Introducing... Solid Foods

1. Introducing... Solid Foods

2. Current Guidelines • Children should be exclusively breast fed for at least 6 months (WHO, AAP & AAFP) • Gradual introduction of solid foods after 6 months (AAP & AAFP) • No cow’s milk before 1 year ( American Academy of Pediatrics)

3. Exclusive breast-feeding for 6 months • First semi-solid foods should be: • cereals without gluten • vegetables and fruits with low allergenic potential • Withhold foods with high allergenic risk until after 8-12 months • All household foods should be introduced gradually in the second year Torun B. Eating behavior from birth to 5 years. [Spanish] Arch Latinoam Nutr 1999 Jun; 49(2):97-100.

4. Most Proven Allergens: • Cow‘s milk • Egg • Fish • Wheat • Soy • Nuts • Citrus-fruits Stogmann W, Kurz H. Atopic dermatitis and food allergy in infancy and childhood. [German] Wein Med Wochenschr 1996;146(15):411-4.

5. Guidelines-Vegan Infants • Breast-milk for the first 4-6 months • may need B12 supplementation • soy-based formula is a possible alternative • Tofu, dried beans, and meat analogs should be introduced around 7-8 mnths • supplement zinc, iron and vit D and B-12 Mangels AR, Messina V. Considerations in planning vegan diets: infants. J Am Diet Assoc 2001 Jun; 101(6):670-7.

6. Guidelines-Vegan Infants • Soy milk should not be the primary beverage until after 1 year (Mangels) • Nutritional deficiencies have been found in children drinking “health food milk alternatives“ • Rice milk kwarshiorkor (protein) • Soy milk rickets (vit D) (Carvalho)

7. Based on Development • The introduction of solid foods should parallel the developmental changes that occur throughout the first year Bronner YL, Paige DM. Current concepts in infant nutrition. J Nurse Midwifery 1992 Mar-Apr;37(2Suppl):43S-58S. Kwavnick BS, Reid DJ, Joffres MR, Guernsey JR. Infant feeding practices in Ottowa-Carleton: the introduction of solid foods. Can J Public Health 1999 Nov-Dec; 90(6):403-7.

8. Must consider... • Development of digestive system • Lack of digestive enzymes • Teeth • Choking • tongue thrust reflex (4 months) • baby's tongue pushes food out • Immature kidneys • increased renal solute load • Food allergies

9. Signs of physical readiness: • Interested in the foods he sees the rest of the family eating • Can move foods from the front of his mouth to the back with his tongue • No tongue thrust reflex • Can sit up with support • Can control his head • Can control upper body movements

10. Signs of physical readiness: • Is at least 4 months old • Has doubled his birthweight • Wants to breast feed more than 8-10 times during a 24 hour period • If formula fed, drinks more than 32 oz. In a 24 hour period

11. Common Practices • Unfortunately, studies show that many mothers, around the world, are not following these guidelines...

12. USA • Although recommendations for delaying introduction of solid foods until 4-6 months have been in place for more than a decade, about half the mothers in this study did so earlier Skinner JD, et al. Transitions in infant feeding during the first year of life. J Am Coll Nutr 1997 Jun;16(3):209-15.

13. Risk Factors • Mothers were more likely to introduce solid foods before 4 months if they: • did not breast feed • were younger • had lower education • lacked support after birth • smoked Kwavnick BS, Reid DJ, Joffres MR, Guernsey JR. Infant feeding practices in Ottowa-Carleton: the introduction of solid foods. Can J Public Health 1999 Nov-Dec; 90(6):403-7.

14. Low Income Mothers & Feeding • Believed that it was better to have a heavy infant because infant weight was the best marker of child health and successful parenting • Feared that their infants were not getting enough to eat (therefore introduced rice cereal and other solid foods before recommended ages) • Used food to shape their children‘s behaviors (calm fussiness)

15. Low Income Mothers & Feeding “Acknowledged that some of these behaviors went against the advice of WIC nutritionists and physicians but chose instead to rely on their mothers‘ advice.” • Researchers stressed the importance of including grandmothers in educational programs Baughcum AE, et al. Maternal feeding practices and childhood obesity: a focus group study of low-income mothers. Arch Pediatr Adolesc Med 1998 Oct;152(10):1010-4.

16. Cultural Norms...

17. African American • Studies report the addition of semi-solids as early as 1-2 weeks of age • Cultural norm to feed cereal in the bottle and to feed other semi-solid foods within the first month of life • Grandmothers played a dominant role in deciding what the infant would eat Bentley M, Gavin L, Black MM, Teti L. Infant feeding practices of low-income, African-American, adolescent mothers: an ecological, multigenerational perspective. Soc Sci Med 1999 Oct; 49(8):1085-100.

18. Asian Indian Americans • Asian Indian American (AIA) mothers breast fed for shorter durations and introduced formula and solids at a younger age that Anglo American mothers • AIA mothers based these decisions primarily on the family network, not healthcare professionals Kannan S, Carruth BR, Skinner J. Infant feeding practices of Anglo American and Asian Indian American mothers. J Am Coll Nutr 1999 Jun; 18(3):279-86.

19. Early introduction of solids…What’s the big deal?

20. Early introduction of solid foods • Results in a displacement of energy intake from breast milk/formula • decreased caloric intake from protein and fat • increased carbohydrate Mehta KC, Specker BL, Bartholmey S, Giddens J, Ho ML. Trial on timing of introduction to solids and food type on infant growth. Pediatrics 1998 Sep;102(3 Pt 1):569-73.

21. Nutritional deficiencies? • Diabetes?

22. Opinion against early introduction of solid foods is based on concerns about • renal solute load • obesity • celiac disease • food allergy Haschken F. The Nutrition Committee of the Austrian Society of Pediatrics and Adolescent Medicine. Comment on nutrition with solid foods in infancy and early childhood. [German] Patiatr Padol 1992;27(3):57-9.

23. Dangers of Early Solids Research has shown links to… • Respiratory illness • Eczema • Allergies • Asthma • Diabetes

24. Introducing Solids

25. Introducing Solids • Accustoming infants to solid foods is a lengthy process... Patience! • Begin at a time that‘s relaxing for both you and your baby • If your baby is very hungry, prevent frustration by feeding him a little breast-milk or formula first

26. Introducing Solids • Use a very small spoon • plastic coated to protect gums • Never use a bottle or infant-feeder for semisolid or solid foods • increase the possibility of choking and/or overfeeding

27. Introducing Solids • Remember that breast-milk or formula is still the main source of nutrition during the first year • Increase the size of feedings very gradually • start with a tablespoon or two until your baby gets the idea • Respect baby's signals for being full • start to play, blowing bubbles, pushing the spoon away or turning the head

28. Introducing Solids • Introduce only one food at a time • wait a week before introducing another food • Always watch to see if the baby has any reaction • Vomiting • Diarrhea • Wheezing • Skin rash

29. Do not add salt, sugar or other seasonings to food! • Infants consuming commercially prepared baby foods had significantly less sodium in their diets than infants fed primarily table foods. Endres J. Poon SW, Welch P, Sawicki M, Duncan H. Dietary sodium intake of infants fed commercially prepared baby food and table food. J Am Diet Assoc 1987 Jun; 87(6):750-3.

30. As they grow… • 6-9 months old, start encouraging the infant to drink from a cup • As your baby gets more teeth, you can start to give him finger foods • teaches him how to feed himself

31. Finger Foods • Acceptable finger foods include • hard toast, melba toast, crackers, zwieback and soft/cooked vegetables and fruits • The following foods can cause choking and should not be used until your baby is older: • berries, grapes, cherries, and raw vegetables such as peas and carrots, nuts, raisins, adult dry cereals, whole kernel corn, hot dogs, chips, pretzels, and popcorn

32. Common Questions

33. Fruit Juice • 4-6 oz of juice per day (1 food serving of fruit) is more than adequate • must be pasteurized • not “drink”, “cocktail” or “beverage” • fruit juice offers no nutritional advantage over whole fruit • doesn’t promote “fruit-eating behavior” Committee on Nutrition. American Academy of Pediatrics: The use and misuse of fruit juice in pediatrics. Pediatrics 2001 May; 107(5):1210-3.

34. Fruit Juice • No nutritional indication to feed juice to infants younger than 6 months • Could risk having juice replace breast milk (formula) in the diet • reduced intake of protein, fat, vitamins, and minerals (Fe, Ca, Zn) • malnutrition and short stature have been associated with excessive consumption of juice Committee on Nutrition. American Academy of Pediatrics: The use and misuse of fruit juice in pediatrics. Pediatrics 2001 May; 107(5):1210-3.

35. Iron Absorption • Drinks that contain ascorbic acid consumed simultaneously with food can increase iron absorption by twofold • Fruit juice should be used as part of a meal or snack • not to be sipped throughout the day Committee on Nutrition. American Academy of Pediatrics: The use and misuse of fruit juice in pediatrics. Pediatrics 2001 May; 107(5):1210-3.

36. Fruit Juice... Concerns • Excessive juice consumption has been associated with chronic diarrhea, excessive flatulence, abdominal pain, and bloating • malabsorption of carbohydrate • Dental caries have been associated with juice consumption • prolonged exposure of the teeth (begin to erupt at approx. 6 months) to sugars Committee on Nutrition. American Academy of Pediatrics: The use and misuse of fruit juice in pediatrics. Pediatrics 2001 May; 107(5):1210-3.

37. American Academy of Periodontics recommend that: • juice be offered in a cup, not a bottle • infants should not be put to bed with a bottle (of any kind) • should not allow children to sip juice throughout the day • not only dental carries, also displaces nutrients Committee on Nutrition. American Academy of Pediatrics: The use and misuse of fruit juice in pediatrics. Pediatrics 2001 May; 107(5):1210-3.

38. Whole milk or 2%? • No differences in height, weight or % body fat • Reduction in total fat and saturated fat intake in toddlers can be achieved through the use of 2 % milk without compromising growth Wosje KS, Specker BL, Giddens J. NO differences in growth or body composition from age 12-24 months between toddlers consuming 2% and toddlers consuming whole milk. J Am Diet Assoc 2001 Jan;101(1):53-6.

39. Commercial vs. Homemade? • Homemade is cheaper and not as much work as it may seem • Super Baby Food by Ruth Yaron • e.g.. beets and spinach (nitrates in the soil) • If using commercially prepared baby foods, best to buy organic

40. Commercial Baby Food • Modified food starches are used in strained and junior foods and in some infant formulas • Few studies on the effect of starch feeding on the growth of young infants • bioavailability • effect on nutrient absorption • intestinal changes • toxic mutagenic and carcinogenic effects • Caution that they should be used prudently and sparingly Lanciers S, Mehta DI, Blecker U, Lebenthal E. Modified food starches in baby foods. Indian J Pediatr 1998 Jul-Aug; 65 (4):541-6.

41. Definite need for continued research • In the meantime, conservative approach is warranted • minimize potential problems

42. References • Baughcum AE, et al. Maternal feeding practices and childhood obesity: a focus group study of low-income mothers. Arch Pediatr Adolesc Med 1998 Oct;152(10):1010-4. • Bentley M, Gavin L, Black MM, Teti L. Infant feeding practices of low-income, African-American, adolescent mothers: an ecological, multigenerational perspective. Soc Sci Med 1999 Oct; 49(8):1085-100. • Borresen HC. Rethinking current recommendations to introduce solid food between four and six months to exclusively breast feeding infants. J human Lact 1995 Sep;11(3):201-4. • Bronner YL, Gross SM, Caulfield L, et al. Early introduction of solid foods among urban African-American participants in WIC. J Am Diet Assoc 1999 Apr; 99(4):457-61.

43. References • Bronner YL, Paige DM. Current concepts in infant nutrition. J Nurse Midwifery 1992 Mar-Apr;37(2Suppl):43S-58S. • Carvalho NF, Kenney RD, Carrington PH, Hall DE. Severe nutritional deficiencies in toddlers resulting from health food milk alternatives. Pediatrics 2001 Apr;107(4):E46. • Chandra RK. Food Allergy. Indian J Pediatr 2002 Mar;69(3):251-5. • Cohen RJ, Brown KH, Canahuati J, Riviera LL, Dewey KG. Effects of age of introduction of complimentary foods on infant breast milk intake, total energy intake, and growth: a randomized intervention study in Honduras. Lancet 1994 Jul 30;344(8918):288-93. • Committee on Nutrition. American Academy of Pediatrics: The use of whole cow‘s milk in infancy. Pediatrics 1992 Jun;89(6 Pt 1):1105-9.

44. References • Committee on Nutrition. American Academy of Pediatrics: The use and misuse of fruit juice in pediatrics. Pediatrics 2001 May; 107(5):1210-3. • Dewey KG, et al. Do exclusively breast-fed infants require extra protein? Pediatr Res 1996 Feb;39(2):303-7. • Donath SM, Amir LH. The introduction of breast milk substitutes and solid foods:evidence from the 1995 National Health Survey. Aust NZ J Public Health 2002 Oct: 26(5):481-4. • Edwards N, Sims-Jones N, Breithaupt K. Smoking in pregnancy and postpartum: relationship to mothers‘ choices concerning infant nutrition. Can J Nurs Res 1998 Fall; 30(3):83-98. • Endres J. Poon SW, Welch P, Sawicki M, Duncan H. Dietary sodium intake of infants fed commercially prepared baby food and table food. J Am Diet Assoc 1987 Jun; 87(6):750-3.

45. References • Esfarjani F, Azar MR, Gafarpour M. IDDM and early exposure of infant to cow‘s milk and solid food. Indian J Pediatr 2001 Feb; 68(2):107-10. • Fergusson DM, Horwood LJ. Early solid food diet and eczema in childhood:a 10-year longitudinal study. Pediart Allergy Immunol 1994;5(6 Suppl):44-7. • Fergusson DM, Horwood LJ, Shannon FT. Early solid feeding and recurrent childhood eczema: a 10-year longitudinal study. Pediatrics 1990 Oct;86(4):541-6. • Forsyth JS, Ogston SA, Clark A, Florey CD, Howie PW. Relation between early introduction of solid food to infants and their weight and illnesses during the first two years of life. BMJ 1993 Jun 12;306(6892):1572-6.

46. References • Freeman V, van‘t Hof M, Aschke F. Patterns of milk and food intake in infants from birth to age 36 months: the Euro-growth study. J Pediatr Gastroenterol Nutr 2000; 31 Suppl 1:S76-85. • Gerrish CJ, Mennella JA. Flavor variety enhances food acceptance in formula-fed infants. Am J Clin Nutr 2001; 73:1080-5. • Gustafson D, Sjoberg O, Foucard T. Development of allergies and asthma in infants and young children with atopic dermatitis-a prospective follow-up to 7 years of age. Allergy 2000 Mar;55(3):240-5. • Hampton SM. Prematurity, immune function and infant feeding practices. Proc Nutr Soc 1999 Feb; 58(1):75-8.

47. References • Haschken F. The Nutrition Committee of the Austrian Society of Pediatrics and Adolescent Medicine. Comment on nutrition with solid foods in infancy and early childhood. [German] Patiatr Padol 1992;27(3):57-9. • Hornell A, Hofander Y, Kylberg E. Introduction of solid foods and formula to breast fed infants: a longitudinal prospective study in Uppsala, Sweden. Acta Paediatrr 2001 May; 90(5):477-82. • Kannan S, Carruth BR, Skinner J. Infant feeding practices of Anglo American and Asian Indian American mothers. J Am Coll Nutr 1999 Jun; 18(3):279-86. • Kostraba JN, et al. Early exposure to cow‘s milk and solid foods in infancy, genetic predisposition, and risk of IDDM. Diabetes 1993 Feb;42(2):288-95.

48. References • Kwavnick BS, Reid DJ, Joffres MR, Guernsey JR. Infant feeding practices in Ottowa-Carleton: the introduction of solid foods. Can J Public Health 1999 Nov-Dec; 90(6):403-7. • Lanciers S, Behta DI, Blecker U, Lebenthal E. Modified food starches in baby foods. Indian J Pediatr 1998 Jul-Aug; 65 (4):541-6. • Mangels AR, Messina V. Considerations in planning vegan diets: infants. J Am Diet Assoc 2001 Jun; 101(6):670-7. • Mehta KC, Specker BL, Bartholmey S, Giddens J, Ho ML. Trial on timing of introduction to solids and food type on infant growth. Pediatrics 1998 Sep;102(3 Pt 1):569-73. • Mennella JA, Jagnow CP, Beauchanp GK. Prenatal and postnatal flavor learning by human infants. Pediatrics 2001 Jun; 107 (6):E88.

49. References • Skinner JD, et al. Transitions in infant feeding during the first year of life. J Am Coll Nutr 1997 Jun;16(3):209-15. • Stogmann W, Kurz H. Atopic dermatitis and food allergy in infancy and childhood. [German] Wein Med Wochenschr 1996;146(15):411-4. • Sullivan SA. Birch LL. Infant dietary experience and acceptance of solid foods. Pediatrics 1994 Feb;93(2):271-7. • Torun B. Eating behavior from birth to 5 years. [Spanish] Arch Latinoam Nutr 1999 Jun; 49(2):97-100. • Wosje KS, Specker BL, Giddens J. No differences in growth or body composition from age 12-24 months between toddlers consuming 2% and toddlers consuming whole milk. J Am Diet Assoc 2001 Jan;101(1):53-6.