Category: Nutrition

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.


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.

Infant Formulas –They’re All the Same, Right? Nope.

Infant Formulas –They’re All the Same, Right? Nope.

When it comes to feeding your infant sometime we need to rely in part or in full on infant formula. Breast milk is viewed by many as the “best” or “healthiest” choice for feeding infants. However, often for various reasons (some medically driven and some simply by choice) infant formula is chosen as a baby’s main source of nutrition. 

Choosing and understanding the differences between all the infant formulas on the market can be very overwhelming. 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 tolerance and support 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 baby to be on the specific formula for a minimum of 2 weeks to determine if the formula is making a difference.  The price of the formulas increases as the amount of broken down proteins increases. 

Pre-term 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 higher concentration of calories and bone minerals. These babies did not have the opportunity to build up fat or bone mineral stores prior to birth as this occurs during the 3rd trimester. Most 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: have completely intact milk protein which requires the gut to break them down to utilize 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 gut health).

  • Enfamil Infant
  • Similac Advance 
  • Gerber Good Start

Gentle or Sensitive formulations of standard infant formula often get used if babies are gassy, spit up a lot and appear to have a general discomfort. These formulas have a small amount of the whey protein broken down to help ease the workload on the gut. 

  • Enfamil Gentlease
  • Similac Sensitive
  • Good Start Gentle

Low Lactose Formulas: are also often tried when there is lots of gassy, bloating, spit up, crying and general discomfort is present. 

  • Gerber Good Start Soothe
  • Similac Spit Up

Soy Formula: some families do not want to utilize a cow milk based formula. Other times baby’s tolerance to cow’s milk protein is in question. It is interesting to know that more than half of the babies who are intolerant to dairy are also intolerant to soy proteins. 

  • Enfamil Prosobee
  • Similac Isomil
  • Gerber Good Start Soy

Extensively Hydrolyzed formulas – these are just fancy words to describe a formula with proteins that are mostly (not fully) broken down. Often milk protein intolerance is suspected if baby spits up or vomits excessively, has lots of stomach upset with excessive gas, diarrhea – sometimes with mucus or blood in stools, cries and arches with feeds, or has reflux. Infants with intolerances are to intact milk proteins do well on these. 

  • Nutramigen
  • Alimentum
  • Pregestimil 
  • Extensive HA

Elemental Formulas: these formulas contain 100% broken down proteins. They are not typically available to purchase on the shelfs at the store. They no longer contain any intact proteins (only the individual amino acids) that can cause allergy or intolerance reactions.

  • Neocate 
  • Elecare
  • Pure Amino

Choosing the best formula for your infant can be overwhelming and complicated. It is highly recommended to meet with a pediatric registered dietitian and feeding specialists to discuss your concerns about your infant before making alterations to their formula. Infant comfort, formula tolerance, growth and development are of highest concern. Choosing the most appropriate formula for your infant is one of several areas evaluated by UNC Feeding Team. The team is dedicated to achieving a smooth and comfortable progression through developmental feeding stages.  

Written by Kelly Brower, RD, LDN, CSP,  Pediatric Registered Dietitians.

Malnutrition Defined


Everyone knows a few “nutrition-specific” words, like protein, vitamin and carbohydrate. Dietitians have very specific definitions of such words that are often quite different than the general public’s understanding. Malnutrition is one of those words. Malnutrition can be a scary word that brings up images of bone thin children with large bellies. Those images are examples of a very severe form of malnutrition rarely seen in the United States. Hearing the word malnutrition can catch parents off guard,  especially since failure to thrive has been the more familiar descriptive term in the recent past.

The Academy of Nutrition and Dietetics and the American Academy of Pediatrics follow the same guidelines for identifying and categorizing malnutrition.  We follow those same guidelines here at the NC Children’s Hospital. Diagnosing malnutrition and categorizing its level (mild, moderate or severe) is a critical part of developing a nutritional care plan for each individual patient.  We do our very best to incorporate everything we know about a child before assigning that child with the diagnosis of malnutrition. Our guidelines tell us to take medical conditions, questions about accuracy of measurements and recent illnesses all into consideration before diagnosing malnutrition.

In children, malnutrition is identified using several difference pieces of information and is based on the child’s age. Slightly different for children under age two, we generally assess the following:

  • How much weight is gained compared to the ideal amount for a child his/her age
  • How much a child weighs compared to his/her height
  • Weight loss relative to usual weight
  • Height or length for age
  • At times, we also measure a mid-upper arm circumference (MUAC) and compare it to the ideal MUAC for a child of the same age

So that we make consistent comparisons, we use a statistic called a z score. The z score not only provides cut off information about whether or not a child is likely to be malnourished, but also the degree of malnutrition. Z scores are very useful because they give us much more concrete comparisons for growth information over time rather than looking solely at standard growth percentiles. We can see shifts in z scores sooner than changes in growth percentiles. This helps us, and you, know if our plans are effective.

As we hope you can see through this description, malnutrition is a much more specific term than its predecessor, “failure to thrive”.  Failure to thrive simply means that a child is not growing adequately compared to a standard growth chart. This alone is not enough information to plan and monitor treatment.

Although the word malnutrition may feel negative, it really is a positive way for medical providers to communicate, identify and track the success of our treatments so that we can provide the best care possible.

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

A Word of Encouragement from our Dietitians


In her book First Bite, Bee Wilson wrote, “Seeing a child fed reassures you that you have done your duty as a parent, like a mother bird ferrying worms to the nest.”

Unfortunately, parents of children with feeding challenges miss that regular reassurance, which can leave them feeling frustrated and unsuccessful in parenting their child. Then, parents come into the feeding clinic and the dietitian asks, “What does your child eat?”  Parents, particularly those new to our clinic, take a deep breath and sometimes even look away before answering. In that pause between question and response, it seems parents hear a different question: “How good of a parent are you?”

Similarly, the medical words we use can sometimes feel negative. Malnutrition is one of those words. Providers use medical terms to communicate quickly and specifically with one another.  But, “malnutrition” isn’t specific to medicine and the word can bring up images of children who are being starved on purpose. We use the term very specifically as it medically defined by national organizations (more about that in our next post so stay tuned!!). This is a much more specific word than “failure to thrive,” because malnutrition is defined by specific growth parameters. Indeed, the word failure is not exactly helpful in understanding feeding problems. In most cases, by the time families encounter our team, they have been creative and persistent in the face of very big feeding challenges (“Ferrying worms to the nest”).

Please know that our questions are to gather information – not to judge you! The primary purpose for the dietitians on the team is to craft best strategies for each unique child to be well-fed and to thrive, often using formulas and alternative ways of feeding. Asking about what your child eats and classifying his/her nutrition status, helps the dietitians to formulate best ways to help your child. Our ultimate goal is that each of our parents will feel the reassurance of that mother bird ferrying worms to the nest.

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

Blenderized Tube Feeding


Children with feeding disorders may require G-tube feeding to assist them in meeting their nutrient requirements. G-tube feedings may be given with a commercial formula, homemade blenderized tube feeding or commercialized blenderized tube feeding. Speaking with your medical team (physician, nurse practitioner, registered dietitian and feeding therapist) can help to guide your decision on which formula is best for your child.

Parents who choose blenderized tube feeding often do so due intolerance of commercial feeding formula, food allergies, desire to use “real food” or for improvement in GI symptoms such as gagging, retching, vomiting, reflux and constipation. When choosing to use blenderized tube feeding you have the option of using a commercial blenderized tube feeding or homemade blenderized tube feeding.

Homemade blenderized tube feedings are less expensive and can give more of a variety of foods. However, they also can raise food safety concerns, have a short hang time (~2 hours), may have unpredictable nutrient levels by using non-standardized recipes and are not often covered by insurance. Choosing homemade blenderized tube feeding will require close work with your child’s registered dietitian to ensure adequate nutrients are provided.

Commercial blenderized tube feedings are convenient, processed to ensure food safety, have a longer hang time of 8-12 hours, standardized nutrient levels and may be covered by insurance. Below is a comparison of several commercial blenderized tube feedings:


Nutrients Nourish Real Food Blends Compleat Pediatric
Serving Size 355 mL (foil pouch) 282 mL (pouch) 250 mL
Calories (Kcals) 400 330-340 250
Protein (g) 14 11-14 9.5
Fat (g) 17 18-20 9.5
Carbohydrate (g) 50 28-32 34
Fiber (g) 7 2.2-4 2
Water (%) 76% 75-78% 88%
Cost per 8 ounces $5.33 $4.16 $3.12
Additional Info Contains no dairy. Complete source of nutrition Contains no dairy however not a complete source of nutrition Contains dairy. Complete source of nutrition


Whether you decide to use a commercial, homemade or commercial blenderized tube feeding the UNC Pediatric Feeding team is here to help and support you during the entire process.

Written by Kerry Gibson RD, CNSC, LDN

When Purees Have a Purpose: Part 2

 This blog post is a follow up to the previous post discussing how to successfully manage your child on pureed diets. This post will address many of the practical questions that are asked along with some “pearls” provided by our parents. We also wanted to provide you with some tasty, nutritious recipes to get you started. Enjoy!

“Where do I start with purees? What kind of blender should I buy? “

Blender Cost General Information
Blendtec® HP3 blender Range from 300.00 refurbished to 700.00 professional series new (800) 253-6383-there is patient assistance program available for this.
Vitamix® Wide range of 400-700.00 Inquire about Medical Needs Discount Program which is available to all eligible candidates at (800) 848-2469 or email: reference code 07-0036-0011


There are also refurbished models that are less expensive

Ninja Kitchen System Plus Average 75.00 (varies per site) Some come with storage/pureed recipes
Oster Immersion Blender 19.00 Per parent report one with a flat blade tends to puree best
Beaba Babycook 95-120.00 (varied per site) Baby food machine and cooks and purees-holds 2 ½ cups at one time
NutriBullet (also a Magic Bullet) Varies 75-120.00 Contains attachments and storage containers

Parents often ask us whether they need to buy the more expensive blenders to make effective purees. Our parents have given us great feedback and have found this not to be true. In fact, the primary inpatient intensive feeding program we often work with typically use the Immersion Blender which is the least expensive option.


“A lot of foods on the pureed diet look bland and boring and don’t seem to contain much nutrition. My child needs to gain weight. How can I achieve this? How can I add calories and protein to a pureed diet?”

Liquid fish oil (adds omega-3s) 1 tsp 40
Canned tuna/salmon (adds omega-3s) 2 ounces 60
Chia seeds 1 Tbsp 60
Boiled lentils 1/4 cup 60
Boiled Egg 1 70
Ground Beef or Chicken 1 ounce (3 oz is “palm of hand”) 70
Cooked oatmeal 1/2 cup 75
Avocado 1/4 mashed 80
Greek Yogurt 6 ounces 100-150/ 13 gm protein
Cooked Brown Rice or Quinoa 1/2 cup 110
Almond/Peanut Butter 1 Tbsp 100
Butter 1 Tbsp 100
Raisins 1/4 cup 55 (also great Iron Source)
Sweet potato 1/2 cup 70
Hummus ¼ cup 10

Written by Sharon Wallace, RD, CSP, LDN

When Purees Have a Purpose

You may hear some surprising things when your child comes to the UNC Pediatric Feeding Team clinic. For example, you may hear that we would like your child to return to eating puree textured foods (yes, we are referring to baby foods…but also to homemade high calorie blends that are of the pureed variety). We thought a post explaining this recommendation would be helpful.

Our team will first observe your child eating and drinking foods from home.

Foods we commonly see:

  • chopped foods (cut fruit, cut vegetables, cut granola bars/nutri-grain bars)
  • crunchy snacks (chips, crackers, wafers, cookies, dry cereals)
  • solid foods (hamburgers, French fries, granola bars, mini pizzas, dessert bars)
  • juice, water, milk supplements

Things we observe while your child eats:

  • Volume of food eaten
  • Speed/Rate at which they eat
  • Sophistication of chew and swallow
  • Demeanor/comfort while eating

Using  a combination of key findings from our very detailed history and the expertise of our pediatric speech therapist, we will determine if the food texture given is the most appropriate for your child. This can have a direct impact on how well your child will grow and thrive.  Based on the findings, we may ask that you “back down” to a pureed diet texture in order to assist in overall ease of eating. Your child’s oral motor skills may be delayed and not sufficient for an age appropriate meal of solid foods. Your child also may be underweight and require higher calorie purees/mashed foods or liquids. It is far easier to add in supplemental powders and additives to purees than it is to solid foods.

See below for some frequently asked questions related to this topic:

  1. My child is four years old. Why would they need to have a pureed diet? Eating is actually a much more complex process than people realize. Biting and chewing skills are developing as early as six to twelve months of age. Children do this by accepting new tastes and textures introduced around five to six months of age first with spoon feeding of purees, beginner dissolvable solids and then real solids foods.  As babies move into chewing, they move from sucking in the middle of their mouth to moving foods with their tongue to the side of their mouth with coordinated biting. With time and practice this process becomes easier and easier as more complex foods can be introduced. The transition from sucking to chewing takes a typically developing child a long time to develop. They start around six months and do not achieve fully mature chewing skills until age three.
  2. What can cause this process to get off track? Medical issues such as chronic disease, surgery, prematurity or prolonged hospital stays can interrupt this process. Untreated reflux over time causing  pain or discomfort with eating, which can lead to volume limiting and refusing of foods. We often hear reports of babies and children who hold foods in their cheeks, turn their head to refuse, and cry at meal times. Some children are extremely picky eaters, taking 30, 40 and even 60 minutes to eat a meal. Some of our patients refuse to try any new foods. Our team can quickly identify when the “normal” eating process has been interrupted and when a pureed diet might be necessary to get your child back on track.
  3. How will my child grow and gain weight eating baby foods? Ensuring that your child gets proper nutrition is the primary role of the dietitian on the feeding team. A pureed diet needs to have as much thought as any other diet you would prepare for your child. We work with families to use the best purees and mashed foods possible, which may mean higher calorie store bought purees or homemade purees. Our goal is to assist you in avoiding serving the same flavors repeatedly.  Every day we watch our pediatric patients come back to clinic with stories of improved developmental milestones, improved sleep and overall better temperament as a result of an improved nutritional intake, often beginning in the pureed form.
  4. What are some things I should think about when making a pureed diet? We want to see a variety of tastes and flavors being offered- and foods coming from at least two food groups per meal. For example: breakfast might consist of yogurt and pureed fruit, lunch might consist of a pureed peanut butter and jelly sandwich with fruit, and dinner might consist of pureed spaghetti with meatballs and green beans. Many parents ask us about using store bought baby foods. Baby foods (usually stage 2) often have the texture of a smooth puree and can certainly be used when traveling or “on the run”. Additionally, there are many pureed pouches with a wide variety of flavors that are the perfect smooth texture our feeding kids tolerate best. The “best case scenario” would be to use a combination of baby foods and pouches with homemade purees (this is especially true when using a pureed diet is new and parents are still trying to figure out the best way to make tasty smooth purees). Keep in mind, we are here to help…and enjoy doing it…

Part Two: Tune into part two of our pureed diet blog this month to find out more about comparing blenders to get the job done, healthy but high calorie additions to a pureed diet and some fun recipes!

Written by Sharon Wallace, RD, CSP, LDN