Transcript Introduction of Solid (Complementary) Foods to Infants

INTRODUCTION OF
COMPLEMENTARY FOODS TO
INFANTS
When is it OK, and why?
By: Nicole Parello
FOOD INTRODUCTION
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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)
FOOD INTRODUCTION (CONT.)
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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)
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)
PREMATURE INFANTS
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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)
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)
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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)
IRON DEFICIENCY ANEMIA (CONT.)
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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)
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)
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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)
SIGNS OF READINESS (CONT.)
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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)
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)
WHICH FOODS FIRST (CONT.)
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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)
INTRODUCTION OF HIGHLY ALLERGIC
FOODS
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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)
INTRODUCTION OF HIGHLY ALLERGIC FOODS
(CONT.)
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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)
IN CONCLUSION:
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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
SOURCES
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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 ReportDiagnosis 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.
SOURCES (CONT.)
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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.