Posted tagged ‘infant feeding’

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

March 9, 2017

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!

Previous:

When to start solid foods, and what to start with

Want to avoid celiac? Don’t delay wheat past six months

Bottle and formula feeding questions and answers

February 2, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

 

What’s the best way to warm up the bottle?

Cool formula can be warmed up safely by dunking the bottle in warm water. This method isn’t quick, but it works and it’s safe. There are also “bottle warmers” you can buy that surround the bottle with gentle warmth from all sides—though I am not sure they work any quicker than using warm water in the sink.

Bottle and formula manufacturers caution against using a microwave to heat a bottle. There is a possibility of creating “hot spots” either in the formula or on the nipple, with small areas becoming hot enough to burn.

 

Is it necessary to warm up a baby’s bottle?

No, it’s not necessary—but it’s traditional, and some babies get used to warm formula and don’t like it chilled. As babies get closer to weaning off the bottle at 12 months, many families back off the warming for convenience, and those babies do fine. There is no harm in trying cool or lukewarm formula to see if your baby likes it.

 

Should I use tap or bottled or boiled water to mix the bottles?

Ordinary city municipal tap water is fine. Tap water is very highly regulated, and is monitored far more closely than bottled water for purity. There is no reason to waste your money on bottled water or special nursery water. It is also unnecessary to boil tap water—it’s very clean right out of the tap. Heart surgeons wash their hands in that stuff, you know. And babies’ mouths (and mom’s breasts) are loaded with germs. Sterility is not necessary for feeding humans.

If your water supply comes from a well or cistern, check with your local water authorities for guidance on using that water for formula.

 

Do I need to boil or sterilize bottles and nipples?

No, running them through an ordinary dishwashing cycle or handwashing them is sufficient. Clean is good, sterile isn’t necessary.

 

How do I mix formula?

Always follow the instructions on the package, using the scoop that came with the product. Typically you’ll first measure the correct amount of water, then add the leveled scoops of powder. The exact proportions will be on the packaging. Mixed formula should be kept refrigerated and used within 24 hours. Once the package of powder has been opened, keep it in a cool dry place and discard any unused powder in one month.

 

What should I do with leftover formula if by baby doesn’t finish the bottle?

Throw it away. Once formula has been re-heated OR once a baby has taken any from the bottle, the formula should be considered contaminated and used within one hour, or discarded. Do not re-refrigerate warmed or partially-consumed formula.

 

Is there a kind of nipple or bottle system that’s best?

I don’t think so. There are many varieties, and some are marketed quite heavily with promises to reduce colic, or promises that they’re more like breast feeding. All of that is advertising hype. I suggest you purchase simple, cost-effective bottles and nipples.

Once choice you’ll have to make is to use traditional bottles versus the kind with the drop-in, disposable bags. While neither has any advantage for your baby, the drop-ins may save some trouble with fewer bottles to wash—in return for more plastic bags to throw away. Either style works well for most families.

 

Are generic or store-brand formulas any good?

They’re as good as name brand, commercial formulas. With name brands, you’re not getting a better or more-nutritious product—you’re just paying for fancier packaging and marketing hype.

 

Maybe I should just make my own formula. I found a recipe on the internet!

No, no, no, no. Do not make your own formula. It is not safe, it is not nutritious, and it is dangerous. Homemade cookies? Good. Homemade formula? Bad.

 

What about BPA and chemicals in plastic bottles?

In 2008 Congress banned BPA and several related compounds from baby products, based on sketchy and indirect evidence of potential harm. Still, it seemed prudent to avoid the chemical, as there were still unanswered questions about long term exposures. Since then, there’s now new concerns being raised about chemicals that have replaced BPA.

I say: there’s always something to worry about. And when things are really safe (ahem, vaccines), the modern media feeds into our own worries, especially about purity and food and children. I don’t think there’s any reliable evidence that parents need to worry about plastics used in baby bottles or spoons or anything else. But if you’re concerned, use glass bottles.

 

 

Homemade infant formula is not a good idea

September 15, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Miranda wrote in with a topic suggestion—she wanted to know about homemade infant formula. She had noticed a lot of people suggesting it. What’s the deal?

Speaking about nutrition and human babies, it makes sense to start with this: human breast milk, from mom, is the best food for babies. But even that is an over-simplification. It turns out that in the modern world, human breast milk is often deficient in vitamin D, and maybe iron, too. I know I’m going to get some heat over this, but it’s true: even human breast milk isn’t “perfect.” It’s close, but if we’re going to be honest, even straight-up mom’s milk isn’t “ideal” for babies.

So what’s the best alternative? The contestants: human breast milk, which we’ll just call “human milk.” Commercial infant formula, which we’ll call “science milk.” This is the stuff that’s been studied for years, and is lab-designed to give babies the exact nutrition they need to thrive. Then there’s home-mixed infant formula, which we’ll call “homemade milk”, usually prepared based on an internet recipe.  What kind of “grade” should we give our three competitors, based on an objective assessment of their composition?

The number one “ingredient”, so to speak, is water. Clean, pure, safe water. Human milk, fresh from the breast, is free of harmful contaminants and infectious germs. Science milk is made under sterile conditions, and the liquid versions are pasteurized—as long as they’re stored correctly, there’s essentially no risk of infections spreading. Homemade milk? Who knows. I doubt anyone at home is sterilizing all of their surfaces to the extent done in a commercial lab. And some of the homemade milk recipes call for unpasteurized, “raw” milk—which can be loaded with animal colon bacteria as has been linked to all sorts of colorful infections. Winners: human milk and science milk (tie); loser: homemade milk.

Then there’s protein. There’s too much protein of the wrong kind in most mammal milks (including cow and goat), so science milk relies on modified mammal milk or soy to get the right amounts of the right kind of proteins. The wrong proteins can cause intestinal and kidney damage. One homemade milk recipe I found used blenderized livers as a protein source, which is even more dangerous. Human milk, protein-wise, is perfect. Winner: human milk, with science milk a close second. Loser: homemade milk.

The carbohydrate in all mammal’s milks is mostly lactose. Goats, humans, cows—our milk is all lactose-based. Science formulas sometimes substitute other carbs, largely to take advantage of the fear of lactose intolerance (which doesn’t occur in human newborns.) There’s no known downside to this, though it’s kind of silly. Winner: tie! Lipids (fats) are pretty much the same across the board, or near-enough so.

Sodium: ordinary milk from other mammals (goats and cows and presumably kangaroos, though I honestly don’t know about them) has far, far too much sodium. To properly reduce this, homemade formulas have to dilute that out somehow. Winners: human and science formulas.

Other micronutrients: there are a lot of these, of course—iodine and vitamin C and vitamin D and iron. And these really are important. Iron deficiency in infancy can contribute to permanent cognitive problems. You really do want to make sure that Junior is getting all of these vitamins and minerals in the exact proportions needed. The micronutrient content of human milk has been extensively studied, and science formula does a great job in either copying that, or even improving on that (re: iron and vitamin D.) Winner, science formula, by a nose; human milk is a very close second. Homemade formula are based on dozens or maybe hundreds of recipes, and no one has systematically figured out which if any actually deliver the micronutrients that are needed.

 Here’s a funny, true story from my residency: an 8 month old baby was admitted to the pediatric intensive care unit, near death. (Wait, it gets funnier.) He was very, very anemic—I remember noticing when drawing blood from his nearly lifeless body that the blood itself was kind of watery and runny. He also had neurologic problems and his vital organs had shut down. It turns out that his father was traveling hours a day, back and forth, to a farm to pick up fresh goat’s milk to feed him (because his parents had heard that goat’s milk was healthy!) Since goat’s milk is entirely deficient in one of the B vitamins (folate), the child’s blood marrow pretty much shut down. And there were a whole bunch of other health consequences related to other nutrient deficiencies and protein overload. After a few weeks in the ICU the baby survived. Isn’t that a funny story? No, of course it isn’t. It isn’t funny at all.

Ease of use and preparation: human milk wins, here, of course—though it has to be said, not always. Some women really do have a hard time nursing. It’s not always the easiest choice. Fortunately, we have another reasonably easy alternative: science milk. Mix the powder with water in the right proportion, and you’ve got pretty much exactly what your baby needs. The worst choice, here, would be homemade milk: it’s complicated and fiddly, has a lot of ingredients to get wrong, and it still may not even provide the nutrition your baby needs.

Homemade infant formula is a terrible idea. There is no way for parents to make something as pure and complete as either human milk or commercial infant formula (science milk.) There’s no evidence whatsoever that it even might be safer or better in any tangible way. This is one case where homemade is not the way to go. If you’re not breastfeeding, you should use commercial infant formula. Do not trust your baby’s health on your chemistry skills and recipes from the internet.

What should a seven-month-old baby eat?

March 31, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Naomi wrote, “I’d like to start letting my 7 month old try some of the foods we’re eating during dinner. He always sits at the table with us and seems fascinated by what we’re putting in our mouths. It seems like most baby books say not to give babies anything with added salt, however, and cooking for adults without salt would ruin dinner. My question: if we’re only talking about home made food, is a little salt really so bad for a baby that’s eating solids? And if it is, at what age can he start eating table foods? I get that the salt levels in processed foods might be too high, but I’ve always thought home made food had much less.”

Listen to your baby—he’s fascinated by what you’re eating, and wants to try it. As long as the food isn’t a choking hazard, let him enjoy!

We think of “traditional” baby food as the stuff in boxes and little jars and little plastic tubs. Cereal, pureed veggies, pureed fruits—single-ingredient, bland, with minimal salt and other stuff. Of course, this is hardly “traditional” at all. It’s just what the baby food companies have been selling in the developed world for the last 100 years or so. “Traditionally,” once babies started weaning, they ate whatever everyone else ate.

There are a few different reasons why some have recommended sticking with “baby food” for toddler-aged kids. None of them are really very good reasons—and in fact, moving towards “real food” as soon as practical is better for everyone involved.

Naomi asked specifically about added salt. The thinking goes: many of us consume too much salt, which has been linked to hypertension in some genetically-predisposed individuals. So why get Junior used to the taste of salt too early? Won’t that cause him to crave salt later? But there’s no evidence whatsoever that more or less salt at seven months is going to make any difference. Later on, he’ll get used to the kind of meals eaten by everyone else, salted or low salt. There’s no critical window for deciding how salty someone likes their food.

There are also concerns that the early introduction of a mix of foods to youngish babies might increase their risk of food allergies. The truth is the opposite. There’s no evidence that waiting until later than four to six months of life increases the risk of allergy to any foods—not peanuts, not eggs, not fish. Those and any other foods can safely be introduced starting within the usual four to six month window. In fact, there’s some evidence that this earlier introduction can make food allergies less common.

The only significant health concern I have about early “real food” is whether it could be a choking hazard. Early foods should be a mashed-up or pureed consistency that can easily be eaten without teeth. Once Junior can pick up a morsel with his hands, start with soft little bits (about the size of the last part of his thumb, past the knuckle.) It’s messy, it’s fun, and it’s the best way for Junior to learn about textures and flavors. Eat as a family, and eat the same things. Yum!

When to start solid foods, and what to start with

November 11, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

I like writing about food and feeding issues, especially for babies and toddlers—mostly because there is so much misinformation out there, information that’s complex and confusing and difficult for anyone to keep straight. Start avocados at 33 weeks, start egg whites at 42 weeks, move from stage 1 to stage 2 jars after baby gets 1 ½ teeth. Rules, rules, rules.

All that stuff is a crock. Feeding babies is much simpler.

When to start solids: somewhere between 4 -6 months of age is an ideal window. Babies are happy to meet new things and have new experiences then, and they’re really interested in what you’re eating. So give them a taste.

There’s plenty of medical evidence that 4-6 months is an ideal time. You’ll minimize your child’s risk of celiac and type 1 diabetes, and provide essential iron and vitamin D that’s inadequately supplied by nursing alone. Starting earlier than this window seems to increase the future risk of obesity; starting later can lead to problems with oral motor functioning, and can increase the risk of food allergies.

What foods to start with: anything you like. The old advice, to start with (and stick with) rice cereal never made any sense. There’s nothing magic about rice cereal.

The only requirement for first foods is that it can be mushed up. Junior isn’t going to chew anything just yet, so whatever you’re feeding him needs to be, essentially (but not literally) pre-chewed. You can start with a banana or avocado, and mash it up with a fork; you can start with some well-cooked noodles, and mush them up; you can start with some soup vegetables, or a bit of egg, or ground meat, or just about anything else. Don’t be afraid of flavor, and don’t limit yourself to what the baby food companies put in jars.

The only foods to watch out for are choking hazards, foods that are too stiff or unmushable for babies to handle. Think steak, pecans, raw vegetables, or Al Gore.

There’s also a special admonishment against honey for babies less than 12 months of age, because it can transmit botulism in babies. That’s a really short list of things that babies shouldn’t be fed.

If you like, you can start with a single food and build up from there, starting a new food every few days. That’s been advised for years, to help parents tell which foods might have caused which reaction. But most babies will not have food allergies; and most food reactions in babies are mild. If there is a strong family history of genuine food allergies (say, in both parents or in siblings), you can take feeding slowly, one food at a time—but it is probably a mistake to delay solids altogether. Remember: introducing foods later may increase the risk of allergy.

That’s it—it’s almost too simple. Start at 4-6 months. Start with, pretty much, whatever you’re eating, just mushed up. Let your baby enjoy many different flavors, and share the meals (and the mess!) together. Yum!