The basis of deciding on when the best time to introduce solid foods in infancy has, until recently, been more art than science. Important variables to consider mostly involve the baby’s age: When is a baby developmentally able to accept food from a spoon and swallow without choking or aspirating; when have they attained sufficient head control/neck strength to be able to sit up and eat; when are their gastrointestinal systems able to digest first foods adequately, without significant consequences like reflux, vomiting, diarrhea, gas, eczema, food allergies, etc. It’s also important to consider how little nutrition young babies actually get from solid foods, especially when compared to being fed exclusively formula or, even more so, breast milk. Subjectively, parents may feel that their baby seems very interested in watching other family members eat, or that their baby would sleep better at night with just a little more food in the belly.
The recommendation from pediatricians has traditionally been to start solid foods between 4-6 months of age. Except for adding rice cereal to the bottle to help treat babies fussy with reflux, evidence for starting baby food before 4 months is entirely lacking. We know there is no evidence that a young baby with a belly full of solid food sleeps any better than with a belly full of milk. In fact, pediatricians are aware that starting first foods before 4 months old can be risky.
Then, in 2012, the American Academy of Pediatrics changed the recommendation to begin introducing solid foods at about 6 months old. The main impetus for this was to encourage mothers to breastfeed exclusively for the first 6 months, when the greatest benefit for breastfeeding is attained. The concern was that by introducing solids before 6 months old, babies would rely on (prefer?) real food over the real thing, and mothers would stop breastfeeding sooner.
The recommendation does not really take into account some very real world issues. A lot of moms don’t breastfeed. Infant formulas are expensive. Parents are pressured by other people (Grandma, Aunt Dorothy, friends, media) to start early. And, it turns out, a lot of parents just don’t listen to their pediatricians anyway! Karen Rowan tells us:
Two-thirds of parents say they don’t always follow the advice they get from their child’s doctor, according to a new poll.
The findings showed that 56 percent of parents said they follow the advice they’re given most of the time, while 13 percent said they follow it only occasionally, according to the findings from the University of Michigan C.S. Mott Children’s Hospital National Poll on Children’s Health.
Ouch! When it comes to introducing solid foods to babies, parents don’t seem to be listening. A recent study done by the CDC and published in Pediatrics concludes:
More than one-third of mothers in our study reported introducing solid foods before their infant was 4 months old, which is higher than previously published findings that revealed ∼19% to 29% of US mothers introduce solid foods early. The AAP recommendation in place at the time of IFPS II data collection was that solid foods were to be introduced no earlier than 4 months of age. Notably, with the 2012 revision of this recommendation by the AAP, the recommended age for introduction of solid foods was increased from 4 to 6 months, which would result in 92.9% of our analytic sample being classified as “early introducers.”
The reasons why 40.1% of parents in the study started solids before 4 months of age:
The most commonly cited reasons for early introduction of solid food were as follows: “My baby was old enough,” “My baby seemed hungry,” “I wanted to feed my baby something in addition to breast milk or formula,” “My baby wanted the food I ate,” “A doctor or other health care professional said my baby should begin eating solid food,” and “It would help my baby sleep longer at night.”
The study also found that breastfeeding mothers tend to start their babies on solid food later than those who bottle-feed. In fact, when I ask breastfeeding moms whether they think their 4 month old babies are ready to start baby foods, the response is usually spot on: “Why would I do that?”
Why, indeed.
So let’s be clear. The AAP recommends starting solid foods at around 6 months old. I don’t think it’s wrong to begin the conversation about starting solids at the 4 month check-up, encouraging parents to wait until closer to 6 months to begin. (I know, I don’t listen very well either!) Starting solid foods should not begin before 4 months of age unless the pediatrician or parent has a compelling reason to do so. Pediatricians can dictate to parents at the risk of parents tuning us out.
These are decisions that we can, and should, make together.