by Warren P. Silberstein, M.D.
One of the things that Pediatricians do at routine visits is to give parents advice on feeding their infants, but the truth is, there is no mystery to infant feeding. It's really all very logical. Pediatricians may vary in the exact order and timing of introduction of certain foods but they all follow some basic principles. Your Pediatrician may give you a schedule to follow, because if he doesn't follow some schedule, he'll never know what advice he gave anyone, but there's no magic to it.
The first principle is that human milk or formula has all the nutrition your infant needs for rapid growth during the first 6 months of life. Infants should be on human milk or infant formula for the entire first year. Many hospitals still adhere to the every 4 hour feeding schedule, but in my experience, most newborns nurse or feed every 2 to 3 hours at first. Eventually your newborn will settle into a rhythm, but it's not important for your infant to have an exact feeding schedule. Usually the best advice is to feed your newborn when he is hungry. But you do want to avoid having your baby feed small amounts every half hour. This kind of snacking is difficult for you and your baby. If your infant has gotten in to such a pattern you will either have to get him to take a full feeding at some point or hold him off long enough to be hungry enough for a full feeding. If necessary, a feeding of water which has been sterilized and cooled can be used between feedings to help get your baby's feeding schedule on track.
As a general rule I advise not waking babies for feedings. If you wake babies for feedings they usually don't eat well. If you have a schedule you must follow, for example, you have to leave the house at a certain time, and it is just about time for the baby's next feeding, it is perfectly reasonable to wake the baby to accommodate your schedule. Most infants will scream quite regularly for their feedings; however, if you have an unusually placid baby who never acts like he is hungry, you may have to wake him for feedings. The same is true if your infant is very small and needs extra feedings, but your pediatrician will advise you if that is the case.
By the time your baby is a few months old many of you will start to think about feeding him some food (solids). Many of you will be concerned that your baby is hungry just taking milk. Remember, milk is food, not just a drink. If your baby has ever spit up on you several hours after a bottle or nursing, you know that there is solid in his stomach. That's because even though the milk is liquid, it has protein in it.
The next principle is that the purpose of introducing solids such as cereal is to introduce spoon feeding. Sooner or later all humans eat food. We don't live on milk for our whole lives, so we have to introduce food. But when we first introduce food, there isn't any food or amount of food that the baby must get to be nourished. Remember, all the nutrients in his milk are still sufficient for his growth. That is why I advise against putting cereal in the bottle unless your child has a condition that requires thickened formula. There is no nutritional benefit to putting cereal in the bottle. If you put cereal in the bottle the amount of cereal the baby gets is controlled by his need for milk rather than his appetite for cereal.
The American Academy of Pediatrics recommends not introducing spoon feeding until at least 4 months of age. The reason for that is that most infants have adequate head control and swallowing control to sit supported in a chair, lean forward and open their mouths for food they want, and to close their mouths and refuse food they don't want. If you spoon feed a younger infant his tongue and sucking movements will result in his swallowing some food, but that doesn't mean he is ready for spoon feeding. I once had a mother tell me her infant cried because she couldn't get the food into him fast enough. When I asked her how she knew he wasn't crying because he didn't want it, she didn't know.
The baby's grandmother may tell you that you started cereal at one month of age and you turned out just fine. She may be right. Children certainly don't grow two heads from early spoon feeding. But there is some evidence that early spoon feeding is associated with obesity. But what's more important is that even though early spoon feeding isn't likely to do any harm, the optimal source of nutrition for infants up to 6 months of age is nursing or infant formula. You can start spoon feeding at 4 months if your baby seems ready, but there is no rush to start before 6 months. If we didn't have convenient baby food jars available, we'd probably be waiting 6 months or more like great grandma did.
The basic principle behind introducing solids is to introduce only one new ingredient at a time and to give it for at least 3 days before trying something else new. That way if a baby has a problem with a food you can more easily figure out which food. The second principle of introducing new foods is to introduce foods that might cause allergic reactions later. The reason for this is that as the intestines mature the intestines only absorb small molecules. Immature intestines absorb larger, more complex molecules (less digested), and these are more likely to sensitize the child and result in allergic reactions. If you have an allergic child, a child with eczema, or a strong family history of allergy, it pays to delay introducing solids.
Many of the things that may look like reactions may not be. If an infant has gas pains or diarrhea from a food, or develops a rash, you should discontinue the questionable food and reintroduce it 2 or more weeks later. If the reaction is the same, there is a greater possibility that your infant doesn't tolerate the particular food. Rashes that occur just in the diaper area generally are not reactions to foods.
When you first introduce spoon feedings keep in mind that your baby's instinct is to suck when he is hungry. He will have to learn to eat off a spoon. He will also have to learn that eating off a spoon will satisfy his hunger. It may be tempting to try the first feeding when your infant is starved so that he will be hungry for the new food, but your baby won't have the patience for spoon feeding. When he is hungry he wants to suck. He doesn't need to eat a lot of food at first because he is getting his nutrition from milk. Start with just a teaspoon or two and start with a thin consistency. Offer the feedings between milk feedings, after a feeding, or even part way through a feeding - whatever works best for you. Increase the amount and the thickness of the feeding based on how well the baby does with it. Once the baby has become established on spoon feedings then you can offer solids as a whole meal.
In my practice I generally start solid feedings with rice cereal. After the introduction of cereal you can offer fruit with the cereal as long as you introduce only one new item at a time. After that you can try all the different single fruits and cereals one at a time. The amounts may vary depending on your child's appetite, but usually it will be up to about 4 tablespoons of cereal and of fruit twice daily.
Vegetables are introduced next, but if you choose to introduce vegetables in place of fruit, the order is not important. After that, meat is next on the schedule, but some families don't eat meat and some babies don't like it. There isn't any food you are introducing that is a crucial part of your baby's diet. And there's no rush to try all the different foods.
Yogurt and cottage cheese can be introduced between 8 and 10 months as a prelude to introducing cow's milk. Some pediatricians introduce eggs at that time but because of their allergic potential I generally hold off introducing eggs until 1 year. To decrease the likelihood of allergy you can introduce first the hard cooked yolk and then the white. Next you can do the same with a medium egg. You should avoid soft eggs because of the high risk of salmonella. Fish can also be introduced at 1 year.
Juice should be introduced in a cup after the baby has been introduced to fruit and generally after 6 months of age. By introducing the juice in a cup you get the opportunity to introduce a cup since most infants insist on getting their milk in a bottle (unless they're nursing). While juice provides some useful vitamins and minerals it isn't advisable for children to drink bottles of juice. Firstly, children who drink a lot of juice bottles drink less milk. Secondly, excess juice can cause diarrhea and may even result in poor growth.
Table food can be introduced between 7 and 12 months depending on whether or not your baby handles food particles without gagging. Teeth are not the major issue since the first teeth to come in are biting teeth, not grinding teeth. Some babies at 7 months can handle little pieces of food while some babies at a year will gag if they feel any particles in their mouths. I'm not a big fan of junior foods or stage 3 foods which are a mixture of pureed foods with chunks. It is easier and less confusing for a baby to handle one small piece of soft food that he puts into his mouth than a whole spoonful of the familiar mush mixed with pieces. Good choices to start with include banana cut into small pieces, well cooked carrots, pasta, cheese, and Cheerios softened in milk.
Remember that even if you introduce cow's milk into the diet before 1 year of age that the baby should get most of his milk nutrition from nursing or infant formula because those have the right mixture of nutrients for optimal growth. From 1 to 2 years of age babies should get whole milk. The developing brain requires fat so skim milk and low fat milk is not recommended until 2 years of age. After 2, children should be given skim milk.
For advice on feeding toddlers and children see Nutrition Without Tears.
The concepts involved in infant feeding are simple. The hard part is dealing with all the advice you'll get and cleaning up afterwards.
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