by Dr. Perle Feldman
It is remarkable to me, considering the general abundance of food in our society and the inborn drive to eat enough to survive, that so many parents are convinced that their darling baby is about to commit suicide via slow starvation. Many parents will come to their family physician with a toddler and declare that the child “doesn’t eat enough to keep a bird alive.” On examination it becomes obvious that the child is growing well and is not underweight for their height. One must take a careful nutritional history, determining what, where and how much the baby eats. If there are no concerning symptoms such as vomiting, gagging or diarrhea, it is obvious that the child is eating adequately. So what is triggering this parental concern?
Babies triple their weight in the first 2 years of life. Growth starts leveling off at around 18 months of age. The 18 month old is no longer growing as quickly as he/she did before, and their caloric needs fall dramatically. This is accompanied by a fall in appetite. The toddlers eat less food than they did previously. This makes parents anxious. There are also two major competing drives, which interfere with a baby’s appetite. These are the desire for mobility and the desire for independence.
Toddlers love to say “NO”. They want to exert their independence and sometimes the need to be oppositional is simply overwhelming. They want control but cannot deal with too much choice. Parents are disturbed and upset by this new display of contrariness. If you can help parents understand what is happening, normalize the changes in behavior and give them a repertoire of responses to reduce frustration, you will have done a great service. Encourage parents to give toddlers limited choices. “Do you want noodles or tunafish?” is a good question. Many parents are so worried that their toddler is starving they want to keep spoonfeeding them. They develop all kinds of strategies to sneak food into their child by distracting them. This is asking for trouble. It teaches the child to ignore its own hunger cues.
While most toddlers need some help with certain foods, there should be more and more finger and spoon foods on their plates. Inform parents that when serious messing and dumping starts, this is a signal that mealtime is over. Let them get down. Do not give them any snacks for at least an hour and a half after meals. The child will learn not to eat, run and return every 15 minutes and drive their mother crazy.
For many toddlers the bottle is their security object, and they walk around with it in their mouth all day. This also allows them to satisfy their hunger while they keep playing. Many toddlers consume huge amounts of apple juice or milk in this manner using up all their caloric needs for the day. This has been shown to lead to Iron deficiency anemia as they consume large amounts of iron poor milk to the exclusion of other nutrients. The introduction of Iron enriched formulas in the first year of life delays but may not remove this risk. It is a good idea to encourage parents to wean their toddler from the bottle and to limit milk intake to less than 18-24 oz/day. If they don’t have the heart to take the bottle completely away, limit the milk bottles to morning, nap and bedtime, giving water at other times. Juice in the bottle should also be limited and/or watered down so that it does not interfere with the baby’s appetite.