Category Archives: Nutrition

The Runt of my Litter. Why I Worry About my Smallest Child and When You Should Worry about Yours.

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CharlottesWebEvery day in the office at least one parent expresses concern over their smallest child: “His siblings were so much bigger at this age”; “Why is she sick all the time?”.

I can completely relate to their concerns. My 4 year old daughter is a runt1. Like Wilbur the pig2,3, she is sweet and brilliant, but small and often sickly. My husband and I are both tall, athletic people. Her sister has always been in the 95th percentile for her height and weight. Little E is taller than average, but she is scrawny, and she gets sick… a lot. Her sister didn’t have a cold until she was 2 years old. E had her first cold at a few weeks of life and seemed to be sick constantly for her first 3 years.

Why do I worry? Since I first entered medical school 18 years ago I have studied everything that can go right with a child’s health and everything that can go wrong. I have seen innumerable children who have suffered from accidents, cancer, infections, genetic disorders, and autoimmune diseases. When I was in training we used to say “the sweeter the child, the more horrific the diagnosis will be”. There was no truth in our statement. It was just a reaction to the heartbreak we felt; time after time we had to share devastating news about a child to the family that cherished him.

Unfortunately I have kept that superstition with me. My little E is a cup-half-full kind of girl. She dances around the house singing “Let It Go”, yells “wheeeee” the whole time she is flying down the trail on her bike, and shows more determination and grit than almost any child or adult I know. She is also prone to covering me with thousands of kisses and 10 second bear hugs on a daily basis. I have tears in my eyes when I write this because my overwhelming love and admiration for this child is matched by my overwhelming fear that something bad will happen to her. I try to reassure myself by remembering that many of my friends, and parents I see in the office, share my neurosis about their littlest child.

So when do we really need to worry?

  1. Is my child continuing to grow? Your child may be in the 3rd or 30th percentile on her growth curve. What really matters is if she is continuing to follow that percentile (normal) or if she is continuing to drop off the curve (concerning).
  2. Is my child reaching his developmental milestones appropriately (or is he doing well academically)? Check here for more information on developmental milestones.
  3. Does my child get frequent infections requiring antibiotics or hospitalizations? Frequent ear infections in the first year of life are often due to anatomy (small, flat eustachian tubes that don’t drain the middle ear space well), but frequent ear infections are unusual after the age of 2. Recurring bacterial pneumonia, frequent skin infections, or blood infections are more concerning for an immune deficiency.
  4. Does my child have bloody stools or frequent cramping and diarrhea? These can be signs of inflammatory bowel disease or celiac disease.

So how do you protect your runt? Fortunately there are a few great things you can do to keep your children healthier: good hand washing, proper nutrition, consistent sleep schedules, limiting screen/TV time, regular exercise, and vaccines. We do all of these things in our home but my baby still get sick. If your child is in daycare or preschool (or his older sibling attends school) then he may get 10-12 viral respiratory infections per year. Exposure to second-hand smoke will also significantly increase his risk of frequent infections.

Thankfully now that E is 4 years old, her illnesses are less frequent and less severe. Hopefully her physical composition will eventually match her emotional one. In the meantime I will still snuggle up next to her when she has a fever, and I will hold her all night when she has a cough. It makes us both feel better.

1. runt (definition from

– an animal that is small or stunted as compared with others of its kind.

– the smallest or weakest of a litter, especially of pigs or puppies.

2. E.B. White, Charlotte’s Web, (New York: Harper and Bros, 1952).

3. No children or animals were harmed in the writing of this post. Both Wilbur and my 4 year old can’t read yet. If little E does read this in the future I am fairly certain she will forgive her mommy for calling her a “runt”.

5 Common Questions about Introducing Solid Foods to Your Baby

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baby led weaning, introducing solid foodsTomorrow I am speaking at a Parent Participation class about introducing solid foods to your baby. In preparation I collected the most common questions I am asked about this very fun stage in a baby’s development and I wanted to share them with you. Put down your spoon, grab your mop, and be prepared for the messy fun!


When is my baby ready for solid foods?

Can your baby hold his head up and sit properly in a high chair? Does your baby express interest in food? This typically happens between 4 and 6 months of age. Before this your child’s GI system is not ready to properly handle anything other than breastmilk (or formula) and he has not developed the motor skills to chew and swallow food properly. When you offer him food, if he turns his head away from you, chokes, or lets the food just dribble out of his mouth, then he is not ready. Try again in a few weeks.

Do I start with infant cereal?

Traditionally it was recommended that infant’s start with a single grain infant cereal. It is a nice option because you can mix a very small amount with breastmilk or formula when you are trying solids for the first time. Infant cereals are also fortified with iron and don’t have added sugar. Today we know that there really is not a bad first food to start with. You can choose a vegetable, fruit or even meat. The most important thing is that you are offering a single ingredient in a consistency that your baby can handle, without any added salt, sugar or chemicals. In fact there is some evidence that “baby led weaning” may be a preferable way for some families to introduce solid foods to their infants.

What is baby led weaning?

Baby led weaning is a fancy term for letting your baby feed himself, skipping the spoon feeding stage completely. This is a skill that is typically not found in infants until they are 6 or even 7 months of age, so it is best for parents who are not in a hurry to introduce solid foods. Initially your baby will get most of the food in his hair or on your floor, so it is also best for parents who are not mess-ophobic.

The goal with this method is to offer your child smushy versions of common foods that he can pick up himself (soft, steamed and peeled sweet potato wedges, steamed broccoli, scrambled eggs, etc). You want to avoid honey and anything that he could choke on. Some studies have shown that children introduced to solid foods this way may have lower rates of obesity and tend to be less picky eaters, although you may need to supplement with spoon feeding for a child who is underweight. The theory is that babies learn to pace themselves, chew their food, decide when they are done, and get a greater variety of food. How many times can you really serve your baby pureed peas anyway?

It is also nice to sit down at a table with your family and eat together, instead of spending the whole meal spoon feeding your infant. When my 4 year old looks at me at dinnertime some nights and says “feed me” I wish that we had skipped spoon feeding in her infant days! She does love being the baby some days, and I guess mommy secretly loves it too 🙂

What foods should we avoid?

There is increasing evidence that children introduced to a greater variety of foods before 11 months of age will have a lower risk of food allergy. This means that you should introduce eggs, seafood, meat, cheese, yogurt, wheat and nut products to your infant. You do NOT want to give your infant honey, milk, or choking hazards; no nut butters, grapes, hot dogs, large pieces of meat, hard pieces of fruits or vegetables, popcorn, candy, seeds or nuts. There is also no benefit to fruit juice unless your child’s physician has recommended it for constipation.

Exceptions: If you have severe food allergies in your family then you should not introduce any solid foods to your baby until you have discussed it with your child’s physician.

When do I start to decrease breastfeeding?

Your baby will let you know when she is getting enough solid food and will back off naturally on her frequency of breastfeeding. This shouldn’t happen before 6 months of age, and it will typically not occur until she is 10-12 months old.

My bottom line?

As long as you avoid choking hazards and honey there is no right or wrong way to feed your baby. Eat together as a family and enjoy each other instead of your smartphone. The most entertaining moments of your child’s life are often at the dinner table. Have fun!


Please comment below if you have any questions (or funny baby feeding photos and stories to share).

For more information:

Parenting MD: Guide to Baby’s First Year



  1. Rapley, G. 2006. Baby-led weaning, a developmental approach to the introduction of complementNwaru BI, Takkinen HM, Niemelä O, et al. Introduction of complementary foods in infancy and atopic sensitization at the age of 5 years: Timing and food diversity in a Finnish birth cohort. Allergy 2013;68(4):507-16.
  2. Hourihane JO, Aiken R, Briggs R, et al. The impact of government advice to pregnant mothers regarding peanut avoidance on the prevalence of peanut allergy in United Kingdom children at school entry. J Allergy Clin Immunol 2007;119(5):1197-202.
  3. Du Toit G, Katz Y, Sasieni P, et al. Early consumption of peanuts in infancy is associated with a low prevalence of peanut allergy. J Allergy Clin Immunol 2008;122(5):984-91.
  4. Poole JA, Barriga K, Leung DY, et al. Timing of initial exposure to cereal grains and the risk of wheat allergy. Pediatrics 2006;117(6):2175-82.
  5. Brown A, Lee MD.Early influences on child satiety-responsiveness: the role of weaning style. Pediatric Obesity. Published online December 17 2013
  7. Rapley, G. 2006. Baby-led weaning, a developmental approach to the introduction of complementary foods. In Hall Moran, V and Dykes, F. eds. Maternal and Infant Nutrition and Nurture: Controversies and Challenges. Quay Books, London. pp 275-298.



Parenting MD: Guide to Baby’s First Year

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This book, written exclusively for e-readers, is filled with straightforward and up to date information to guide you from preparing for your baby’s birth to celebrating her first birthday.

The ebook format includes links to useful resources within the book and online.

Quickly access helpful information about feeding, sleeping, development, and common ailments, as well
as a glossary of terms and conditions.

Every day, research continues to expand our knowledge about keeping our children safe, healthy, and thriving. The information and recommendations contained in this book are based on the most current evidence available. Printed books can take years to get to publication, and medical knowledge and safety recommendations often change before the book even hits the shelves. This electronic format allows the reader to have access to the information within days of the final edit. Dr.Raja will also provide periodic updates to the ebook for free. Subscribe to and follow Dr.Raja on Facebook to find out more.

10% of proceeds will be going to St. Jude Children’s Research Hospital


Fiber: It’s Not Just for Pooping

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Photo by Aaron McIntyre, Flickr Creative Commons

Photo by Aaron McIntyre, Flickr Creative Commons

A recent study from the University of Minnesota found that only 3 percent of American children and 8 percent of adults are getting the amount of fiber recommended per day by the U.S. Department of Agriculture and Department of Health and Human Services.

Why do we care?

High fiber intake has been shown to lower risk for heart disease, stroke, high blood pressure, high cholesterol, diabetes, and obesity. It is also great for pooping.

How much should my child get?

This really depends on his age and energy requirements. The basic formula is 14 grams of fiber for every 1000 kcal consumed. This equates to about:

19 grams for a toddler
25 grams for a preschool through elementary school aged child
26 grams for a middle school aged girl
30 grams for a middle school aged boy
29 grams for a teenage girl
38 grams for a teenage boy

This really means feeding your kids at least 5 servings of fresh fruits and vegetables each day, as well as beans, nuts, and whole-grain breads and cereals. Cereals should have at least 3 grams of fiber and less than 10 grams of sugar per serving.

What specific foods are high in fiber?FiberTable

Can I get enough fiber on a gluten-free diet?

Yes, but… gluten-free often means fiber-deficient unless you pay close attention to what you are eating. A gluten-free diet that includes plenty of fruits, vegetables, nuts, seeds, and beans can be sufficient. This can be hard to achieve with a carbo-crazed toddler. Children are better off eating multigrain cereals and snacks instead of gluten-free puffs of nothing (unless they have true celiac disease).


Nutr Rev. 2009 Apr;67(4):188-205. doi: 10.1111/j.1753-4887.2009.00189.x. Health benefits of dietary fiber. Anderson JW, Baird P, Davis RH Jr, Ferreri S, Knudtson M, Koraym A, Waters V, Williams CL.

American Heart Association

Mayo Clinic

Eat your vegetables!

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vegetablesEvery day in the office I have at least one parent expressing concern over their child’s diet. I know I shared this same concern as a new mom, but as I continue to watch my children grow and thrive I have finally relaxed a bit. I wanted to share some facts and tips on starting your infants and toddlers on a path to healthy eating.

Tip #1: Your infant and toddler watch EVERYTHING you put in your mouth. If you are drinking sodas they will want soda too. If you are eating cheese puffs they will expect the same. The best way to ensure your child establishes good eating habits is by eating well yourself.

Tip #2: Variety is the spice of life. A study from researchers at the London Metropolitan University (Wansick, et al.) showed that children are most attracted to food plates with seven different items and six different colors. Adults prefer only three items and three different colors. Using this knowledge can give you an opportunity to diversify your child’s palate and improve their nutrition.

Tip #3: Meal time should not be a battle zone so if you can negotiate a bite of each thing you are a lucky parent. Forcing a child to finish her meal will not help the physical or mental health of you or your child. It is more important to teach her to eat until her tummy is happy.

Tip#4: Children who sit down to eat with their family eat more nutritious diets. This may not be an option every day but when you can, make the most out of this time. Turn off the T.V. (and mobile devices!) and focus on each other. Your infant or toddler will rarely make it through a whole meal without wanting to get down and wiggle, but this will get better as they get older. Just make sure the eating part of the meal only happens when they are sitting down. A toddler eating on the run is a risk for choking (and a risk for ruining your rug). Remember: family mealtime should not be a battle zone so have realistic expectations.

Tip#5: Juice works great for a constipated infant, but has NO role in good nutrition. It can also be helpful when you are introducing a sippy cup or trying to keep a toddler well hydrated on a really hot day. In these cases it is still better to water it down and limit his juice intake to less that 4-6 ounces in a day. Yes, juice originally came from fruit, but after it is processed you are left with a lot of sugar. Unfortunately, you won’t find many of the vitamins or fiber that were in the skin and pulp of the original fruit.

Tip #6: French fries should NOT be considered vegetables! There was actually a survey done about 10 years ago of 3000 kids from 4-24 months that showed the most common vegetable eaten by these kids was….. french fries. I really hope we are doing better now. French fries are really a salty, fatty starch. If you offer your kids fries please do it infrequently and in very small amounts. Dark, leafy green and orange vegetables tend to be the most nutritious. I haven’t figured out how to get my kids to love salad but they do eat a lot of carrots, peas, and sweet bell peppers. I am optimistic though, so every day they get a small offering of our salad and can usually be talked into one bite.

Tip #7: Too much milk CAN be a bad thing. After his first birthday your child can start drinking whole milk, but too much milk will fill his tummy and make less room for solid food. Too much milk (over 24 ounces in a day) can also block your child’s ability to absorb iron from other foods leading to severe anemia (low red blood cells). In my opinion, chocolate milk should not even be considered a dairy but rather a dessert. There is more sugar in a cup of chocolate milk than in most sodas or juices!

Tip #8: Vitamins may make us feel better about our child’s nutrition but they do little to improve your child’s health. I admit it. I gave my picky little toddlers a multivitamin because it made me feel better. That is OK. The truth is a healthy child who is growing well is getting enough nutrients from their food. The exception is vitamin D. We need to use sunscreen to protect our kids from the real dangers of UV radiation, but we are also blocking their absorption of vitamin D. Vitamin D is important for bone growth and immune function. It is therefore recommended that all infants and children receive vitamin D supplementation (400 IU/day for infants less than 1 year and 600 IU/day for over a year).

Tip #9: Snacks should be nutritious too. Did you know that 2 tablespoons of Nutella have as much sugar as 5 Oreos? Wow. Most of our diets are already overloaded with carbohydrates, salts and sugar. It is better to offer veggies, fruits, or protein rich snacks (cheese, yogurt or nuts in older children) a few times a day. Having a bowl of fishy crackers available for them to graze on all day will diminish their interest in real food at meal time.

Tip #10: Try, try again. Kid’s are fickle with food. My daughter will swear she hates avocados and a week later they are her “absolute favorite”. If you reintroduce an unpopular food regularly your child may actually decide she likes it.

The bottom line: If you put everything your child ate in one week on a plate how would it look? One day she may not eat many veggies, another day she may not have much protein. At the end of the week was her overall consumption pretty well balanced?

For more information on what a well balanced plate would look like check out:

Do you have any tricks for getting your kids to eat more veggies? Any great kid-friendly recipes to share?

Candy Purge

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witch_on_broom_02What will you do with all of that Halloween candy tomorrow? My answer until last year was of course: “keep eating it until I puke or it is all gone”. Previous years my kids would forget about the candy after a day or two, but last year I knew their sweet tooth had developed. They, like their mama, began to dream about candy all day long!  Luckily we found a solution: Dentists around the country will actually “buy back” the candy from your kids. The candy is then donated to Operation Gratitude and sent to U.S. troops across the globe. Your kids may get cash, stickers, or a gift card for every pound of candy donated. You may even be able to talk your kids into just donating their candy and pass on the “buy back” option. I figure every pound we donated last year was one less pound on my rump! Check out their website for participating dentists in your area.

Another great idea is the Switch Witch. The story I have been told is the Switch Witch is a good witch who comes to your house a few days after Halloween and collects the candy your kids set out. She then leaves them a gift in exchange. This is a new concept for our family, but I am thinking we could have fun with it this year. They are excited about the Tooth Fairy coming one day (they both still have their baby teeth), so I am fairly certain they would love the idea of the Tooth Fairy having a witch as a cousin. I know they would definitely love the swag I  throw together from the dollar store. If it all works out then I will take the Switch Witch’s candy to donate instead 🙂

Has the Switch Witch visited your house before? How did it go? I would love to hear about your successful ideas and of course the flops too (so the rest of us can avoid them!).