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Posts from the ‘Breastfeeding’ Category

Weaning My Toddler

So, I have some more big news to catch you up on. I weaned Cee a few weeks ago, soon after her second birthday. I took a few notes along the way, but I never pulled it together to post on the blog about it. I thought I’d share some of those notes here and reflect back on our experience.

Cee may be weaned, but she still nurses her own baby all the time.

Cee may be weaned, but she still nurses her own baby all the time.

11/24/12

Tonight, I nursed my baby girl for the last time. She’s not so much of a baby anymore. She turned two last week. But I savored the feeling of her curled into my arms. I noticed how her long eyelashes cast a shadow across her cheeks and how soft her face looked, the tension of the day melted away.

I remembered nursing her in those early days, when her eyelids were still translucent, tiny blood vessels visible. I remembered how she would be frantic to nurse one second and peaceful the next, her little hand clasped in a fist, resting on the top of my breast.

Cee and I started talking about weaning a few weeks ago. We usually read books while we nurse, and lately I’d noticed that she was so enthralled with the books that she could hardly nurse. I’d turn a page, and she would break her latch to look closer at a picture, pointing something out to me. We were going through the motions because we always had, but nursing didn’t feel that important to either of us anymore. It felt like it was time to make this change.

We had been down to nursing just at naptime and bedtime since the summer. We dropped the naptime feeding first. All fall, Cee had gone down just fine without me and my milk at daycare and with Husband, and there were only a couple of days of brief protest over this change.

Down to just nursing at bedtime, Cee and I talked about how Mama didn’t have very much milk anymore. We talked about how babies (like our friends’ 3-month-old) need a lot of milk, but kids like Cee eat lots of good food and can drink their milk in a cup. We talked about how we love snuggling and nursing, too. I guess I wanted a chance for us both to appreciate our final days of nursing.

A couple of days ago, Cee watched me as I undressed for a shower. She pointed at my naked breasts and said, “Milk?” Read more

Why Consider Delayed Cord Clamping?

I first heard about delayed cord clamping as a doctoral student in Nutrition at UC Davis. One of my professors, along with her graduate students, was conducting research on delayed cord clamping in Mexico. Their findings were exciting, and their research was eventually published in the Lancet [1]. I remember being impressed that a simple change in protocol at the birth of a baby – effectively, a non-intervention – could have a profound effect on that baby’s health.

Fast-forward five years, when I was pregnant with Cee in 2010. My OB was an attending physician at an academic hospital and very knowledgeable. However, even she was skeptical when I told her that I was interested in delayed cord clamping. I emailed her a stack of journal articles showing that, at least in an uncomplicated delivery, the benefits outweigh the risks. She was convinced, and we agreed to delay clamping, providing everything went smoothly at the delivery. In the couple of years since Cee’s birth, I think delayed cord clamping has become more mainstream and in some cases, it has become standard protocol. Still, in many hospitals, you may need to advocate for delayed clamping or at least be prepared to discuss the risks and benefits with your OB or midwife.

What exactly do we mean by delayed cord clamping?

Wikimedia Commons

Delayed cord clamping means waiting 2 to 3 minutes after the delivery of an infant before clamping and cutting the umbilical cord. During this time, blood continues to pulse from the placenta to the baby until the pulses naturally stop around 3 minutes. The transfer of blood from the placenta to the baby is most effective if the baby is placed on the mother’s abdomen or lower.

What are the benefits of delayed cord clamping?

Research has found that delayed cord clamping allows 20 to 40 mL more blood to pulse from the placenta to the newborn, carrying with it an additional 30 to 35 mg of iron [2].  As a result, babies have higher newborn hemoglobin, lower risk of anemia at birth and through 2-3 months, and higher iron status and storage through 6 months of age [2, 3].

Delayed cord clamping gives your baby more iron. Why is this important? The extra iron is stored and becomes your baby’s main source of iron until she starts eating solid foods, particularly if you breastfeed. Your baby will use that iron to form red blood cells and transport oxygen, to build muscle, and to develop her brain cells. Severe iron deficiency can cause anemia, but iron deficiency during infancy (even without anemia) also increases the risk of cognitive, motor, and behavioral deficits that can last into adolescence [4-6].

How much stored iron do babies have at birth? That depends. Because the final 8 weeks of pregnancy are most important for iron storage, babies born prematurely can really come up short in iron. Size also matters; big babies are born with more iron stores than their smaller peers. Finally, maternal iron deficiency seems to increase the risk that baby will become iron deficient later in infancy. Depending on these factors, most babies will use up their stored iron between 4 and 8 months of age, after which they’ll need to get iron from fortified formula, iron supplements, or solid foods [8].

This can pose a real problem for exclusively breastfed babies, especially since both the AAP and WHO recommend waiting until babies are 6 months old to begin introducing solid foods. Breastfed babies are at higher risk for iron deficiency than those fed formula, because formula is fortified with iron. Breast milk, on the other hand, is very low in iron. (Why is breast milk so low in iron? I ruminate about that in this post.) Although breastfed babies are very efficient at absorbing that little bit of iron, the quantity is still too small to meet their needs once their iron stores have been depleted. The AAP estimates that U.S. infants that are exclusively breastfed have a 20% risk of iron deficiency by 9-12 months of age [7].

Delayed cord clamping can give babies an extra 1-3 months of iron stores to help bridge their transition from exclusive breastfeeding to solid foods [8]. This can be especially helpful for breastfed babies that are a little slow to start solid foods. Other mammals do not rush to clamp the cord immediately after birth and therefore also get that extra dose of iron to baby before cutting her off from mom’s supply. However, immediate cord clamping does not mean your baby is destined to be iron deficient – it just increases the likelihood that she will need a boost from iron supplements and/or iron-fortified foods.

An added benefit of delayed cord clamping is that it may protect your baby from lead poisoning. One study found that in breastfed infants at risk for lead exposure in Mexico, delayed cord clamping was associated with lower blood lead levels than immediate clamping [9]. This effect is probably related to the improvement in baby’s iron stores, since iron deficiency increases lead absorption. The CDC estimates that 4 million U.S. households have children exposed to lead, so this benefit has the potential to be very relevant to these kids.

Delayed cord clamping is likely even more important for preterm infants, and in fact, is beginning to be adopted by hospitals as general protocol. Preemies are at higher risk for iron deficiency. Delayed cord clamping improves hematocrit and reduces anemia and the need for blood transfusions in these babies [10]. In one trial, it also improved motor development in 7-month-old baby boys who were born prematurely [12]. In another, it increased oxygenation of brain tissue in newborn preemies [13]. Delayed cord clamping has also been shown to decrease the incidence of intraventricular hemorrhage and late-onset sepsis in preemies [10, 11]. Many of these studies used only a 30-45 second delay in cord clamping, but these benefits were observed even with this short delay.

Are there risks to delayed cord clamping?

To date, there is no evidence for significant risks to the mother or the baby associated with delaying cord clamping by 2-3 minutes. Until 2007, early cord clamping was part of the WHO protocol for preventing maternal postpartum hemorrhage, leading many practitioners to believe that late clamping might increase maternal bleeding. However, studies have found that this is not the case [14], and the WHO modified their protocol to reflect this evidence.

Delayed cord clamping does not increase an infant’s risk of jaundice, elevated bilirubin, or the need for light therapy [2, 3]. Some studies have found that delayed cord clamping increases the risk of polycythemia in newborns. Polycythemia occurs when infants have too many red blood cells in circulation – it is the opposite of anemia. However, infants with delayed cord clamping that were diagnosed with polycythemia had no symptoms and did not require treatment. Polycythemia may be a normal outcome of delayed cord clamping in some babies, and as far as we know, it does not appear to pose a health risk in these babies [2].

One other common objection to delayed cord clamping is that it is unnecessary in a developed country, because iron deficiency and anemia are only problems in developing countries. Quite simply, this is not the case. Approximately 10% of toddlers in the U.S. are thought to be iron-deficient [15]. A study in Sweden, a country with a very low prevalence of anemia, still found benefits of delayed cord clamping in this advantaged population [3].

When is delayed cord clamping not appropriate?

If a baby is born in distress and in need of resuscitation to help her breath, delaying cord clamping takes a back seat. Babies in distress need immediate attention, and it may not be practical to care for them while the cord is still attached. To get an idea of how quickly pediatricians need to assess newborn health and take appropriate action, check out their guidelines for newborn resuscitation. As more is learned about the benefits of delayed cord clamping, pediatricians may adjust their protocols to do some procedures at the bedside, allowing the cord to remain attached. In the meantime, it is my opinion that we should let them do their jobs and not ask them to practice outside of their comfort zone when it comes to caring for newborn babies. If the cord is clamped immediately, you can make up for the lost iron by giving your baby an iron supplement or feeding her iron-rich foods when she is ready for solids.

Other resources:

The Academic OB/GYN blog, written by Dr. Nicholas Fogelson, has several articles on delayed cord clamping, as well as links to a 50-minute Grand Rounds video, which is very informative. Squintmom also has a nice, well-cited article on the topic. Links to cited studies are included in the reference list below.

REFERENCES

1.  Chaparro, C.M., L.M. Neufeld, G. Tena Alavez, R. Eguia-Liz Cedillo, and K.G. Dewey. Effect of timing of umbilical cord clamping on iron status in Mexican infants: a randomised controlled trial. Lancet. 367(9527): p. 1997-2004. 2006. Link (abstract)

2.  Hutton, E.K. and E.S. Hassan. Late vs early clamping of the umbilical cord in full-term neonates: systematic review and meta-analysis of controlled trials. JAMA. 297(11): p. 1241-52. 2007. Link (full text available)

3.  Andersson, O., L. Hellstrom-Westas, D. Andersson, and M. Domellof. Effect of delayed versus early umbilical cord clamping on neonatal outcomes and iron status at 4 months: a randomised controlled trial. BMJ. 343: p. d7157. 2011. Link (full text available)

4.  Hurtado, E.K., A.H. Claussen, and K.G. Scott. Early childhood anemia and mild or moderate mental retardation. Am J Clin Nutr. 69(1): p. 115-9. 1999. Link (full text available)

5.  Lozoff, B., E. Jimenez, J. Hagen, E. Mollen, and A.W. Wolf. Poorer behavioral and developmental outcome more than 10 years after treatment for iron deficiency in infancy. Pediatrics. 105(4): p. E51. 2000. Link (full text available)

6.  Sherriff, A., A. Emond, J.C. Bell, and J. Golding. Should infants be screened for anaemia? A prospective study investigating the relation between haemoglobin at 8, 12, and 18 months and development at 18 months. Arch Dis Child. 84(6): p. 480-5. 2001. Link (full text available)

7.  AAP. Pediatric Nutrition Handbook. 6th ed, ed. R.E. Kleinman. Elk Grove Village, IL: American Academy of Pediatrics. 2009.

8.  Chaparro, C.M. Timing of umbilical cord clamping: effect on iron endowment of the newborn and later iron status. Nutr Rev. 69 Suppl 1: p. S30-6. 2011. Link (full text available)

9.  Chaparro, C.M., R. Fornes, L.M. Neufeld, G. Tena Alavez, R. Eguia-Liz Cedillo, and K.G. Dewey. Early umbilical cord clamping contributes to elevated blood lead levels among infants with higher lead exposure. J Pediatr. 151(5): p. 506-12. 2007. Link (abstract)

10.  Rabe, H., G. Reynolds, and J. Diaz-Rossello. A systematic review and meta-analysis of a brief delay in clamping the umbilical cord of preterm infants. Neonatology. 93(2): p. 138-44. 2008. Link (abstract)

11.  Mercer, J.S., B.R. Vohr, M.M. McGrath, J.F. Padbury, M. Wallach, and W. Oh. Delayed cord clamping in very preterm infants reduces the incidence of intraventricular hemorrhage and late-onset sepsis: a randomized, controlled trial. Pediatrics. 117(4): p. 1235-42. 2006. Link (full text available)

12.  Mercer, J.S., B.R. Vohr, D.A. Erickson-Owens, J.F. Padbury, and W. Oh. Seven-month developmental outcomes of very low birth weight infants enrolled in a randomized controlled trial of delayed versus immediate cord clamping. J Perinatol. 30(1): p. 11-6. 2010. Link (full text available)

13.  Baenziger, O., F. Stolkin, M. Keel, K. von Siebenthal, J.C. Fauchere, S. Das Kundu, V. Dietz, H.U. Bucher, and M. Wolf. The influence of the timing of cord clamping on postnatal cerebral oxygenation in preterm neonates: a randomized, controlled trial. Pediatrics. 119(3): p. 455-9. 2007. Link (full text available)

14.  McDonald, S.J. and P. Middleton. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database Syst Rev. (2): p. CD004074. 2008. Link (abstract)

15.  Baker, R.D. and F.R. Greer. Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0-3 years of age). Pediatrics. 126(5): p. 1040-50. 2010. Link (full text available)

(An earlier version of this post was published here, where it was hardly noticed. Maybe I’m too conservative for that crowd. Regardless, I’m having a hard time keeping my head above the water with teaching this term, much less find time to research and write sciency posts. I miss it. A lot. Teaching is good, but not as much fun. I’ll be back soon, promise.)

Tummy Troubles, Colic, and Mama’s Diet

This question comes from a ScienceofMom reader, who wrote me to ask:

I’m looking for good quality information on whether mom’s diet can really cause tummy trouble in babies, outside of perhaps a milk protein allergy.  I’ve seen arguments that it does, but they seem largely anecdotal.  Yet my pediatrician has never mentioned the possibility that my diet might be causing my 3-month-old infant to have gas bouts at 4 a.m. or so every. single. night.  Instead I’m routinely told that I just need to wait and by 4 months her digestive system will grow up.  –KT

Most of us have heard and read that we don’t need to give up any of our favorite foods in order to breastfeed our babies. In general, this is true, and it is an important message. Between sore nipples and engorged breasts during those first few weeks of motherhood, moms need to know that breastfeeding will eventually (usually) be an easy fit to their lifestyle.

There has even been some recent research showing that maternal diet restriction during lactation may increase baby’s chances of developing allergies. If your baby is NOT showing any signs of tummy troubles, your best bet is to eat a balanced variety of whole foods. Think of it as gently introducing your baby to the proteins of the world via your milk.

However, there have been several studies of the effect of mom’s diet on colic symptoms. Approximately 1 in 5 U.S. infants between 0 and 4 months are considered to have colic. The “Rule of Threes” is used to define colic: A colicky baby has incessant, inconsolable crying for at least 3 hours per day on at least 3 days per week, for more than 3 weeks. Crying is usually the worst in the evening hours. {It isn’t clear from K.T.’s note if her baby actually has colic or just gas – they’re not always the same. I’ve focused this post on colic, because that’s where the research is, but I’m willing to speculate that what works for colicky babies may also help babies with milder types of GI discomfort.}

The truth is that we really don’t know what causes colic. It is probably multi-factorial and has different causes in different babies. (For an interesting account of the history of our understanding of colic and how to manage it, check out this article,The Colic Conundrum, from The New Yorker.) However, there are several lines of evidence that colic is related to intestinal immaturity or imbalance. Colicky babies often seem to be gassy and to have GI discomfort, pulling their legs up to their bellies while crying as if in pain. Research has also shown that colicky babies have intestinal inflammation and abnormal gut motility [1]. In addition, we know that proteins from mom’s diet can pass into breast milk, and some babies seem to be allergic or intolerant of these proteins. That’s where the role of mom’s diet comes in.

Cow’s milk appears to be the most common culprit when it comes to food allergies in infants. It has been estimated to occur in about 0.5-1.0% of exclusively breastfed infants [2]. Studies on the relationship between cow’s milk allergy and colic are mixed, however. In one study, 66 mothers of exclusively breastfed colicky infants eliminated cow’s milk from their diets, and “colic disappearance” was noted in more than half of the infants [3]. When the moms later drank cow’s milk again as a test, colic symptoms returned in 2 out of 3 of the babies. Based on this study, cow’s milk allergy or intolerance would seem to be an important cause of colic. Read more

Why Care About Breastfeeding Research?

Since becoming a mom, and especially since starting this blog, I have paid particular attention to new breastfeeding research. After all, my training is in nutrition, and breast milk is one of the most interesting foods around. Plus, I’m currently lactating and still breastfeeding my daughter a few times per day, so it’s on my mind.

When I look back at the papers that I have covered and those that I find on other blogs and media outlets, I notice that many focus on how breastfeeding improves outcomes in babies.

But I also notice that when I blog about breastfeeding research, I have to spend a big chunk of the piece talking about the limitations of the study. Breastfeeding research – at least when conducted in humans – will always have big limitations that require disclaiming and explaining. The problem is that it is impossible to randomize breastfeeding trials or to “blind” the subjects to feeding type. It is difficult to know, despite the fanciest statistical methods, if it is breast milk that makes those babies thinner, smarter, stronger, cry more, etc, or if there are other factors at play in this complex thing called human life. Sometimes, by the time I’ve listed the problems with interpreting a breastfeeding study, I wonder if these findings were actually meaningful, and I’m sure my readers feel the same way.

Elsewhere around the Internet (not so much on my blog), I often see comments to this effect on articles about the latest research on the benefits of breastfeeding:

“Another useless study. Obviously we mammals were meant to feed our babies breast milk. I don’t know why scientists waste their time and our money with this stuff.”

Why bother doing more research on outcomes associated with breastfeeding? It is pretty clear that breastfeeding is a great way to feed an infant. Maybe it is time to stop oohing and awing over breast milk. Read more

Bottle-feeding and Obesity Risk

Source: Wikimedia Commons

A study published this month in Archives of Pediatric and Adolescent Medicine looks at the relationship between infant feeding practices and weight gain (1). Breast milk vs. formula? Nope, it isn’t that simple.

Led by Dr. Ruowei Li of the CDC, this prospective longitudinal study tracked feeding and weight gain in 1900 infants during their first year of life. Each month, mothers were asked how they fed their babies in the last 7 days, and from their replies, infants were grouped into the following categories across ages:

  1. Breastfed only
  2. Breastfed and human milk by bottle
  3. Breastfed and formula by bottle
  4. Human milk by bottle only (i.e. exclusive pumping)
  5. Human milk and formula by bottle
  6. Formula by bottle only

The mothers in this study were mainly white, married, and had at least a high school education. A third were on WIC. About 50% were overweight or obese. Statistical methods were used to adjust the findings for a range of maternal factors, including BMI, as well as infant sex, gestational age, birth weight, and age of solid food introduction.

The most important finding from this study was that infants fed by bottle only – whether fed formula or breast milk – gained more weight than those fed breast milk at the breast. Read more

The Apparent Breastfeeding Paradox: What is optimal nutrition for a premature baby?

Last week, I wrote about some of the unique challenges (and one potential solution) to breastfeeding a baby born prematurely. Another study recently published in BMJ Open provides more food for thought on breastfeeding preemies (1; full text available here).

A team of French researchers examined the relationship between breastfeeding, growth, and neurodevelopment in two observational cohorts of babies born very prematurely, at less than 32 or 33 weeks of gestation.

Between the two cohorts, a total of 2925 very preterm infants were included in the study. These babies were in the hospital for 50-60 days before they were allowed to go home. In the two cohorts, 19% and 16% of babies were breastfeeding at the time of discharge from the hospital. The study looked at associations between type of feeding at discharge (breast milk or formula), growth during hospitalization, and growth and neurodevelopment at 2 and 5 years of age.

Source: Wikimedia Commons

What were the findings? In these cohorts, formula-fed babies had gained more weight by the time they were discharged from the hospital. However, at 2 and 5 years of age, the formula-fed babies scored lower on neurodevelopment assessments compared to the breastfed babies. Breastfed babies also had greater head circumferences by 2 and 5 years of age, suggesting improved brain development, and they appeared to catch up to formula-fed babies in height and weight. Read more

Pump up the music: Improving breast milk production in the NICU

The breast pump is a fabulous invention. It is what gives modern moms the option to pursue a career and breastfeed. And for moms of babies born prematurely, it is everything. Their babies get a great start with breast milk, and moms can establish milk supply even if they are separated by prolonged stays in the NICU.

Source: Wikimedia Commons

In a study published in Advances in Neonatal Care last week, Douglas Keith and colleagues reported on their attempt to increase production in moms pumping milk for their preemie babies [2]. 162 moms of preemie (average 32 weeks) or critically ill newborns admitted to the NICU were given a hospital-grade breast pump and encouraged to pump 8 times per day. They were randomly assigned to one of 4 groups. A control group received standard support for breastfeeding, and the remaining 3 groups were given a recording to listen to during pumping. The second group received a recording with a spoken guided relaxation. The third received the same guided relaxation, but it was accompanied by soothing guitar lullabies. The fourth received the relaxation/guitar recording, plus a video player with images of their own babies. Milk production and milk fat content were measured over 14 days.

What effect did a little music and pictures have on milk production? The results were actually quite striking. Read more

Put down the phone, Mama!

We were getting settled for nap time. As I changed BabyC’s diaper, I talked with her in a quiet tone and told her that we were preparing to rest. We did one slow and whispered round of “Head, Shoulders, Knees, and Toes” on the changing table. I closed BabyC’s curtains and dimmed the lights. We fished her special doll and blanket from her crib, and then we all sat down into the rocking chair to nurse. BabyC was still a little wound up, though, and as we were getting settled, she swiped my phone from the side table. I don’t usually let her play with my phone, but in the interest of keeping things mellow, I figured I’d let her hold it for a while. She latched, and we both started to relax.

But then, BabyC turned on my phone. She started swiping her finger across the touch screen, just as she watches me do throughout the day. She hit at icons and watched colors flash on the screen, her eyes darting around. Suddenly, she was opening the address book and initiating a FaceTime video call with – who? Oh, an old college buddy of Husband’s, someone I’ve met once, about 5 years ago. Yikes! A surprise video call from my boob is probably not the best way to get back in touch. 

OK, BabyC, no more phone. I felt annoyed. I wanted BabyC to snuggle up with me and enjoy calming milk and our time together. It seemed ungrateful for her attention to be somewhere else entirely. Read more

10 Tips for Starting Your Baby on Solid Food

Starting solid foods is one of the major landmarks of a baby’s first year.  You play a very active role in your child’s experience with food, and your goal is to make that experience healthy, fun, and safe.

Here are 10 tips to get you off to a good start.

 1.     Introduce your baby to solid foods between 4 and 6 months of age. The World Health Organization and the American Academy of Pediatrics recommend that babies be breastfed exclusively for the first 6 months, but other professional and public health organizations recommend starting solids anytime between 4 and 6 months. You can read more about age of solids introduction and health outcomes (including lost of references to the research) in this post: Starting Solids: 4 Months, 6 Months, or Somewhere In Between?

Solid food should never be introduced before 4 months of age, and your baby should display the following signs of readiness before trying his first bite:

  • Your baby should be able to sit up in a high chair and hold his head up on his own.
  • He should show signs of interest in food and open his mouth when it is offered.
  • He should be able to move food from his mouth into his throat. If you offer a spoonful of food to your baby and he seems to push it right back out of his mouth, give him a few more practice bites, but also consider waiting another week or two. He just might not be ready yet.

I’ve written more about recognizing your baby’s signs of readiness to start solids in this post: 4 Signs Your Baby Is Ready for Solid Foods

I can remember being really concerned about the decision of when to start BabyC on solid foods. In hindsight, I wish I had relaxed a bit more. She didn’t really start eating more than a few nibbles until around 6.5 months, and there was no rushing the process. Besides, life was easier before solid foods! Breastfeeding was simple and not nearly as messy as solids. That being said, it is important that your baby have opportunities to try solid foods around 6 months, because around this age, breastfed babies in particular need to start eating iron- and zinc-rich foods.

 2.     You can skip the white rice cereal.  Yes, it is fortified with iron, and that is a good thing, and yes, it is easy to digest.  On the other hand, white rice cereal is pure starch (refined rice flour) and not that tasty or nutritious, except for the added iron.  Try whole grain baby cereals like oatmeal, barley, or brown rice cereal, which are also fortified with iron.  Just start with single-grain cereals so that you know the culprit if your baby has an allergic reaction (see #4).  There is also no reason that cereal has to be your baby’s first food.  Whoa, you say, now you’re really blowing my mind.  I know, keep reading… Read lots more about infant cereals here: The Whole Truth About Infant Cereals: 7 Science-Based Tips.

 3.     Focus on meats, legumes, veggies, and fortified cereals.  Meat is a great complement to breastfeeding in older infants, because it is a good source of iron and zinc, both of which are low in breast milk (Krebs and Hambidge, 2007).  However, there is a common misconception among parents that meat should not be used as an early food for infants.  In a 2008 survey of the dietary habits of infants and toddlers, only 8% of 6-9-month-old infants ate meat or poultry at least once per day (more ate those jarred baby food “dinners” which contain some meat but also a lot of crap) (Siega-Riz et al. 2011).  There is no reason to wait on meat – you can make it one of your baby’s first foods.  Eggs and fish are also a great choice. Legumes are packed with protein and fairly high in iron – try lentils, mashed chick peas, or beans.  Vegetables are nutritious and usually well received by your budding foodie.  Offer some fruits, but know that they don’t give you as much nutritional bang for your buck, being higher in sugar and water.  Including two daily servings of fortified cereal in your baby’s diet will help ensure that he is getting enough iron, but check out my recent post (5 Practical Ways to Increase Iron in Your Baby’s Diet) for other tips.  Dairy products such as cheese and yogurt are also fair game but should be fed in limited amounts.

4.  Wait 2-3 days between introducing new foods.  This gives you time to watch for symptoms of a food allergy, and if those symptoms should appear, you will know that they are likely due to the new food. Symptoms of food allergy include diarrhea, rash, and vomiting. Common food allergies include egg white, fish and shellfish, wheat, cow’s milk, soy, citrus, and berries. Pediatricians used to recommend delaying the introduction of egg whites, fish, and peanuts, but the AAP now gives these a green light at 6 months. In fact, delaying the introduction of these foods may increase the chance that your child will develop an allergy to them. However, if you have a history of food allergies in your family, talk with your pediatrician about the timing of introduction of high allergy foods. For all babies, avoid honey until the first birthday. Honey can be contaminated with botulism spores, and the risk of botulism is greatest in infants.

5.  Experiment with different textures.  Your baby may prefer a thinner or thicker puree.  Or he may prefer to skip the purees altogether.  We tried giving BabyC purees very little success, but then we discovered that she loved finger foods and moved straight to those.  Soft fruits, avocado, cooked vegetables, and pasta were a big hit.  There is a movement called Baby Led Weaning that advocates for skipping purees all together.  A recent study found that toddlers that were initially introduced to solids with a baby-led finger-food approach had a lower incidence of obesity (Townsend and Pitchford, 2012). It was a small study with a few limitations, but the results are interesting nonetheless.6. Let your baby set the pace of meals. Whether you start with purees or finger foods or a combination, your baby should decide how fast and how much food to eat. This comes naturally when your baby eats finger foods. If you are spoon-feeding, be sure to stay tuned in to your baby and enjoy the meal together. Wait for your baby’s cues that he wants more before pushing the spoon into his mouth. Let him lean forward and open his mouth to show you that he’s ready for the next bite. By being responsive to your baby in this way, you are teaching him to listen to his body and honor his own cues of hunger and fullness, a skill that will serve him well throughout life.

7.  Do you know what to do if your baby starts choking?  Make sure you do.  Learn the baby Heimlich maneuver.  The Heimlich is easy enough, but if you haven’t already, this is a good time to take an infant/child CPR class, which will include handling a choking emergency.  At this age, any number of things in your house and the world, including food, can be choking hazards, and you should be ready.  Obviously, avoid giving your baby foods that are small and firm such as raisins, popcorn, and nuts.

8.  Start slow.  Start with one solid meal per day, which may be just a tablespoon or two at first.  As your baby starts to show more interest in food, gradually increase the amount offered and the number of meals up to three solid meals per day around nine months of age.  Think of this time as a gradual transition towards more solid foods, but let your baby set the pace.  At first, your baby will not be eating enough solids to affect breast or bottle feeding, but you will gradually decrease the number of milk feedings as your baby gets more and more calories from solids.

9.  Know that every baby is different.  Some babies will eat like a pro on day one.  Ours did not.  If your baby is slow to start solids, don’t worry and don’t rush him.  Just trust that he’ll get it eventually.  Meal timing may be important to your success.  If your baby is too hungry or too full, he may not be interested in solids.  Many parents find that nursing on one side, then trying some solid food, then returning to nurse on the other side, works well.

10.  Set your baby up for a lifetime of healthy eating by modeling healthy eating habits.  Your baby will reach an age when he wants to eat what is on your plate, so if there are french fries on your plate, that’s what your baby will want.  Babies are remarkably adept at recognizing hypocrisy when they see it.   Make an effort to sit down to eat as a family, with your baby included.  Make mealtime a social, pleasant time.  It should never be rushed or forced.  For more ideas, check out my recent post – Enjoying and Exploring Food with Baby.

I hope these tips help as you embark on your baby food adventure!  But like I said, every baby is different.  If you are just beginning this process, what other questions do you have?  Experienced mamas and papas – what did I leave out?

read more about feeding

REFERENCES

American Academy of Pediatrics. Breastfeeding and the Use of Human Milk, Policy Statement. Published online February 27, 2012. www.pediatrics.org/cgi/doi/10.1542/peds.2011-3552

Krebs, N.F. and K.M. Hambidge. Complementary feeding: clinically relevant factors affecting timing and composition. Am J Clin Nutr. 85(2): p. 639S-645S. 2007.

Siega-Riz, A.M., D.M. Deming, K.C. Reidy, M.K. Fox, E. Condon, and R.R. Briefel. Food consumption patterns of infants and toddlers: where are we now? J Am Diet Assoc. 110(12 Suppl): p. S38-51. 2010.

Townsend E. and N.J. Pitchford. Baby knows best? The impact of weaning style on food preferences and body mass index in early childhood in a case-controlled sample. BMJ Open Feb 6;2(1):e000298. 2012.

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Breastfeed for your child’s future… as a long-jumper?

I try to stay abreast of the latest in breastfeeding research (hehe), and this paper, published last week, caught my eye:

Exclusive breastfeeding duration and cardiorespiratory fitness in children and adolescents. (Labayen et al., American Journal of Clinical Nutrition)

Was it possible that breastfeeding BabyC could affect her level of fitness as a teenager? I was intrigued.

The study tested cardiovascular fitness on a stationary bike in about 2000 children and teenagers from Sweden and Estonia. The kids’ mothers were asked to recall if they breastfed their children, and if so, for how long (<3 months, 3-6 months, or >6 months). Children that were fed a mix of breast milk and formula for any period were eliminated from the study.

The researchers found that breastfed kids had about 5% greater cardiovascular fitness than those fed formula, and fitness was highest in children who had been breastfed exclusively for at least 3 months. This finding held true even after the researchers adjusted for country, gender, age, puberty, BMI, birth weight, physical activity level, maternal BMI and maternal education.

A 5% increase in cardio fitness may not seem like much, but it is actually rather impressive when you consider all the other factors that are involved. Genetics are thought to explain about 50% of fitness, and body weight and activity level (how much aerobic activity a person routinely does) also play a big role.

As often happens when I read journal articles, this study led me to another published in 2010. Among more than 2500 teenagers from around Europe, Enrique Artero and colleagues found a significant correlation between how long they were breastfed as infants and how far they could long jump. Boys that were breastfed for 6 months or longer had an 11-cm edge over formula-fed boys, and girls had a 7-cm edge. On the other hand, there was no association between breastfeeding and speed in the 20-meter shuttle run. (That sure brings back memories from middle school!) Like the previous study, these data were adjusted for factors like the children’s physical activity and body composition and parental weight and education.

So breastfeeding my child means she’ll be better at both cycling and the long jump?!

Not so fast. You know I’m not going to report the results of new research without talking about its limitations. Both of these studies are retrospective, cross-sectional studies. They looked at kids that were breastfed and those that weren’t and compared their physical fitness. In an ideal world, if you wanted to know if breastfeeding was related to physical fitness later in life, you would enroll a bunch of pregnant women and assign them to either the breastfeeding group or the formula-feeding group. Then, 10-15 years later, you would run their kids through physical fitness tests. We all know that this type of prospective, randomized trial will never happen. No mother is going to let a researcher tell her how to feed her baby. Instead, each mother makes that choice herself, and there are many factors that contribute to her choice.

These types of retrospective, cross-sectional studies of breastfeeding always have one big flaw: they simply can’t account for every factor that may be different between breastfeeding and formula-feeding mothers. My guess is that the researchers have only scratched the surface by including maternal BMI and education in their statistical models. What about exercise during pregnancy? Or mom’s nutrition during pregnancy and lactation? How about exposure to cigarette smoke? These are all factors that might be different between breastfeeding and formula-feeding moms. Any of these factors, in addition to breastfeeding, might influence children’s later fitness level by epigenetic mechanisms or more directly, such as by affecting the rate and timing of muscle growth. Research on the benefits of breastfeeding is very hard to do.

As a skeptic and a scientist, I tend to think that this fitness effect is not just about breast milk but probably intertwined with other factors. But as a nursing mom, it is kind of cool to think about. I’ve tried to tell my daughter that the long jump may be in her future, given her 7 cm edge. She doesn’t seem to care. She has been practicing athletic feats during our recent nursing sessions, but they are more yogic in nature. I swear she did a one-legged downward dog the other day without breaking her latch!

References:

Artero EG, Ortega FB, Espana-Romero V, Labayen I, Huybrechts I, Papadaki A, Rodriguez G, Mauro B, Widhalm K, Kersting M, et al. 2010 Longer breastfeeding is associated with increased lower body explosive strength during adolescence. J Nutr 140 1989-1995.

Labayen I, Ruiz JR, Ortega FB, Loit HM, Harro J, Villa I, Veidebaum T & Sjostrom M 2012 Exclusive breastfeeding duration and cardiorespiratory fitness in children and adolescents. Am J Clin Nutr. Published online ahead of print 01/11/12.