Baby and Beyond - The Feeding Survival Guide: Paula Elbirt, MD

Last Editorial Review: 10/23/2003

By Paula Elbirt
WebMD Live Events Transcript

Babies grow and change so fast, and their diet requirements change with them. We learned how to meet the nutrition needs of your child at every stage of life when pediatrician Paula M. Elbirt, MD, was our guest in the WebMD University Student Lounge.

The opinions expressed herein are the guest's alone. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only and is sponsored by Enfamil.

Moderator: Welcome to WebMD University: "Feeding Yourself, Feeding Your Baby." This event is sponsored by Enfamil. Our instructor today is pediatrician "Dr. Paula," Paula M. Elbirt, MD.

Dr. Paula: Parenting is the hardest and most rewarding job out there. I am privileged to be both a parent and a guide for parents so enjoy this hour and remember your children are your most precious gift to the future.

Member: What do you think of Enfamil Lipil? I have a 7-month-old on Enfamil with Iron. He was breastfed for his first five months and weaned himself.

Dr. Paula: This new formula has been long awaited and adds to the importance of knowing what we're feeding our babies by expanding the quality of supplementary feedings. Breast is still superior on many levels that cannot as of now be replicated in the laboratory, but the addition of these essential oils or fatty acids takes us a huge step closer to the right stuff. I look forward to other formulas and early infant first foods similarly being manufactured with these essential fatty acids, so look for them.

Member: I am nursing a healthy 8-month-old girl and working full time, so I pump while I am at work. I am only able to pump three 3-ounce bottles to leave for her during the day. She is eating some foods, but I am concerned that I am not leaving enough milk for her. How much milk should an 8-month-old be drinking in a 10-hour period?

Dr. Paula: Yours is a very common problem compounded by the anxiety you feel about how much milk your baby is getting directly from your body. Pumping does, in fact, result in fewer ounces produced than direct breastfeeding but the majority of the benefits that we expect from breast milk is still provided at this age by the 10 ounces or so of milk that you are providing. Most infants at this age still drink closer to 25 ounces a day so you may need to provide formula supplementation if you cannot nurse more often, but it would be just as advantageous to your baby if you would nurse after work directly and let nature provide the correct total amount in that way. Your body will adjust to producing more milk at night by this method and your baby will not need as much or perhaps any formula supplementation. Also know that at 10 months, you will see a natural decline in milk intake so that by 1 year of age, many infants only require 16-20 ounces of milk a day.

Member: Why does pumping produce less milk?

Dr. Paula: Clearly, the human system of contact between an actual baby's mouth and your actual nipple is the most advantageous. Anything less similar to that such as a pump will decrease the quantity by removing some of the basic natural stimulants that exist when mouth touches nipple. Some people have measured oxytocin levels produced during pumping and, not surprisingly, the levels are lower than with direct breastfeeding. It also hurts more to pump for some women and that signal also turns down production.

Member: I have a 1-year-old who has recently started waking up at night, sometimes two times, and wants a bottle. She had been sleeping all night while I was breastfeeding but seems to only want the bottle during the night.

Dr. Paula: Your baby misses the physical contact with your body and probably no longer needs nighttime feeds. In fact, continuing to offer nighttime bottles may contribute to more frequent wakeups, not to mention nutritional imbalances. What your baby needs to eat during the day may be diminished by large intakes at night or if not, may just add unnecessary calories. I strongly suggest holding your baby when she wakes, preferably close to your chest, and then lying your baby back down with a light garment like a T-shirt that you were holding together with your baby during that wakeup. This will provide most of what your baby really is looking for and hopefully diminish the nutritional errors that are made when this common situation occurs. Good luck and persist because your baby is willful and strong and won't go easily back to sleep for a good week or so. Don't give up!

Member: She refuses the bottle during the day and we are constantly playing with her. She will eat her food but not the bottle.

Dr. Paula: Again, your baby's refusal of daytime bottles supports the idea that your baby really doesn't need more milk and certainly doesn't need it at night. What she wants you can give her simply by holding her and don't worry about her total milk intake. It will rearrange itself in a few weeks so that she gets the 16-20 ounces she needs during daytime hours. Remember, don't give up!

Member: I breastfed my first child for two and a half years. I now have a four month old who has just gone completely to formula. My question is whether or not it is possible to build a milk supply back up enough to at least pump and supplement with breast milk if not to go completely back to nursing. I would love to nurse again but because of some complications in the beginning, formula has always been a part of the equation and has only increased as my supply decreased from not nursing frequently enough. Any suggestions?

Dr. Paula: Yours is also an unfortunate but common situation. Most women who have only quit breastfeeding for one month or less can in fact reinstitute breastfeeding. You may need the consultation of a lactation specialist to get started but a breast pump and a lot of fluids and determination can get you where you want to be. A device that allows your breast milk to be enhanced by additional formula can also be useful in getting your baby to suck on your breasts again directly, and it is well known that direct sucking on your breast will get you the success you want faster than other methods such as pumping. This is a worthy goal but don't be too hard on yourself. Whatever you produce is beneficial no matter what the amount. Good luck!

Member: I'd like to breastfeed and use formula. At what age is it OK to start introducing formula?

Dr. Paula: Breast milk is best for the entire first year of life and the addition of formula is usually associated with a decrease in breast milk production. Therefore, it would be best to delay the use of formula when possible for as long as possible, certainly at least until after the first three months when most immunologic factors are transferred from breast milk to baby. Many circumstances interfere with full breastfeeding and you should not feel pressured by the breast milk quality to do anything that might harm you, but continue breastfeeding for as long as you reasonably can.

Member: I am pregnant with my fourth child. I was only able to breastfeed my first for a few weeks, my second for a few weeks, and my third not at all. I had terrible postpartum [depression] with my last two. Does it offer any advantage to only breastfeed for a few weeks?

Dr. Paula: Any amount of breastfeeding is a great gift to give your new child. Interestingly, some research strongly points to nursing as an advantage for women with a history of postpartum depression and you may want to inquire about this with the intention of delaying the addition of formula for both your benefit and your baby's. Certainly, a happy, healthy mother is of vital importance to your infant so let that be your guiding principle. Gynecologic endocrinologists are the specialists you would want to check with.

Member: I have an almost 4-month-old, when is a good time to introduce cereal? What are some signs I can look for from my baby?

Dr. Paula: Early introduction of solids such as cereal is now understood to be less than a good idea for your infant and when possible, delaying this introduction until close to 6 months would be best. We now know that adding cereal or other foods earlier than 6 months contributes to the development of allergies, eczema, and asthma, as well as obesity. Most important, never add cereal to a bottle as that system is not only developmentally inappropriate but it can be harmful to your child's health. I'm glad you asked about signs of readiness and the most important one is being able to sit up with little or no support. Most infants are close to or even beyond 6 months when this happens. Babies smacking their lips when you're eating dinner doesn't mean they want your food. There will be plenty of time soon for exotic foods; wait now for everyone's benefit.

Moderator: When you do start on solids, is there a preferred order?

Dr. Paula: Although many doctors pay little attention to the order of food introduction when giving new parents instructions, there is good, solid research to support introducing foods in a conscientious manner one at a time and in simple to complex order. That is, always start with single-component foods rather than mixtures, and choose low-allergenic type foods over the more risky ones such as wheat and egg. Wheat and egg should not be introduced until a year of age even for children with no family history of allergies. The list is long but start with cereals. Move on to fruits and vegetables and only move on to complex proteins when your baby is closer to a year of age. Complex proteins include animal protein and fish protein. Simple proteins exist in vegetables like soybeans and in dairy products.

Member: Is there a certain amount of cereal/fruits/veggies for my 7-month-old? When should I start finger food and what kinds of finger foods?

Dr. Paula: One of my golden rules is to let your child lead the way. Quantity of food is one of those important areas of control that you should relinquish to your baby with some caveats. Your new eater may not have the skill to ingest as much as she needs in the first few weeks, so offer solids several times a day even if only a few tastes occur each time. This will familiarize your infant with the technique for swallowing solids as well as for the taste and texture and digestion of them.

Similarly, finger foods depend on your child's development. An important tip is to put whatever finger foods you offer not only in front of your child but also in each of your child's hands. The balance your child needs for ordinary hand to mouth coordination at this age is best achieved with the two-handed approach; not to mention you will still have the opportunity to spoon feed when her hands are already occupied. Most infants are not ready for finger foods until after 8 months, but teeth are not a requirement as an infant's hard gums can do satisfactory damage to soft food as any breastfeeding mom whose been bit can attest to. Don't fret over quantity and attend to quality in choosing your child's menu.

Member: Why is it unacceptable to feed my 6-month-old milk, but my pediatrician recommended that I give her yogurt?

Dr. Paula: Ordinary milk is processed in a way that is difficult for the infant gut to utilize and the result can be nutritional deficiency and iron deficiency anemia when ordinary milk is used in the place of breast milk or formula before age 1. Another problem with ordinary milk is that the lactose is difficult to digest and yogurt is a lactose-free way to introduce a semi-solid to your infant's growing menu. Be sure you use active live-culture yogurt, preferably whole milk yogurt, for your infant to ensure adequate fat intake and to address the lactose issue. Only live culture guarantees that lactose will not be a problem.

For more fun information about this subject, you might want to check out Chapter 11 of my Good Nutrition Guide for Babies, Toddlers, and Preschoolers. It's called "The Good and Bad 'Moos' About Milk."

Member: My 1-year-old weaned herself off formula but won't really drink milk. Sometimes she drinks it; mostly she just lets it dribble back out of her mouth. She's eating table food and drinking juice and water. Should I be concerned about her not wanting milk?

Dr. Paula: First, dump the juice. Even if it's calcium-fortified, it is nutritionally imbalanced and does more harm than good. Your 1-year-old doesn't need as much milk as you probably think. Remember that a slice of cheese is equivalent to 2-4 ounces of milk depending on the quality of the cheese, so home-made pizza and cereal with milk and a little yogurt more than covers most infant's calcium and vitamin D needs. For a true milk rejecter, you may need a vitamin D supplement to be sure your child gets enough. Your doctor can prescribe that. A 1-year-old needs only 16 ounces equivalent of milk a day.


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Some infants reject milk because they experience discomfort when drinking it from lactose intolerance, although this is not as common as people think. You might try lactose-free milk but you will have to search for whole milk versions and they are difficult to find. True milk allergy is very rare and very obvious in that your infant would not just reject milk but would also have physical signs you could not miss. Most infants reject milk because they are in need of other types of textures and foods and it is the parent who is usually most anxious as a result of not knowing how different the needs of a toddler are from the huge milk needs of early infancy. Count the ounces in these other dairy products before deciding to continue urging milk on your infant. And never offer chocolate milk as an incentive.

Member: My baby has breast milk intolerance when I eat milk products. There is a family history of food allergies. Our doctor has told me not to eat any milk, wheat, or soy products. Why is she having a reaction and is it the breast milk?

Dr. Paula: Your doctor has put you on the right track as far as protecting your infant from future allergies. The protein of cow's milk passes easily into breast milk much the way that medications do. So, you are feeding your baby cow's milk through your breasts to a degree when you ingest cow's milk products yourself. This is not uncommon. Even moms without strong allergic histories should be cautious with their cow's milk intake during the nursing period and remember you don't need to drink milk to make milk. Cows eat grass!

Dr. Paula: I drove my poor mom crazy as a kid, not eating anything she fed me. Can anything be done to avoid getting a taste of my own medicine as a parent? Or are picky eaters born that way?

Dr. Paula: Picky eaters are made, not born, and usually they are made by example. I suggest that you broaden your own food choices if you are still picky as a way of modeling good eating habits for your child. Don't expect quick results, but in the long run, the more variety both in color and category of foods that you present to your infant, the more likely you will avoid the picky eater syndrome. Vegetables and fruits are usually eagerly eaten when they are presented as finger foods and in interesting shapes.

Don't overreact to your growing infant's choosiness, which is not the same as picky eating. Your infant's interest in round shapes should only lead you to provide round food at the right age (meaning early toddlerhood). This is not an introduction to picky eating. Parents are very often hyper-eager to introduce new and interesting foods to their child's menu but choosing carefully extends to safety issues as well as nutritional ones. Your infant's gag reflex goes a long way to guiding you so that if your baby returns foods that you think are soft enough, that is probably a signal that the foods were not soft enough for safety. A good early finger food is a soft-baked french fry along with soaked Cheerios, but never leave your child unwatched while eating and aim for appropriate shapes that fit not only in your child's hand comfortably but also cannot block your child's airway. Anything larger than a nickel needs to be cut smaller. Number one foods to be avoided are: carrot sticks, all nuts, hot dogs, and popcorn. I'm also a fruit fan but avoid berries unless you squash them first and your baby is over a year of age. They make unfortunately perfect plugs.

Moderator: Grapes too!

Member: What is your opinion of the impact of Bovine Growth Hormone (bGH)? Do you give your daughter milk from cows that could have been injected with this hormone?

Dr. Paula: Mounting evidence is pointing to the risks involved in additives for any kind for children's foods including hormones in milk. However, as the story is not yet complete, most milk products, with the exclusion of formula, do contain hormone additives. To the extent that you can avoid any food additives without compromising your child's total nutrition, you should aim for purity of food.

Moderator: Dr. Paula, we are almost out of time. Before we wrap up for today, do you have any final comments for us?

Dr. Paula: Food for thought: There are so many pitfalls and potential errors to be made in raising our children that sometimes we miss the mark in the key components of parenting and that is to pay attention to our child's needs above the needs of convenience and time-saving and to make the most joy of every interaction. You will never regret the time you spent on this. And last, never mistake calories for nutrition.

Moderator: Here are some other tips from Dr. Paula's Good Nutrition Guide for Babies, Toddlers, and Preschoolers.

Dr. Paula's Ten Commandments of Nutrition

1. Thou shall not confuse love with food.
2. Thou shall not use food to control behavior.
3. Though shall not punish or reward your child with food.
4. Thou shall not turn the dining-room table into a battlefield.
5. Thou shall not overreact to a picky eater.
6. Thou shall understand that children don't need as much food as you think they do.
7. Thou shall not get hung up on three meals a day.
8. Thou shall not fear fat in your infant.
9. Thou shall not create a dessert monster.
10. Thou shall not mistake calories for nutrition.

The Four Types of Eaters

Generally, your child will arrive in this world fitting more or less into one of the following categories:

  • The grazer: This is particularly common style for toddlers who "munch" as they toddle about.
  • The ruminator: Ruminators are children who put food in their mouths, but hardly ever swallow. (It's an hour later, and the mashed potatoes are still in there.) This child may become a picky eater.
  • The barracuda: This eater rolls through the table at dinnertime -- maybe eating off of every family member's plate. This child can consume large amounts of food and may be destined to be obese.
  • The stuffer: As the name implies, the child eats quickly (as if a sibling is poised to come by and steal his food) and stuffs lots of different foods into his mouth. (Stuffers often complain of stomachaches.) This child may end up being an overeater.

Moderator: Thank you Dr. Paula, and thank you members for joining us today. For more information, please read Dr. Paula's Good Nutrition Guide for Babies, Toddlers, and Preschoolers: Answers to Parent's Most Common Questions Plus Help for Coping with Fussy Eaters, as well as Dr. Paula's House Calls to Your Newborn.

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