Feeding & Eating

If you’re raising a picky eater, you might worry that your child isn’t getting the nutrients necessary for proper growth and development.

But you probably don’t need to worry unless your doctor tells you that your child isn’t growing at the normal rate for that age range. Over time, most finicky eaters do get enough calories and nutrients to meet their needs.

What Are Hunger and Malnutrition?

Everyone feels hungry at times. Hunger is the body’s signal that it needs food. Once we’ve eaten enough food to satisfy our bodies’ needs, hunger goes away until our stomachs are empty again.

Malnutrition is not the same thing as hunger, although they often go together. People who are chronically malnourished lack the nutrients needed for proper health and development. Someone can be malnourished for a long or short period of time, and the condition may be mild or severe. People who are malnourished are more likely to get sick and, in severe cases, might even die.

Chronic hunger and malnutrition can cause significant health problems. People who go hungry all the time are likely to be underweight, weighing significantly less than an average person of their size. If malnourished as a child, their growth may also be stunted, making them much shorter than average.

Causes of Hunger and Malnutrition

People who don’t get enough food often experience hunger, and over the long term this can lead to malnutrition. But someone can become malnourished for reasons that have nothing to do with hunger. Even people who have plenty to eat may be malnourished if they don’t eat foods that provide the right nutrients, vitamins, and minerals.

Some diseases and conditions prevent people from digesting or absorbing their food properly. For example:

• Someone with celiac disease has intestinal problems that are triggered by a protein called gluten, which is found in wheat, rye, and barley.
• Kids with cystic fibrosis have trouble absorbing nutrients because the disease affects the pancreas, an organ that normally produces enzymes necessary for digestion.

Someone who doesn’t get enough of one specific nutrient has a nutritional deficiency, a form of malnutrition (although it doesn’t necessarily mean the person will become seriously ill). The most common nutritional deficiency in the world is iron deficiency, which can lead to anemia.

Who Is at Risk for Malnutrition?

All over the world, people who are poor or who live in poverty-stricken areas are at the greatest risk for hunger and malnutrition. In poor countries, wars and natural disasters such as droughts and earthquakes also can contribute to hunger and malnutrition by disrupting normal food production and distribution.

In the United States, food manufacturers fortify some common foods with vitamins and minerals to prevent certain nutritional deficiencies. For example, the addition of iodine to salt helps prevent some thyroid gland problems (such as goiter), folic acid added to foods can help prevent certain birth defects, and added iron can help prevent iron-deficiency anemia.

Malnutrition affects people of every age, although infants, children, and teens may suffer the most because many nutrients are critical for normal growth and development. Older people may develop malnutrition because aging, illness, and other factors can lead to a poor appetite, so they may not eat enough.

Alcohol can interfere with nutrient absorption, so alcoholics might not benefit from the vitamins and minerals they consume. People who abuse drugs or alcohol can be malnourished or underweight if they don’t eat properly.

Children and teens on special diets — such as vegetarians — need to eat balanced meals and a variety of foods to get the right nutrients. Vegetarians and vegans, for example, should make sure they get enough protein and vitamins like B12.

Symptoms and Effects of Malnutrition

Malnutrition harms both the body and the mind. The more malnourished someone is — in other words, the more nutrients that are missing — the more likely he or she is to have problems.

The signs and symptoms of malnutrition depend on which nutritional deficiencies a person has, although they can include:

• fatigue (tiredness) and low energy
• dizziness
• poor immune function (which can harm the body’s ability to fight off infections)
• dry, scaly skin
• swollen and bleeding gums
• decaying teeth
• slowed reaction times and trouble paying attention
• underweight
• poor growth
• muscle weakness
• bloated stomach
• osteoporosis, or fragile bones that break easily
• problems with organ function
• problems learning

If a pregnant woman is malnourished, her child may weigh less at birth and have a lower chance of survival.

Vitamin A deficiency from malnutrition is the chief cause of preventable blindness in the developing world, and kids with severe vitamin A deficiency have a greater chance of getting sick or dying from infections such as diarrhea or measles.

Iodine deficiency can cause mental retardation and delayed development. Iron deficiency in infancy can delay development and make older kids less active and less able to concentrate. Teens who are malnourished often have trouble keeping up in school.

Treating Malnourished Children

Fortunately, many of the harmful effects of malnutrition can be reversed, especially if a child is only mildly or briefly malnourished.

If you think your child isn’t getting enough of the right nutrients, talk to your doctor, who may perform a physical exam and ask about the types and amounts of food your child eats. The doctor may also:

• measure height, weight, and body mass index (BMI) to see if they’re within a healthy range for your child’s age
• check for underlying conditions that could cause malnutrition
• order blood tests to check for nutritional deficiencies
• order additional tests based on your child’s medical history and physical exam

Treatment for malnutrition depends on its cause. A doctor or dietitian might recommend specific changes in the types and quantities of foods your child eats, and may prescribe dietary supplements, such as vitamins and minerals.

If there’s an underlying problem causing the malnutrition, the doctor will help you find ways to ensure your child gets the necessary nutrients.

Can a Picky Eater Become Malnourished?

Parents often worry that kids who seem to live on peanut butter sandwiches or hide at the sight of vegetables might not eat enough to stay healthy. Few kids in the United States and other developed nations experience severe malnutrition like that seen in Third World countries. Even finicky eaters usually get enough calories and nutrients.

The best way for parents to make sure that kids are properly nourished is to serve a variety of healthy foods and limit unhealthy snacks. If you’re concerned that your child’s energy level is lagging or that he or she isn’t growing normally, share your concerns with your doctor.

Red blood cells deliver oxygen to the body’s tissues and organs. Every red blood cell in the body contains iron in its hemoglobin, the part of the red blood cell that carries oxygen from the lungs to the body. Iron gives hemoglobin the strength to “carry” (bind to) oxygen in the blood, so oxygen gets to where it needs to go.

Without enough iron, the body can’t make hemoglobin and makes fewer red blood cells. This means tissues and organs won’t get the oxygen they need.

People can get iron by eating foods like meat and dark green leafy vegetables. Iron is also added to some foods, such as infant formula and cereals.

How Much Iron Do Kids Need?

Depending on their age, kids need different amounts of iron:

• Infants who breastfeed tend to get enough iron from their mothers until 4-6 months of age. Around this time, rich foods like fortified cereal and puréed meats are usually introduced. Breastfed babies who don’t get enough iron should be given iron drops prescribed by their doctor. Babies given iron-fortified formula do not need additional iron.
• Infants ages 7-12 months need 11 milligrams of iron a day.
• Toddlers ages 1-3 years need 7 milligrams of iron each day. Kids ages 4-8 years need 10 milligrams while older kids ages 9-13 years need 8 milligrams.
• Adolescent boys should be getting 11 milligrams of iron a day and adolescent girls should be getting 15 milligrams. (Adolescence is a time of rapid growth and teen girls need additional iron to replace what they lose monthly when they begin menstruating.)
• Young athletes who regularly engage in intense exercise tend to lose more iron and may need extra iron in their diets. People following a vegetarian diet might also need additional iron.

What’s Iron Deficiency?

Iron deficiency is when a person’s body doesn’t have enough iron. It can be a problem for some kids, particularly toddlers and teens (especially girls who have very heavy periods). In fact, many teenage girls are at risk for iron deficiency — even if they have normal periods — if their diets don’t contain enough iron to offset the loss of blood during menstruation.

After 12 months of age, toddlers are at risk for iron deficiency because they no longer drink iron-fortified formula — and, they may not be eating enough iron-containing foods to make up the difference.

Iron deficiency can affect growth and may lead to learning and behavioral problems. If iron deficiency isn’t corrected, it can lead to iron-deficiency anemia (a decrease in the number of red blood cells in the body).

Iron in an Everyday Diet

Be sure to teach kids that iron is an important part of a healthy diet. Foods rich in iron include:

• beef, pork, poultry, and seafood
• tofu
• dried beans and peas
• dried fruits
• leafy dark green vegetables
• iron-fortified breakfast cereals, breads, and pastas

(Note: Iron from animal sources is more easily absorbed by the body than iron from plant sources.)

To help make sure kids get enough iron, also:

• Limit the amount of milk they drink to about 16-24 fluid ounces (473-710 milliliters) a day.
• Serve iron-fortified infant cereal until kids are 18-24 months old.
• Serve iron-rich foods alongside foods containing vitamin C — such as tomatoes, broccoli, oranges, and strawberries. Vitamin C improves the way the body absorbs iron.
• Avoide serving coffee or tea at mealtime — both contain tannins that reduce the way the body absorbs iron.

What Is Irritable Bowel Syndrome?

Irritable bowel syndrome (IBS) is a common intestinal problem that can cause cramps, gas, bloating, diarrhea, and constipation. It’s sometimes called a “nervous stomach” or a “spastic colon.” Certain foods can trigger the symptoms of IBS. So can anxiety, stress, and infections.

Although IBS can be uncomfortable and embarrassing for kids, it doesn’t cause serious health problems. Doctors can help kids manage IBS symptoms with changes in diet and lifestyle. Sometimes doctors will prescribe medicines to help relieve symptoms.

Causes of IBS

The specific cause of IBS is unknown, though it tends to run in families. Kids with IBS may be more sensitive to belly pain, discomfort, and fullness than kids who don’t have IBS. Some foods — like milk, chocolate, drinks with caffeine, gassy foods, and fatty foods — also tend to trigger IBS. Sometimes, people never find out what triggers their IBS symptoms.

Some kids with IBS tend to be more sensitive to stress and emotional upsets. Because nerves in the colon are linked to the brain, things like family problems, moving, taking tests, or even going on vacation can affect how the colon works.

Symptoms of IBS

People with IBS have belly pain or discomfort and a change in bowel habits (pooping). Other signs of IBS may include bloating, belching (burping), flatulence (farting), heartburn, nausea (feeling sick), and feeling full quickly.

IBS symptoms last for at least 3 months and include at least two of the following:

• pain or discomfort that feels better after a bowel movement
• pain or discomfort together with changes in how often a person has to go to the bathroom
• pain or discomfort along with changes in the way the stool (poop) normally looks. Some people get constipated and their stools become hard (and difficult to pass). Others have diarrhea.

Diagnosing IBS

There is no specific test for IBS. Doctors usually diagnose it by asking about symptoms and by doing a physical exam. Your doctor will also want to know if anyone in the family has IBS or other gastrointestinal problems.

Answering questions about things like gas and diarrhea can be embarrassing for kids. Assure your child that the doctor deals with issues like this every day and needs the information to help your child feel better.

The doctor may suggest that you help your child keep a food diary to see if certain foods trigger IBS symptoms. The doctor may also ask about stress at home and at school.

Most of the time, doctors don’t need medical tests to diagnose IBS, but sometimes they order blood and stool (poop) tests, X-rays, or other tests to make sure another medical problem is not causing the trouble.

Treatment

There’s no cure for IBS. But many things can help reduce IBS symptoms, including:

• Changes in eating. Some kids with IBS find that careful eating helps reduce or get rid of IBS symptoms. Your child might have to avoid milk and dairy products, drinks with caffeine, gassy foods, or other foods that seem to trigger the symptoms. Some people with IBS feel better when they eat smaller, more frequent meals.
• Changes in lifestyle. If your child’s IBS seems to be related to stress, talk about what you can do to help manage pressures related to school, home, or friends.
• Regular exercise. Exercise can help digestion. It’s also a great stress reliever.
• Medicines. Doctors sometimes prescribe medicines to treat diarrhea, constipation, or cramps. Antidepressants may help some people with pain management and depression. Talk with your doctor before giving a child with IBS any over-the-counter medicines for diarrhea, constipation, cramps, or other digestive problems.
• Counseling and coping strategies. If your child has a lot of anxiety or seems depressed, your doctor might recommend a child psychologist or therapist. Therapy, hypnosis, breathing exercises, or other relaxation techniques can help some people manage IBS.

IBS can affect your child’s quality of life. Talk with your doctor about ways to manage IBS to help your child lead an active and healthy life.

About Peanut and Tree Nut Allergies

First grade has been a difficult parenting year for Anne. Her 6-year-old son, Justin, began eating lunch in the cafeteria with hundreds of other students armed with their peanut butter sandwiches, peanut butter crackers, and all those hidden peanuts in their processed foods.

For Justin, who has an extremely severe allergy to peanuts, it means sitting at a peanut-free table. But Justin isn’t alone: About 5% of school-aged kids have some kind of food allergy, putting them at risk of an allergic reaction at home or, even more dangerously, away from home.

Peanuts are among the most common allergy-causing foods, and they often find their way into things you wouldn’t imagine. Take chili, for example: It may be thickened with ground peanuts.

Peanuts are actually not a true nut, but a legume (in the same family as peas and lentils). But the proteins in peanuts are similar in structure to those in tree nuts. For this reason, people who are allergic to peanuts also can be allergic to tree nuts, such as almonds, Brazil nuts, walnuts, hazelnuts, macadamia nuts, pistachios, pecans, and cashews.

Allergic Reactions

An allergic reaction happens when someone’s immune system mistakenly believes that something harmless, such as a tree nut or peanut, is actually harmful. The immune system responds by creating specific antibodies to proteins in that food. These antibodies — called immunoglobulin E (IgE) — are designed to fight off the “invading” proteins.

IgE antibodies trigger the release of certain chemicals in the body. One of these is histamine. The release of histamine can affect the respiratory system, gastrointestinal tract, skin, and cardiovascular system, causing allergy symptoms like wheezing, stomachache, vomiting, itchy hives, swelling, and a drop in blood pressure.

Reactions to foods, like peanuts and tree nuts, can be different. It all depends on the person — and sometimes the same person can react differently at different times. Some reactions can be very mild and involve only one system of the body, like hives on the skin. Other reactions can be more severe and involve more than one part of the body.

Most reactions last a few hours or less, and affect any of these four body systems:

1. Skin. Skin reactions are the most common type of food allergy reactions. They can take the form of itchy, red, bumpy rashes (hives), eczema, or redness and swelling around the mouth or face. A rash can happen when a nut or peanut comes in contact with the skin, without the person even eating it.
2. Gastrointestinal system. Symptoms can include belly cramps, nausea, vomiting, or diarrhea.
3. Respiratory system. Symptoms can range from a runny or stuffy nose; itchy, watery eyes; and sneezing to the triggering of asthma with coughing and wheezing.
4. Cardiovascular system. A person may feel lightheaded or faint and lose consciousness.

In really bad cases, an allergy can cause anaphylaxis, a sudden, potentially life-threatening reaction. Besides the symptoms mentioned above, anaphylaxis can make airways swell and blood pressure drop. As a result, a person may have trouble breathing and could lose consciousness.

Even a small amount of peanut or tree nut protein can set off a severe reaction. But allergic reactions just from breathing in small particles of nuts or peanuts are rare because the food needs to be digested to cause a reaction. Most foods with peanuts in them don’t allow enough of the protein to escape into the air to cause a reaction. And just the smell of foods containing peanuts won’t produce a reaction because the scent does not contain the protein.

In very rare cases when people do react to airborne particles, it’s usually in an enclosed area (like a restaurant) where lots of peanuts are being cracked from their shells. The person inhales and then swallows the protein, which can lead to a reaction when the protein gets digested. Although some people outgrow certain food allergies over time (like milk, egg, soy, and wheat allergies), peanut and tree nut allergies are lifelong in many people.

Living With Peanut or Tree Nut Allergy

If allergy skin testing shows that your child has a peanut or tree nut allergy, a doctor will provide guidelines on what to do.

The best way to prevent a reaction is to avoid peanuts and tree nuts. Avoiding these nuts means more than just not eating them. It also means not eating any foods that might contain tree nuts or peanuts as ingredients.

The best way to be sure a food is nut-free is to read the label. Manufacturers of foods sold in the United States must state on their labels whether the foods contain peanuts or tree nuts. Check the ingredients list first.

After checking the ingredients list, look on the label for phrases like these:

• “may contain nuts”
• “produced on shared equipment with nuts or peanuts”

People who are allergic to nuts also have to avoid foods with these statements on the label. Although these foods might not use nut ingredients, the warnings are there to let people know they might contain traces of nuts. That can happen through “cross-contamination,” when nuts get into a food product because it is made or served in a place that uses nuts in other foods.

Some of the highest-risk foods for people with peanut or tree nut allergy include:

• Cookies and baked goods. Even if baked goods don’t contain nut ingredients, they might have come in contact with peanut or tree nuts through cross-contamination. Unless you know exactly what went into a food and where it was made, it’s safest to avoid store-bought or bakery cookies and other baked goods.
• Candy. Candies made by small bakeries or manufacturers (or homemade candies) may contain nuts as a hidden ingredient. The safest plan is to eat only candies made by major manufacturers whose labels show they are safe.
• Ice cream. Unfortunately, cross-contamination is common in ice cream parlors because of shared scoops. It’s also a possibility in soft-serve ice cream, custard, water ice, or yogurt places because the same dispensing machines and utensils are often used for lots of different flavors. Instead, do as you would for candy: Buy tubs of ice cream at the supermarket and be sure they’re made by a large manufacturer and the labels indicate they’re safe.
• Asian, African, and other cuisine. African and Asian (especially Thai, Chinese, and Indian) foods often contain peanuts or tree nuts. Mexican and Mediterranean foods may also use nuts, so the risk of cross-contamination is high with these foods.
• Sauces. Many cooks use peanuts or peanut butter to thicken chili and other sauces.

Always proceed with caution. Even if your child has eaten a food in the past, manufacturers sometimes change their processes — for example, switching suppliers to a company that uses shared equipment. And two foods that seem the same might have differences in their manufacturing.

To help reduce contact with nut allergens and the possibility of severe reactions in someone with a peanut or tree nut allergy:

• If you keep peanuts and nuts in your home, watch for cross-contamination that can happen with utensils and cookware. For example, make sure the knife you use to make peanut butter sandwiches is not used in preparing food for a child with a nut allergy, and that nut breads are not toasted in the same toaster as other breads.
• Don’t serve cooked foods you didn’t make yourself, or anything with an unknown list of ingredients.
• Tell everyone who handles the food your child eats, from waiters and waitresses to the cafeteria staff at school, about the allergy. If the manager or owner of a restaurant is uncomfortable about your request for peanut- or nut-free food preparation, don’t eat there.
• Consider making your child’s school lunches, as well as snacks and treats to take to parties, play dates, sleepovers, school functions, and other outings.
• Work with the childcare supervisor or school principal to create a food allergy emergency action plan.
• Keep epinephrine accessible at all times — not in the glove compartment of your car, but with you, because seconds count during an anaphylaxis episode.

With a little preparation and prevention, you can make sure that your child’s allergy doesn’t get in the way of a happy, healthy everyday life.

Weaning is when a baby transitions from breast milk to other sources of nourishment. When to wean is a personal decision. A mom might be influenced by a return to work, her health or the baby’s, or simply a feeling that the time is right.

Weaning a baby is a gradual process that calls for patience and understanding from both you and your child.

When Is the Right Time?

The American Academy of Pediatrics (AAP) recommends feeding babies only breast milk for the first 6 months of life. After that, the AAP recommends that a combination of solid foods and breast milk be given until a baby is at least 1 year old. At a year, babies may begin drinking whole cow’s milk.

Most experts agree that breastfeeding should continue for as long as mutually desired by mother and baby. Many women choose to wean after their baby’s first birthday. At this age, babies are starting to walk, talk, and eat more solid foods so they may just naturally lose interest in nursing.

Other moms choose to breastfeed longer than a year (this is called extended breastfeeding). Extended breastfeeding is a healthy and reasonable option for mothers and children who aren’t ready to wean. In fact, the World Health Organization (WHO) recommends that moms breastfeed for the first 2 years of a child’s life.

Weaning does not have to be an all-or-nothing proposition. Some women choose to wean during the day and breastfeed at night, depending on their work situation and their schedules.

Whenever you decide to wean, your child may have another time in mind. Some children wean themselves earlier than the mother intended and others are resistant to weaning when the mother is ready. Those who are weaned later in life tend to be more resistant. For example, a 2-year-old toddler may be more attached and less flexible about giving up breastfeeding than a 12-month-old baby. At times like these, it’s important to take it slow and be sensitive to each other’s needs.

Signs Your Baby May Be Weaning

Some kids are content to nurse indefinitely. But others will give moms clues that they’re ready to begin the process of weaning, such as:

• seeming disinterested or fussy when nursing
• nursing in shorter sessions than before
• being easily distracted while nursing
• “playing” at the breast, like constantly pulling on and off or biting (babies who bite during nursing should immediately be taken off the breast and told, calmly but firmly, “No biting. Biting hurts.”)
• nursing for comfort (sucking at the breast but not drawing out the milk)

Approaches to Weaning

To allow both mom and baby to adjust physically and emotionally to the change, weaning should be a gradual process.

One approach is to drop one feeding session a week until the child is taking all of the feeds from a bottle or cup. If you are planning to continue to give your child pumped breast milk, you will need to pump in order to keep up your milk supply. If you are weaning your child off breast milk, slowly dropping feeds can help avoid engorgement.

You might begin by stopping the midday feeding because it’s usually the smallest and most inconvenient — especially for working moms. Many mothers let go of the bedtime feeding last because it’s still a special part of bonding.

Another approach is to leave the decision of when to wean completely up to a child. Once they’re eating three meals of solid food a day (plus snacks in between), kids often breastfeed less and less. In this situation, you may find that your milk will dry up from lack of demand, and pumping may be necessary if you want to keep the milk flowing. If your child is breastfeeding less, make sure he or she is getting enough iron-fortified formula or milk. Check with the doctor about how much your child get.

If your baby weans before 1 year of age, or you find that you’re not making enough milk, you will need to give your baby formula. Check with the doctor to see what formula is right for your child.

Easing the Transition

Weaning is easier if a child has also taken milk from another source. So try giving an occasional bottle of breast milk to your little one once breastfeeding is well-established. Even if you plan to continue breastfeeding, this can ease weaning later. It also lets other family members feed the baby and makes it possible to leave your child with a caregiver.

It’s important to remember that infants over 6 months should have solid foods as well as breast milk. After 1 year, breast milk alone does not provide all the nutrients a growing child needs; solid foods must become a regular part of the diet.

As you start to wean, remember that your child needs time to adjust to drinking from cups. So be patient as your little one begins exploring the world of food. Here’s some more ways to make this change easier:

• Engage your child in a fun play activity or an outing during times when you would usually nurse.
• Avoid sitting in your usual nursing spots or wearing your usual nursing clothes.
• Delay weaning if your child is trying to adapt to some other change. Trying to wean when your little one is just beginning childcare or during teething might not be a good idea.
• If your baby is younger than 1 year, try to introduce a bottle or cup when you would typically be nursing. For an older child, try a healthy snack, offering a cup, or maybe even just a cuddle.
• Try changing your daily routine so that you’re otherwise engaged during breastfeeding times.
• Enlist your partner’s help to provide a distraction at a typical nursing time.
• If your child begins to pick up a comforting habit (such as thumbsucking) or becomes attached to a security blanket, don’t discourage it. Your child might be trying to adjust to the emotional changes of weaning.

How You Might Feel

Many moms make the decision to wean with mixed emotions. On the one hand, weaning brings with it more freedom and flexibility, as well as the proud realization that her child is reaching a major milestone. On the other hand, nursing is an intimate activity that fosters a strong bond between mother and child — and some women find it difficult to let that go.

As you go through this process, expect a wide range of emotions and understand that your child may have them, too. But also remember that there will be countless other ways to nurture your child in the days ahead.