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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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Confused Which Vitamin To Give To Your Child?

Written by Sandra Graba, MD

With so many vitamin options available, choosing the right vitamin for your child can be a daunting task.

Not all vitamins are all the same! The age and health history of your child are important factors to consider. A premature infant will have different requirements than a healthy 2 year old.

My goal here is to give a sense of direction in the vitamin isle, but it is important to discuss individual needs with your doctor.

Often doctors will prescribe vitamins for your newborn, so that makes it much easier! Other times, they tell you the name of the vitamin to choose in the isle. The vitamins your pediatrician recommends at this age is a little different depending on whether your breastfeeding your child or not.

Vitamins For Newborns

Vitamin K is very important in the newborn period but thankfully all babies get a vitamin K shot right at birth and the subsequent needs are met by breastmilk and formula. Breast-fed babies need extra vitamin D: 400 IU and iron supplement of ~ 11mg daily starting at 6 months.

Six Month Old

Typically, pediatricians will give D-visol (vitamin D) through 6 months of age, then switch to poly-vi-sol (multivitamin) with iron starting at 6 months, but some pediatricians opt to start the multivitamin from the start. Either choice is fine. All formulas are iron and vitamin fortified to contain at least the recommended daily amounts for the first year of life.

12 Month Old

After the 1st birthday, life is completely different! Your little baby is turning into a toddler and with it comes a whole new challenge: feeding. We switch them from their vitamin fortified breastmilk or formula to whole milk and table foods.

Toddlers

The tricky part is that toddlers are inherently picky! They manage to get enough calories through all of the “picking” of their food, but do they get enough vitamins and minerals?

Consider this: One cup of whole milk (about 8 oz) has only ¼ of the recommended daily allowance of vitamin D, ½ to 1/3 of the amount of calcium, and no iron. This means that your child will need to drink 16- 32 oz (2-4 glasses) of milk to get all the vitamin D and calcium they need – but you would still need to consider their iron needs.

Also, high volume of milk intake (more than 16 oz a day) can lead to anemia. Translation: your mom was right that milk is good for you but there is too much of a good thing.

So, what to do? In general, all vitamins and minerals are important, but some are easier to get them to eat than others. We can focus on a few important ones: vitamin D, calcium, iron, B vitamins, and folate.

Iron is important in red blood cell formation and neurologic development among other things. It is plentiful in meat, dark leafy green vegetables, beans, tofu, cereal and bread. 1-3 year olds need about 7mg per day, 4-18 year olds about 10-12 mg per day except for menstruating adolescent girls who need about 15mg daily.

B vitamins are important for production of oxygen carrying cells and can be found in fish, poultry, meat, eggs, dairy, leafy green vegetables, beans/peas, breads and cereals. B6 and B12 are fairly easy to get in the diet. 1-8 year olds need about 0.5 – 0.6 mg per day and teenagers need about 1.0-1.3 mg/day.

Calcium is very important for growing bones. Some sources of calcium include cheese, yogurt, orange juice, fortified breads and cereals, spinach, and salmon. 1-3 year olds need ~ 500 mg a day, 4-8 yo need ~ 800 mg a day. and 9-18 year olds need ~ 1,300 mg a day.

Vitamin D is a tough one! The best source is the sun…but we spend most of our year bundled in sweaters, coats, scarves…you get the idea. There are a few natural food sources: cod liver oil, salmon, mackerel, tuna, liver, and egg yolk. My 3 year old definitely won’t eat liver. Thankfully, cereals and dairy are fortified. The current recommendation for all age groups is a minimum of 400 IU daily.

After sorting through the vitamin isle, it seems that either Flintstones’ Complete – it is ½ tablet for 2-3 year olds and a full tablet for older than 4 years or Centrum Kids Complete Multivitamin are the best bet for toddlers and school age kids.

Even still, they don’t provide 100% of the calcium and vitamin D in 2-3 year olds but they are pretty good for iron, B vitamins, and folate.

There are so many character and flavor choices available but the nutrition guide for these two vitamin types can at least provide a guide to compare the other vitamins to while your head is spinning in the isle. Overall, remember that vitamin supplements are just that – supplements to a healthy diet. Children with any special needs will have different requirements.

A few words on Gummy vitamins…

Though they taste good and are probably easier to get your children to take, the vast majority I have seen fall short in providing the necessary daily nutrients. Many contain ¼ to ½ the amount of vitamin D and 10% or less of the needed calcium;No gummies contain iron. Many have the minimum amount of B vitamins but less than the recommended folate. Each gummy does, however, contain about 3g of sugar. If the serving size for your child is 2 gummies, giving them their vitamins is about the same as giving them a ¼ cup of soda!

 

Dr. Graba is a practicing pediatrician at Salud Pediatrics.

Does My Child Need Vitamins?

By Jennifer Gruen, MD

This is one of our most commonly asked questions at well-child checkups.

Vitamins and minerals are important elements of the total nutritional require­ments of your child. Because the human body itself is unable to produce ade­quate amounts of many vitamins, they must be obtained from the diet. The body needs these vitamins in only tiny amounts, and in a balanced diet they are usually present in sufficient quantities in the foods your youngster eats.

Breast fed infants need vitamin D supplementation until they are able to eat foods containing at least 400 IU of vitamin D a day. Children in homes with well water may need a fluoride supplement to support dental health — ask your dentist or us for a prescription if your child does not consume fluoridated water elsewhere, such as school or daycare. Otherwise, in middle childhood, supplements are rarely needed.

For some youngsters, however, we may recommend a daily sup­plement. If your child has a poor appetite or erratic eating habits, or if she con­sumes a highly selective diet (such as a vegetarian diet containing no dairy products), a vitamin supplement should be considered.

These over-the-counter supplements are generally safe; nonetheless, they are drugs. If taken in excessive amounts (in tablets, capsules, or combined with other supplements), some supplements — particularly the fat-soluble vita­mins (A, D, E, and K) — can be toxic. Scientists are finding that in some special situations and diseases, vitamin supplementation can be an important con­tributor to health.

However, so-called megavitamin therapy or orthomolecular medicine — in which vitamins are given in extremely large doses for conditions ranging from autism to hyperactivity to dyslexia — has no proven scientific validity and may pose some risks. Vitamin C, for example, when consumed in megadoses in hopes of undermining a cold, can sometimes cause headaches, diarrhea, nausea, and cramps.

As much as possible, try to maximize the vitamins your child receives in her regular meals. Click here to read more about some of the vitamins and minerals necessary for normally growing children, vitamin rich foods and recommendations for specific supplements.

Dr. Gruen opened her practice, Village Pediatrics, in 2009, but prefers spending time creating fantastic kids birthday parties.