Beyond Breast and Bottle

by Daniel Neuspiel, MD and Steven Schwartz, MD

Research shows early feeding can have long-term effects on your child's health. How can you make sure your child is eating the right foods once he or she is off the bottle? Dr. Daniel Neuspiel, associate chairman of pediatrics at Beth Israel Medical center, and Dr. Steven Schwartz, professor of pediatrics at SUNY Brooklyn, will be helping us ready to begin solids.

When do you start giving your child solid food?
The answer is not "as early as possible," which is sometimes what I see. There are no hard and fast rules, but I can tell you what I do. Typically, when an infant is taking an appropriate amount of formula and they're consuming greater than 32 ounces per day, that usually signals the time to start some form of solids. It's harder to measure intake with breastfed infants, but developmental readiness is a good sign. And for infants that are breast-fed or bottle-fed typically that's around four to five months.

What's the best time to stop breast-feeding?
I really recommend breast-feeding for as long as it's comfortable and possible for the mother and child, given their own preferences and lifestyle. Certainly, six months of breast-feeding is recommended as the optimal early nutrition for babies.

How is it best to introduce solids?
It's important to take a couple of things into consideration. In addition to the time you're introducing solids, the way they're introduced is also important. Giving solids only by spoon and not putting them in the bottle is an important rule. Many parents start putting cereal and other solids in the bottle. And while they're well-meaning in doing that, that can often cause some digestive problems.

There are clinical conditions in which we recommend rice cereal in the bottle, but that's specifically on a physician's recommendation. I'm reminded of an advertisement I received several years ago. I'm not even going to mention what it was called, but it was a bottle with a spring-loaded plunger in it that was for the administration of solids in the bottle. And clearly that is not the way to go.

It's advisable to start with one solid at one time to give the baby an opportunity adjust to that new taste, new food and perhaps more importantly to watch for any potential allergic reactions, difficulties the baby may have.

There are no good tests for food allergies that are reliable. The most reliable is give a single food and see if there is a reaction. And use withdrawal and rechallenge. So it's very important to only start one food at a time.

What do you think of solid food in a baby bottle?
In general it's not recommended. There are certain medical conditions where there may be some recommendation for thickening a formula. But unless a pediatrician recommends it, parents should stay away from putting any solids into bottles.

Giving a child solid food in a bottle, increases the risk of obesity. Solids are very calorically dense substances. And you're in fact overfeeding a child. If you're going to put solid food in a bottle, you're going to have to open up the nipple because it's very hard to get solids through that nipple. So again, it is really, I think, a symptom of overfeeding. We're not going to see digestive problems; you may see allergies, particularly if you start the solids very, very early. And indeed, if solids are going in the bottle, my assumption is that the child is not physiologically ready to take the solids on the spoon, so that's why we're giving it in the bottle. Again, it's just not correct. It's not a good idea.

What about a six-week-old who doesn't sleep well?
First of all, they're not going to be able to digest it. Second of all, a six-week-old or a two-month-old is not going to be able to coordinate getting the cereal from the front of the mouth to the back of the mouth and then swallowing it. And if they're unable to do that, you may find them gagging or choking -- sometimes with bad consequences. So again, they're not ready for it so don't give it.

Which foods we should start?
Cereal has a number of benefits to start early. For one thing, it's rich in iron and there's a increasing iron need around the time of introduction of solids, that four to six month period. Secondly, it can be mixed with milk in different quantities and different textures that could work better for different babies. And it's a good way to give more concentrated calories to babies who are at a point that Dr. Schwartz mentioned, where they're drinking a lot of formula.

Other good first foods include sweet potatoes, avocados and other fruits and vegetables.

What's the earliest you should introduce cereal?
The problem with a newborn infant is that they're not going to be able to digest the starch that's present in cereals. We would not recommend it before four to five months. That's a pretty much a hard and fast rule, as far as I'm concerned, unless there's some mitigating circumstances.

After starting one thing at least three days apart, you're also looking at not just the type of food but the quantity. There's no hard and fast rule, but what works very well for many infants and parents is to give after cereal is going okay once a day, to perhaps add fruits or vegetables at a second feeding a day. Sometimes it works out to give the fruits together with the cereal, even mixed together as long as the foods are very smooth, what some of the baby food companies might call stage 1 or junior foods. And for many families, making their own baby foods is perfectly safe.

I'd like to talk about that. Because I have a lot of families who make baby food and that's wonderful and I recommend it, but you're making baby food, not adult food that you give babies. Don't taste it and say, "Well, it needs a little salt or it needs a little sugar," because that's the last thing you want to do.

If you're going to buy jarred foods, use one of the very recognizable brands and use the pure food. For example, give peas, give carrots. I don't like the dinners, the dinners tend to contain other things. I've often had a running battle with the baby desserts, which I find something that I'm not terribly fond of.

Why are you not fond of the desserts?
Baby desserts tend to contain additives; an example is added sugar. There's no reason for a baby to have added sugar in their diet, just like there's no reason for a baby to have added salt in their diet. They certainly don't provide anything that the baby needs and they can potentially do harm.

Stick with a single food, prepared purely. If you want to add some moisture to it, I sometimes tell parents you can add a little unsweetened, pasturized apple juice or water even to it. But stay away from sugar, stay away from salt, stay away from mixtures of things where you're not 100% sure what's in there.

What about juices?
While commercial juices are fine for babies, many are meant for older children and adults, have a little too much sugar for babies and often have to be diluted with extra water. I usually advise as a good recommendation to mix the commercial juices half with water.

I generally advise for young infants not to get juices at all. There's no reason for it. Babies need breast milk, babies need formula. They don't need added things. Now in the summer, in the hot months, we may recommend fluid to be added to a formula-fed baby's diet. But typically, I see a two-month old who comes in with a bottle of apple juice, I mean, this is inappropriate.

Even water is not recommended under six months of age for babies.

How do you know when a child is ready for a food and they can chew it and swallow it responsibly?
We need to be careful with anything that babies are given that could potentially be a choking hazard that is a size that can block the airway or can be broken into a piece that can block the airway. And it's especially important when children reach that age of five or six months when they're putting everything inside their mouth to make sure that there aren't things around that they'll choke on. And that includes a lot of foods that parents may think are healthy, like some biscuits that may break off into pieces that kids can choke on, grapes and peanuts.

Raisins are a big choking hazard for infants. And I would like to make one plea: Toddlers don't need lollipops. And the danger of the lollipop is, if you've seen a child walking around with a lollipop and then running with a lollipop. Not to mention the problem with sugar and effect on the developing teeth, they fall and the problems can be life-threatening.

Is honey dangerous for children?
Yes, there is a potential serious danger of honey, because there's a condition called botulism which is spread by certain spores of bacteria that can be present in honey. And that's a condition that could cause cessation of breathing and even death in some babies. So we recommend never giving honey to infants and certainly below a year of age.

These botulism spores have been found in some other syrups such as molasses, corn syrup or maple syrup. In the past, even currently, some parents have used some of these syrups as treatments for constipation and other reasons. And we recommend really staying away from those and any kind of sweetened syrups in infants under a year.

Many babies are anemic. Why?
The most common reason is nutritional anemia. Now, how do you develop nutritional anemia? These are most commonly formula-fed infants, very often receiving a formula that's not supplemented with iron. And one of the biggest culprits is the early introduction of whole cow's milk. Whole cow's milk is not only devoid of iron, but it also can cause blood loss. And so the American Academy of Pediatrics, again, recommends not instituting any whole cow's milk prior to ten months of age. I like to say a year, to be on the safe side.

Babies who are breast-fed generally are fairly replete in iron, because iron in breast milk is very highly absorbed. It's very poorly absorbed in formula, so I recommend that all formula-fed infants receive an iron-fortified formula. The use of cereals as the first food, again, provides you with an added source of iron.

Copyright © Daniel Neuspiel and Steven Schwartz. Permission to republish granted to Pregnancy.org, LLC.