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Starting Solids: The Old and the New and the Myths

Written by Kristen Stuppy MD

Many parents are excited yet apprehensive to start foods with their infants. So many questions, so many fears. So much food introduction guidance has changed in recent years, that what you did with your older kids might not be current. Change takes time, so not everyone agrees on the “new” rules. Talk to your own pediatrician to see their take on it all!

The older “rules” for starting foods were so confusing… different sources will vary on these rules.

  • don’t feed before 6 months is now ok to feed at 4 months if baby’s ready
  • don’t give nuts, eggs, and other “allergy” foods until ____ (2/3/5 years, varying by expert) is now it is okay to give allergy foods unless there is a family history of food allergy
  • don’t start more than one food every 3-5 days is now introducing multiple foods at one time is ok
  • start with rice, then add vegetables, then meat., wait until last for fruit is now begin with any foods, but try to make nutritious choices, such as meat which is high in iron and protein

Variations of this were plenty, depending on the provider’s preferences. No wonder there is so much confusion!!!!

New rules are much easier. I like easier.

  • Start new foods between 4 and 6 months, when your baby shows interest and is able to sit with minimal support and hold the head up.
  • Don’t give honey until 1 year of age.
  • Don’t give any textures your baby will choke on.

Done.

That’s it. Nothing fancy. Any foods in any order. Multiple new foods on the same day are okay. Common sense will hopefully guide types of foods. Nothing too salted. Try nutritious foods, not junk.

These minimal rules can make parents weary.

What about food allergies if foods are given too early?

Research does not support the thought that starting foods earlier lead to allergies. In fact, there is research to support that starting foods earlier might prevent food allergies. A full 180 degree change!

Pregnant women and breastfeeding mothers no longer have to avoid nuts or other allergy foods in most cases. If there is a close family member with a food allergy, it might still be beneficial to wait to introduce that food. Talk with your pediatrician in that case.

I admit that I was initially nervous about telling parents it was okay to give nut products in infancy. Not just the allergy aspect, but also choking risks. ~ Back to the no textures your baby will choke on… nuts are hard and round– two no-nos, peanut butter is thick and sticky– another choking risk.

Any of the more allergy prone foods should first be offered in small amounts at home. These foods include nuts, egg, and fish. Do this only if there is no one in your house who is allergic to that food.

Have diphenhydramine allergy syrup around just in case, but remember most kids are NOT allergic, and starting younger seems to prevent (not cause) allergy. In the case of nuts, since there is also a choking risk, you can try a food cooked with nuts or nut oil.

What about saving the fruit for last so they don’t get a sweet tooth?

Babies who have had breast milk have had sweet all along! Breast milk is very sweet, yet babies who are graduating to foods often love the new flavors and textures with foods.

Formula babies haven’t had the sweet milk, but they can still develop a healthy appreciation of flavors with addition of new foods. Saving fruit for last simply doesn’t seem to make a difference.

Adding fruits alone is not very nutritious though, so fruits should be added along with other more nutritious foods. The more colors on our plates, the healthier the meal probably is!

I thought they couldn’t have cow’s milk until after a year?

Cow’s milk is not a meal in itself (like breast milk or formula). It is missing many vitamins and minerals, so babies need to continue breast milk or formula until at least a year. Cow’s milk may lead to allergies or eczema, including formulas made with cow’s milk.

Milk products, such as cheese and yogurt can be given to babies as part of an otherwise well rounded diet as long as they don’t show any allergy risks to milk. Regardless of dairy intake, it is recommended for infants under 6 months to have 400 IU Vitamin D/day and those over 6 months to take 600 IU Vitamin D/day as a supplement.

I thought they should have cereal first…

Rice cereal has been the first food for generations, probably because grandma said so. There has never been any research supporting giving it first. With white rice and other “white” carbohydrates under attack now, it is no wonder the “rice first” rule is being debated. Despite being fortified with vitamins and iron, it is relatively nutrient poor, so choosing a meat or vegetable as first foods will offer more nutrition.

Shouldn’t we wait on meat?

Waiting on meat due to protein load was once recommended, but no longer felt to be needed. Pureed meats (preferably from your refrigerator… baby food meats are not very palatable!) are a great source of nutrition for baby! Some experts recommend meat as the first food due to its high nutritional value and low allergy risk.

How do we know what they’re allergic to if we start several new things at once?

First, most kids are not allergic.

Second, if they are allergic to a food, it is often days/weeks/months before the allergy is recognized. Waiting 3 days between food introduction simply doesn’t allow recognition unless it is hives or anaphylaxis, and there are a small number of foods that account for most of these reactions.

If your child has one of these reactions we can test to see what the offender was. This is recommended with severe allergies since people with one allergy might have other allergies, and identification for avoidance is important.

Allergy symptoms can be broad and often are not specific: dry skin (eczema), runny nose, hives, swelling of lips, difficulty breathing, vomiting, diarrhea, or blood in the stool. If you think your child is allergic to a food, discuss with your doctor. Severe symptoms (anaphylaxis) demand immediate attention!

How do we know when to start foods? I wanted to start to help baby sleep through the night, but I heard starting too soon increased obesity and diabetes.

When babies are able to sit with minimal support and hold their head up and when thye show interest in food by reaching for it they might be ready. They can wait until 6 months to start foods, but some studies show poor weight gain and nutritional balance as well as resistance to foods if started after 6 months.

In formula fed babies it has been shown to increase the risk of obesity at 3 years (6x!) if foods are started before 4 months of age. That risk is not seen in exclusively breast fed infants or those who begin foods after 4 months of age.

It is still an old wive’s tale that starting solids will help baby sleep through the night. Babies tend to sleep longer stretches at this age, so it is no wonder that this myth perpetuates. Start foods because you see signs that baby is ready, not because you want longer sleep patterns!

How do I know how much to feed my baby?

Babies will let you know when they are full by turning away, pursing their lips, spitting out food, or throwing foods. As they eat more food, they will need less breast milk or formula. In general a baby who is gaining weight normally will self regulate volumes.

What’s better: baby foods bought at the store or home made foods?

Marketing and ease of preparation has made pre-prepared foods for us all common place. It does not mean they are any better. They cost more than home made foods. I didn’t make baby foods when my kids were babies because I thought it would be too hard, but now I puree foods to put into recipes (my kids are like many who aren’t fans of veggies and I want to improve their nutrition). It really isn’t hard. You can take whatever you are cooking for your family and put it in a food processor or some blenders and with a little water to get it to a texture baby can eat: voila! Home made food. There are of course many baby food cook books and ideas of how to freeze meal-sized portions so you can make multiple meals at one sitting. There is help for parents who want to safely prepare baby food at home at the USDA website.

My baby only wants table foods. Is that okay? Don’t they need pureed foods first? He doesn’t have many teeth!

Pureed foods are what most babies start with due to the easy texture, but some babies quickly develop the ability to pick up small pieces of food with the pincher grasp (finger/thumb) and want to feed themselves. If they are able to get the food in their mouth, move it to the back safely with their tongue, and swallow without choking, they are ready to feed table foods… at least with some textures. Beware of chewy or hard foods as well as round foods ~ these all increase the risk of choking.

Most babies will be able to eat table foods between 9 and 12 months. They tend to not have molars until after 12 months, so they grind with their gums and use all their saliva to help break down food. They need foods broken into small enough pieces until they can bite off a safe bite themselves.

Don’t put the whole meal on their tray at once… they will shove it all in and choke! Put a few bites down at a time and let them swallow before putting more down. Rotate food groups to give them a balance, or feed the least favorite first when they are most hungry, saving the best for last!

This is a great time for parents, sitters, and other caregivers to take a refresher course on CPR in case baby does choke. Infants and young children are more likely to choke on foods and small objects, so it is always good to be prepared!

How much juice should my baby drink?

In general I think babies don’t need juice at all. They can practice drinking from a cup with water. Juice adds little nutritional value and a lot of sugar. Eating fruit and drinking water is preferable. If they do drink juice, it should be 100% fruit or vegetable juice, not a fruit flavored drink! No more than 4 ounces/day of fruit juice is recommended.

What about organic?

There is not enough evidence to recommend organic food, since the nutritional components of the foods are similar regardless of how they were farmed.

Organically grown foods do have lower pesticide residues than conventionally farmed produce, but it is debated if this is significant or not to overall health. Conventionally farmed produce have the pesticide levels monitored, and they fall within levels that are felt to be safe.

Organic farming rules also dictate no food additives or added hormones, which is also an area of study for health risks and benefits, but not enough data is available to give an educated opinion yet.

Organic farming is generally felt to be better for the environment, but the sustainability of that is questioned.

Many argue that the taste of organic foods is superior.

Organic farming might increase the risk of bacterial and fungal contamination or heavy metal content, so it is very important to wash fresh fruits and vegetables well prior to cutting or eating (as you should with all fresh foods).

For more information, see the USDA site.

A backyard garden can be inexpensive, organic, and a great way for your kids to learn about growing and preparing healthy foods!

 

Dr. Stuppy is a practicing pediatrician in Kansas. I feels privileged to be able to help families keep their children healthy and she loves watching entire families grow!  Dr Stuppy is active on Facebook and puts a more personal touch to pediatric topics on her blog.  

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What can I do to help my child’s allergies?

Written by: Kerry Frommer Fierstein, MD, FAAP

Pollen counts are high and allergies are bad. Phone calls and office visits regarding allergy have risen sharply in the last week or so. There are many steps you can take to help your child with allergies this time of year. We hope these suggestions will help, but if they don’t, please make an appointment with your pediatrician to learn about further treatment options.

What can I do to help my child’s allergies?

The best way to decrease allergy symptoms is to avoid the things to which you are allergic.

  • Wash hands when coming indoors – at school and at home.
  • Change clothes upon entering the house and do not keep the laundry hamper in the child’s room.
  • Shower nightly and as soon as possible when finished playing outside.
  • Keep plenty of tissues around and teach your child not to use a tissue to rub his eyes, especially outdoors, because this brings the pollen right to his eyes.
  • A cool compress will also help reduce swelling and itchiness.
  • If the allergy is to pollen, keep the windows closed and the air-conditioner on. (Clean filters regularly.)

What over-the-counter (OTC) medicines can I use?

Allergies are caused by the body’s release of histamines. Anti-histamines are a mainstay of allergy treatment. They treat the general symptoms of runny nose and itchiness.

 Benadryl is the most widely known anti-histamine, however, it is not the best choice for allergy sufferers, because its effects only last a few hours, and it often causes sleepiness. It can be useful at bedtime when symptoms are interfering with sleep.

Claritin (Loratadine is the generic name) is the most commonly used OTC allergy medication. It is dosed once a day, usually in the morning. The dose for ages 6 and up is 10mg – given either as a pill or a dissolvable tablet. A liquid form is available. It comes as 5mg per teaspoon. Children over 6yrs get 2 tsp. Children 4-6yrs get 1 tsp. Children 2-4yrs. get ½ tsp.

Zyrtec, generically known as cetrizine, is another commonly used allergy medicine available over-the-counter. Often providing more effective relief than Claritin, Zyrtec is also slightly more likely to cause sleepiness, so most physicians recommend using this once daily medication at night. The dose for ages 6 and up is 10mg – given either as a pill or a chewable tablet. A 5 mg chewable is available for children 4-6 years old. A liquid form is available as well. It comes as 5mg per teaspoon. Children over 6yrs get 2 tsp. Children 4-6yrs get 1 tsp. Chlidren 2-4 yrs get ½ tsp. Zyrtec brand liquid was taken off the market last year (along with Tylenol) and has not come back yet. Store brands of Cetrizine will work as well.

Allegra (fenofexadine) just became available over-the-counter in March 2011. If you have noticed that claritin or zyrtec are not working as well for your child, you should try Allegra. Dosing for those 12 years and older is 60 mg twice a day or 180 mg once a day. Dosing for children 6-12 years is 30 mg twice a day. For children under 6 years, check with your pediatrician. Allegra comes as liquid -30 mg per teaspoon and as 30 mg ODTs (orally disintegrating tablets.) It also comes as 60 mg and 180 mg tablets.

Decongestants, like Sudafed, can be added to antihistamines when congestion is the major problem, but this is not typically needed for Spring-time allergies.

If OTC antihistamines are not working make an appointment to discuss a prescription strength anti-histamine.

Will eye drops help?

Yes, if eye itchiness is a major symptom, then allergy eye drops will help. Zaditor is a medicated eye drop that is now available over-the-counter. It can be used in children as young as 3 yrs. It can be used on an as needed basis but will be more effective if used every day. If your child’s eye allergies are very bad this year, next year we would recommend starting eye drops in April, just before the season hits.

What can I do if over-the-counter medicines don’t work?

There are lots of prescription medicines for allergies. There are antihistamines such as Clarinex and Xyzal. Also, there are anti-inflammatories such as Singulair and there are eye drops such as Pataday, Elestat and Optivair. Lastly, pediatricians often recommend nose sprays  such as Nasonex, Flonase, Veramyst and Rhinocort.

As always, we recommend to make an appointment with the pediatrician to help you map out a plan for your child.

My child is on prescription medicines but is still having symptoms.

Often, when one medicine doesn’t work, another medicine in the same class will be more helpful. Or, it is possible to combine several different medicines. Make an appointment to see us and discuss the situation.

How can I tell an allergy from a cold?

  • Allergies don’t cause fevers.
  • Allergies often cause itchy eyes and noses, along with the clear runny nose.
  • Allergies cause sneezing “fits” as opposed to the occasional “achoo” of a cold.
  • Allergies can linger for weeks to months; colds are usually done within 2 weeks.

Do I need to see an allergist?

Allergists can be helpful when your child has not found relief from OTC meds or the prescriptions we have given you. Allergists can be helpful in many ways – identifying the cause of allergies, helping to adjust or minimize medications in chronic sufferers, and as a last resort, the formulation and treatment with allergy shots (immunotherapy).

Dr. Fierstein is a practicing pediatrician. Born in the Bronx and raised in Queens, Dr. Kerry Frommer Fierstein is a New Yorker all the way. She works atPediatric Health Associates, PC, a division of Allied Pediatrics of New York.