Tag Archives: American Academy of Pediatrics

First Foods

We’ve already established that long before getting to the high chair, babies benefit from experience with:

  • handling and mouthing a variety of objects that difer in shape, texture, material and even temperature
  • different sights, smells and potential licks of your food (given that it is safe to do so!)
  • many kisses from loved ones! What better positive way to provide safe sensory input to little cheeks and mouths!

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We’ve talked about readiness signs and the reasoning behind starting to offer calories from “food” at approximately 6 months of age/development.

What to start with:

North American parents have traditionally introduced rice cereal as a first food.  There seems to be a movement away from this practice in the general mama community, especially white rice cereal.  It is a prominent belief for followers of  the baby-led weaning method.  Baby-led weaning is a method of  foods introduction wherein the baby is offered whole foods.  The baby has complete control with this method.  For example, you steaming a whole artichoke, place it on the baby’s tray and allow him to decide what to do with it.   Purees and spoon-feeding is discouraged. I will elaborate on the benefits and definite risks of this approach in another post.  US Pediatrician, Dr. Green has also spearheaded  a “Whiteout” campaign.

Infant cereal, pureed meats and fish are recommended as first foods by the American Academy of Pediatrics, Canadian Paediatric Society (CPS), Dieticians of Canada, Breastfeeding Commitee for Canada, Public Health Agency of Canada, and Health Canada.  CPS also identifies poultry, cooked egg yolk and well-cooked legumes (beans, lentils, chick peas) to be good sources of iron and suitable for first foods.

Choice of first food is influenced by a host of factors, including tradition and culture.  Regardless of the actual food choice, it is critically important that it is iron rich.  Iron stores are low in exclusively breast fed babies by 6 months, thus introduction of iron-rich foods is critical to prevent iron deficiency.

You will make small incremental changes from familiar to unfamiliar, until you get to know your baby’s preferences.  Some babies have an early love for eating and enjoy bigger changes.  Other baby’s are skeptical and learly of food and you will be more successful with gradual changes.     The first time you offer a new food, you may mix a small amount of the new flavor in a larger amount of breast milk.  Additionally, recommendations for a slow food introduction (one food at a time, waiting 2 – 3 days between new foods) are to ensure identification of allergies and reactions. As a result, it could take weeks to get a few foods on board.

So… bottom line.  You don’t need to start with rice cereal if you feel strongly against it.  Options include:  rice cereal (white, whole grain), or meats/alternatives (eg. lentils, red kidney beans, cooked egg yolk).   Meats are tricky to puree to a runny, smooth state and are easily grainy, not great for a first experience.  Cooked egg yolk pureed with breast milk/formula is a great way to achieve a smooth consistency.

Big picture:  Once first foods have been accepted, introduce other pureed fruits and vegetables.   Aim for something high in Vitamin C once a day to ehance iron absorption (eg. kiwi, orange, broccoli, strawberries).  Of note, delaying wheat cereal introduction until after 6 months has not been shown (to date) to protect against the development of a wheat allergy.

The nitty gritty:

*When starting out, you want to offer solids after a breast feed/bottle.  This is still the primary source of energy when you are starting out.

1. Set the scene: Prepare food and equipment before you put baby in the high chair.  Make sure your baby fits in his high chair.  Some high chairs are huge! Your baby  may need some help feeling snug and secure.  If he isn’t quite sitting independently, provide support by rolling up tea towels and placing them beside his trunk and/or legs.  The new experience will be challenging enough.  Your baby doesn’t need to waste additional energy trying to keep himself from toppling over.   Add the tray and place a spoon or other implement (even a teething toy) for him to bang around.

You can just see a rolled up tea towel peeking out at her side.

You can just see a rolled up tea towel peeking out at her side.

2.  Mix your first food of choice with breast milk or formula.  Use the familiar taste to bridge the change.  The consistency should be very runny and a just noticeable difference from breast milk (think running off a tipped spoon).   Start by putting some of the mixture on baby’s hands and tray  before offering the spoon to his mouth.  Let him feel it and smell it before it gets to his mouth.   Don’t worry about volume.  These are first experiences… it’s even a success if he looks at the food!

I KNOW it’s messy to put food right on the tray and let your baby muck about.  It is a small price to pay to build a solid, trusting foundation for food interaction.  Remember what it felt like to have your feeder place an unknown food in your mouth?  DSC01265

Now comes the mealtime dance.  You and your baby are constantly communicating during this experience and he needs to learn that you will listen and respect what he is saying. Don’t push a spoon into a closed mouth.  Allow him time to explore with his hands, he will likely lick the new food off of his hand.  Dip your finger in the new food and touch it to his lips.  With the next dip, offer it to his lips and maybe he will open his mouth. Take this as your cue to place your finger in his mouth! Your job is to follow his lead.

Signs of Yes, I like this, give me more

Signs of No, this is not fun, give me a break, stop

Makes happy sounds Leans away
Leans toward spoon or your hand Closed mouth
Looks at food and smiles Turns head away
Reaches for spoon or your hand Cries
Opens mouth Looks away from food

If you chose to introduce cereal first, breast milk will break it down.  The  consistency will become runnier the longer it sits in the bowl.  This change can be reassuring for baby as it slowly changes to a consistency he is familiar with.

The next day, offer the same thing with a slight change.  Add  a little less breastmilk so that it is just a tiny bit thicker (i.e. doesn’t pour off the spoon like a thin liquid but has a few drops to it).  Again, do not worry about the volume your baby actually takes in, these first experiences are about learning.   Some babies prefer slightly thicker consistencies while others prefer thinner consistencies.    Your job is to tweak things and really discover what your baby loves.

You do not get a “bigger bang for your buck” if you load the spoon full of a new food.  Start with a small amount on the spoon while your baby learns how to use his lips, jaw, tongue and cheeks.  He now needs to transfer the food from the front to the back of his mouth.  Heck, I’d be more likely to turn my head in protest to an approaching mountain of food too!

3. When you and baby are ready, move onto your next food!

Calgary area community resources related to first foods:

Free Class Alberta Health Services Childbirth and Parenting Education.  Feeding your baby (up to 12 months).

As of Fall 2013, I will be offering feeding therapy services for Calgary and its surrounding area. New this year are in-home consultations to help set you up for success on the journey to table foods.  Details to follow.

* References for information above available on request*

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A misnomer… starting solids

“Starting solids” is a ridiculous expression for teaching a baby to transition from breast milk/formula to table foods. The whole concept is misleading.  It makes you think of sitting a baby in a highchair and putting a spoon in his mouth.  In reality, babies can and should have many opportunities to learn about the whole process of eating long before their butts hit the highchair.  Please don’t misinterpret this to mean you should be spoon feeding your baby before they are safe to do so.

The term “starting solids”  makes parents think that they have to wait until 6 months of age to venture into the process of eating.… NOT TRUE.  Let’s redefine starting solids.   I haven’t yet developed a more accurate and concise expression.  I have been toying with: transition to everyday foods, breast to table…. however, none of them are ideal.  I’ll keep working on it.  DSC01116

This transition is significant. Most healthy babies obtain approximately half of their energy needs from table foods by the end of their first year.  Breast milk or formula, initially the exclusive sources of a baby’s energy, gets downsized to 50% [1].  This change really occurs over the short course of  6 months.  In addition to the dramatic change in energy source, the table food transition also imposes abarrage of new textures: runny liquid, dissolvable food, lumpy puree, and soft food!  So many new sensory challenges…..talk about a lot of work!

Okay, so:  readiness signs.

Baby should have:

  • Interest!  (looking at you when you are eating and drinking, reaching for your food)
  • Trunk control (able to push up on arms when on their tummy, sitting with support, able to lean forward and open his mouth to indicate desire)
  • Head control (able to hold up his head in supported sitting, able to turn his head away to tell you he doesn’t want any more)
  • Decreased tongue thrust (pushing tongue straight out of their mouth when something is placed there) [2,3,4 ]

Previous recommendations have suggested that solids be introduced  between 4 and  6 months of age.  Newer recommendations suggest introducing solids at 6 months of age [5].  World Health Organization (WHO) and Canadian Pediatric Society recommend exclusive breastfeeding for the first 6 months of life.  Most babies are developmentally ready for solids around 6 months of age.  In addition,the 6 month mark is  the point at which a breast-milk exclusive diet is inadequate to support a baby’s nutritional demands; the volume of breast-milk required to meet his needs for energy, protein, iron, zinc and other vitamins is untenable [6].

Also, later solid introduction (i.e. much later than 6 months)  may put babe at risk for developing oral aversion (not wanting anything in the mouth).

So how we do set the stage for success?  We all dislike abrupt change.  Opportunities to learn about different shapes, textures, and temperatures will help your baby feel more comfortable with something other than breast-milk or formula in her mouth. This needs to happen before she is put into a high chair!

What if the interest is there but you are not sure if motor skills are?

What if the motor skills are there but the interest isn’t?

There is no reason you can’t teach your baby about the eating process before all of the readiness indicators are present.  If she is awake and you like babywearing, put her in a carrier as you prepare dinner so she can be exposed to the smells.  This might be a necessity anyways for those cranky babies during “witching hour”.  Someone is always needy when it’s time to make dinner at my house.  Always.  Since my kids were tiny, dinner hour has  been witching hour.   If it’s not the cranky one holding her little arms up, the older one is demanding to sit on the counter and help!DSC01236

Unless you just plain need a break from baby or you have your hands full with older kids,  hold baby in your lap as you eat dinner.  Give her intermittent kisses as you eat.  She will smell the food on your breath and maybe even get a taste if you give her a smacker00 right on the lips.  I recently attended a feeding conference and the presenter suggested the idea of “kiss therapy” for  kids who are ultra-sensitive.  I like the idea for all kids before they end up in a high chair for meals.

Once she has the ability to grasp an object and bring it to her mouth, be creative with the object you offer her to play with and mouth.  angelcare_toothbrush_blue Obviously make sure they are safe, but you don’t need to stick with baby toys.   Her hands and toes are wonderful things to shove in her cheek, lick and drool all over.  It teaches her about her tongue, jaw, lips and cheeks.  Your fingers are great too!  Think beyond hard plastic toys… she can hold one of your raw carrot sticks as she sits on your lap during dinner.  It’s safe if is is thick enough that she cannot bite through it.  Or a piece of beef jerky.  A lick of your apple as you eat it (you would control handling the actual apple).  Baby toothbrushes are usually textured and some even come with a guard that prevents baby from gagging herself over and over.  Try freezing teethers or links.  zoli-gummy

These ideas are not meant to replace therapy recommendations for babies who are identified as at-risk feeders.  Default to your physician or therapist if your baby has medical differences and has been deemed to be an unsafe swallower. 

References:

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

2. Food and Agriculture Organization of the United Nations (FAO), World Health Organization (WHO) and United Nations University (UNU): Human Energy Requirements. Chapter 2: Energy requirements of infants from birth to 12 months. Available at: http://www.fao.org/docrep/007/y5686e/y5686e05.htm (Accessed on January 21, 2013).

3. Committee on Nutrition American Academy of Pediatrics. Complementary feeding. In: Pediatric Nutrition Handbook, 6th ed, Kleinman RE (Ed), American Academy of Pediatrics, Elk Grove Village, IL 2009. p.113.

4. Eiger MS. Feeding of infants and children. In: Primary Pediatric Care, 4th ed, Mosby, St. Louis 2001. p.184.

5. Canadian Paediatric Society, Community Paediatrics Committee. Weaning from the breast. Paediatr Child Health 2004;9(4):249-53

6.Agostoni C, Decsi T, Fewtrell M, et al. Complementary feeding: a commentary by the ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr 2008; 46:99.

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Before starting solids…..

Starting solids can be OVERWHELMING.  It feels like you just have things under control and its time for change again!  Breast or bottle feeding is well established, nighttime sleep has grown into longer chunks and napping seems to be under some semblance of a routine.  Now you are supposed to sit your baby in a chair and teach him to eat from a spoon?!    And transition to offering these “meals” after a breast or bottle feed numerous times a day?!

There seems to be a lack of specific instructional information out there.   The medical community offers little concrete assistance, at least until difficulties arise.  The first and only formal reference to the solids transition for us was at my daughter’s 6 month immunization; the only investigation was a superficial, seemingly “check-box” question “are solids going well?”.  The feeding support was completed with the provision of a handout.

We are told when we should introduce solids, and to do it one food at a time.  To the “Introducing Solids” handout developers credit, the of pictures of textures for different stages and the menu suggestions are very useful. It is no wonder that many parents rely on friends, family members and Google as their trusted sources for feeding information. These people, often with good intentions, can offer some great information; they can also perpetuate myths such as babies sleep better with rice cereal in their bottles.

Beyond that, there aren’t many ideas readily available for what to do when things don’t go according to plan.  Not only that,  general handouts often do not explain the rationale supporting  recommendations. In the face of conflicting recommendations, an understanding of the rationale can be the compass.

Learning to eat is an incredibly sensory experience.  This sensory adventure can be stressful for parents and baby.  We often fail to appreciate the complexity of this task, expecting baby to instinctively open his mouth for the incoming food-laden spoon.

It is a disarming experience to have someone else to feed you.  You are vulnerable to the whims of the feeder; they control volume, temperature and rate of spoonfuls.  Imagine trying to coordinate your breathing, chewing and swallowing while an insensitive giant automatically shovels mountains of goo into your tiny mouth?!

You have to trust that she will know when to offer another bite, when its too hot, when its too cold and when you are full!  Not to mention that for the baby, every morsel loaded on that spoon is brand spanking new in look, smell, feel and taste!

Before introducing solids to your baby, I challenge you to have someone else feed you while you are blindfolded. The blindfold will prevent you from DSC_0149recognizing the food and subsequently preparing yourself for the sensory load.  This artificial novelty is meant to mimic a baby’s anxiety with new foods.  In this experiment, your feeder should prepare two very different dishes.  For example, warm chicken and cold applesauce; foods that differ in flavor, texture and temperature.  To create a realistic experience, ensure that you do not know what the foods are in advance.  Blind ingestion of varied foods in an unpredictable fashion will help to better approximate a baby’s experience.  For this same reason, you are not allowed to speak to your feeder – he must read your cues.  You laugh but I think deep down you know why you are laughing…..this is a scary task!   You will feel totally ridiculous.  Trust me,  it will help you empathize when your baby turns his head to an incoming spoon.  It will also help you problem solve different strategies to gently prepare your baby for an incoming spoonful or new food.

If you are interested in reading about developing a healthy feeding relationship with your child,  pick up the book “Feeding Your Child with Love and Good Sense”.  The feeding community widely embraces this dietician written book.  I have incorporated concepts into my work and home life.   Read excerpts of it before you start solids (yes I realize this is nearly an impossible request… hah! Reading… I just started reading again and my second daughter is 16 months old!).

Was introducing solids exciting for you?  Scary?  What do you wish you would have known?

More to come…..  ideas around when, why and the nitty gritty how to…..plus my favourite places to find new ideas for recipes and foods to try!

M

PS… I’ll take guesses on who is who in the photos!  One is F and one is E.

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