Solid foods in infancy

[Dave Paprocki]

The WHO and American Academy of Pediatrics recommend exclusive breastfeeding for about 6 months, with introduction of solid foods thereafter. Other organizations suggest parents can introduce solid food between age 4 months and 6 months while continuing breastfeeding or bottle-feeding. Before 4 months, solid food is not needed nutritionally, and the extrusion reflex, in which the tongue pushes out anything placed in the mouth, makes feeding of solids difficult. The introduction of solid food before 4 months of age and after 6 months of age may be associated with an increased risk of food allergies and celiac disease.
Increasing evidence suggests that the introduction of solid foods between 4 months and 6 months of age might actually be protective against the development of food allergies. In 2008, the American Academy of Pediatrics released guidelines stating there was no evidence that delaying the introduction of solid food (including allergenic foods such as egg and peanuts) beyond 4 to 6 months is protective against the development of food allergies (1). Subsequently, several studies have assessed the potential benefit of the early introduction of allergenic foods in infants (2–4). Thus, the introduction of any specific solid food need not be delayed beyond 4 to 6 months in most children. Per current guidelines for the prevention of peanut allergy in the United States, even high-risk children with severe eczema or egg allergy or both should be introduced to age-appropriate peanut-containing food as early as 4 to 6 months of age to reduce the risk of peanut allergy as long as peanut-specific IgE measurements and/or skin test results are negative (5).
Initially, solid foods should be introduced after breastfeeding or bottle-feeding to ensure adequate nourishment. Iron-fortified rice cereal is traditionally the first food introduced because it is nonallergenic, easily digested, and a needed source of iron.
It is generally recommended that only one new, single-ingredient food be introduced per week so that food allergies can be identified. Foods need not be introduced in any specific order, although in general they can gradually be introduced by increasingly coarser textures—eg, from rice cereal to soft table food to chopped table food.
Meat, pureed to prevent aspiration, is a good source of iron and zinc (both of which can be limited in the diet of an exclusively breastfed infant) and is therefore a good early complementary food.
Vegetarian infants can get adequate iron from iron-fortified cereals and grains, green leafy vegetables, and dried beans and adequate zinc from yeast-fermented whole-grain breads and fortified infant cereals.
Home preparations are equivalent to commercial foods, but commercial preparations of carrots, beets, turnips, collard greens, and spinach are preferable before 1 year if available because they are screened for nitrates. High nitrate levels, which can induce methemoglobinemia in young children, are present when vegetables are grown using water supplies contaminated by fertilizer.
Foods to avoid include

Honey until 1 year because infant botulism is a risk
Foods that, if aspirated, could obstruct the child’s airway (eg, whole nuts, round candies, popcorn, hot dogs, meat unless it is pureed, grapes unless they are cut into small pieces)

Whole nuts should be avoided until age 2 or 3 years because they do not fully dissolve with mastication and small pieces can be aspirated whether bronchial obstruction is present or not, causing pneumonia and other complications.
At or after 1 year, children can begin drinking whole cow’s milk; reduced-fat milk is avoided until age 2 years, when their diet essentially resembles that of the rest of the family. Parents should be advised to limit milk intake to 16 to 24 ounces/day in young children; higher intake can reduce intake of other important sources of nutrition and contribute to iron deficiency.
Juice is a poor source of nutrition, contributes to dental caries, and should be limited to 4 to 6 ounces/day or avoided altogether.
By about 1 year, growth rate usually slows. Children require less food and may refuse it at some meals. Parents should be reassured and advised to assess a child’s intake over a week rather than at a single meal or during a day. Underfeeding of solid food is only a concern when children do not achieve expected weights at an appropriate rate.
(See also Nutrition in Infants.)