You are a paediatric registrar, discharging a 5-month-old boy (Sam) home after an overnight admission with a respiratory illness. When you check if there are any final questions, Sam’s parents want to know whether they should be commencing solids now, and if so, how they should go about it.
This is a great opportunity for some quick education for the family, made a little more efficient on a busy ward with the provision of some written information (see the resources section for my favourite websites). There have been lots of changes to infant feeding advice over the years, and a plethora of ideas about what comprises a healthy infant diet, so families can easily become confused. Some targeted, sensible advice can get most families on track towards safe and healthy eating for their infants, with positive implications for long term health and wellbeing.
When to introduce solids?
According to the World Health Organisation, all infants should ideally be exclusively breastfed for the first 6 months of life – no food and no extra water (medicines are, of course, allowed) – as introducing solids too early can interfere with this provision of nature’s perfect nutrition. However, the Australasian Society of Clinical Immunology and Allergy (ASCIA) has advised that food exposures can start occurring from (but not before) 4 months and that this is beneficial for allergy prevention. I encourage this for families in my care, explaining that from 4-6 months, these are to be just exposures, not meals – e.g. a lick of nut butter from a parents’ finger, a taste of bolognaise sauce, a finger play with mushy vegetables, and so forth.
From 6 months, babies particularly need sources of iron (as placental-derived stores will have run out), so regular small meals can commence – all solids should be offered AFTER a breastfeed until around 9-10 months of age when this can usually be reversed. Babies will need to be developmentally ready to start solids, with good head and neck control, ability to sit upright with support, showing an interest in food, and opening their mouth when offered a spoon. If not showing these signs by 7 months, the infant should be seen by their GP.
Infants can be fed purees, and/or soft hand-held foods (including foods they can safely suck on, such as a strip of toast or meat). There are different philosophies around the benefits of each method, but practically, it can work best for families to use a mixture of spoon- and finger-feeding. Finger-feeding provides great sensory and developmental experiences, but is messy and time-consuming, and requires a developmental level equivalent to around 8-9 months of age to reliably consume anything, so purees do have their place. Regardless of the feeding method, all meals must be closely and actively supervised by a competent adult.
What foods can be given and what should be avoided?
Infants can and should be exposed to all food groups from as early an age (at least prior to 12 months) as possible, except for honey, due to the risk of botulism (this can be introduced after 12 months if desired). Hard foods pose a choking hazard, so fruit and vegetables should be softened with cooking, and nut butter should be used instead of whole nuts. Home-cooked wholefoods are typically best for health, but there are some healthy commercial preparations.
To avoid confusion if allergic reactions occur, families should, according to ASCIA, introduce food types one at a time, a couple of days apart. This also gives the infant time to adjust to all the new, exciting textures and flavours.
Water should be offered with all solids from 6 months onwards to encourage good drinking habits. Infants and children shouldn’t drink juice, and cow’s milk shouldn’t be used a drink until after 12 months, although small amounts can be used on cereals or as a component of other meals for dairy exposure. After 12 months, limit cow’s milk to 500ml per day (less or none is fine, especially if still breastfeeding, and/or if having plenty of other calcium sources, such as other dairy products, or green leafy vegetables). ‘Toddler formula’ is almost never needed, and then only on specialist advice.
What happens if Sam has a reaction to a food?
Allergic reactions to food can be immediate or delayed and are highly variable and sometimes controversial. Symptoms may include rashes, respiratory difficulty, or gastrointestinal issues. Any suspected reactions require an immediate cessation of the suspected food(s), and medical review (urgency dependant on the severity of the symptoms) should be sought.
What if the family follows a special diet, like veganism?
Vegetarian and vegan families, or any other families following a relatively restricted diet for any reason, would benefit from an early assessment by a registered dietician. These diets may lack vitamins and minerals critical for the health of the developing infant, but can usually be safely adhered to with support and planning. Restrictive diets do increase the risk for food allergy and intolerance on later exposures, however, and families must be aware of this.
Ultimately, food should be about fun, togetherness, and good health. Families should be encouraged to keep mealtimes positive and family-centred, with everyone eating together at a table whenever possible (with all devices turned off). Parents should evaluate their own diet and ensure they are setting a good example, and empowering and teaching their children how to fuel their amazing, active bodies with a wide variety of healthy, delicious foods. It’s never too early to start forming good habits and positive food relationships.
References and Resources:-
Australasian Society for Clinical Immunology and Allergy (allergy.org.au)
- Information on how to introduce solid foods to infants (
- Infant feeding and allergy prevention (
Raising Children’s Network (raisingchildren.net.au)
The Royal Children’s Hospital Melbourne (rch.org.au)