New Research: Why Parents Give Solid Foods Early

The American Academy of Pediatrics (AAP), American College of Obstetrics and Gynecology (ACOG) and American Academy of Family Physicians (AAFP) all recommend parents wait to start solid foods until about 6 -months of age. Why? Babies are not developmentally ready for solid foods until around this time and babies started on solid foods early are also at higher risk of certain chronic diseases such as diabetes and obesity . Yet, many parents start solid foods earlier than is recommended.

A group of researchers from the Centers for Disease Control (CDC) in Atlanta, Georgia decided to look at the age at which parents start solid foods and whether or not this varies by feeding method (breastfeeding,  formula feeding, or a combination of breast milk and formula feeding,). They also assessed the reasons why parents start solid foods in the first place.

The Study
1334 mothers were asked to complete food-frequency questions as part of a larger infant-feeding study. Reasons for starting solid foods before 4 months of age were assessed as well.

What they found was that fewer mothers who were exclusively breastfeeding started solid foods early compared to mothers who were formula-feeding and mixed feeding (24.3% exclusive BF, 52.7% formula fed, 50.2% mixed fed). About one quarter of mothers breastfeeding exclusively started solids before 4 months of age whereas about half of babies fed formula or both formula and breast milk were started on solids early.

Many of the reasons parents started solid foods early were related to the baby’s behavior. The most common reasons for starting solid foods early were: “My baby was old enough”; “my baby seemed hungry”; “I wanted to feed my baby something in addition to breast milk or formula”; “my baby wanted the food I ate”; “a doctor or other health care professional said my baby should begin eating solid food” and “it would help my baby sleep longer at night.” Let’s take a look at each of these reasons:

“My baby seemed hungry”

A baby showing hunger cues should be fed and babies only need breast milk or formula for the first 6-months of life. Sometimes it might seem that babies are more hungry than usual. There are several reasons why this might happen. Babies go through growth spurts when they will eat more than usual. This is normal! It does not mean your baby needs to start other foods besides breast milk or formula. Every baby is different, but growth spurts are normal around about 7-10 days, 2-3 weeks, 4-6 weeks, 3 months, 4 months, 6 months and 9 months of age. Watch for hunger cues to be sure your baby is hungry. Babies may also “act hungry” about 10-15 minutes after a feeding. This fussiness is generally caused by either gas or a bowel movement that is making the baby uncomfortable. Sometimes your baby will wake up after you lay him down to sleep after a feeding. This does not mean that your baby is still hungry! For more information about why this and other behaviors occur, click here.

“I wanted to feed my baby something in addition to breast milk or formula”

While it is very exciting to reach the milestone of starting your baby on solid foods, breast milk or formula is enough nutrition for your baby to grow and develop normally for the first 6-months of life. Exclusive breastfeeding until 6-months is also recommended by the AAP. When your baby is old enough you will get to introduce many new foods and share lots of feeding experiences!

“My baby wanted the food I ate”

While we don’t know exactly why the mothers in this study thought their babies wanted the food the mothers ate, we do know that it is developmentally normal that around 4 months of age babies develop the ability to point at things they want to learn about. Sometimes parents misinterpret this pointing as the baby “wanting” the food that the parent is eating. Your baby is just trying to explore his new world! Offering other things to reach for such as a toy or book can fulfill your baby’s need to explore.

“A doctor or other health care professional said my baby should begin eating solid food”

The AAP, ACOG and AAFP all recommend waiting to start solid foods until about 6-months of age. However, it can be confusing when doctors recommend something different than what you would expect. When other recommendations are made that you are not familiar or comfortable with, discuss the reasons for the recommendation and any concerns you have with the health care provider.

“It would help my baby sleep longer at night”

Starting solid foods does not help babies sleep longer. One study (Macknin 1989) showed that adding cereal to a baby’s diet before bedtime did not make the baby sleep any longer.

Understanding hunger cues and other normal baby behaviors may be helpful in delaying solid food introduction! Knowing why babies behave the way they do may help parents address the common concerns listed above without having to start solid foods early. When did you start solid foods with your baby? How did you make the decision to start at that age?

References

Clayton HB, Li R, Perrine CG, Scanlon KS. Prevalence and reasons for introducing infants early to solid foods: variations by milk feeding type. Pediatrics. 2013;131(4):e1108-14.

Macknin ML, Medendorp SV, Maier MC. Infant sleep and bedtime cereal. Am J Dis Child. 1989 Sep;143(9):1066-8.

Baby Behavior in the News: Spoon-feeding vs. Finger-feeding and Obesity Risk

With all of the buzz around obesity prevention in the US, you may have seen this in the news recently: claims that babies starting pureed solid foods (referred to as traditional spoon-feeding) first are more likely to be obese compared to babies whose first tastes of solid foods were finger foods (also known as baby-led weaning). Here are just a few of the headlines you may have encountered: "Babies Fed on Solid Foods Less Likely to be Obese"; "Solid ‘Finger Food’ May Help Babies Avoid Obesity"; and "Giving Babies Finger Food Could Stop Obesity." Today we will take a look at the study behind the headlines and explain why the the results of the study are overblown in the media.

The Study: Baby knows best? The impact of weaning style on food preferences and body mass index in early childhood in a case–controlled sample

155 parents of children between 20-78 months of age were given a questionnaire asking about their children’s feeding styles, starting solid foods, food preferences and consumption patterns, whether or not the child was considered a “picky eater” and the child’s height and weight. This was a cross-sectional study, meaning that the questions were asked at one point in time, and in this case, the answers to the questionnaires were compared between 2 categories of infants, those who were “spoon fed” vs. “finger fed” their first solid foods (referred to respectively as traditional spoon feeding and baby-led weaning in this study). Specifically, baby-led weaning refers to babies who are fed their first tastes of solid food via finger feeding or self-feeding. Traditional spoon feeding refers to babies who receive their first solid foods from a spoon (parent-initiated).

When these 2 categories were made, 63 children remained in the spoon fed group and 92 in the finger fed group. All of the health information gathered via questionnaire was then compared based on these 2 categories. The researchers were interested in seeing if children who started solid foods via either spoon feeding or finger feeding were more likely to be overweight or picky eaters.

The Study Results

There was no significant difference in BMI between babies in the spoon fed vs. finger fed group (10 spoon-fed children were above a healthy weight compared to nine in the finger fed group). There was a difference in the number of babies in the obese category, with 8 babies in the spoon fed group obese and no babies in the baby-led group obese. Three babies in the baby-led group were underweight and no babies in the spoon fed group were.

Study Limitations: What does all this mean?

While it does make sense that self-feeding, such as finger feeding, might result in better self-regulation of food intake compared to spoon feeding in which the parent is in charge of the feeding, this study was not designed to support this hypothesis. Cross-sectional studies only provide information about a snapshot in time, in this case provided via parental reports of infant feeding and health. Because this is not a randomized controlled trial, we cannot know for sure if finger feeding your baby first, as opposed to spoon feeding, actually leads to healthier weights and food choices.

Other limitations of this study include its small sample size and the majority of the sample itself had normal weights and longer than average breastfeeding durations. Babies in the finger-fed group were breastfed on average 23 months, more than double that of the spoon-fed group (9.5 months). The association between breastfeeding and obesity could have impacted the results of this study as well.

Bottom Line

We would need larger studies with different designs to be able to make a strong statement about which method of feeding baby’s first food results in better health outcomes. Also, knowing that every baby is different and developmentally ready for new food textures at different ages, it’s hard to make one conclusion as to what is best for all babies. So for now, the original guidelines for starting solid foods still apply: for the specifics, read our post Starting Solid Foods: It’s Worth the Wait. You can also take a look at another related news flash we posted entitled: Breastfeeding and Later Solid Food Introduction are Protective against Obesity in Young Children.

Reference
Townsend E, Pitchford NJ. Baby knows best? The impact of weaning style on food preferences and body mass index in early childhood in a case–controlled sample. BMJ Open 2012;2:e000298.

News Flash: Breastfeeding and Later Solid Food Introduction are Protective against Obesity in Young Children

A 2007 report from the CDC showed that 3 out of every 4 new mothers in the United States initiate breastfeeding. However, only 33% are exclusively breastfeeding at 3 months. That means 64% of babies nationally are at least partially formula-fed. (1) A 2011 study, that received widespread news coverage, now shows that formula-fed babies are at higher risk of obesity at age 3. Among those that are formula-fed and started on solid foods before 4 months of age, the risk of obesity at age 3 is even greater. (2)

Recommendations vs. Reality
Currently, 26% of infants in the US are introduced to solid foods before 4 months-of-age and, while the World Health Organization (WHO) and the American Academy of Pediatrics (AAP) Breastfeeding Section recommend introduction of solid foods at 6 months of age, many pediatricians (and even the AAP Committee on Nutrition) continue to endorse starting solids between 4-6 months of age. However, a recent study may provide more proof that starting solid foods before 4 months of age could have negative effects lasting into early childhood. (2)

Pediatrics recently published the results from a large study conducted at Harvard that compared age of solid food introduction (less than 4 months, 4-5 months or ≥6 months) and risk of later obesity in preschoolers. (2) Sixty seven percent of infants in the study were “breastfed” (defined as at least partly breastfeeding) at 4 months-of-age and 33% were “formula-fed” (defined as never breastfed or breastfed less than 4 months). Two factors were linked to increased obesity risk at age 3:

1. Early solid food introduction among babies who were never breastfed or were breastfed for less than 4 months - Those introduced to solids before 4 months-of-age had a 6-fold increase in odds of obesity at 3 years-of-age. Interestingly, early introduction of solid foods in babies who were at least partly breastfed for more than 4 months had no effect on later obesity, and moms who “breastfed” for longer than 4 months were less likely (8% compared to 33%) to start solid foods early compared to “formula-fed” babies and babies who breastfed less than 4 months. (2)

2. Breastfeeding Status - Breastfeeding status was also connected to obesity at age 3 years, with almost double the percentage of “formula-fed” babies obese compared to babies breastfed at least 4 months. (2)

What does all of this mean?
With 1/4 of babies in the US never breastfed and 1/2 breastfed for less than 4 months, delaying solid food introduction until after 4 months-of-age may be an important step towards decreasing obesity in young children. (2) Other studies also indicate that introduction of solid foods before 4 months of age is associated with rapid weight gain in infancy and higher body fat or weight in childhood. (3,4) Also, breastfeeding, even partly, for at least 4 months may be protective against early childhood obesity. (2) This is not to say that babies don’t reap added benefits when exclusively breastfed (such as reduced risk of gastrointestinal and respiratory illness, Sudden Infant Death Syndrome (SIDS) and allergies, to name a few)! (5) However, this particular study only compared breastfed (at least partly breastfed for at least 4 months) to formula-fed (breastfed less than 4 months or fed only formula) infants.

It’s also important to note that while it is recommended to delay solids until close to 6months-of-age, developmental signs of readiness for solid foods must still be observed in the infant before solid foods are introduced. For more information about what developmental signs to look for and which foods to feed first, click here.

Next time: Baby Behavior during illness

References:
1. CDC Breastfeeding Report Card –– United States, 2010. Web. 28 Mar. 2011.
2. Huh SY, Rifas-Shiman SL, Taveras EM, Oken E, Gillman MW. Timing of Solid Food Introduction and Risk of Obesity in Preschool-Aged Children. Pediatrics. 2011 Mar;127 (3):e544-51.
3. Baker JL, Michaelsen KF, Rasmussen KM, Sørensen TI. Maternal prepregnant body mass index, duration of breastfeeding, and timing of complementary food introduction are associated with infant weight gain. Am J Clin Nutr. 2004;80(6):1579-88.
4. Kim J, Peterson KE. Association of infant child care with infant feeding practices and weight gain among US infants. Arch Pediatr Adolesc Med. 2008;162(7):627-33.
5. Kramer MS, Kakuma R. The Optimal Duration of Exclusive Breastfeeding: A Systematic Review. WHO, 2002.

Starting Solid Foods: It's Worth the Wait

I can remember being very excited to start solids foods with my daughter (what dietitian turned first time mom wouldn’t be, right?). I saw starting solids as an important milestone to be achieved. And though I knew that starting solid foods would not help my baby sleep through the night (yes, I’ve read the research!), I secretly hoped it might help her sleep just a little bit longer. I can remember family members saying “Oh! She’s eating solids now. She must be sleeping more at night!” Then, they would look at me strangely when I would say “Nope. It had no effect on her sleep. In fact, she may be waking more frequently now.” They would counter with: “Wow. She’s a stubborn one!” True. She was (and is) one stubborn girl, but babies sleep through the night when they are ready to, and starting solids or giving a nice hearty bowl of oatmeal before bedtime won’t change that.

I’m sure I was not the first parent (or the last) to be confused by all of the information out there about starting solid foods. So, the following information is based on the American Academy of Pediatrics recommendations, my experience as a dietitian working with mothers and infants in a clinic setting, and my experience raising (and feeding) my own little girl.

The Recommendations
In the past, parents have been told to start solid foods when their babies are around 4-months old. Then, in 2004, the American Academy of Pediatrics provided updated recommendations stating that “infants may be physically ready to accept solid foods sometime between 4 and 6 months.” And just to make it more confusing, the Breastfeeding Section of the American Academy of Pediatrics* published their own recommendation stating that “Complementary foods rich in iron should be introduced gradually beginning around 6 months of age.” But, results from a 2008 study** showed that nearly half of all infants are still being fed solid foods before 4 months, and many doctors are still recommending starting solids around 4 months old. No wonder parents are confused!

Why wait so long?
While an infant’s GI (gastrointestinal) tract may be capable of handling solid foods by 3-4 months of age, oral, gross, and fine motor skills required for eating solids generally don’t emerge until around 4-6 months of age. Yes, that is a wide age range, but the new guidelines focus more on developmental readiness than on age. One baby may be ready at 4 months, while another isn’t ready until 6. When I tried to feed my daughter baby cereal at about 5 ½ months, she immediately turned her head away. I tried again at her next mealtime and she spit the cereal all over me. I took that as a sign that she wasn’t quite ready.

Ready or not?
So, how do you know for sure when a baby is developmentally ready to eat solid foods? Your baby needs to be able to do ALL of the following things to be ready to eat solid foods: sit up with support, hold her head steady, put her fingers or toys in her mouth, show she wants food by opening her mouth, close her lips over her spoon, show she doesn't want food by turning her head away and keep food in her mouth and swallow it.

What to feed first
The important thing is to start with an iron-rich food. Examples are iron-fortified infant cereal or baby food meats. Many parents start with cereal. You do want to start with single-ingredient foods, and feed only one food at a time to identify any foods that the baby may be allergic to. After starting a high-iron food, there is no specific order for new foods as long as there is a gradual progression of textures as tolerated. The progression of textures is smooth, mashed, chopped, and then tiny pieces. Just be sure that one texture can be chewed and swallowed before moving onto the next one.

How much should I feed?
Watch your baby’s cues. Babies will let you know when they have had enough. My daughter was very dramatic about this. When she was full, she would pick up her bowl of food and throw it across the room. Other, less messy, fullness cues include slowing the pace or stopping eating, spitting out or refusing the food or spoon, batting the spoon away, or closing mouth as spoon approaches. Maybe I should have paid closer attention to those early cues!

A final word about solid foods
If your baby doesn’t eat solid foods when you first offer them, don’t panic! At first, babies must learn to eat solid foods. Respect your baby’s fullness or disengagement cues, and try offering the food at a later feeding or on another day or week. Never force your baby to eat; that can create feeding problems later in life. As far as sleeping through the night is concerned, adding a little cereal before a baby is ready for it can do more harm than good and it won’t help a baby sleep longer. Starting solid foods early has been linked to increased risk for developing allergies and diabetes. As always, talk to your baby’s doctor about when it is best for you to start solid foods. But be sure to watch for those early disengagement cues, or you might get hit by a flying bowl!

Next time: What to Expect from Follow-up Appointments with A Preterm Baby

*http://www.pediatrics.org/cgi/content/full/122/Supplement_2/S25
**http://pediatrics.aappublications.org/cgi/reprint/115/2/496