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Tips on Mealtime and your Underweight Child

If you’re like me then you’re searching for ways to get good nutritious food in your kids’ belly but also finding ways to give them enough calories. Remember that as parents you are responsible for what is offered and where and when it is presented. You are also responsible for providing a safe and enjoyable environment during meal times.

Children on the other hand are responsible for deciding how much food they will eat and whether they will eat at all. Make sure you:

1. Offer variety of nutritious foods.
2. Offer foods that are safe.
3. Offer serving sizes that are appropriate.
4. Eat meals at the table.
5. Eat at regular times.
6. Serve as good role models when choosing foods to eat.
7. Don’t pressure or bribe the child to eat.
8. Avoid arguing or negative behaviors during meals.

Children should be eating at least three meals a day with two snacks. I’ve had parents think their child was “always eating” but when you broke it down they weren’t eating a lot of calories. They were snacking on rice cakes and grapes. I had one mom say that she thought carbohydrates were bad for her child and tried to limit them. Contrary to the adult diet kids actually need a lot of carbohydrates. Because kids are little and not eating a lot they need to have nutrient dense foods as well as energy dense foods.

A food is nutrient dense if the vitamin and mineral content is more than its energy or calorie content such as lean meats, beans, oranges, carrots, broccoli, whole-wheat bread, and whole-grain breakfast cereals. Energy dense foods contribute more calories than they do nutrients such as chips, sodas, cookies and ice cream. Remember to balance healthy nutrient dense foods with energy dense foods.

Feeding children particularly an underweight child can be stressful if you micromanage their meals. I know it’s tempting to chase them around the house with a forkful of food. But don’t. Try instead to:

1. Give them small meals that have both nutrient dense and energy dense foods and drinks.
2. Add fats to food such as butter on potatoes and toast, mayo and cheese on sandwiches.
3. Offer whole fat products, such as milk, cottage cheese, creamed soups, pudding and yogurt.
4. Add calories to foods such as fruit in heavy syrup and vegetable with cheese sauce.

Don’t forget to visit your pediatrician for a thorough exam.

Sheila Cason MD

Pretty Things

The Underweight Child

Dear Dr. Cason,

My underweight 2 1/2 year old (negative in the weight charts) was breastfeed until 22 months of age. She always refused a bottle. When I started to introduce milk to her at 12 months she wouldn't have anything to do with it.

I didn't really worry about it until after I stopped breastfeeding her. After trying all forms of milk (various formulas, even chocolate and strawberry milk) it turns out the only thing she would drink is Pediasure vanilla milk. That was fine but it started to get really expensive (I'd limit her to a bottle a day, but they cost more than $1 a bottle -- and that adds up). I found out that she loves "cafe con leche" -- milk with a tiny bit of decaf instant coffee, a little sugar, and a capful of vanilla extract. She looooooves it. It is cheap, healthy (I think), and tasty.

My husband is concerned that the coffee, since it is a diuretic, could dehydrate her (she does have a constipation problem which is relatively under control with Benefiber, Miralax, water, prunes, persimmons, whole wheat bread, etc.). I serve her about 2 cups of milk with a scant teaspoon of decaf coffee -- she drinks only one of these a day. I'd really appreciate it if you could tell me if this is healthy or dangerous? - J.

Dear J-

I feel for you. In a country that has excessive rates of childhood obesity, it can be disconcerting when the problem is actually the opposite- your child is underweight. The first thing you need to do with your underweight child is go to your pediatrician. There is a difference between a child who is just thin for their age and actually “failing to thrive”. Some people will think that every child that is less than the 5% in the growth charts is “failing to thrive” but this isn’t so. There can be healthy children that are just small and that is normal for them. A physician evaluates a child’s weight not based on just one point in time but rather over multiple points in time. At their well-child checks, we analyze their growth by looking at how their growth is plotted against the growth chart. It may be normal for a child to be at the bottom of the growth chart as long as they are still moving along at an acceptable rate. But there are some children who plateau and then drop, failing to even keep up with the expected growth patterns. These children are truly “failing to thrive”.

Making the diagnosis of “failing to thrive” vs. “small for size” is important. In a thin child who is still growing and doing well, you would just offer them nutritious foods and continue to monitor them. It’s important to avoid micromanaging a child and their meals. Over controlling a child can lead to control issues and food “strikes”. If, however, your child is actually dropping off the growth curve or failing to grow at the expected rate, then a diagnostic workup is indicated. Your pediatrician can look into whether there is a chronic medical condition that is contributing to their declining growth. If they are found to be otherwise healthy, then they may recommend keeping a food diary and meeting with a nutritionist to help boost their caloric intake.

In regards to your question about Pediasure and Milk here is the breakdown: Pediasure (8 oz) has 237 calories, 7 grams of protein 9 grams of fat and 31 grams of Carbohydrate. Whole Milk (8oz) has 146 calories, 7.8 grams of protein, 7.9 grams of fat and 11 grams of carbohydrate.When you compare the two, you are actually probably doing okay in terms of calories by giving her 2 glasses of her café con leche but she is definitely missing out on some iron.

Excessive dairy intake (greater than 24 ounces in one day) can lead to iron deficiency. Kids will fill up on the calorie rich but iron deficient milk products and avoid any other “real" food. Pediasure can get expensive but some insurance companies will pay for it if it is part of the medical treatment for the child. The diuretic action of coffee is due to the caffeine. So a scant amount of decaf coffee, while not exactly nutritious, probably isn’t all that bad as well. You may want to try blending different things in with the milk such as a banana. My sister did this with great success for her kids!

To help the- otherwise healthy but underweight- child, try to look at why your child isn’t gaining much weight. Here are some common reasons:

1. Too much juice: Excessive juice can start to replace other food groups when children are too full to eat real food.

2. Low fat diets: Children under two years of age need high fat diets for growth and brain development.

3. Skipping breakfast: It’s just as important that children get calories and nutrients in the morning as well as at other mealtimes.

4. Restricted diets: Kids who are served vegan diets need to have their meals planned carefully to make sure that they are getting the nutrients that they need.

I hope this helps! My next post will offer tips on mealtime and your underweight child.

Sheila Cason MD

Banana Bread Anyone?

Memories

I wonder what my children will remember.

Will it be the rushed mornings as we run out the door? Regularly I call to Gabby to check if the bus has come. A loud noise rumbles by and I shout, " Is that the bus honey?"

"No Mommy, it's the trash tuck!" She always exclaims.

They sound amazingly similar to me.

Or will they remember that daily, just before that, I always brush their hair. Will they remember that I kiss the top of their heads after the loose strands are all tucked away.

I know that I think I'll remember. Of course I'll remember, for it is stuck in my mind and repeated day after day. But I know that I too will forget.

Maybe when we are older and sharing a cup of coffee, they'll remind me and we'll all laugh about how Mommy used to confuse the bus with the trash truck.

And I'll smile as I laugh and remember the smell of their hair...

Sheila Cason MD

Corneal Abrasions in Children

A pitiful site isn’t it?

I thought so too! She broke my heart all day long. It started at 3:30 am when she came running to my room screaming, “I scratched my eye! I scratched my eye!”

I pulled her to me and saw that she was rubbing her eye like crazy with the corner of her blankie. I thought that might be the problem but she distinctly corrected me saying that her fingernail scratched her eye and that the blankie was helping. Who was I to argue?

This sounded classically like a corneal abrasion, a scratch or injury to the cornea, the clear surface that covers the front of the eye. It can be very common in kids and presents often with symptoms of eye pain, tearing, and light sensitivity. Because I never delay treatment when it comes to the eye – and neither should you- I took her to go see her Daddy. Lucky for us he’s an Ophthalmologist. We talked all about her fears before we got there: “No, he won’t cut on you. No, there are no shots. No he won’t poke your eye out.” She seemed a little reassured but still clung to me.

It was a relatively easy examination because of the mixture of anesthesia and fluorescein stain drops he put in her eye. I was surprised to see that – no kidding- within seconds she was back to normal. “How long does this last?”, I asked hopefully. “Only about 15 minutes”, he replied. It was just long enough for him to get his exam. The stain allowed him to see the scratch when viewed with a special light. And, as he said, it looked like she’d caught her fingernail on the cornea and peeled a piece of it off like wallpaper. After he prescribed some antibiotic ointment to prevent infection, placed a patch over her eye for comfort, she was my shadow for the rest of the day.

She did great despite my fear that she would cry all day long. My oldest hovered over her. It was such a cute site to see her leading her by the hand. For once there was no fighting! My youngest, however did his best to antagonize her; He kept leaning over and ripping the patch off. Poor thing! But within 12 hours she was feeling better. And by the next day you’d never know that anything was wrong!

Sheila Cason MD

American Sign Language: Fingerspelling E,F,G,H

E

F

G

H













Here's the next lesson in fingerspelling the alphabet. The girls were all over the place but between the two I was able to get 4 letters! Whew!

Sheila Cason MD

A Faithful Ride

Looks a little lonely don't you think?

American Sign Language:How to Fingerspell A,B,C,D

A






















B






















C






















D






















That's my girl giving you Mommy MD's first fingerspelling lesson! She's been signing since she was eight months old and loves to learn new signs! Make sure the shapes are crisp and clear and facing outward. Practice in front of a mirror if you want to see how they look to other people.

Sheila Cason MD

Goofing Around

Back to school and the uniform policy is now being strictly enforced! She didn't seem to mind though. She was all giggles and spunk coming off the bus this afternoon.

That's my little ham!























Sheila Cason MD

Baby's Sensitive Skin

Baby soaps and lotions always sound so nice, almost irresistible. Even I can hardly wait to use a special product when it claims to give me a delicious smelly baby as well as a calm happy baby who drifts off to dreamland peacefully. But for some babies it can be havoc for their skin. “Soothing” “Calming” “Refreshing”. Even I’m tempted to lather up my children and send them to bed squeaky clean and smelling delicious. In fact, when I mention to some parents to stop the sweet lotion and soaps they look a little dejected. If you’re using these baby soaps and lotions without any problem then keep on using it.

Unfortunately a baby’s skin is so sensitive and prone to rashes you may have to sacrifice the baby perfumes in favor of health skin. A baby can have an allergic reaction to what appears to be the most simple of cleansers, even those labeled just for baby or sensitive skin. Cetaphil liquid soap or a baby’s soap can work well for some babies but there are those few that will break out with even these good choices. If your child is this sensitive here’s what I like to use.

• Plain water or a mild bar soap such as Dove for sensitive skin. I also like California Baby shampoo and cleansers.

• Follow the bath with a good mild lotion. My favorite is Vaseline Deep Moisture Creamy Formula. Make sure you put it on when the skin is still moist.

• Hydrocortisone 1 % cream used twice daily for 3-4 days can be used on reddened areas. Be sure to check with your pediatrician because the rash may a fungal infection and will need different medication.

These three things used in combination can calm most irritated skin. There are babies whose rashes are a sign of eczema and they will need to have their skin cared for by their physician. Make sure you check with your pediatrician for guidance. For now you’ll have to be content to see the pink fresh skin only scented with their natural sweet smell. What could be better than that?

Sheila Cason, MD

Best Friends

New Year's Resolution: The 7 Habits of Highly Effective People

Every year I make resolutions. Too often though, I have gotten caught up in the day to day grind of everyday life and these resolutions became merely wishes. Last year I wanted to make my life calmer and I’m happy to say that I accomplished this. I’m lucky this occurred at all because my plan was a little sketchy. I did however believe that regardless of what I had going on in my life I could experience calm. This turned out to be imperative in succeeding. – (Moving to a tropical island also helped!)

I’m reading the wildly popular book “The 7 Habits of Highly Effective People” and in it Stephen Covey makes observations about human nature and individuals. Most of it is I've heard over the years in one place or another but I find myself still nodding and saying “Mmmm…Hmmm” as if I've never heard them before. The first principle that he talks about is the need to be proactive instead of reactive. He states that being "proactive" means taking responsibility. When you're reactive, you blame other people and circumstances for obstacles or problems. He reminds us that we have the power of free will to choose our response. We can literally choose to create the life we so desire.

I like this empowering philosophy and I need to keep reminding myself of this. In light of this, my New Year’s resolution is to put into practice the principles that Stephen Covey speaks about in his book: The 7 Habits of Highly Effective People. For fun I’ll be checking into his new blog: StephenCovey.com/blog and seeing how applying these principles affect my life. For me, this is a way to actively create the life I want. Resolutions shouldn’t be merely wishes but opportunities. It’s like they say, “If you keep doing what you’ve always done, you’ll keep getting what you’ve always got.” This year I'm going to be proactive.

Happy New Year!

Sheila Cason, MD