with the additional nutrients needed and fed to her baby. When the baby is ready to breastfeed directly from mother, the switch can be made.

What’s in It for My Baby?

Although no formulas on the market even come close to matching the hundreds of known ingredients in human milk, most provide a comparable balance of fat, protein, and sugar. Formulas are also supplemented with various vitamins and minerals, especially calcium, iron, and vitamins C, D, and K. Should you choose not to breastfeed, your pediatrician can advise which formula is most suitable for your baby. Regardless of which formula you use, it’s critical that you prepare it according to instructions. It is especially important not to add more or less water than recommended.

Families who are short of money may be tempted to add extra water to make the formula go farther. Formulas are designed to provide the energy (about 20 calories per ounce) and nutrients that a baby needs for proper growth. If the formula is diluted, your baby will be underfed and may have stunted growth and develop serious nutritional deficiencies. Formula that is too concentrated can also be dangerous. Not adding enough water can result in dehydration, kidney problems, and other potentially serious disorders.

Sterilizing and Warming Bottles

Parents and pediatricians today are not as concerned with sterilizing bottles and water as they were a generation ago, but many are now having second thoughts in light of recent reports of contaminated city water supplies and increased concern over food safety. For starters, always wash your hands before handling baby bottles or feeding your baby. If you use disposable plastic bottle liners and ready-to-use formula, you still need to make sure the nipples are clean. Scrub them in hot, soapy water, then rinse to get rid of all traces of soap; some experts recommend boiling them for 5 minutes. Always wash and thoroughly rinse and dry the top of the formula can before you open it; make sure the can opener, mixing cups, jars, spoons, and other equipment are clean.

(Continues…)Excerpted from Nutrition by William H. Dietz, Loraine Stern. Copyright © 2012 American Academy of Pediatrics. Excerpted by permission of American Academy of Pediatrics.
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