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Baby 411

Nutrition & Growth

Baby 411

Welcome to the world of food. This section of Baby 411 is dedicated to growth and nutrition–first, we’ll look at the general questions you might have about your baby’s growth, like what those ominous-looking growth charts really mean. We’ll also discuss HOW your baby will grow (height, head size, weight), as well as the needed calorie and nutrition for the first year. Should you put your baby on a feeding schedule? We’ll hit that hot-button issue here, as well as discuss vitamin supplements, obesity and your baby’s needs for calcium, fiber and iron.

The next two chapters (Chapter 6, Liquids and Chapter 7, Solids) will get into the nuts and bolts of nutrition, as we discuss liquids (breast milk, formula, juice) and solids (baby and table foods). But first things first–let’s dive into Baby Nutrition 101.

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  • Infant Growth

    • +Q. At my baby’s well checks, my doctor charts her growth on a chart. What’s this for?

      Growth charts help your doctor follow the trends of your child’s growth.

      Your baby’s height, weight, and head size are checked at every well child visit. (Weight is usually checked at sick visits too, to assess the severity of an illness–for example, dehydration–and in case medication needs to be prescribed). Many doctors currently compare your child’s statistics to standard charts provided by the Centers for Disease Control (CDC). These charts were created in 2000. The percentiles on the charts compare your child to other children the same age and gender in America. (For example, a boy in the 75th percentile for height is taller than 75% of boys his age.)

      While not nearly as popular, doctors should adopt the newer World Health Organization (WHO) growth charts for children under two years of age. That’s the advice of both the American Academy of Pediatrics and the CDC.

      Why? Because the WHO charts are based on how a breastfed baby should grow, regardless of what country she lives in. Breastfed babies gain slightly less weight than their formula-fed counterparts from four to six months of life–and therefore may look like they are not thriving on the CDC’s charts. Breastfed babies also weigh less than formula-fed babies at their first birthdays. (Kim) The WHO also used more children’s growth data to create their percentiles, which makes them more accurate. See Appendix E to find the WHO growth charts.

      The key issue: is your baby’s growth consistent? In other words, if your child is at the 50th percentile for height at three months, he should roughly be at the 50th percentile at six months. What if your child’s height and weight percentiles are significantly different? We’ll address the issue with a discussion of the Body Mass Index (BMI) later in the section on overeating, obesity, and the BMI. Also later: what if you child’s head size is growing too fast or too slow? We’ll cover that too.

    • +Q. How much weight can I expect my baby to gain in his first year?

      Here are some general guidelines. Babies double their birth weight by four to five months of age. They triple their birth weight by one year, and quadruple their birth weight by age 2. After age 2, kids gain about four pounds a year until they hit puberty.

      For example: A seven-pound newborn should weigh about 14 pounds at five months and 21 pounds at one year. (Behrman)

    • +Q. How tall will my baby grow in his first year?

      Your baby will grow ten inches in his first year (about an inch a month for the first six months and 1/2 inch per month from seven to twelve months). He’ll grow another four inches from age one to two. After that, he’ll grow three inches a year from ages three to five, then two inches a year until he hits his growth spurt at puberty (rule of thumb is 10-4-3-3-2 inches per year). For example: A 20-inch tall newborn should be about 30 inches tall at one year.

    • +Q. Can you predict how tall my baby will be?

      For boys: Add five inches to Mom’s height and average that number with Dad’s height.

      For girls: Subtract five inches from Dad’s height and average that number with Mom’s height.

      This number is your baby’s growth potential. Of course, some people exceed their potentials and some people never reach their potentials.

      The first fairly accurate height predictor is the measurement taken at age two years. Kids have established their growth curves by then. A good rule of thumb is that kids are half of their adult height at 24 to 30 months old.

    • +Q. Why do you measure my baby’s head size?

      Because your baby’s brain is also growing at a tremendous rate. Most of this growth occurs in the first two years of life. His brain weight doubles, just in the first six months. We want to make sure this is happening, and that the skull is providing enough room for this to happen (see CRANIOSYNOSTOSIS).

      Some babies have huge heads (see MACROCEPHALY) and some babies have tiny heads (see MICROCEPHALY). Most of the time, this is thanks to their gene pool. The apple doesn’t fall far from the tree. A baby’s head size percentile may be completely different than his height or weight percentiles–and that’s okay.

      The average newborn head size is 35 cm. It grows 12 cm in the first year, and then only 10 cm more for an entire lifetime!

    • +Q. When does the soft spot (anterior fontanelle) close?

      Anywhere between nine to 18 months. The anterior fontanelle gives the brain the growing room it needs.

      Pediatricians rely on that soft spot to provide clues for fluid status (dehydration), infection (meningitis), and problems inside the skull (brain tumors, hydrocephalus).

    • +Q. My baby has a flat head. Will he need to wear a helmet?
      Unlikely. Changes in infant sleep position recommendations have done wonders to reduce the risk of sudden infant death syndrome (SIDS) by 50%. (See Chapter 9, Sleep in the sleep safety tips section for more discussion of SIDS.) However, many babies have flat heads (official name: POSITIONAL PLAGIOCEPHALY) as a result of being placed to sleep on their backs. In most cases, the head shape improves once kids begin to move and reposition themselves during sleep. Helmets are recommended as one of a few treatment options for severe flattening, and effective if used only between four and 12 months of age. (AAP) See the section later in this chapter for more on flat heads and tummy time
    • +Q. When will my baby’s teeth come in?

      Anytime between six and 12 months.

      Teeth may erupt as early as two months, but that is a rare event. As discussed in Chapter 4, Hygiene, teething is variable. A baby might have several teeth at his one-year birthday, another may just have one. Don’t worry either way.

      As a rule, the first teeth to erupt are the bottom middle teeth (medial incisors). After that, it’s anyone’s guess. There is no order to further eruptions. Frequently, a baby’s one-year molars will come in before the middle or eye teeth (incisors/canines).

      By the way, once the teeth arrive, you need to clean them! See Chapter 4, Hygiene for the section on dental care for teeth cleaning tips and a handy visual aid to explain which teeth are which.

  • Flat heads and tummy time!

    • +Q. Why is it important for babies to have tummy time?

      Why do some babies wear helmets? And what the heck is tummy time, anyway?

      Before we answer that, here’s a quick 411 on your baby’s skull: newborns have skull bones with soft tissue between them (sutures) and a couple of bigger gaps or soft spots (anterior and posterior fontanelles). This skull structure allows the baby’s head to squeeze through the birth canal and the brain to grow rapidly in the first two years of life.

      By the time the child is two years old, her skull has hardened and those gaps and sutures have closed.

      A newborn’s malleable skull can put her head at risk for some really odd shapes after delivery. Later if a baby spends much time on her back (or in one position), the skull may flatten. While most newborn heads will eventually round out and look normal, here are some things to be watching for:

      • Molding. Some newborns look like they have a “cone head” because the skull compresses as it goes through the birth canal (more common in vaginal deliveries than C-sections). Babies who have had vacuum- or forceps-assisted deliveries may have pretty dramatic molding or even a large bruise (CEPHALHEMATOMA) that can harden and leave a lump on the skull for several weeks. These irregular head shapes are present at birth and resolve by six to eight weeks of life.
      • Positional Plagiocephaly. Yes, we know this is a mouthful–it literally means “oblique (flat) head.” Babies who spend significant time lying on their backs or leaning their heads back (sleeping, sitting in a car seat or in an infant swing) are at risk for a flat head. This odd head shape becomes noticeable after eight weeks of life. In most cases, the flattening is mild or moderate, and rounds out over the first year. You can try to avoid this problem by following the tips at the end of this section.
      • Torticollis. A tightening, shortening, or bruising of a neck muscle when baby’s head favors in one position for a long time. This becomes a vicious cycle, because the baby then develops a preference for turning his head to one particular side. The result? The skull flattens on one side and the facial structure starts to look asymmetric. TORTICOLLIS can be present at birth or begin during infancy. Aggressive neck stretching exercises are required to fix this problem.
      • Craniosynostosis. This is a premature closure of one of the suture lines that sits between the skull bones. Unlike some of these other problems, CRANIOSYNOSTOSIS is not something that is preventable–it’s an uncommon disorder that just happens to some kids. Early closure not only causes a funny looking head shape, but also interferes with the brain’s ability to grow. If untreated, these babies can be at risk for vision defects and increased pressure within the skull. Surgery is required to fix this problem.

      Now you know how your newborn’s skull will change and what problems to look for. But let’s look at the most common cause for head-shape problems: sleep position.

      Ever since safety advocates recommended infants sleep on their backs, babies have spent an increasing amount of time in that position. Add in time spent in car seats and swings–and you can understand why positional plagiocephaly (flat head) is an increasing concern. Of course, there is a simple answer: tummy time.

      So, what is tummy time? Simply put, tummy time is an opportunity for your baby to lie on his belly while awake and practice lifting up his head. This will develop neck and other muscles for head control and rolling over. Tummy time also keeps the pressure OFF the back of baby’s head by altering his position.

      Here are some simple guidelines for tummy time. For babies age birth to eight weight weeks, offer at least five minutes of tummy time a day. For older babies (two months and up), do tummy time five minutes or more at least three times a day.

      What if your baby hates tummy time? One idea: have him lie on your chest and he will work to lift up his head. Or get on the floor with baby so it doesn’t seem so lonely down there. To help baby lift up his head, you can use a rolled-up receiving blanket under the chest.

    • +Q. What else can you do to prevent a flat head?

      Good question! Here are some suggestions:

      • Alternate which direction you do diaper changes so your baby has to turn his head both ways to look at you.
      • Alternate turning your baby’s head from left to right on his back when he is sleeping.
      • Play “airplane” with your baby and let him lift his head to look at you.

      What to do once your baby has a flat head or torticollis:

      1. Aggressively work on neck stretching exercises at home. See Chapter 14, Common Diseases, in the muscles/bones section for specific advice on exercises you can do.
      2. Hire a personal trainer (okay, really it’s a physical therapist) to help with neck exercises.
      3. Encourage your baby to spend more time holding his head up–see the tummy time tips above.
      4. Check in with your doctor every month so she can monitor your baby’s progress.
      5. If the head is significantly misshapen and not improving with exercise, consult with a neurosurgeon or a craniofacial surgeon and consider a helmet. Again, your doctor should be able to give some guidance. (Nield, Persing)
  • Infant Calorie and Nutrition Needs

    • +Q. How quickly will my newborn grow on a day-to-day basis?

      Faster than you want him to.

      After you look at the following stats, you will never buy newborn clothes as baby gifts again. You can also understand why babies need to eat all the time. It takes a lot of caloric energy to grow that much.

      On a day-to-day basis, here is what you can expect:

      • Birth to four days old: A weight LOSS of 5-10%. As we discussed earlier, babies are born with extra baggage for the trip out into the world.
      • Four days to three months: A weight GAIN of about 2/3 to one ounce a day (1/2 lb a week). Note: newborns should be back to birth weight by their second week doctor visit.
      • Three months to six months: A weight gain of about 1/2 to 2/3 ounce a day (1/2 lb every 2 weeks).
      • Six months to 12 months: A weight gain of about 1/4 to 1/2 ounce a day (3/4 to 1 lb per month).
    • +Q. Can you show me how a baby’s calorie needs change for the first year of life?

      Okay, here is an example... but remember these are ballpark figures. Fair warning: we get many emails from worried readers who think their babies aren’t reaching these numbers. Again, there is no reason to obsess over these figures.

      So here are the numbers for a 7 lb. newborn: (AAP Committee on Nutrition)


      Common Conversions

      For the mathematically challenged (that is, us writers) and for those who have forgotten the metric system, here are the common conversions you’ll need to digest this section:

      cc (cubic centimeter) or ml (milliliter) are ways of measuring fluid volumes.

      1cc = 1ml

      5cc or 5ml = 1 teaspoon

      15cc or 15 ml = 1 tablespoon

      3 teaspoons = 1 tablespoon

      There are 30cc per ounce, or 2 tablespoons per ounce (oz).

      There are 16 ounces (oz) in 1 pound (lb).

      There are 2.2 pounds in 1 kilogram (kg).

      There will be a quiz on this next Tuesday.

      image BOTTOM LINE

      Do NOT calculate your baby’s dietary needs at every moment. You will drive yourself, your spouse (and your doctor) nuts. This is especially challenging to do if you are breastfeeding and can’t see the volume. It’s just helpful information to help you gauge things.

    • +Q. How many calories does my baby need to eat?

      It depends on her age. Another factor: babies born very small... or very big.

      The calculations are listed on the next page, but please don’t get too wound up about these numbers. Do NOT do calorie counts on your baby. As you can see, your baby’s calorie needs will increase as she grows.

      Real mom tip: baby’s appetite can vary from day to day. This advice also applies to older children. Focus on what your child eats over the space of a week, not every meal. Let’s put this in bold: Obsessing over every ounce of milk/formula or spoonful of rice cereal isn’t healthy for you or your baby.

      That said, here’s how many calories a baby typically needs to eat per day (given your baby’s weight in kilograms):

      • Babies birth to two months consume 90-120 calories per kilogram in 24 hours.
      • Babies three to eight months consume 80-100 calories per kg in 24 hours.
      • Babies nine to 12 months need 90–100 calories per kg in 24 hours.

      Don’t know your baby’s weight in kilos? To convert pounds to kilograms, divide the weight in pounds by 2.2. For example, a baby weighing seven pounds would weigh 3.2 kilograms.

      Now that we have all the formulas, let’s figure out how many calories your average seven pound newborn will need each day to grow normally. Realize this is a ballpark figure because each person has individual energy (calorie) needs. Your little 3.2 kg bundle of joy needs between 288–384 calories per day (3.2 × 90 or 120). Breast milk and formula have 20 calories per ounce. So divide 288 or 384 by 20 calories per ounce and you’ll find that your baby needs to consume about 15 to 19 ounces a day. But, once again, obsessingover every ounce will only give you an overwhelming need for Zantac.

      A word on preemies: Premature babies have higher calorie needs to catch up on their growth. Some babies go home from the Neonatal Intensive Care Unit (NICU) with a higher calorie diet requirement. This is achieved with either a higher-calorie formula or a special human-milk fortifier that is added to expressed (pumped) breast milk.

      A word on big babies: The calorie calculations we’ve made here are accurate for average sized babies. All babies gradually increase their daily breast milk/formula intake and eventually max out at about 40 oz. a day. Average-sized babies get to that point at four to six months of age. A ten-pound newborn may reach that 40 oz. a day maximum before his friends do and will just stick to that daily volume. We point this out so you don’t try to give him 50 or 60 oz. at six months of age.

  • The Big Picture: Nutrition For The First Year

    • +The Big Picture: Nutrition for the First Year

      The details will become clearer to you as you read through the next couple of section, but here is the big picture:

      1. Babies need either formula or breast milk exclusively for the first four to six months of life.
      2. Some babies are ready to eat solid food (a.k.a. “complementary food”) at four months old, and others aren’t. The right time to start offering solid foods mostly depends on when a baby knows what to do with food in his mouth. However, allergists, nutritionists, and pediatricians all agree that there is no need to start before four months of age. Breast milk and formula are the main source of nutrition and solid food is complementary. (for details see Chapter 7, Solids).
      3. From six to nine months of age, a baby drinks less liquid nutrition (breast milk or formula) as he eats more solid food nutrition.
      4. From nine to twelve months of age, a baby usually eats three solid meals a day and takes 20 to 30 oz of breast milk or formula.
      5. After a year of age, a toddler can drink breast milk or whole or 2% milk, with a goal of 16 oz. or dairy serving equivalent a day. Formula is no longer needed. The norm: three solid meals and one to two snacks per day. Toddlers can continue breastfeeding, but they need additional sources of nutrition.


      Babies will have growth spurts and their appetites may seem insatiable at times. These episodes usually occur at three weeks, six weeks, and occasionally later in the first year. They may last a couple of days or a week. If you are breastfeeding, do not be alarmed that you can’t satisfy your baby. His appetite will ramp up your milk supply.


      *Liquid volumes decrease as solid volumes increase.

      See later in this section for information on calcium and dairy requirements at one year of age. For a more detailed chart of liquids and solids, see Chapter 7, Solids in the section titled “The Big Picture on Liquids and Solids.”

  • Feeding Schedules

    • +Q. I’ve heard about putting my newborn on a feeding schedule. How do I do it?

      You don’t. Your baby does it for you.

      The phrase “newborn feeding schedule” is an oxymoron. Newborns are learning how life works outside the womb. Before birth, they were on a 24/7 feeding schedule. Now, your newborn will have to rely on her innate sense of being hungry when her body needs energy. However, she will not have a neat and tidy schedule.

      Newborns need to eat about eight to 12 times in a 24-hour day. This may be every 1 1/2 hours for a few cycles, then four hours later, then two hours, etc. Somehow, in 24 hours, they do it. This is called “ad lib” or feeding on demand. Ideally, parents (and their doctors) would like their baby to have ‘“cluster feeding’” of every 1 1/2 hours during the day and a nice four hour stretch at night. But, short of divine intervention, there is little that can be done to make this happen.

      For parents of preemies: Premature babies really need those feedings frequently. Their smaller tummies, and need for catch-up growth often require feedings every two to three hours until they are at least four months old. (That is, four months from the original due date, not the actual birth–their so-called adjusted age).

      image BOTTOM LINE

      Although newborns can’t be put on a schedule, by four months of age, your baby WILL BE capable of regular feeding andsleeping patterns. Some lucky moms and dads will have a baby that falls into a predictable feeding/sleeping pattern by two months of age.

    • +Q. My six-week-old seemed to have somewhat of a feeding schedule... but now seems insatiable. Is my milk drying up?

      No. Babies often have growth spurts at three weeks and six weeks of age. They will have feeding frenzies during those periods of time. As your baby’s demands increase, so will your milk supply. (We have a comprehensive breastfeeding section ahead in Chapter 6, “Liquids”.) If your baby continues to act this way, it’s time to check in with your doc and make sure you are making enough milk and your baby is appropriately gaining weight.

  • Special Concerns

    • +Q. My 6 month old has dropped his weight percentiles from 75% to 25% since his four-month visit. What happened?

      Did he start solid food? Solid foods contain significantly fewer calories than formula or breast milk. When babies are given solid foods before their milk, it reduces the amount of formula or breast milk they drink. Don’t get carried away with feeding your baby solid foods until he can take one or two jars (two to four oz. of solids) at a sitting. What many parents don’t realize is that your baby will tell you when he or she wants more. If your little one is finished, you’ll know it. And until she’s asking for more, don’t push the solid food. (We cover solid foods in-depth in Chapter 7, Solids.)

      If your baby is exclusively breastfed, check out the World Health Organization’s growth charts. Remember, your baby’s doctor may still use the CDC’s growth charts, which may not reflect a breastfed baby’s growth curve from four to six months. If your baby is tracking fine on WHO’s curves, that’s all the reassurance you need (see Appendix E, References).

    • +Q. My nine month old seems to be dropping on his growth percentiles. Is he malnourished?

      Probably not.

      Babies these days are born much bigger than they used to be (good for them, bad for Mom’s pelvis)–thanks to good prenatal care. But not all babies turn out to be sumo wrestlers. Their genetic makeup (i.e. Mom and Dad) determines their ultimate size. Big babies that have more average sized parents start to plateau, showing their truer growth curves as they approach a year of age.

      Your doctor will check for iron deficiency anemia at this age, as this can also be a cause of poor growth (a drop in growth percentiles). If your baby is dropping off the growth charts, your doctor should perform a thorough evaluation to figure out what’s going on.

    • +Q. My baby has dropped off the growth charts for his weight. What is wrong with him?

      No, your baby hasn’t begun the South Beach Diet behind your back. The official term for this problem is FAILURE TO THRIVE.

      Babies whose weight percentiles start off fine, then plateau or fall below the third percentile need to be evaluated. The causes are various and include: poor feeding routines, incorrect formula preparation, gastroesophageal reflux, malabsorption of food from intestinal problems, kidney disease, metabolic disease, hypothyroidism, and anemia.

      An extensive medical evaluation is usually performed, unless a cause is found easily. If no cause is identified, a higher calorie diet is initiated and baby’s weight is checked frequently.

  • Vitamin Supplements

    • +Q. Does my baby need a multivitamin?

      Babies do NOT need multivitamin if they born at full-term, are growing appropriately on breast milk or formula and have a relatively “balanced” diet once they start eating solid foods. So, no, we don’t routinely recommend iron or multivitamins for all babies.

    • +Q. I’ve heard about fluoride supplements. Does my baby need this?

      The answer is riddle . . . wrapped in an enigma.

      Fluoride prevents tooth decay. The process of adding fluoride to water supplies that do not contain it naturally is one of the top public health achievements of the twentieth century. Despite the overwhelming evidence of benefit, there are a few vocal skeptics who think this is a government conspiracy to hurt children. I’ll respectfully disagree on that one.

      However, kids need the right amount of fluoride. Too little, and you risk tooth decay. Too much, and you risk fluorosis (a permanent stain on tooth enamel). Fluorosis occurs only in teeth that are developing under the gums—the teeth are not at risk once they have erupted. So, the greatest risk of fluorosis is in kids under three years of age.

      So, how much fluoride the right amount? Fluoride is measured in parts per million or “ppm.” As of 2011, the U.S. government recommends that the maximum fluoride level in drinking water should be 0.7ppm. Be aware that some communities (particularly in Texas, Oklahoma, South Carolina and Virginia) have water supplies with high levels of naturally occurring fluoride—above 2 ppm. Some towns have 4ppm or more of fluoride in their water, which is clearly a concern. You can contact your local water department or public works agency to find out the fluoride level in your local tap water.

      Here’s the key point: babies under six months don’t need fluoride, babies over six months do. Both breast and formula-fed babies should drink fluoride-containing water on a daily basis starting at six months of life. They need 0.25 mg fluoride a day. (Note: the dose for fluoride is in milligrams; fluoride content of water is measured in ppm or parts per million).

      So, exactly how much water should baby drink to get the recommended 0.25mg dose? Well, there’s no easy answer. That’s because your child gets fluoride from sources other than drinking water. Fluoride is not only found in your tap water, but also in foods you prepare with water, and commercially produced beverages, etc. Since the American Dental Association (ADA) doesn’t specify volumes, I’ll conservatively suggest four to six ounces of fluoridated water a day.

      Because striking the right balance for fluoride intake is key in babies, the American Dental Association (ADA) has some very specific advice:

        • Breastfed babies. Babies who are breastfed for the first year of life should drink fluoride-containing water (tap or bottled water that has 0.7 ppm fluoride) on a daily basis starting at six months of life.
        • Formula-fed babies. For the entire first year, use ready-to-feed formula (no water added) or prepare formula with “low fluoride” water (less than 0.3 ppm is probably okay). The ADA further advises to offer drinking water with fluoride (0.7ppm) once your baby is six months old. Yes, you read that correctly. Always prepare formula with low-fluoride water, but offer additional fluoride-containing water starting at six months of age.
        • All babies from 6 to 12 months old. Babies over six months of age need 0.25 mg fluoride a day (about four to six ounces a day of water that has 0.7ppm of fluoride) to get their daily recommended fluoride intake.

      So, let’s sum this up for babies over six months of age:

      1. First: Call your local water supplier and find out how much fluoride is in your water.

      2. If you are breastfeeding or using ready-to-feed formula, your baby should also drink fluoridated water daily. Again, the safe level is 0.7 ppm. There is no official recommendation from the AAP or ADA on the amount of water a baby should drink. Our rough guess: aim for four to six ounces a day. If your tap water has the right amount, go for it. If not buy nursery water or talk to your doctor about a fluoride supplement.

      3. If you use powder/liquid concentrate formula: continue mixing it with low/no fluoride water for the entire year.

      4. Which children need a fluoride supplement? If your baby is over six months of age, and is drinking water that contains LESS than 0.6ppm fluoride for whatever reason (reverse osmosis filtered tap water, well water, etc), your doctor or dentist can prescribe a fluoride supplement. Be sure to ask about it! For yet more details on fluoride supplements, see Appendix A, “Medications.” And we’ll tackle other formula preparation details in Chapter 6, Liquids.


    • +Q. Does my baby need a Vitamin D supplement?

      Probably. But bear with us–the answer is confusing.

      Babies from 0-1 years of age need 400 IU (International Units) of Vitamin D a day to prevent RICKETS, a bone malformation (see glossary). Vitamin D may have other health benefits as well but the data on this is less conclusive.

      While Vitamin D is present in some foods (cod liver oil, salmon, sardines, fortified milk), we get most of our Vitamin D from the sun’s rays. Mother Nature planned on children producing Vitamin D in their skin after sun exposure. She did not plan on the creation of sun block that blocks UVB rays–an essential component of Vitamin D synthesis. (Gartner, Taylor)

      Because it is impossible to determine the amount of sunlight every baby needs to make enough Vitamin D (skin color, sun block, and the latitude you live in complicate the equation), the American Academy of Pediatrics and the National Institutes of Health recommend Vitamin D supplementation for all babies. (AAP Committee on Nutrition)

      Before we list the specific guidelines, here are few comments:

      • Breast milk is perfect nutrition with one caveat. Frequently, there is not enough Vitamin D in breast milk for your baby’s growth (primarily because most mothers are deficient in Vitamin D themselves).
      • One formula, Enfamil Premium “Newborn” formula (it has a big “N” on the label) contains higher concentrations of Vitamin D, allowing a 0-3 month old to get 400 IU of Vitamin D by drinking 27 oz/day.

      Here are the Vitamin D supplement guidelines from the AAP (updated 2008). Vitamin D supplements of 400 IU per day are recommended beginning after birth for:

      1. Babies who are exclusively breastfed.
      2. Babies who are breastfed and receive less than 1000ml (32oz) of supplemental formula daily (or 27 oz daily of Enfamil Premium Newborn formula).
      3. Babies who are formula fed but eat less than 1000ml (32oz) of formula daily–this covers most babies under two months of age. (Or, babies who drink less than 27 oz/day of Enfamil Premium Newborn formula).
      4. After twelve months of age, children and adults need 600 IU of Vitamin D daily. Since that would require drinking 6 cups of milk or consuming other Vitamin D rich foods (salmon, or a daily dose of cod liver oil) on a daily basis, most people need to take a Vitamin D supplement. Yes, that means you, too.

      FYI: Babies who are at the greatest risk of Vitamin D deficiency rickets are those with darkly pigmented skin living above latitude 40 degrees (that’s Iowa and north). However, breastfed babies in Texas and Georgia have been found to have rickets too.

      Factoid: The peak incidence of rickets is between 3 and 18 months of age. However, adequate daily Vitamin D intake may also play a role in preventing autoimmune disease, some cancers, and Type 2 Diabetes later in life, although the jury is still out on those health benefits. (Institute of Medicine)

    • +Q. Does my baby need an iron supplement?

      There are a few kids who will need this.

      Here’s the 411 on iron. Our bodies need iron to carry oxygen on red blood cells. Iron deficiency causes ANEMIA (see glossary). Anemia causes fatigue, poor weight gain, and poor intellectual functioning.

      Newborns have a large iron bank, thanks to Mom. They fill up that bank while in the womb during in the third trimester (which is one reason why babies born prematurely are more prone to iron deficiency). As withdrawals are made from the bank, the supply needs to be replenished via baby’s nutritional intake. By six to nine months, the original iron stores are gone and baby is on his own. So, it becomes important for baby to get iron in the diet.

      Formula fed babies get an appropriate amount in their iron-fortified formula. According to a recent AAP report, exclusively breastfed babies need an additional source of iron after four months of age until they start to eat iron-containing solid foods. (Baker) (Note: some nutrition and breastfeeding experts argue that breastfed babies do not need an additional source of iron until six months of age– saying the AAP recommendation is based on a very small study of just 77 babies. We point this out because you may see or hear some conflicting advice on this topic).

      Here are the latest AAP guidelines on iron:

      • Babies who are born full term and are fed with an iron-containing formula do NOT need iron vitamin supplements. Babies should eat iron-rich foods when they start solid foods. (See the list later in this section in the “Calcium, Fiber, Zinc, and Iron” section for food ideas!)
      • Babies who are exclusively breastfed or those who are primarily breastfed (supplemented with only a small percentage of formula) DO need an iron supplement from four to six months of age until they start eating iron-containing solid food. Your baby’s doctor can recommend an iron supplement that is the right dose for your baby.
      • Babies who are born prematurely (under 37 weeks) DO need an iron supplement (2mg/kg of weight–your baby’s doc can give you the dosing) starting by one month of age. Breastfed preemies need that iron supplement until they are weaned to formula or they begin eating iron-containing solid foods... although some docs may recommend an iron supplement be continued until age one.
      • Babies from 6-12 months of age should get about 11 mg per day of iron in their diets. The AAP Nutrition Committee recommends red meat, high-iron containing vegetables, and iron-fortified cereals to get those dietary needs met. In general, babies should start eating red meat sooner than later.
      • Toddlers from 1-3 years of age need 7 mg per day of iron in their diets. (If you have a toddler who definitely does not eat iron-containing foods–we know, toddlers can be picky–talk to your child’s doc about an iron vitamin supplement. See our sister book, Toddler 411, for more about this issue.)
      • All children should be screened for iron deficiency anemia at 12 monthsof age. (Note: this is not a new recommendation. Many docs screen their patients at either the nine-month or one-year-old well child visit.) A child needs an iron supplement if he is anemic.

      ImageMany babies get the iron they need, but make a concerted effort to offer iron rich foods once your baby starts eating solid foods. And if you have a preemie or you are exclusively breastfeeding, be sure to ask your child’s doc about iron supplements.

      Now you can see one of the key reasons to start solid food at four to six months of age: to get more iron into your baby’s diet. (Baker)

    • +Q. Does my baby need DHA/fish oil supplements?

      Docohexaenoic acid (DHA) is an Omega-3 fatty acid used in our bodies to make nerve tissue, hormones, and cell membranes. Found in fish oil among other foods, DHA promotes brain and vision development in infancy. But are there lifelong health benefits to daily DHA intake?

      Here’s a reality check: there is no long-term data that shows DHA has a significant health impact. The most compelling studies, however, show some protection against heart disease and high cholesterol.

      Foods that contain DHA naturally are human breast milk, fatty fish (salmon, herring, tuna, rainbow trout, whitefish), and organ meats. Most commercial infant formulas contain DHA. Some foods, including commercial baby foods, are now “fortified with DHA.”

      But here’s the rub: the fortified foods do NOT have nearly the same amount of DHA that you can find in fish. Example: a three-ounce serving of Atlantic salmon has 1825 mg of DHA. An eight ounce cup of Horizon Organic milk fortified with DHA has 30 mg.

      While there is no official recommendation about adding fish oil supplements to your child’s diet, the AAP does recommend that nursing moms have 200-300 mg of daily DHA. (AAP) FYI: Adults with heart disease should have 1000mg of DHA per day. There are no such nutritional guidelines for kids.


      If you want your child to get DHA in his diet (beyond what he gets in breast milk or formula), offer fish on a regular basis.

  • Overeating, Obesity, And The Body Mass Index

    • +Q. I am concerned that I am overfeeding my baby. Is that possible?
      It is unlikely, but it can happen in rare cases. Let’s look at this rationally. Most infants do not think, “I’m full, but that dessert looks pretty good.” That is a learned behavior in our society. Most infants self-regulate. In other words, they will eat until their tummies are full and stop. If they do overindulge, they usually just throw up. But, it is a good idea to learn your child’s cues. Some new parents think their baby needs to eat every time he cries. This becomes a set up for obesity.  
      Your baby gets weighed in at every well child visit with his doctor. That’s when you will see if your baby is eating enough or too much.
    • +Avoiding the 4 C's


      You’ve seen the statistics and you’re worried. You don’t want your child to be one of them. We’re talking about overweight and obese children. They are a statistic on the rise and if they start out overweight, most likely they’ll be overweight adults. You’ve also seen the incredible array of snack foods on the shelf at your local grocery store. So it’s time to ask our experienced moms for tips on keeping your baby off the junk and excited about healthy snacks.

      1. It takes a family. Julie DeCamp Palmer of Seattle, WA spoke for most of our readers when she said, “It takes the whole family eating a healthy diet.” So lead by example and don’t stock the four C’s (cola, chips, cookies, candy) in your home. For those of us who want a little of the forbidden items ourselves, eat them when your child is not around or when you’re out and about without him.
      2. Presentation is important. Healthy snacks can still be exciting to a child when they are presented with enthusiasm. One reader Tiffany Johnson from Vancouver, WA, who is also a daycare provider noted that “children like anything that isn’t called what it is... i.e. celery sticks with cream cheese and raisins becomes much more appealing when you call it ants on a log. Cottage cheese with raw fruit or veggies is a hit when you make it into a face and call it clown food.”
      3. Moderation. Yes, an occasional cookie as a treat is just fine. In fact, S. Von Lengerke had a great story about her own childhood where the four C’s were completely banned: “I believe everything in moderation is OK. I was raised in one of those families where we could never have soda or sweets, so my brother and I chose our friends based on their snacks. We were chubby kids. I think having some access to sweets, rather than forbidding them, makes them less of an allure to kids and the children, in turn, will have a healthy regard for snacks.”
      4. Go with the flow. “One item I think many parents forget is that kids’ eating often ebbs and flows. Kids will be starving and eat more than Dad at one meal and turn up their noses at even favorite foods the next. It’s not easy, but we offer a variety of healthy and favorite foods at meal- and snack-time and let the kids decide if they are going to eat or not. We don’t take it personally and trust that our children will eat when they are hungry. Not always easy, but usually very successful.” –Wendy Stough

      Not only did our readers have great tips on avoiding the four C’s, they also offered food recommendations on what snacks work best in their households. Here are a few suggestions:

      1. Pirate Booty. Manufactured by Robert’s American Gourmet (web: robscape.com), the veggie variety of this puffed rice snack food is sprinkled with a blend of spinach, kale, cabbage, carrots and broccoli. Pirate Booty is a cheddar version of the snack and there is a fruit version as well. Readers report their kids love them.
      2. Another reader recommended dehydrated vegetables from a company called Just Tomatoes (web: justtomatoes.com). Crunchy and salt- and fat-free they don’t spoil like fresh food so they’re great to pop into your diaper bag.
      3. Other readers recommend rice cakes, whole grain crackers, or organic products from Hain (web: hain-celestial.com), including their all-natural animal cookies.
      4. Yogurt pops: Several brands come in those easy to transport squeeze tubes (hint: pick the brands with the least sugar). One mom recommended freezing the tubes for a popsicle treat!
      5. Fresh fruits and veggies are the ultimate snacks. Bananas, peaches, avocados, or pears are easy to pack and then cut up at snack time. Cooked peas or soft-cooked carrots are also easy to transport and make for great finger foods.

      When you find a great product, check to see if they have a web site. We discovered that they are full of nutritional information, fun games and even e-coupons for their products.

    • +Q. Is it possible for my baby to be overweight? His weight percentile is off the charts!

      Yes, but that does not mean he needs to join Weight Watchers.

      A landmark  study found that 32% of American babies were already overweight at nine months of age and 44% of those babies were still overweight at age two. Boys, and those of Latino heritage, are most at risk. FYI: overweight is defined as a Body Mass Index of at least 85th percentile or more. If your baby fits into this category, your baby’s healthcare provider may chat with you about appropriate baby-sized serving sizes of solid foods, daily intake of breast milk/formula, and discontinuing night-feedings if he was born full-term and is over four to five months of age.
    • +Q. How can I find out if my child is overweight?

      There is a calculation called the BODY MASS INDEX (BMI) that compares your child’s height to his weight. The formula is applicable to children ages 2-20 years of age. The ranges vary for gender and age (because the BMI varies as kids grow).

      Here’s the formula:


      For children, the risk for obesity is a BMI of 85-95%. An overweight child has a BMI of 95% or higher. To check your child’s BMI, go to www.KeepKidsHealthy.com (click on “Useful Tools” and then the “BMI Calculator”).

      The BMI range for ADULTS is based on the number derived from the calculation above:

      Healthy BMI18–25
      Overweight BMI25–30
      Obese BMIGreater than 30

      For more information on body mass indexes for both children and adults, check out the Centers for Disease Control’s website at: cdc.gov/nccdphp/dnpa/growthcharts/bmi_tools.htm

    • +New Parent 411: Avoiding Obesity


      Set up the right routines while your baby is an infant and toddler. Here are our tips:

      1. Keep your child physically active.
      2. Make restaurant food a treat. McDonald’s should be a once a month treat–not a weekly outing.
      3. Offer appropriate serving sizes. Start with two tablespoons per serving. Most older babies eat about 4-6 oz, three times a day until their first birthdays. Offer seconds on fruit and vegetables.
      4. Banish the “Clean Plate Club.” Don’t force your child to eat. Yes, there are starving children in India, but they won’t be eating your leftovers.
      5. Make juice a low-priority item.
      6. Keep the four C’s out of your pantry: cola, chips, cookies, and candy. If you have to go out of the house to get these items, they will truly be a treat.
      7. Be a good role model. Your child is watching what you are eating.
      8. No TV while food is being served. Watching the tube while you eat encourages overeating. Don’t watch the news during dinner–set the DVR and watch it after the kids go to bed.

      One of the realities of being a parent is that you often end up eating what your kids eat. That’s how you end up at the end of baby’s first year still wearing those prenatal pounds. What to do? Change your eating habits now and everyone in the family will benefit.

      Next, buy healthy, yet good snacks: think portable fresh fruit, veggie spreads/dips, yogurt, and whole grain cereals and bread products. And if you are going to buy juice, stick with 100% juice products. Read the package labels. You may be stunned at what you discover. It comes in individual boxes, too, for easy transport. And be a good example to your kids. Don’t drink soda in front of them day and night. Instead opt for milk or here’s a crazy thought: water!

      In the end, an outright ban on cookies, soda, chips and candy can backfire. As we said earlier, these can be occasional treats. Otherwise, you’re going to have a kid who sneaks out to a neighbors’ to indulge or spends his allowance on the sly to buy candy bars.

    • +Q. Is there anything I can do while my baby is an infant to prevent obesity later in life?

      Yes. Here are three things you can do.

      START A HEALTHY DIET AND LIFESTYLE FOR YOU AND YOUR CHILD FROM DAY 1. Before parenthood, maybe you didn’t work out as much as you should have... or ate too much take-out food. It’s time to change those habits. Your baby looks to you as a role model–so be a good one. He also looks to you to put his food on the table for the next 18 years–so make it good, healthy food.

      BREASTFEED FOR AT LEAST FOUR MONTHS. Breastfeeding for at least the first four months lowers the odds of childhood obesity. Breastfed babies (no matter when they begin eating solid food) have only a one in 14 chance of being obese as a preschooler.

      START SOLID FOODS AT FOUR MONTHS OF LIFE OR LATER. Introducing solid food at four to six months of life seems to reduce childhood obesity rates. One study showed that formula-fed babies who started solid food before four months of age had a one in four chance of being obese at three years of age. Those who indulged in solid food at four to five months of age had only one in 20 odds. (Huh)

      The Rise In Childhood Obesity

      The United States is super-sized, to paraphrase an article in U.S. News and World Report. A startling fact: the number of overweight school-aged children has doubled in the past 20 years.

      Why? Here are some of the key reasons:

      1. Lack of activity. Children are spending more time (about three hours a day) watching TV and playing on computers and other screens than ever before. Whatever happened to the good old days of playing outside?
      2. Eating out and take-out food. 34% of our calories are eaten outside of the home. Restaurant food has more fat, salt, and sugar than home prepared meals.
      3. Larger serving sizes. Super-size servings have become the norm at all types of restaurants, not just fast food outlets. This trend toward giant portions has even crept onto our own dinner tables.
      4. Too many sugar drinks. Although juice has some nutritional benefits, they are also full of sugar. This adds extra calories to your baby’s daily intake. (More on this in the Other Liquids section of Chapter 6, Liquids.) Don’t let your child become a juice-a-holic. Kids graduate from juice to soft drinks. Believe it or not, the average teenage boy drinks three sodas a day.
  • Calcium, Fiber, Zinc, And Iron

    • +Q. Are there any nutrients that children eat too little of?

      Calcium, fiber, zinc, and iron. Let’s take a look at each.

      CALCIUM. Calcium is a key nutrient for healthy bones. The requirements change as children grow. Babies from birth to 12 months get enough calcium from breast milk or formula. For ages one to three years, children need 500 milligrams per day (mg/day). Kids ages four to six need 800 mg/day. Kids ages seven to 14 need a whopping 1300 mg/day. If your child has a milk intolerance or allergy, try calcium fortified orange juice, broccoli, rhubarb, or tofu as alternative calcium sources. If you are looking for a vitamin supplement that contains calcium, get one with Vitamin D added (it helps the body absorb calcium better).

      Calcium Content Of Foods


      Note: As you can see, milk is the most efficient way of getting calcium. But don’t lose sleep if your child has a milk allergy. Calcium fortified beverages have comparable absorption to dairy products and the calcium in green leafy vegetables is absorbed better than milk (that is, if you can get your kid to eat kale or collards).

      FIBER. Not only does fiber make your child a regular guy or gal, it also has potential benefits to reducing heart disease. So, make it a little family project to increase everyone’s fiber intake.

      The fiber requirement for children is calculated by: Age in years + 5 = Number of fiber grams/day. Example: a two-year old needs seven grams of fiber day. However, there are no established guidelines for children under one year of age. So, you and your baby’s healthcare provider will have to tinker with how much fiber to offer if your baby gets constipated! Adults need 25–30 grams of fiber per day. The average American diet doesn’t come anywhere close to our daily needs.

      So, how do you get a baby to eat high fiber foods? Try whole grain cereals and breads, prunes and other fruits, beans, and green leafy vegetables. If you are laughing at the prospect of convincing your baby to eat kale, see the section Solid Food Equals Solid Poop in Chapter 8, The Other End for our tricks.

      ZINC. Zinc is necessary for immune function, cell growth and repair. Research shows kids who have high zinc levels also have fewer serious respiratory infections. Babies from birth to six months need 2 mg per day and babies from seven months to age three need 3 mg per day of zinc.

      Zinc is in both breast milk and formula. However, babies need an additional source of zinc in their food, starting around six months of age. This is especially important for babies who were born prematurely and are growing faster than their peers.

      The best and most practical source for zinc is meat. Lentils are another great option. Fortified cereals for infants also contain zinc, but this is less effective (it is harder for the body to absorb this type of zinc). Less baby friendly sources of zinc include oysters, beef liver, and crab.

      IRON. We have already chatted about this one. It’s important for babies six to 12 months old to have a daily intake (11 mg/day) for growth and brain function.

      Here are some good sources of iron:

      Meat, poultry, fish, bread, enriched pasta, dark green vegetables (spinach, broccoli, kale), legumes (dried beans, soybeans, lentils), eggs, nuts/seeds, peanut sauce and butter, dried fruits (raisins, etc)*, cereals (infant as well as grown up breakfast cereals are iron fortified). Note: Eating iron in combination with Vitamin C (orange juice, etc), helps the body absorb iron.

      *Because of risk of choking, hold off on these foods until after three years of age.

  • Happy Birthday, You’re Turning One!

    • +Food guidelines for a one year old
      Yes, your child is turning one! How exciting, no? Unfortunately, there aren’t any cool food pyramids for one year olds. The following servings should help you determine the proper diet for your child. You can check out choosemyplate.gov for food guidelines for kids ages two and older.

      Food Guidelines for a One Year Old

      The serving size is listed beside the food item. The average calorie intake for a one year old is 900 calories. Two to three year olds consume 1000-1400 calories a day. image
    • +Q. My one year old is on a hunger strike. Help!
      Very few one year olds have a world cause they support that passionately! The toddler diet appears as your baby approaches one year old. The typical toddler eats well once every three days or eats one good meal in 24 hours. The food that is loved for seven straight days will be refused shortly thereafter. A good strategy is to offer three food choices in a meal. Pick one that is sure to be a hit–the others are trial offerings. If your child refuses everything, do not make another meal for him. Mealtime is over. Don’t worry, your child will eat at the next opportunity. All humans have both a hunger and thirst drive that compels us to fulfill our calorie and fluid needs. Your toddler is regulating his food needs. Embrace it.