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Tuesday, January 27, 2009

Tuesday Tips

As you know by my little bio up there in the corner, I'm an RN. I have 15 years experience in Pediatrics, mostly from the emergency department in a children's hospital. For the past 5 years I've been working as a telephone advice nurse. As you can probably guess, I get many calls from parents about everything from A to Z, including growth and development and symptoms of illness.
There are many subjects that come up over and over again. I thought I would address one question here each week to try to shed some light on some of the common concerns. I would love it if readers added their comments. If you have a question you'd like me to cover here, please send it to

**This information is not a replacement for your doctor's advice and I don't diagnose. All the information I share is from reliable sources and my nursing experience and is general in nature. For advice on a specific child's situation, please consult your Health Care Provider**

Today's Question: Why won't my toddler eat?

This is a very common issue and there are many things that contribute to feeding problems in this age group. I get so many calls about this and the problems that it causes. First, it's important to remember that a toddler's stomach is very small and their appetite is easily satisfied with small amounts of food.

Bottles and Sippys
Keeping their stomach size in mind, if they are drinking milk or juice (anything other than plain water) from a bottle and/or sippy cup throughout the day or night, their appetite will be low for other foods. Excessive milk or juice consumption is a big problem for toddlers. It can cause tooth decay when bottles and sippy cups are used as pacifiers. It can also cause constipation and iron deficiency anemia.

Too Much Cow's Milk or Juice
Did you know that a toddler's daily milk intake should be limited to 16 ounces per day? That's 2 cups over 24 hours. Juice should be limited to 4 ounces per day. It can be offered in small servings at meals. Milk or juice is not a good snack if it exceeds their daily requirements. Teaching your child to use an open cup early on (while seated to prevent spilling and choking) rather than carrying a bottle or sippy is preferable. Other dairy products like yogurt or cheeses should be given in moderation as well. Remember that servings for toddlers should be smaller. Drinking too much milk can also contribute to iron deficiency anemia, because milk is very low in iron. Anemia makes kids sluggish and tired and can interfere with brain development. I once cared for a child who was 3 years old and drank ONLY cow's milk and drank it constantly from a bottle. She ate no solid foods other than pancakes. Her anemia was so severe that she didn't even have the energy to play. Of course, this is a very extreme example!

When I child drinks milk or juice at night, the natural sugars in milk or juice pool around the emerging teeth and erode the enamel. There is even a name for it: Nursing Bottle Caries. Many parents don't even know their children have this problem until it causes them pain and needs surgical intervention. The cavities (or caries) begin behind the upper and lower front teeth so they often aren't noticed until they spread around the teeth or cause pain. As you can imagine, damaged teeth can affect the child's desire to eat solid foods. The teeth often require extraction or crowns. It's heartbreaking to see a young child with rotted or missing front teeth from such a preventable problem!
Too much milk and dairy products can also cause constipation. Constipation can be very painful and can become worse once toilet teaching begins. If milk or dairy products replace fruits, vegetables and whole grains in your child's diet, bowel problems are very likely at some point. If your child starts to resist toileting due to fear of pain, the constipation will become worse and then the cycle begins. Once constipation becomes a long-term pattern, it takes a long period of treatment with diet and sometimes stool softeners or other treatments to get it under control.

So, you might be wondering if that's enough fluid for a child to drink in a day. Well, water is the best thing for thirst and will also help to prevent constipation. Plain water should be available to your child throughout the day to quench thirst. It won't satisfy hunger the way milk or juice does, so your child will be more likely to try new foods and eat more solid foods. If you are trying to transition away from a night-time bottle or sippy cup, try offering water only in the bottle, although it is obviously much better to avoid starting the bottle-in-bed habit than to try to change it later on! Get your own water bottle and model water-drinking to your child.

Variety and Autonomy
It's important to offer your child a choice of a few different foods at each meal and serve them food when other family members are eating. Make mealtime enjoyable but not distracting. No TV, video games or toys at the table. Let them feed themselves (I know it's messy, but it's all part of the learning) and offer milk or juice after the meal instead of alongside. Meals and snacks should only be served with the child safely seated to reduce the risk of choking. A suggestion for breakfast might be: a small bowl of hot whole-grain cereal, a few pieces of cut-up fruit and 1/2 a scrambled egg, with 2-4 ounces of milk offered in a cup after he's finished eating. He may not eat it all, but he will likely eat more than if you offer only one food. Allow your child to decide when he is full. Don't force him to eat more than he wants. It's important for him to learn to eat to satisfy hunger, not to please Mom! Focus on offering whole grains breads and cereals, fruits and vegetables at each meal. Since toddlers' stomachs are tiny (and their attention spans are short!) 3 small meals and 2-3 snacks per day are recommended.
If you are breastfeeding, nursing after meals is preferable at the toddler stage, to encourage the child to try new foods. Breastfeeding doesn't cause the same problems as cow's milk, but limiting night-feedings can help to encourage a more varied and complete diet.

Remember to offer foods again and again periodically, even if your child rejects them the first few times. Children's tastes change, and they will often accept foods they previously refused (or threw across the room!) This is even true in my house where the kids are teenagers now, although they don't throw food (when I'm around anyway:-)
Try to offer your child similiar foods to what other family members are eating. Toddlers like to copy what older siblings and parents do. Mealtimes are excellent opportunities to model healthy eating habits.

Here is a good, general online resource for Toddler Feeding advice in PDF format.
From "Toddler's First Steps"

This is a big topic. I tried to keep it concise, but there's a lot to be discussed and I'm sure other parents have great tips to share. Feel free to comment!


Jenn said...

Some great tips here! One thing I've learned with my two toddler girls is not to freak out about their eating habits. Both are growing well and are happy, and both have their own "style" of eating. I make sure to offer healthy foods at all meals, and allow the occasional treats, and try not to freak out when my daughter eats raisin bran for 5 meals in a row!

Helen said...

So true Jenn! They do often go on a 'bender' and seem to eat one food only for a while. So funny you mentioned raisin bran! I was the camp nurse at a children's camp one summer, and my son was about 4. He ate so much raisin bran (several bowls each morning!) The other nurse that was sharing our cabin wasn't too thrilled when the 'results' started showing up...let's just say we needed some air freshener...LOL!

sassy.mrs said...

I am not a mother, but those tips are fabulous! I'm going to follow your blog if you don't mind.

Helen said...

Thanks so much! Welcome to my blog- thrilled to have you following:-)

Michelle said...

Hi Helen
I'm linking this article if you don't mind.I'm going to challenge McKenna with water she loves apple juice/water.Thanks :)