Introducing Solid Foods to Infants

Nathan R. Harmon, D.O.

Definition
The AAP defines Complimentary foods as any food which reduces the intake of breast milk

Strength-of-Recommendation Grades Strength of recommendation Basis for recommendation A Consistent, good-quality patient-oriented evidence* B Inconsistent or limited-quality patient-oriented evidence* C Consensus, disease-oriented evidence,* usual practice, expert opinion, or case series for studies of diagnosis, treatment, prevention, or screening *-Patient-oriented evidence measures outcomes that matter to patients: morbidity, mortality, symptom improvement, cost reduction, and quality of life. Disease-oriented evidence measures intermediate, physiologic, or surrogate end points that may or may not reflect improvements in patient outcomes (e.g., blood pressure, blood chemistry, physiologic function, pathologic findings).

Assessing Quality of Evidence Level 1: good-quality, patient-oriented evidence Validated clinical decision rule
SR/meta-analysis of high-quality studies High-quality diagnostic cohort study* SR/meta-analysis or RCTs with consistent findings High-quality individual RCT All-or-none study SR/meta-analysis of good-quality cohort studies Prospective cohort study with good follow-up

Level 2: limited-quality patient-oriented evidence Unvalidated clinical decision rule

SR/meta-analysis of lower quality studies or studies with inconsistent findings Lower quality diagnostic cohort study or diagnostic case-control study SR/meta-analysis of lower quality clinical trials or of studies with inconsistent findings Lower quality clinical trial

Cohort study
Case-control study SR/meta-analysis of lower quality cohort studies or with inconsistent results Retrospective cohort study or prospective cohort study with poor follow-up Case-control study Case series

Level 3: other evidence Consensus guidelines, extrapolations from bench research, usual practice, opinion, disease-oriented evidence (intermediate or physiologic outcomes only), or case series for studies of diagnosis, treatment, prevention, or screening

SR = systematic review; RCT = randomized controlled trial. *-High-quality diagnostic cohort study: cohort design, adequate size, adequate spectrum of patients, blinding, and a consistent, well-defined reference standard. -Highquality RCT: allocation concealed, blinding if possible, intention-to-treat analysis, adequate statistical power, adequate follow-up (greater than 80 percent). -In an all-or-none study, the treatment causes a dramatic change in outcomes, such as antibiotics for meningitis or surgery for appendicitis, which precludes study in a controlled trial.

Goals
When to introduce complimentary foods Reasons/Evidence behind proper timing How to be successful Other pearls

Case
Two Family practice residents are thinking of introducing solid foods to their first child, who is now 5 months old. They realize that they know little about pediatric nutrition, and have had different advice from their parents versus their pediatrician.

Case
Their parents tell them to give rice cereal as early as possible to help the baby sleep through the night. (They gave us cereal as early as 3 months old!) Their pediatrician gives very different advice.

Criteria for When to Introduce Solids

Age: 4 to 6 months
Too Early Too Late

Proper Motor skills (neurodevelopment)

Sit with support Good head and neck control Truncal Control Extinguishing of Extrusion Reflex

Review
When introducing solids, the parent should wait until
A. They are exhausted and just want to baby to sleep through the night (i.e. as early as possible) B. The Baby has good truncal control, no extrusion reflex, and can sit with support.

Extrusion Reflex

Food Allergies
Definition Diagnosis Most common foods
Eggs, Cows milk, Wheat, Soy, Peanuts, Tree nuts, fish and shellfish

How to reduce risk

General population High risk

How to begin
Cereals Single ingredient foods Decrease breast milk and/or formula as solids are introduced Foods to avoid
Under one y/o High risk of Atopy

Juices

Review
When counselling on introducing solid foods, you should recommend A. Begin with pureed foods B. Begin with cereals, especially rice C. Maintain the same amount of breastmilk / formula when giving solids D. Ignore any family hx of Atopy

Minerals and Vitamins

Iron
Daily requirements Dietary recommendations

Fluoride Vitamin D Vitamin B12

Review
Is your child ready for solids? Proper head control, truncal control, extrusion reflex extinguished, 4 6 months old Introduce CerealsSolidsone new every week gradually increase texture; no cereal in bottle; Get family hx of Atopy and avoid high risk foods Avoid milk, honey, choking risk foods for first year Supplement for iron at 6 months or sooner if high needs Fluoride at 6 months Vitamin D if exclusively breastfed or < 17 oz of formula per day Vitamin B12 if breastfed only with vegetarian mother.

References

Duryea, T., Introducing Solid Foods; Vitamin and mineral supplementation during infancy. www.uptodate.com, 2007. Butte, N., The Start Healthy Feeding Guidelines for Infants and Toddlers., J of Amer Dietetic Assn., 2004, 104:3, pp 442-54. Pediatric Nutrition Handbook, 5th ed., American Academy of Pediatrics, 2004, pp 103-9.
Resources for Parents MayoClinic.com http://www.mayoclinic.com/health/healthy-baby/PR00029 Heinz -http://www.forbaby.com.au/modules/feeding_baby/index.php?cat_id=7