Sunday, March 27, 2011

Starting Solid Foods

Every day in my office I can see and hear tension in the faces and voices of parents as we discuss the introduction of solids into their baby's diet. Mothers take notes as I give advice on adding cereal and other baby foods. I receive requests for exact amounts a baby should be eating, as well as how to time breastfeeding or bottles with meals of solid food. Sometimes I sense that my answers and general guidance in this area are not specific enough to satisfy parents. An entire well visit for a four or six month old can be taken hostage by this topic, leaving little to no time to talk about anything else!

I can find myself baffled by this outcome. After all, feeding is only one of many topics I would like to discuss at a well visit. What about sleep issues, stooling patterns, infant development, behavior, illnesses, vitamins, safety, and immunizations? I have spent quite a bit of time thinking about this and discussing it with the other pediatricians in my practice. I think I understand why feeding solid foods can be such a source of confusion for parents, AND I want to help make it easier!

To first-time parents starting solid foods can be a complete mystery. Guidelines are vague and often seem to conflict. Lots of advice is given by friends and family members. Parenting magazines offer new suggestions in every edition. There are lots of feeding "myths" out there. Research on the dietary needs of infants is ongoing, which leads to changes in recommendations on when and what to feed. Some recommendations seem to be based on well-researched scientific evidence, while others are based on convention, custom, and experience. Parents often feel weighed down by the responsibility to provide good nutrition for their child. The baby food aisle at the grocery store is vast and overwhelming.

And then there are decisions to be made on whether to make or purchase your own baby food, in what order food should be introduced, and what foods to avoid until a certain age. If we top that off with the fear that one's baby will choke on thicker, textured, or chunky food, parents can be left completely paralyzed by the thought of introducing solid foods.

To first reassure you, I would like help you understand my overriding view on introducing solid foods. The following statements may help:

1. It's really hard to do it wrong!

2. There are many correct ways to introduce solid foods.

3. Even if you do something that you read, or hear is "wrong" it probably isn't really that bad. You can always stop what you are doing if you find out it really isn't advisable.

4. You can't "break" a baby by giving them solid foods in the wrong order.

5. Babies all over the world have been successfully introduced to solid foods since before the time of recorded history. This has been done in all different ways, with many different kinds of foods. Practically everyone was weaned from the bottle or breast and was eventually able to chew and eat chunks of food.

6. The mouths, tongues, throats, stomachs, digestive tracts, and fine motor ability of infants will naturally direct and allow them to consume solid foods.

7. Feeding solid foods isn't a competition between parents or babies. So what if your own mother had you eating steak by the time you were 3 months old? Or cereal, or squash, or prunes... Who cares if your sister's baby has tried all the vegetables and yours has only had green beans? This all will fade away in time, and you will move on to new arenas of competition: potty training success, behavior, reading ability, and athletic skills. But, I digress...

8. It's very difficult to really mess up on feeding solid foods. Try to relax.

9. I actually think feeding solid foods can be fun!

Now, on to specifics. In guiding you on how to introduce solid foods I have tried to take into consideration the available research on dietary concerns for infants. These include vitamin D supplementation, adequate iron intake, obesity, recommendations on exclusive breastfeeding, issues surrounding food allergies, asthma, and eczema, and more. After reviewing the research, policy statements, updates, and revisions on infant nutrition and feeding practices I, too, feel a bit overwhelmed! I have to let it all wash over me to condense it into some practical advice.

For a full-term healthy infant, introduction of solid foods should most likely take place somewhere between the ages of four to six months. Introducing solid food before four months is not recommended as it has been linked with a higher risk of obesity and may not supply a nutritionally complete diet. Formula or breast milk are the only nutrition a baby needs before he reaches four months of age. Contrary to popular belief, feeding solid foods such as infant cereal will not help your baby sleep through the night! Helping your baby sleep is an altogether different topic, and it does not involve solid foods.

As a general rule, to obtain maximum benefits from breast milk, exclusive breastfeeding (without adding solids) is encouraged until six months. Infants who are exclusively breast fed should receive 400 IU of vitamin D as a supplement starting in the first few days of life. In my experience, some individual infants are ready to eat solids before they reach six months of age. Infants who are ready to eat are able to sit (with a little support), hold their head steadily upright, reach for things, and grasp objects. They may show interest in what you are eating. When you put food in your mouth you may see them open their own mouths, or try to grab your spoon or fork. They may like to sit with you at the table, and seem to enjoy being present at a family meal. Even if your baby shows all these signs, if she is happy and content with nursing alone you can wait until six months to start solid foods. Or, if it would be enjoyable for both of you, you could start before six months in a relaxed, low-key way. Once again, how well your baby is sleeping at night should really not factor into your decision on when to feed solid food.

As you can see, except for encouraging you to wait until at least four months before introducing solids, I really encourage flexibility in determining when is best for your baby and your family.

Infants born at 36 to 37 weeks gestation will probably fit into these guidelines, as well. An infant born at less than 36 weeks gestation might need to be a little older, or an adjusted age could be used. Specifics for infants born early or with complex medical illnesses could be discussed with your own personal pediatrician, and are beyond the scope of this blog. Premature infants may need supplemental iron in addition to the recommended vitamin D supplements for breast fed babies.

My usual advice is to start with infant rice cereal. This comes in a dry, almost powdered form, that can be mixed with formula, breast milk, or water. You can find it in the baby food aisle at your grocery store. The rice cereal recommendation is traditional. I think it was originally made because hardly anyone is allergic to rice. Now we know a lot more about food allergies, and far fewer restrictions are in place for infants than in the past. However, traditionally the first food is still infant rice cereal. Probably infant oatmeal or barley cereal would be ok, too. Infant cereal is a good staple, and a good source of iron. Some extra iron is needed at around six months of age.

The nice thing about starting with cereal is that you can mix it to your desired consistency! There is no recipe here--just put a tablespoon of dry cereal into a bowl (not a bottle) and drizzle in some formula or breast milk (water is ok, but won't taste as familiar to your baby). Stir while dripping in the liquid and make the first little bowl of cereal kind of a thick cream soup consistency. Put your baby in a high chair and feed it to her with a little spoon. I generally discourage putting cereal in a bottle. That isn't the same as feeding solid foods, and it doesn't move a baby forward in her development.

This is the fun part! Get out your camera or video recorder. Watch the funny faces, and see the tongue push most of it out at first. Your baby has to learn how to handle the new texture, how to manipulate it with her tongue, and how to swallow it.

After feeding creamy soup consistency cereal to your baby once a day for a few days, if he is taking and swallowing it well, you can thicken the cereal to an applesauce or baby food consistency and continue to give it daily. After a minimum of three days you could think about introducing a new food, while continuing to give the cereal every day. Cereal usually stays in a baby's diet for months, generally twice a day. But there are lots of other foods to try, so after a while you will reduce its frequency.

One or two meals of solid foods per day is probably enough for the first month of feeding. The second month of feeding you could then go to two to three meals per day. By the third month three meals a day seems reasonable. However, there are no well-established rules, nor research-based evidence to direct you on how many meals a day to give your baby by a certain age. My guidelines here are general. Think about what fits into your schedule, how to work around naps, who will be providing the meals, etc.

Most babies seem to be eating three meals a day by nine months of age. By age one they are usually eating three meals a day, plus a few little nutritious snacks. Nursing or bottles just fit in around the meals. In the beginning just keep nursing and/or giving bottles as you have in the past. At first your baby won't eat enough food to fill himself up and he will still need the same amount of milk. Once solids are well-established and your baby is eating more of them (which might take a few months) you may naturally move to a different routine around nursing or bottles. Try not to feel stressed about this. Remember that, as you are introducing food, your baby's primary source of nutrition is still breast milk or formula.

After cereal has been started, and is being taken well, you can give other foods. These will include strained or pureed vegetables, fruits, and meats. Start only one new food at a time, and give that food to your baby each day for three days in a row. If your baby tolerates it without showing signs of an allergic reaction (hives, which look like welts, repeated vomiting, or wheezing and difficulty breathing), then you can add that food to your baby's list of safe foods and move on to another one. Your infant can have one of the safe foods at any time.

Just move through the single ingredient fruits, vegetables, and meats that are available as "First Foods" in your grocery store. I usually suggest alternating them. But there are no hard and fast rules here. Try a yellow vegetable, then a fruit, then a green vegetable, then a meat. Babies have taste buds that taste sweet things best, so you may find they especially like some of the fruits at first. To develop your infant's palate you should offer the full variety of foods, even the ones you find he doesn't like. Research shows that sometimes it takes 8 to 15 tries to get a baby to be willing to eat a food! Trying a variety also gives you some foods you can use if your baby's stools get too hard or soft. Bananas and rice cereal can sometimes be constipating, while prunes and pears can soften the stool. Oatmeal and barley cereals tend to be less constipating than rice cereal.

If you move through the foods (single ingredient cereal, fruits, vegetables, and meats) at a new food approximately every three days, then in about six weeks you will have tried all of the "First Foods." You can take it slower than this, especially if you start solids before six months of age. A typical meal plan after introducing all the "First Foods" would be cereal (mixed with formula or breast milk) plus a fruit, or vegetable, or meat for two meals in the day. An approximate serving size to work toward is one-half to one of the small baby food containers (2.5 oz.), plus an equal volume of cereal at a meal. I am trying to be quite general here. Your baby may advance more quickly or more slowly than this, and I am sure it will all work out just fine.

If you are making your own baby food (and please, no guilt here if you are buying food, I never made a drop of baby food for my children and I think they all turned out quite nutritionally replete!) then you might consider avoiding making a few foods that could be high in nitrates (spinach, beets, green beans, squash, and carrots) and simply buy these instead. Apparently baby food manufacturers use vegetables that are especially grown to be low in nitrates. According to the research the higher nitrate issue is more important for infants under three months of age, who won't be eating solid foods anyway. A more worrisome source of nitrates is contamination of wells, which makes it important to have your well water tested...another topic beyond the scope of this blog.

Juice can be useful if your baby becomes constipated. A few ounces of pear, apple, or prune juice is quite helpful to loosen hard stools. In that case juice should be given from a cup or sippy cup, not a bottle. Maximum juice intake per day should be 4 to 6 ounces. Other than for constipation, I don't recommend juice. Infants learn to love it, and end up preferring it to milk. There is not much nutrition in juice. It is actually mostly sugar, and even though it is "natural" sugar, the child's body doesn't know any difference. Many toddlers end up preferring it to milk, and their nutrition suffers from lack of calcium and vitamin D. It can cause tooth decay because children like to sip on it all day long. And it can lead to excessive calorie intake, or poor food intake because the child is all filled up on juice. Excessive juice can even cause chronic diarrhea!

Babies get lots of rashes, so how do you know if one is a food allergy? For the three day food trial I have described above you are simply looking for hives. Hives look kind of like insect bites. They are raised welts of various sizes that are lighter in the middle raised part, and red on the flat skin around the welt. They change locations and can be here one minute and gone the next. They can be itchy.

A little red rash around the mouth is a common result of the messy eating process, and is almost always more of an irritation from acidic foods than an allergic reaction. Tiny red dots on the upper chest and back are probably more likely to be heat rash. And a diaper rash by itself is hardly ever an indication of a food allergy. However, lots of fruit or other more acidic foods and drinks can cause stool or urine to irritate the skin in the diaper area. This is an irritation, not an allergy. Eczema can be due to a food allergy, but it most likely won't develop in the three day trial I am suggesting. If your baby has eczema you could talk to his doctor about any possible relationship to food he is eating.

Don't panic if she gags. Gagging is not choking. Gagging is the retching sound humans make when something unexpected hits the back of the mouth or throat. It is protective, and helps keep objects, food, and fluids from "going down the wrong pipe." A baby might turn red, make gagging noises, and have watery eyes or even vomit after gagging--but the presence of the noises and the pink or red color are signs that air is still moving and your baby is not actually choking. It is very unlikely that a healthy infant will actually choke (have airway obstruction) while eating infant cereal or other strained, pureed, or mashed baby foods.

If you are really worried about the possibility of choking then you should consider reviewing techniques to clear the airway of an infant, or take an infant CPR course.

If your baby repeatedly gags on food and doesn't seem to be making progress day-to-day in tolerating solid food then you should talk to his doctor. You may need to just back off for a week or two and then try again, but persistent difficulties should be discussed with your personal pediatrician.

I'm exhausted after covering this topic, so I will have to save the next step for another blog. I hope this information is helpful and takes some of the mystery out of starting solid foods. What I really want is for you to enjoy this next stage of your baby's life, to take lots of pictures, and create wonderful memories of your incredible little person starting to grow up! Have fun!

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