Confused about introducing solids?

Joy Anderson AM, Accredited Practising Dietitian, International Board Certified Lactation Consultant and Breastfeeding Counsellor.

Joy has a special interest in food intolerance and food allergy in babies.

The World Health Organisation (WHO),1 the National Health and Medical Research Council (NHMRC)2 and ABA all currently recommend 6 months of exclusive breastfeeding and then the introduction of solids while breastfeeding continues. Exclusive breastfeeding means no other food or drink.

Many mothers are confused about introducing solids as they get different advice from different authorities and health professionals. This article is designed to help explain why there is conflicting advice.

There are two questions:

1. What age should a baby be introduced to solids?

2. What foods should be offered and when?

In 2008, authorities in several Western countries3,4 recommended that solids should definitely not be introduced before 4 months and should be offered no later than 6 months.

The intention was not to mean the ‘right’ time to begin solids is 4 months, rather at some point in between these two ages, when the baby shows readiness. Unfortunately, some have incorrectly interpreted this as meaning all babies should start solids at 4 months.

With regard to allergies, we used to think we knew how to reduce the risk of allergy, that is, delay new foods until the baby was older and more mature. However, recent research studies have shown this to be incorrect. The number of children becoming allergic to foods has risen sharply in recent years in Western countries. Finding out what we are doing wrong has been the aim of recent and current research in several parts of the world, including UK and Australia.

However, there has been no good evidence that introducing solids at 4, versus 5, versus 6 months is any different in terms of allergy risk. In addition, it should be recognised that allergy is not the only consideration in timing of solids.5 There are also nutritional issues, risk of illness, risk of the baby receiving too little breastmilk and developmental readiness to be considered. Many people think that risk of illness from formula-feeding or dirty solids is only a significant problem in poor countries. However, there are many studies showing that breastfeeding protects babies from illness in Western countries as well. 5 This supports keeping the timing for exclusive breastfeeding to around 6 months.

Therefore, Australian recommendations in the current (Dec 2012) Australian Infant Feeding Guidelines2 are to introduce solids at around 6 months of age.

An Infant Feeding Summit hosted by the Centre for Food and Allergy Research was held in May 2016. A consensus agreement, supported by published evidence, was accepted at this Summit and the following recommendations were:

  • When your infant is ready, at around 6 months, but not before 4 months, start to introduce a variety of solid foods, starting with iron rich foods, while continuing breastfeeding.

  • All infants should be given allergenic solid foods including peanut butter, cooked egg and dairy and wheat products in the first year of life. This includes infants at high risk of allergy.

  • Hydrolysed (partially and extensively) infant formula are not recommended for prevention of allergic disease.

    The Australian Society for Clinical Immunology and Allergy (ASCIA) has a web page6 on Infant feeding and allergy prevention to reflect these recommendations and this provides a good summary of the topic overall.

    Guidelines with ages can only ever be approximate as babies develop at different rates. When your baby is ready for solids, he will show signs of readiness, which is a better guide for an individual baby – he will show a great interest in what you are eating, perhaps try to grab your food; he will have lost the tongue-thrust reflex that pushes food back out of the mouth; and he will be able to sit upright. These tend to occur at around 6 months of age, with some a little earlier and others a little later.

    Iron and zinc are two minerals needed from solids from about 6 months onwards but this varies between babies. Because we don’t know which babies are in most need, we usually aim to start giving all babies solids containing these minerals from this age. Iron-fortified cereals are often used in Australia but these do not contain zinc. The best foods for these two minerals are meats and their vegetarian alternatives.

    The older guidelines also recommended delaying introduction of certain foods that are considered particularly allergenic, such as cows’ milk, nuts, wheat, soy, egg and fish, which was thought to reduce the risk of allergy to these foods by allowing the baby’s system to mature. However, recent population studies and some large controlled trials carried out in the UK7 and Australia8 have disproved this, for peanuts and egg respectively. This change is also reflected in the recommendations listed above.

    It is now recommended that once solids are introduced, a variety of foods should be given and the type and order do not matter. Research suggests that introducing the most allergenic foods (as mentioned above) by about 10–12 months of age is associated with a reduced risk of allergy developing. A gap of 2–3 days between each new food should be enough, in case there is some reaction.

    Regardless of the age your baby starts solids, it is recommended that breastfeeding continue during the process of introducing new foods. Research suggests that this may reduce the risk of the baby developing allergies.2 It used to be thought that this also applied to coeliac disease,9 however, the latest evidence is that whether a baby is being breastfed at the time of gluten introduction or not does not affect this risk.10

    Note that parents with a baby who has symptoms of allergy already should seek advice from a health professional about introducing solids.

    If a baby or child already has a food allergy, they and their breastfeeding mother usually need to avoid those foods. Also, studies have shown that avoiding allergens during pregnancy does not reduce the risk of allergy development in the child.6

In answer to these questions:

1. What age should a baby be introduced to solids?

Currently the WHO and NHMRC recommendation of around 6 months for introduction of solids is current and backed up by research.

2. What foods should be offered and when?

A wide variety of foods when the baby shows readiness, starting at about 6 months.

For more information

See ABA booklet Breastfeeding: and family foods

And website article Breastfeeding and family foods

References

1.    World Health Organization 2014, Exclusive breastfeeding. http://www.who.int/nutrition/topics/exclusive_breastfeeding/en/index.html

2.    National Health and Medical Research Council 2012, Infant Feeding Guidelines. Australian Government, Canberra. (Available at http://www.nhmrc.gov.au/guidelines/publications/n56

3.    ESPGHAN Committee on Nutrition: Agostoni C, Decsi T, Fewtrell M, Goulet O, Kolacek S, Koletzko B, Fleischer Michaelsen K, Moreno L, Punti J, Rigo J, Shamir R, Szajewska H, Turck D, van Goudoever J 2008, Complementary feeding: a commentary by the ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr 46(1): 99–110.

4.    Greer FR, Sicherer SH, Burks AW, the Committee on Nutrition and Section on Allergy and Immunology 2008, Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolysed formulas. Pediatrics 121(1): 183–191.

       Available at http://pediatrics.aappublications.org/content/121/1/183.long

5.    Anderson J, Malley K, Snell R 2009, Is 6 months still the best for exclusive breastfeeding and introduction of solids? A literature review with consideration to the risk of the development of allergies, Breastfeeding Review 17(2): 23-31.

6.    Australian Society of Clinical Immunology and Allergy 2016, ASCIA Guidelines – Infant Feeding and Allergy Prevention. http://www.allergy.org.au/health-professionals/papers/ascia-guidelines-for-infant-feeding-and-allergy-prevention

7.    Du Toit G, Roberts G, Sayre PH et al 2015, Randomized trial of peanut consumption in infants at risk for peanut allergy. New Engl J Med 372(9): 803-813. Available at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4416404/

8.    Koplin JJ, Osborne NJ, Wake M et al 2010, Can early introduction of egg prevent egg allergy in infants? A population-based study. J Allergy Clin Immunol 126(4): 807-813. http://www.jacionline.org/article/S0091-6749(10)01173-5/abstract

9.    Ivarsson A, Hernell O, Stenlund H, Persson LA 2002, Breast-feeding protects against celiac disease. Am J Clin Nutr 75: 914–921.

       Available at http://www.ajcn.org/cgi/content/full/75/5/914

10.   Szajewska H, Shamir R, Mearin ML et al 2016. Gluten introduction and the risk of coeliac disease. A position paper by the European Society for Paediatric Gastroenterology, Hepatology & Nutrition. J Paediatr Gastroenterol Nutr 62(3): 507-513.

© Australian Breastfeeding Association June 2016

The information on this website does not replace advice from your health care providers.