Milk requirements |
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For the first 6 months, it's all about the milk.
Solids from 4-6 months are just about exploration. Until your little one is 6 months old, the only thing they really need is milk. Everything else is just for fun. While it is fine to carefully introduce milk-based products such as cheese or yogurt to your children once they are over 6 months, until that first birthday, cow's milk is not an appropriate substitute for formula or breast milk. It lacks the correct balance of nutrients. When you do offer dairy products for the first time, watch carefully to make sure they don’t have any reactions (such as diarrhea or hives). From 7-12 months ideally your baby has a mix of milk ( breastmilk or formula) plus solids. I recognize that many parents stress about the exact balance of milk and food. The truth is, while milk is much more important for the first six months, at this age, there are no exact ratio requirements between milk and solids. Some kids are so excited by real food and others still prefer their milk. Your job is to offer both. There are some simple tips. If you are trying to increase the solids, offer those first and vice versa. As long as the baby is happy, growing, sleeping, pooping and peeing you can likely trust them. If your baby isn’t growing well then at that point it is worth checking in with your pediatrician to make a firm plan. Blink and they are a year old! Once they are a year it is fine to expand your milk options. Are you still nursing? Great! There is nothing like breastmilk. Don't be in a rush to stop. For those moms who are able to continue to breastfeed beyond the first year, that magical breast milk feels like a godsend if your child doesn't feel well. Not only is nursing a comfort, but breastmilk is great for tummy bugs, eye issues and all sorts of stuff. Do you have a huge stash of formula left over? Great! Feel free to use it up. Do you need a toddler formula? I don’t think so. Toddler formulas are designed to help bridge the gap between infant formula and regular milk. I have never really seen the need for this step and I have seen many kids get constipated from some of the brands. If you do opt to go in that direction, make sure you keep an eye on the poops. Dairy Milk Choices and considerations Most kids who were on a milk-based formula have no trouble moving on to cow's milk. It is fine to do it gradually so that they get used to the taste (add a few ounces to the formula and see how they do). Intolerance will likely show up as tummy aches, poop changes or rashes. My older daughter got a terrible flare up of eczema when we first got her on milk (Eczema post). I put her back on her formula for a couple of months and when we retried the milk she seemed to tolerate it just fine. I don’t have any clinical understanding for why this happened, but I have seen it happen with many other patients over the years. That first year, Most pediatrician will recommend that kids get whole (full fat) milk. Once they are two, if they are growing well and eating lots of cheese and yogurt it is okay to switch to 2% if you like. We are so conditioned to think that fat is bad, but your child actually needs all of that fat for their brain development. Do you need to spring for Organic? My bias leans toward organic, but there are NO studies showing any clinical significance. What about raw milk? Here, the studies are clear. Raw milk comes along with some health risks. I would avoid it. Vat pasteurization seems to be safe. A1/A2 milk If you thought that the main choices about cow's milk were organic or fat content, think again. Along comes the choice between A1 and A2. Huh??? It turns out that there are indeed two kinds of cows out there (don't worry, there won't be a test on the following paragraph). A1 and A2 beta-casein are genetic variants of the beta-casein milk protein that differ by one amino acid. The A1 beta-casein type is the most common type found in cow's milk in Europe (excluding France), the USA, Australia and New Zealand. This is what most of us have grown up drinking. African and Asian cows are predominantly A2 cows. Milk from goats and humans contains only the A2 beta-casein. There was a lot of buzz about this when I first wrote this post several years ago. The claim is that folks who have trouble with our common (A1) milk may in fact be able to tolerate A2 milk without any issues. I rolled my eyes when it first came around, but I confess that I have had some patients with milk intolerance who seem to do better on the A2 milk. In the past years, A2 milk has become more widely available at many grocery stores and doesn’t seem to be all that more expensive. For those of you with milk issues, it is worth checking out. https://www.a2milk.com/our- Non dairy milk alternatives The array of plant based dairy alternatives has exploded over the last several years. Just this month, February 2023, the FDA ruled that they are allowed to keep including the name milk. The new ruling also requires better labeling. Here is a good guide to a lot of the options out there. There are big variations among the choices. If you decide to skip cow's milk altogether, you won’t get a lecture from me as long as you are paying attention to the nutritional components. The key is making sure that your kids are getting adequate amounts of protein and calcium. Nutritional considerations Protein and Amino Acids - Milk is a great source of calcium, protein, vitamin D and the fat that your child needs for brain development. For those who can tolerate it, dairy milk is a complete source. It contains essential amino acids – the “building blocks” of protein – that our bodies need. It is important to pay attention to the fact that not all proteins are the same. Except for soy milk, the protein in most nut or plant-based milk substitutes is incomplete, meaning it's lacking in some of these essential amino acids. Since your body can’t produce essential amino acids on its own, it has to come from the choices you make in your daily diet - like dairy or soy milk. If you have a hard time getting your child(ren) to drink milk, it is important to make sure they are meeting those nutritional needs through other sources. If you choose to use a milk alternative such as goat, soy, rice, almond, coconut or pea (seriously, there is a wide array of choices) read the labels and see how they compare. Vitamin D - After age 1, kids need 600 IU of Vitamin D per day. In general: having the milk fortified with vitamin D is a bonus, but many kids either need a multivitamin supplement or a lot of high vitamin D foods. Milk fortified with vitamin D has 100-150 IU per cup, so if you’re sticking to 3 cups of milk per day as a maximum (see above) you’re only getting 300-450 IU daily. The rest needs to come from elsewhere. The best source is a bit of sunshine, but that comes with its own risks. Calcium - The calcium requirements for 0-6 months / is 200 mg/day and for 6-12 month is 260 mg/day. Very little thought or effort is needed to make sure they get enough at those ages. Babies who are growing well and feeding within the normal range will have no trouble getting their calcium needs met. The calcium in breast milk is very ‘bioavailable’ meaning that it absorbs very well. Once they are a year old, that calcium recruitment jumps up to 700 mg/day With a little planning, getting enough calcium should be reasonably easy especially if they are eating cheese and yogurt. Calcium absorbs better with Vitamin D. See the chart below for a list of good calcium rich foods. Iron Iron isn’t something that you are going to be getting from most milk sources, but it is so important that I want to include some considerations in this post. If your little one is a picky eater, some physicians like to see a blood test result showing that the baby has an adequate hemoglobin level( a proxy for iron) before leaving the formula behind. Cow's milk does not have as much iron as formula, so it is important to make sure your little one is getting iron from other sources. Iron is such an important but tricky nutrient. It absorbs much better with high vitamin C foods. Take a moment to review the Iron Post from several years ago Is there such a thing as too much milk? It is not uncommon for my little patients who are ‘milkaholics’ to be anemic. Due to its high casein and calcium content, excessive cow's milk can block the absorption of the non-heme iron in the gut. This is even more of an issue for a vegetarian diet. At the same time, kids who fill up on milk instead of eating other foods with wider nutritious content can become even more. This is why, with your toddlers, ideally keep milk intake under 24 ounces per day. One more reason to pay attention to this? Anemic kids often have sleep issues. Cutting back on the milk can be an easy fix. Dr. Ted’s Research The 24 oz per day milk limit is a tough concept. Every gut is different, and kids have wildly different needs based on their diet. What’s with all the fuss? To add some scare to your milk motivation: I’ve seen milk-induced anemia in action. I’ve had patients that have wound up in the pediatric ICU with dangerously low hemoglobins that needed blood transfusions. Why does this happen? In the child that I’m thinking of, they subsisted on essentially only milk (well over 36oz per day) every day with very little other food sources, basically bread. There are a couple of theories as to why this happens. It’s known that cow’s milk can lead to increased intestinal blood loss (we all bleed a little into our guts, milk just makes us do it more). That blood takes iron with it. At the same time, studies have shown that unmodified casein protein in cow’s milk, as well as calcium, have the potential to bind with iron and limit its absorption, but mostly for none-heme iron (aka iron that’s not from meats or animals). There’s still some ambiguity in these guidelines, but use the above research to direct how you approach nutrition. If you have a total milkaholic, the occasional 30oz day is ok if you pair it with hamburger meat. If you have a picky carb-atarian who skips meat, it might make sense to stick to the 24oz or under guidelines. From Bottle to Cup I personally don't feel the need to be completely off of the bottle at 12 months. I am perfectly fine with a snuggle bottle when first waking up or going to sleep until 18 months or so, as long as you keep this important rule: NEVER leave a bottle of anything other than water in bed. If a child falls asleep and keeps the milk bottle in their mouth it will risk tooth decay. After a year, try to transition most of the fluid intake to a cup. Once you start moving away from the bottle and transitioning to a cup you may find that your child doesn’t take in nearly as much milk. I couldn't tell you why, but I have seen it over and over again. Milk in a cup just isn’t as comforting. Some parents like to hold on to that bottle option just to make sure that their kids are getting at least some milk every day. In any case, once you lose the reliable amounts of milk that you used to count on from the bottle, it becomes even more important to pay attention to other sources of calcium. If your little one is two and has managed to convince you that the bottle is essential, it is time for an intervention. It is time for that bottle to disappear. Consider making a big production about “gifting” all of your bottles to someone else’s baby. At the same time go out and pick out a special ‘big kid’ cup. Sippy cups are not the best option. Straw cups are preferred. Extra little tricks If you are trying to encourage your child to drink the milk from a cup, try adding a few drops of vanilla. Some kids might like it better warm. You can also try frothing it. Consider making smoothies with milk as the base. Kids like adding things into and turning on the blender. As you are reading those labels, watch out to make sure you aren't getting a sweetened version that is adding all sorts of extra sugar. We want kids at this age to be getting at least 700 mg of calcium per day. You can see from the chart below that this should be reasonably easy if they are eating cheese and yogurt. Yogurt 1 cup 400 mg Soy milk 1 cup 299mg Dairy Milk 1 cup. 300 mg Cheddar cheese 3 ounces 325 mg Tofu 1/2 cup 200 mg Mozzarella cheese 1.5 ounces. 275 mg Fortified OJ. 6 ounces. 200 mg Kale. 1 cup cooked. 95 mg Ice cream. 1/2 cup 85 mg Almonds. 1 ounce 75 mg Broccoli. 1/2 cup 21 mg Corn tortilla. 1 small 42 mg Chia Seeds. 1 Tablespoon. 76 mg |
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