The Anti-Walnut Campaign

Food allergies- when food is the enemy. Allergic reactions range from the mild rash to the very scary anaphylaxis. We have known for some time that little Ellie Rose is allergic to walnuts but thought it was prudent to pursue testing to rule out any other allergies.

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What happens in the body to make your child puff up like a puffer fish?

The spectrum of allergic responses to food trigger is modulated by the immune system. It is important to note that not all allergens result in “Food anaphylaxis” or are IgE-mediated.  The difference in how the immune system responds results in the array of visual symptoms. The role of specific cells and mediators remains a hot topic for debate. Most people believe that more mild food allergy and intolerance symptoms are the result of increases in histamine without a change in basophils, however some have found that eosinophils increase. Basophils and eosinophils are both granulocytes, and white blood cells active in immune responses. The basophils are called to the front lines to interact with foreign bodies and are involved in inflammation by releasing histamine and heparin; histamine dilates blood vessels leading to warmth and swelling while the heparin prevents blood clotting. Eosinophils are phagocytes and consume, or “Eat” foreign bodies and can help to calm inflammation.

IgE, or immunoglobulin E, is an antibody that leads to a systemic inflammatory cascade which utilizes mast cells. Mast cells are another white blood cell rich in histamine and heparin. The IgE response causes reactions in the nose, lungs, throat or on the skin. Epinephrine is the antidote for anaphylaxis; at recommended doses epi can constrict the blood vessels and alleviate symptoms of swelling and itching via α-adrenergic pathways and can restore airways by β-adrenergic properties. In low concentrations, epinephrine can also block the antigen, or allergenic protein.

At Ellie’s first encounter with walnuts, she simply didn’t like them and told me they hurt her mouth. I, originally, thought it was a new texture that she needed to get used to. At second try a few weeks later, her face quickly swelled causing her eyes to swell shut and her breathing became labored. I quickly rushed to get Benadryl (anti-histamine) which calmed her body down and she recovered in a little less than an hour. Since that day, we have carried out a strong educational campaign among the quints and her caretakers to strongly reduce the risk of another exposure. The campaign has worked but knowing that she will be starting school in a few short months, we thought an epi pen may be a great tool in our tool box. This warranted a visit to Allergy Clinic.

Big Eight

Food allergens are water-soluble glycoproteins that are typically stable to heat and acid. The most common food allergens are called the big eight and include:

  1. Cow’s milk
  2. Chicken Eggs
  3. Peanuts and Legumes (almond, pecan, coconut, cashew)
  4. Tree Nuts (Brazil nut, chestnut, hazelnut, pine nut, walnut)
  5. Cereals (Wheat)
  6. Soy
  7. Fish
  8. Shellfish

In clinic, the team tested Elliott using the skin-prick test. Since Elliott consumes peanuts, almonds and coconut safely, they chose to only test those nuts, legumes and tree nuts that are unknown and most similar to walnuts: Black walnuts, English walnuts, Hazelnuts, Pine Nuts and Pecans.

The skin prick test is completed by scratching the surface of the back while applying a diluted allergen solution. Then, a labeled grid is drawn around the test area. The control is always included to demonstrate a sample “wheal,” or raised, red and itchy bump. After 15-20 minutes, the team can see which allergens cause a response. It is important to note that the size of the wheal does not necessarily correlate with the allergic response. So, as one can see in Ellie’s photo the A column demonstrates her response to the control solution and the two types of walnuts, as well as, pecans in column B. Despite, pecans larger than walnuts it may not produce anaphylactic reactions. Of course, we have added pecans to Ellie’s list and have restarted our walnut and pecan allergy campaign. We also left the office with school plans and a prescription for epinephrine.

Now, while Elliott won’t be eating any walnuts or pecans in the near future, the doctor said it is unlike wheat allergies/gluten allergies and we can keep them in the house. They shared that despite popular knowledge, nuts do not commonly produce allergic responses via airborne contact. Therefore, Theo can still enjoy his walnuts at snack time despite sitting right across from Ellie.

To lighten up this post, I’ve also provided some fun Snapchat photos which were taken while waiting for the Doc.

Trick, Treat, or Teaching Opportunity

Halloween can be a scary time for more reasons than the goblins and spooky ghosts. Halloween seems to kick-off the season of treats beginning with the tempting sweets that line the grocery store aisles. Many parents dread Halloween due to the amount of candy that their child drags home after a long night of trick-or-treating.  However, I am looking forward to this teaching opportunity.

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Many of you know that food, nutrition and overall wellness are near and dear to my heart. I love equipping and empowering people in their health pursuits… especially my children. Trick-or-treating is a great time to teach moderation. There is a growing body of research that encourages families to mark no food as forbidden. Ellyn Satter encourages parents to help their children to, “Learn to manage sweets and to keep sweets in proportion to the other food [they] eat.” Moderation can be a difficult concept to grasp, but it is a lesson worth learning. According to research, treat-deprived children often end up weighing more later in life due to hoarding forbidden foods. I appreciate these findings but also recognize that these lessons need to be age-appropriate.

At three years young, my kiddos still are led by their frontal lobes (aka Impulsivity) therefore, we have tailored the moderation conversation to one of “wants” versus “needs” and “wants” have a time and a place. Since candy and sweets are unnecessary “wants,” my children have never had any. We don’t have any in the home so, if they encountered a candy bar on the street they wouldn’t know what it is. This is intentional because I know the power of sugar and I also know the consequences. Sugar is a sweet and silent killer that is a great contributor of morbidity and mortality around the world. Because of this I often associate excess sugar with excess alcohol or even smoking. As parents, we are guides and guardians for our children. We are blessed with the opportunity to guard their hearts, minds, bodies and souls until they are able to “digest” the media and message and then tasked with helping to guide them through this muddy world.

This does not mean my children will never have the pleasure of candy; recall those that are deprived often become the secret hoarders. Instead, we will continue to be intentional about when, where, why and how we introduce these types of foods and experiences. I also feel led to set others up for success that is why we will continue to be the weirdo house on the street that does not handout candy, but rather an allergen free snack. There are also a host of other food and non-food alternatives including…

Non-Food Alternatives:

  • Stickers
  • Glow sticks
  • Play dough
  • Rings
  • Toothpaste/Floss/Toothbrush
  • Pencil/Erasers
  • Seasonal Post-it’s
  • Bubbles

Food Alternatives:

  • Gum
  • Granola Bars
  • Pretzels/Crackers
  • Popcorn or Puffed Corn

So, with moderation in mind may the force be with you as we forge into the season of sweets and continue to guard and guide our children in the days to come!

Declaration of Independence

What better way to declare your independence then by eating all by yourself?!

On Monday morning Mom was preparing breakfast for her five beautiful children and decided that their traditional oatmeal and yogurt needed a splash of color. While apples and bananas are favorites they weren’t bright enough, but berries certainly would do the trick! Strawberries, blueberries and raspberries turned the dreary oats into a bright purple surprise! Little did Mom know that today was the day that her children were going to exercise their right to feed themselves! DSC02414 Kali was the first to say, “No thanks, Mom, I got this.” Of course, she chose not to use her words, but rather to swat the spoon from Mama’s hand sending it flying onto Bella’s lap. She then proceeded to raspberry her raspberries all over the table and her brother, Theo, sitting 2 seats over. Theo thought this was hilarious and joined the raspberry spray fest. Of course once the spoon hit Bella, she, too, caught on, and soon Mom had a mutiny on her hands. While I would have appreciated a subtler request to learn how to feed themselves; the message was nevertheless received. DSC02407 I am eager to celebrate this milestone with my children. I won’t be packing away the Baby Bullet just yet, but now that four out of the five have at least 2 choppers we will be discovering the quints’ finger food faves! DSC02412 Their new meal plan that embraces their new found independence and celebrates their 11-month milestones is as follows: Breakfast:

  • 5-6 ounces Milk (Breast Milk with Goats Milk)
  • Banana OR Cooked Pears, Peaches, Fig, Plum or Apple
  • Cheerios OR Oatmeal OR Oat-based Teething Biscuit

Lunch:

  • 5-6 ounces Milk
  • Cooked Carrots, Peas, Summer squash
  • Ground Meat (Beef, Chicken, Turkey) OR Flaked Fish
  • Cooked Potato OR Spiral Whole Grain Pasta

PM Snack:

  • 5-6 ounces Milk OR Water (Will switch to water after 1 year)
  • Avocado OR Chopped Hard Boiled Egg
  • Cheerios OR Oat-based Teething Biscuit

Dinner:

  • 5-6 ounces Milk
  • Cooked Carrots, Peas, Summer squash
  • Cooked Beans (Chick peas or Kidney beans) OR Soft Cubed Tofu

Evening Snack:

  • 6-8 ounces Milk

The V-5 “Enjoy the Taste of Eating Right”

The V-5 definitely “Enjoy the Taste of Eating Right.” As a registered dietitian nutritionist (RDN) I couldn’t miss the opportunity of featuring my beautiful children during National Nutrition Month®!

Lily enjoying some pre-meal tummy time.
Lily enjoying some pre-meal tummy time.

Eating well is a pillar in the pursuit of overall wellness, especially if you are/were a premature infant. I attribute my children’s well-being to their healthcare team’s (which includes Mommy & Daddy) dedication to feeding them well from day one.

I have bragged on and on about breast milk in past posts, including Mommy Nutrition and 2 Simple Acts, so the following will feature the best solid foods for infants, or Baby’s Super Foods. These also happen to be super foods for the oldest of children- aka adults. I selected the following foods based on their nutrient density, ease of digestion and preparation and friendliness to the young palate.

Tummy time-out for Kali
Tummy time-out for Kali

Grass-fed Beef & Organic Poultry

Meat and poultry are great first foods due to their iron content.  Baby’s stores of iron begin to fade around 6 months so, a food rich in iron is important. Additionally, iron from animal sources (heme-iron) is much easier to absorb and use by the body. Meat also is loaded with B-vitamins and zinc. If you opt for grass-fed over grain-fed cattle, you will also get meat with more healthy omega-3 fats, vitamins A and E, and less of the unhealthy saturated fats, hormones and antibiotics. Organic poultry is ideal for the same reasons; basically more time and attention are directed towards the birds living quarters and nutrition creating a better quality end product.

Lentils

Lentils may be small but they are mighty. They are loaded with protein, fiber, iron, zinc and a host of B-vitamins. They are also a good source of copper, potassium and molybdenum. These legumes are quick and easy to prepare and generally more tender than other types of dried beans.

Bone Broth

This nutritional powerhouse can be made by boiling chicken or beef bones in water and a touch of vinegar. It is a significant source of GAGs, or glycosaminoglycans, chondroitin sulfate, keratan sulfate and hyaluronic acid, which are all “ingredients” for cartilage. Additionally, the red marrow has myeloid stem cells, which supports red blood cell development and the immune system. This broth also is a great source of glycine and proline, which are the building blocks for other amino acids (protein). Glycine and proline are also used by the body to aid digestion, promote healing, and create healthy plasma. Logically, bone broth also provides a good source of minerals found in bone: calcium, phosphorus and magnesium to aid in bone development and maintenance.

Theo chowing down on avocado
Theo chowing down on avocado

Avocado

This fatty fruit is a good source of fiber, vitamins K, E and C, a few B-vitamins, as well as, potassium, and copper. Avocadoes provide a host of anti-inflammatory phytochemicals (antioxidants from plants) and can help with absorption of other nutrients, like carotenoids (orange, yellow and red phytochemicals). Besides aiding in blood sugar regulation and heart health, they also make a great beauty product.

Butternut Squash

This orange, winter squash may require some extra prep work but the sweet flavor and benefits are well worth it. Although squash are a starchy vegetable, their carbohydrate is much different than a potato; it has anti-oxidant and anti-inflammatory properties. The orange color gives away that it is a great source of vitamin A, but it is also loaded with vitamins C, B6 and several minerals.

Gluten-free Oatmeal

This hardy cereal is a great first food for infants. My vote goes to oats over rice for an infant cereal because it is rich in iron, zinc, phosphorus, fiber and protein, as well as, several other vitamins and minerals. It also comes without the worry of arsenic toxicity.

Why gluten-free? Well, gluten is a very inflammatory agent that is found in wheat, rye, barley and some oats and can be difficult to digest. Often times, traditional oats can also be “contaminated” with wheat due to shared processing equipment. I feel it is best for babies to be wheat-free until their first birthdays when they dive into that cake! Overall, I opt for gluten-free because it is much nicer to the kiddos’ digestive tract.

Bella loves to help feed herself
Bella loves to help feed herself

Banana

I had to include at least one common fruit. Bananas are a great first fruit because they are a good source of vitamins C, B6, B2 and of course, potassium. They also provide bone-building minerals, including magnesium, calcium and phosphorus. Besides the benefit of being very convenient to prepare, they are also known as nature’s antacid because they contain a substance that can help the stomach and intestines produce the mucus lining.

Another bonus of the foods mentioned above is that when they are pureed they contain at least 20 calories per Tablespoon, which is equivalent to the average amount of calories in one-ounce of breast milk. When you have picky bottle-feeders who love solids this can be a huge lifesaver!

Ellie loves to help feed herself, too.
Ellie loves to help feed herself, too.

Whether these foods are old favorites or perhaps news ones to try, I encourage children of all ages to serve up these super foods and “Enjoy the Taste of Eating Right!”

The sign of good food (Kali)
The sign of good food (Kali)

Let the Games Begin!

At 5 ½ months the quints are starting solids!spoons

How do you know when to start solids?

There are several signs that a child is ready to start solids:

  • At least 4 months old (Check!)
  •  Significant weight gain.

The quints have definitely doubled their birth weights)

    • Theo is now 14½ lbs.,
    • Bella is 11lbs,
    • Lily is our little one at 10½ lbs.,
    • Kali is 12 lbs., and
    • Ellie is just shy of 12 lbs.
  • Able to make chewing motions and loss of “extrusion reflex.”

The extrusion reflex is when an infant uses their tongue to push solids from their mouth. An infant’s mouth develops in sync with their digestive tract. Therefore, if the little one is able to push food to the back of their mouth with their tongue and simultaneously swallow their gut is ready to accept the food.

  • Able to support their own heads with good neck strength. bumbo

In preparation for solid food we began feeding the kids in their bumbo seats. At first this was a disaster! The bumbo is designed to teach little ones to use their core to sit up, so you can imagine what happens when they are all tensing their abs during mealtime. Spit ups and blowouts galore! But, thank goodness this did not last long. A week’s worth of feedings and they got the hang of it.

I attribute the great gains in their neck and head strength to their time in the bumbo seats. Even big brother, Theo, with his 95th percentile noggin can hold that coconut up proudly!

  • Good appetite and often still hungry after their feeding.

This is definitely the case for Theo, Kali and Lily who often are quite upset to be sucking air at the end of their bottles.

  • Curious with what Mom and Dad are munching on.

So, needless to say after reviewing the list above, I was confident that the quints were physically ready for solids.

Which foods do you start with?

There is a bit of a debate on which food is best to start with. Currently, there is no strong evidence to support a specific sequence of introduction. Nutritionally, the best foods to start with are those that are highest in iron. This is because around 4-6 months of age a child’s iron stores are becoming depleted. This is especially true for premature infants because their time to accrue these stores was cut-short. Additionally, foods high in zinc and vitamin D are especially important because these nutrients are traditionally low in breast milk.

Traditionally, people start with iron fortified rice cereal. However, from my research this appears to be merely a generational tradition and in fact meat is a much better first food. This article from Dr. Greer, one of the quints’ physicians at the Madison NICU, offers a great explanation! Rice cereal is very easy to digest and has a very low allergy risk, but the iron from the food is not as easily absorbed and this food is high calories and low in nutrition. Plant-based iron (non-heme iron) is not used by the body as easily as that from an animal source (heme iron). Additionally, meat is a great source of zinc.  I believe that chicken is a fantastic first food, followed by beef.

The quint’s sequence will be as follows, with a new food every three days: Baby-Bullet-Batchbowl

I chose butternut squash and sweet potatoes because they are fairly high in vitamin C. The body uses vitamin C to help the absorption and use of iron. Zucchini was next as their first dark green vegetable because it is easy to digest and a low allergy risk. Their first grain will be gluten-free oatmeal because it is naturally high in iron and B-vitamins.

This delicious faire will be homemade with an awesome Baby Bullet, courtesy of a fellow quint mom. I puree the vegetables using breast milk and the meats using bone broth. Both are fantastic sources of vitamins and minerals and freeze very well! In just one hour, I had a month’s worth of food for the kiddos.

Let the games begin!

Frank and I thought we would catch this monumental meal on film. This video illustrates why it is important to feed your little one their bottle before trying solids. Can you guess which quints had eaten first?

If you guessed Theo and Lily you were right! They were cool and calm during their trial. Ellie and Bella were quite the opposite and approached meltdown mode. Kali, well, Kali enjoys mealtime in whatever order it is presented.

The other very important reason to offer solids after their milk is because breast milk should remain the primary source of nutrition for infants until at least 1 year of age, and thus you don’t want to ruin a feeding with an unfortunate food trial. I do promise you that Theo, Ellie and Bella all recovered from this feeding experience.

So, at the conclusion of food trial #1, all of the quints tolerated chicken. I would say that Lily, Ellie and Kali even liked it. I believe Bella will come around to liking it, too. As for Mr. Theo…I’m pretty sure he just wants a butter burger and some crinkle cut fries.

Baby Central: The V-5’s Domain

The Vanderwall home has quickly transformed into baby central with pack and plays, bouncy seats, burp cloths and pacifiers abounding. Everywhere you look you see signs of our little ones. We are also trying hard to create an environment at home that is conducive to growth and development.

Theo is home!
Theo staking out in the Pack N Play

We hope that the V-5’s domain will:

  • Help them differentiate between night and day.

During the day the kiddos stay on the main level in well-lit areas. Here they are exposed to the sounds and hustle and bustle of day time. At night we keep them upstairs in their nursery where it is dark and quiet. We also are intentional about not talking or playing with them during their night-time care times. We are down to business at 12am and 3 am. This has proven to be very helpful in getting them on their care schedule.

  • Practice good nutrition.

All of the quints enjoy breastmilk for all their meals. However, since they were premature it is common practice to fortify their milk for additional calories, protein, vitamins and minerals (sodium, calcium, phosphorus to name a few).  Their calorie goals vary quite a bit and like adults are based on their weight, ranging from 108-120 Calories per kilogram body weight. On average breastmilk has 20 calories per ounce, whereas the quints require 24 to 26 calories per ounce to grow at the desired rate. Therefore, we are adding Similac Neosure to their milk. We also are sure that they get their multivitamin (poly-vi-sol) daily.

Rare Occurrence- Ellie is quiet and alert, awaiting lunch.
Rare Occurrence- Ellie is quiet and alert, awaiting lunch.
Mommy & Lily
Mommy & Lily
  • Exercise their Mind.

Lots of time and attention is poured into identifying strategies to develop baby’s brains. There are an assortment of toys, books, apps, programs, etc. that promise to make your baby a genius. However, I’m a firm believer in simplicity and believes that attention, bonding and communication, or ABC’s, develop the brain just as efficiently as any of these other tools. I have actually learned that some toys touted for brain development can actually over-stimulate the child and increase the risk of ADHD/ADD.

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Currently, the V-5 enjoy tracking exercises where we use a black and white images or toys and move the image from left to right. This activity strengthens communication between the left and right hemispheres of the brain, or communication across the corpus callosum. We also love to chat and sing with our little ones. An ideal time to chat is when we are changing them, because we are 12-14 inches away from their little faces and are able to maintain their attention.

  • Massage for Emotional Well-being. 

There are many benefits of baby massage, including stress management. Massage can help to foster emotional health and promote self-soothing.  Touch via gentle strokes stimulates the central nervous system to produce more serotonin, the happy hormone, and create less cortisol, a stress hormone. Typically, as a result the infants breathing and heart rate will slow and they become more relaxed. Often times, this relaxed state does not result in sleep but rather a quiet, alert state perfect for play-time, snuggle-time, or positive feeding interactions.

  • Massage for their Tummies.

Our quints are a gassy bunch. It is no joke that post-feeding sounds much like a barnyard. Therefore, anything we can do to ease their gas pains and help their digestion is a must. Frank loves to take them on bicycle rides all over “town,” moving their little legs in a circular fashion. They have also come to enjoy this and almost do it on their own when you lay them on their backs. Frank tends to take them to the Candy Shoppe, where Mom prefers a trip to the Puzzle Place. We also practice the “I Love You” strokes on their bellies, which can help to stimulate movement throughout the digestive tract. A fool-proof method for gas relief is to place them on their tummies with rounded shoulders and knees tucked up and to glide your hands down their back while supporting their bottoms.

  • Stretch their Bodies.

Since sleep is one of their favorite past times, these little ones can get awful stiff. We continue to try to prevent flattening of their heads and promote good neck mobility. Moving their limbs up and down and inward and outward can help to preven

t these little hedgehogs from staying all bound up. We also like “windshield wipers” with their bent knees to help open up their hips.

Tummy time is also a great way foster good motor development and upper body strength.  It is best done when the infant is alert. Some of the quints love tummy time and others are still learning to like it. It can be quite a frustrating position for them, so we are sure to keep the sessions short and sweet.

Ellie Lays
Elliott is prepping for her calisthenics
  • Encourage Good Coordination.

Newborns are able to open and close their hands, but often times these movements are reflexive. During the first three months of life grasping becomes more intentional and an ideal time for developing foundational skills for hand-eye coordination. The quints are already starting to show signs of good coordination as they reach and grab items from their mobiles, as well as, objects near their face…including mommy’s hair.

Quints circled up for Yoshi Calisthenics
Quints circled up for Yoshi Calisthenics on Halloween
Yoshi egg line-up
Now it’s time for Follow-the-Lily.

All of these activities certainly add up for a full day, but there’s nowhere else we’d rather be!

The Race Home

Stork-with-Blue-BlanketThe quints are one week from being full-term babies and the race is on! Bets have been placed by many on their healthcare team as to who will make it home first.

This past week has provided some challenges on their road home, including getting their 2-month vaccinations, which included:

The doctors warned us that the kids may not be themselves for about 24 hours after the vaccinations and they were right. The most common symptoms include:

  • Fever
  • Pain at the injection site
  • Poor appetite
  • Fatigue/Sleepiness
  • Increased Spells
  • Periodic breathing

Everyone spiked a fever and ended up sweating through their clothes. Their appetites were not the best the following day either due to them being a bit sleepier. Honestly, the best way to describe it is that all of their “issues” from a few weeks back, reared their ugly heads.

Silly Kali Mae who may be one part screecher monkey and another part parakeet.
Silly Kali Mae who may be one part screecher monkey and another part parakeet.

For example, Kali who tends to “bear down,” meaning to grunt to either pass gas, poop, or protect her airway from reflux, was doing so much more often. When she bears down she often forgets to breathe… she isn’t the best multi-tasker, yet. The frequent bearing down led to poor respiration and thus desaturation (decreased oxygen in her blood) where she had to be put back on her nasal cannula to receive extra air flow. Luckily, she only had to remain on it for 24 hours. The unfortunate news is that because she had this “Spell” she got 5 days tacked on to her stay before she can be discharged. So, Ms. Kali’s discharge is now projected for October 15th.

Lillian Grace playing peek-a-boo when she is supposed to be snoozing.
Lillian Grace playing peek-a-boo when she is supposed to be snoozing.

Lily and Bella are now focusing primarily on waking up and staying alert enough to eat by mouth. These two are the last with their feeding tubes. They are currently meeting 50% of their nutritional needs by mouth and need to get to 80% before they can consider sending them home.

Bella who somehow has a striking resemblance to Dwight Schrute from the Office in this photo.
Bella who somehow has a striking resemblance to Dwight Schrute from the Office in this photo.

So, that leaves Mr. Theo and Ms. Elliott who have been favored by Frank and I to win the race home for some time. These two, despite their bowel surgeries, will most likely be the first ones home and arriving via stork, or Honda Odyssey, this weekend!

Mr. Theo snug as a bug in his sleep sack.
Mr. Theo snug as a bug in his sleep sack.
Our little doll face, Elliott Rose.
Our little doll face, Elliott Rose.

In other news, Frank and I are doing well. We are so excited that our NICU journey is coming to an end, and are more than ready to start the next chapter at home! Frank is coming out of his busy season at work and is planning on taking some time off as the kids trickle home.

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I am excited to have him home, so we can establish what life will look- aka a routine- as a family. I am also excited to share that I have returned to my pre-pregnancy weight. I share this for three reasons:

  • One, I believe it is a testament to good nutrition and regular exercise (just practicing what I preach),
  • Two, it is clear to me that weight truly is just a number because my body is definitely not what it was before in terms of composition therefore, operation “rebuild your temple, based on I Corinthians 6:19-20), remains in full swing, and
  • Three, because it has opened my eyes to a whole new population of people I want to empower for better health- Moms!

We also wanted to share with those who were praying for our insurance appeal that we had our grievance hearing. Unfortunately, the committee decided to uphold their decision to deny payment of our perinatal care in Arizona. We would appreciate continued prayer for this journey as we trudge on to the next level. It has become a moral battle of proving the value of life. We are now fighting for more than just our five miracles, and feel as though we have the opportunity to speak for parents who were encouraged to consider multi-fetal reduction and may have moved ahead with those decisions, and thus had to grieve those losses. We also will not back down because we believe in the importance of having a choice in healthcare, and speak for those who may have thought at one point they had no other choice but to give in, or to give up. Most importantly, we also speak for all of the children who did not get a chance at life. We are fired up and ready, so please pray that the committee in this next round would be more open to our appeal.

As always, we thank you for your well wishes, prayers and support. Please know you are a valued citizen of the village that is helping to raise the V-5!

Two Simple Acts

Mama Kanga and her Roo's, Lily (right) & Kali (left)
Mama Kanga and her Roo’s, Lily (right) & Kali (left)

When becoming a new parent, best practices, guidelines, and all of the “must-do’s” flood our mind.  All mom’s and dad’s want the best for their children. I find peace in getting back to basics and focusing on two simple acts: Kangaroo care and Breastfeeding.  Both of these can be practiced whether a parent takes their newborn home shortly after birth or for those trying to learn how to be mom and dad in a NICU setting.

Kangaroo care is an endearing term used to describe skin-to-skin holding.  This snuggle time has benefits for both mom, dad and baby. The newborn benefits from skin-to-skin holding because they learn their parents’ scents. The sense of smell is the first to develop and is quite strong, which is why many encourage the use of scent cloths. Additionally, the baby’s vitals mimic those of the person, which is holding them and can help to regulate their heart and respiration rates.  When mom is caring for her baby this way, the infant can be soothed by the sound of her heartbeat since it is what they heard for many months while in utero. Kangaroo care can foster quality sleep for infants. This is why it is typically done for at least 90 minutes at a time. We know that sleep is critical for a newborn, or preemie because it encourages both growth and healing. If time is of the essence, swaddling and hold the baby is also beneficial and many hospitals have “cuddlers” who are happy to help.

"Nana B" & Bella cuddling
“Nana B” & Bella cuddling

Kangaroo care also benefits parents as a unique bonding experience. One is able to simply hold, love and adore their baby. This is also a great time to sing, read or gently speak to the baby while they drift to sleep. A mother can specifically benefit from this practice because oxytocin is released during infant bonding.

Oxytocin is known as a love hormone, but plays a significant role in building, maintaining and letting down a mother’s milk. It also can cause uterine contractions that help the uterus return to its normal state. Therefore, it is evident how the first act leads to our second- breastfeeding.

The breast is best! Breast milk is often referred to as “liquid gold,” due to its nutritional superiority over other methods of feeding. A mother’s milk may vary in composition of nutrients, but on average it is 4.5 % fat, 7.1 % carbohydrate and 0.8-0.9 % protein. It is produced in the body by the mammary glands by pulling sugar, protein, cholesterol and other nutrients from the mother’s bloodstream. Therefore, good nutrition is also very important during the “4th trimester.” Most hospitals recommend fortifying breast milk to increase the calories from the natural 20 calories per ounce, to 22-24 calories per ounce. These fortifiers can also supplement the baby with much needed vitamins and minerals.

UnknownBreast milk is also unique because it contains IgA, or Immunoglobulin A, which is critical to helping to build the infant’s immune system. IgA is quite high in breast milk from day 10 through the 7th month. Additionally, if the mother is breastfeeding, the child can expose the mother to their bacteria and in turn the mother will create antibodies to fight the bacteria, which in turn will be delivered back to the baby via the breast milk.

I have never breast-fed; I have only pumped, but I certainly hope to in the future. The act of breastfeeding is a remarkable bonding experience that also provides an outlet for giving the infant attention. Pumping, with a caretaker present, is also not bad and can grant mother’s a few minutes alone to think, pray, or even grab a quick snack. Another benefit of breast feeding for mothers is that it can foster post-partum weight loss to help the mother achieve a healthier weight after pregnancy. Typically, mothers burn 300 to 500 Calories when breastfeeding or pumping 8 times per day, or every 3 hours. Again, it increases oxytocin which assists the uterus in returning to normal size. For further tips and information on breastfeeding, visit La Leche League.

Both of the acts described above may be simple on paper, but more difficult to practice in daily life. I hope the benefits listed above encourage mom’s and dad’s to explore these ways to attend to, bond and communicate with their baby.

The Elite Eight Plus One

food and supplementsRegistered dietitians stand behind the mantra of “food first;” which means skip the supplements, as long as, you can obtain what you need from what you eat or drink. I have also always practiced and preached this stand point, but now I can no longer obtain enough of certain vitamins and minerals to reach the recommended daily values.

The Institute of Medicine (IOM) publishes dietary reference intakes, or DRI’s, for most vitamins and minerals. This administration individualizes the values based on gender, age, pregnancy and lactation. For example, it is recommended that a 30 year old woman strive for 18 mg of Iron everyday, however if that woman is pregnant she now needs 27 mg. As one can imagine the needs for moms-to-be of multiples are even greater, and while the IOM does not have current recommendations for these individuals, such as myself, the research literature does. I have obtained most of my micronutrient goals from Dr. Barbara Luke‘s and Dr. John Elliott‘s publications, which give specific recommendations for the following vital amines (vitamins) and minerals.

Vitamin B6This water soluble vitamin, like the other B-Vitamins, is critical for the metabolism, or breakdown and use, of protein, fat and carbohydrates. It also helps to form the developing brains and nervous systems of all the growing babies, while also playing a role in the formation of new red blood cells, antibodies to support the immune system, and neurotransmitters, which are those happy hormones such as serotonin, dopamine, and DHEA.

It can be found naturally in chicken, fish, pork, chickpeas, and baked potatoes. The DRI is 1.9 mg, but people can tolerate up to 600 mg without side effects. The literature also supports the use of vitamin B6 to help control morning sickness/nausea with recommendations of 25mg, three times per day along with Vitamin B12. Although, the mechanism of how this works remains unknown, my hypothesis is that it alters pathways in the vomiting center of the brain by increasing serotonin.

Folic Acid (Vitamin B9): This B-vitamin is one of the most popular pregnancy vitamins, partially due to the movement to fortified all refined grains in the United States to insure adequate folate to prevent neural tube defects during pregnancy. Most prenatal vitamins have 400-800 mcg of this vitamin, which is the DRI for a singleton and multiple pregnancy, respectively. Thus, it is evident that folate plays a critical role in the neural development of the babies, but also is required for DNA synthesis and aids in cell division. Also, like vitamin B6 it helps in the formation and maintenance of red blood cells to prevent anemia. Good sources of folate include dark leafy green vegetables, beans and legumes, egg yolk, sunflower seeds and liver.

Vitamin B12: B-12 is another powerhouse for neural and blood development and maintenance. It also helps to regulate DNA synthesis and can be found in every cell of the body. It can be found naturally in animal-based foods (meat, chicken, fish), dairy and eggs, as well as, from fermented teas such as kombucha. The DRI for B12 is 2.6 micrograms. As mentioned previously, Vitamin B12 can also be taken in conjunction with vitamin B6 for morning sickness. The recommended doses vary from 4 mcg per day up to 25 mcg, two times per day.

Vitamin DThis fat-soluble vitamin is unique in that in can be synthesized in our skin with the help of the sun. Unfortunately, for folks in the Midwest there is only adequate sunlight in a small window of the year. Therefore, most are commonly deficient in this vital amine. The DRI for vitamin D is 200 IU, however the human body can make 10,000 IU in about 20 minutes in the sun, which tells us our bodies can handle much more. Some research literature suggests that some women need up to 4,000 IU to obtain adequate serum levels during pregnancy. Vitamin D is not found in very many foods, but can be found in mushrooms, eggs, and fatty fish. It is also added to some foods such as in the case of milk.

Most people know that vitamin D helps to support bone development and maintenance by increasing the absorption of calcium and magnesium from the gut. It also plays a role in preventing cardiovascular disease, multiple sclerosis, and some forms of cancer.

IronIron is commonly supplemented during pregnancy and is the cause of several unwanted side-effects, such as nausea and constipation, but it is important in providing oxygen-rich blood to both mom and babies. Most moms-to-be need more than the DRI (27mg) for iron to maintain adequate amounts. The research that I have reviewed recommends 325 mg of iron daily for moms of multiples.

Iron can be found in red meat, liver, chicken, fish, beans, leafy vegetables and molasses. But, typically a supplement containing Iron sulfate is recommended. I encourage, and take myself, a slow releasing version of iron. SlowFe is a common name brand for this type. I also always take iron with vitamin C to improve absorption, and avoid taking it with calcium-rich foods which tend to inhibit absorption and utilization.

Calcium and MagnesiumThese minerals are the super heroes for building and maintaining mom’s bones while constructing baby’s skeletal structure. The DRI for calcium is 1,000 mg, however the research literature recommends closer to 2,000 mg and the DRI for magnesium is 36o mg but again the literature suggests 1,200 mg per day. In addition to calcium’s bone building role, it also acts as a signaling messenger for some hormones and a co-enzyme, or “right-hand man” in blood clotting. Magnesium also has significant roles in over 300 bodily reactions, including muscle and nerve function, maintaining a steady heart rhythm and regulating blood sugar and blood pressure. There is also a growing body of research on the use of magnesium sulfate to prevent pre-term labor. It is usually administered intravenously (via IV) in boluses of 4 to 6 g over 30 minutes and then maintained at 1 to 3g per hour to achieve serum levels of 5 to 8 mg/dL. This level is considered therapeutic at inhibiting, or stopping, myometrial (middle layer of the uterus) activity a.k.a. contractions. Needless to say, food sources of calcium and magnesium, as well as, supplements are very important for moms of multiples. Calcium is found in high amounts in tofu/soy, green vegetables, sardines, molasses and of course dairy products. Magnesium is found in wheat bran, dark leafy green vegetables, nuts and seeds and beans and legumes.

ZincThis mineral is required for an assortment of processes in the body. It is necessary for the activation of over 100 enzymes, and plays a large role in immune function, protein and DNA synthesis, cell division and wound healing. Therefore, one can see how it helps to support normal growth of the fetus during pregnancy. The DRI for zinc is 11 mg and daily intake is very important because it is not stored in the body. This mineral is another one that researchers believe is required in larger amounts. It is recommended to strive for 45 mg per day when preparing for a multiple birth.

So, those are the elite eight! Or, the eight micronutrients that are touted for playing very crucial roles in the maintenance of mom and growth and development of babies during a multiples pregnancy.

There is one more nutrient, a macronutrient, that recent research has pin-pointed as another key to neural development during pregnancy- DHA. Omega 3 fatty acids have exploded in popularity due to their powerful role in reducing inflammation, or putting out the fire, in the body. This decrease in inflammation can be attributed to two of the omega-3’s found in fatty fish, Docosahexaenoic acid (DHA) and Eicosapentaenoic acid (EPA).  DHA, specifically, is now being added to some prenatal vitamins due to studies noting that DHA can help reduce risks of poor retinal (eye) development and poor cognitive development. The International Society for the Study of Fatty Acids and Lipids currently recommends 300 mg per day of DHA for pregnant and lactating moms.  A new article published in the American Journal of Clinical Nutrition stated that mom’s who took 600 to 900 mg of DHA per day had longer gestations, bigger babies and longitudinal data points to better cognition for the children in their preschool years.

Despite obtaining 150-200% of the DRI for the nutrients listed above, supplements are still a critical part of my daily dietary regimen. If you’re a mom-to-be and have questions, or recommendations, about the information above, please contact me.

Written by: Cassie Vanderwall, MS RD CD CDE CPT

Double Time

It’s double time!  For those bandies and musicians or Tae-bo pros out there, you know this means it’s time to pick up the pace.

During the 2nd trimester, from weeks 15 to 20, babies double in size. So, you can imagine that the nutrient needs of both mom and babies alsoescalate. There are a variety of methods to determine how many calories are ideal during pregnancy. There are estimated energy requirement equations, some just say 300 extra calories and 30 extra grams of protein per day, and others encourage moms to add 500 calories per fetus and 25g protein. I, personally, think it is best to consume the amount of calories that promotes the ideal weight gain per week. For a mom of high order multiples it is 2.0-2.5 lbs. per week.

I was able to gain this at 3,000 Calories per day during the first trimester. This was a true blessing because with the nausea there was no way I was going to get to the original 5,000-calorie estimation. During weeks 13 to present, I have watched this weight gain slow-down, so I know it’s time to bump up the kCals. I really was quite surprised that there were not any meal plan examples- that I could find anyway- on the Internet. My best resource was in Dr. Barbara Luke’s book, “When you’re expecting twins, triplets, or quads.” This is where I derived the information regarding calorie and food group goals. Since there seems to be a gaping whole on the World Wide Web, I thought I’d go ahead and fill it.

Below you will find recommendations for calories, macronutrients (carbs, protein and fat) and suggested food group goals during pregnancy. While this information is targeted at high order multiple pregnancies, it is of course applicable to any pregnancy.

Calories goals may vary from 3,000-5,000 Calories per day, and I recommend watching your average weight gain from week-to-week to be sure you are getting enough. The composition of these Calories is important and different than the recommendations for the average American. Typically, it is recommended to consume a daily diet composed of 50-55% calories from carbohydrate, 15-20% calories from protein and 25-30% calories from fat. However, during pregnancy with super twins it is recommended to consume 40% of calories from carbohydrate, 40% calories from fat and 20% calories from protein. The reduction in calories from carbohydrate, I presume is to decrease one’s risk of gestational diabetes, which is much higher in pregnancies with 3 or more. Per Dr. Luke, this breaks down to the following:

Nutrients

3,000

3,500

4,000

4,500

Protein

 150g

176g

200g

225g

Fat

 133g

155g

178g

200g

Carbohydrate

 300g

350g

400g

450g

Food Groups

Servings per day

Lean Protein

4

5

5

6

Dairy

4

8

10

12

Grains

8

10

12

12

Fat

5

6

7

8

Fruit

7

7

8

8

Vegetables

4

4

5

6

This type of meal plan is quite different than my pre-pregnancy diet, so my typical pattern is a bit different. For example, prior to pregnancy I ate very little dairy and meat/poultry and the majority of my protein came from beans, peas, lentils, whole grains, and fish. It has been easiest for me, and my mild lactose intolerance, to add the lean meats versus 8-10 servings of dairy per day.  Also, before pregnancy I ate a lot of veggies and not so many fruits, so I continue to consume only 2-3 fruits per day and 8-plus servings of vegetables.

As mentioned previously, I have been consuming 3,000-3,500 Calories per day so I decided to share a few meal plans, or as RD’s call them “Typical days” to help make these recommendations real.  There are a few original high calorie, high protein recipes in the meal plans that I will add later. If you’re interested check back because I will be adding a recipe section to my blog. Also, I did not comment on the variety of supplements that I believe are a crucial safety net, so look out for that content coming soon!

Day 1

(3,065 Calories: 316g Carb, 92g Fat, 175g Protein)

Breakfast

  • Breakfast Taco Dip
    • ½ tsp Olive Oil
    • 1 Organic Egg
    • ½ Avocado
    • 4oz 0% Plain Greek Yogurt
    • Lentil Loaf (Recipe coming soon)
    • 2 Hard Shell Tacos, broken into chips
    • Up Your MassBanana Smoothie (Recipe coming soon)

AM Snack

  • Fruit and Yogurt Parfait with Granola
    • ½ cup Fresh berries
    • 1 cup Low-fat Vanilla yogurt
    • ¼ cup Nutty Granola

Lunch

  • Turkey and Avocado Sandwich
    • 2 slices Homemade Whole Wheat Bread
    • 3 oz Oven-roasted Turkey Breast*
    • ½ Avocado
    • 1 cup Fresh Spinach
    • 2 Clementines
    • ½ Cup Baby Carrots

PM Snack

  • Oat and Nuts Cereal
    • 1 ¼ C Oat Cereal
    • 1 C Unsweetened, Organic Soy Milk
    • ¼ C Roasted Pepitas
    • ¼ C Slivered Almonds

Dinner

  • Basil Mac & Cheese (Recipe coming soon)
  • 12 medium shrimp, cooked
  • 1 C Asparagus Spears
  • Skinny Cow Ice Cream Sandwich

Evening snack

  • PowerBarHarvest Peanut Butter Chocolate

Day 2

(2,993 Calories: 319g Carb, 94g Fat, 171g Protein)

Breakfast

  • 4 Up Your MassBanana Nut Pancakes (Recipe coming soon)
  • 1 C Unsweetened, Organic Soy Milk

AM Snack

  • Cinnamon Raisin Bagel with 1oz Cream Cheese
  • 1 C 2% Milk

Lunch

  • 1 Large Baked Potato with Lentil Loaf, melted Cheese stick and 2 Tbsp Salsa
  • 1 C Asparagus spears
  • 1 C Fresh Pineapple

Dinner

  • ¾ C Cooked Quinoa with 1 tsp Olive oil
  • 4oz Organic, Skinless Chicken Breast
  • 1 C Steamed Zucchini Squash
  • Skinny Cow Ice Cream Sandwich

 

Day 3

(3,710 Calories: 367g Carb, 154g Fat, 176g Protein)

Breakfast

  • Stuffed Baked Potato
    • 1 Large Baked Potato
    • ½ tsp Olive Oil
    • 1 organic Egg and 1 Egg white
    • 1 Melted Cheese stick
    • ¾ C Kidney Beans
    • ¼ C Salsa

AM Snack

  • ¼ C Dried Fruit
  • ½ C Almonds and Pumpkin seeds, mixed
  • 1 C Organic Skim Milk

Lunch

  • ¾ C Pasta with ½ C Meat Tomato Sauce and ¼ C Melted Mozzarella Cheese
  • 1 C Steamed Spinach
  • 1 Banana
  • 2 Tbsp Peanut Butter

PM snack

  • 1 Whole Wheat Pita
  • ½ C Original Hummus

Dinner

  • 5 oz Salmon with ¼ C Avocado Salsa
  • 1 C Wild and Brown Rice
  • 1 C Steamed Broccoli

Evening Snack

  • 1 ½ C Neapolitan Ice Cream**

* I try not to consume deli meat, so this was a baked turkey breast. I do reheat any lunch meat/protein that I bring as a food safety precaution.

** When you want to promote glycemic (blood sugar) control, eating sweets and desserts alone is a no-no. However, if the dessert is consumed within 1 hour of a meal or healthier snack, typically the blood sugar response is more favorable.

Written by: Cassie Vanderwall, MS RD CD CDE CPT