Is an apple a good bedtime treat?

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As parents we try to get as many fruits and vegetables in our kids as they will take, so when Junior asks for a bedtime snack, it is tempting to allow a piece of fruit. Sounds healthy, right?  Surely better than ice cream...

An apple is healthy and can be a great part of a healthy snack, but kids (and adults) shouldn't have a high carbohydrate snack before bed without some protein and / or fat.

Why?

When we eat, our body senses the increase in blood sugar and sends out insulin to store the sugar in cells for future energy. An apple (or other fruit) is high in carbohydrates (sugar) and low in fat and protein. Sugars and can be quickly stored, lowering the blood sugar pretty fast unless there is fat or protein to stabilize it.

Fats and proteins are more complex to digest.  They must first be converted into smaller molecules before insulin can store the food for energy.  This allows a more gradual fall of the blood sugar.

Why is this important at bedtime?

We always have some sugar in our blood, ideally 70-100 mg/dl, but rising after eating and falling when fasting (not eating).  Normal sugar levels give our cells energy for all they need to do. We go for many hours without eating again when we sleep all night. If the insulin level is still high after storing all the easy to store carbohydrates but there aren't more molecules from the breakdown of protein or fat around to start storing, the insulin lowers the normal blood sugar to unsafe levels.  This is especially dangerous at night because one early sign that the blood sugar is too low is tiredness, which is unnoticed when asleep.

Diabetics should be especially aware of this response because their body does not regulate insulin normally, and they can suffer from severe low sugar if too much insulin is given without the proper balance of nutrients.

It would be extremely uncommon for a person with normal sugar management to have serious consequences of low blood sugar (such as coma or seizures) from this apple before bed, but without a good sugar level, the body will not get the most benefits of sleep: restoration of the body and growth in children.

So what's my recommendation for that bedtime snack? Go ahead and give that apple-- with a glass of milk, yogurt, peanut butter, cheese, or other food with protein.

And ice cream isn't all that bad as far as a snack that won't lower blood sugar too much... it just has less nutritional value.  So as a fun treat when kids are eating enough fruits and veggies the rest of the day and have gotten exercise and not an overabundance of empty calories, it's okay to have an ice cream once in awhile.  After all, it's made from milk, so not all bad!

Which reminds me of this great Bill Cosby clip: Chocolate Cake  (Who says we can't have a little fun when talking nutrition?)

Excessive milk can cause anemia? How?

A recent facebook posting recommending limiting milk intake prompted questions from followers about iron deficiency anemia from milk.  Nutrition and iron balance is actually a relatively lengthy discussion, so I will try to explain it here.

Short answer:  Cow's milk has little iron.  When kids drink a lot of milk, they don't eat iron-containing foods in sufficient volumes.  Cow's milk also has big proteins that can cause microscopic bleeding in the gut. The more milk consumed, the more bleeding (though usually still not seen in the stools).

More milk = more blood loss from the gut

                              but less blood produced because less iron in the diet

                                                 = anemia

Iron is used to build healthy red blood cells that carry oxygen throughout our bodies.  Too few red blood cells in the body is called anemia.  Red blood cells are made in our bone marrow and they live for about 3 months.  It is important for the body to continually make new red blood cells as it breaks down and removes old ones.

In general anemia can be caused from several factors:

• too little blood produced (iron deficiency being a major risk for this)
• increased blood loss (ie excessive bleeding)
• increased destruction of blood cells in the body (typically from abnormal blood cells or infection)

Iron deficiency can be due to several factors:

• poor iron absorption due to disease (some studies show milk inhibits iron absorption)
• poor iron in the diet (the most common cause)
• long term slow blood losses (such as heavy monthly periods or GI bleeding)
• increased iron need (such as a growth spurt or pregnancy)

Why does preventing iron deficiency anemia matter? Because the most common symptom of anemia is no symptoms.  It can go unnoticed for quite a while in some kids, yet cause long term problems with growth and development.  Symptoms develop when the anemia becomes more severe and include tiredness, looking pale, irritability, decreased appetite, slowed development, weakness, immune dysfunction, and pica (eating non food substances- such as dirt).

Newborns are designed to drink their mother's milk.  Humans have learned to make formulas that can nourish babies if they aren't able to drink their mother's milk for whatever reason.  Cow's milk, soy milk, and goat's milk are not acceptable for infants due to the nutritional voids they have (not just iron).  After about 1 year of age babies tend to wean from mother's milk and/or formula onto whole milk.  (Newer recommendations allow weaning onto low fat milk--another topic entirely.)  Unfortified non-human milks contain very little iron.  The iron in human milk is better absorbed and iron is supplemented into formula.  If toddlers and children drink too much milk, they fill up on it and don't eat a variety of other food groups that include iron and other important nutrients missing in their milk.

Foods that are good sources of iron:

• meats and poultry (especially organ meats, such as liver)
• lentils, peas, and dried beans
• eggs
• oysters, clams, and fish
• molasses
• peanut butter
• soy
• pumpkin or sesame seeds
• fruits such as prunes, apricots, and raisins
• vegetables such as spinach, kale, broccoli, and other greens
• whole grain fortified breads and cereals

Vitamin C increases iron absorption, so eat foods with iron and Vitamin C at the same meal!

Starting Solids-- The Old and the New and the Myths

Many parents are excited yet apprehensive to start foods with their infants.  So many questions, so many fears.  So much food introduction guidance has changed in recent years, that what you did with your older kids might not be current.  Change takes time, so not everyone agrees on the "new" rules.  Talk to your own pediatrician to see their take on it all!

The older "rules" for starting foods were so confusing... different sources will vary on these rules.

photo source: Shutterstock

• don't feed before 6 months is now ok to feed at 4 months if baby's ready

• don't give nuts, eggs, and other "allergy" foods until ____ (2/3/5 years, varying by expert) is now it is okay to give allergy foods unless there is a family history of food allergy

• don't start more than one food every 3-5 days is now  introducing multiple foods at one time is ok

• start with rice, then add vegetables, then meat., wait until last for fruit is now begin with any foods, but try to make nutritious choices, such as meat which is high in iron and protein

Variations of this were plenty, depending on the provider's preferences.  

No wonder there is so much confusion!!!!

New rules are much easier.  I like easier.

• Start new foods between 4 and 6 months, when your baby shows interest and is able to sit with minimal support and hold the head up.
• Don't give honey until 1 year of age.
• Don't give any textures your baby will choke on.

Done.  

That's it.  Nothing fancy.  Any foods in any order.  Multiple new foods on the same day are okay. Common sense will hopefully guide types of foods.  Nothing too salted. Try nutritious foods, not junk.  

These minimal rules can make parents weary.

What about food allergies if foods are given too early?

Research does not support the thought that starting foods earlier lead to allergies.  In fact, there is research to support that starting foods earlier might prevent food allergies.  A full 180 degree change!  Pregnant women and breastfeeding mothers no longer have to avoid nuts or other allergy foods in most cases.  If there is a close family member with a food allergy, it might still be beneficial to wait to introduce that food.  Talk with your pediatrician in that case.

I admit that I was initially nervous about telling parents it was okay to give nut products in infancy.  Not just the allergy aspect, but also choking risks.  ~ Back to the no textures your baby will choke on... nuts are hard and round-- two no-nos, peanut butter is thick and sticky-- another choking risk.   

Any of the more allergy prone foods should first be offered in small amounts at home.  These foods include nuts, egg, and fish.  Do this only if there is no one in your house who is allergic to that food.  Have diphenhydramine allergy syrup around just in case, but remember most kids are NOT allergic, and starting younger seems to prevent (not cause) allergy.  In the case of nuts, since there is also a choking risk, you can try a food cooked with nuts or nut oil.

What about saving the fruit for last so they don't get a sweet tooth?

Babies who have had breast milk have had sweet all along! Breast milk is very sweet, yet babies who are graduating to foods often love the new flavors and textures with foods.  Formula babies haven't had the sweet milk, but they can still develop a healthy appreciation of flavors with addition of new foods. Saving fruit for last simply doesn't seem to make a difference. Adding fruits alone is not very nutritious though, so fruits should be added along with other more nutritious foods.  The more colors on our plates, the healthier the meal probably is!

I thought they couldn't have cow's milk until after a year?

Cow's milk is not a meal in itself (like breast milk or formula). It is missing many vitamins and minerals, so babies need to continue breast milk or formula until at least a year.  Cow's milk may lead to allergies or eczema, including formulas made with cow's milk.  Milk products, such as cheese and yogurt can be given to babies as part of an otherwise well rounded diet as long as they don't show any allergy risks to milk.  Regardless of dairy intake, it is recommended for infants under 6 months to have 400 IU Vitamin D/day and those over 6 months to take 600 IU Vitamin D/day as a supplement.

I thought they should have cereal first...

Rice cereal has been the first food for generations, probably because grandma said so.  There has never been any research supporting giving it first.  With white rice and other "white" carbohydrates under attack now, it is no wonder the "rice first" rule is being debated. Despite being fortified with vitamins and iron, it is relatively nutrient poor, so choosing a meat or vegetable as first foods will offer more nutrition.  

Shouldn't we wait on meat?

Waiting on meat due to protein load was once recommended, but no longer felt to be needed. Pureed meats (preferably from your refrigerator... baby food meats are not very palatable!) are a great source of nutrition for baby!  Some experts recommend meat as the first food due to its high nutritional value and low allergy risk.  

How do we know what they're allergic to if we start several new things at once?

First, most kids are not allergic.  

Second, if they are allergic to a food, it is often days/weeks/months before the allergy is recognized. Waiting 3 days between food introduction simply doesn't allow recognition unless it is hives or anaphylaxis, and there are a small number of foods that account for most of these reactions. If your child has one of these reactions we can test to see what the offender was.  This is recommended with severe allergies since people with one allergy might have other allergies, and identification for avoidance is important.  

Allergy symptoms can be broad and often are not specific: dry skin (eczema), runny nose, hives, swelling of lips, difficulty breathing, vomiting, diarrhea, or blood in the stool.  If you think your child is allergic to a food, discuss with your doctor.  Severe symptoms (anaphylaxis) demand immediate attention!

How do we know when to start foods? I wanted to start to help baby sleep through the night, but I heard starting too soon increased obesity and diabetes.

When babies are able to sit with minimal support and hold their head up and when they show interest in food by reaching for it they might be ready.  They can wait until 6 months to start foods, but some studies show poor weight gain and nutritional balance as well as resistance to foods if started after 6 months.  

In formula fed babies it has been shown to increase the risk of obesity at 3 years (6x!) if foods are started before 4 months of age.  That risk is not seen in exclusively breast fed infants or those who begin foods after 4 months of age.

It is still an old wive's tale that starting solids will help baby sleep through the night.  Babies tend to sleep longer stretches at this age, so it is no wonder that this myth perpetuates.  Start foods because you see signs that baby is ready, not because you want longer sleep patterns!

How do I know how much to feed my baby?

Babies will let you know when they are full by turning away, pursing their lips, spitting out food, or throwing foods.  As they eat more food, they will need less breast milk or formula.  In general a baby who is gaining weight normally will self regulate volumes.

What's better: baby foods bought at the store or home made foods?

Marketing and ease of preparation has made pre-prepared foods for us all common place.  It does not mean they are any better.  They cost more than home made foods.  I didn't make baby foods when my kids were babies because I thought it would be too hard, but now I puree foods to put into recipes (my kids are like many who aren't fans of veggies and I want to improve their nutrition).  It really isn't hard.  You can take whatever you are cooking for your family and put it in a food processor or some blenders and with a little water to get it to a texture baby can eat: voila!  Home made food.  There are of course many baby food cook books and ideas of how to freeze meal-sized portions so you can make multiple meals at one sitting. There is help for parents who want to safely prepare baby food at home on How to Make Your Own Baby Food from What to Expect. (link updated 9.16.17)

My baby only wants table foods. Is that okay? Don't they need pureed foods first?  He doesn't have many teeth!

Pureed foods are what most babies start with due to the easy texture, but some babies quickly develop the ability to pick up small pieces of food with the pincher grasp (finger/thumb) and want to feed themselves.  If they are able to get the food in their mouth, move it to the back safely with their tongue, and swallow without choking, they are ready to  feed table foods... at least with some textures. Beware of chewy or hard foods as well as round foods ~ these all increase the risk of choking.  

Most babies will be able to eat table foods between 9 and 12 months.  They tend to not have molars until after 12 months, so they grind with their gums and use all their saliva to help break down food.  They need foods broken into small enough pieces until they can bite off a safe bite themselves.  

Don't put the whole meal on their tray at once... they will shove it all in and choke! Put a few bites down at a time and let them swallow before putting more down.  Rotate food groups to give them a balance, or feed the least favorite first when they are most hungry, saving the best for last!

This is a great time for parents, sitters, and other caregivers to take a refresher course on CPR in case baby does choke.  Infants and young children are more likely to choke on foods and small objects, so it is always good to be prepared!  

How much juice should my baby drink?

In general I think babies don't need juice at all. They can practice drinking from a cup with water.  Juice adds little nutritional value and a lot of sugar.  Eating fruit and drinking water is preferable.  If they do drink juice, it should be 100% fruit or vegetable juice, not a fruit flavored drink!  No more than 4 ounces/day of fruit juice is recommended. 

What about organic? 

There is not enough evidence to recommend organic food, since the nutritional components of the foods are similar regardless of how they were farmed.   

Organically grown foods do have lower pesticide residues than conventionally farmed produce, but it is debated if this is significant or not to overall health.  Conventionally farmed produce have the pesticide levels monitored, and they fall within levels that are felt to be safe.

Organic farming rules also dictate no food additives or added hormones, which is also an area of study for health risks and benefits, but not enough data is available to give an educated opinion yet.  

Organic farming is generally felt to be better for the environment, but the sustainability of that is questioned.  

Organic farming might increase the risk of bacterial and fungal contamination or heavy metal content, so it is very important to wash fresh fruits and vegetables well prior to cutting or eating (as you should with all fresh foods).  

For more information, see the USDA site.

A backyard garden can be inexpensive, organic, and a great way for your kids to learn about growing and preparing healthy foods!  

Got Milk? Cow, Coconut, Soy, or Almond?

A Facebook follower asked about how to choose a milk substitute recently. There is not a simple answer.

For many years it was easy:  The American Academy of Pediatrics recommended whole milk from 1 year to 2 years of age, then 2% until 4 years.  At 4 years it was recommended to switch to skim milk. If kids couldn't tolerate cow's milk they were given soy.

Then came questions about the estrogen like effects of soy and the problem that soy allergy is common in milk allergic kids.

The obesity rates climbing in kids has put into question whether whole milk is needed until 2 years and if lower fat milks should be given at younger ages.  The answer to this is probably not routinely, but toddlers who are overweight can benefit from a lower fat milk.

Grocery store shelves now offer not only whole, 2%, 1%, and skim cow milks (regular, hormone free and organic of each of these!) and soy milk, but they also sell lactose free milk (in several fat concentrations),  rice milk, almond milk, coconut milk, and goat milk.

How do you make the right choice for your child?  Below is a nice chart from MyHealthNewsDaily.com comparing calories, fat, protein, and calcium contents of various milks.  Taste is a very important consideration for the picky child.  If they don't like the taste, they will not drink it.  Even the textures of the milks can vary quite a bit and might require acclimation.  Food allergies and intolerances drive many of the choices.  Note: none of these are appropriate for infants under one year.  Breast milk or formula are the only healthy options for infants due to other nutrients needed in an infant's diet! 

Historically it has been felt that toddlers need more calories from milk, and should not regularly drink a low fat/low calorie milk.  Because of the rising obesity rates (even among toddlers and preschoolers) this recommendation is changing and kids can drink lower calorie products if their caloric intake from foods is sufficient.  Beware of high calories in milks like coconut milk, goat milk, rice, or soy milk.  They have nearly as many calories (or more!) than whole fat cow's milk.

One cup of coconut milk has over 50 grams of fat and over 460 calories!  A special treat: yes. A routine daily drink: no!  

(For comparison, a BK vanilla milkshake has 412 calories and 23 grams of fat in 227 grams (just 1/2 oz shy of a full cup).

Calcium levels vary widely in various milks and should be taken into consideration when choosing a milk for your child.  Other foods, such as calcium fortified orange juice, yogurt, tofu, leafy greens, cheese, and fortified cereals, can (and should) incorporate calcium into the diet.

Vitamin D is very difficult to get through diet alone and it is recommended that everyone take a Vitamin D supplement.  For more information, click here.

There is no consensus that organic milk offers any health benefit.  Due to it's high cost, it is prohibitive for many families to buy organic.  Hormone free milk is available for a mid-range cost without the potential (yet unproven) risks of hormones given to cows.  There isn't any nutritional benefit of the hormone free milk or organic milk compared to conventional milk, but if you are concerned about hormone exposure from milk, hormone free is less expensive than organic.


Lactose free milk: 160 calories, total fat 9g, protein 8 g, calcium 30%
Lactose free reduced fat milk: 130 calories, total fat 5g, protein 8 g, calcium 30%
Lactose free fat free milk: 80 calories, total fat 0g, protein 8g, calcium 30%
(Lactose milk nutrition facts based on one cup, from www.fatsecret.com)