Saturday, November 27, 2010

When to do What: Guidelines for Nutrition the First Year of Life

Parents often wonder when is the appropriate time to introduce solid foods to their infant's diet. It seems like a simple question. So simple that the American Academy of Pediatrics (AAP) cannot agree on the answer. The AAP Committee on Breastfeeding recommends starting complementary foods (rice cereal and baby foods) after six months of age and the Committee on Nutrition recommends the introduction of complementary foods between four to six months old. Pretty simple, right? Obviously, we do not know the exact answer, but there are some general themes which seem to make sense. Below are my recommendations based on the limited scientific evidence, developmental milestones, and common sense. These recommendations will fit most infants, but understand that each child is different and may be ready to transition from one stage to the next at a slightly different time.

There is some scientific evidence, although not overwhelming by any means, that introduction of solids prior to four months may have some adverse effects, such as increasing the risk for Celiac Disease or Type 1 Diabetes in your child. Likewise there seems to also be some increase risk later in life if solids are delayed beyond 6 months. Babies around four months old typically have enough head control that they can sit in a high chair and hold their head up. I generally recommend that parents hold off on rice cereal and baby foods until the infant is at least four months old. This is extremely hard for some parents despite my warnings of possible adverse health consequences. Many believe that giving the infant rice cereal will help them sleep. Wrong. Sleeping through the night is a training process, not a rice cereal deficiency.

Once infants reach four months old, I recommend feeding them rice cereal mixed to an apple-sauce-consistency with either breast milk, formula, or water. Do this once or twice a day for a week or so. This allows your infant to get the hang of eating from a spoon. Notice that I did not say put the cereal in the bottle, cut a bigger hole in the nipple and have him drink his solid food. Use a spoon, interact with your child. Sure, it is more labor intensive and it is messy, but that is what a bib is for.

After about a week, you can start introducing the Stage 1 baby foods. You can use vegetables or fruits. Some people will insist that you have to introduce one prior to the other, but there is no scientific evidence regarding this. Most theories are based on the adult palate ("introduce fruits last because they are sweeter"). If you have ever tasted formula you will realize that the infant's palate and taste preferences are not the same as an adult. So pick a fruit or vegetable and go with it. I do recommend a three to four day trial period for each new food. Whenever you introduce a new food, make it the only new one for three to four days, so if there is some sort of reaction or rash, you can narrow down which one likely caused the problem.

Around six months old, you can move onto the Stage 2 foods, which are slightly thicker and come in larger jars. I think two to three meals a day is adequate at this point. Some of the Stage 2 foods will have meats, which is fine. In the past, parents were often told to introduce meats very last. There is no scientific evidence that this is necessary. In fact, there has recently been increased attention to preventing iron deficiency in infants and toddlers. Meats are a good source of dietary iron and I suspect pediatricians will be recommending meats earlier rather than later.

Around nine months, I give parents the green light with Stage 3 foods. These are, once again, thicker (chunks) and come in larger jars. I recommend offering three meals a day. Parents can also start with finger foods (e.g., veggie puffs or cheerios) as the infant typically has a pincer grasp (finger to thumb) and can pick up finger foods easily.

Between nine to twelve months, parents can start introducing soft, mushy table foods. By their first birthday, most infants are eating table food and have transitioned off baby foods. At their birthday, it is alright to change the infant from formula to cow's milk. Whole milk used to be solely recommended, but there is no evidence that it is necessary, so I recommend either whole or 2 percent milk. Also, get your baby off the bottle and switched over to sippy cups by a year old (no wimps please).

I do not recommend "next step" formulas and baby foods after an infant is a year old. I believe these products are just a way to make their companies more money. A well rounded diet (like the one you should be eating) is adequate to meet your infant's nutritional needs, and "next step" products are not necessary.

I will address vitamin and mineral supplements (vitamin D, iron, fluoride) in a future post.

1 comment:

  1. I realize Gerber is all over this site, so I'll tread lightly, but parents need to think twice when they start cruising the baby aisle for finger foods. Read labels. We bought veggie puffs only to realize they were basically Cheetos dusted with ranch seasoning, and that our kid was probably being set up for some super healthy snack patterns in the future! Keep it simple. Once your kid is ready for finger foods, you can forego the designer baby items and transition to normal foods you are already eating.