Baby B is 9 months old. She is a cute bundle, bright and curious, she likes to get in and out of corners creeping around the house with awesome speed. At the blink of the eye, she has moved out of her grand parents' arms leaving them in tears and ready to cry and also pull their hair out!! Yes, in frustration.
Why? Almost in tears baby b's grandparents narrate their tale of woe, feeding their grandchild. Baby B just refuses to eat, does not open her mouth, stubbornly keeping it closed, hiding her face, turning her face away and moving away at the sight of food. If forced she vomits, pushes away with her hands. They don't know what to do!! Not only that she is not gaining any weight. How will she gain weight if she refuses food like that? The only thing she takes is mother's milk that too only when she is asleep. B's mother is working in a firm and the baby is with grandparents.
They have consulted their usual doctor. He has given some advice on what to feed the child, examined the child to make sure that she does not have any medical issues. They were relieved to know that at least there was no medical issue to deal with.
Now does that sound familiar??
So how did this start? B was born with a slightly below average weight. She took time to learn to breast feed and then was feeding well and gaining weight. Because of her low weight, parents were asked to feed her every 2 hours which continued into her second and third month also. She was fed by the clock and she fed for shorter and shorter periods. Her weight gain slowed down from the fourth month onwards which worried the parents a lot. So they renewed their efforts to feed her more and by the clock. This did not help. She was introduced other foods at 5 to 6 months. Baby cereal, apple juice and formula were the foods she was given. She was fed with a dropper and Pallada. Her intake became less and less and parents and grandparents started feeling desperate and started force feeding her. Whenever she was really hungry, she would take 3 or 4 tsps. and then crawl away. At nearing 9 months, she stubbornly refused food and bottle and only survived on breast milk fed in sleep.
Feeding babies and young children needs a lot of patience. Parents get very worried about the child's weight. After the initial few days of birth it is not necessary to feed babies by the clock except in some special circumstances. It is better to feed on demand as babies then learn to recognise hunger cues, empty stomach and also the feeling of full stomach and satisfaction. They are able to regulate their feeds better if they are fed on demand. Babies have to be fed in a relaxed manner without anxiety. Overstimulation during feeds should be avoided. In the first 6 months, exclusive breast feeding on demand takes care of the growth needs of the baby.
Introduction of other foods is recommended from 6 months onwards as baby's energy needs are not met by breast feeding alone. New foods can be introduced gradually. Good foods to start with are cereals like rice, Ragi porridge etc. along with this vegetable soups, fruit juices can be given. The consistency and texture of offered foods is important and is gradual transition from liquid milk till 6 months to family pot food by 12 months. By 6 to 8 months, foods given should be thickened and given by spoon. Foods given should be thick enough and not drip off the spoon. Watery foods and thin consistency are low in energy density and do not satisfy the growth requirements. This will be seen as poor weight gain. Single cereals can be changed to multigrain foods and then cereal pulse combinations like rice with dhal etc. Pureed or mashed fruits like banana, papaya can also be given.
6 to 8 month old babies can be fed 2 to 3 times a day in addition to frequent breast feeding. The quantity of foods should be started with few teaspoonfuls increased to 3 to 4 tablespoons. By 9months babies can be fed half a cup. 9 to 12 month old babies are fed 4 to 5 times a day.
After the age of 6 months, babies can be fed most of the foods, only the consistency of food needs to kept in mind. Additionally small snacks may be offered. From 9 months, baby can be given finely chopped and mashed foods as this encourages development of chewing. Introduce lumpy foods from 10 months. Baby may refuse new foods initially but if offered frequently in small quantities, begin to accept them. Babies need foods from all food groups to get a balanced diet. Food groups mean cereals like rice, Ragi, protein rich foods namely milk, curd, cheese etc, lentils, pulses and beans, source of fat ex., oils, ghee and butter. Besides these vegetables like carrots, beans, peas, potato, pumpkin, green leafy vegetables and fruits like banana, papaya, apple sauce, are necessary Non vegetarian foods are a good source of iron and egg yolk and white are also good for the baby. However, uncooked eggs should not be given and honey is best avoided until after 12 months of age. Commercial baby foods are easy to prepare and fortified with vitamins and minerals and therefore can be given twice a day while introducing homemade foods. But remember don't continue with them longer than necessary as these are very smooth and do not help in developing chewing. If lumpy foods are not introduced by 10 to 11 months, feeding difficulties may appear and continue.
Generally parents or grandparents feeding the baby need to be responsive to baby's cues of hunger and fullness and avoid force feeding as this results in food refusal and behavioural problems related to feeding.
Weight and growth monitoring is important, even more important is awareness and knowledge on what to feed, how much and how frequently to feed the baby.
Coming back to our cute little Baby B, who prompted this article, what happened to her?
Parents and grandparents were extensively counselled on how to feed the baby, and to avoid force feeding. They were given a food plan for the baby. Pallada and dropper were thrown out and spoon feeding was introduced. Foods were thickened to improve the calories and butter and ghee added in appropriate amounts to enhance the calories. Overstimulation during feeding was reduced and one person was assigned to feed the baby calmly with patience and taught to recognise baby's cues. Commercial cereal was continued twice a day and home cooked food introduced twice a day. As home cooked meals were increased, commercial foods were reduced and stopped. Breast feeding was continued. Vitamins and mineral supplements added to prevent and correct deficiencies.
Parents were reassured and encouraged to continue with the plan and persuaded not to go back to force feeding.
With the improved knowledge and awareness, parents cooperated, relaxed and stuck to the plan given with the help of grandparents. Finally baby b started feeding and enjoying her food and this showed in improved weight and growth. Now she is 15 months and when she says firmly "no" to food, parents know to stop feeding her.
Dr. Chitra Sankar
Consultant Developmental Pediatrician