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The American Academy of Pediatrics has increased the recommended daily requirement for Vitamin D in children and adolescents to 400 IU (international units), based on studies of decreasing bone density in kids. This is equivalent to 32 ounces of milk per day. This is TOO MUCH milk for anyone other than an older formula-fed baby who has not yet started solids foods. All breastfed babies, babies on formula AND solid foods, and all other children and teens should be given a vitamin D supplement such as Tri-Vi-Sol or a chewable children’s vitamin. Read the labels: look for “Vitamin D—400 IU.” The goal is to prevent rickets (a bone disease that results in brittle bones) and to make sure growing bones reach their maximum potential for strength. Vitamin D is also important for other body systems such as the immune system.

Interestingly, 15 to 30 minutes of direct sunlight per week is all kids need to absorb enough vitamin D through skin. However, concern for increased risk of skin cancer from cumulative sun exposure means that kids are absorbing less vitamin D from sunlight because we parents are so good at applying sunscreen. Also, especially in winter months, children spend more time playing inside than playing outside.

Calcium requirements vary somewhat by age but generally can be met with 16 to 24 ounces (2-3 cups) of milk, or less if kids consume other calcium containing foods such as cheese, yogurt, broccoli, sweet potatoes, fortified cereals, or a supplement. The milligram (mg) requirements are around 500mg for toddlers, 800mg for children and 1200-1500mg for kids 11-18 years. To give you an idea of how to visualize this amount, one cup of milk contains 300mg of calcium. When you read food labels that report calcium as a percent of daily requirement, know that the “standard” for food labels is set as 1000mg. So if a yogurt container reports “25% of daily calcium requirement” you assume that the yogurt contains 250mg of calcium (25% of 1000mg).

So continue to have your kids Drink Milk! But remember to give them a Vitamin D supplement as well.

For more interesting tidbits about milk, please refer to our blog post: “Got Milk? Dispelling Myths About Milk

Julie Kardos, MD
©2009 Two Peds in a Pod

 

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Acetaminophen, brand name Tylenol, has been in the news recently, and parents are asking me if it is safe.


This medication, used as a pain reliever and as a fever reducer, is safe to give to babies older than two months, but you must be very careful about the dose that you give. Medicine doses are based on the weight, not the age, of a child. So when checking the label on the bottle that tells how much acetaminophen to give, look at the weight recommendations if there is a discrepancy between your child’s weight and age. If you are not sure, then ask your child’s health care provider. I cannot stress proper dosing enough because of how dangerous an overdose can be.


 Here are some facts you need to know in order to avoid over-dosing your child with Tylenol:


1)      Always measure the medicine in the dropper or cup provided by the manufacturer of that particular medicine bottle.


 


2)      Be aware that Tylenol infant drops are more concentrated than the children’s suspension liquid. This means that if you were to pour out equal amounts of infant drops and children’s suspension, the amount of drug is actually HIGHER in the measurement of infant drops than in the same measurement of children’s suspension. For example, one full infant dropper of Infant Tylenol Drops, measured to the 0.8ml line of the dropper, is 80mg of Tylenol. The same 0.8ml of Children’s Tylenol Suspension Liquid is only 25mg.


Another way to look at this medicine math: if you intended to give 80mg = 2.5ml = 1/2 teaspoon of Children’s Tylenol Suspension Liquid   but you actually gave your child 2.5ml = ½ teaspoon of Infant Tylenol instead of Children’s Tylenol, you would be giving them over 240 mg of Tylenol, which is THREE TIMES the amount that you wanted to give. Again, use the dropper provided to give Infant Tylenol drops and use the cup provided when dosing the Children’s Tylenol Suspension Liquid.


 


3)      Note that other medications have acetaminophen (Tylenol) in them. I advise my patients’ parents to avoid combination cold and flu medicines for two reasons. First, there is little evidence that shows that they actually provide symptom relief. Second, from a safety perspective, parents can accidentally overdose their child with acetaminophen because many contain acetaminophen in them. For example, as of this writing, the following medications all contain acetaminophen as stated in the ingredient list:


Benadryl  Allergy and Cold Tablets, Sudafed PE nighttime Cold Maximum Strength Tablets, Theraflu Nighttime Severe Cold and Cough Powder, Tylenol Plus Children’s Cold and Allergy Suspension, Tylenol Sore throat Nighttime liquid, Tylenol Chest Congestion Liquid, and Nyquil.


4)      Be aware that “APAP” in the ingredient list means acetaminophen.


Tylenol overdoses can be fatal by causing liver failure. If your child has a chronic liver disease, it is likely that she should avoid Tylenol altogether.


Because of the risk of overdose, I also avoid advising my patients to “alternate Tylenol (acetaminophen) with Motrin (ibuprofen).” I discourage this practice because I am afraid of parents forgetting which medicine they gave last and possibly over-dosing by mistake. Tylenol is meant to be dosed every 4 to 6 hours unless otherwise specified on the label or by your child’s health care provider. 


If you ever have questions about possible overdose, call the national US Poison Control Center at 1-800-222-1222.


Julie Kardos, MD
©2009 Two Peds in a Pod

Addendum 10/11/2011: The manufacturers of Tylenol (acetaminophen) responded to the hazard of parents and caregivers accidentally giving the wrong dose of infant drops ( see point #2 above) and stopped making the “concentrated infant drops.” Instead, they now manufacture the “infant drops” and “children’s liquid” using the same concentration as each other. Continue to use the measuring dropper or cup provided with the medication for proper measuring.

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A friend of mine who has no children commented to me that many people tell him, “You just can’t know happiness until you have children of your own.” However, I know several adults who are very happy people and who have made a conscious decision to not have children. So I would actually amend the above adage to: “You just can’t know WORRY until you have children of your own.”


Especially in winter, many illnesses circulate. All these sick kids make for many worried parents. Some questions that I answer many times a day in the office are: “Okay, Doc, you just told me that my child is handling her illness right now, but how will I know if she is getting worse? When do I need to worry?”


Here is what I tell my patients’ parents:


First and foremost, trust your parent instincts that something is wrong.


Think about these THREE MAIN SYSTEMS: breathing, thinking, and drinking/peeing.


Breathing:


Normally, breathing is easy to do. It is so easy, in fact, that if you take off your child’s shirt and watch her breathe, it can be hard to see that she is breathing. You should try this while your child is healthy. Normal breathing does not involve effort. It does not involve the chest muscles.


If your child has pneumonia, bad asthma, bronchitis, or any other condition that causes respiratory distress, breathing becomes hard. It becomes faster than baseline. It involves chest muscles moving so it looks like ribs are sticking out with every breath. The chest itself moves a lot. Kids’ bellies may also move in and out. Nostrils flare in attempt to get more oxygen. Sometimes kids make a grunting sound at the end of each breath because they are having difficulty pushing the air out of their lungs before taking another breath in. Also, instead of a normal pink color, your child’s lips can have a blue or pale color. Pink is good, blue or pale is bad. Children old enough to talk may actually have difficulty talking because they are short of breath. Any of the above signs tell you that your child needs medical attention.


Thinking:


This refers to mental or emotional state. Normally, children recognize their parents and are comforted by their presence. They are easy to console by being held, rocked, massaged, etc. They know where they are, and they make sense when they talk.


Change in mental state, whether it comes from lack of oxygen/shortness of breath, pain, or severe infection, results in a child who is inconsolable. She may not recognize her parents or know where she is. Instead of calming, she may scream louder when rocked. She may seem disoriented or just too lethargic/difficult to arouse. Being very combative can also be a sign of not getting enough oxygen. In a baby, extreme pain can cause all these signs as well.


Drinking/peeing:


While this varies somewhat depending on the age of the child, most kids urinate every 3-6 hours or so. Young babies may urinate more frequently than this and some older kids urinate perhaps 2-3 times daily. You should know your child’s baseline. Normal urine reflects a normal state of hydration. If you don’t drink enough, you will urinate less.


If your child has fever, coughing, vomiting, or diarrhea, she will use up fluid in her body faster than her baseline. In order to compensate, she needs to drink more than her baseline amount of liquid to urinate normally. A child will refuse to drink because of severe pain, shortness of breath, or change in mental state, and may go for hours without urinating. This is a problem that needs medical attention. Occasionally a child will urinate much more than usual and this can also be a problem (this can be a sign of new diabetes as well as other problems). Basically any change from baseline urine output is a problem.


A note about fever: any infant 8 weeks of age or younger with fever of 100.4 F or higher, measured rectally, requires immediate medical attention, even if all other systems are good. Babies this young can have fever before any other signs of serious illness such as meningitis, pneumonia, blood infections, etc. and they can fool us by initially appearing well.


In older babies and children, fever is defined as 101 F or higher. Some kids can look quite well even at 104 and others can look quite ill at 101. Fever is a sign that your body’s immune system is working to fight off illness. In addition to fever, it is important to look at breathing, thinking, and hydration state because this will help you determine how quickly your child needs medical attention. A child with a mild runny nose and fever of 103 who can play still play a game with you while drinking her apple juice is less ill than a child with a 101 fever who doesn’t recognize her parents.


To summarize, any deviation from normal breathing, thinking, or drinking/urinating (peeing) is a problem that needs medical attention, even if no fever is present. In addition, any change in the wrong direction (getting worse instead of getting better) is a problem that needs medical attention.


Finally, all parents have PARENT INSTINCT. Trust yourself. Ultimately, if you are wondering if you should seek medical advice, just do it. If parents could just worry every problem away, no one would ever be sick.


Julie Kardos, MD with Naline Lai, MD
© 2009 Two Peds in a Pod

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Sudden Infant Death Syndrome, or SIDS, refers to the sudden unexplained death of an infant between the ages of 1-12 months and seems to occur during sleep. We (meaning pediatricians and the rest of the scientific community) still don’t know exactly what causes SIDS, although we do know that some babies seem to be more at risk, such as premature infants and infants of multiple births (twins, triplets, etc).While parents cannot control prematurity and multiple births, parents CAN control other risk factors. 

Here is a summary of ways to reduce the risk of Sudden Infant Death Syndrome (SIDS) as recommended by the American Academy of Pediatrics:

·    Place babies on their backs (supine) to sleep. Do not waste money buying positioners or wedges for the crib because they are not proven to prevent SIDS and are not endorsed by the American Academy of Pediatrics. A newborn cannot roll from back to stomach. If you start out always placing your infant down on his back to sleep, he will stay this way and learn to like to sleep this way. Side sleeping is not as safe as back sleeping.

·    Do not sleep with your baby in a chair, couch, or adult bed. You can take your infant into your bed to nurse/feed but then put him back in his own sleep space.

·    Do not let your infant sleep in a bed with older siblings. Put your baby in his own crib.

·    Put nothing in the crib other than your baby. No stuffed animals, blankets, pillows, etc. Even bumpers are not recommended.

·    Do not smoke in the room where your baby sleeps.

·    Offer a pacifier. This has a protective effect.

·    Breastfeeding has a protective effect.

Some parents admit to us that they place their babies stomach down (prone) to sleep because “the baby sleeps better that way.” Unfortunately, what seems to be easier in the short run isn’t always the best for children in the long run. For the same reason that you should insist your children wear bike helmets and seatbelts, even if they protest at times, you should put your children down on their backs (supine) to sleep as infants. The rate of SIDS in the USA has dropped by over 50% since 1994 after the start of a “Back to Sleep” campaign. This sleep position change has been the single most effective way, to date, of reducing the rate of SIDS. Of course if your child has any rare medical condition that may prevent supine sleep, your child’s doctor should advise you on the safest sleep position for your child.

The best way to form good habits is to use them from the beginning. It is perfectly safe to position your newborn on his belly during awake time/ playtime while you are with him. However, if you are putting your baby down to sleep, or if you are putting your baby down and walking away and during this time he might fall asleep, just put your baby down on his back. And remember to tell anyone else who cares for your baby the same instructions, including daycare workers, nannies, and even well-meaning grandparents, because safe sleep advice has changed over the generations.

 

Julie Kardos, MD  and Naline Lai, MD
©2009 Two Peds in a Pod

 

 

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And speaking of vaccines…

Do you ever wonder how a vaccine works?

To understand how vaccines work, I will give you a brief lesson on the immune system. Trust me, it is interesting. Let me give you an example of me. When I was eight, I had chicken pox. It was a miserable week. I started out with fever and headache, then suffered days of intense body itching from blister-like spots, and ultimately, because I “scratched off” some scabs, ended up with scars. During this time, my immune system cells worked to battle off the chicken pox virus. Immune cells called memory cells also formed. These cells have the unique job of remembering (hence the name “memory cells”) what the chicken pox virus looks like. Then, if ever in my life I was to contact chicken pox again, my memory cells could multiply and fight off the virus WITHOUT MY HAVING TO GET SICK AGAIN WITH CHICKEN POX. So after I was well again, I was able to play with my neighbor even while he suffered with chicken pox.  I even returned to school where other children in my class had chicken pox, but I did not catch chicken pox again. Even now, as a pediatrician, I don’t fear for my own safety when I diagnose a child with chicken pox, because I know I am immune to the disease.

This is an amazing feat, when you think about it.

So enter vaccines. A vaccine contains some material that really closely resembles the actual disease you will protect yourself against. Today’s chicken pox vaccine contains an altered form of chicken pox that is close to but not actually the real thing. However, it is so similar to the real thing that your body’s immune system believes it is, in fact, real chicken pox. Just as in the real disease, your body mounts an immune response, and makes  memory cells that will remember what the disease looks like.  So, if you are exposed to another person with chicken pox, your body will kill off the virus but YOU DON’T GET SICK WITH THE CHICKEN POX. What a beautiful system!

Before chicken pox vaccine, about 100 children per year in the US died from complications of chicken pox disease. Many thousands were hospitalized with secondary pneumonia, skin infections, and even brain damage (encephalitis) from chicken pox disease. Now a shot in the arm can prevent a disease by creating the same kind of immunity that you would have generated from having the disease, only now you have one second of pain from the injection instead of a week of misery and possible permanent disability or death. I call that a Great Deal!

All vaccines operate by this principle: create a safe environment for your immune system to make memory cells against a potentially deadly disease. Then when you are exposed to someone who actually has the disease, you will not “catch” it. Your body will fight the germs, but you do not become sick. If everyone in the world were vaccinated, then the disease itself would eventually be completely eradicated. This happened with small pox, a disease that killed 50 percent of infected people. There is no longer small pox because nearly everyone on earth received the small pox vaccine. Now we do not need to give small pox vaccine because the disease no longer exists. This is a huge vaccine success story.

Friedrich Nietzsche said “What doesn’t kill us makes us stronger.” We pediatricians feel this is unacceptable risk for children. We would rather see your child vaccinated against a disease in order to become immune rather than risking the actual disease in order to become immune.

Hopefully this blog post answers your questions about how vaccines work. For more details or more in depth explanations, I refer you to the AAP (American Academy of Pediatrics) website www.aap.org, the Children’s Hospital of Philadelphia’s Vaccine Education Center at www.chop.edu,  and the book Vaccines: What You Should Know, by pediatricians Dr. Paul Offit and Dr. Louis Bell.

Julie Kardos, MD and Naline Lai, MD

© 2009 Two Peds In a Pod®

updated 1/18/2015

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Stumbled onto a novel use for a diaper, courtesy of the nursery nurses at Doylestown Hospital. 

Diapersmake a perfect ice pack.  At the end of the diaper which has adhesivetabs, make a hole in  the inner lining.  Push your hand into the diaperto separate the the lining from the back of the diaper.  This will makea pouch.  Put crushed ice into the pouch and roll the end of the diaperwith the hole a couple times.  Secure with adhesive tabs. Now you havea soft, waterproof icepack which will remain cool as the ice melts andis absorbed by the gellatinous diaper innards.

Perfect for all sorts of boo-boos.

WhenI told one of my patients’ mom about this hint today, she told me thatshe used a number 5 diaper when her water broke.  I suppose Plato wasright , necessity is the mother of invention.

Naline Lai, MD

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I’ve heard some interesting things about milk over the years. I am going to share with you three myths about milk that  I heard when I was a kid and I still hear from my patients’ parents.


Myth #1: Don’t give milk to a child with a fever, the milk will curdle (or some other variation).


Truth: As long as your child is not vomiting, milk is a perfectly acceptable fluid to give your febrile child. In fact it is superior to plain water if your child is refusing to eat, which is very typical of a child with a fever. Fevers take away appetites. So if your child is not eating while he is sick, at least he can drink some nutrition. Milk has energy and nutrition, which help fight infection (germs). Take milk, add a banana and a little honey (if your child is older than one year), and maybe some peanut butter for protein, pour it into a blender, and make a nourishing milk shake for your febrile child. Children with fevers need extra hydration. Even febrile infants need formula or breast milk, NOT plain water. The milk will not curdle or upset them in any way. If, on the other hand, your child is vomiting, I advise sticking to clear fluids until his stomach settles.


Myth #2: Don’t give children milk when they have a cold because the milk will give them more mucus.


Truth: There is NOTHING mucus-inducing about milk. Milk will not make your child’s nose run thicker or make his chest more congested. Let your runny-nosed child have his milk! Yet my own mother cringes when I give any of my children milk when they have colds. Never mind my medical degree; my mom is simply passing on the wisdom (?) of her mother which is that you should not give your child milk with a cold. Then again, my grandmother also believed that your body only digests vitamin C in the morning which is why you have to drink your orange juice at breakfast time. But that’s a myth I’ll tackle in the future.


Myth #3: You can’t over-dose a child on milk.


Truth: Actually, while milk is healthy and provides necessary calcium and vitamin D, too much milk can be a bad thing. To get enough calcium from milk, your child’s body needs somewhere between 16 to 24 ounces of milk per day. Of course, if your child eats cheese, yogurt, and other calcium-containing foods, she does not need this much milk. The recommended daily intake of  Vitamin D was increased recently to 400 IU (International Units).  This amount translates into 32 ounces of milk daily.  But, we pediatricians know that over 24 ounces of milk daily leads to iron deficiency anemia because calcium competes with iron absorption from foods. You’re better off giving an over-the-counter vitamin such as Tri-Vi-Sol or letting older children chew a multivitamin that contains 400 IU of vitamin D. In addition to iron deficiency anemia, drinking excessive amounts of milk is bad for teeth (all milk contains sugar).  Extra milk can also lead to obesity from increased calories. Ironically, too much can also lead to poor weight gain in children who are picky eaters.  The milk will fill them up, leaving them without an appetite for food.


In summary, you can safely continue serving your children milk in sickness and in health, in moderation, every day. Now, all this talk about milk really puts me in the mood to bake cookies…


Julie Kardos, MD

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Well it finally happened.  The day all mothers with daughters regard with mixed feelings.  No, I’m not talking about my daughter’s first period.  Today I discovered that my oldest daughter’s foot size is the same as mine.

I took it as a sign.  Time to blog a little about shoes and feet.

First shoes:  Shoes are to prevent injury to feet. While indoors, let your infant stand and walk without shoes.  Bare feet are best.  Your baby will learn to balance better when he or she can feel the floor directly under her feet.  However, for protection, shoes are needed.  Start with a sturdy sneaker.  No need for the clunky white leather shoes of the past.  Also, avoid sandals, toddlers are more liable to trip and there is not much protection against stinging insects.

For school: The average length of recess per day is about 30 minutes(
www.centerforpubliceducation.org)  Therefore, pick comfy shoes which allow your children to utilize this time for physical activity.

Athlete’s foot: Caused by a fungus, athlete’s foot appears as wet, moist, itchy areas usually between the toes.  The fungus loves moist areas and can be treated with over the counter antifungal creams or powders such as clotrimazole (Lotrimin AF), and tolnaftate (Tinactin). While common in teens, athlete’s foot is much less common in general than foot eczema. Vinegar soaks are helpful- put half a cup of vinegar into a small basin of warm water and have your child soak for 10 minutes daily. 

If your child has eczema on other areas of his or her body, be more suspicious of eczema than athlete’s foot. Both can look alike, but be careful, the steroid creams used for eczema may worsen athlete’s foot.

Flat feet: Most children with flat feet have flexible flat feet which do not require any intervention. Nearly all toddlers have flexible flat feet. A child with flexible flat feet will not have an arch upon standing.  However, the arch should reappear when the child’s feet are relaxed in a sitting position off the floor. Any pain in the arch or suspicion of an inflexible flat foot should be brought to a physician’s attention.

Ingrown toe nails: Ingrown toe nails occur when the sides of the nails grown into the skin.  After enough irritation, bacteria can settle in and pus pockets form.  To prevent ingrown toe nails from becoming infected, at the first sign of redness, soak feet in warm water with Epsom salts.  Gently pull the skin back from the area of the nail which is in grown.  Attempt to cut off any area of the nail which is pushing into the skin.

Clipping newborn toe (and finger) nails: A newborn’s nails have not separated enough from the nail bed to easily get a nail clipper under a nail. For the first few weeks, stick to filing the nails down.  Parental guilt warning: at some point almost every parent mistakenly cuts their child’s skin instead of their nail.

Naline Lai, MD

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Parents often ask how they can tell if their child has The Flu or just a common cold. Here’s how:


A cold, usually caused by one of many viruses such as rhinovirus, starts out gradually. Think back to your last cold: first your throat is scratchy, then the next day your nose gets stuffy or then starts running profusely, then you develop a cough. Sometimes during a cold you get a fever for a day or two. Sometimes you get hoarse, losing your voice. Usually kids still feel well enough to play and attend school with colds, as long as their fevers stay below 101 and they are well hydrated and breathing without difficulty. The average length of a cold is 7-10 days although sometimes you feel lingering effects of a cold for 2 weeks or more.


The flu, caused by influenza virus, comes on suddenly and basically makes you feel as if you’ve been hit by a truck. Flu always causes fever of 101 or higher and some respiratory symptom such as runny nose, cough, or sore throat (many times, all three at once actually). Children, more often than adults, sometimes have vomiting and/or diarrhea with the flu along with their respiratory symptoms. Usually the flu causes total body aches, headaches, and the sensation of your eyes burning. The fever usually lasts 5-7 days. All symptoms come on at once; there is nothing gradual about coming down with the flu.


Fortunately, vaccines against the flu can prevent the misery of coming down with the flu. In addition, vaccines against influenza save lives by preventing flu related complications that can be fatal such as flu pneumonia, flu encephalitis (brain infection), and severe dehydration. Hand washing also helps prevents spread of flu as well as almost every other disease of childhood. Please see our blog post on flu posted on September 6, 2009 for more information on prevention and care of children with flu.


The much touted “Tamiflu” is a prescription medication that can ameliorate the effects of the flu. In an otherwise healthy person, this medicine can shorten duration of symptoms by ½ to 1 day. Are you underwhelmed by this fact? So is the medical profession, which is why we reserve this medicine for people ill enough to need hospitalization or who we know have underlying medical conditions, because this medicine has been shown to decrease hospital stays and complication of flu in people who have asthma, diabetes, immune system defects, and heart disease.


Because of all the hype over the novel H1N1 flu (again, please see our blog post on this subject) I am already getting many anxious phone calls and office visits from parents who are worried that their child might have “the flu” when their children are having runny noses and some cough but no fever. Hopefully this blog post will help you sort out your child’s symptoms.


Julie Kardos, MD

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While starting your child on solid food isn’t always “love at first bite” it also does not have to be complicated or stressful.

Here are some overriding principles to keep in mind when feeding your baby:

1)      It’s not just about the food. It’s about teaching your child to eat when hungry and to stop when full.

2)      Eating a meal with family is social as well as nutritious. Keep eating pleasant and relaxed and never force feed or trick your child into eating.

3)      Babies start out with pureed foods in a spoon between 4-6 months and progress to finger foods when physically capable, usually between 7-9 months. Teeth are not required; hand to mouth coordination is required.

Start with food on a spoon at 4-6 months. Before this age, babies don’t really digest solids. Also it’s hard to feed a baby who still slumps when propped in a sitting position. In addition, the normal “tongue thrust” reflex is less pronounced after 4 months of age. Putting cereal into a bottle doesn’t count as “eating” and is not necessary.

Timing is important when offering solid food for the first time. Babies learn to expect a breast or a bottle when hungry. So make sure your baby is happy and awake but NOT hungry the first time you feed her solid food because at first, she is learning a skill, not eating for nutrition. You should wait about an hour after a milk feeding when she is playful and ready to try something new. Keep a camera nearby because babies make great faces when eating food for the first time.  Start a new food in the morning so that you have the entire day to make sure it agrees with your baby. Watch for rash or stomach upset. Once you know the food agrees with your baby, that food can be fed at night if you prefer.

Traditional first food in the USA is single grain rice cereal because it is easy to digest and most kids are not allergic to it. This is the one food I suggest keeping store bought rather than home made because this cereal is fortified with iron which is important for your baby’s growth. Mix the cereal with breast milk or formula so it smells familiar to your baby and because it adds calories (vs. mixing with water).  Don’t worry about measuring. This is not an exact science. Just mix up a small amount to the consistency that you would likely eat oatmeal. Then put a small amount in a spoon and Go For It.

Some babies take one feeding to “figure it out.” They learn quickly to swallow without gagging and open their mouths when they see the spoon coming. Other babies need more time. They may tongue thrust the food back out, cough when trying to swallow, cry, or seem clueless when the spoon comes back to them. Don’t worry and go back to the above ground rules. Quit and try again another day. Some babies take several weeks to catch on to the idea of eating solids.

It is ok to try another single-ingredient food such as fruit or vegetable or another kind of cereal such as oatmeal if you think your baby does not like rice cereal. The overriding principal is to try one new food at a time so that if your baby has a reaction to the food, you know what to blame.

Stage 1 vs. Stage 2 baby food: The only difference is the size of jars. The consistency of the food is the same. Some stage 2 foods combine ingredients. Combinations are fine as long as you know your baby already tolerates each individual ingredient ( i.e. “peas and carrots” are fine if they’ve already had each one). Avoid the “dessert” jar foods. Your baby does not need fillers such as cornstarch or concentrated sweets. You could also make your own baby food by making a puree with cooked vegetables or soft fruits. Again, avoid introducing many new ingredients at once and avoid added salt and sugar.

Not all kids like all foods. Don’t worry if they hate carrots or green beans or apples. Many other choices are available. At the same time, don’t forget to offer a previously rejected food multiple times because taste buds change.

Be forewarned: poop changes with solid foods. Usually it gets more firm or has more odor. Food is not always fully digested at this age and thus shows up in the poop. Wait until you see a sweet potato poop!

By six months, babies replace one milk feeding with a solid food meal. Some babies are up to three meals a day by 6 months but should be receiving more calories from breast milk or formula than from solids. Also at six months you can offer a cup with water at meals. Juice is not necessary to give if your child eats fruit.

Sample menu by 6-7 months:  breakfast: cereal mixed with formula/breast milk and fruit, lunch: fruit and vegetable, dinner: cereal and vegetable. Cereal has the highest calories and best nutritional content and should be offered at least twice daily. Jar baby food meats can be omitted: most kids don’t like them and cereal and breast milk/formula have plenty of protein. You can wait with meat until offering finger foods.

Finger foods can be given when your baby can sit alone and manipulate a toy without falling over, usually between 7-9 months. Even with no teeth your baby is able to gum a variety of finger foods. Examples include “Toasted Oats” (Cheerios), which are low in sugar and dissolve in your mouth eventually without any chewing, ½ cheerio-sized cooked vegetable, soft fruit, ground meat or pieces of baked chicken, beans, tofu, egg yolk, soft cheese, small pieces of pasta. Start by putting a finger food on the tray while you are spoon feeding and see what your child does. They often do better feeding themselves finger foods rather than having someone else “dump the lump” into their mouths.

Children should always eat sitting down and not while crawling or walking in order to AVOID CHOKING.  Feed them while other family members are also eating. Babies imitate at this age and learn how to eat by watching others.

Finger food sample meals: Breakfast: cereal, pieces of fruit. Lunch: pasta or rice, lentils or beans, cooked vegetables in pieces, pieces of cheese. Dinner: soft meat such as chicken or ground beef, cooked veggies and/or fruit, bits of potato, or cereal.  By nine months, kids can eat most of the adult meal at the table, just avoid these choking hazards: raw vegetables, chewy meats, nuts, hot dogs.  You can use breast feedings or formula bottles as snacks between meals or with some meals. By this age, it is normal for babies to average 16-24oz of formula daily or 3-4 breast feedings daily.

Avoid fried foods and highly processed foods. Do not buy “toddler meals” which are small versions of adult TV dinners and very high in salt and “fillers.” Lastly, do not give honey before one year of age because honey can cause botulism in infants.

A word about food allergies: Even the allergists lack a definitive answer of what makes a child allergic to a food. A general rule of thumb is that if there is a known food allergy in a family, avoid THAT food as long as you can. If no food allergies run in the family, focus more on avoiding choking hazards (see above) than on potentially allergenic foods. Please refer to our blog post on food allergies for more information.

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