Solid Foods in Infancy

The World Health Organization (WHO) and American Academy of Pediatrics (AAP) recommend exclusive breastfeeding (chestfeeding), when possible, until introduction of solid foods at approximately 6 months of age (1, 2). Other organizations suggest that parents introduce solid food between age 4 months and 6 months while continuing breastfeeding or bottle-feeding (3). Infants younger than 4 months do not nutritionally need solid food, and the extrusion reflex, in which the tongue pushes out anything placed in the mouth, makes feeding of solids difficult.

Over the past decade, there has been increasing evidence that the introduction of solid foods between 4 months and 6 months of age may actually be protective against the development of food allergies (4). The current guidelines from most major international societies recommend that complementary solid foods be introduced when infants demonstrate developmental readiness, typically around 6 months but not before 4 months, and the introduction of allergenic foods (eg, well-cooked eggs, peanuts) should not be delayed. Systematic reviews of moderate-quality or higher have found that introduction of multiple allergenic foods in the first year of life was associated with a reduced risk of food allergy and confirmed that peanut and egg should be introduced between 4 and 11 months to prevent food allergy and that the timing of complementary solid food introduction was not associated with increased food allergy risk (4, 5).

Initially, solid foods should be introduced after breastfeeding or bottle-feeding to ensure adequate nourishment. Iron-fortified cereal (oatmeal, barley, or rice) is traditionally the first food introduced because it is nonallergenic, easily digested, and is supplemented with iron.

It is generally recommended that only 1 new, single-ingredient food be introduced every few days so that food allergies may be identified. Foods do not need to be introduced in any specific order, although in general they can gradually be introduced by increasingly coarser textures—eg, from cereal to soft table food to soft, 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 (6). 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 or beans, 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 and continue doing so until age 2 years (7, 8). They may drink unflavored reduced fat or fat-free milk after 2 years, when their diet essentially resembles that of the rest of the family. Parents should be advised to limit milk intake to approximately 16 ounces/day in young children (9); higher intake can reduce intake of other important sources of nutrition and contribute to iron deficiency anemia.

Juice and other sugar-sweetened beverages are a poor source of nutrition and contribute to dental caries. Children under 1 year of age should not consume juice; children under 2 years of age should not consume beverages (or foods) with added sugar; children 2 years or older should limit total caloric intake from added sugars to 10% (10).

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 follow their growth curves

(See also Nutrition in Infants.)