FEEDING FRENZY: PARADIGM SHIFTING
In the 18 years I have been practicing pediatrics, few things have changed. Normally medicine moves cautiously. Scientific evidence seeps slowly from labs, to offices, into households. However, when new evidence arrives for a better path forward, it is our job as clinicians to interpret, digest and translate that evidence for our patients.
The guidelines for solid food introduction in pediatrics have recently undergone a dramatic transformation. A food revolution is taking place for babies! First, in the recommended age for starting solid food and second, in the management of allergenic food introduction. In this BLOG I will address the first issue: recommended age for solid food introduction.
Pediatricians are key team members in managing infant feeding and nutrition. In the early years of my practice the standard recommendation was to start solid food introduction at 4 months old, unless there were specific medical, developmental or cultural reasons to do otherwise. Pediatricians, in general, recommended starting with rice cereal, then other grains, followed by yellow/orange vegetables, then green ones, next fruits and then proteins.
Although this hierarchy of solid food introduction seemed arbitrary it persisted. The list was a set of inherited “ways it were” that appeared not to cause harm and so it continued on for decades. However, new information has shed light on our old practices, and perhaps they did cause harm.
In the recent revised policy statement from the American Academy of Pediatrics: Breastfeeding and the Use of Human Milk, the AAP recommends introducing solid foods “at about 6 months old.” Pushing the age closer to 6 months is the Academy’s move, to increase the overall rates of breastfeeding and the associated health benefits, in alignment with Healthy People Targets of 2010 and 2020 goals. In addition to exclusive breastfeeding for the first six months of life, the AAP recommends breastfeeding continue until age 12 months, and beyond if mutually desired. These recommendations are echoed by the WHO and the Institute of Medicine.
Reviewing the AAP’s, mostly observational, data there is no doubt that breastfeeding is associated with improved health outcomes. This is true in the categories of respiratory illness, gastrointestinal infection, atopic disease (asthma, eczema, allergies), autoimmune diseases, obesity, and some cancers. However, much of the data is based on breastfeeding of any type and length. https://pediatrics.aappublications.org/content/129/3/e827/tab-figures-data. There is some, but limited, information on the specific benefits of exclusive breastfeeding through 6 months and beyond.
The current recommendations on when to start solids are attempting to balance multiple goals. These include developmental readiness, early exposure to potential food allergens, promoting and maintaining gut and immune system health and the development of an accepting and broad palate. It seems that the time to bring all of these together is around six months. That is a time when an infant is able to sit upright, manage their hands, and fingers and swallow in a way that enables them to progress safely to different foods and textures.
A six month old is interested in seeing and modeling those around them while at the same time, generally excited and open minded about new experiences and flavors, so this is a great time to incorporate common family and cultural foods and spices. I’m hopeful that the solid food introduction revolution taking place will make infant feeding a more enjoyable experience for the entire family.