Feeding infants and toddlers

Newborns

Newborns typically lose weight in the first 3 or 4 days of life. A “normal” weight loss is up to 10 percent of birthweight. Most babies reach their lowest weight on day 3 or 4. Breast feeding is best and mothers who can should try to nurse their babies. It is not known how long a mother should nurse her baby, but the American Academy of Pediatrics recommends nursing for the first 12 months. A common mistake is the infant latches on to the tip and not the whole pigmented areola. Babies should be fed every 2 to 3 hours. A new mothers breast milk usually “comes in” between day 3 to 5. Formula fed infants should take 1 to 2 ounces every 2 to 3 hours.

2 weeks

By 10 to 14 days old children should be back to their birthweight. After two weeks, the average infant should gain 0.5 to 1.0 ounces per day and grow about a inch per month. Once breastfeeding has been established, I recommend breastfed infants receive a bottle once a week. I don’t care if the bottle contains pumped breast milk or formula. Taking a bottle is a skill that most children will need.

2 months

There are no big feeding changes typically discussed at the 2 month visit. Parents should slowly space out feedings with the hope of getting the child to sleep through the night. As the feedings are spaced out, children gradually take more milk at each feeding.

My daughter is just 2 months old and eating CONSTANTLY (it seems).  Sometimes, she eats every 4 hours and sometimes, she eats every two.  She is already "eating" 6 ounces every feeding.  When she wants a bottle every two hours, can I give her some water instead of more milk?  Also, when can I switch from formula to regular milk?

Two month old children typically feed every two to three hours. The average two month old will take about 20 ounces of milk per day. The key to knowing if your daughter is eating enough calories is her growth. This should be discussed with her health care provider at her 2 month check up. If your daughter is growing well and is overall happy I would recommend you gradually increase the spacing of her feedings. There is a direct correlation between sleeping through the night and being able to space out feeding to every 4 hours.

As a whole, pediatricians do not recommend water for young children. When parents give infants excessive water, they can cause electrolyte changes that trigger seizures. In the 1960s and early 70s pediatricians routinely recommend extra water to compensate for that generations formula’s imperfections. Today’s formulas are complete and there is no need for extra water.

In Orlando, many of my patient’s parents ask about giving water on hot days. After four months, I am okay with giving some extra water to healthy well grown children beyond 4 months old. My rule of thumb is children can have the same number of ounces of water per day as they are old in months. Such that a 5 month old could have 5 ounces of water a day.

4 months

Starting solid foods - I often joke that if you ask ten pediatricians, read ten books and ask 10 grandmothers you would get thirty different opinions on how to start solid foods. There is very little research on starting solids. Who would like to enroll their infant in a research study where you feed them only carrots for 5 years?

During my training the American Academy of Pediatrics (AAP) recommended starting at 4 months and now 10 years later they recommend starting at 6 months. The stated reason for this change was an increased risk of food allergies when starting solids too young. There is absolutely no scientific bases for this change, it is only an opinion.

Most experts universally recommend starting with iron fortified rice cereal. After that it gets confusing. I’d expect If you surveyed grandmothers as to what to feed next:
50% would recommend vegetables (Often the stated reason is that if you feed sweet fruits first then they won’t learn to like veggies)
30% would suggest fruits (Often the stated reason is that if you feed sweet fruit first then they will like to eat and always be a “good eater”)
15% would recommend a variety of grains (wheat, barley, etc.)
5 % would say in their day they began in ribs, chicken wings and steak

I recommend beginning solids between 4 to 6 months old. We begin with rice cereal mixed with breast milk or formula. Start with 3 or 4 tablespoons of rice cereal. We then mix it to a runny oatmeal consistency, warm it slightly in the microwave, remix and test for temperature. I’d put the child in a bouncey seat and feed it on a small plastic coated spoon once or twice a day. Typically, the first few feedings end up all over. This should be fun. If its a miserable experience retry in a few weeks.

After a week of tolerating rice well we begin the stage 1 fruits and vegetables. We add a new fruit or vegetable every 5 to 7 days. I like the idea of moving slowly to look for any reactions. While most people recommend either veggies or fruits, we alternate adding fruits then vegetables. We quickly end up on rice cereal & fruit in the morning and rice cereal & veggies in the evening.

Typically a child’s milk intake stays the same from when they start solids until 9 months. Formula fed infants typically take 25 to 35 ounces a day from 4 to 9 months old. When you are starting solids feed the child milk and then offer the solid foods. If you offer rice cereal (prior to formula or breast milk) to a 5 month old that just slept 8 hours you are bound to have lots of crying.

Many grandmothers believe that you must feed an infant solid foods to sleep through the night. I do not believe this. All seven of my children slept through the night consistently prior to beginning solid feedings.

6 months

The 6 to 9 month period involves dramatic dietary changes. At six months, some children are taking a variety of stage 1 foods and some children have not started solid foods. By 9 months most children are able to eat a variety of table foods.

During this period, children usually drink a consistent amount of milk. Formula fed children typically drink 25 to 35 ounces a day. I would recommend offering your child a sippy cup. Once they learn to take it well, you can get rid of bottles.

At 6 months, children can begin stage 2 foods (these are courser than stage 1). They can also chew on what I call “too big foods”. These are things like a toasted half of a bagel, a large carrot, a large piece of apple or zwieback teething toast (Items the child can chew on and taste, but are “too big” to really eat)

At 7 -8 months children can begin the small pick up foods like Cheerios or Puffs. Offering these type of foods should improve the child’s fine motor pincer grasp. We often begin fresh fruit offered in a mesh fruit feeder. They are gross to clean, but the kids like them.

At the Gordon house, 9 month olds will often be offered thinly sliced turkey from the deli, cut up pieces of fruit (like halves of a grape) and pieces of pasta.

As children near 9 months old, they often closely watch their parents eat. They begin to want to eat what you eat and when your eating it. In this way, by 9 months most children are receiving solids 3 times a day.

9 months

By 9 months, my children are eating thinly sliced deli turkey, pasta, and cut up pieces of fruit.  We will often begin some dairy (cheeses and yogurt).  They usually are eating 3 meals a day.

Children should be off (or weaning off) baby foods and on all table foods by 12 months. They should be eating mostly what their parents are eating.

Normally we see a decline in formula/milk intake between 9 to 12 months as children continue to eat more solid foods.  The typical 9 month old drinks 25 to 35 oz of formula a day, while the average 12 month drinks 10 to 16 oz of whole milk. Encourage your child to take a sippy cup and wean them off bottles as soon as possible. It is okay for most children to start whole milk at 10 to 11 months.

9 to 10 month olds are typically your "best eaters". Parents often ask when to stop feeding them.  Most of these "good eaters" gradually eat smaller and smaller quantities until 18 months.  Between 18 to 36 months children often eat infrequent small quantities.

12 months

One year olds should be off formula and off bottles. Prolonged use of bottles causes cavities and increases the risk of ear infections. They should move onto sippy cups and whole milk. I do not recommend follow-up formula.
The average 9 month drinks about 30 ounces of formula a day, while the average 1 year old should take 10 to 12 ounces of whole milk a day. Milk is now only a part of the child’s diet. I’d rather hear that your 1 year old refuses all milk than they drink so much milk they refuse solids.

One of my daughters refused to drink milk for several months. When this happens in other families, I recommend persistently serving milk as the only beverage option at lunch and dinner. Eventually, children (as my daughter did) learn to drink milk.

Typically, 9 to 10 month olds are the “best eaters” in term of quantity of food and some parents will notice a decline in appetite as early as 12 months.

By 12 months, most children should be eating what you are eating. Higher fat foods should be encouraged until 2 years old as this helps brain development. Toddlers should be strapped into a chair and be required to sit for the entire meal. Parents should set a good example by eating a healthy diet.

Children should be offered the same dinner as the rest of the family. In our home, we serve our 1 year olds salad even though we know they cannot chew and eat it yet. By consistently and repetitively presenting our children healthy foods they will learn to eat them.

Weaning

In general, I do not recommend mothers stop nursing their babies. The AAP recommendation to nurse for a year is an arbitrary round number. How long a mother nurses is a personal decision. I often joke,”You know you have nursed too long when you child can say the phrase “whip it out””.

When you are ready to wean your child, I recommend dropping out one feeding about every 2 weeks. The last feeding to drop out is typically the bedtime feeding.

15 months

Typically , 9 to 10 month olds eat the greatest quantity and variety of foods. Hence, grandmothers love to feed 9 month olds. As children get closer to 18 months they often eat less and less. Between 18 to 36 months children often eat next to nothing. During this time parents often report things like, “Yesterday, she only ate 4 bites of a bagel and 3 goldfish off the van floor”. Despite such poor diets, the toddlers continue to grow and be active.

As children begin to eat less, the parent’s role changes. No longer are they “to feed”. Parents need to present their child with healthy options, set a good example and back off.

Toddlers should be strapped into a chair and be required to sit for the entire meal. If they scream and fuss either ignore them or roll their high chair into another room until they calm down. If they throw food, take their food away.

If your toddler drinks too much apple juice or eats too many goldfish quit buying apple juice and goldfish. If you are worried that your child is not eating enough, I’d recommend you make an appointment with your pediatrician.

18 months

Around 18 months, we will often begin to experiment with open cup drinking. We give the child an empty plastic cup and fill another cup with the amount of milk we think they will drink during the meal. We sit by the child and pour single sips into their cup. That way there is less mess when they throw the cup and we don’t have to keep getting up to refill their cup.

Choking hazards

Parents are right to worry about choking. Avoid hard candies, nuts, whole grapes, clumps of raisins, popcorn and anything of similar size and consistency. We often introduce raisins, popcorn, whole grapes and some nuts when our children our 3 years old. When giving any child these things they should be seating and calm. Anything can be a choking hazard when a child is running around. There is considerable variability in the size and shape of these chokeables. I recommend you sort them and be present when a your child eats these type of items.

By: Dr Gregory Gordon, Pediatrician in Orlando