Introduction of Complementary Foods to Infants

1. Introduction of Complementary Foods to Infants When is it OK, and why? By: Nicole Parello

2. Food Introduction • The introduction of complementary foods to infants should be postponed until 6 months of age, when their iron needs increase, as advised by the American Academy of Pediatrics (AAP), World Health Organization (WHO), and Women, Infants, and Children (WIC) (Duryea et al., 2013) • Some believe food can be introduced between 4-6 months, but no earlier then 4 months due to the possibility of atopic dermatitis and atopic sensitization along with development of allergies and obesity later in life (Duryea et al., 2013) • Breast milk is the ideal food for full-term infants; human milk or infant formula contains all the nutrients infants need for the first 6 months even though breast milk is preferred (Duryea et al., 2013)

3. Food introduction (cont.) • The proper introduction of complementary foods depends on the infants developmental stage; some can sit up and show developmental changes earlier than others (before 6 months of age); also, some premature babies need solids earlier due to their need for a higher calorie diet; at any rate, at 6 months infants need complementary foods along with breast milk or formula due to increased iron needs (Duryea et al., 2013)

4. Introduction of solids • Full term infants receive enough iron from their moms • breast milk or formula (formula contains 12 mg iron per liter), since they only need 0.27 mg/day, until they are 6 months old; at 6 months their iron needs increase to 11 mg/day and complementary food need to be introduced to fill this need (Baker et al., 2010); breastfeeding or formula feeding should continue for at least one year along with the complementary foods (Berglund et al., 2013) • Foods that contain iron include: proteins such as beef, chicken, and fish; beans and peas; fortified cereals; etc; infants should only consume the baby forms of these foods such as the baby mashed cereals and meats up until 1 year; parents can mash their own foods or buy the baby foods (Duryea et al., 2013)

5. Premature Infants • Premature infants are those born before 37 weeks gestation (Premature infant: MedlinePlus Medical Encyclopedia, 2014). • Iron stores in premature infants may deplete sooner than full-term infants since babies receive most of their iron stores in the 3rd trimester; iron could be depleted by 1-4 months for premature babies (Iron Therapy for Preterm Infants, 2009) • Exclusively breastfed premature babies may need a supplement from the doctor (Iron Therapy for Preterm Infants, 2009) • Formula fed premature babies are giving special formulas that are higher in calories and iron (Iron Therapy for Preterm Infants, 2009)

6. Sick pre-term infants who are given transfusions can develop iron overload (Baker et al., 2014) • Premature infants are therefore at risk for iron deficiency and toxicity (Baker et al., 2014) • It is estimated that premature infants need 2-4 mg/kg per day of iron given orally (Baker et al., 2014)

7. Iron Deficiency Anemia (IDA) • Anemia for female and male children aged between 12-35 months is a hemoglobin (Hb) concentration of less than 11.0 mg/dL, which is caused by a low iron intake (Baker, 2010) • IDA can cause neurodevelopmental problems in infants which is dangerous, so it is important to monitor their iron levels through various ways such as taking blood samples to test hemoglobin levels (Baker, 2010) • Iron levels in the blood can be tested by measuring hemoglobin, Vitamin B12, ferritin, or folate (Hemoglobin tests, involving a finger stick, are the most common) (Mahoney et al., 2013)

8. Iron deficiency anemia (cont.) • Children over 12 months with low iron levels should eat iron rich foods (proteins, fortified cereals, etc) along with Vitamin C rich sources (at least 1 serving per day), such as any fruits and vegetables, while also limiting milk intake to no more than 20 oz per day, which helps with the absorption of iron (Mahoney et al., 2013) • You can give iron supplements to marginally low birth weight (MLBW) infants at 6 weeks to 6 months of age; this is because they have high risks of developing iron deficiency anemia (IDA) due to their lack of absorbing enough iron from mom before birth, causing them to be born with a lower iron level (Berglund, 2010) • Iron supplements (3-4 mg/kg elemental iron/day) causes hemoglobin levels to rise 1 g/dL within 4 weeks (Mahoney et al., 2013)

9. Vitamins and Minerals • A fluoride supplement is recommended for children between 6 months and 3 years old if the fluoride in the local water supply is low; call water department or have the well tested (Duryea et al., 2013) • All infants, whether breastfed or formula fed should be given a supplement containing 400 IU Vitamin D per day starting at birth (Duryea et al., 2013) • Vitamin B12 is recommended for breastfeeding infants of strict vegetarian (vegan) mothers, and infants eating a vegetarian diet (Duryea et al., 2013)

10. Signs of readiness • Sit up supported • Push themselves up from face down position • with their elbows straight • Have neck and head control • Place their toys and hands in their mouth showing their ready for supplemental textured foods • Lean forward for food and back when not interested • (Duryea et al., 2013)

11. Signs of readiness (cont.) • Single ingredient pureed foods, including vegetables, fruits, and meats should be introduced one at a time, every few days; if no signs or symptoms of allergies, a second food item can be introduced (Duryea et al., 2013) • Once infants tolerate thin purees and can sit up and grasp foods with hands, thicker purees may be introduced, such as mashed potatoes (Duryea et al., 2013) • By 8 months, tongue flexibility has increased so infants can chew and swallow more textured foods, such as ground and mashed foods with lumps; by this point, infants should be eating ½ cup (4 oz) of vegetables, and ½ cup of fruit per day (Duryea et al., 2013) • Finger foods (finely chopped soft foods like fruit, veggies, cheese etc) can be eaten by infants on their own at 8-10 months when they can sit independently, have eye-hand coordination, and can chew (Duryea et al., 2013) • Infants can self feed at 9-12 months of age, eat foods the rest of the family is eating, and can drink from a cup (Duryea et al., 2013)

12. Which foods first? • There is no food recommended as a first food; single ingredient foods should be introduced first, one at a time, every few days (usually 3-5 days) to determine an allergic reaction (Duryea et al., 2013) • No more then 28 to 32 oz of formula should be given when foods are introduced, or breastfeeding continued on demand (Duryea et al., 2013) • Infant rice based cereals should be introduced first, 1 tsp at a time, since they are a single grain cereal and least allergenic; wheat cereals can be offered at 6 months (Duryea et al., 2013) • Cereals should be given by spoon; cereal should not be used in the bottle unless recommended by healthcare providers for gastroesophageal reflux (GER) (Duryea et al., 2013) • Infant cereals and pureed meats should be offered before the pureed and strained fruits and veggies (Duryea et al., 2013) • Baby vegetables should be offered before the fruits, since babies tend to like fruits more than vegetables if their not introduced first (Duryea et al., 2013) • Juice may be introduced when the infant can drink from a cup, beginning at 6 months; only offer 100% juice with added vitamin C in the cup, no more then 4 to 6 oz per day(Duryea et al., 2013) • Baby bottles should be eliminated by 12 months of age (Mahoney et al., 2013)

13. WHICH FOODS FIRST (Cont.) • Milk, eggs, peanuts, tree nuts, seafood, and fish can cause allergies and should be introduced with caution, one at a time in small portions to test for allergies (Duryea et al., 2013) -If child has a first-degree relative (parent or sibling) with a documented allergic reaction, they are at high risk and should take precautions when introducing highly allergic foods; if child has a sibling with a peanut allergy, an allergy test can be done first, but fatal reactions to peanuts have not been reported with the first exposure (Fleischer et al., 2013) -Children with one underlying food allergy are at risk for others; for example, a peanut for tree nut and cow’s milk or egg allergy for peanut allergy, so should be referred to an allergist (Fleischer et al., 2013) -If an infant has moderate-to-severs atopic dermatitis, or a history of allergic reactions to foods, they could be referred to an allergist before trying highly allergic foods (Fleischer et al., 2013) -If commercial food specific serum IgE testing’s positive in food settings not yet introduced to their diet, they should see an allergist before trying an allergic food (Fleischer et al, 2013) -Infants at increased risk for allergies who can’t exclusively breastfeed for 4 to 6 months, should take a hydrolyzed formula to prevent allergic disease and cow’s milk allergy; breastfeeding is the best for preventing allergies when introducing foods. (Fleischer et al., 2013)

14. Introduction of Highly Allergic Foods • Old recommendations: for introducing highly allergic foods to infants to prevent the development of food allergies was the delayed introduction of cow’s milk until 1 year; eggs until age 2; and peanuts, tree nuts, and fish until age 3 years (Fleischer et al., 2013)

15. Introduction of Highly Allergic Foods (Cont.) • New recommendations: Can introduce highly allergic foods at 4 to 6 months old, after other complementary foods have been introduced first; this should be done in the home, not at a restaurant or day care; wait 3 to 5 days between each food introduction to check for allergies; delayed introduction may put infants at risk of food allergy or eczema, whereas an earlier introduction may prevent food allergies (Fleischer et al., 2013). -Cow’s milk added to complementary foods in small amounts like dairy products (yogurt and cheese), baked goods, and cow’s milk protein formula can be introduced before 1 year; however, cow’s milk should not be given to an infant until 1 yr, due to low iron content and increased renal load (Fleischer et al., 2013) -Honey is not recommended until 1 year due to potential risk of exposure to harmful bacterial toxins, botulism poisoning (Duryea et al., 2013) - Introduce eggs at an early age in small amounts in cooked (scrambled, hard-boiled, fried, or poached) or baked goods; introduction at 4 to 6 months had a lower risk of egg allergy (Fleischer et al., 2013); one source says only egg yolk should be given to infants under 1 yr old (Infant Feeding Guide for Healthy Infants, 2009) -Wheat cereals can be offered at 6 months (Fleischer et al., 2013) -Peanut butter can be introduced between 6 to 12 months; exception is a child who has a sibling with a peanut allergy; avoid peanut kernels that can cause aspiration; peanut butter, peanut butter cups, other formulations and tree nut butters are safe to introduce at a young age (Fleischer et al., 2013) -Fish introduction before the age of 9 months reduced the risk of eczema in infants at 1 yr; also, the introduction of soy and shellfish into the diet does not need to be delayed (Fleischer et al., 2013)

16. In Conclusion: • The introduction of complementary foods to infants should be at 6 months of age, when their iron needs increase to avoid the development of iron deficiency • Some infants can take solids earlier, between 4-6 months, while continuing breastfeeding or formula feeding, depending on their developmental stage • Introduction of highly allergic foods at 4 to 6 months is OK as long as the infant doesn’t have a first relative (parent or sibling) with allergies; only cow’s milk and honey should be delayed until 1 year old

17. Sources • Baker, Robert D., Frank R. Greer, and The Committee on Nutrition. "Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in Infants and Young Children (0–3 Years of Age)." Pediatrics. N.p., n.d. Web. 22 Apr. 2014. • Baker, Robert D; Frank R Greer; The Committee on Nutrition. “Clinical Report- Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in Infants and Young Children (0-3 Years of Age).” American Academy of Pediatrics. October 5, 2010. 126:5:2010-2576. • Berglund, Saffron; Bjorn Westrup, Magnus Domellof. “Iron Supplements Reduce the Risk of Iron Deficiency Anemia in Marginally Low Birth Weight Infants.” The American Academy of Pediatrics. September 6, 2010. 126:4:2009-3624. • Duryea, Teresa K; David M Fleischer. “Starting Solids During Infancy.” March 21, 2013. UpToDate. • Duryea, Teresa K. “Introducing Solid Foods and Vitamin and Mineral Supplementation During Infancy.” April 13, 2013. UptoDate.

18. Sources (Cont.) • Fiocchi, Alessandro; Amal Assa’ad, Sami Bahna. “Food Allergy and the Introduction of Solid Foods to Infants: A Consensus Document.” Annals Allergy Asthma Immunology. 2006; 97:10-21. • Fleischer, D. M., Spergel, J. M., Assa'ad, A. H., & Pongracic, J. A. (2013). “Primary Prevention of Allergic Disease Through Nutritional Interventions.” The Journal of Allergy and Clinical Immunology: In Practice, 1(1), 29-36. Retrieved from http://dx.doi.org/10.1016/j.jaip.2012.09.003 • Fleischer, David M. “Introducing Formula and Solid Foods to Infants at Risk for Allergic Disease.” April 1, 2013. UpToDate. • Infant Feeding Guide for Healthy Infants. New Jersey WIC Services 2009. • "Iron Therapy for Preterm Infants." National Center for Biotechnology Information. N.p., Mar. 2009. Web. 22 Apr. 2014. • Mahoney, Donald H. “Iron Deficiency in Infants and Young Children: Treatment.” April 23, 2013. UpToDate. • "Premature infant: MedlinePlus Medical Encyclopedia." National Library of Medicine - National Institutes of Health. N.p., 26 Feb. 2014. Web. 22 Apr. 2014.