At the Table with the MomNP

Mary Catherine Exland is a pediatric nurse practitioner and creator of the Mom NP Instagram account, where she provides pediatric medical education and resources to parents. She discusses common concerns parents have about infant feeding, such as how much to feed their baby and when to introduce solids. She explains that breastfed babies typically consume less volume compared to formula-fed babies, and that each baby is unique in their feeding needs. Mary Catherine also provides advice on transitioning to cow's milk or milk alternatives at one year old, and the signs of readiness for starting solids. She emphasizes the importance of reassurance and support for parents in their feeding journey. Welcome to At The Table with Sarah and Julie. At The Table is a podcast by two pediatric registered dieticians and moms who love food and wine. We cover a wide range of topics with our goal to provide you with evidence-based insights but also to be a hub of true expert voices in the food and nutrition field. In this episode of At The Table we welcome Mary Catherine Exland. She's a mom to two kids ages five and two and a half and she's a pediatric nurse practitioner who's been working in the private practice industry for the past six years. She's also a certified lactation counselor and has worked as an RN in the Pediatric Intensive Care Unit as well as the Child Life Specialist working with pediatric trauma departments and emergency rooms. She's over a decade working in pediatrics and absolutely loves the pediatric population. She's also the creator behind the Mom and Pee on Instagram where she provides lots of pediatric medical education and assurance to stressed-out families and the parenthood journey. We hope you enjoy this episode as much as we had fun creating it. Welcome Mary Catherine. We are so excited to have you at the table. Thank you very much for joining us today. I have followed you on Instagram for a while now and as I was saying to Sarah earlier have saved us on a variety of occasions with the pediatric health and wellness advice. So thanks so much for all you do. Can you tell us a little bit about your background and current roles within the pediatric space? Sure, yeah. Thank you guys for having me. First off, this is exciting. So yeah, my name is Mary Catherine. Most people call me MC and I am a mom to two kids. I have a five-year-old and a two-and-a-half-year-old. We live in Kentucky and professionally I am a pediatric nurse practitioner. I work in pediatric primary care, pediatrician's office. So I'm doing well checks and sick visits just like when you guys bring your kids to the office. That's what I do for a living. Before that, I was a pediatric nurse in a pediatric intensive care unit. Before that, I was a child life specialist. I focused on psychosocial needs of kids admitted to the trauma department. So all my professional background is pediatrics. So I really love kids. After I became a mom, I started the mom NP on Instagram because I felt like there was such a need for more medical education. While checkup visits are five, ten minutes of face time with the provider and parents usually have a lot of questions and there's a lot that kind of gets left uncovered. So I created that space just to help kind of bridge that gap and provide more education, more resources to moms and dads and it's been really fun and it's just grown a lot over the years and so here we are. Amazing. Yeah, it's so relatable. So I know you deal with a wide variety of pediatric questions, not only feeding related but for our purposes today, we'll be focusing more on the feeding topics. So what are the primary infant feeding concerns that families often have when coming to visit you? Everybody wants to know if they're feeding their baby enough. Everybody really stresses about that I feel like and sometimes knowing specific volumes just isn't realistic especially if you're breastfeeding or strictly breastfeeding, you're not going to know volumes but moms and dads just really care about wanting to know if their baby's getting enough and then that even transcends into older kiddos too. The whole feast and famine phase of toddlerhood where they eat or they don't eat and everybody just really wants to know am I feeding my baby enough and I do feel after the first few months parents usually do start asking them about solid introduction. So usually the four to six month checkup mark that's a big question and then another big question is how to introduce cow's milk or a milk alternative at one. So within the first year of life definitely how to know how much to give my baby and then how to start solids and then how to transition off of formula or how to wean breastfeeding, that kind of stuff are the main questions. So do you find that the volume differs substantially on a baby that is taking breast milk versus a baby who may be formula fed? Have you found that the quantity that they need to drink is often different between the two or not necessarily? Most of the time yes it's a little bit different. In general breastfed babies they really dictate the volumes and as long as they're gaining weight well they rarely go over 5-ish ounces per feed. There may be a bedtime bottle that's a little bit more than that but 5 ounces is typically kind of the cap for breastfed babies because mom's milk calorie content is going to increase as a baby gets older. So the volume stays the same but the calorie content grows which is really cool and amazing that that we can do that. And then formula doesn't have that ability so we do have to increase calories by increasing volume. So I do feel older kiddos are closer to six to eight ounce bottle range. So yes I do think that the volumes vary a little bit but everybody's unique and I always really guide parents if your baby is gaining weight well they have good wake and sleep windows. They're generally content at certain points through the day. I mean every baby's going to be fussy and gassy and all that kind of stuff and then they are peeing and pooping well they're getting enough milk. So I always try to make volume geared towards what the baby is telling us at every stage but yeah I do think that breastfed babies tend to take a little bit less volume. Yeah I think that's so important to recognize that each baby is different and to not get too hung up on the exact quantity because I know it's easy to obsess as parents. Did my baby get enough with that feed? Do I need to feed him more at this next one? Again that approach that we continue throughout toddlerhood of them listening to their body and that intuitive eating. So keeping that in mind is very helpful. Yeah definitely and I feel the one and two month checkups are easily the most tearful checkups for moms because they're so stressed about that. Yeah. And I can tell a mom and I don't ever tell a mom calm down don't worry about that because it's impossible. As moms that's just innate in us we're gonna worry about these things and so I try to tell parents both mom and dad being upset about this or showing emotion about this shows that you care you're being a good parent and then I'll kind of go over what to look for. So I'll show weight charts and graph and this shows that we are gaining beautifully. We'll go over how many pees how many poops and general kind of contentment and kind of give that reassurance. I feel like that's so much of it is just parents really do know what they're doing and they are feeding their babies well they just need a lot of reassurance to feel confident in that. I can certainly agree with that. I mean I remember being a first-time mom even as a registered dietitian I knew the volumes I knew how I fed my patients but it's so different when you become a mom yourself and there's so much insecurity in those moments of what should they be doing. When you're a parent for the first time you really don't know you're learning as you go so I think it's very interesting how you approach it. And I have actually a follow-up question because I would like to know what is your approach when you are transitioning once they reach one year old to cow's milk? I think most babies do fine with just transitioning. It's really more of a taste thing as long as a baby has done fine with dairy leading up to cow's milk. I don't see a ton of issues with cow's milk causing GI upset. It definitely happens. I mean we'll see constipation, we may see some diarrhea and we kind of will pull back and say okay let's explore this a little bit closer but most babies do fine. I do think just from a taste perspective and just it feels a little bit more gentle. I'll suggest doing half formula and breast milk and half cow's milk just to kind of ease into it but most of the time babies transition fine and then I'm also fine with the milk alternative. It doesn't have to be cow's milk. I feel like a lot of parents have a lot of questions about almond milk, ripple milk, goat's milk, all that kind of stuff so I've had to learn a little bit about each of those. Y'all probably have a lot more knowledge on calorie content, fat content. We can go into that at my visits and if that's the route that the family wants to go but I do think just gentleness for the child just half and half sometimes works a little bit better. It just feels a little bit easier sometimes I think. I like that. So what are the signs of readiness for starting solids? Sure. So really my heart and fast rules for starting solids is they've got to have perfect neck control so they've got to have mastered that neck and they're not doing any of that falling forward head bobbing or falling to the side. I want them to be able to sit upright in a supported seat like an upseat or a high chair but they don't have to be sitting independently on the floor to start solids but I just want them to have good trunk control, good neck control so that they can manage the food and then I want them to be showing interest. So I start talking about introducing solids at the four-month checkup. I prefer parents start introducing solids at six months but I start kind of getting them thinking about it at the four-month checkup typically and so those are the things that I go over for them to be watching and then I'll encourage them to eat around their baby if they're not doing that already just so that baby can watch hand to mouth, fork to mouth, those kinds of things and so most times at the six-month checkup parents are like oh my gosh they're watching us eat and their mouths wide open they're like so ready can we do this so yes I like waiting until six months so research really shows that waiting until six months helps with gut maturity they have better microbiome to tolerate digestion and I'm going to read this little clip for me just I think it's interesting but so introducing solid foods after the recommended six months of age it's optimal because if you do it before it can cause some deficiencies of zinc, protein, iron, it can suppress growth and it can cause feeding problems so I definitely like waiting until the six-month mark and that is what I suggest for my patients there are some parents that feel really strongly about wanting to do it before and we'll talk about how to safely do that but I do think waiting until six months is the magic spot and I think it gives parents the time to look into do I want to do purees do I want to do a model of both and I don't have a preference I'm totally pro whatever feels most comfortable to the family but that process has worked well. Are there certain foods that you recommend families introduce first? I as a dietician tend to go more for the vegetables knowing that we want them to be introduced to those flavors in that palette first. I don't have any strong preferences I don't push starting with rice or oatmeal I like oatmeal over rice cereal personally but I don't push that they need to start with that I do think using that as a base to mix flavors into can sometimes be helpful especially peanut butter introducing allergens I think mixing that because everybody always wants to know how do I get my baby peanut butter and I'll say we'll mix a little bit in the oatmeal and that's one option to do it but I don't have a strong preference on it but I do think that introducing vegetables is really nice just because it has a different taste like you said just kind of building their palate and then I'm totally fine with fruits and veggies next or one just the vegetables once they start like really introducing I don't see a huge issue with how you adapt that introduction but I think once you decide to start you just kind of go for it it just totally is different for each kid and so I say go in with kind of a generalized mindset of what you think you want and then let your kid kind of lead what they're interested in it's so true we as parents I think love to try to have that control or have these ideas of how we want things to work but then ultimately the kids will make that decision for us. Well let's talk constipation so we know that constipation is super common in more so maybe the toddler range at when we're again introducing those foods and when we have more selective eaters who may not eat a whole variety of fruits and vegetables and fiber so what is your tried-and-true solution to constipation? So constipation is huge I literally talk about poop every single day at work and it is probably one of my top three questions on my Instagram page and so I was thinking about this recently and so some statistics that I didn't realize that I had looked up from American Family Physician 30% of kids worldwide deal with constipation and it accounts for 3% of all pediatric office visits and 25% of all pediatric GI visits which I thought is interesting that is huge. I created a holistic constipation remedy guide for it's on my mom and pee page because of how much I see the need for going into other alternatives because I'm not a fan of Miralox which is the number one prescribed treatment plan it's not FDA approved for anyone that's under 17 and it's not supposed to be used long-term and so many kids are on the max dose for years it's just wild to me and that's a whole other conversation but I do think magnesium is my favorite place to start with constipation treatment so I like magnesium citrate or magnesium oxide and a lot of people ask the dosing it's on Amazon but it's a Maggo kids powder so it's for kids over 40 pounds so you have to be like four-ish I can't remember the exact dose that that powder is but I like 200 to 600 milligrams for a dose but I do think that Maggo kids powder works really well and I've gotten a lot of my patients off of Miralox and onto that powder and it works so that's a big one and then I also think that a trusted pediatric chiropractor who knows what they're doing and works with kids and has extensive training in kids can be really helpful with constipation but a lot of constipation actually is not diet related it's more behavioral so especially that toddler age when they're learning to potty train they have one big poop and it scares them or just their release fears they've always pooped right into a diaper and it's never that dropping feeling you wouldn't think is a big deal but to some kids it feels like they're falling I've learned for research that it's mistrust with the toilet so that's where a lot of constipation stems from because kids learn to withhold they're like oh that hurt or that was scary and I don't want to do this I'm gonna hold hold hold hold hold and then they get backed up so that's where really the bulk of constipation comes from that I'm dealing with in pediatrics some is definitely diet related don't get me wrong but a lot of it is behavioral and trying to figure out how to work through that pediatric physical therapists can do pelvic floor therapy with kids and I think that's an underutilized tool that a lot of people don't know about because when you hear pelvic floor therapy and at least for me when I first heard that I thought invasive something was going to go into the bottom or that kind of thing but it's not invasive for kids so they're not doing any internal exams with kids they're just learning to teach kids how to breathe and release those pelvis muscles and the rectal muscles and so that's a really good option for some kids when behavioral issues are at the core of constipation. Love that magnesium I guess I have heard of but not even as frequently as nerolax I feel like it is so over prescribed and I had no idea actually that it wasn't approved for under age 17 so really fascinating. You're talking about the toddler ages what are the transitions are you seeing most constipation between the body training or do you see it throughout childhood? I definitely see it throughout all of childhood times I feel when I see the beginning of constipation start is at that potty training time so infants babies under two years of old that definitely I see constipation but most of the time in those age groups it's just here and there they're get backed up one week and then they're fine for three months and then that kind of thing you can kind of acutely see some constipation with starting solids with transitioning to milk but that usually resolves but that two to five age range I feel like is when I start to really talk about constipation and then I definitely see it throughout all ages but I feel that two to five age range is when chronic constipation kind of starts from what I see. That's interesting so what are the signs for a new parent or somebody that hasn't deal with constipation before what would be some key signs or symptoms to look for? So signs of constipation are going to be big hard poops that are painful to come out that they have to really strain to get out it can also be for lack of better terms like little rabbit turds so just these tiny little balls that they're pooping out I like everybody to poop daily but some people just don't and every other day it's fine but if we're not pooping every three to four or longer days that's constipation so a lot of the constipation that I see is a kid is pooping every two to three days they're having these really huge bulky stools that are painful to come out and that's probably the majority of what I see especially and then when it becomes chronic it's actually I think the definition is three months or longer of having these symptoms classifies it as chronic but to me if you're doing that for several weeks in a row I mean that tells me something's going on and we need to fix that so really hard poops or these tiny little pebbles just a lot of little rabbit turds or not pooping daily is when I'm going to start talking about constipation issues. Because you often see that constipation also impacts intake right you notice sometimes when kids come in and they don't really have an appetite is that one of the first things that you're looking at is the constipation piece or how often they're having bowel movements? Yeah it's definitely a piece of the puzzle and whenever we're doing any kind of GI conversation I go in depth and pooping habits what does it look like how often are you going is it easy is it hard to go that kind of stuff because yeah definitely plays a part. I even took my own daughter to the emergency room and this was probably two years ago but I was convinced she had appendicitis I was like you are in so much pain I couldn't palpate her belly she wanted me nowhere near her stomach she was screaming I was like something's wrong middle of the night of course when every bad thing happens she pukes in the ER waiting room I was like oh yep it's appendicitis where this is going down and then we get there and they do a belly x-ray and she's completely full of poop and it's all constipation and I was shocked they had to do two enemas to remove stool. It made me relate to parents because that was so aggressive or air quotes just constipation but it definitely can affect a lot of things I mean it can be really painful it can be the reason for chronic abdominal pain it can definitely be the reason why kids don't want to eat or can develop picky eaters and they're so full and they're comfortable so I definitely see it as the source of some other issues. So you're an advocate for holistic medicine and you do speak to the benefits of hemp-based supplements or CBD often in more of the adult population but I believe in children occasionally as well. Can you speak to some of the instances that you might recommend that and if you've found any research or its impact on eating whether it be to decrease anxiety around mealtimes or even if it does have any effect on appetite? So yes I'm definitely a big hemp advocate and just holistic medicine plant medicine I think there's room for all of us to learn a lot more about those routes. So in terms of hemp there's not a ton of research on kids specifically so it's still really new it just became federally legal in 2018 so those studies for pediatrics and hemp and CBD I think formal studies are still years off but we have a lot of anecdotal evidence. So I don't know necessarily any evidence with hemp and appetite for kids but I will say I have several children that have autism diagnosis or just other developmental delay kind of diagnoses that are using hemp to help with behaviors and anxieties and I can't necessarily say that it's helping with food and meals necessarily but I definitely think that it helps with behaviors and helps create a more calming child. They feel a little bit more in control of themselves and things like that which certainly can lead to better eating and just overall improved mood and in terms of adults it has been shown actually to decrease appetite. It doesn't bind to CB1 receptors in the brain like THC does which is marijuana which is not what CBD not what hemp is and THC does affect appetite usually you'll hear in popular culture THC gives you the munchies that kind of stuff so CBD does not do that and so I do think it's interesting there's a lot of people who are using CBD or hemp more not for weight loss but for weight management so appetite management. There's a big benefit and a big need for alternative medicine and how we approach treating those kiddos. My daughter is five she uses them and then a lot of school-aged kiddos so a lot of ADHD focus kind of stuff is probably the predominant reason why I'm using hemp in practice in pediatric practice and then anxiety depression and postpartum kind of stuff is the predominant reason for adults why they're using it. It's fascinating. I don't know how closely you get any reports from school or anything but do you see that there's a big change in school behavior if somebody's going through a hard time and once they get put on this is there any progression or any evidence that you see that it has helped them in their school? Yeah definitely so I have a few kids who are avoiding pharmaceutical ADHD medicines their parents don't want them on stimulants for various reasons and they're not needing them. I think stimulants have a great place for the right kid but there are so many side effects with stimulants I mean appetite is a huge one we see a lot of kids come off of stimulant medicines because they have no appetite they're not eating enough they're losing weight it's a big reason why kids come off of stimulants it's the side effects so with CBD we're not seeing those side effects and we're seeing kids are having improvement in school and then I have several kiddos that are using CBD alongside of their stimulants ADHD hyperactivity and anxiety can really be a fine line of chicken and egg is one causing the other or is the other causing the other and so yeah there's a lot of kiddos that are avoiding pharmaceutical meds because that's what they want to be avoiding and then a lot of kids who are managing side effects with pharmaceuticals using their CBD products but they're all doing well and I get a lot of positive feedback from parents on their school and performances a lot of good anecdotal feedback from parents. Very interesting and so artificial dyes and I know there's a connection with ADHD here too we know that they're ubiquitous in a lot of our processed foods as well as food additives and chemicals what is your take on how best to avoid those or are you seeing some connection between maybe growth and development with higher intakes of these types of foods or again the ADHD or some of the more attention disorders are you seeing any difficulties there? Yes 100% I could go on a whole tangent about dyes I think that added food dyes are just so horrible and I get really frustrated that they're even allowed to be in our food but again that's a whole nother tangent as a mom I've done research and learned more about it because red dye 40 is our biggest culprit so that's going to be the biggest thing that I would advocate any parent or anybody any human to remove from their diet. Studies link it to ADHD type symptoms irritability depression migraines I was looking at another study that shows a link with all food dyes and hyperactivity and attention restlessness sleeplessness aggression I could go on and on and on but definitely that like hyperactivity is a huge component of dyes so I do really advocate to omit those it's a great place to start and a really realistic place to start because reading nutrition labels is challenging I mean I get confused and it's hard to know what to focus on what to look for but I do think that added dyes you're going to see a red yellow blue so it kind of an easy trigger word to look at an ingredient list see those things and say okay this is not an option that I want and so I do think that it's a great step to cleaning up what your kids are eating I will preface and say we're like 80 20 at our household in terms of healthy and non healthy or other options so I don't want anybody to feel like my kid can never have a food diet just all in moderation but I have learned Trader Joe's Aldi and Whole Foods are all completely artificial dye free so that's one good easy place to start if those are in your your area and then I use Thrive Market which is an online grocery store subscription so yeah I definitely think that that is a good place for parents to start looking if you're wanting to kind of clean up diets and things like that because it absolutely is linked to a lot of behavioral issues. That's very interesting and yeah I agree it is a easier place to start than trying to tackle the entire food label which really can be daunting even for registered dietitians there's a lot on there but again those diet foods and obviously if the food is a bright color but you basically kind of know that that might be one that has some of those additives so very helpful. It's something that you kind of know but it's also nice to hear it and get it reinforced and I think a lot of our listeners will appreciate that information as well. So finally what are your top three tips for feeding busy families? So I'm going to tell you my top three and I'm going to explain a little bit about each one. This is obviously going to look different for every family. Every family has their own unique things. We have two kids. We are two working households. Both my husband and I work. These are kind of my top three tips so 80-20 rule of healthy versus fun food and then parents serve the food kids decide what to eat and then you find a reliable place for healthy alternatives. 80% of the time we're going to try to eat healthier options. 20% of the time we're going to do fun foods. So we talk a lot about this with my five-year-old. We talk about healthy foods as these are foods that make you stronger. They're going to make you run faster. They're going to make you do your math at school better that kind of stuff. So we try not to make it like good and bad foods or junk foods or placing this negative label on it. We want to teach kids that some food is really nutritious for our body and other food just doesn't fuel our body as well but that it's fine. So I just don't want to create a complex for kids. So that's the 80-20. There are nights where I'm like you have not eaten a single thing. I'm going to make you whatever you are going to eat. But we really try my husband and I as parents to stick to we serve the food kids decide what to eat and that goes back to the whole Easter famine concept where kids they actually eat pretty intuitively. We could all learn from kids. They are going to eat when they're hungry and they're not going to eat when they're not hungry. And then the last one is to find a reliable place for healthy alternative options. So we talked about Trader Joe's, Aldi, Whole Foods are all die-free. Those are all great. I survive on Thrive Market. I have all of our snacks set up on AutoShip. So they just come it's every two months that they come and that really helps me a lot. And so I will say like Walmart, Target, Meyer. I think that they all have really good like organic gluten-free options. Whole Foods is a great place to shop but not everyone has a Whole Foods budget. But I think trying to kind of learn like okay what are some healthier alternatives. If my kid really loves the Nutri-Grain bar okay we're going to try the Go-Macro bar instead or something like that. Or my kids love to eat hot dogs so let's find a hot dog like an Applegate brand because they don't have any nitrates added. They don't have any fillers things like that. So that takes a lot of time to kind of learn what those healthier options are. I try to talk about it a lot on my Instagram page just to educate. But yeah I'm just finding a more reliable place for healthier alternatives so that you can go into that place and know okay if these are a better alternative than maybe what I was choosing before. Awesome. I feel I always learn so much on all of these podcast interviews and I go immediately and apply it to my kids. That's so helpful. Yeah and even being professionals there's sometimes that you you forget about certain things like you're going through day-to-day as a mom and so I think it's been a fascinating conversation. So thank you so much for all you do for your input. I'm excited to continue to follow you on Instagram and I hope our listeners really enjoy our conversation and all the tips that you had for us. Thank you guys so much. I really appreciate it and just a really great service that you guys are doing. Thank you. Thank you MC. It was a pleasure getting to finally speak with you. We might be having you back as another guest if you're willing. Absolutely. But thank you so much for being at the table. Thank you guys. Bye MC. Bye. Thank you so much for joining us at the table. Be sure to follow us on Instagram as well as on Spotify, Apple or wherever you get your podcasts. We are Sarah and Julie. Talk to you next time at the table.