Monday, June 20, 2016

Calorie Packing 101 - Part 3 - Big Kids

This is part 3 of a 3 part series on calorie packing.

Part 3 Calorie Packing For Bigger Kids

A nutritionist is generally going to first look to liquid calories first as they are easier to quantify.  Liquid calories are awesome, but sometimes REALLY hard to get into a stubborn kiddo (like mine).  If you can do liquid calories, fantastic.  There are a number of great options out there.  Smoothies and shakes are a great way to hide nutrition and calories in a quick drinkable form.  My favorite recipe page is the Golisano Children's Hospital recipe page.  In general, avocado, oils, nut butters, heavy cream (a little goes a long way), and protein powders are a great way to calorie pack any liquid shake.  However, you should talk with your nutritionist to make sure you balance how you add calories into your child's diet.  You don't want to overload their system (for example, too much protein can be hard on the kidneys).  Beyond home made smoothies and shakes, there are a range of high calorie commercial drink options.  First, of course, there is the ubiquitous carnation instant breakfast.  This standby is a pediatric goto for getting kiddos to up their calorie intake.  From there, you can get into some boxed drink options like pediasure, ensure, and boost.  The creamy type drinks can also be made into ice cream and shakes.  If your child doesn't like the creamy/milk based drinks, there are some commercial options for you as well.  Boost Breeze is a juice based option and comes in a variety case of 3 flavors.  Ensure Clear is another clear drink option which last I checked came in apple or mixed berry.

My child, of course, would have none of that easily quantifiable liquid calorie intake.  Instead, we were stuck with calorie packing our solid food offerings.  This is, to me a more difficult proposition. Especially if your child (like mine) won't take anything of a liquid or puree consistency.  In general, your calorie packing options for solid foods revolve around heavy cream, butters and oils.  We found, for example, that adding coconut oil to dole fruit cups would make them taste like pie filling.  Cheese is another great option for calorie packing.  My son's spaghetti always got an extra dose of olive oil and a large helping of cheese. For anything that uses eggs, you can add extra egg yolks, which is a great way to boost calories in baked goods.  In general, calorie packing in the solid food arena is all about unobtrusive additions of oils and fats.  My rule of thumb has been to add coconut oil to anything sweet and olive or rice bran oil to anything savory.

In my kiddo's case, we got pretty desperate to add calories, so I went into the full on medical calorie packing options.  The main options here are Benecalorie and Duocal.  I found that Benecalorie was pretty dang gross and for me, not much better than an oil when added to food.  Duocal on the other hand, was awesome.  We could send it to daycare so they could add it to his lunch.  Also, in small quantities (we found about a scoop per 5 oz water) it can add calories to water without really affecting the taste.  Every little bit counted, so "white water" became our goto drink.

In the end, one of our best tools has been Periactin as an appetite stimulant.  Periactin is an allergy medication that has a side effect of boosting appetite (it can also help with cyclic vomiting issues). Over time, the side effect of appetite stimulation wears off. We have found that taking one week off per month gets us the best bang for our buck.  The down side is that the first 2-3 days he goes back on Periactin are pretty miserable. He's tired and grumpy, and super hangry.  We get a lot of weight gain, but a few days of the grumps at the same time.

I found that the focus on eating has led to a lot of anxiety and stress over the whole eating and weight process.  My best defense has been to employ the Ellyn Satter Division of Responsibility in Feeding.  I have to be careful to find balance, because if I completely relax, he tends to stop growing, but if I pay too much attention, I make myself crazy.

I hope this helps, please let me know if I missed anything or if you have any questions.

Pumping to feed baby when you have to be away

Having to go back to work and the associated stress can really do a number on a mom's sense of well being.  Trying to balance the demands of pumping while at work can be a huge undertaking and lead to significant stress.  Often moms become panicked about their supply once they begin pumping and can physically see milk quantities instead of just breastfeeding and watching baby grow.

Generally speaking, your best bet is to pump at the times baby would normally feed.  Part of the Patient Protection and Affordable Care Act (Obamacare) worked hard to address the needs of nursing moms who go back to work.  The law provides for breastfeeding/pumping equipment to be provided through insurance (check with your insurer for details) and requires employers who fall under the act to provide adequate facilities and time so that moms can express breast milk for her nursing child (up to 1 year after birth).  You can read more details on federal breastfeeding laws here.

Moms are often shocked by the amount they express when they start pumping.  There are several factors at play that feed into their concern.  First, effective pumping will generally empty about 65% of the available milk, babies on the other hand will empty about 85% (on average).  Second, when baby is bottle fed in the traditional methods, they will drink about 25% more than they'd comfortably drink while breastfeeding, this can lead parents and caregivers to think baby needs more milk than is actually required per feeding.  Third, when mom is home, baby can be fussy and demand more time at the breast.  This is called cluster feeding and can be attributed to both a desire for food and comfort.  In my experience, when mom has been gone for a while, baby likes to nurse more frequently as a way to reconnect.  Babies may also choose to reverse cycle when away from mother during the day.  This means they will choose evening and overnight as their high demand eating time, instead of during the day.  They do this because they prefer to eat from mom and be with mom, it can be a bit exhausting sometimes, but it is all out of love.

Generally speaking, a mom who is away from baby can expect to express a total of 2-4 oz per pump session.  Because pumping will always remove less than baby can, this can lead to a tight supply of expressed milk.  There are a couple of tricks you can use to make sure there is adequate milk available for baby when you have to be away.  First, you can add a pump after the first morning feeding.  Because your prolactin level speak overnight, you generally have a lot more milk in the morning vs the evening.  By pumping off the excess after baby eats in the morning, you can add to your baby's stash during the day.  Second, if you can swing it, you can pump once more than baby would eat while you are away.  I have been told (and noted from personal experience) that your body will produce milk when it expects to be used, so a consistent pumping schedule will also help you achieve the results you are looking for.  Kellymom has a great article on how much milk is needed when you are away from baby.  You can read it here.  Kellymom is an amazing resource for all breastfeeding questions in general, if you haven't bookmarked it by now, you really shoud!

Another way to help ensure your baby has all the milk they need is to have caregivers practice paced bottle feeding.  Paced bottle feeding has many benefits, not the least of which is helping make sure baby doesn't eat and preventing flow preference issues that can make breastfeeding more difficult.  This is my favorite video for paced bottle feeding techniques.

Pumping is all about technique and mental cues.  The letdown reflex can be trained, which is something you can use to your advantage.  When I pump, I always have ice water with me and when I hear the pump's letdown sequence, I always drink seven swallows of water.  Over time, following that same routine helped my body cue that the sound plus the water meant it was time to release milk.  You can use any cue you'd like to achieve the same result. Here is a great article from Kellymom on working with letdown and cues you can use both for nursing and pumping.

Additionally, when you pump, you should use hands on pumping techniques to maximize milk expression.  This video from Stanford's Lucille Packard hospital is fantastic for learning hands on pumping techniques.   For me, I find hands on pumping practically impossible without a hands free pumping bra.  After years of pumping, I've found that the bra I like best is the Simple Wishes bra (now with even more awesome options such as all in one versions and more color choices!). I also hand express directly into the shield when I am finished pumping.  I can get as much as another ounce out by hand expressing using the marmet technique.

To make my work pumping life easier, I have several sets of pump parts.  I keep one at the office for emergencies (which has come in handy for myself and several of my coworkers).  I also bring all the sets of pump parts I need.  If standard breast shields aren't working for you, you may want to look into the pumpin pal shields.  If you need a hand pump, I'm hearing neat things about the Haakaa pump.  If you have a long driving commute, or suitable public transpo, you can also consider pumping en route using a battery pack, power bank, or rechargable pump.  Most of my links are for Medela products, which have been my sole experience (I own a Symphony and a Pump In Style Advanced (PISA)). But I've heard fantastic things about the Spectra system as well.  Note: Insurance provided the PISA, I bought the Symphony off of Craigslist.  If you buy off craigslist, be sure to get the Serial Number and call and check with Medela to make sure it wasn't stolen.

You can put your pump parts in a ziploc bag and keep them in the fridge between pumps, but I personally don't like the cold, so I prefer to have several pump sets and make my husband wash them, haha!  As far as drying pump parts, I really like the Boon's grass drying pad and accessories.  The trees are excellent for hanging the valves and the flowers are a great place to store membranes.  If you have your own office space, a small fridge may be a great way to keep your milk stored away from coworker lunches.

For more tips on breastfeeding in general, pumping, supply boosting, etc.  You can check out my post Breastfeeding Primer.  I also have more tips on pumping in my post about initiating milk supply with a pump.  If you've been exclusively pumping and want to transition to breastfeeding as well (or know someone in this situation) I also wrote a blog post on that topic.

Tuesday, January 19, 2016

Calorie Packing 101 - Part 2 - Medical Barriers

Medical Barriers to eating

In this post I'm planning to cover oral aversions, reflux and delayed gastric emptying, but mostly, reflux.  We had a bad round of reflux with C.  R was a bit unsettled, but it was mostly due to the neosure we added to her breastmilk 3x per day.  For the most part, R was a happy spitter, C was rather grumpy about the whole thing (and still is).

Please note, I am not a doctor, these are my personal experiences.  Please speak with your baby's medical team about your baby's particular condition as all children have unique circumstances that must be taken into account.

This is part 2 of a 3 part series on calorie packing.

Oral Aversions

By the time C was 10 weeks old, we'd established a pretty strong oral aversion.  He HATED eating.  Everything about the process, the effort, the feelings, the reflux, all of it made him (and us) miserable.  Eating was a 1.5 hour process that we undertook every 3 hours around the clock.  Our goal was to get C to ten pounds so he could have open heart surgery.  

Each time we needed to feed C, we'd rock him to sleep to dream feed (see section below on dream feeding for more information) which took about 30 minutes, then feed him using a 45 ml bottle with the slowest preemie nipple so he could better control the flow.  We'd have a second 45 ml bottle standing by for after he finished the first.  If we used a larger bottle than 45 ml, he'd be overwhelmed and unable to finish the bottle, even with the very slow flow nipple.  It took us the entire half hour allotted to get 75-90 ml into him.  Then we held him upright for about 30 minutes.  Then, an hour and a half later, we'd start all over again.  You can see why feeding was no fun for anyone and why C decided that food was no fun.

Oral aversions can occur for a host of reasons.  Extended periods without food by mouth, problems with the Suck-Swallow-Breathe action pattern, a lack of facial sensory stimulation, and procedures that result in pain in the face/mouth area (such as intubation, NG tubes, OG tubes, etc) can all contribute to oral aversions.   The University of Colorado has a great article on preventing oral aversions  I used many of these techniques in an attempt to mitigate the problems we were seeing crop up.  You can read more here:  Sense memory and muscle memory are powerful forces.  You must be diligent and use creativity to overcome negative associations with eating and facial sensory interactions.

After surgery, we worked a lot with his oral aversion.  We contacted our local early intervention program and they sent out an occupational therapist who was a feeding specialist.  She helped us find different ways to decrease the negative oral associations C had with eating and being around his mouth in general.  

We found vibrating teethers to be incredibly helpful.  C wouldn't use any type of cold teether, so this was the only relief he had while teething. It also gave great oral feedback and helped desensitize his mouth.

The baby fingertip toothbrush and training toothbrush set were also great ways to increase positive associations.  I especially liked the training toothbrush set because the guard kept him from choking himself and he was able to use it himself, giving him the control without risking negative outcomes. 

We're left with some lingering consequences to C's early eating experiences. To this day, he won't eat anything with a puree consistency, he won't drink anything but water, and he won't ingest anything that is freezing or close to it in temperature. His strong need to be in control of his feeding meant that we went straight to baby led weaning.  He still uses food as a means of control and has a pretty limited set of foods he'll eat at any given time. 

Dream Feeding 

Our best strategy for feeding C was dream feeding.  Dream feeding is when you feed baby while they are in a relaxed, mostly asleep state.  They still actively root for the bottle and actively suck, but their eyes are closed, they are relaxed and appear to be fast asleep.  Never force a bottle into the baby's mouth.  Make sure they accept the bottle themselves.  You don't want them to get a mouth full of milk and aspirate it because they are unprepared.  

Given C's rapid breathing, dream feeding became the only safe way he could eat.  While sleeping, his respiratory rate dropped enough that he was able to successfully eat about 75 ml per feeding (his goal was 90 ml).  

Here is an article with more information on dream feeding.

Delayed Gastric Emptying  (DGE)

Because cardiac defects tend to make the GI tract slow down and become less efficient, we had to deal with delayed gastric emptying.  This compounded our eating issues as C legitimately wasn't hungry most of the time when he was due to eat again according to the schedule. Bethanechol became our best friend.  It was one of the few medications C was eager to take, we knew it made him feel better and so did he.  If you are faced with DGE Bethanechol worked pretty well for us.  I'd be hesitant to try the other option out there Reglan, it has long term effects that are pretty scary.  


Along with DGE, reflux is practically a given with cardiac kids.  We do our best to manage it and mitigate the symptoms, but it is pretty miserable for everyone involved.  We made some handy environmental modifications that I wanted to share, as well as some meds that really made a difference.  The best purchase we made in the battle against reflux (and nasal congestion for that matter) has been our bed riser set.  I bought a set that could lift a bed either 3, 5 or 8 inches.  We used 1/2 the set for the crib, the other 1/2 for the pack and play.  They have proven to be invaluable in making both of our kids more comfortable when sleeping.

Additionally, after feeding our little refluxers, we were careful to always hold them upright for at least 30 minutes so that a good portion of the meal had digested and there was less sloshing around in there to make them miserable.

I learned a lot about H2 Blockers and Proton Pump Inhibitors while working through C's reflux. I had a number of concerns about using Proton Pump Inhibitors, as did my pediatrician and our GI doc.  So we stuck with H2 blockers like zantac to control C's reflux.  The trick with h2 blockers is that they are VERY quickly outgrown.  You should be ready to adjust the dose every week or 2 as baby gains weight if you want your H2 blocker to remain effective.

Back when C had reflux, I found a group called the Reflux Rebels.  If you are having issues with reflux, they are worth talking to.

In part 3, I will talk about calorie packing for bigger kids.  There is a whole world of options when you are calorie packing for a big kid!

Back to Part 1On to Part 3