Nutrition Without Tears

by Warren P. Silberstein, M.D.
02/26/97

From the moment our children are born one of their most urgent needs is to be fed. Feed a screaming newborn and he instantly calms. From that moment on our relationship with our children and our definition of nurturing is defined by food. Even though most of a child's weight gain is due to growth (and not because we fatten them up), when they are infants their parents always ask "How much did my child gain?" to gauge how their child is doing. They don't ask, "How much did my child grow?" And since parents tend to measure their infants' well being in pounds, their child's weight gain becomes a significant portion of how they gauge their success as parents. So it is no surprise that when a child is skinny or doesn't eat well it causes a great deal of parental anxiety.

If somebody tells you that you look slim, you know you've just received a compliment. But if somebody says your kid is skinny.... It's not good news. Even though between 5-25 percent of children and teenagers in the United States are obese and there is evidence that obesity among children is on the increase, many more parents come to me worried that their skinny child is malnourished than those who come concerned about their child being overweight. And this parental anxiety translates into parents pushing their children to eat what they believe to be the essentials of good nutrition. Unfortunately all this pushing often meets considerable resistance from the children. And before you know it, mealtime becomes a nightmare.

Let's try to understand how this problem develops. Most infants start out eating well and gaining well. Of course, since the normal range of sizes runs from the 5th percentile to the 95th percentile with the 50th percentile being the average, there is quite a wide variation in normal size. With the emphasis on weight gain as a symbol of health, nobody worries about the big babies, but early on the parents of the tiny ones start to worry that their child isn't growing normally. The best way to tell if your child's growth is normal is to review your child's growth chart with your pediatrician. If your child's weight is appropriate for his height and his growth has been progressing steadily along the same percentile curve, then it doesn't matter if your neighbor's child weighs more.

Even the child who isn't small can eventually cause parental nutrition anxiety. If you look at the normal growth curve for weight (these are for girls, but boys growth charts are similar) you can see that the most rapid growth occurs during the first 6 months. By a year the growth rate has slowed down considerably. In the second year you can see that the growth rate slows even more and doesn't pick up again until around 7 years of age.

As the growth slows down, so does the appetite. At the same time the infant is becoming progressively more interested in his environment. The young infant who was once firmly focused on satisfying his hunger can now become distracted from his feeding by the exciting world around him. And then he starts to become independent, wanting to feed himself. Table food is introduced, and because it has much less liquid in it than baby food, the volume of food eaten becomes even less. So we now have this toddler or slightly older child who is intent on feeding himself who wants to get out of his chair after two bites to do something else. And if that's not enough to make a parent crazy, since he's no longer your starving infant, he's become a picky eater. He won't eat meat and he throws the vegetables at the wall.

So what do you do? The first thing you do is take a deep breath and relax. Most parents worry needlessly about their child's nutrition. One of the most important things your pediatrician does as part of his assessment of your child's health is to measure your child and plot his growth for height and weight on a growth chart. If your pediatrician has found your child's growth to be normal, then he must be getting enough nutrients to grow. But you're still worried because he won't eat meat, and the only meal he eats is breakfast.... Here are the facts you need to know about nutrition so that you can relax.

Nutrition doesn't have to happen at every meal. It has to happen over the long haul. Your child can't become malnourished between breakfast and bedtime.
There is no one food that is essential for good nutrition. Meat is an excellent source of protein, but the protein in Milk is just as good. Yogurt is ounce for ounce the equivalent of milk as a source of protein and calcium. Eggs and Fish provide complete protein as well. Even cereals and grains can provide adequate protein if they are taken in the right mix.
Protein is the essential ingredient for cell growth and repair. But the traditional American (meat and potatoes) diet has about 20% of it's calories from protein. A diet with 7% of it's calories from protein is sufficient to prevent protein malnutrition. A high protein diet tends to be high in fat since very few protein foods are low in fat. As a result, the traditional American diet derives about 30% or more of it's calories from fat. A healthy diet should have about 60% of its calories from carbohydrate. This includes pastas and cereals which are the kinds of foods most kids prefer. If you look at the Food Pyramid you can see that the base is made of cereals and grains, indicating that these should be the foundation of a healthy diet. Just remember that the amounts of food shown on this Pyramid are for adults.
It is possible to be well nourished without eating vegetables. I wouldn't share this information with your kids, but I'm telling you so you can worry less. There's no question that we're still learning about the benefits of certain ingredients in vegetables that prevent cancer and heart disease. And that's a good reason to encourage variety in anyone's diet. But the main ingredients that make vegetables nutritious can be found in other foods. Fiber can be found in fruits, cereals, grains, and breads (whole grain). The calorie source in vegetables is mostly carbohydrate just like pastas, breads, and cereals. The same vitamins and minerals can be found in a mix of fruits, fruit juice, and cereals. In fact, in the United States, even the popular highly sugared breakfast cereals are fortified with vitamins and minerals to help them sell.
While we're on the subject of vitamins and minerals, these are ingredients that are needed in small amounts. You don't need to eat ton's of food to get your recommended daily allowance of vitamins. And most parents give their children a vitamin supplement as additional nutrition insurance.
Many children prefer vegetables raw, which is the way they have the most nutrient value.
If you provide a diet of nutritious foods, even if your child doesn't eat a lot or eat them all, he should be adequately nourished. The worst mistake you could make is to offer your child treats instead of food out of fear that your child will starve if he doesn't eat. Once you give a child with a small appetite junk food in place of meals, since his appetite is small, he will just continue to refuse food until he gets the treats he wants. That may provide calories, but it isn't nutritious. Even overweight kids can be malnourished if they live on junk.
Some foods that are usually thought of as junk food can still provide your children with the basic nutrients. Hot dogs are high in fat and salt. I wouldn't feed them to my child every day, but they do have meat protein in them. Same for hamburgers from fast food places. Pizza is an excellent source of nutrition. The cheese provides essential protein and fat while the crust provides carbohydrate calories. Maybe you can even sneak some vegetables onto the pizza.

Some of the biggest feeding problems develop when parents push their kids to eat or to finish what's on their plate. The only healthy infant I ever saw who didn't gain weight was one whose mother was so anxious about his eating that she followed him around all day with food. When we finally convinced his mom to relax and leave him alone about food, he began to eat. Some older children develop belly aches as a result of the pressure to eat, especially if their eating habits are handled as a disciplinary matter.

Parents push their kids to eat because they want the best for them. I hope I've provided you with information that will make it easier for you to worry less about your child's eating habits. If your child regularly eats certain nutritious foods, even if the variety is small, build your child's diet around his favorite good foods. Provide an opportunity for him to try new things with you when you eat. There is no triumph for you or your child in forcing him to eat something he doesn't like. Food is not medicine. Mealtime should be a happy occasion. If you create a pleasant, stress free environment for eating and provide a variety of nutritious foods which regularly include your child's favorites, eventually, you will go out to a restaurant with your child and he will surprise you by ordering the most exotic, expensive thing on the menu.

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