Feeding 101: When to Introduce Solid Foods
By Graciela Wetzler, M.D.
My advice to parents who want to start their young infant on solid
foods: Don't be in such a rush. Breast milk, supplemented by vitamin D
and iron, and iron-fortified baby formulas provide all the necessary
nutrients during the early months of life. So, despite advice from
friends or family to give solids to your two month old, remember that
there is no nutritional advantage to starting solids at that age. In
fact, there may be some risks associated with starting solid foods
Some infants may appear not to be satisfied by breast or bottle-feeding, especially those who have accelerated growth. It is as if they are always hungry and demanding, and this can be particularly upsetting to parents who are exhausted by sleepless nights and infants constantly sucking at the breast. For these infants, increase the volume and frequency of milk feedings since they may not yet be neurodevelopmentally prepared for the introduction of solid foods.
Young infants exhibit an "extrusion reflex" in which their tongue pushes away something placed in the mouth, and it is impossible to eat non-liquid foods until the infant loses this reflex. Parents who try to force a spoon into an infant's mouth are fighting a losing battle. When the child is able to sit in a receptive position for spoon-feeding - that is, keep his head and neck upright - he is considered neurodevelopmentally ready to "learn how to eat." Learning how to eat entails leaning forward and opening the mouth when hungry, swallowing the food, tasting the food and identifying flavors, and closing the mouth and pulling away when full. The baby's gastrointestinal system also needs time to develop the ability to digest and metabolize food. The American Academy of Pediatrics recommends the introduction of solid foods by four to six months, when these processes should be adequately developed.
If you have a faster growing and demanding baby, you may want to start solid foods at the earlier end of this range, and babies who are content with milk may be started at the later end of the age range. But just as there are dangers associated with starting solid foods too early, there are also problems with postponing this developmental milestone past six months of age. Some mothers, especially those who breast-feed, find it so easy and enjoyable that they are reluctant to start solid foods. Keep in mind that breast and bottle-feeding should continue until at least age one, when cow's milk may be introduced, and that solid foods should be considered a supplement to, not a substitute for, human milk.
The two biggest risks of introducing solid foods are choking and allergies. To prevent choking, parents need to make certain that the texture of the solid food is soft. Babies should always be fed in an upright position, and parents should be nearby in case of choking. Although there is no way to prevent allergic reactions, I recommend that new foods be introduced one at a time, at five to seven day intervals. If an allergic reaction does occur (i.e., vomiting, diarrhea, skin rashes), you will be able to identify which food is the cause. Spitting up is not an allergic reaction, and may merely be an indication that the baby does not like the flavor or texture. Babies' preferences change quickly, so you should try the rejected food again in a few weeks.
When introducing solid foods, start at once a day and build gradually to three feedings per day. These feedings should be at family meal times, when baby and parent will find it most convenient. Middle of the night feedings won't help the baby learn that eating should occur at meal times. Once this routine is established and enjoyable, daytime snacks can be added. The introduction of solid foods will change baby's stools. Don't be surprised when the color and texture of the stool becomes darker and harder. Most babies do not become constipated.
Iron-fortified infant cereals are ideal as the first solid foods because they can be mixed with either breast milk or formula for high caloric content. Unless the baby is being treated for gastroesophageal reflux disease, it is not recommended to add cereal to the bottle. Nor is it recommended to put other solid foods in a bottle because this can cause choking, and babies do not learn how to eat. The cereals I recommend are rice, barley, oat, and mixed cereals once all of them have been introduced in the infant's diet. Try to avoid barley and oat cereals until six months of age.
After cereals, introduce yellow vegetables (carrots, squash, sweet potatoes) because they are sweet and less gassy. Then come green vegetables (green beans, peas) and later fruits (apples, bananas, pears). Once all these foods have been introduced, I encourage parents to offer their baby a varied meal, including cereal, vegetables and sweet fruits. Food should be warmed to body temperature since, if it is too hot, it can burn a baby's soft palate. Parents should be wary of microwave-heated food because it's heated unevenly, and so the food's temperature should be tested throughout the container.
The risk of choking decreases with age, so parents can introduce more complex and textured foods by eight months. This includes well-cooked, chopped solid foods (e.g., tender carrots and other vegetables, and different fruits), finger foods, and teething biscuits, which babies can feed themselves. More dangerous foods, such as hot dogs, raw carrots, peanuts, whole grapes, popcorn, and round candies, should not be given until age three. By one year of age, infants should be eating most of the same foods as the rest of the family.
There are merits to both commercially prepared and homemade foods. Commercially prepared foods have added vitamins, homogeneous texture, and are hygienic, but certain canned foods may contain large amounts of salt and sugar that are not suitable for infants. Homemade foods are equivalent to commercially prepared foods, and in some cases may be more nutritious and flavorful. If you serve homemade foods, however, make sure that they have a soft texture, which can be achieved by mashing with a fork or pureeing in a food processor with a little water if necessary. Homemade foods do not need to be sweetened or salted, and honey should not be given to babies until 12 months of age because of the risk of botulism.
One of the biggest factors in the development of healthy eating habits is limiting the amount of sweetened juices that the baby receives. These juices contain fructose and sorbitol, and parents rely too heavily on them as a substitute for nutritional feeding. They suppress the baby's appetite for solid foods and can cause loose stools and diarrhea. Juices should not be introduced until a baby is able to drink from a sippy cup (sucking a bottle of juice for long periods of time can cause tooth decay) and limited to no more than 10 ounces per day. The amount of water in breast milk or infant formula is sufficient for babies' needs, and there is no need to supplement these liquids except when the weather is especially hot.