“She will eat when she is hungry.” That in so many words is the mantra of grandparents blessed with experience and common sense and of most pediatricians when consulting parents challenged with a picky eater. From birth, children understand the simple equation that to survive they must eat. With rare exception, the motivating power of hunger can be leveraged for success even with infants who have spent their first months relying on enteral feedings. I have written an entire book based solely on the premise that if you present a young child food she will eat it … eventually ( “Coping With a Picky Eater: A Guide for the Perplexed Parent” New York: Simon and Schuster, 1998).

But if we reverse the words to read, “When she is eating, she is hungry,” do we have an equally valid observation? I think we have ample evidence that it is not.

I recently encountered an anecdote in one of the New York Times op-ed pieces by Perri Klass, MD, that got me thinking more broadly about the perception of hunger and its power to motivate (“Do parents make kids fat?” the New York Times, Jan. 8, 2018 ). Dr. Klass relates a story of an obesity specialist who herself had struggled with obesity. Despite her careful attention to everything she had learned about obesity management and breastfeeding, this woman was unprepared for giving birth to an infant who was “instantly a very dramatically hungry baby.”

The result was a year-long odyssey of pumping that included consultations with five different lactation consultants in the first frustrating month and a half. She eventually received some comforting advice from a pediatrician who reassured her that there was little research to guide her and to “just feed him; trust your instincts.”

While it is unfortunately true that there is very little good science we can fall back on when counseling women who are struggling with breastfeeding, I wonder about the wisdom of telling this mother to trust her instincts. I guess my hesitancy is based on 40 years of primary care pediatrics in which I could generally count on the instincts of young children, but their parents’ not so much. While maternal intuition is generally superior to the paternal version, I am hesitant to rely totally on either when facing a clinical dilemma such as defining hunger.

Is a fussy infant hungry because he seems to be comforted only by a bottle or breast? What about the fussy baby who is comforted by just a pacifier? What is the difference? There are several explanations, but it will require introducing the concept of nutrition deficiency.

Most babies who are satisfied with just a nipple, be it silicone or flesh, simply find sucking a comfort measure. A few, and I am sure you have seen some of them, are overly patient. They seem to be saying, “I need the calories, but you’re a good mom and I enjoy sucking. I can wait. Some day, you may make more milk or give me a bottle.” In the worst-case scenarios, their patience leaves these babies so nutritionally deficient that they can slip into apathy and die.

On the other end of the spectrum are infants who love to suck so much that they will ignore (or maybe lack) their own satiety center. They may be fussy for some other reason than hunger, most likely sleep deprivation, and will suck and swallow to comfort themselves even though they have met their nutritional needs. The surplus milk or formula is converted to unhealthy weight or is misdiagnosed as “reflux.” Could this phenomenon have a genetic basis? Has the mother in Dr. Klass’ scenario shared an inheritable problem with satiety with her infant?

There are no easy answers. As pediatricians, our job is to sort out those fussy “hungry” babies whose behavior means they are overtired from those who are nutritionally deficient, from those with a dysfunctional satiety center. Making the differentiation is difficult but much easier than helping parents ignore one of their instincts.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Email him at pdnews@frontlinemedcom.com .

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