Online Health Chat with Mona Rifka, MD

August 15, 2012


Cleveland_Clinic_Host: Did you know that your baby is growing approximately one inch per month from birth to six months of age? From the very beginning, infants need proper nutritional support to assure appropriate physical growth and development, as well as maintaining a strong immune system. During infancy, nutrition can have a considerable effect on health, as well as on the ability to learn, develop, communicate and socialize. Infants and children who fail to get the right type or amount of calories and nutrients are at risk for malnutrition, which may cause a number of growth and development issues. Nutrition is crucial in a baby’s first year of life, as well as when the infant grows at his or her fastest rate. Infants will generally double their birth weight after six months and triple it after one year.

The choices parents make about their baby’s eating habits may have a lifetime impact on their child’s health. Improper feeding and inadequate nutrition can affect your child’s development and growth. Because of this, parents may be asking:

  • ‘How much food does my child need?’
  • ‘Is he or she getting enough calories and nutrients?’
  • ‘When is the best time for my child to start consuming solid foods?’

Parents naturally want what is best for their child from the very beginning. That is why proper nutrition from newborns to infants can be a confusing and frustrating topic to parents. Whether you’re a mother whose child is 5 weeks old or 5 years old, the Cleveland Clinic can answer your questions to help make the nutritional transition easier for you and your child.

For More Information

Cleveland Clinic Children's Hospital has a staff of more than 50 pediatric primary care physicians who serve the healthcare needs of newborns, infants, children and adolescents at convenient locations throughout northern Ohio. Our pediatric physicians offer comprehensive general and preventive care, as well as care for children with complex or chronic health issues. With access to leading-edge diagnostic and treatment resources, as well as a total commitment to family-centered care, our pediatric professionals are well-equipped to diagnose and treat common, everyday illnesses, as well as serious childhood diseases and conditions like cancer, diabetes and attention deficit/hyperactivity disorder.

For Appointments

If you would like more information on the Cleveland Clinic Children's Hospital, pediatrics and nutrition visit us online at To make an appointment with any of our pediatricians or pediatric specialists, please call 216.444.KIDS (5437) or call toll-free 800.223.2273, ext. 5437.

About the Speakers

Mona Rifka, MD, is a primary care pediatrician for Cleveland Clinic, and is board-certified in pediatrics and neonatology. With specialty interests in newborn care, breastfeeding and nutrition, Dr. Rifka helps parents meet the everyday nutritional needs of their children.

Dr. Rifka completed her fellowship at Baylor College of Medicine, in Houston, Tx in 1995, and has been with the Cleveland Clinic since 2007. She currently sees patients at Cleveland Clinic's Hillcrest Hospital.

Let’s Chat About Early Childhood Nutrition

Cleveland_Clinic_Host: Welcome to our Online Health Chat with Cleveland Clinic specialist Dr. Mona Rifka. We are thrilled to have her here today for this chat on Early Childhood Nutrition: From Liquids to Solids. Let’s begin with some of your questions.

Breast Milk and Formula
claytonp: Is it OK to give my baby breast milk and formula?
Dr__Rifka: Yes, as long as you don't mix them together in the same container (bottle).

iop: How long can mixed formula keep in the refrigerator? And how long can a bottle stay at room temperature?
Dr__Rifka: Mixed formula (reconstituted powder formula) can keep fresh in the refrigerator for 24 hours, only if it has not been touched or fed to baby. A bottle can stay out only one hour.

nogo: If formula is left over, can I offer it again?
Dr__Rifka: If it is placed in refrigerator and the bottle is covered, it would not keep for more than three hours.

full_tilt: Is it OK to mix some cereal in the bottle, especially at night, so that my baby is fuller and sleeps a little longer? Someone told me to never do this.
Dr__Rifka: Usually we discourage this, since it can commonly cause inappropriate weight gain, as well as a lack of desire for the regular bottle by the baby after being exposed to the extra food. It also can cause constipation. This used to be used to help the baby with reflux, but it is not as popular anymore.

Pinky123: How long will breast milk keep if you pump? Can you freeze it?
Dr__Rifka: You can freeze breast milk for six months. Once pumped, you can store it in the refrigerator for 24 hours


Medicine via Bottle
Joanie: If I have to give my baby medicine, is it OK to put it in the bottle when I feed her?
Dr__Rifka: No, that is not recommended as almost always the bottle is not entirely ingested and some medicine is left in it. Also, your baby usually takes some time to drink a bottle, and so the medicine will not reach its appropriate peak as needed.


Feeding on Demand
jolot: My baby seems to want to eat all the time. Do I feed him when he is hungry, or do I set a schedule and keep to it? He is 14 months old.
Dr__Rifka: He needs to be eating three meals a day and two snacks along with three 8 oz cups of milk. Keeping him on this schedule will be helpful. Having said that, some kids are 'grazers' and don't eat full meals at a time, but small quantities all day. That's fine as long as his growth parameters are adequate for weight and height, so check with you pediatrician on that.


Newborn Hunger
playtime: I am going to be a first time mom and I am concerned that I will not know the difference between a hungry baby and a sleepy baby. How will I know when my baby is hungry?
Dr__Rifka: A baby who is hungry will not stop crying with any soothing techniques, whereas a baby who is sleepy will respond to holding, rocking, swaddling, etc. Hunger crying only stops when you feed the baby.

Transitioning to Cow’s Milk
spector: At what age can babies switch from breast milk or formula to cow’s milk?
Dr__Rifka: At 12 months, full-fat regular milk with vitamin D is ideal, if there is no intolerance.

usure: At what point is it OK to switch a child from fattier milks to low-fat or non-fat milks?
Dr__Rifka: The recommended age is two years. You can go down to skim milk at that point if needed.

powders: When do you typically recommend that parents switch from a bottle to a sippy cup? I am concerned that I have waited too long since my son is now 18 months.
Dr__Rifka: The recommended age is 12 months. Usually, the longer you wait the harder it gets. It does take time, so if you start at 12 months usually the baby will be bottle-free by 18 months.

good_guys: I’ve heard that too much cow’s milk consumption can lead to an iron deficiency in children, is that true?
Dr__Rifka: If the child is drinking too much milk, then they are probably eating fewer solids. Since milk is poor in iron, it is taking the place of nutrients that potentially can be an iron supply.


New Food Introduction
enough: My sister just started giving her three-month-old applesauce and rice cereal. My daughter is just two weeks younger than hers, and I am wondering if I should be introducing solids soon, too. What do you think? What are the typical ages or signs that you should be switching to more solids?
Dr__Rifka: If a baby is exclusively breastfeeding, six months is the usual age for solid food introduction. Otherwise, four months is the ideal age. Two and a half months is a bit too early for several reasons—tolerance, choking, etc.

mclaypool_2: Does the order of food that is introduced to my six-month-old matter?
Dr__Rifka: Introducing cereals first, then vegetables and then fruits is the most desirable order. Do not introduce more than one new food at a time. Give the new food three or four days to see if there are any signs of intolerance.

dolly: When is it OK to start giving a baby juice to drink, and how much can they have? Someone told me that it should be limited, but I thought like apple juice or grape juice would be good? My daughter will not drink water, and is it OK to give them water?
Dr__Rifka: Juice is not a necessary part of any baby's diet. If you choose to give it, once a day is plenty. Water should be offered once your baby starts eating solids, and does not need it before then—except if very hot day and you are out in the heat.

b_one: When is it OK to start giving a baby frozen or cold foods, like ice cream?
Dr__Rifka: The issue is not that they are frozen, but what they consist of. Babies do not usually tolerate dairy products, like milk or ice cream, before 12 months of age, so I would not expose dairy much before that age.


Early Childhood Nutrition
jodo: I typically give my toddler three meals a day with a snack in between breakfast and lunch and lunch and dinner, is that too much? How much should a three-year-old child be taking in?
Dr__Rifka: You are doing it right. Three meals and two snacks are ideal. Of course, the food—especially the snacks—should be healthy in nature. Following your child’s weight at the doctor’s office is also important to make sure he or she is growing well.

pordon: My four-year-old has issues with constipation, are there foods you would recommend that are safe for children to eat that are high in fiber? I try to increase his water intake, but then I am concerned that he is not getting enough milk and calcium. How should I balance all of this to regulate his system?
Dr__Rifka: Try to move to ‘brown’ from ‘white’, that is, wheat bread and wheat pasta, and decrease white flour and carbohydrates from his diet. Your child should  not drink more than 3 cups of milk a day. Dried fruits, like raisins and cranberries, are very helpful. Over-the-counter fiber, like Benefiber®, can also be very helpful in keeping your child regular. One cup of orange or prune juice a day also might be good, but eating the actual fruit is better.

maryp: We give our toddler a lot of fruit and vegetables each day, but I am concerned that she is not getting enough calcium and protein. What are the suggested daily intake quantities for the food groups for a three-year-old?
Dr__Rifka: Suggested daily intake is the same as adults, but of course the child servings are smaller. Cheese, milk and yogurt are good calcium sources; also some juices are fortified with calcium if dairy is a problem. Any kind of meat is good source of protein, so are beans and lentils.

yesterday: As my child transitions to solid foods I’m really concerned about the choking hazard. Are there certain foods or types of foods that you suggest I stay away from to ensure that he does not choke?
Dr__Rifka: Here is a list of absolute no-no's:

  • Hot dogs
  • Carrots (raw)
  • Popcorn
  • Peanuts
  • Grapes (give only cut in very small pieces)

Cheerios seem to be very popular but are not safe if there are not enough teeth to chew them. So basically stick to softer foods that do not require a lot of breaking up.

dsc: Scrambled eggs are an easy finger food. Is there a limit on how many eggs young children should have?
Dr__Rifka: Eggs are nutritionally rich, and daily consumption is OK as a source of protein. They do contain cholesterol though, so one egg per day might be a good average, give or take.


Lactose Intolerance
cordy: I notice that my two-year-old is having issues with diarrhea, especially within short periods of time after she has consumed a cup of milk. Could it be that she is allergic to milk?
Dr__Rifka: She could be, but she could also be lactose intolerant. Try Lactaid® milk (lactose free) or soy milk (which can be constipating.) Also, try to notice if she has the same problem when she eats a large serving of cheese or ice cream, as that is typical of lactose intolerance.

mommy265: My child was diagnosed as lactose intolerant and was put on a soy-based formula. Will he always be lactose intolerant, or can he grow out of it? If so, at what age would I start reintroducing milk products to see, and what is the best way to go about doing it?
Dr__Rifka: Yes, the lactose intolerance may very well improve over the next few years, but sometimes it resurfaces in adulthood. When you switch your baby to milk from formula at 12 months, you can try regular milk. If it is not tolerated, you can switch to Lactaid® or soy milk.


Selective Eating
I_know: My son is a very picky eater and I have to make him special meals each night, otherwise he will not eat. How can I change this? I am concerned about malnutrition and, frankly, starvation if I stop catering to him.
Dr__Rifka: That depends on the age. If they are old enough to understand what is good for them as well as cause and effect behavior, then you can try limiting him to what you have. When he is hungry enough, he will eat.

Otherwise, if your child is younger, this is usually a phase they pass through—that can last a couple of years—until they mature more, where they only eat three foods. You just have to keep trying to expose him to new foods as much as possible and hope for the best.

trouble: Is there any way to start feeding my child so that as he grows older, he won't be such a fussy eater? I know that you cannot make a child like everything, but my nephew is such a picky eater. He will hardly eat anything, and I don't want to go through that with my child if there is any way I can avoid it!
Dr__Rifka: Expose the child to as wide a variety of foods as possible, as early as possible, and hope for the best. There will probably be a phase where they will stick to only three foods and refuse all else, but that will pass.


Vegetarian and Organic Diets
jennyk: My husband and I are both vegetarians. We would like to raise our child as a vegetarian. I am eight months pregnant now. I have not really started researching this yet, but what advice can you give me on this issue? Can you list some of the pros and cons? Above all, we want our baby to be healthy.
Dr__Rifka: You can raise your child as a vegetarian, but be aware that there are vitamin deficiencies that might occur if the right foods are not consumed. Mainly, vitamin B deficiency can be serious, so you need to research a list of foods rich in that specific vitamin. Iron can also be an issue, eating a lot of lentils and green leafy vegetables is key to both nutrients. Sometimes that is difficult to achieve in a child, so you have to follow closely with your pediatrician to have a sufficient diet for your baby.

trueblu: Is there any merit to only giving my child organic foods?
Dr__Rifka: Yes, if you can afford to do feed your child organic foods, it will save him or her from chemicals and pesticides, but you do have to study the organic labels. Not all organic is created equal, and you might be paying too much and not getting enough benefit. The 'organic' label is somewhat loose and can be deceiving at times.


Cleveland_Clinic_Host: I'm sorry to say that our time with Cleveland Clinic specialist Mona Rifka, MD is now over. Thank you both for taking the time to answer our questions today about Early Childhood Nutrition: From Liquids to Solids.
Dr__Rifka: Thank you. These were excellent questions!

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