Diet in the First Year Jenny Thomas, MD, MPH, IBCLC, FAAP, FABM Home
Newborn through Four months
This one's easy. Their diet should either be breastmilk, or if a medical contraindication to breastfeeding exists, then formula. They don't need any water or juice or cereal or anything else. Exclusive breastfeeding is very important for the immune system, brain and is not just food so we try to help you in any way we can to stay away from supplementation with something other than breastmilk unless it is medically indicated. The daily intake should reach about 30 ounces by four months. (Warning: that 30 ounces thing is an average. That’s all. If your child grows on less or seems to need more, then fine. It’s a guideline and not a rule.) And those who are breastfeeding may never know how much the child is getting in ounces per day, That's one of the many reasons we think breastfeeding protects against obesity. If you are told, as I was, that adding cereal to the feeding helps your child sleep through the night, ignore it. It's bunk.
The parents are responsible for the "what, where and when" food is offered, and the child is responsible for "whether" and "how much" to eat.
Ellyn Satter, author of Child of Mine: Feeding Your Child with Love and Good Sense.
The American Academy of Pediatrics, the World Health Organization and almost every other group concerned about the health and well-being of infants has said that 6 months is the recommended time for starting solid foods. Six months. I know that there are still those recommending that solids should be started at 4-6 months because of some inconsistencies in AAP policy, but as of the publication of the new AAP Statement on "Breastfeeding and the Use of Human Milk " in early 2012, there is no disagreement within the AAP any longer. There should be NO RUSH to start solids. The timing of this recommendation has nothing to do with developmental milestones. This is a recommendation based on good studies which tell us that waiting until six months can prevent chronic disease in the long-term.
If you have made the commitment to breastfeed, the AAP (of which I am a member) says that exclusive breastfeeding for the first 6 months of life is beneficial and desirable. Again, this is for long-term disease prevention for conditions like diabetes but also provides better infectious disease protection to your breastfed infant. Complementary foods are not necessary, and may detract from the nutritional and infection-fighting benefits of breastmilk.
Most breastfed kids have a “growth spurt” at about this time, and start getting up in the night (if they hadn’t before). Breastmilk is supply and demand, and then kids are “demanding” to increase mom’s supply. It does not mean the kids need solids. Solids don’t make kids sleep. There is no sedative effect of rice cereal (since when did starch make a child sleep?) carrots or peas.
We should NOT be making decisions about solids based of sleep schedules. Four month olds may wake up and not be able to go back to sleep because they realize that there is a world out there. It is about safety and not hunger. We wake up and we are hungry but we don't wake up because we are hungry.
I also know that four month olds are eating more and may not seem "satisfied" with what we just fed them. If they need more food, then it should be breastmilk or formula. Breastfed kids may not be satisfied because they are trying to increase mom's milk supply and formula fed kids may not be satisfied, but they need more formula. Giving cereal, or whatever, doesn't give them the nutrition they need at this age. Similarly, there is no amount of formula that they are taking that should equal us giving solids.
The decision to start solids should have nothing, nothing, to do with sleep patterns. Nothing!
So when we decide that the kids are ready for food, what food do we start with? The American tradition has always been rice cereal. In Germany, many kids start with carrots or cooked pumpkin. In Holland they start with bananas or apple mash. There are no studies out there that tell us what the best foods to start with are. Which means, that the insistence on cereal in our kids' diet is a tradition, not a necessity. In fact, the AAP has officially stated to that we need to "throw out the rice cereal."
When you get right down to it, rice cereal is
starch, and sometimes iron-fortified starch. If we are giving it,
and it decreases the amounts of breastmilk or formula the child takes,
we aren’t doing them any favors nutritionally. Click
here for a lovely summary of initiating complementary foods
in breastfed children written by the WHO. Our focus
should be on good carbohydrates and protein.
Cereals started as an important part of a child's diet back when the infant formula companies couldn't get an absorbable form of iron into the formula. They then fortified rice cereal with iron and introduced the rice cereal early into the diet as a way to make sure the kids got the iron. Now, all the infant formulas are fortified with iron and of course, breastmilk has an abundant and easily absorbable supply of iron in it, so we really don't need an extra source.
Six
to Eight Months: give consideration to baby-led feeding/solids/weaning
(whatever they call it where you are)
The parents are responsible for the "what, where and when" food is offered, and the child is responsible for "whether" and "how much" to eat.
Ellyn Satter, author of Child of Mine: Feeding Your Child with Love and Good Sense.
Your child should be exhibiting
clues that they are ready to take solids, before you actually start them
in the diet. Prior to four months of age, your child has a
well-developed "tongue-thrust" reflex, which makes spoon feeding pretty
difficult, and extremely messy. If your child turns away from the spoon,
spits the food out at you, and in general, does not seem to be enjoying
meals -- they aren't ready for the advancement in the diet. This tongue
thrust on non-interest in food can exist for longer than 6 months--
meaning, if you child is six months old and is not ready for solids, no
worries. It'll come.
If they are ready to eat, then we should start on food. Real
food, like fruits and vegetables and meat. My favorite first food
is avocado. Maybe sweet potatoes. It can be home prepared
foods, or baby food. Start on the pureed foods and see what
happens. We all have a reflex in the back of our throat that
doesn't let us swallow something that we have no business trying to
swallow. If we were to try to swallow a golf ball, for example, we
would make a horrible face and try to throw up.
This "golf ball" reflex is what stops us from going to more textured foods. I'm not going to say that a child has crossed some magic starting line and therefore can have thicker foods. It'll be the ability to handle texture that lets us go forward. I take care of kids I swear can eat steak at 6 months and some kids who can't handle anything but pureed food at 14 months. It's up to your child how we move through these textures. And that goes for finger foods too. Whatever texture they can handle is OK to give-- if you're not comfortable trying a new texture, don't! Your child never has to eat Cheerios, ever, and they can go to college on pureed foods. We aren't in a hurry. We can get iron now from many sources, the easiest of which is meat. And meat can be pureed if need be.
You can start at whichever feeding you want to-- whichever feeding your child seems most interested in trying the new food. let them eat until they are done. No specific amounts are necessary. Breastfeeding mothers may find that the kids won't eat from them, so daddy may be the better person to be feeding solids.
This might be a good time to explore the idea of baby-led solids.
After each new food, you can wait two or three days to see if signs of an allergic reaction, such as diarrhea, rash or vomiting occur, but this is not necessary and need only be done if you have a family history of food allergy.
I like holding off on starting juice until about 9 months or later (if at all), when you can bribe your child off the bottle by putting the juice in a cup. Plus, juice can cause diarrhea and diaper rash by making the stool very acidic to the skin.
There's nothing special about store-purchased baby foods: meaning, if you want to make them yourself, go ahead. I think that if I was a better cook, this is the way I'd have done it.
Kids in this age group don't have a taste for salt or for unsaturated fat. They don't even know that they want them. Start good eating habits early and don't give salt or unsaturated fat to your child in this age group. Spicy foods are different from salty ones. Many cultures give flavored foods early. If they were exposed to those flavors in breastmilk, they may be more adventurous now.
Now is a perfect time to start getting your child off the bottle (if they take one) and on to a sippy cup. There is nothing that says that children need formula out of a bottle. Negotiating with a 12 month old, trying to get them to give up their bottles is hard to do. Try to get them off of it now, while it’s only a source of nutrition and not a source of comfort!
But remember, the sippy cup was designed for parents, not kids, so the kids may have a hard time using them. I personally feel that the "spill-proof" ones are also "drink-proof" and that they shouldn't be used. Most kids can do fine with a cup without a lid. I can even get newborns to drink from cups.
The growth rate of a child in this age group slows a bit, so it's not surprising that their appetites slow down a bit now too. They can usually tolerate food with a little more texture. You can even try to let them use a spoon now if you are brave.
There is no minimum amount of breastmilk that they should be getting. There is no minimum of solid food. There is no minimum of formula. Kids in this age group are really, really good at taking enough calories to grow. They will eat when they are hungry, drink when they are thirsty and if you guess wrong, you will wear what you chose. If you do this wrong, and they are hungry, they will squawk at you until you get it right. I have never met a kid who will let their parents starve them, at least without a fight. But they are not growing as fast as they were, so they don't need that many calories. We are trying to teach this generation to respond to hunger cues, not eat simply because the Packers are on or because it's noon. If they are not hungry, they are really not hungry.
Danger foods -- have risk of choking
· Spoonfuls of peanut butter ( and no peanut butter until after 1 year)
· popcorn
· nuts
· raisins
· grapes
· uncooked peas
· celery
· hard candy
· whole hot dog
There really isn't any magic to this. Just switch over, without worrying about weaning or a slow transition. Even kids who were on soy or other formulas usually do OK with the switch to cow's milk. And if you are breastfeeding (good for you!) there are still plenty of benefits of breastmilk in this age group- there is no cow out there making better milk for your child than you are.
Cow's milk is not the perfect food (unless you are a cow), despite all that we learn, especially in Wisconsin. And I see more problems with kids getting too much milk rather than too little. Too much cow's milk (which is more than 20-24 ounces a day) can lead to severe iron deficiency and iron deficiency in a growing brain is not a good idea, in fact, childhood iron deficiency can cause developmental problems that the kids may not overcome. See, cow's milk has no iron in it, can interfere with iron absorption and can cause a low grade blood loss in some kids by creating an inflammation in the gut. Meat is the best source of iron. Other foods that are fortified with iron have a form that is a little harder to absorb.
The kind of milk you transition to makes little difference to me. Kids need a source of fat in their diet for the first two years of life because the fat helps with brain maturation and development. The AAP had previously said to use whole milk as a way to provide that fat, but there isn't anything special in the fat of whole cow's milk that helps human brains grow. The recommendation now is that 2% or lower fat -concentration in milk should be used in children with a family history of a risk factor for heart disease. That pretty much means almost every kid in America. You therefore, unless you come from a very rare family, do not need whole cow's milk. So...try and make sure that your child gets about 30% of their calories from fat every day, just like we, as adults, are supposed to do.