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 cows 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

• Cows 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 1996146(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-Apr37(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

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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 Jun16(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 childrens behaviors
  (calm fussiness)

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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
  Oct152(10)1010-4.

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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.

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Early introduction of solidsWhats 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
  Sep102(3 Pt 1)569-73.

21

• Nutritional deficiencies?
• Diabetes?

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• 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 199227(3)57-9.

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Dangers of Early Solids

• Research has shown links to
• Respiratory illness
• Eczema
• Allergies
• Asthma
• Diabetes

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Introducing Solids
25
Introducing Solids

• Accustoming infants to solid foods is a lengthy
  process... Patience!
• Begin at a time thats 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

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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

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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

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• 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.

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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

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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

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Common Questions
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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
• doesnt 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.

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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.

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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.

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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.

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• 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.

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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
  Jan101(1)53-6.

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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

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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.

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• 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
  Oct152(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 Sep11(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-Apr37(2Suppl)43S-58S.
• Carvalho NF, Kenney RD, Carrington PH, Hall DE.
  Severe nutritional deficiencies in toddlers
  resulting from health food milk alternatives.
  Pediatrics 2001 Apr107(4)E46.
• Chandra RK. Food Allergy. Indian J Pediatr 2002
  Mar69(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
  30344(8918)288-93.
• Committee on Nutrition. American Academy of
  Pediatrics The use of whole cows milk in
  infancy. Pediatrics 1992 Jun89(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
  Feb39(2)303-7.
• Donath SM, Amir LH. The introduction of breast
  milk substitutes and solid foodsevidence 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 cows milk and solid food.
  Indian J Pediatr 2001 Feb 68(2)107-10.
• Fergusson DM, Horwood LJ. Early solid food diet
  and eczema in childhooda 10-year longitudinal
  study. Pediart Allergy Immunol 19945(6
  Suppl)44-7.
• Fergusson DM, Horwood LJ, Shannon FT. Early solid
  feeding and recurrent childhood eczema a 10-year
  longitudinal study. Pediatrics 1990
  Oct86(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
  12306(6892)1572-6.

46
References

• Freeman V, vant 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 1S76-85.
• Gerrish CJ, Mennella JA. Flavor variety enhances
  food acceptance in formula-fed infants. Am J Clin
  Nutr 2001 731080-5.
• 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
  Mar55(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 199227(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 cows milk
  and solid foods in infancy, genetic
  predisposition, and risk of IDDM. Diabetes 1993
  Feb42(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
  Sep102(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 Jun16(3)209-15.
• Stogmann W, Kurz H. Atopic dermatitis and food
  allergy in infancy and childhood. German Wein
  Med Wochenschr 1996146(15)411-4.
• Sullivan SA. Birch LL. Infant dietary experience
  and acceptance of solid foods. Pediatrics 1994
  Feb93(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
  Jan101(1)53-6.