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Solid Foods in Infancy

By Deborah M. Consolini, MD, Assistant Professor of Pediatrics;Chief, Division of Diagnostic Referral, Sidney Kimmel Medical College of Thomas Jefferson University;Nemours/Alfred I. duPont Hospital for Children

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(See also Nutrition in Infants.)

The WHO recommends exclusive breastfeeding for about 6 mo, with introduction of solid foods thereafter. Other organizations suggest introducing solid food between age 4 mo and 6 mo while continuing breastfeeding or bottle-feeding. Before 4 mo, solid food is not needed nutritionally and may be associated with an increased risk of food allergies, and the extrusion reflex, in which the tongue pushes out anything placed in the mouth, makes feeding of solids difficult.

Some evidence suggests that the early introduction of some foods (eg, egg, peanuts, wheat) might actually be protective against the development of food allergies (1). In 2008, the American Academy of Pediatrics released guidelines stating there is no current evidence that delaying the introduction of solid food (including egg and peanuts) beyond 4 to 6 mo is protective against the development of food allergies (2). However, there is still insufficient data to definitively show that early introduction of these foods prevents the development of a food allergy. Thus, the introduction of any specific solid food need not be delayed beyond 4 to 6 mo in most children. Exceptions may be children who have older siblings who have a peanut allergy because these younger children have an almost 7-fold increased risk of developing a peanut allergy. Skin testing of these younger children should be considered before introducing peanuts (3).

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 yr 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 yr 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 yr 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 yr, children can begin drinking whole cow’s milk; reduced-fat milk is avoided until 2 yr, when their diet essentially resembles that of the rest of the family. Parents should be advised to limit milk intake to 16 to 24 oz/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 oz/day or avoided altogether.

By about 1 yr, 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.

References

  • 1. Du Toit G, Katz Y, Sasieni P, et al: Early consumption of peanuts in infancy is associated with a low prevalence of peanut allergy. J Allergy Clin Immunol 122:984–991, 2008. doi: 10.1016/j.jaci.2008.08.039.

  • 3. Liem JJ, Huq S, Kozyrskyj AL, Becker AB: Should younger siblings of peanut-allergic children be assessed by an allergist before being fed peanut? Allergy Asthma Clin Immunol 4:144–1499, 2008. doi: 10.1186/1710-1492-4-4-144.