The World Health Organization (WHO) and American Academy of Pediatrics (AAP) recommend exclusive breastfeeding Breastfeeding (See also Nutrition in Infants.) Breast milk is the nutrition of choice. The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for a minimum of 6 months and introduction... read more 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 Formula Feeding The only acceptable alternative to breastfeeding during the first year is formula; water can cause hyponatremia, and whole cow’s milk is not nutritionally complete. Advantages of formula feeding... read more . 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 AAP 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 References The World Health Organization (WHO) and American Academy of Pediatrics (AAP) recommend exclusive breastfeeding for about 6 months, with introduction of solid foods thereafter. Other organizations... read more ). Subsequently, several studies have assessed the potential benefit of the early introduction of allergenic foods in infants (2–4 References The World Health Organization (WHO) and American Academy of Pediatrics (AAP) recommend exclusive breastfeeding for about 6 months, with introduction of solid foods thereafter. Other organizations... read more ). 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 US, children 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, and 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 as long as peanut-specific IgE measurements and/or skin test Specific tests Allergic (including atopic) and other hypersensitivity disorders are inappropriate or exaggerated immune reactions to foreign antigens. Inappropriate immune reactions include those that are... read more results are negative (5 References The World Health Organization (WHO) and American Academy of Pediatrics (AAP) recommend exclusive breastfeeding for about 6 months, with introduction of solid foods thereafter. Other organizations... read more ).
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
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 Nutrition in Infants If the delivery was uncomplicated and the neonate is alert and healthy, the neonate can be brought to the mother for feeding immediately. Successful breastfeeding is enhanced by putting the... read more .)
1. Greer FR, Sicherer SH, Burks AW, American Academy of Pediatrics Committee on Nutrition; American Academy of Pediatrics Section on Allergy and Immunology: Effects of early nutritional interventions on the development of atopic disease in infants and children: The role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas. Pediatrics 121:183–191, 2008. doi: 10.1542/peds.2007-3022
2. Du Toit G, Roberts G, Sayre PH, et al: Randomized trial of peanut consumption in infants at risk for peanut allergy. N Engl J Med 372:803–813, 2015. doi: 10.1056/NEJMoa1414850
3. Perkin MR, Logan K, Tseng A, et al: Randomized trial of introduction of allergenic foods in breast-fed infants. N Engl J Med 374:1733–1743, 2016. doi: 10.1056/NEJMoa1514210
4. Du Toit G, Sayre PH, Roberts G, et al: Effect of avoidance on peanut allergy after early peanut consumption. N Engl J Med 374:1435–1443, 2016. doi: 10.1056/NEJMoa1514209
5. Togias A, Cooper SF, Acebal ML, et al: Addendum guidelines for the prevention of peanut allergy in the United States: Report of the National Institute of Allergy and Infectious Diseases–sponsored expert panel. J Allergy Clin Immunol 139(1):29–44, 2017. doi: 10.1016/j.jaci.2016.10.010
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