Meet our Pediatric Dietitian: Tiffani Ghere
I’m Tiffani Ghere, a Registered Dietitian, Board Certified Specialist in Pediatrics and Certified Lactation Educator. I’ve been married to Ryan for 29 years and I have 3 sons— Matthew (21), Ethan (18) and Carter (16)— plus a yellow lab named Birdie. I’ve been a clinical dietitian for 15+ years at a children’s hospital in Southern California, in the NICU, PICU and pediatric units. Currently, I’m working with our Medical Intelligence and Innovation Institute which is advancing children’s health through new technologies, products/devices, etc.
What I love most about my job:
I love educating parents and helping them feel confident about their choices in how they feed their babies. There is a lot of information and science to understand in deciding what children need to grow and thrive. Being able to translate complex medical evidence into language parents can understand and empowering them to make educated choices about food is one the best parts of being a pediatric dietitian. I love working on a multidisciplinary team where the different clinical perspectives challenge us to work together to provide the best plan of care for the patient. It creates empathy and makes us better practitioners.
I’m very proud that CHOC hospital (a pediatric healthcare system based in Orange County, California) was the first children’s hospital to add Bobbie formula to its enteral formulary. This addresses the very real problem of not previously having an FDA-approved substitution for European formulas, which are banned from use, for parents who wanted that type of formula.
Five most asked questions for a pediatric dietitian:
1- I put my baby to breast every 1-2 hours, how is he failing to thrive (FTT)?
As a clinical Pediatric RD who works in a children’s hospital, we often see normal, healthy newborns being admitted in the first few weeks of life for FTT. The baby may be cold, dehydrated, have jaundice or be hypoglycemic- all due to not being fed enough. It’s so frustrating for moms because they are doing everything they’ve been taught and are exhausted. The diagnosis with the term “failure” in it only adds insult to injury. And technically, it’s not a failure to thrive, but a failure to launch. The baby eats for a short time, falls asleep, wakes again in an hour, and eats again.
With breastfeeding, the foremilk that comes out first has a very high water content and is very dilute with regards to nutrients. It’s as the breast is emptied, that milk transitions and the hindmilk (rich in fats and nutrient-dense) is delivered. By having a weak or inefficient suck, the baby isn’t emptying the breast and getting to the hindmilk. The breast is also not replenishing its stores (supply-demand), so the milk volume decreases over time. The baby feeds, and feeds, gets less and less volume and nutrients- all while burning a lot of energy while trying to eat.
Fortunately, it’s usually easy to correct the course, and get mom and baby back on track. We supplement with formula (to avoid IV fluids), have mom pump so we can quantify the milk volume, and follow the baby’s weight trend closely. Usually, they go home with a combo feeding plan, follow up with their pediatrician and can get back to exclusive breastfeeding if that is the goal. If a full milk volume isn’t possible, then they are at least familiar with how to manage combo feeding and are in communication with their doctor to ensure adequate growth for their little one.
2- If I feed my baby formula, will he sleep through the night?
Parents, understandably, are desperate to get a baby to sleep. The newborn period is very challenging. The topic of feeding type and volume has prompted several studies looking into the effects of breast milk, formula and combo feeding on sleep patterns1. There is melatonin in breast milk, which is associated with sleep, however there is also evidence that breastfed babies wake more often at night than formula fed babies. Ultimately, there is no consensus for optimizing sleep with feeds, but the evidence does show that with time, usually by 6 months, sleep cycles become longer, irrespective of the type of feeding provided2.
3- How do I know my newborn baby is getting enough to eat?
Every parent wants to do things “right” with their newborn. In the first week, we track the number of wet diapers and poops a baby has as an indicator of adequate intake. For moms who are breastfeeding, milk volumes (milk “coming in”) can increase anywhere from 3-7 days depending on their anatomy, birthing experience and frequency and techniques with putting the baby to breast, so the baby may need some formula supplementation to meet the demand. Weight trends are the easiest indicators for how feeding is going with a newborn.
We expect all babies to lose weight after birth and aim to get them back to birth weight by day 10-14. If a baby is slow to meet this milestone, we dive deeper into the feeding practices and work with the pediatrician on a plan. The most important thing to remember is that every baby is unique and we follow his/her data, not that of other babies. If they are within an acceptable percentile and are following their curve on the growth chart, they are thriving.
4- If my baby is fussy does it mean I need to change what I’m feeding him/her?
This is a very common question and difficult to give one simple answer. All newborns will be fussy and cry because it is their only way of communicating with you. Their nervous and GI systems are immature and transitioning from the womb to the outside world takes time to adapt. Many babies are fussy at the same time period each day, which can be from overstimulation, being overtired, uncomfortable or in need to be held.
Can what they are being fed contribute to the fussiness? Absolutely, but it’s not the only thing to consider. The baby may need to be burped, changed, swaddled, unswaddled, held, massaged or repositioned (placed on tummy, back, etc). She may need the lights dimmed, less noise, white noise, a swinging motion or to be still.
Signs that a baby formula change may be necessary:
Loose, watery or bloody poops
Rash (diaper or other parts of the body)
Significant increase in the usual fussy period that doesn’t go away.
This should be addressed by your pediatrician so a full medical evaluation can be done.
5- How do I make a baby formula switch?
For the parents who find themselves, wanting to consider a formula change I would suggest a few things:
1. Let your pediatrician know you are changing your feeds, especially if you are jumping categories of formula (see below). It’s always good to keep them in the loop.
2. Give the new formula time (I usually say 4-5 days) before you evaluate if it is or isn’t working. Don’t make 3 formula changes in 1 week. Be strategic about it so you can evaluate if it’s making a difference.
3. Consider other factors in making the formula switch (availability of the formula, cost, safety).
Categories of infant formulas:
Intact formulas (Cow’s milk or soy)
Partially hydrolyzed formulas (Gentlease, Similac Sensitive, Total Comfort, Gerber Soothe)
Extensively Hydrolyzed formulas (Nutramigen, Alimentum, Pregestimil)
Elemental formulas (by Rx only: Elecare Infant, Neocate Infant)
Tiffani Ghere, RD, CSP, CLEC is a Bobbie Medical Advisor.