Author: Kristen Cole (Page 1 of 3)


Feeding Team Availability During COVID-19

It’s been a while, dear UNC Feeding Team followers! We are a lot like you all and have been working hard to stay above water during the past 6 months.

We at least wanted to update you to let you know that we are seeing patients both live out of our Raleigh Location and via telemedicine for any patient who is not comfortable coming in person. Please call 984-974-8872 to schedule an appointment. We do apologize if you have missed an appointment and have not heard from us to reschedule. We look forward to seeing you soon and hope you are safe and well.

-The UNC Feeding Team

Eosinophilic Esophagitis (EoE)

Although a rare diagnosis, the number of children diagnosed with Eosinophilic Esophagitis (EoE) is increasing. In the United States, approximately 10-50 children out of every 10,000 are being diagnosed per year. Because there are cases when difficulty eating is the first sign of EoE, we asked our colleague and expert in EoE, Dr. Sabina Mir, to write the following information for our patients.

What is Eosiniophilic Esophagitis (EoE)? Eosinophilic (e-o-sin-o-filek ) (e-so-fa-gitis) is a chronic allergic inflammatory condition of the esophagus. The esophagus is the food pipe that connects the mouth to the stomach. In EoE, there is a build up of too many white blood cells, called eosinophils, in the esophagus.

What causes EoE? Food allergies are one of the most common causes of EoE. Approximately 50%–80% of children with EoE have other allergic diseases such as eczema, asthma and/or allergic rhinitis. EoE can also run in families.

What are the symptoms of EoE? The symptoms of EoE are non-specific and are similar to many other conditions (abdominal pain, vomiting, heartburn, feeding refusal). Feeding difficulties are not uncommon in kids eventually diagnosed with EoE. Infants/toddlers may present as slow feeders, may limit volumes of foods and liquids and/or may have difficulty transitioning from liquids to solid foods. Older children may avoid foods with harder textures (beef, bread) and prefer softer foods. These children may also chew for long periods of time and be labeled as “slow eaters”. Adolescents may experience food impactions where food gets stuck in the esophagus.

How is EoE diagnosed? EoE cannot be diagnosed definitely without an upper endoscopy, performed by a gastroenterologist. There are certain clues to the diagnosis that the gastroenterologist can see with his/her eyes during the procedure (rings, furrows, narrowing of the esophagus). However, the diagnosis is made based on a specific number of white blood cells (eosinophils) seen only under a microscope. Biopsies (small pieces of tissue) are taken at the time of the upper endoscopy and reviewed by a pathologist.

What are the treatments for EoE? There are two main forms of treatment, medical and dietary. Sometimes a combination of both may be required.

Medical: Topical oral steroids, available in two forms, are delivered directly to the esophagus, where the irritation and inflammation exists:

  • liquid budesonide (usually made to be inhaled into the lungs for asthmatics) where a “slurry” is made with Splenda to be swallowed
  • fluticasone inhaler where the released vapor is swallowed instead of inhaled

* Both types of steroids require strict oral care following the treatment to prevent yeast from developing in the mouth and esophagus*

Dietary: Since food allergies are thought to be the main factor driving the inflammation in EoE, food elimination is an important part of treatment. Diet therapy can be a combination of 1, 2, 4 or more food group elimination. The most common triggering foods include dairy, wheat, eggs, soy, peanuts, tree nuts, fish, shellfish, beef and corn.

Repeating an upper endoscopy is often necessary to monitor the effectiveness of the treatment. The usual recommended time frame between scopes is between 8-12 weeks until remission of the disease is reached (less than 15 eosinophils per high powered field under the microscope). At that time, yearly endoscopies are often recommended unless a new symptoms or change in treatment occurs.

Age appropriate treatment with a multidisciplinary team consisting of a gastroenterologist, an allergist, a dietician and a speech therapist is critical in developing the best treatment plan for children with EoE.

Dr. Sabina Mir is an Assistant Professor of Pediatrics at the University of North Carolina at Chapel Hill’s School of Medicine. She is the Director of Endoscopy and Expert in Eosinophilic Esophagitis within the Division of Pediatric Gastroenterology at the NC Children’s Hospital. We are deeply appreciative of all of the outstanding education she provides for our team and the time she took to write this informative piece for our patients.

Vitamins and Supplements

It is important to note that we do not endorse, support or contract with any specific brands. All products presented and discussed within this article have been found to be acceptable by nutrient breakdown and seem to work from a patient preference aspect observed through clinical practice alone. It is not a fully exhaustive list. Please be sure to check with your physician and/or dietitian prior to starting any vitamin/mineral supplementation.

Are your infants, toddlers and children eating the picture perfect balanced diet? Are they eating a diet with five or more fruits and vegetable servings daily? Are they eating a diet where the fruits and vegetables are all different colors and varieties? Do your children eat mostly whole grains? Do they drink 16 oz milk/milk alternative and eat yogurt every day? More than likely the answer is NO. Well, you are not alone.

I have 3 children and even as a dietitian my answer is NO. We have the best intentions as parents. There are many obstacles that often interfere with our best laid plans. For children who have feeding difficulties, these challenges become even greater.

On a routine basis, the UNC Feeding Team sees children who do not eat fruits or vegetables on a regular basis. Most often we find children will eat a few select fruits or vegetables but their variety and volumes are minimal. Fruits and vegetables alone do not provide enough calories or protein for best growth and development. However, they do provide extremely important vitamins, minerals and fiber that keep us healthy and boost our immune system.

We strongly encourage, promote and stress the importance of eating fruits and vegetables. Vitamins and minerals from food sources have been shown in multiple studies over the years to be best absorbed and used by our bodies. Because it is hard to get the perfect diet every day, it is recommended that we have a “safety net”, a supplement, to fill any vitamin and mineral gaps in our diet. In general, a child or infant that does not consume large volumes of oral nutrition supplements will not receive excessive vitamins or minerals with an age appropriate “one a day” multivitamin and/or mineral supplement. An iron containing supplement is typically recommended for infants and children who don’t eat enough meat.

There is a never ending array of supplements on the market. It is important to understand that not all supplements are created equal. In general, gummies are not preferred. They do not contain all of the necessary vitamins or minerals and they increase the risk of cavities. Crunchy chewable or liquid vitamins are the best options for children. Below are some products we have found to be acceptable broken down by age.


Name Serving Size Form Allergens Price per Serving Other
Enfamil Poly-Vi-Sol 1 mL Liquid Top 8 Free $0.24 Multivitamin
Enfamil Poly-Vi-Sol with Iron 1 mL Liquid Top 8 Free $0.26 Multivitamin with iron
Zarbee’s Baby Multivitamin with Iron 2 mL Liquid No gluten $0.37 Multivitamin with iron
Upspring Baby Iron and Immunity 1 mL Liquid No dairy, egg, gluten, nuts, corn $0.18 Multivitamin with iron
NovaFerrum Multivitamin with Iron 1 mL Liquid No gluten, dairy, soy, corn, peanuts, tree nuts $0.38 Multivitamin with iron
NovaMV Pediatric Multivitamin 1 mL Liquid No gluten, dairy, soy, corn, peanuts, tree nuts $0.38 Multivitamin
Natures Plus Animal Parade Baby Plex 1 mL Liquid Hypoallergenic $0.27 Multivitamin


Toddlers: 1-3 year olds

Name Serving Size Form Allergens Price per Serving Type
Zarbee’s Baby Multivitamin with Iron 2 mL Liquid No gluten $0.37 Multivitamin with iron
NovaFerrum Multivitamin with Iron 1 mL Liquid No gluten, dairy, soy, corn, peanuts, tree nuts $0.38 Multivitamin with iron
2 scoops Powder Hypoallergenic $0.67 Multivitamin and mineral with iron
Flintstones Toddler Chewables 1 tablet Chewable Contains soy $0.09 Multivitamin and mineral
Animal Parade Gold Children’s Multivitamin 2 tablets Chewable Hypoallergenic $0.36 Multivitamin and mineral with iron
Animal Parade Gold Liquid 15 mL Liquid Hypoallergenic $0.50 Multivitamin and mineral with iron
Centrum Kids ½ tablet Chewable Contains dairy, soy, wheat $0.06 Multivitamin and mineral with iron


Children’s: 4 to 8 year olds

2-4 year olds; ½ standard dose daily

4-8 year olds and older; 1 full dose daily

Name Serving Size Form Allergens Price per Serving Type
Flintstones Complete with Iron 1 tablet Chewable Contains soy $0.18 Multivitamin and mineral
NovaFerrum Multivitamin with Iron 1 mL Liquid No dairy, gluten, soy, corn, peanuts, tree nuts $0.38 Multivitamin with iron
2 scoops Powder Hypoallergenic $1.92 Multivitamin and mineral with iron
4 scoops Powder Hypoallergenic $1.92 Multivitamin and mineral with iron
Centrum Kids 1 tablet Chewable Contains dairy, soy, wheat $0.12 Multivitamin and mineral with iron
Chewable Maxi Health 3 tablets Chewable No wheat, soy, dairy, gluten $0.67 Multivitamin and mineral with iron
Animal Parade Gold Children’s Multivitamin 2 tablets Chewable Hypoallergenic $0.36 Multivitamin and mineral with iron
Animal Parade Gold Liquid 15 mL Liquid Hypoallergenic $0.50 Multivitamin and mineral with iron

Written by Kelly Brower, RD, LDN, CSP, one of our highly trained and enthusiastic Pediatric Registered Dietitians.

Medically Complex Patients

A large majority of the patients we see as a part of the interdisciplinary feeding team here at UNC have very complex medical diagnoses. This fact makes it very difficult to have standards of care as far as how we treat our patients. Often, in medicine, we have protocols and clinical pathways that guide our care for “types” of patients. These care plans are fantastic when dealing with more typical presentations of problems such as Reflux (not Reflux Disease), Constipation and even Abdominal Pain or Eosinophilic Esophagitis. Large samples of such patients are taken and evaluated as to which treatments produce results, how long such treatments typically take and pathways of which direction to take if a certain treatment is not proving beneficial.

In the case of a large percentage of the population we see within the feeding clinic, there are no other patients with their exact diagnosis or combination of diagnoses. In the medical world we would call these patients and “n” of one. With patients who are unique only to themselves, a standard protocol or pathway cannot be established or followed. This can prove very stressful and confusing to parents and caregivers alike.

A benefit you will receive from visiting our interdisciplinary feeding team is a “meeting of the minds,” so to speak. Three different disciplines will take a detailed feeding history specific to your child and develop the best plan of care to fit your child’s individual needs. Whether your child has eaten by mouth from birth or has never eaten by mouth makes no difference in our ability to develop a plan of care. A large majority of our patients require some type of supplemental feeding tube to consume all of the necessary calories for good growth.

We care for patients who have a range of feeding difficulties from very mild to extremely complex. Eating by mouth is something that is easy to take for granted and also to overlook as a possibility in many patient populations. The one thing that all of our patients have in common is the desire to eat by mouth, even if only in small tastes, which we promote as long as safety has been established. If the ability to eat by mouth enhances the patient’s quality of life, we work hard to assist the patient in doing so.

Medically complex patients are always a bit of a puzzle. Establishing best treatment plans for feeding these patients vary from patient to patient. It often takes a lot of time and patience when trying medications and formulas and evaluating their effectiveness. It also takes a lot of love for these special kids and we have that for sure! Please contact us with any specific questions if you have them or come see us.


Getting children to eat enough calories and protein can be a real challenge for parents. Eating well can be especially hard for children who have a medical and/or feeding problem. Here are some ideas to help boost calories and protein without giving little tummies too much volume to handle.

Who may have a need for increasing calories and protein in their diet?

  • Children who have difficulty chewing and swallowing
  • “Picky” eaters
  • Children who are trying to wean off of tube feeding onto a table food diet
  • Children with poor growth
  • Children who have frequent illness or infections that increase calorie and protein needs
  • Children with extra-high activity levels (Example: a child who is constantly moving his/her upper and/or lower body (such as certain types of cerebral palsy)

Calorie and Protein Boosters

Eggs (75 calories and 7 grams of protein per egg) – Add to salads, casseroles, cooked cereals; serve as egg salad, scrambled or hardboiled. (Do not use raw eggs in uncooked items – this poses a large risk for food-borne illness). Cooked egg yolks are considered safe after nine months of age, but hold off on egg whites until after one year to reduce allergy risk.

Avocado (160 calories, 2 grams protein per 1/2) – One of our favorite “superfoods,” it is packed with fiber, vitamins and “good fats”. Serve sliced, mixed in salads or sandwiches, mashed into casseroles or purees, made into smoothies.

Butter or Margarine (45 calories per teaspoon) – Mix in casseroles, baby food, sandwiches, vegetables, cooked cereals and bread products. Dairy free versions are also available.

Cheeses (approximately 100 calories, 7 grams of protein per ounce) – Try string cheese or sliced cheese as a snack. Sprinkle in baby food, cooked cereals or over potatoes or pasta. Melt in casseroles, vegetables and soups. Dairy free versions are also available.

Wheat Germ (25 calories, 2 grams of protein per tablespoon) – **also a good source of zinc** – Add 1-2 Tbsp. to casseroles, cooked cereals, yogurt and cooked items (muffins or breads).

Sour Cream (25 calories per tablespoon) – Add to potatoes, casseroles, and use as ingredient in dip for vegetables and crackers.

Peanut Butter (95 calories, 4 grams of protein per tablespoon) – Add to toast, crackers, pancakes, various recipes, or spread on fruits (sliced apple/banana) or veggies (carrots/celery).

Submitted by Sharon Wallace, RD, CSP, LDN, one of our Feeding Team Dietitians.

Juice is Healthy, Right?

Dietitians often say “everything in moderation” when advising patients on their diets and that same advice pertains to children. Everyone may have a different definition of moderation, so what does moderation really mean? For the first time in over 15 years, The American Academy of Pediatrics (AAP) has published new guidelines on how much juice is recommended for children due to the increase in obesity and concern for dental health.

Juice can be part of a healthy diet for a child but should not be substituted for whole fruit, as whole fruit not only has the vitamins that juice has but is also a significant source of fiber. Usually children are advised to have 2-2 ½ servings of fruit per day. The serving size of fruit can depend on the child’s age and often children exceed the necessary daily fruit intake with juice alone.

Here are the current recommendations from the AAP for the moderation of juice intake in children.

  • 12 months an younger- Do not routinely give juice
  • 1-3 years of age- No more than 4 ounces (1/2 cup) juice per day
  • 4-6 years of age- No more than 4 to 6 ounces juice per day
  • 7-18 years of age- No more than 8 ounces (1 cup) juice per day
  • Parents are advised to not allow children to carry juice around throughout the day in a cup or carton as it is high in sugar and could impact dental health.

These recommendations are not meant to scare or shame parents for giving your child juice but to better define how much juice you give your child as part of a healthy diet. If you ever have questions about how much juice to give your child feel free to talk to your child’s provider or dietitian.

Written by Kerry Gibson, RD LDN CNSC

Non-Dairy Beverages: What’s New and Trending?

Non-dairy milk alternatives have become quite popular over the last several years. Most of the families we take care of have tried soy or almond beverages.  A few have even tried rice and coconut beverages.  Many people ask us if there are other options…the short answer is… YES! Several companies have developed new non-dairy products, many of which are being sold in “regular” grocery stores, not just specialty stores.

Non-dairy beverages are not right for every child. They tend to be very low in calories and protein per ounce. Because most children in our clinic require high calorie beverages for optimal growth, we typically recommend fortifying non-dairy beverages. Children with dairy allergies or intolerances fortify with an amino acid formula (e.g. Elecare Jr or Neocate Jr).  Children who can tolerate dairy typically fortify with Carnation Instant Breakfast or a powdered toddler formula. Non-dairy beverages are a good source of calcium and vitamin D and an option for children who eat low amounts of these nutrients in their overall diet.

The following list is not to be confused as an endorsement for any of the named products and does not include all of the non-dairy alternatives on the market. Instead, this is a list of the most popular non-dairy beverages used by families in our clinic. If your family favorite is not listed, please share it in the comments!

Cashew Drink: Several companies make cashew beverages: Silk, So Delicious, and Imagine Foods are the most popular in our clinic. Cashew milk has a creamy feel, a mild nut taste, and is high in calcium. It is also among the lowest calories (about 25 calories per 8 oz) of non-dairy beverages.

Pea Protein: The newest kid on the dairy alternative block, pea protein first became popular with adults and was only available in a powder form in specialty stores. That changed in the last year when Ripple was introduced in the refrigerator section of many stores. Silk, also introduce their Protein Nutmilk, which added pea protein to a blended almond and cashew milk. Also in the last year, Kate’s Farm introduced their line of oral pea protein and brown rice oral supplements to the market. Pea protein milk and milk blends are much higher in protein than other dairy alternatives with about 8 grams protein per 8 ounce serving, the same as cow’s milk.

Hemp or Hemp Seed Milk: Living Harvest and Pacific Natural offer hemp milk in shelf-stable cartons. Hemp milk is high in fat and naturally includes omega 3 and 6 fatty acids. It tends to be more expensive than other milk alternatives, but can be a good alternative for families wanting to provide a plant-based source of fatty acids. With about 140 calories per 8 ounces it is also a higher calorie beverage than most nut milks.

Oat milk: Although it is not new to the market, oat milk has increasing availability in stores. Prior to the launch of hemp and pea protein drinks, oat provided the highest calories and protein with the lowest fat of the dairy alternatives. An added benefit of oat milk is that it includes 2 g soluble fiber per 8 ounce serving, the same as a packet of instant oatmeal. As far as we know, Pacific Natural is the only manufacturer of oat milk in the United States.

You may be wondering about goat milk. Why isn’t that on this list? The proteins in goat milk are very similar to the proteins in cow’s milk, too similar in fact. Children who have allergies or intolerances to cow’s milk are very likely to have the same reaction to goat milk and should not drink it.  Goat’s milk is an option for children who do not like the taste of cow’s milk or non-dairy beverages.

We hope you enjoyed this overview of some of the most popular dairy alternatives on the market. We are very open to discussion about the use of such products in our feeding clinic as long as patients are over one year of age and our dietitians are able to calculate and recommend calories per ounce necessary for good growth. As previously mentioned, dairy alternatives are not right for every child. We always recommend consulting with your provider before starting a specialized formula of any kind.

Written by Lisa Richardson, one of our highly trained Pediatric Dietitians.

The Skinny on Infant Formulas

 Taking care of an infant can be overwhelming, especially if the baby is having trouble feeding. Breast milk is considered the healthiest option for infants and should always be supported. However, for a variety of reasons some infants are  fed formula. Our feeding team takes care of infants who are breast fed, bottle fed pumped breast milk, and formula fed. Our primary goal is the health of the infant and working closely with families to support their feeding goals and desires for their children.

Choosing and understanding the differences between all available infant formulas can be very daunting. Most term babies do well on standard infant formula. Occasionally, there are valid reasons to consider alternative formulas. The UNC Feeding Team and your Pediatric Registered Dietitian can help identify the most appropriate formula choice to promote both tolerance and good growth and development.

The various formula classifications and the formulas which fit within each category are outlined below. It must be known that a trial of infant formula requires the infant to be on the specific formula for a minimum of 2 weeks to determine if the formula is making a difference. The price of formula increases as the amount of predigested (broken down) proteins increase.

Preterm Infant Formulas: Preterm infants come with their own special nutrition and medical needs which causes them to fall into a special category of infant formula. These formulas have a higher concentration of calories and bone minerals. Preterm infants do not have the opportunity to build up fat or bone mineral stores prior to birth during the 3rd trimester. Most of these formulas come as 22 calories per ounce and are often concentrated further to 24 calories per ounce by the medical team.

  • Similac Neosure
  • Enfamil Enfacare

Standard Term Infant Formulas: These formulas have completely intact milk protein, which requires the infant’s body to break them down to be able to use them. Most have DHA and ARA (important for brain development), iron (necessary after 4-6 months of age as infant stores are used up) and prebiotics (to promote health of the child’s GI tract).

  • Enfamil Infant
  • Similac Advance
  • Gerber Good Start

Gentle or Sensitive Formulas: These formulas are special versions of standard infant formulas that are used when babies are gassy, spit up a lot and appear to have general discomfort. These formulas have a small amount of the whey protein broken down to help ease the workload on the GI tract.

  • Enfamil Gentlease
  • Similac Sensitive
  • Good Start Gentle

Low Lactose Formulas: These formulas are often recommended when an infant is gassy, bloated, spit ups up a lot or has frequent crying and general discomfort.

  • Gerber Good Start Soothe
  • Similac Spit Up

Soy Formula: Some families do not want to utilize a cow milk based formula. Other times, tolerance to cow’s milk protein is in question. It is important to note that more than half of the infants who are intolerant to dairy proteins are also intolerant to soy proteins.

  • Enfamil Prosobee
  • Similac Isomil
  • Gerber Good Start Soy

Extensively Hydrolyzed Formulas: These are fancy words to describe a formula with proteins that are mostly (not fully) broken down. Often milk protein intolerance is suspected if the infant vomits excessively, has lots of stomach upset with excessive gas and sometimes, diarrhea. These infants also often cry, arch with feedings and appear uncomfortable.

  • Nutramigen
  • Alimentum
  • Pregestimil

Elemental Formulas: These formulas contain 100% broken down proteins and are especially for those infants with suspected milk protein allergy. These infants are often fussy, seemingly cry in pain, have blood in their stools and/or poor weight gain. These formulas are not typically available to purchase on the shelves of a grocery store. They do not contain any intact proteins (only the individual amino acids or building blocks of proteins) that can cause allergy or intolerance reactions.

  • Neocate
  • Elecare
  • Pure Amino
  • Extensive HA

Choosing the best formula for your infant can be overwhelming and complicated. We strongly recommend meeting with a Pediatric Registered Dietitian and/or feeding specialist to discuss your concerns about your infant’s feeding before making alterations to their formula. Growth and development, infant comfort and formula tolerance are of highest concern when choosing the right formula for each infant. The UNC Feeding Team evaluates each infant seen for the milk best suited for each one – and they sure are all unique little beings!

Written by Kelly Brower, RD, LDN, CSP, one of our highly trained and enthusiastic Pediatric Registered Dietitians.

Down Syndrome and Difficulty Swallowing

Children with Trisomy 21 or Down Syndrome can be at increased risk for feeding and swallowing problems. This is primarily due to anatomical differences, such as low tone. Low oral muscle tone (weak muscles in the mouth including the lips, cheeks, tongue) can result in weak lip closure, poor suction on the bottle nipple, strong tongue thrust and poor chewing. These problems can be diagnosed and treated with an oral motor assessment and clinical swallow evaluation performed by a speech pathologist.

The most concerning feeding and swallowing issue for children with low tone is aspiration, or the ingestion of food and/or drink into the airway. The act of aspirating typically results in an alerting sensation or a cough response. However, a recent study from the Children’s Hospital of Colorado reported that children with Down Syndrome are at higher risk for silent aspiration, which is when food or drink enter the airway without eliciting a sensation or a cough response. Silent aspiration can only be detected and diagnosed by a test. The two tests that evaluate swallowing are the modified barium swallow study (MBSS) (this might also be called a videofluorscopic swallowing study) or a fiber optic endoscopic evaluation of swallowing test (FEES), either of which can be conducted by a trained speech pathologist. Left untreated, aspiration can result in health problems including pneumonia, chronic cough, low grade fevers, congestion, dependence on supplemental oxygen and poor weight gain.

What does this mean for parents?

  • Not every child with Down’s syndrome has aspiration. However, parents of children with Down’s syndrome should understand that their child has an increased risk for swallowing problems and that sometimes aspiration is silent meaning there are no obvious symptoms when the child is swallowing.
  • Children with low oral motor tone can have difficulty with the mouth skills needed to manipulate a bottle, cup or solid foods.
  • Parents should seek an evaluation from a speech pathologist for feeding and swallowing skill development and get treatment early to prevent long term consequences.

If parents are concerned, they should request a referral from their pediatrician for a feeding and swallowing evaluation from a trained speech pathologist.

Jackson A, Maybee J, Moran M, Worlter-Warmerdam K, Hickey F. Clinical Characteristics of Dysphagia in Children with Down Syndrome. Dysphagia. 12 July 2016 doi: 10.1007/s00455-016-9725-7

Written by Sarah Studley, MS, SLP-CCC, one of our speech pathologist’s on the UNC Pediatric Feeding Team who specializes in pediatric feeding and swallowing intervention. 


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