The Art and Science of Food and Feeding


What is the number one job of parents to keep their children alive? Feed them. It is the most primal act any parent offers as the most elemental form of nurturing. There is a reason for the stereotyped Italian and Jewish mothers fixated on cooking and feeding their children, worrying if their young or grown child has “had enough.” Although I am neither Italian nor Jewish, I think this is especially true for mothers as we women have those lactating devices built in to our very beings. What could be more natural than feeding our babies and children? Well, for a lot of reasons, it can be pretty difficult and stressful.

Breastfeeding v. Formula

As a health psychologist, I have spent years working in hospitals. The great science of “breast is best” surrounded me during my pregnancies, so it was not even a question of how I would feed my infant. I do not think this hope, expectation, and pressure are uncommon these days, but what we are uniformly unprepared for is that this natural act of breastfeeding HURTS and it is HARD.

I know, I know – any lactation consultant reading this is talking back to me that “if you do it right, it doesn’t hurt.” I honestly just don’t believe it. I have done my own in-person research by talking to so many women, and I have yet to find a single woman who did not experience pain for at least a couple weeks. I mean, you have a pair of jaws chomping on an extremely sensitive body part ALL the time.

And it’s not just the actual feeding, it’s the filling of the milk, especially when your body has never done this before. Nature’s breast augmentation has some perks (literally) ,but can come at a cost – a cost that led me down the path of cabbage leaves and eventually the dreaded mastitis.

I had researched every detail of this whole breastfeeding thing, worked with a doula, called my hospital’s lactation consultants, and still it was HARD. I will never forget in those early weeks the literally toe-curling pain of that first “bite” for every nursing session. And my babies had it all – no tongue ties, mostly good latch, great temperaments – there was no reason for it to be so stressful. Except that it is. Until it’s not, and then it really is wonderful, which is why I committed to nursing with all three of my children.

I share my own experience because I really resent the pressure and judgment that has become tied to breastfeeding versus formula. In fact, this could be a whole book in itself (and those books are out there aplenty).

I completely support the availability of resources and information to support breastfeeding because I know many mothers who feel like failures if they do not breastfeed and I support every woman having access to what helps her be the mother she wants to be. Obstetricians should counsel their pregnant patients about breastfeeding and its benefits, maternity units should have protocols that support breastfeeding, every hospital should offer lactation consultants, pediatricians should be critical resources during those first few weeks and months of gaining weight, AND using formula is just fine.

This issue exemplifies the pressure placed on parents by headlines and soundbites from research studies, which I believe contributes to a regrettable shame and guilt in mothers who either are unable to breastfeed or make a choice not to breastfeed, for a multitude of reasons. Breastfed babies are smarter! Breastfed babies are healthier!

There is definitely a reason the AAP makes a strong statement about recommending exclusive breastfeeding for the first six months. From the perspective of illness, many studies across many years have consistently shown that breastfed babies do fight off infections better and overall have fewer health problems during infancy (eg, respiratory illness, ear infections, gastrointestinal diseases, allergies).

In addition, the complexity of nutrients in breastmilk, and its changing composition across the months to match the baby’s development, cannot be replicated by formula. (A bonus for formula: it does include some nutrients that are lacking in breastmilk, such as iron and Vitamin D).

Some other claims of breastfeeding benefits, however, have shown more inconsistencies when you take a closer look at the research. For example, a study in 2013 did what is called a meta-analysis of long-term health outcomes following breastfed and formula-fed babies into adulthood. (A meta-analysis can be a very helpful type of study because it examines all the current published studies and analyzes all the outcomes and how strong each study was to make a more informed conclusion about a topic.) This meta-analysis included intelligence as an outcome and concluded “strong evidence of a causal effect of breastfeeding on IQ.” They did add, “although the magnitude of this effect seems to be modest.”

Let me tell you – the IQ difference was 2-3 points. In the real world of real people out there living their lives, 2-3 points in IQ MAKES NO DIFFERENCE! A person with an IQ of 92 and another person with an IQ of 108 are in the same range: AVERAGE. A 2-3 point difference is well within the margin of error for any IQ score (eg, if I give a kid an IQ test, and he scores 100, the actual IQ is likely between 94 and 106, because there is always some variability accounted for that could have affected performance on that day for that test).

Someone who comes across this finding, however, and does not have a background in IQ testing, might feel like their decision to formula feed their baby 10 years ago has now doomed their child to get Cs instead of As in school, especially with the highly misleading headlines, “Breastfed babies are smarter!”

It does not have to be an all or nothing decision – the best news is that the evidence shows that even small amounts or a brief time breastfeeding has benefits. Even if you just get through giving your newborn colostrum in the hospital, before the actual milk comes in, this magical substance is packed with nutrients that helps your hours-old baby’s immune system and helps make possible her first itty bitty bowel movement.

Take-home message: Do your best to do what works for you and your baby. In fact, the stress of negative emotions such as shame, guilt, and feelings of failure in the face of social pressures that breastfeeding equates with being a “better” mother, is worse for you and your baby than formula.

This is where I will insert my own expertise in the negative impacts of stress, which can translate into normal and abnormal levels of depression and anxiety. If a mother is doing everything “right” with her new baby -- waking up at every cry to ensure attachment (and sleep deprivation), breastfeeding exclusively no matter the challenges, being 100% present for that sweet baby that is sometimes also colick-y and impossible – but the stress of all of this availability starts to feel like a slow drowning . . . THIS is not good for baby.

I have witnessed and supported friends and loved ones and acquaintances so tearful and stressed about having to turn to formula, when it was really the best decision for everyone’s stress level. Remember – this parenting gig is a MAJOR marathon and we need to pace ourselves, be kind and forgiving to ourselves, and remember there are about a billion factors influencing how our babies and children grow up. The formula versus breastmilk struggle is just one chapter in an entire “how to raise a child” cannon of literature.

Solids

With my first child, I was so excited to open that first jar of baby food (oh wait, I mean puree my own veggies) and watch her discover the joys of the taste and texture of a substance that was not my breastmilk! How amazing it will be to not be her one and only source of nourishment because I don’t even know who owns this body of mine anymore! As any experienced parent may guess, this excitement was short-lived as it gave way to lots of rejected spoonfuls and a new level of mess – finding that crusted orange substance in the most random crevices of the kitchen. And then dealing with that little infant gastrointestinal system – gas pain, constipation, oh my! Suffice to say, I introduced solids later and later with each of my next two children, partly because I was following the breaking research and recommendations to introduce solids closer to 6 months instead of 4 months, and partly because I was delaying the inevitable chaos.

Breaking News

How many of you have googled “when to start solids” because maybe you want to try anything to help your baby have a longer sleep stretch? The results across the sites popping up say uniformly “4-6 months.”  For some reason, though, between my second and third child, I started to hear and read that 6 months was the recommendation. In doing digging, it turns out that the American Academy of Pediatrics has been recommending holding off on solids until 6 months old since at least 1997.  What had I done to my first two children?

This is another area where relying on your old-fashioned parenting instinct becomes important. Just as discussed in the sleep section, each baby can have a very different make-up that contributes to a true readiness for solids. I have heard parents agonizing about the dangers of starting solids too early but then baby is nursing constantly and seems suddenly dissatisfied and not satiated, reaching for your fork when you are eating from your plate. In fact, reading the AAP policy from 2011 line by line, I found this: “Unique needs or feeding behaviors of individual infants may indicate a need for introduction of complementary foods as early as 4 months of age, whereas other infants may not be ready to accept other foods until approximately 8 months of age.”

I worry that much of the angst about starting solids too soon is intertwined with the above-discussed pressure to breastfeed as exclusively and as long as possible. I in no way dispute the health benefits, but in our modern world, we are not hooked up to our baby day in and day out. Have you seen images of those incredible women nursing their papoosed infants while they work in fields, doing manual labor I couldn’t even do untethered to my baby?  Many of us are apart from our baby during the day (don’t even get me started on the inhumanity and insanity of maternity and paternity leave laws in this country) and pumping is a widely loathed necessity that may mean less time exclusively breastfeeding.

When it comes to what the research tells us about starting solids, the most important part is safety. The clearest guidance to prevent choking is to not put rice cereal in bottles, and to introduce soft finger foods when babies are able to sit up and put objects in the mouth. The other common advice – start with a grain like oatmeal or rice cereal, introduce vegetables before fruit so babies don’t just want the fruit – does not actually have an evidence base. Babies and young children naturally prefer sweet flavors so the order of introduction does not affect that. In terms of nutrition, however, there is years of data supporting the conclusion to NOT give babies 12 months and younger juice because it reduces appetite for more nutritious choices, and can cause diarrhea, diaper rash, or weight gain (healthychildren.org). The most recent report released by the American Academy of Pediatrics strongly recommends fewer than 4 ounces a day for toddlers ages 1-3 due to risk for cavities, excessive calories, and interference with nutrition.

Good news: there are some pretty basic, manageable guidelines for these early months of eating that include common sense AND solid evidence. Better news: instinct matters by paying attention to your baby and what works, and all those babies who started solids at 4 months old (mine included) are probably just fine now.

The Food Pyramid

“I don’t like that.” We had to crack down on this sentence at the dinner table. They look down at their plates of home-cooked, well-balanced food and wrinkle their noses, with a sometimes calm and sometimes hysterical, “I don’t like that.” “YOU HAVEN’T EVEN TRIED IT!” we shout back in unison. If your family never went through a phase (or what feels like a lifetime) of tense dinners arguing about the food, please bless us all with your wisdom because children are the most stubborn and change-able food critics on earth. One day, our daughter decided she no longer likes “melted cheese,” and falls apart if there is a remnant of it on top of her portion of the casserole (yet, she could eat cheese pizza every day of the week, so please explain that one). Our toddler will obsess and demand pasta and then as soon as it’s placed in front of him, “all done” without eating a bite. What?

Food.Drawing.jpg

Feeding our young children can become an emotional, stress-laden, power struggle even in families doing everything “right” (eg, offering vegetables, sitting all together at the table, using fresh and healthy ingredients). And that power struggle may be part of internal struggles within ourselves to “be healthy,” as well as between parents with different ideas and priorities. 

A great example of an upheaval in “common knowledge” dictated by the experts is the drastic changes to the food pyramid that most of us grew up with emblazoned on our psyche.  This recent change is embedded within an American society full of paradoxes around food and eating (huge restaurant portions AND listing the calorie count -- so make good choices!). All of us likely struggle to some extent with what we consider “healthy” versus what we want for our children. (My husband has a Coke zero every afternoon, but we tell the kids “no soda.”) Struggling with food and feeding as parents is likely the norm and not the exception, so know that if you are struggling, you are not alone.

Food and eating behaviors are intertwined to create that tension between wanting our children to have adequate nutrition for growth, and just wanting the kids to eat . . . anything at all. As I first entered this phase as a new parent, I was fortunate to work with registered dietitians who recommended an excellent book, Child of Mine, by nutritionist Ellyn Satter. She uses an evidence-based approach to food and eating across developmental stages. This is another example of tailoring the guidelines to what works best for each family, but some principal tenets are: the parent is responsible for providing healthy, well-balanced options for each meal, the child is responsible for eating it; implementing a “no-thank-you bite” policy (at every meal) so kids try new foods (even 25 times) even if they do not want to eat them; refraining from tying dessert to eating enough since this sets up sugary treats as even more desirable and worth pursuing over other types of food. As I have been preaching, Ellyn Satter’s website includes a list of references, including studies published in peer-reviewed articles, considered the gold standard for “good evidence.” 

From a behavioral perspective, it is absolutely key to your meal-time psychological survival over many years of mealtimes to cut out the power struggle as early as possible. Children are in a constant state of figuring out how to assert control, and this is an area they often "win" because parents live in fear of a malnourished child. However, I have seen in my own clinical practice, that what happens more than malnourishment is a picky eater whose behaviors become more entrenched and hard to change over time. There can be many contributing factors to this picky eating phenomenon, but in the case of a child accustomed to eating exactly what they want since a young age, this can be prevented by sticking to consistent practices in the early years, such as not making special meals (eg, he will only eat a quesadilla, so when he refuses the chicken and carrots, I just make him a quesadilla so he doesn’t go hungry). It may take weeks to months for your children to “give in” and eat what is on their plate, but this short-term pain is worth the long-term gain. It ends up that the eating behavior is much more important than the food itself when we are aiming as parents to be “healthy.”

In our family, water is our main staple for beverage (it might help that we, the adults, have the habit of drinking a ton of water). In fact, we somehow convinced our children that flavored water is a fancy, special beverage they can have at dinner Friday and Saturday nights. Lemonade has become the drink of choice when eating at restaurants but due to the cost and chaos of a family of five eating out, it doesn’t happen frequently. The point of sharing this is that each family develops its own culture around nutrition and drinking and eating habits. A zealously served cup of fruit punch at a birthday party is not going to ruin your child’s health, but these daily habits in the home can be manageable and make nutrition easier later.

As always, you do what works for your family and if a problem seems to arise (the pediatrician expresses concerns about growth or a lab shows a nutritional deficiency), then you respond and deal with it. As with all other areas of parenting, the stress and pressure you feel as a parent may negatively affect your child more than eating chicken strips a little too often, so relax and enjoy your meal.