AppId is over the quota
It’s a primal impulse to worry about an infant’s growth. But experts on child nutrition, mostly enlisted nowadays in the battle against childhood obesity, point out that some of our standard infant feeding practices and attitudes may need revising, including some of those encouraged by pediatricians like me. My grandmother’s attitude — stuff food into the baby, be proud of a “good eater” — may not make sense in an environment of abundant food and rising obesity.
But it gets medically controversial, and emotionally sticky, when doctors start talking about obesity in babies. Is there an epidemic of infant obesity? Are fat babies at greater risk of turning into fat children at higher risk for medical consequences later on in life? And what can doctors advise parents about feeding a baby — which ought, after all, to be one of the basic joys of parenthood?
The answers to those questions aren’t always clear. Scientists do know that the number of obese children has been on the increase. But not the proportion of those under age 2 whose weight-for-length curve is at the 95th percentile or above — that has held pretty steady since 1999.
Perhaps more important, no one wants to see babies on diets, no one wants to see hungry babies not given food. Dr. Elsie M. Taveras, a pediatrician on the faculty at Harvard Medical School and a leading expert on obesity risk factors in children, says that the evidence indicates that when parents too severely restrict a child’s food intake, that child is at higher risk for obesity.
“When we are overly controlling, either overly restrictive or we overly pressure a child to eat, that doesn’t allow the child to respond to their own hunger and satiety,” she said.
Satiety cues (spitting out the bottle or the breast, turning the head away, closing the mouth) are the signals that infants send when they’ve had enough to eat. One promising line of research involves helping parents recognize babies’ hunger signals (rooting, putting a hand to the mouth, sucking mouth movements) and when they’re saying that they’ve had enough.
Decades ago, “we really were more worried, and needed to be more worried, about failure to thrive,” said Leann L. Birch, director of the Center for Childhood Obesity Research at Penn State. “Overfeeding seems to be more dangerous these days.”
Dr. Birch and Dr. Ian M. Paul, a professor of pediatrics at Penn State College of Medicine, are testing a multipronged intervention aimed at helping parents learn healthier feeding habits. This includes strategies for helping babies sleep longer — in part by responding to night waking with something other than food — and learning to identify those hunger and satiety cues. In addition, parents are counseled on how and when to introduce solid foods, and how to help babies enjoy new offerings.
In their pilot study, published earlier this year in the journal Obesity, the babies of parents who received this training were lower in weight-for-length percentiles — so the strategies seemed to work. But there are many unanswered questions, as pointed out in an accompanying editorial by Dr. Jack Yanovski, a pediatric endocrinologist and head of the growth and obesity section of the National Institute of Child Health and Human Development.
“This pilot study was a great beginning,” he told me. “The concerns all of us have is that we do it in a way that’s going to be effective and not too burdensome for families.” An obesity prevention intervention should work for children who are being overfed, but without slowing the healthy growth of other children.
For a long time, breastfeeding was thought to be protective against later obesity. That connection is now being questioned; other differences in social situation and behavior may account for some of the pattern. And in recent studies in other countries — Belarus and Brazil — breastfeeding infants did not seem to protect against later obesity.
And in any case, there need to be helpful strategies for mothers who choose to bottle feed.
“I don’t know that we as pediatricians do as good a job promoting responsiveness as we do promoting breastfeeding,” Dr. Taveras said.
Responsiveness is a helpful watchword. It’s easier for doctors to offer feeding advice to parents if we do it as a way to help them enjoy all the pleasures of tending their babies — holding them, cuddling them, singing and talking and reading to them, playing with them. We have to avoid scaring parents into restrictive patterns, subtracting pleasure from mealtimes, and casting blame.
Dr. Paul suggests that pediatricians also should explain those growth charts more carefully. It’s true that the charts now on my screen look so familiar and basic to me that I may not always take the trouble to discuss the nuances. Several studies show that parents from a variety of backgrounds and social classes all prefer to see their children growing at the high percentiles.
Dr. Paul recalled two educated parents whose child he had cared for. “They’re both small people, but when their daughter weighed between the 5th and the 10th percentile, they felt they were doing something wrong,” he said. “Percentiles on a growth chart are very different from percentiles in academic achievement, but almost all parents want their children to be above the 50th percentile on the growth chart.”
But of course, except in Lake Wobegon, it doesn’t work that way.
“Half the population should be below the 50th percentile, 10 percent of the population should be below the 10th percentile,” Dr. Paul said. “In most cases that’s healthy growth, and I think we do a disservice to the family by not explaining this clearly.”
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