Introduction to Solid Foods
INTRODUCTION: The introduction of solid foods marks a significant change in the nutritional intake of your child. A complex series of mouth related, neurological and muscular activities are now being initiated, resulting in the smooth transition to independent feeding processes and the drinking from a cup. This presentation will help guide you along the path; it will provide practical tips for a process that often seems utterly confusing. Try to keep things in perspective. Very few people get to kindergarten without having learned independent eating skills. This guide is simply that - a guide. No matter how you introduce solid foods, most children are eating finger food by a year. So try to smile - it will certainly help when your little angel spits up all over your freshly laundered dress clothes or suit jacket.
WHEN TO START: Ask a dozen grandmothers and you will get a dozen answers. Ask a dozen pediatricians and you will get two dozen answers. In general, when there are so many pathways to the truth, it is probably worthwhile to listen to everyone and then choose your own direction. In 1958, the Nutrition Committee of the American Academy of Pediatrics (AAP) recommended that infants under 4-6 months be exclusively fed breast milk or formula. Although our understanding of nutrition has changed significantly in the past 5 decades, the time for starting solid foods has not changed, and the 2006 guidelines reaffirm the original position.
The medical advantages of waiting until 4-6 months include:
- Loss of primitive reflexes. Newborns have a number of primitive reflexes, which are protective in early life. The sucking reflex is helpful in initiating breast or bottle-feeding. However, try to put a spoon into a newborn’s mouth and he will not let go. At 4-6 months this reflex disappears and effective feeding patterns can emerge. The extrusion reflex is helpful in pulling the nipple into the baby’s mouth. Put a spoon even near the mouth and immediately, the tongue thrusts it out getting it all over the nearest person’s clothes. At 4-6 months this reflex also begins to disappear.
- Improvement of eye-body coordination. At 4-6 months the random motion of the hands disappears, replaced instead by more purposeful grabbing and transferring.
- Sufficient nutritional balance with breast milk or formula alone until 4-6 months. The mistake that most people make is that somehow solid food is more ‘solid’. In fact, breast milk or formula has up to 1/3 more calories than peas, their closest solid food competitor. The reason for introducing solid foods is to allow the chewing muscles to become more developed, as well as to augment the iron stores in the body.
- Reduction in allergies. Many studies have associated the early introduction of solid foods with a higher incidence of eczema, early gastroenteritis (loose stools and vomiting) and wheezing. This is because the immature gut allows foreign proteins to leak into the bloodstream, thus sensitizing the entire body to these proteins and leading to the above reactions. 2006 studies suggest that the optimum time to introduce solids from an allergy perspective is 4-6 months. There is a higher incidence of food allergies and skin problems when solids are introduced under 4 months as well as over 6 months.
- Reducing the mess. When everything is said and done, there are some very practical reasons to get started too early. Experienced parents will tell you that the earlier you start, the messier it is and reducing the baby food phase in order to jump right into finger food is always preferable.
Unfortunately, for many first time parents, the 4-6 month guideline is not sufficiently narrow. So how do you really know when your child is ready? One helpful guide is the growth chart that we review at each visit. Children in the 95th percentile are probably ready to start cereals closer to 4 months (unless there is a strong family history of allergies, eczema or asthma) while children in the 5th percentilecan probably wait until closer to 6 months. (Children in the middle percentiles should start after 5 months.) Most children, whether breast or bottle feeding, are taking 28-36 ounces of milk by 4 months of age. Children who are breastfeeding more often than every 2 hours past 4 months may be ready to start solids. Nighttime waking is rarely associated with hunger. Many children stop waking at night around 4-6 months but that appears to correlate with increased daytime activity at that age that spills over at night. Solid or no solid food, self-soothing babies whose parents allow them to fuss or cry themselves to sleep by 4 months are almost all sleeping fine at that age, while almost half of parent-soothing babies, who get rocked to sleep, are still waking at 8 months. When in doubt, it is fine to start a little cereal, but only to convince yourselves that it is not hunger so that you will be better prepared to let the baby cry a little in the middle of the night.
HOW TO GET STARTED: Traditionally, dry cereals (rice, oatmeal and barley) have been the first supplementary solid foods offered. When a child is ready for cereal, it should be mixed with breast milk or water (for breast feeders) or formula (for bottle feeders). Cereal should never be placed in the bottle; it only clogs the nipples and is never so important from a calorie standpoint to cause you to go through such contortions. When a child is ready for cereal, he or she is also ready for a spoon. Begin with 2 tablespoons mixed with 2 ounces of room temperature liquid (see Temperature below) and offer it 1-2 times a day, advancing to 4 tablespoons if tolerated well. There is rarely a problem with rice cereal (although some soy allergic children may have difficulty because it is made with soy oil). Cereals should be introduced at 4-7 day intervals and in children who start at 4 months, should probably be the only foods offered until 5 months. Start with rice and move on to barley and oatmeal (or vice versa). And do not expect to finish the whole box of cereal before going on to the next one. They usually last a long time!
GETTING A BABY TO TAKE BABY FOOD: If your child doesn’t appear to like a particular food, it is rarely the taste, but rather the texture. Remember formula fed children gobble down that horrible smelling formula, but place some grit in their mouths and they refuse it. Often you can tickle a child - make him laugh and open his mouth and you are on your way. But if it doesn’t work, forget it and try again 2 weeks later. And remember it is a slow process, which often gets more food on the baby than in the baby. According to the American Academy of Pediatrics, it is often necessary to try up to 10 times to introduce a particular taste. If your child will not take cereal, skip to vegetables and circle back and add the cereal to the vegetables or the fruits.
AFTER CEREAL, WHAT’S NEXT? Once your child has begun to eat baby food, there is no turning back! Although most grandparents recommend some applesauce or bananas, it is usually smoother to try yellow vegetables, green vegetables and then fruit. Although in the ivory tower of research, there is some controversy, if you had a choice between peas and applesauce, which would you take? When your child is taking vegetables, move up to feeding 3x per day with cereal in the morning (because that is what older children eat) and vegetables and fruits at lunch and dinner. Try to feed your child around the time that your family eats so that he can easily move into the swing of things with an eating schedule that approximates your own.
HOW MUCH TO SERVE? The answer is variable. Keep feeding until the baby gets tired of eating or you get tired of feeding! Some babies are bottomless pits and never stop eating. A rough guide is to give ½ of a jar initially and build up to a jar within a month. More than a jar is almost never necessary.
BASIC BABY FOOD BRANDS: The major brands of baby food, found on local aisles, are Beech-Nut (www.beech-nut.com) and Gerber (www.gerber.com). These product lines are divided into 3 stages. Stage 1 or beginner foods are pureed with the smoothest texture and have the purest formulation without additives or flavorings. Corn is corn and peas are peas. They are typically found in 3.5 oz jars and are introduced during the 4-6 month period. Stage 2 or intermediate foods are for more sophisticated eaters because they contain combinations of food (mixed vegetables) and are typically a little more textured. They are found in 5 oz jars and are introduced generally after 6 months. Stage 3 or toddler foods are for children who are learning to chew and mash. We generally do not recommend this stage except for parents looking for convenience because you can boil a pot of noodles or mash a hamburger and accomplish the same taste and texture sensation. There is no difference nutritionally between the two major brands and you should make your decision based on the availability in your local store or on price and coupon availability. There is no problem in mixing brands.
BASIC ORGANIC BABY FOOD BRANDS: The two companies with the most experience in the organic baby food market are: Earth’s Best (www.earthsbest.com) and Gerber Organic (www.gerber.com) and these can be found on the shelves of most supermarkets as well as at Toys R Us and Babies R Us. In order to be labeled organic, a baby food, like anything else, must meet standards set by the US Department of Agriculture and be at least 95% organic which means that they can prove that less than 5% of the content was produced with any pesticides or fertilizers. Organic food can not be irradiated (exposed to x rays to kill bacteria), genetically modified or produced with hormones or antibiotics. A recent study by Consumer Reports found that indeed, there were fewer traces of pesticides than in conventionally grown foods. The cost for organic baby food is considerably higher than that of regular baby food, about 25% across the board. The real question is organic better. The American Academy of Pediatrics has found regular baby food to be safe for use in infants and we have no reason to disagree. The choice to go organic is a personal one and one that can be implemented for your infant, your toddler, your school age child, your adolescent or your entire family.
NEWER ORGANIC BABY FOOD COMPANIES:
For those with more sophisticated interests and a willingness to pay a premium for organic baby foods and tastes, we offer the following:
- Homemade Baby (www.homemadebaby.com) – Can be found locally at Whole Foods in the refrigerated section. The “unique fresh chill preparation is designed to lock in freshness”. It is kosher and vegan as well as gluten free.
- Plum Organics (www.plumorganics.com) Can also be found locally at Whole Foods. They are cooked and flash-frozen, much the way you might cook and freeze your own foods.
- Tasty Baby (www.tastybaby.com) Can be found on Amazon.com. This company was founded by a chef at a major restaurant and comes in many tasty flavors.
- Yummy Spoonfuls (www.yummyspoonfuls.com) Is produced fresh every other week in a Dallas kitchen and is shipped frozen. There is no heat treatment and more complex tastes compared to other brands.
NUTRITIONAL VALUE OF BABY FOOD: A baby who is fed a proper, varied diet should get all of the necessary vitamins and minerals. But remember if 100% is good, 200% is not better. Vitamin drops are usually a waste of money (even in the pickiest of toddlers) but especially so in the first year because they are present in abundance in a typical infant diet. For the same reason most minerals are not necessary. Some of the typically fortified vitamins and minerals are mentioned below.
- Iron is a critical element in early childhood development. Many studies show that untreated moderate anemia in the first two years leads to irreversible intellectual deficits in older children. All full term babies have adequate iron stores that persist for three months, however, after that age; formula fed babies require some form of iron supplementation. Currently the most effective form of supplementation is found in the formula itself. And contrary to what 9 out of 10 grandmothers believe, there are many studies that demonstrate no constipating effect from added iron. Iron is present in smaller amounts in breast milk; however, because it is more bio-available (better utilized), supplementation is only necessary after 6 months. In breastfed babies the most practical source of supplemental iron after that age is iron-fortified cereals. Iron can be found naturally in beans (kidney and lima), peas (black-eyed, lentil and green), oatmeal, potatoes, collard greens, spinach, broccoli, prune juice and tomato juice. And if all else fails, Vitamin C and meat/fish/poultry enhance iron absorption. We will monitor a blood count at 12-15 months to ensure that even mild iron deficiency is noted and corrected.
- Sodium: This mineral is found naturally in many foods including human milk, cow’s milk, carrots, peas and applesauce. In other foods, it is added as a supplement in the form of sodium chloride or salt. Because it is unclear if excess exposure to sodium in the first year of life is associated with high blood pressure, in 1977 the food industry adopted a no-salt-added standard for commercial baby foods. You will not see a Recommended Daily Value for sodium on baby food jars because no sodium is necessary.
- Sugar: The term sugar is confusing to the average consumer. Clearly, complex sugars or carbohydrates are necessary as the suppliers of energy to the body and brain. In fact, more than 50% of an infant’s daily intake should be in the form of carbohydrates. Simple sugars, however, are the problem. The three most common simple sugars are lactose (milk sugar), fructose (fruit sugar) and sucrose (so-called table sugar). Lactose and fructose are part and parcel of a diet of milk and fruit. It is sucrose, which is unnecessary. Most baby foods are naturally sweet and contain no added sugar except for some of the fruits. Beware of foods that say “added corn syrup”. A baby should be experiencing a wide variety of tastes including tangy and tart and does better without a diet of uniformly sugary foods.
- Modified starches or tapiocas thicken a food and make it less watery and this is felt to be more appealing to parents. In general, starches are okay except that they replace real food. And soy based fillers are not necessary for growth. Because they are really just filler, you will notice that they are not present in most first stage type foods.
- Zinc is essential in maintaining cell growth by regulating the proteins that control genes and chromosomes as well as the immune system. It is present naturally in breast milk, meats and poultry and eggs and is added to formula, fortified cereals, wheat germ and certain cheeses.
- Calcium is essential for bone and teeth development, muscle contraction and blood coagulation among other things and is particularly important in preventing osteoporosis in females. It is found in adequate amounts in breast milk, formula, any dairy products, broccoli and apricots.
- Vitamin B complex which is necessary in metabolism or energy production, is found in highest concentration in green vegetables.
- Vitamin D is provided as a supplement in all commercial formulas. Breast fed babies do not receive sufficient Vitamin D and should be supplement with extra Vitamin D in the form of Tri-vi-sol (found in most Walgreens and some CVS’s). One dropper daily from 2 weeks until a year.
MAKING YOUR OWN BABY FOOD: The major advantage of homemade food is cost. It is much cheaper and easier to cook fruits and vegetables and blend them, than to buy baby food. It is not necessarily healthier to make your own baby food because the FDA regulates the use of preservatives and pesticides more carefully for baby food than it does for the food that the rest of us eat. For example, pesticides like Alar have been eliminated from all baby foods. Therefore, if this is the route you choose, carefully wash all the food that you use to eliminate pesticides as much as possible. Pouring the pureed food into ice cube trays, freezing it and putting the cubes into plastic bags is an efficient way to mass-produce and store. Please do not add sugar or salt; it took pediatricians 20 years to get the major companies to stop adding these substances because of their potential long-term deleterious effects on teeth and blood pressure. As your child grows, you can simply vary the blade on the processor and add texture and chunks. When serving meat or fish remove the bones and serve slightly warmed. Nitrate containing vegetables (beets, spinach, turnip and collard greens) may reduce the blood’s oxygen carrying capacity and should be avoided in the first 6 months.
FROM SIX TO NINE MONTHS: By this time, your child has hopefully begun to master cereals, vegetables and fruit.
- Stage 2 or strained food: The next step is to move on to a greater variety of foods, a greater texture and a cup. Unless your child is on a soy-based formula because of a reaction to a milk based formula, it is perfectly fine to introduce plain yogurt (fruit flavored yogurt has too much sugar) by 6-7 months. You can flavor the yogurt by putting in some baby food fruits. In general, introducing small amounts of dairy products (yogurt, cheese, cottage cheese etc.) in the second half of the first year is fine. However, the main beverage should continue to be breast milk or formula until one year because in infancy, large volumes of dairy products can damage a still-forming gut. Meats can also be introduced at this time, however, because of their texture, they are often not tolerated until 7-8 months. Strained or Stage 2 foods are not appreciably different from pureed or Stage 1 foods in texture. The tastes are a bit more complicated, the size is bigger and they come in combinations to make mixing easier.
- Finger Foods: Finger foods may be introduced at any times (usually 6-8 months) depending on the courage of the parents. Good initial finger foods include grains (bread, toast, zwieback), fruit (banana, apple, peach, pear, apricot - all without the peel), meat (meatballs, chicken pieces, hamburger, fish sticks), vegetables (carrots, mashed potatoes) and dairy (American cheese, macaroni and cheese, cottage cheese). Many 9-month olds are taking only baby food, a few are taking only finger foods and most are somewhere in between. CheeriosTM and KixTM are a great value - low in sugar, high in iron and tough to choke on. Then there are mashed bananas, carrots, hamburgers, spaghetti and macaroni and …the sky’s the limit.
- Stage 3 or chunky foods: Stage 3 foods or dinners and so-called graduate foods are convenient but rarely necessary. By the time a child is ready for dinners, he can eat part of your dinner. Remember you do not need any teeth to eat chunky foods; there are a lot of 80 year-olds around with no teeth that manage to do quite well with textured foods. Ignore the age ranges on the labels; no child reads labels. Go with your gut instinct and to give you added peace of mind, we will review what to do about choking at the 6 month visit.
JUICES: Strained juices provide a maximum of 4% of the daily caloric intake of infants during the first year. In general, they are made by strained and homogenized natural fruits and by removing the particles and supplementing them with vitamin C. They are excellent sources of potassium, vitamin B6 and of course, vitamin C. Are they necessary? In general, no! Both breast feeders and formula feeders get all the nutrients they need from their milk. Getting a child use to juice at an early age makes it difficult to introduce more bland foods and gives unnecessary calories and also provides a clear source for tooth decay and is a waste of money. The average two-year consumes over $200 in juice a year. According to the 2006, American Academy of Pediatrics recommendations, no more than 4-6 oz of juice should be provided to any child between 6-12 months. Our recommendation is to give your infant no juice.
ESTABLISHING A SCHEDULE: Schedules are nice when they work out but almost impossible to establish especially with breastfed babies. In general, start with 2 feedings a day when just introducing cereals and move to a three-meal schedule by six months with breastmilk or formula upon waking and breakfast/milk, lunch/milk, late afternoon breast milk or formula, dinner/breast milk or formula and breast milk or formula before bedtime. The late afternoon nursing or formula bottle is usually the first to go.
TEMPERATURE OF BABY FOOD: Cereals can be served with warm or cold milk (breast or formula) or water. Fruits are at their best at room or refrigerator temperature. Meats and vegetables alone, and in combination, are best when slightly warmed. Microwave heating is not recommended because pockets of superheated steam may form, causing very caustic burns.
REFRIGERATION: Don’t open a jar until you are ready to serve the first portion. Two signs show the jar has kept its vacuum seal: the convex position of the safety button and the pop heart when it is opened. If you don’t notice both, return the jar to your grocer. At each feeding, transfer the desired amount to a serving dish. Then return the jar to the refrigerator. Baby food will keep very well in a refrigerator for 72 hours. However, any portion of the food that has touched the baby’s saliva is contaminated with bacteria and should not be used for more than 3-4 hours even when subsequently refrigerated.
MISCELLANEOUS FEEDING TIPS:
- Offer a variety of tastes and textures: the first year of life is all about experimenting and we want to give the baby as many different such experiences as possible.
- Never put baby food in a bottle, if the baby is ready for solid food, he will take it from a spoon.
- Expect a change in stool patterns; in general, the stools become a little more formed, a little greener and a little less frequent. This is not because of any additive or mineral but rather, because the child is simply eating a different food that requires adjustment by the gut. If the stool remains hard, add 1-2 ounces of prune juice (adult is fine) to 2 bottles a day or mix it in with the cereal.
- Never put a baby to bed with a bottle in his mouth. The sugar from milk can leach into the teeth, causing erosion of the teeth (milk bottle caries).
- Foods upon which the baby can choke: popcorn, nuts, unmashed peas, raisins, potato chips, corn on the cob, uncut grapes and uncut hot dogs.
- In general, don’t worry about fat content in the first two years of life. Fat is necessary for brain growth (hence the term fathead) and should not be restricted until much later. In 2008, new recommendations from the American Heart Association suggest that if there is excessive weight gain by 18 months, it is fine to restrict fat. Please discuss with us any concerns about weight.
- Begin the introduction of a cup between 7-9 months. Start with water occasionally at mealtime and try the cups without handles. Just be prepared for significant spilling.
- Smile! This period lasts such a brief time that if you get too stressed out you’ll miss it. Flexibility and an easy-going attitude are both necessary ingredients for getting to the first birthday. And then it is celebration time for both parents and child. Good luck!