This is more a blog post for us for future reference and to share with fellow parents who are trying to figure out how to start feeding their baby. So readers who just like the cute baby pictures, here's one. Feel free to skip the rest :)
When?
Now that Ezra is nearly 5 months adjusted, we are starting to look ahead to introducing solids - or complementary foods as they are called in the literature. While the AAP used to recommend starting solids between 4 and 6 months, they now recommend exclusive breastfeeding until 6 months. The WHO agrees with this recommendation. (The link the the AAP position paper lists the many reasons for exclusive breastfeeding until 6 months - including significant reduction in risk for ear infections, pneumonia, and severe colds). The WHO says, "Given that growth is generally not improved by complementary feeding before six months even under optimal conditions (i.e., nutritious, microbiologically safe foods) and that complementary foods introduced before six months tend to displace breast milk... the potential health benefits of waiting until six months to introduce other foods outweigh any potential risks" (from page 11 of the Guiding Principles).
So we will wait until Ezra is at least 6 months adjusted and also shows signs of readiness for solids - good head control (check), ability to sit up, interest in food, and the loss of the tongue thrust reflex. Breastmilk remains an important source of calories, as well as its myriad other benefits, as long as babies drink it. My breastfeeding goal is 14 months - til Ezra is 1 year adjusted - but I am open to going longer.
What Foods?
Recent American tradition recommends rice cereal as a first food. We will not be introducing rice cereal first, or probably ever, into Ezra's diet. A PubMed search for "infant rice cereal" reveals many studies about arsenic content in this food. A Spanish study and UK study found that the daily intake of inorganic arsenic from baby cereal exceeded recommended safe maximum intake in drinking water for adults when adjusted for bodyweight. The FDA is examining arsenic levels in rice, and as of September 2012, having analyzed 1/6 of the products they plan to analyze, recommended "a balanced diet that includes a wide variety of grains." While we feel comfortable eating rice occasionally as part of an adult diet, there are plenty of other foods we'd rather introduce at first.
In addition, rice cereal does not address one of two main vitamin deficiencies found in breastfed babies around the appropriate time for introducing solids - iron and zinc. Infant rice cereal is fortified with iron, and this practice has helped greatly to address iron deficiency in babies; however, zinc deficiency is unaddressed. This paper is a very informative review of zinc deficiency, how it relates to breastmilk levels and maternal diet, and zinc content of early complementary foods. It, as well as the pediatrician we saw for Ezra's 6-month visit, recommended introducing meats early on. Meat also helps with iron deficiency, although Ezra will continue to receive polyvitamin supplements with iron (they're drops we add to a bottle of breastmilk) until he is 1 year adjusted. This kind of supplementation is not usually necessary, but for a preemie it is beneficial since he missed out on most of the nutrient storage that occurs in the 3rd trimester.
However, just because we're not doing rice cereal doesn't mean we won't introduce grains. There is some evidence that introducing gluten in small amounts between 4 and 7 months while a baby is still breastfeeding reduces the risk for celiac disease and type I diabetes. So we will introduce grains in the first month of foods, starting with oatmeal (which is often contaminated with gluten) and occasional wheat cereal or crackers. We will make the cereal (as well as any purees that need to be diluted) with breast milk, not water, for the additional calories, protein, immunological factors, and digestive enzymes.
The position statements of various professional organizations from around the world recommend NOT delaying the introduction of common allergens such as milk, fish, and eggs. (AAAAI, AAP, ASCIA, ESPGHAN) This is a change from the AAP's previous recommendations, though the previous position statement linked said their recommendation was "based on consensus rather than direct evidence" (Table 1). (They do, however, recommend waiting until 1 year to introduce cow's milk since it is a poor source of iron compared to human milk.) However, Ezra may have had a reaction to shellfish in my diet via breastmilk (episodes of diarrhea and irritability after I ate shrimp a couple of times), so we will probably wait until he is 2 or 3 to introduce shellfish. Waiting may not prevent him from sustaining a potential allergy, but in a few years he will be able to tell us if his mouth itches, his stomach hurts, he is having trouble breathing, etc.
And of course, vegetables and fruits! Because they provide many vitamins and minerals as well as fiber, they should make up a large part of any human's diet, and that includes babies. However, according to this journal article, as well as the AAP, precautions should be taken to reduce nitrate consumption from vegetables in infants, as some veggies - particularly leafy greens - contain high levels of naturally occurring nitrates and nitrites that can cause methemoglobinemia in infants (particularly infants younger than 3 months because their hemoglobin is more easily oxidized by nitrites - and of course, we are not planning to feed anything but breast milk to a baby that young). (Here is a brief review of nitrate/nitrite toxicology and physiology.)
The AAP says to buy baby food because it's tested for nitrate & nitrite levels. However, the Chan abstract indicates that fresh, undamaged vegetables grown without pesticides can be prepared in ways that minimize nitrate/nitrite content. Cooking, freezing, not pureeing, removing stems from leafy greens, and peeling vegetables with skins help keep nitrate content low. We are joining a CSA (Community Supported Agriculture) this summer and will have lots of organic produce in our diets. High-nitrate produce includes leafy greens, beets, rhubarb, radishes, celery, string beans, This article is long, but has a bunch of tables with nitrate content of fruits, vegetables, and herbs grown across Europe as well as how different preparation methods affect conversion of nitrate to nitrite.
How?
Spoon-feeding purees is a time-honored tradition. However, with recent advice about the time to introduce solids having changed, it's also worth questioning if it's necessary to puree food and spoon-feed infants at 6 months. A 4-month-old lacks the dexterity to feed herself, but a 6-month-old typically is quite skilled at putting things in his mouth.
This has led to a recent trend called Baby Led Weaning (weaning in the British sense, meaning introducing solids). Basically, it theorizes that babies can be given a variety of soft table foods from 6 months on and allowed to feed themselves, and that doing so is a good sensory experience. (Of course, this is not a new idea, just a new name. Plenty of experienced parents will tell you that they skipped purees and just fed their babies table foods from the get-go, especially with their second, third, fourth, etc. children.)
There are a few studies (like this one and the one discussed here) to support Baby Led Weaning, but the evidence is pretty thin. There doesn't seem to be much research about whether spoon-feeding or letting the baby pick up food is better. (And these are almost certainly not the only ways babies are fed around the world and throughout history.)
There are, however, recommendations to support the consistency of food a baby should eat and when. The WHO guidelines (page 20) say mashed and semisolid foods at 6 months, "finger" foods by 8 months, "lumpy" foods no later than 10 months, with all "family foods" being appropriate by 12 months, to follow the baby's neuromuscular development - that is, the ability to chew. This should be fairly easy to assess.
Because of the lack of evidence, we'll just do whatever works for us. We will likely do a combination of spoon feeding and Baby Led Weaning. Ezra certainly likes to put things in his mouth and gnaw on them, so I think he will be ready to eat things like banana, baked sweet potato, or avocado from the beginning.
In Summary
- Continuing breastfeeding to at least 12 months adjusted.
- Waiting until 6 months adjusted and showing signs of readiness to start solids.
- Beginning with foods that can be eaten without chewing, increasing in lumpiness until 10 months.
- Primarily soft finger foods with some spoon feeding (preference-based).
- Introducing meats between 6-8 months.
- Not avoiding common allergens (except the one to which we think he may actually be allergic).
- Introducing gluten in small amounts before 7 months.
- No rice due to concern for arsenic levels.
- No cow's milk until weaning from human milk (nutritionally inferior to human milk or infant formula), but dairy products such as yogurt and cheese are fine.
- Limited leafy greens and string beans due to nitrite concerns.
- Limited vegetable purees due to nitrite concerns.
- Continue to give daily vitamins (due to prematurity).
- Organic fruits & vegetables.
 |
| Daffodil: not exactly part of a recommended infant feeding schedule. |
Now that Ezra is nearly 5 months adjusted, we are starting to look ahead to introducing solids - or complementary foods as they are called in the literature. While the AAP used to recommend starting solids between 4 and 6 months, they now recommend exclusive breastfeeding until 6 months. The WHO agrees with this recommendation. (The link the the AAP position paper lists the many reasons for exclusive breastfeeding until 6 months - including significant reduction in risk for ear infections, pneumonia, and severe colds). The WHO says, "Given that growth is generally not improved by complementary feeding before six months even under optimal conditions (i.e., nutritious, microbiologically safe foods) and that complementary foods introduced before six months tend to displace breast milk... the potential health benefits of waiting until six months to introduce other foods outweigh any potential risks" (from page 11 of the Guiding Principles).
So we will wait until Ezra is at least 6 months adjusted and also shows signs of readiness for solids - good head control (check), ability to sit up, interest in food, and the loss of the tongue thrust reflex. Breastmilk remains an important source of calories, as well as its myriad other benefits, as long as babies drink it. My breastfeeding goal is 14 months - til Ezra is 1 year adjusted - but I am open to going longer.
What Foods?
Recent American tradition recommends rice cereal as a first food. We will not be introducing rice cereal first, or probably ever, into Ezra's diet. A PubMed search for "infant rice cereal" reveals many studies about arsenic content in this food. A Spanish study and UK study found that the daily intake of inorganic arsenic from baby cereal exceeded recommended safe maximum intake in drinking water for adults when adjusted for bodyweight. The FDA is examining arsenic levels in rice, and as of September 2012, having analyzed 1/6 of the products they plan to analyze, recommended "a balanced diet that includes a wide variety of grains." While we feel comfortable eating rice occasionally as part of an adult diet, there are plenty of other foods we'd rather introduce at first.
In addition, rice cereal does not address one of two main vitamin deficiencies found in breastfed babies around the appropriate time for introducing solids - iron and zinc. Infant rice cereal is fortified with iron, and this practice has helped greatly to address iron deficiency in babies; however, zinc deficiency is unaddressed. This paper is a very informative review of zinc deficiency, how it relates to breastmilk levels and maternal diet, and zinc content of early complementary foods. It, as well as the pediatrician we saw for Ezra's 6-month visit, recommended introducing meats early on. Meat also helps with iron deficiency, although Ezra will continue to receive polyvitamin supplements with iron (they're drops we add to a bottle of breastmilk) until he is 1 year adjusted. This kind of supplementation is not usually necessary, but for a preemie it is beneficial since he missed out on most of the nutrient storage that occurs in the 3rd trimester.
However, just because we're not doing rice cereal doesn't mean we won't introduce grains. There is some evidence that introducing gluten in small amounts between 4 and 7 months while a baby is still breastfeeding reduces the risk for celiac disease and type I diabetes. So we will introduce grains in the first month of foods, starting with oatmeal (which is often contaminated with gluten) and occasional wheat cereal or crackers. We will make the cereal (as well as any purees that need to be diluted) with breast milk, not water, for the additional calories, protein, immunological factors, and digestive enzymes.
The position statements of various professional organizations from around the world recommend NOT delaying the introduction of common allergens such as milk, fish, and eggs. (AAAAI, AAP, ASCIA, ESPGHAN) This is a change from the AAP's previous recommendations, though the previous position statement linked said their recommendation was "based on consensus rather than direct evidence" (Table 1). (They do, however, recommend waiting until 1 year to introduce cow's milk since it is a poor source of iron compared to human milk.) However, Ezra may have had a reaction to shellfish in my diet via breastmilk (episodes of diarrhea and irritability after I ate shrimp a couple of times), so we will probably wait until he is 2 or 3 to introduce shellfish. Waiting may not prevent him from sustaining a potential allergy, but in a few years he will be able to tell us if his mouth itches, his stomach hurts, he is having trouble breathing, etc.
And of course, vegetables and fruits! Because they provide many vitamins and minerals as well as fiber, they should make up a large part of any human's diet, and that includes babies. However, according to this journal article, as well as the AAP, precautions should be taken to reduce nitrate consumption from vegetables in infants, as some veggies - particularly leafy greens - contain high levels of naturally occurring nitrates and nitrites that can cause methemoglobinemia in infants (particularly infants younger than 3 months because their hemoglobin is more easily oxidized by nitrites - and of course, we are not planning to feed anything but breast milk to a baby that young). (Here is a brief review of nitrate/nitrite toxicology and physiology.)
The AAP says to buy baby food because it's tested for nitrate & nitrite levels. However, the Chan abstract indicates that fresh, undamaged vegetables grown without pesticides can be prepared in ways that minimize nitrate/nitrite content. Cooking, freezing, not pureeing, removing stems from leafy greens, and peeling vegetables with skins help keep nitrate content low. We are joining a CSA (Community Supported Agriculture) this summer and will have lots of organic produce in our diets. High-nitrate produce includes leafy greens, beets, rhubarb, radishes, celery, string beans, This article is long, but has a bunch of tables with nitrate content of fruits, vegetables, and herbs grown across Europe as well as how different preparation methods affect conversion of nitrate to nitrite.
How?
Spoon-feeding purees is a time-honored tradition. However, with recent advice about the time to introduce solids having changed, it's also worth questioning if it's necessary to puree food and spoon-feed infants at 6 months. A 4-month-old lacks the dexterity to feed herself, but a 6-month-old typically is quite skilled at putting things in his mouth.
This has led to a recent trend called Baby Led Weaning (weaning in the British sense, meaning introducing solids). Basically, it theorizes that babies can be given a variety of soft table foods from 6 months on and allowed to feed themselves, and that doing so is a good sensory experience. (Of course, this is not a new idea, just a new name. Plenty of experienced parents will tell you that they skipped purees and just fed their babies table foods from the get-go, especially with their second, third, fourth, etc. children.)
There are a few studies (like this one and the one discussed here) to support Baby Led Weaning, but the evidence is pretty thin. There doesn't seem to be much research about whether spoon-feeding or letting the baby pick up food is better. (And these are almost certainly not the only ways babies are fed around the world and throughout history.)
There are, however, recommendations to support the consistency of food a baby should eat and when. The WHO guidelines (page 20) say mashed and semisolid foods at 6 months, "finger" foods by 8 months, "lumpy" foods no later than 10 months, with all "family foods" being appropriate by 12 months, to follow the baby's neuromuscular development - that is, the ability to chew. This should be fairly easy to assess.
Because of the lack of evidence, we'll just do whatever works for us. We will likely do a combination of spoon feeding and Baby Led Weaning. Ezra certainly likes to put things in his mouth and gnaw on them, so I think he will be ready to eat things like banana, baked sweet potato, or avocado from the beginning.
In Summary
- Continuing breastfeeding to at least 12 months adjusted.
- Waiting until 6 months adjusted and showing signs of readiness to start solids.
- Beginning with foods that can be eaten without chewing, increasing in lumpiness until 10 months.
- Primarily soft finger foods with some spoon feeding (preference-based).
- Introducing meats between 6-8 months.
- Not avoiding common allergens (except the one to which we think he may actually be allergic).
- Introducing gluten in small amounts before 7 months.
- No rice due to concern for arsenic levels.
- No cow's milk until weaning from human milk (nutritionally inferior to human milk or infant formula), but dairy products such as yogurt and cheese are fine.
- Limited leafy greens and string beans due to nitrite concerns.
- Limited vegetable purees due to nitrite concerns.
- Continue to give daily vitamins (due to prematurity).
- Organic fruits & vegetables.
I <3 your spectacularly science-y self. I read this entire thing. :)
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