Spitting up and Gerd.

 

If you are a new parent, comparing your situation to that of other new parents is rarely helpful.

But sometimes there is some comfort in knowing that you are not alone.

Reminding yourself that issues you are dealing with are fairly common, can be somewhat of a relief.

And if your baby has just thrown up all over the place, this one is for you.

Let’s start with some empathy from Nurse Judy:

All babies spit up. It is just a fact of life. Of course some of them do it more than others.

My oldest daughter Lauren rarely spit up. I simply didn’t need to pay much attention to the occasional ‘urp’

But as you will learn if you have multiple children, kids do things differently.

My younger daughter gave me a clear understanding of what so many of my patients were fretting about. Alana was a prodigious spitter. It was shocking to me how much this baby could regurgitate! I marveled that any of the milk was actually staying in, but fortunately she grew in leaps and bounds. She was enormous and never dropped her growth percentiles. Alana was the example of a perfectly happy spitter.

I wasn’t quite as blissful. I often didn’t bother changing my shirt unless there were 15 splots of spit up all over it; it simply wasn’t worth it.

My husband Sandy, the clean freak in our family, would follow after her with a spray bottle of Resolve carpet cleaner and a scrub brush, so that she didn’t completely ruin the carpets with the constant puking. (No, he isn’t for rent)

With large babies like Alana, sometimes the spit up is simply the overflow. I know that it is very hard to estimate how much milk your baby is actually spitting out. When I was working at Noe Valley Pediatrics, parents would call me all the time reporting that the baby seemed to spit up the entire meal and yet, there they were, gaining weight just fine. In most cases, the spit ups are not nearly as much volume as you think they are.

In Alana’s case, she ignored the rules, as she most often did, and didn’t slow down with her spitting up until she was seven months old. Most kids will slow it down long before that.

It’s important to distinguish between “reflux” (normal) and GERD (gastro-esophageal reflux disease).

Simple reflux describes what happens with almost all babies: they might be described as “happy spitters.”

This common spitting up resolves with ‘tincture of time’; all babies grow out of it, unlike the disease.

Dr. Ted reminds his patients there’s a light at the end of the tunnel:

Spit up often peaks around 3-4 months of age before it starts to spontaneously show signs of improvement in practically all children. So if things seem like they’re getting worse before they get better… you’re not imagining it. That’s a very normal part of the timeline. And no matter which interventions you try, whichever one you do at 3-4 months will seem like the ultimate cure.

On the other hand, GERD is actually a disease and as such shouldn’t be ignored. It is defined by reflux that seems to cause problems - poor weight gain, excessive fussiness with feeds, arching the back, coughing or sleep disruption linked to spit-ups. The spit-ups usually appear uncomfortable.

Here are some things it is helpful to know about spitting up.

When babies spit up it is not unusual for it to also come out of the nose. This can be scary. If they seem to be having a moment of difficulty when this happens, having a Nose Frida or aspirator handy will help you clear the nasal passages. I remind new parents to always know where it is kept so that you can easily grab it at the moment’s notice.

Once in a while you might note some blood in the spit up. To no ones surprise this tends to freak many parents out, but take a deep breath. Most of the time this is simply a symptom of mom’s sore nipples. There is a good chance that if the nipples are cracked at all, the baby might get a little blood when they are sucking. If it is persistent, there is a way for a lab to check the blood to see if it is from the baby or the mom.

As an aside, if your little baby vampire swallowed some blood during nursing it is also possible that you may see some of it show up in the poop. It will no longer look like fresh blood by the time it makes its way through the system but would more likely look very dark and tarry. If the baby seems perfectly fine, it is very unlikely that they have any type of active bleeding going on.

While most spitting up is fairly benign, projectile vomiting is something that warrants attention. There is a fairly uncommon condition called pyloric stenosis that usually shows up between 2-6 weeks of age. For some reason it is more common in little boys. There is no need to fret about the occasional more forceful spit up, but with pyloric stenosis it might remind you of the movie the exorcist. The spit up literally flies out of your baby and this happens multiple times a day and can land about 3 feet away from the body. Of course you never want to have anything wrong with your baby, but on the scale of things, this condition is very treatable with a simple surgery when caught early (so don’t ignore it). If untreated, it can lead to electrolyte issues and dehydration.

If it feels like your baby is getting thinner, regardless of how fussy they are, it is never the wrong answer to get a weight check! If they’re dropping percentiles they may need an intervention.

Here are things to try if your baby spits up a lot

These are appropriate for ALL spitters. They are also often the first step in managing a GERD diagnosis.

Feeding Strategy Interventions:

• Smaller more frequent feedings. This might look like doing multiple “snacky” small feeds during the day, especially in the latter half when the kids are generally more fussy. This might make it feel like you’re constantly feeding your baby, but it’s worth it. Better to spend your time feeding, than cleaning up vomit, or soothing a fussy baby.

• If you are bottle feeding, try something called “paced feeding.” This slows the flow of milk to mimic breastfeeding:

  • You hold the baby more upright (not flat)

  • Keep the bottle horizontal (not tipped straight down)

  • Let the baby actively suck to get milk, rather than gravity doing the work

  • Pause every ~20–30 seconds or every 1–1.5 oz to give breaks and burp

• Experiment with different nipples. You want the flow that causes the least air to be swallowed and delivers milk at a slow enough rate that doesn’t promote too much spit-up. There are also bottles out there that tout ‘less air’. There might be some trial and error figuring out what works best for your baby.

• Gently warming the milk in the bottle can impact the amount of spit-up. Dr. Ted recognized that his baby Ori was spitting up much more if the milk was cool. We don’t fully understand why this works, but if you notice a difference with your baby it is worth a try.

• Gravity helps! After the feed, keep your baby upright as much as possible. The recommendation calls for at least 15-20 minutes of upright time after a feed. That sounds reasonable enough until you actually try to be a rule follower. We recognize that in reality, that 20 minutes is a luxury that you just may not have and you’re lucky if you can get 10 minutes. Do the best you can and try for at least 5 minutes.

• There are some wedge pillows available that some parents find helpful. These are not safe to be used for sleep, but are fine for supervised awake time. Wedge pillows can keep babies in an up-angled position to help the milk to flow down.

• Some babies are very burp dependent. You will notice that if you aren’t patient enough to get a good burp, part of that meal is going to come back up. Other babies never seem to burp and have no issues. Nurse Judy’s favorite method is to move them from a flat position on your lap and flip them up and over your shoulder. Dr. Ted is a burp evangelist and has a library of at least 10 different moves to ensure an effective burp. Sometimes getting that bubble out includes some creative calisthenics.

• Pressure on the belly might make some kids spit up. That might come from a tight diaper (imagine trying to eat a Thanksgiving dinner while wearing spanx), or from tummy time on a hard floor right after a feed.

Dietary Interventions

• Breast feeding moms should see if there are any dietary factors that impact the spitting. This doesn’t mean you need to go on a full elimination diet right away (please don’t make your life harder than it already is). But if you start to notice a pattern, like more spit up, fussiness, or gassiness after certain foods, it’s reasonable to experiment with cutting one thing out at a time for a week or two. The most common culprit is dairy, but it’s not the only one. If you do try eliminating something, give it a little time, these changes aren’t immediate. And if you don’t see a difference, don’t be afraid to add it back in. The goal here is not perfection, it’s just seeing if there’s an obvious trigger that’s easy to fix.

• Probiotics may be useful. This is one of those “might help, probably won’t hurt” interventions. Some babies seem a little less gassy and a little more comfortable on them. Others may show absolutely no change. If you decide to try one, give it a week or two and see if you notice a difference. If not, no need to keep going. There’s no prize for the longest probiotic streak. When the issue is excessive spitting, we tend to reach for ones that contain Lactobacillus reuteri, which has a bit of data behind it in infants. But again, this is not a magic fix, it’s more of a gentle nudge in the right direction for some babies.

• Babies getting formula might improve using one of the sensitive formulas. Every formula reacts differently. Dr. Ted has noticed anecdotally that many of his patients do very well starting off with the Kirkland brand formula, but if your baby has reflux disease, most brands have a separate “sensitive” version. There are some very good specialty formulas to investigate as well, but they tend to be fairly pricey.

  Reminder: If you’re going down the formula rabbit hole, try not to change five things at once (we know…easier said than done when you’re tired and your baby just spit up on your last clean shirt). Pick one formula, give it a solid 5–7 days if you can, and see how your baby does. These changes take a little time, and switching too quickly can make it hard to know what’s actually helping. If things aren’t improving, it’s reasonable to step up gradually, from a standard formula to a “sensitive” one, and then to a more specialized option if needed. Most babies do not need the very expensive formulas, but there are situations where they can make a big difference. And just to say it out loud: if your baby is gaining weight and generally content, a lot of spit up alone doesn’t mean you need to keep switching formulas in search of perfection. Sometimes the best formula is the one your baby tolerates reasonably well… and that you can actually find at the store without stress.

Medical Interventions

If you have done 2 to 4 weeks of the above interventions and have seen no significant improvement it is time to make a plan with your doctor. Start the discussion and evaluation with a weight check, so an office visit is usually needed.

Your pediatrician may suggest thickening the feeds. To do this, start small with a teaspoon of oatmeal or rice cereal to 2-4 ounces of formula. This can help the milk stay down in the stomach a bit better. Keep in mind that a faster flow nipple might be required for the thicker milk. If you want to keep it simple, there are some formulas that are thickened with rice starch, such as Enfamil AR.

Medications are used as a last resort for babies that have a true diagnosis of GERD (reflux disease), not the happy spitters. If you’ve tried everything on the list above, and you’ve committed a good 4+ weeks to the behavioral and dietary interventions without good effect, medications can be considered if it is suspected that stomach acid is the cause of the reflux symptoms. These are the babies who are consistently arching, refusing feeding and or struggling to gain weight.

Medications are usually tried for a short window ( about 4-8 weeks) with the goal of using the lowest dose for the shortest amount of time possible.

If it’s not clearly helping, it is time to stop and rethink the plan. This might be time for a referral to a specialist.

Reminder:These medications are helpful in the right situation, but they’re not a magic fix—and most babies don’t need them.

Alternative approaches to consider

Traditional Chinese Medicine (TCM)

Nurse Judy asked her ‘go-to’ acupuncturist to weigh in on this topic.

Traditional Chinese Medicine (TCM) views spitting up and reflux as an imbalance in a baby’s immature and developing digestive system. TCM approaches are extremely gentle and safe, including some possible changes to feeding practices (that of a nursing parent and/or the baby), massage, warming the baby’s digestive system, activating specific acupuncture points (needles NOT necessary), and sometimes an herbal remedy for the nursing parent and/or the baby. Dr. Den specializes in pediatrics, and regularly works with babies experiencing a lot of spit up or reflux, and the relief can be tremendous, for both the baby and their concerned parents. Reach out to Dr. Den with any questions, or schedule an appointment directly through her website: The Acupuncture Den.

Chiropractic

While clinical data proving that this works is limited, anecdotally, Nurse Judy’s chiropractor Sandra Roddy Adams, says that she has treated many babies who appear much more relaxed following a gentle adjustment. She speculated that the all important vagus nerve is part of that equation, although there have been no studies to definitively prove this.

Random Extra thoughts

Skin folds

Kids who do a lot of drooling and spitting up can be prone to skin irritations in the skin folds of the neck and the area behind their ears. Make sure you do a daily skin check. Being proactive will work in your favor. It is much easier to prevent a nasty skin fold rash than it is to clear it up.

Sleep

Parents often express concern about the baby spitting up and choking if they are on their back. Fortunately, repeated studies are reassuring. Babies’ anatomy actually makes choking more likely when they are lying on their bellies.

So, even if they are frequent spitters, it is still strongly recommended that you place them on their backs when they are sleeping. The data backs that up!

You might have noticed this marvelous new model!

Introducing Ori Handler!

Mazel Tov to Dr Ted and his husband Chris!

The power of Storytelling

 

Happy Birthday to my mom, this one's for her!

My mom could go into a room full of chaos. “Once upon a time..” she would start in a steady calm voice.

It wouldn’t be long before everyone in the room was hanging on her every word; whatever they had been in a snit about a moment ago was forgotten.

She would then take her audience on a magical journey with a story that she often made up as she went. If it were a classic tale, you could count on her to take dramatic liberties. I don’t believe she told any story quite the same way twice. In her kindergarten classroom she would have her students shut their eyes as she told her tales.

“Use your imagination”, she would tell them. “I am thinking of a big black dog, he has 2 floppy ears. He also has 2 tails and 3 eyes!”

One distinct recollection of a time when mom’s storytelling saved the day comes to mind. Many years ago, my younger daughter Alana had several friends spending the night. In one of my bigger lapses in good “mommy judgement” I had rented a movie that I thought they would all enjoy. It turned out to be fairly dark and scary (always pre-screen, don’t rely on faulty memory of what may or may not be appropriate.) One of the girls started to cry and some of the other girls started to get sad and upset. While a few of them wanted to stop the movie, of course the majority wanted to keep watching. The situation seemed like it could go downhill quickly. Fortunately my mom was visiting. She took control, turned off the movie and started to tell stories. These weren’t toddlers; they must have been about ten. They sat raptly listening to story after story. The evening was saved.

I am my mother’s daughter.

If I happen to be taking a walk outside and see something unusual such as a pair of shoes sitting by themselves on a street corner, I can’t help but think to myself - Here is a story. How did those shoes get there?

I took a page out of my mom’s book, so to say, and used storytelling at work on a regular basis. I can’t even count how many times I would be called into an exam room where a crying, or cowering child was terrified of a ‘dreaded shot’. I would start my story:

“Once upon a time there was a patient who was so big. (How big was he)? He played football for his high school. He was bigger than me, he was probably bigger than the grown up in your house, he was really big.….and he was really scared of getting shots” .

At this point 90% of the kids would now be still and listening to me talk. Yes, they might have been huddled on their parents lap, or on the floor under the chair. They were probably not making eye contact, but I had their attention.

“He wasn’t afraid of getting bumped around on the football field but he hated shots. He was so scared of them that he would try to hide. He tried to hide inside the garbage can, but he wouldn’t fit..” Now 99% were listening and some were almost laughing.

From there I was able to start a dialogue with them about why we were giving the shot. “It is magic protection so that if certain germs get inside of your body, you won’t get sick.” We talked about the fact that we wished there was a less yucky way to get the protection and that it was really normal for lots of people to be scared of shots. We talked about the fact that sometimes being brave is simply trying hard to hold still and it is still really okay to cry and yell if they need to. As soon as they were ready, my medical assistant Josie (the best shot giver in the country) had already gotten it done.

It all started by engaging them with a story.

Books are wonderful too, but in truth, they also are not quite the same as a story. A story is yours to tweak as you please. Stories are powerful mediums for working through issues.

Folks who have asked me for parenting advice over the years know that using stories is a favorite tool. For as long as I can remember I have been counseling parents to create a fictional child of a similar age. Talk about what that parallel child has been going through. This tends to be a very non threatening way to talk about all sorts of issues.

These stories are great ways to launch into a dialogue about all sorts of positive and/or negative ways that the protagonist can deal with a variety of situations. This is an excellent problem solving technique.

Once upon a time there was a little girl who had an ‘owie’ ear. The doctor had given her some medicine to make it better, but when she tried the medicine it tasted yucky….

Once upon a time there was a little boy who kept getting out of bed at night……

Once upon a time there was a little person who get really upset when he didn’t win a game…….

You get the idea.

When I was working on the original version of this post, I mentioned the storytelling theme to one of the wise mamas in my life. She immediately referred to these as “Annie Stories”. That was written back 1988 but the concept is pretty timeless.

Now I am retired from the office job, I am no longer giving shots, or routinely giving parenting advice, but I have a much more important role as Grandma and the story telling continues.

My oldest grandson Elliot and I created a very naughty child named Melvin.

(I had an Uncle Melvin who was quite nice, so I am not quite sure about how this name came about, but Melvin he is)

Melvin gets into all sorts of trouble.

He puts stuff in his nose and ends up at the doctor

He refuses to put on shoes and steps on all sorts of things, the sharper or yuckier the better.

One night he refuses to get into bed unless his favorite spider man sheets were on the bed, but oh wait! Those ones got accidentally peed on previous night and were still in the laundry…..

At his insistence mom puts the pishy sheets back on. They smell like pee.

Melvin decides that perhaps he will sleep in the clean batman sheets after all.

The stories can get pretty convoluted, but EJ can’t get enough of them.

Not everything has to have a purpose. Sometimes stories are just for fun.

Sometimes you can start one and then take turns telling it and see what direction it takes.

Or you can ask your kids it to pick 2 or 3 random things to include along with a certain feeling; an umbrella, a goose and someone who is nervous…go!

Our kids these days are both blessed and cursed with the enormous choices of digital wonders. I am not opposed to limited use of regulated tech time, but it should not be in place of plain old imagination.

Go ahead and ‘power down’ and be thankful for the magic moments that you capture as you snuggle with your kids and simply tell a story. “Once upon a time......

Passover Musings 2026

 Passover is the holiday that celebrates the story of the Jewish people escaping from slavery in Egypt.

This year it is celebrated in the first week of April.

The ritual dinner is called a Seder. For me the Seder is all about tradition. I feel the connection with generations past, through the story and the songs that have transcended thousands of years.

I keep in mind that many people of the Jewish faith over the centuries risked their lives to have a seder when they were living in places where simply being identified as a Jew could be a death sentence.

It is also tradition for my husband to point out that the entire story is most likely completely fabricated, at which point I counter that the accuracy of the story isn’t what it is all about.

It is about gathering with family, celebrating Spring and freedom, and having discussions about how we can end oppression for everyone!

This holiday has certain smells that embrace me as I am preparing for it: Matzo Ball soup, horseradish, Manischewitz wine, apples and walnuts chopped up to make something called charoset that is meant to represent the mortar that the slaves used. I can feel the presence of my mother and grandmother as I putter in the kitchen.

On October 27, 2018, the Tree of Life synagogue was attacked. Eleven people were killed simply because they were Jewish. Many others were injured.

The Tree of Life synagogue happens to be less than a mile away from my childhood home in Pittsburgh Pennsylvania.

While I did not personally know any of the people who were killed, I knew many people who were directly connected to those who were impacted.

The daughter-in-law of one of the victims emerged from the ashes of this tragedy with the agenda to make a difference.

In memory and honor of her mother-in-law Joyce Feinberg, she created a program called 2 to the Seder, with the goal that Jewish people who were having the traditional Passover dinner invite at least 2 people to join them who were NOT Jewish.

In her words, her goal was to push back on antisemitism with love.

If people from different backgrounds can allow themselves to open up just a bit to connect with one another, might this help?

There is too much hate and prejudice in the world. We need to teach our children to do better. This idea completely resonated with me. The April following the shooting we opened the doors to our Seder. We were honored to have Muslims, Christians, Buddhists, Hindus, Amish, quite a few atheists. and of course some Jews. The conversations that we had that evening were fascinating.

Seven years have passed. Our seder next week won’t be quite as diverse but will still be attended by people of various faiths.

On the bright side, I have a son-in-law who’s soup gets accolades as the ‘best ever’ so I happily delegate that task. I am also a grandmother which shines a brighter light on everything.

While frankly eating matzo and drinking the traditional cloyingly sweet wine is fine for once a year, talking about freedom and oppression should NOT be a topic for just one night. There should not be an ‘Oppression Olympics.’

Antisemitism and bigotry are not just reserved for Jewish people. I understand that I have the privilege of being able to ‘blend in’ if I chose to, while many people of color cannot.

Until everyone can be outside without fear of being belittled or harmed because of who they are, we have work to do. There are so many differences, races, faiths, genders, ages, sexual orientations, abilities, personalities…..

Underneath, we are human beings, mothers, fathers, siblings, grandparents, family members, friends, community members. We need to celebrate the differences instead of attacking them.

Happy Passover to all who celebrate.

Let us all put positive energy out into the world and pray for peace.

A Haunted Hotel Room and a toothbrush

 One of the things that I find amusing is watching Sandy’s evolution in regards to his acceptance of the strange energies that seem to surround my family.

He started out as a flat out denier.

That all started to change after my father died in 2007, but I will save those stories for another time.

Sandy now seemed to accept that there were some things we couldn’t quite understand, but his baseline was still to try to find some scientific explanations for some of the strange goings on.

This following story from my book was one of the things that he couldn’t explain away.

It was 2010. Sandy, Alana and I were in Florida visiting Sandy’s mom. Lauren wasn’t able to join us for that particular visit.

Our hotel room had two double beds. It was the first night of our trip.

After testing all of the pillows (Loyal readers may recall that my youngest daughter is the pillow princess) and negotiating who got to claim the best one, Alana got herself settled in bed. She had her laptop all set up, with plans to stay awake a little bit longer than we were.

She announced, “Okay, you can turn off the light now”. The moment she said that, before either of us had made a move for the switch, the light shut off. Aside from the small glow from her computer, the room was pitch black.

“Who did that?” we asked.

“It wasn’t me!!” she replied from the dark.

Okay, well thank you I guess

The next morning when we went into the bathroom, we noticed something strange.

In the glass where three of us had placed our toothbrushes, now there were four. None of us could come up with any reasonable explanation where an extra toothbrush had come from.

At least our hotel spirit had good oral hygiene?

This may have been the point where Sandy gave up and just shrugged his shoulders.

The Milk Transition/ Calcium requirements

 

What is calcium and why is it important

Let’s start with the basics: calcium is one of those behind-the-scenes nutrients that doesn’t get much hype, but it’s doing a ton of essential work for our body. Most people think of calcium as “the bone stuff,” and that’s true; it’s a major building block for strong bones and teeth. But calcium also helps your muscles move, your nerves send signals, and your heart to beat normally. In other words, it’s not just about skeletons. It’s about keeping the whole system running smoothly.

For babies and kids, calcium is especially important because their bodies are growing at warp speed. They’re literally building bones from scratch, and that early foundation matters for the rest of their lives. Getting enough calcium in infancy and childhood helps support healthy growth now and stronger bones later on. The reassuring part? Nature and modern nutrition make this pretty doable. Breast milk and formula are designed to meet babies’ needs early on, and as kids grow and their diets expand, calcium just becomes one more important piece of the overall nutrition puzzle.

Calcium Needs for infants

The calcium requirement for 0-6 month olds is 200 mg/day; for 6-12 month olds it bumps up slightly to 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 quite ‘bioavailable’ meaning that it absorbs very well. Formula also has enough calcium to meet these needs.

A note on Cow’s Milk Protein Allergy

A small subset of babies will show signs of a cow’s milk protein allergy in the first few months of life, often around 2–4 months, but sometimes even earlier. This can look like persistent fussiness or pain with feeds, lots of spit-up or vomiting, blood or mucus in the stool, eczema or rashes, and sometimes poor weight gain. For breastfed babies, symptoms can still show up because tiny amounts of cow’s milk protein can pass through breast milk if a parent is consuming dairy; for formula-fed babies, it may become obvious soon after starting a standard cow’s-milk–based formula. If you’re seeing these patterns, it’s worth flagging for your pediatrician so you can make a plan together.

The really reassuring news - most babies with cow’s milk protein allergy outgrow it. The vast majority tolerate dairy again by late infancy or toddlerhood as their gut and immune system mature. In the meantime, there are great options (like hypoallergenic formulas or temporary dairy elimination) that keep babies comfortable and growing. This is one of those early-baby bumps in the road that feels huge in the moment, but for most families, it’s temporary.

4-7 months

At this age milk is still key. Until your little one is 6 months old, the only thing they technically really need is milk. Offering solids at this age is just for fun and exploration. The exception is a situation when allergens are recommended for some infants before 6 months due to risk of allergies. If you have more questions about solid foods, we did a huge post about this last year.

While it is fine to carefully introduce milk-based products such as cheese or yogurt to your children once they are over 6 months, cow’s milk lacks the correct balance of nutrients to be an appropriate substitute for formula or breast milk for kids under a year. To emphasize: limited cow’s milk products are fine, it just shouldn’t be the main nutritional source at this age.

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

We 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 common sense strategies.

Does your little one strongly prefer milk? Offer some solids first, before they fill up on the milk.

Are they only interested in solids? Offer the milk first.

But don’t let this drive you too crazy. 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! Calcium recruitment jumps up from 260 mg to 700 mg/day. At this age it is fine to expand your milk options.

Here are a few common questions and talking points

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. The only downside to formula at this age is the expense.

Do you need a toddler formula? We don’t think so. Toddler formulas are designed to help bridge the gap between infant formula and regular milk. We have never really seen the need for this step and 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

A lot of parents ask us, at one-year-old, “ok, so now that they’re one we have to switch to regular cow’s milk, right?”

Wrong.

Humans didn’t evolve a dependence on the bovine species. We have a need for calcium, vitamin D, fats and proteins. Whole fat cow’s milk just so happens to be an easy way to get those things, but it’s not the only way. Some kids skip milk altogether in favor of cheese and yogurt, or vegan options, and that’s fine.

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. Nurse Judy’s older daughter got a terrible flare up of eczema when she first switched her over to cow’s milk. They put her back on her formula for a couple of months and when they tried the milk again, she seemed to tolerate it just fine. We don’t have any clinical understanding for why this happened, but we have seen it happen with other patients over the years.

Do you need to offer whole milk?

This society is so conditioned to think that fat is bad, but your child actually needs all of that fat for their brain development. But if they are getting fat from other sources like full fat yogurt and cheese, it is fine to compromise and do 2% so that your fridge isn’t overrun with so many milk options.

The AAP has historically suggested moving all kids to reduced fat milk at 2 years, but this isn’t a hard and fast rule and can be assessed based on your child’s growth and needs.

Do you need to spring for Organic?

Our bias leans toward organic (we are skeptical of the hormones and antibiotics in non-organic milks), but there’s no good consistent evidence that organic milk leads to better health outcomes for kids.

What about raw milk?

Big NO From Us

Here, the studies are clear. Raw milk comes along with health risks. We would avoid it. The purported health benefits have not been consistently shown, they are theoretical and not worth the risk of E. Coli and Listeria.

Vat pasteurization seems to be safe.

What on earth is 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. 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 we 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. Nurse Judy rolled her eyes when it first came around, but she confessed that she has 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-story

Non dairy milk alternatives

The array of plant based dairy alternatives has exploded over the last several years. Although the dairy industry did some grumbling about sharing the name, the FDA ruled that they are indeed allowed to call themselves milk. Fortunately, they are simultaneously mandated clearer labeling.

Below is a good guide to some of the popular options out there. There are big variations among the choices and these numbers vary by brand. If you decide to skip cow’s milk altogether, you won’t get a lecture from us 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.

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.

Lets dive a little deeper into some of the nutritional considerations

Protein:

It is important to note that not all proteins are created equal.

Cows milk contains essential amino acids – the “building blocks” of protein – that our bodies need.

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 children 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 protein, 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. The Vitamin D Post here has a chart with the amount of vitamin D from different foods.

Keep in mind that calcium absorbs better with Vitamin D so if you chose to supplement with vitamins try to take them together.

Iron and Milk

Iron isn’t something that you are going to be getting from most milk sources, but it is so important that we want to include some considerations in this post.

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. In fact, as we discuss below, cow’s milk is notorious for actually blocking the absorption of iron. 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.

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.

Is there such a thing as too much milk?

It is not uncommon for our 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 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 anemic. 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 Tidbit

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 (far over 36 oz per day), every day, with very little other food sources, except 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 science 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

We personally don’t feel the need to be completely off of the bottle at 12 months. Until 18 months or so, we are perfectly fine with a snuggle bottle when first waking up or going to sleep.

But please 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. We couldn’t tell you why, but we 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.

• Experiment with the temperature. 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.

What about Calcium Supplements? Tums?

For most adults, the goal is to meet calcium needs through food first, with supplements used only to fill in the gaps if diet falls short. If you do supplement, smaller doses (like 500mg - 600mg per dose) work better than one big dose, and pairing calcium with enough vitamin D helps with absorption.

Specifically, we recommend against the regular use of Tums for calcium supplementation. While Tums does have calcium in it, it also suppresses stomach acid. If done regularly, it can cause rebound acid production in the stomach (ouch).

With a little planning, getting enough calcium should be reasonably easy.

Reference Section

High-Calcium Foods (per typical serving)

Note the spike during the growing years. If you have a teenage boy who seems to need a new pair of pants every 3 weeks, this will make perfect sense to you.