Examining Your Pediatrician's Feeding Advice

Tamara Duker Freuman

Few medical specialists are asked to dispense as much nutrition-related advice as pediatricians, whose guidance is often taken as gospel by nervous, first-time parents. Unfortunately, future pediatricians receive no more nutrition training in medical school than their peers heading into other specialties. And most doctors freely admit that such nutrition education rarely accounts for more than one day among their four years of formal study.

It probably shouldn't surprise you then that even your fabulous, competent, and well-meaning pediatrician may be prone to dispensing some feeding advice that isn't accurate, up-to-date, or evidence-based. I've heard my fair share of doozies; among them are these four common kinds of flawed feeding advice that originated from otherwise terrific pediatricians.

1. Dispensing formula-feeding advice for infants who are exclusively breast-fed

While formula-fed infants can often be fed on a schedule early on, exclusively breast-fed infants generally need to feed on demand--particularly for the first few months, until they become more efficient nursers. Because mom's milk supply varies by time of day, and the composition of her milk varies according to how long her baby has been nursing on a given breast in a given session, the child's caloric intake can vary from feeding to feeding. In a newborn, this can mean breast-feeding as often as every hour and a half to two hours; this is known as "cluster feeding" and often happens in the evenings.

A breast-fed newborn that feeds more than every three to four hours is not being "spoiled," nor is the child learning "bad habits" by snacking throughout the day rather than having larger feeds less frequently. When my twins were two months old, I was told by a pediatrician that my newborns should be able to drink at least 4 ounces of breast milk in a feeding, and drinking that amount would enable them to go for four hours between feedings. If they were feeding more often than that, I was advised to tide them over with bottles of water (!) so that they would consume more milk at their next meal.

Needless to say, ounce-based guidelines are only applicable to formula-fed babies. How would a nursing mom even know the volume of milk that her baby takes? The proper way to evaluate nutritional adequacy in any infant is by growth and weight gain along the child's individual curve--not by how often or how much that child consumes in a feeding.

2. Propagating outdated feeding advice

While humans have been feeding their young for millions of years, the science of infant nutrition is surprisingly new. Most current infant feeding practices are based on conventional wisdom rather than scientific evidence. That's fine, of course, unless scientific evidence becomes available that disproves some of this common-sense advice.

Take, for example, the decades-old practice of withholding commonly allergenic foods--like dairy, eggs, fish, and nuts--until 12, 24 or even 36 months of age. The common-sense rationale behind this practice was to help prevent food allergies by delaying exposure to likely allergens until a child's immune system strengthened. Until 2008, even the American Academy of Pediatrics (AAP) endorsed this practice. However, the AAP has since retracted these guidelines, citing a lack of evidence to support this practice. In fact, a steadily-growing body of research now seems to be pointing in an opposite direction, suggesting that withholding such foods for too long may actually increase a child's risk of developing food allergies. Still, far too many pediatricians--including nationally-respected ones--continue to advise parents to delay introducing some of these foods long past what emerging evidence suggests may be an optimal window for inducing immunological tolerance.

For the record: After six months of age, no good evidence exists for withholding any foods, except for liquid cow's milk as a beverage (to prevent anemia) and honey (to prevent infant botulism). This is true even for infants who are genetically more disposed to developing food allergies.

3. Applying "healthy" adult dietary patterns to young children

High-fiber, low-carb, and low-fat diets are all appropriate dietary patterns for adults to adopt when trying to manage their weight or reduce their risks for chronic disease. They are also all completely inappropriate dietary patterns for rapidly-growing infants, toddlers, and pre-schoolers with tiny bellies and relatively high energy needs.

A pediatrician in my community reportedly advises moms to restrict carbs when feeding their healthy, normal-weight toddlers, stating that fruits and vegetables yield sufficient carbohydrates. Putting practicalities aside (What on earth would I feed my toddlers if cereal, oats, pasta, rice, and whole-grain crackers were off the table? And, what toddler regularly eats enough vegetables to yield a reliable stream of calories?), it's just not sound advice. A solid half of a young child's energy should come from carbs. This includes fruits, vegetables and dairy, but also complex carbs like cooked grains, whole-grain cereals and breads with little to no added sugar, pasta, potatoes, and beans and legumes.

Similarly, fat is a concentrated source of calories, which makes it ideal for nourishing little people. It's an essential structural component of each cell's membrane, and it facilitates the absorption of essential vitamins A, D, E, and K. Choosing foods higher in heart-healthy unsaturated fats--like olive oil, nuts and nut butters, salmon and seeds as well as grass-fed meats and dairy--will help ensure that the dietary profile of fats is a favorable one for longer-term health.

Lastly, while a small amount of fiber is important for young children, too much calorie-free, tummy-filling fiber can crowd out necessary energy-yielding foods in their diets. Your low-cal, bran-bomb cereal and 90-calorie fiber snack bars are probably not the best choices to share with a young child.

4. Making Stuff Up

A friend's pediatrician cautioned him not to give his healthy toddler more than two eggs per week. A nationally-recognized pediatrician cautions against choosing iron-fortified rice cereal as a first food because it's a refined carbohydrate that will set a child on the forward march toward obesity.

This type of advice might seem to make sense to a new parent. Yet, none of it is based on a shred of actual evidence. And, in some cases, it may actually be counterproductive. Such dogmatic dictates can cause unnecessary anxiety in parents--and unnecessary food restrictions in children. For the record, there are plenty of good reasons to serve eggs to a young child regularly: They're cheap, fast, full of brain-building nutrients like choline and omega-3s, and have not been shown to predispose young children to high cholesterol or heart disease. Breastfed babies in particular may benefit from an iron-fortified cereal as a first food--even if it's made from white rice--to help meet their extremely high iron requirements between the ages of six to 12 months. Family behaviors and attitudes toward food, including excessive restrictiveness, may have much more of an impact on future obesity risk than fat or carbohydrate intake as an infant or toddler.

There is no single "right" way to feed a young child. The approach depends on a family's cultural food practices and a child's likes, eating behaviors, health history and weight status. As a result, one-size-fits-all nutrition advice generally raises a red flag in my book. Particularly when there aren't data to back it up!

If something your trusted and otherwise fantastic pediatrician says about nutrition sounds fishy or rubs you the wrong way, don't assume it's written in stone! Ask your doctor for the basis of his or her advice, talk to other parents whose pediatricians may offer a different perspective, or seek out a second opinion from a pediatric dietitian whose training in childhood feeding practices is likely to be in-depth and up-to-date.

Hungry for more? Write to eatandrun@usnews.com with your questions, concerns, and feedback.

Tamara Duker Freuman, MS, RD, CDN, is a NYC-based registered dietitian whose clinical practice specializes in digestive disorders, Celiac Disease, and food intolerances. Her personal blog, www.tamaraduker.com, focuses on healthy eating and gluten-free living.