Day: October 10, 2016

What Are Some Developmental Milestones for Solid Food Readiness?

Patient Presentation
A 6-month-old male came to clinic for his health supervision visit. The mother had no concerns. “A couple weeks ago I tried him with some cereal and he seemed to like it and last week at Thanksgiving dinner he grabbed my spoon so I gave him a taste of mashed up sweet potatoes. His eyes got really big and he got really excited and wanted more, so I gave him a few spoonfuls. I hope that is all right?” she inquired. The pertinent physical exam showed a happy infant sitting in his mother’s lap with excellent head control and easily manipulating a toy between hands and his mouth. Vital signs were normal with growth parameters around the 25%. His examination was normal including no head lag when pulled to a sitting position.

The diagnosis of a healthy 6 month old was made. The pediatrician inquired about any problems with tongue thrusting when feeding or choking which the mother denied. The pediatrician said, “He seems like he is really ready for starting solids. Continue the breastfeeding and half way through give him a few spoonfuls of the food and then finish the breastfeeding. The foods should be thin and easy to move in his mouth and don’t put too much in his mouth at once. He has to practice learning how to eat it. Only give him 1 new food every 2-3 days in case he has an allergy so then we can better know what it might be. Remember, breastmilk is his real food. Solids are desserts. They are for taste and texture but breastfeeding is the most important.”

Discussion
Introduction of solid, complimentary, foods for infants is a common question that health care providers are asked. The World Health Organization and the American Academy of Pediatrics and other organizations recommend exclusive breastfeeding until 6 months of age and then introduction of solid foods as the infant is developmentally ready. First foods generally are single-grain cereals but strained fruits or vegetables are also appropriate. Introduction of one new food every 2-3 days allows for potential food allergies to be more easily identified.

These may be the professional recommendations but the introduction of what types of foods and when to start them is highly dependent upon maternal beliefs which are influenced by cultural norms and by other individual family members such as grandmothers. In the U.S. 40% of infants are introduced to solid foods before 4 months of age. Early initiation of solid foods potentially increases the risk of obesity in later life as these infants have been found to consume more energy dense food. Formula fed infants or those feed formula and breastmilk are more likely to be fed solid food early than exclusively breastfed infants. Studies have found that mothers that are younger, less educated and have increased body weight tend to feed solid food earlier. Early introduction of solid foods has a higher rate of breastfeeding termination potentially putting children at risk for infections. A controlling or pressuring feeding maternal style is related to earlier solid feeding while a responsive style, following infant cues, is related to longer exclusive breastfeeding duration.

Infants that are more motorically active have also been correlated with earlier solid feeding. Potentially temperament (positive or negative reactivity) may also influence solid feeding with infants with negative reactivity being fed solid foods earlier. One study of young mothers found that “…infant diets mirror maternal diets and eating habits as early as 7 months of age.” This study and others found many poor feeding habits including excessive juice, inappropriate foods (i.e. french fries, pizza, macaroni and cheese, etc.), allergenic foods (i.e. eggs and peanut butter), and prechewing of table foods.

Learning Point
Breastfeeding or formula should be the main meals and calorie sources for infants during the first year. Solid food feeding is important for infant growth and development; they help the infant to learn about tastes and textures during the first year of life but initially should be used in small amounts like a dessert. There are development differences when infants are ready to take solid foods. In general infants should be able to:

  • Have no head lag when pulled from a reclined to seated position
  • Able to sit by self in a high chair or infant seat
  • Able to coordinate to move head and hands to be able to look for food and put it in the mouth
  • Responsively opens the mouth when food comes near
  • Able to move the food from the spoon into the mouth – does not have tongue thrust reflex
  • Able to swallow the food

There is a range of when infants are able to meet these milestones with some children as early as 4 months and others not until 10 months. Most infants are able to do so after 6 months of age. A table of infant and young children’s feeding skill milestones can be reviewed here.

Questions for Further Discussion
1. When can more textured infant foods be introduced?
2. What changes in stooling patterns occur after solid food introduction?
3. In a highly allergenic family, what changes to regular feeding patterns do you recommend?
4. When can children chew foods and eat foods that would be considered choking hazards such as nuts, chunks of meat, popcorn etc.?
5. What are the potential problems of homemade babyfood? A review is here.

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for this topic: Infant and Newborn Nutrition

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Arvedson JC. Swallowing and feeding in infants and young children. GI Motility online (2006) Available from the Internet at: http://www.nature.com/gimo/contents/pt1/full/gimo17.html (rev. 5/16/2006, cited 8/29/16).

Turck D. History of complementary feeding. Arch Pediatr. 2010 Dec;17 Suppl 5:S191-4.

Cattaneo A, Williams C, Pallas-Alonso CR, Hernandez-Aguilar MT, Lasarte-Velillas JJ, Landa-Rivera L, Rouw E, Pina M, Volta A, Oudesluys-Murphy AM. ESPGHAN’s 2008 recommendation for early introduction of complementary foods: how good is the evidence? Matern Child Nutr. 2011 Oct;7(4):335-43.

Karp SM, Lutenbacher M. Infant feeding practices of young mothers. MCN Am J Matern Child Nurs. 2011 Mar-Apr;36(2):98-103.

American Academy of Pediatrics. Starting Solid Foods.
Available from the Internet at https://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Switching-To-Solid-Foods.aspx (rev. 2/1/12, cited 8/28/16).

Doub AE, Moding KJ, Stifter CA. Infant and maternal predictors of early life feeding decisions. The timing of solid food introduction. Appetite. 2015 Sep;92:261-8.

American Academy of Pediatrics. Working Together: Breastfeeding and Solid Foods.
Available from the Internet at https://www.healthychildren.org/English/ages-stages/baby/breastfeeding/Pages/Working-Together-Breastfeeding-and-Solid-Foods.aspx (rev. 11/21/15, cited 8/29/16).

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital