Join your hosts, Betsy Hjelmgren and Jen Karakosta, as they kick off the first episode of their 6th podcast season with an update on everything pertaining to quarantining, COVID-19, and food! Betsy shares the pros and cons of providing nutrition services by telehealth, and Jen shares her insights on food and comfort in times of crisis.
As a pediatric dietitian, I work with some of the youngest clients in our private pediatric nutrition practice. There are many common themes that come up, as the families I work with try to nourish their children in the best ways possible and support their rapidly growing brains and bodies. I am struck in the past couple weeks, with the same question and concern that has come up many times. Should I keep breastfeeding after one year?
This question came from an exclusively pumping client, who wondered whether she should continue to pump breastmilk for her one year old. It also came from another client who’s doctor was questioning why she was still breastfeeding her 13 month old twins (who were former preemies) and a family member who was feeling done with breastfeeding and pumping for her 15 month old, but was feeling guilty about “quitting”.
Many well-meaning friends, relatives and pediatricians may be weighing in and clouding the decision for a breastfeeding mom about whether to continue breastfeeding after a year. The answer is that breastmilk definitely provides nutritional and immunological benefits after a year, however the decision on whether to continue a breastfeeding journey should be made by a mom, not her friends, relatives or pediatrician.
Breastfeeding moms looking for information on how long to breastfeed can quickly become inundated. Social media posts and groups can be incredibly helpful and supportive for breastfeeding moms. After all, the pediatrician’s office is not open at 3am when the baby is screaming and won’t latch, so these sites and groups can be extremely important! However, sometimes information can be opinion-based and judgement laden. The facts can be hard to discern from the rhetoric.
Many breastfeeding mothers are told by their pediatrician that it is “bad” to breastfeed beyond a year, because the baby needs food, not breastmilk. The two are not mutually exclusive. According to the American Academy of Pediatrics, “there is no upper limit to the duration of breastfeeding and no evidence of psychologic or developmental harm from breastfeeding into the third year of life or longer”.1 The American Academy of Family Physicians echoes the AAP’s guidelines. They indicate that, “breastfeeding should continue as long as mutually desired by mother and child”.2
Colleagues and clients also share with me their concerns about continuing breastfeeding or breastmilk feeding after a year because they have been told that their milk does not provide any benefit anymore. Breastmilk has known immunologic benefits beyond a year (if Mom gets sick, she will continue to makes antibodies that then get passed to her breastfeeding child), but also continues to have nutritional benefits. According to a study published in Pediatrics, breastmilk expressed by mothers who had been lactating for over one year, had higher fat and energy content compared with the milk expressed by mothers who had not been lactating as long.3 The study indicates that the fat and calories provided during prolonged lactation may be more significant than medical providers or even the researchers suspected.3
It is also worth mentioning the concept of weaning. Some women feel guilty about discontinuing breastfeeding or breastmilk feeding because the concept of weaning implies “taking something away” from the baby. It is important to note that “weaning” actually begins the day that the baby takes their first bite of table food, baby cereal or a baby food puree. So, truly all mothers start weaning from breastfeeding when complimentary foods start. This process of weaning continues until the child is no longer breastfeeding or breast milk feeding, whether this is at 6 months or 3 years and 6 months.
As a former breastfeeding and breastmilk feeding mom, I understand how difficult it is to integrate information from friends, family and medical providers, all well-meaning. As parents, we just want to do right by our children and we need the support of our community. Sometimes outside comments can get overwhelming. According to research, about 70% of women cease breastfeeding because it was the natural progression lead by either the baby or the mother, but over 11% reported they stopped breastfeeding due to a lack of information or a lack of support/opposition.4
I encourage all hard-working breastfeeding or breastmilk feeding moms to make this about a decision that is best for you and your baby. Approach this decision like so many other parenting decisions you will make down the road for you and your child: weigh the pros and cons, think about how this decision will impact your child in the short term and in the long term, and how it will impact your family as a whole.
For those that are ready to stop breastfeeding, remember you are not “quitting”, so try to let go of the guilt. You are ready for the next steps and to embrace the next chapter in motherhood. For those that want to continue, nurse on – the science is behind you!
Amanda Gordon, RD, LDN, IBCLC is a pediatric dietitian at Feed to Succeed, LLC, a private pediatric nutrition practice. For more information, visit www.feedtosucceed.com
1. Breastfeeding and the Use of Human Milk. Pediatrics. 2012;129(3):e827 LP-e841. doi:10.1542/peds.2011-3552
2. Breastfeeding, Family Physicians Supporting (Position Paper). https://www.aafp.org/about/policies/all/breastfeeding-support.html. Accessed June 14, 2020.
3. Mandel D, Lubetzky R, Dollberg S, Barak S, Mimouni FB. Fat and Energy Contents of Expressed Human Breast Milk in Prolonged Lactation. Pediatrics. 2005;116(3):e432 LP-e435. doi:10.1542/peds.2005-0313
4. Sugarman M, Kendall-Tackett KA. Weaning Ages in a Sample of American Women who Practice Extended Breastfeeding. Clin Pediatr (Phila). 1995;34(12):642-647.
As a pediatric dietitian, daily interactions with amazing children and their wonderful families is the best part of our practice. Walking into a home visit, greeted by a hug or watching a family walk into our office with good news about how nutrition changes have helped make their child feel better is the best. This is not happening right now. We miss our patients and families.
Yesterday, as we sat on our virtual staff meeting, this really started to get to me. I was thinking about all we can’t do as providers right now. What is missing. It made me grumpy and really got me down. However, I decided I needed to reframe my thinking. I started thinking about the telehealth that I have been providing over the past eight weeks. I thought about how it is changing how we practice. And, many good things started to come to mind.
For one, I am listening in such an active way. Without face-to-face interaction, I am listening so carefully to my patients, their families and what they say during sessions. I am honing my skills and remembering the foundations of my training that involved listening and counseling skills.
Words have become very important. My sessions are often shorter, as families are busy at home. I choose my words carefully and am targeted in goal setting as many parents are stretched thin.
The best outcome of telehealth though has been the new ways that I am able to empower families. I can walk families through changes, listen and help them strategize, but it is different than in-person. For example, I can’t be there with my breastfeeding scale to assess how much breastmilk an infant is taking in a breastfeeding session. However, during virtual sessions we discuss other strategies that families can utilize themselves. In follow up sessions, it is amazing to see them feel empowered and confident when they have been able to implement strategies that help their children immensely.
Our practice, Feed to Succeed, is now seeing many children and their families via telehealth. With changes by insurance companies and new policies within the Illinois Early Intervention program, we continue to be able to support the families we serve in new and innovative ways. Eight weeks ago, I did not know how to teach a family how to administer food through a feeding tube virtually, however now I do. It’s working. It is changing the way that we practice, at least for now. And, that might not be all bad.
Amanda Gordon, RD, LDN, IBCLC is a pediatric dietitian at Feed to Succeed, LLC, a private pediatric nutrition practice. For more information, visit http://www.feedtosucceed.com
Exciting news that all of our nutrition-covered BCBS Illinois patients are now eligible to receive nutrition services via telehealth! All the Feed to Succeed dietitians are available to provide new and follow up nutrition visits via Zoom. We are here to keep you healthy and eating well, even during this difficult time. Call the office to schedule your appointment, (847) 724-8015.
March 15, 2020
The safety and security of the families we serve, including both our patients and our care providers, are our top priority. We expect rapid changes and updates to continue to guide our patient care decisions.
To that end, we have made the difficult decision to suspend face-to-face patient consultations beginning today and through March 30th, at which time we will re-evaluate the information and situation, and update our plan of action.
We are offering all of our clientele the opportunity to meet with us by Zoom in a virtual-appointment. If you have an upcoming visit scheduled, you will receive an email within 24-48 hours prior to your scheduled appointment time with instructions on how to join us virtually.
If you have questions or concerns, please contact the office at (847) 724-8015 or email firstname.lastname@example.org. Wash your hands and stay well!
By: Amanda Gordon, RD, LDN, IBCLC and Dan Frazier, RDN-AP, CNSC
Parents feel fulfilled when they feed their children healthy foods. Foods that are fresh, colorful and taste good. Foods sourced from quality ingredients. Food that are less processed and contain fiber and other nutrients that make our bodies work well. Foods that provide energy.
There is an important movement afloat in the nutrition world and a growing body of scientific evidence that supports the idea that children with feeding tubes should eat real food too. Tasty, nutrient-dense, colorful food. The same food that their parents eat. The same food that other children eat.
February 10-14 is Feeding Tube Awareness Week, a campaign initiated by the Feeding Tube Awareness Foundation to bring awareness about tube feeding (https://www.feedingtubeawareness.org/). So, what better time than now to talk and think about children with feeding tubes.
Many adults and children alike are reliant on tube feedings at home to deliver adequate nutrition and hydration. Studies using Medicare and Medicaid data in the United States indicate that the use of home tube feeding is on the rise in the United States.1 According to data from the Feeding Tube Awareness Foundation, children 18 and under represent about 40% of the tube fed population.1 There are many reasons why a child may have a tube placed for feeding and hydration. These can include medical diagnoses, including prematurity, physical, anatomical, or neurologic conditions.
Feeding tubes can also be placed for children with swallowing difficulties and in situations of pediatric feeding disorders (which are also on the rise in the US).2 And, for those who may question or doubt the reality of a pediatric feeding disorder being a real thing, just ask any family who has had a feeding tube placed in their child for this reason.
Feeding children through a feeding tube can be very stressful for families. It can take the whole concept of eating and turn it into something medical. Eating is supposed to be social and enjoyable. When nutrition has to be delivered through a tube, this can change the dynamics, meal times, and how a family views nutrition for their child. And for good reason. Up until a few years ago, most children in the US were fed primarily medical formulas and nutrition supplements through a feeding pump that delivered nutrients on a set regimen over a 24 hour period. (No wonder this would feel more medical that nourishing).
However, families today have more options for feeding children with tubes who are over 12 months old. There is a strong movement, backed by growing scientific research, to feed real food to children with feeding tubes. Yep. Chicken, fish, eggs, fruits, vegetables, milk, yogurt and other dairy. All kinds of stuff.
While some children have medical conditions that require specialized formulas to deliver specific nutrients through a feeding tube, many families are moving away from conventional formulas as possible. With the help of Registered Dietitians who specialize in this area, children with feeding tubes now have the opportunity to eat the same foods that their families, caregivers, and friends eat. Parents blending foods in their kitchens are able to feed this to their children. Recipe sharing and books are now published on feeding table foods to children with feeding tubes. There are also a growing number of companies that are creating wholesome meals meant for children with feeding tubes.
Feeding children real foods, table foods or family foods can help children feel better. Studies indicate that children who eat food by tube instead of formula often have improved tube feeding tolerance due to an improvement in gastrointestinal symptoms such as nausea, vomiting, diarrhea, and gagging/retching3,4,5. Additionally, for kiddos able to eat orally, studies indicate that those using real food versus formula have decreased oral aversion and increased oral intake4.
Parents and caregivers often feel better as well. They feel more empowered by the ability to nourish their children well. Many families relish the opportunity to feed their children family and culturally-appropriate foods. Most importantly, they often feel less stress overall as the feeding experience normalizes in a sense and doesn’t alienate their child. Not surprisingly, parents using blenderized tube feeding reported feeling that their child was happier and healthier; they also unanimously recommended blenderized tube feeding to other parents6.
In many ways, the discussion around feeding real food feels full circle. Prior to the inception of formula in the 1960s, people with feeding tubes were given real food. It is exciting to see this become popular again and given the clinical studies substantiating this practice, in conjunction with the overwhelmingly positive response from parents, feeding real food to children with feeding tubes will likely become more common.
The USDA Dietary Guidelines recommend eating a variety of nutrient dense foods for all Americans. Children with feeding tubes should not be excluded from the opportunity to enjoy real food. It is our hope that families and Registered Dietitians continue to advocate for the concept of feeding as eating, not a medical procedure.
Amanda Gordon, RD, LDN, IBCLC is a pediatric dietitian at Feed to Succeed, LLC, a private pediatric nutrition practice. Feed to Succeed works with families on food-based tube feeding diets for children and on weaning children from tube feedings. For more information, visit http://www.feedtosucceed.com
Dan Frazier, RDN-AP, CNSC is a Registered Dietitian with Real Food Blends. Real Food Blends makes 100% real food meals for individuals with feeding tubes. To learn more, visit http://www.realfoodblends.com
1. Mundi MS, Pattinson A, McMahon MT, Davidson J, Hurt RT. Prevalence of Home Parenteral and Enteral Nutrition in the United States. Nutr Clin Pract. 2017;32(6):799-805. doi:10.1177/0884533617718472
2. Forbes D, Grover Z. Tube feeding: Stopping more difficult than starting. J Paediatr Child Health. 2015;51(3):245-247. doi:10.1111/jpc.12763
3. Hron, B., Fishman, E., Lurie, M., Clarke, T., Chin, Z., Hester, L., Burch, E. and Rosen, R. (2019). Health Outcomes and Quality of Life Indices of Children Receiving Blenderized Feeds via Enteral Tube. The Journal of Pediatrics, 211, pp.139-145.e1.
4. Pentiuk, S., O’Flaherty, T., Santoro, K., Willging, P. and Kaul, A. (2011). Pureed by Gastrostomy Tube Diet Improves Gagging and Retching in Children With Fundoplication. Journal of Parenteral and Enteral Nutrition, 35(3), pp.375-379.
5. Batsis, I., Davis, L., Prichett, L., Wu, L., Shores, D., Au Yeung, K. and Oliva- Hemker, M. (2019). Efficacy and Tolerance of Blended Diets in Children Receiving Gastrostomy Feeds. Nutrition in Clinical Practice.
6. Gallagher, K., Flint, A., Mouzaki, M., Carpenter, A., Haliburton, B., Bannister, L., Norgrove, H., Hoffman, L., Mack, D., Stintzi, A. and Marcon, M. (2018). Blenderized Enteral Nutrition Diet Study: Feasibility, Clinical, and Microbiome Outcomes of Providing Blenderized Feeds Through a Gastric Tube in a Medically Complex Pediatric Population. Journal of Parenteral and Enteral Nutrition, 42(6), pp.1046-1060.
Join Betsy and Amanda for an in-depth and informative discussion on milk, milk-substitute, and nutrition. What is the best option for you and your family? Why does almond milk seem to have more calcium than cow’s milk (but really doesn’t!) Is cow, almond, or soy better? Or is cow’s milk really an acceptable healthy choice? All these answers, plus more are awaiting you in this info-packed episode!
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How does a team of elite athletes fuel themselves before practice? What about after practice? And what do they do for hydration? These five teens joined our program during an energetic carpool, on the way to a distant practice, to bring you their tips and favorite foods for fueling for their sport. Listen in for different perspectives and ideas, and see if there is something you can try for yourself!
Click below to listen, or download on iTunes or wherever you get your podcasts!