What’s the exact, best age to start solids for your baby?

The Pediatric Insider

© 2017 Roy Benaroch, MD

A commenter objected to advice I’ve given about when to start complementary foods in infancy:

Why, when the WHO, UNICEF, and the AAP all recommend exclusive breastfeeding until 6 months of age, do you still have the introduction of solid foods at 4 months. It’s confusing for women who want to do the right thing for their child to come across your articles on starting solids at this age. Study after study show the benefits for both mother and child of exclusive breastfeeding until 6 months.

I wouldn’t rely on WHO and UNICEF recommendations. I’m not so sure that what they say is entirely relevant to babies in the developed world. I’m going to focus here on the AAP recommendations, which reflect the needs of babies in the USA and other highly developed countries.

Current AAP recommendations are deliberately vague about the precise timing of introducing solids. They say that complementary foods shouldn’t be introduced “until 4 to 6 months” – see the phrasing in this abstract and under point 2 of this article. Since AAP recommendations automatically expire 5 years after they’re published, there isn’t a valid AAP published statement on this exact issue right now. These two citations reflect the most-recent recommendation: solids can be introduced during a window of time, from 4 to 6 months.

Why then? Earlier solids are associated with obesity and nutritional problems; later solids are associated with feeding issues, iron deficiency, and an increased risk of allergy. The 4 to 6 month window maximizes nutrition while minimizing allergy risk, and works well for most babies.

But it is a window, not an exact time. We don’t have any research that says 4 months is perfect, or 5 months is perfect, or 6 months is perfect. I know of no studies from a developed country that show an important health advantage of starting to feed at six months rather than four, or starting at four months instead of six.  Probably all of these times are fine. The absolute best time depends on a baby’s development and temperament (as well as the family’s style and feeding preferences.) There’s no perfect, one-size-fits-all answer here.

When I talk about this with families, I try to figure out what the baby thinks about all of this. A 4-month-old baby who’s watching his siblings eat intently, or lunging at their food, or becoming disinterested in the breast or bottle – that’s probably a baby that’s ready to be fed solid foods. Babies of the same age who aren’t so interested in food, those babies can wait another month or so. And if solids aren’t going well at first, it’s fine to stop and wait a few weeks before trying again. We can make all of the plans we want, as parents and pediatricians – but the bottom line is that this is one of many decisions that babies help make on their own. Good for them!

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6 Comments on “What’s the exact, best age to start solids for your baby?”

  1. Karen Urbani, MD Says:

    I agree with what you have to say- and I add one piece of behavioral information that I picked up somewhere and makes sense to me. The tongue thrust reflex that makes infants spit out objects placed in their mouth out goes away between 5 and 6 months of age. I ask parents to try bland soft soupy food on a spoon around that age, and if the infant tongue thrusts it out, try again in a week or two until they accept it. I also discourage rice cereal because of high intrinsic arsenic levels, and ask them to definitely wait to start solids until the infant can sit up supported to eat off a spoon, “and has good enough head control to turn away when full” , reminding them that we should honor satiety, not force finishing one’s plate , which can lead to overeating through life. I also suggest not putting solids into the formula bottle, because our goal is to teach infants to swallow off a spoon gradually thicker consistencies, and ask parents to tell me at the 9 month checkup if the infant has not progressed to Stage three and finger foods as the window of opportunity for texture acceptance is short. The lastest phase of baby-led-weaning has brought in several underfed , texture adverse failure to thrive 9 mos olds to my practice, sad to say .

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  2. wzrd1 Says:

    Our children turned into hungry monsters at three months of age, nearly insatiable with just a bottle.
    Doctor Mom suggested formula-cereal mix, which at the time, pediatricians were recommending at six months of age.
    The mixture was extremely thin, requiring only modest increase in the hole of the nipple.
    We, of course, fed them watchfully, removing the bottle when they would push it away.
    From there, introduction of baby foods and solids stayed pretty much in step with current recommendations.
    As Doctor Urbani touched upon, early introduction of different foods is important, lest one accustom baby to eating one or two specific foods, which could create various issues later in life.
    We introduced our two children to novel foods throughout their lives, even into their late teen years.
    Weight only became an issue when adulthood arrived and our genetic heritage toward, erm, robustness, elevated cholesterol, etc becomes apparent and significant effort must be made to keep our weight within healthy recommended limits.*

    *Well, I did get a respite from that for the better part of a year, courtesy of compensated, occult hyperthyroidism, which became quite overt. That dropped my cholesterol numbers precipitously, my blood pressure began to become dangerously elevated and my weight dropped by 40+ pounds within a few months.
    What seriously grabbed my attention was the measured 200/100 BP, with a resting pulse of 120 and an ECG that showed LVH.
    Once diagnosed and a specialist consulted, effective treatment has resolved those issues, we’re at watchful waiting of an aortic dilation and the hypertrophy should self-resolve, but now I have to watch my weight again.

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  3. Dr. Roy Says:

    There are still alt-practitioners out there treating overweight with thyroid supplements, which isn’t safe and can have big time metabolic, bone health, and cardiac consequences (not that you were doing that deliberately.) Glad you were caught and treated.

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  4. Dr. Roy Says:

    “Baby-led-weaning”, I agree, has gotten ahead of itself, and in some cases seems to have become almost competitive (like natural childbirth. Am I in trouble for saying that?) Both trends started with reasonable ideas, and both can work for many people, but that doesn’t mean either is best.

    I also see more 9 mos olds who seem texture averse. Some of that, I think, is from families eating separately, so the kids never get to model; some (I think) are in kids headed for the ASD realm; some are kids who just aren’t ready and who will do fine on their own. The intervention I’ve found most helpful most of the time is: family meals, and offer child spoonfuls of appropriate family food (not baby-specific bland food.) This doesn’t always work, so sometimes more creative solutions are needed.

    And I’ve never been a big believer in rice cereal. Not because of the arsenic — unless you’re chowing down on that at every meal, that’s probably not going to be a problem — but because it tastes like the cardboard box it comes in, and parents and siblings don’t eat it. So why feed it to your baby?

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  5. wzrd1 Says:

    For any thyroid treatment, TSH, FT3 and FT4 should be the guide, not weight or fad.
    Anyone doing otherwise, without a good reason, such as the rare autoimmune disorder, should have their medical license status questioned by their peers. If that fails to address such quackery, then legislation would have to address it, as peer policing seems to be failing at an ever increasing rate.

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  6. wzrd1 Says:

    One of my earliest memories, other than squirming at an uncertain age, while having a cloth diaper replaced and getting stuck with a diaper pin, is of eating barley infant cereal.
    To this very day, I still like barley in my soups and stews!
    Rice, not so much. Yeah, tasted like cardboard.

    My second earliest memory is far more fixed, mom sat me in front of the TV (something already exceptional, as that just didn’t happen normally), while she took down the drapes to clean them. “Sit here and watch the President, he’s important!”.
    Memorable was, it was JFK and it was 22 November, 1963. I was born in late 1961. I even remember the CBS logo on advertisements.
    It was also the first time I ever saw my parents cry.

    As for children being with their families while eating, that’s a “no-brainer”, they can’t learn to emulate that which they do not witness. They also cannot be supervised if they’re not present.
    Once it’s solid food introduction time, if they don’t like the texture, wait a bit and try reintroduction. Don’t get into a fight over food, as that’s a fight that ends up having two losers.

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