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Cordelia's article "Why wait to 6 months before introducing solids?"

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Cordelia's article "Why wait to 6 months before introducing solids?"

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The WHO and the NHS recommend exclusive breastfeeding for the first 6 months, with solids introduced from then on, alongside continued breastfeeding. In this article I explore the evidence behind the recommendation to wait until your baby is 6 months old before introducing solids.

Parents are often told, sometimes by family members, and sometimes by health professionals, to introduce solids to their exclusively breastfed baby before 6 months, in the belief that the baby needs more calories. This makes no sense since breastmilk and formula have 22kcal per fluid oz, whereas typical weaning foods are very low in calories. For example, an ounce of puréed carrots only has 7kcal per fluid oz, puréed apples has 13kcal per fluid oz, and pear has 16 kcal per fluid oz.

Gill Rapley, the Health Visitor who coined the term Baby-Led Weaning, says:" There is no rationale for pushing solid foods at the expense of breastmilk (or, indeed, formula). No solid food comes close to the concentration of nutrients in breastmilk, so, spoonful for spoonful, breastmilk will always provide better nutrition (and more calories) than any other food. Seeking to replace breastmilk in a child's diet risks them being less well nourished, not more. All that human babies need, once they're over six months, is access to small amounts of other foods - in addition to breastmilk - to make sure they're getting enough of the smallest nutrients."

Another common reason for suggesting solids is to help a baby sleep longer stretches at night. In fact, introducing solids usually has the opposite effect: babies wake up more often because their body needs to get used to digesting foods they aren't accustomed to. Sleeping longer stretches is developmental and has nothing to do with how much a child has eaten.

In 2003, following a systematic review for the World Health Organisation on the optimal duration of exclusive breastfeeding, infant feeding guidelines in the UK were changed to recommend exclusive breastfeeding for the first 6 months, with solid foods introduced from then on, alongside continued breastfeeding:

"Infants who are breastfed exclusively for 6 months experience less morbidity from gastrointestinal tract infection than infants who were mixed breastfed as of 3 or 4 months of age. No deficits have been demonstrated in growth among infants from either developing or developed countries who are exclusively breastfed for 6 months or longer".

In 2018, the Scientific Advisory Committee on Nutrition(SACN) considered evidence relating to feeding in the first year of life, and reached the following conclusions:
'The totality of the evidence reviewed for this report supports current guidance to breastfeed exclusively for around the first 6 months of an infant's life and to continue breastfeeding for at least the first year of life. Each makes an important contribution to infant and maternal health.' 'By around 6 months of age, infants are usually developmentally ready to actively accept foods other than breast milk (or infant formula). The available evidence indicates that the introduction of solid foods or infant formula before 6 months of age reduces the amount of breast milk consumed and is associated with greater risk of infectious illness in infants.'
In addition, according to the independent public health nutrition charity First Steps Nutrition: 'there is increasing evidence that breastfeeding is protective against the development of overweight and obesity, with recent evidence from WHO Europe, after consideration of data from over 100,000 children in 22 European countries, concluding that: 'Breastfeeding has a protective effect: obesity is less frequent among children breastfed for at least 6 months.' This is supported by evidence from the UK Millennium Cohort Study which reported that study participants who were breastfed as infants had lower odds of being overweight or obese at age 14.'

In March 2018, at a conference entitled " Infant feeding: Policies, politics and best practice' at the Royal Society of Medicine, Professor Charlotte Wright, paediatrician and epidemiologist, stated: "Early solids doesn't enhance growth but displaces milk and puts baby at risk.
The world over, parents view the starting of solids as evidence of their child maturing, developing, moving on, and because of this are tempted to start them early. It is really important to resist this assumption, the danger being that introducing solids early will reduce the child's intake of breastmilk, which is really all they need for the first six months. Introducing anything else before this age increases the child's risk of infection, with a number of UK cohort studies showing that exclusively breastfed infants are healthier than partially or non-breastfed babies. There is a push, particularly from the formula industry, for the recommendation to be changed from six months back to four-six months. We've reviewed all of the challenges and found no evidence for them. One argument is that waiting to six months to introduce solids runs the risk of children not having enough to eat and particularly not enough iron, but it actually has been found to have no increase risk of adverse weight gain or iron deficiency anaemia."
Developmental signs of readiness for solids include:

Baby can sit up well without support and hold their head steady.

Baby can co-ordinate their eyes, hands and mouth so they can look at the food, pick it up and put it in their mouth by themselves.

Baby has lost the tongue-thrust reflex and does not automatically push solids out of his mouth with his/her tongue.

Baby is ready & willing to chew. ⁣

Baby is developing a "pincer" grasp, meaning they can pick up food or other objects between thumb & forefinger.⁣

⁣ Baby is eager to participate in mealtimes & may try to grab food & put it in their mouth.⁣

As well as waiting until a baby is 6 months old, it's also recommended to wait until a baby is showing all the developmental signs of readiness.

Showing interest when adults eat doesn't necessarily mean a baby is ready for solids. Anything parents do is fascinating to their baby. A baby who has never had solid food doesn't know what it is, so can't know what they're missing. In this video: https://youtu.be/FefI1J-iDY4 4-month-old baby Sofia is interested in her mother's glass of wine, but that doesn't mean she's ready for alcohol.
Links: https://kellymom.com/nutrition/starting-solids/babyfoodcalories/ https://www.ncbi.nlm.nih.gov/pubmed/15384567 https://www.gov.uk/government/publications/feeding-in-the-first-year-of-life-sacn-report https://static1.squarespace.com/static/59f75004f09ca48694070f3b/t/5d2ef0605808300001efe136/1563357283396/EFSA_consultation_First+Steps_+July19.pdf https://www.karger.com/Article/FullText/500425 https://cls.ucl.ac.uk/wp-content/uploads/2017/12/MCS6-Briefing-02-Overweight-and-obesity.pdf
Understandably new parents are eager to start their baby on solids as it's an exciting new stage. However, preparing food on a daily basis is hard work, and requires much more planning than when a baby is only drinking breastmilk or formula. The novelty soon wears off. A big advantage of delaying solids until your baby is completely ready, is that it means less work, especially as at 6 months babies will be developmentally ready and able to eat many of the same foods as the rest of the family.
Is baby ready for solid foods? (Developmental signs of readiness) * KellyMom.com Your baby's first solid foods - NHS
http://www.rcpch.ac.uk/growthcharts/

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The WHO and the NHS recommend exclusive breastfeeding for the first 6 months, with solids introduced from then on, alongside continued breastfeeding. In this article I explore the evidence behind the recommendation to wait until your baby is 6 months old before introducing solids.

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SACN report of feeding in the first year of life: 

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SACN report of feeding in the first year of life: 

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Feeding in the first year of life: SACN report

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The Scientific Advisory Committee on Nutrition (SACN) report on feeding in the first year of life.

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This is the systematic review on which UNICEFs recommendation for delaying introduction of solids until 6 months is based:

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This is the systematic review on which UNICEFs recommendation for delaying introduction of solids until 6 months is based:

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Infants who are breastfed exclusively for 6 months experience less morbidity from gastrointestinal tract infection than infants who were mixed breastfed as of 3 or 4 months of age. No deficits have been demonstrated in growth among infants from either developing or developed countries who are exclusively breastfed for 6 months or longer... Based on the results of this review, the World Health Assembly adopted a resolution to recommend exclusive breastfeeding for 6 months to its member countries.

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doi: 10.1007/978-1-4757-4242-8_7.

Affiliation

¹ Departments of Pediatrics and of Epidemiology and Biostatistics, McGill University Faculty of Medicine, Montreal, Quebec, Canada H3A 1A2. michael.kramer@mcgill.ca

doi: 10.1007/978-1-4757-4242-8_7.

Affiliation

¹ Departments of Pediatrics and of Epidemiology and Biostatistics, McGill University Faculty of Medicine, Montreal, Quebec, Canada H3A 1A2. michael.kramer@mcgill.ca

Abstract

Although the health benefits of breastfeeding are acknowledged widely, opinions and recommendations are divided on the optimal duration of exclusive breastfeeding. We systematically reviewed available evidence concerning the effects on child health, growth, and development and on maternal health of exclusive breastfeeding for 6 months vs. exclusive breastfeeding for 3-4 months followed by mixed breastfeeding (introduction of complementary liquid or solid foods with continued breastfeeding) to 6 months. Two independent literature searches were conducted, together comprising the following databases: MEDLINE (as of 1966), Index Medicus (prior to 1966), CINAHL, HealthSTAR, BIOSIS, CAB Abstracts, EMBASE-Medicine, EMBASE-Psychology, Econlit, Index Medicus for the WHO Eastern Mediterranean Region, African Index Medicus, Lilacs (Latin American and Carribean literature), EBM Reviews-Best Evidence, the Cochrane Database of Systematic Reviews, and the Cochrane Controlled Trials Register. No language restrictions were imposed. The two searches yielded a total of 2,668 unique citations. Contacts with experts in the field yielded additional published and unpublished studies. Studies were stratified according to study design (controlled trials vs. observational studies) and provenance (developing vs. developed countries). The main outcome measures were weight and length gain, weight-for-age and length-for-age z-scores, head circumference, iron status, gastrointestinal and respiratory infectious morbidity, atopic eczema, asthma, neuromotor development, duration of lactational amenorrhea, and maternal postpartum weight loss. Twenty independent studies meeting the selection criteria were identified by the literature search: 9 from developing countries (2 of which were controlled trials in Honduras) and 11 from developed countries (all observational studies). Neither the trials nor the observational studies suggest that infants who continue to be exclusively breastfed for 6 months show deficits in weight or length gain, although larger sample sizes would be required to rule out modest increases in the risk of undernutrition. The data are conflicting with respect to iron status but suggest that, at least in developing-country settings, where iron stores of newborn infants may be suboptimal, exclusive breastfeeding without iron supplementation through 6 months of age may compromise hematologic status. Based primarily on an observational analysis of a large randomized trial in Belarus, infants who continue exclusive breastfeeding for 6 months or more appear to have a significantly reduced risk of one or more episodes of gastrointestinal tract infection. No significant reduction in risk of atopic eczema, asthma, or other atopic outcomes has been demonstrated in studies from Finland, Australia, and Belarus. Data from the two Honduran trials suggest that exclusive breastfeeding through 6 months of age is associated with delayed resumption of menses and more rapid postpartum weight loss in the mother. Infants who are breastfed exclusively for 6 months experience less morbidity from gastrointestinal tract infection than infants who were mixed breastfed as of 3 or 4 months of age. No deficits have been demonstrated in growth among infants from either developing or developed countries who are exclusively breastfed for 6 months or longer. Moreover, the mothers of such infants have more prolonged lactational amenorrhea and faster postpartum weight loss. Based on the results of this review, the World Health Assembly adopted a resolution to recommend exclusive breastfeeding for 6 months to its member countries. Large randomized trials are recommended in both developed and developing countries to ensure that exclusive breastfeeding for 6 months does not increase the risk of undernutrition (growth faltering), to confirm the health benefits reported thus far, and to investigate other potential effects on health and development, especially over the long term.

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breast feeding / statistics & numerical data*

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national center for biotechnology information

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The optimal duration of exclusive breastfeeding: a systematic review - PubMed

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Although the health benefits of breastfeeding are acknowledged widely, opinions and recommendations are divided on the optimal duration of exclusive breastfeeding. We systematically reviewed available evidence concerning the effects on child health, growth, and development and on maternal health of ...

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Is baby ready for solid foods? (What do the experts say?) * KellyMom.com

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Health experts and breastfeeding experts agree that it's best to wait until your baby is around six months old before offering solid foods. There has been a large amount of research on this, and most health organizations have updated their recommendations to agree with current research.

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Professor Charlotte Wright (Professor of Community Child Health at Glasgow University, who led the Growth Charts Expert Working Group which created the UK-WHO growth charts, 0-18 years http://www.rcpch.ac.uk/growthcharts/) confirmed the recommendation to delay solids until 6 months at the 2017 First Steps Nutrition conference: "Early solids doesn't enhance growth but displaces milk and puts baby at risk.”

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Professor Charlotte Wright (Professor of Community Child Health at Glasgow University, who led the Growth Charts Expert Working Group which created the UK-WHO growth charts, 0-18 years http://www.rcpch.ac.uk/growthcharts/) confirmed the recommendation to delay solids until 6 months at the 2017 First Steps Nutrition conference: "Early solids doesn't enhance growth but displaces milk and puts baby at risk.”

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Here's a link to the kellymom page on the calorie and fat content of common baby & toddler foods, where you can compare the calories in breastmilk and formula to those in common baby foods. There are 22kcals in one oz of breastmilk, and 20kcals in one oz of formula, but only 7kcals in one oz of cooked carrot. I think that knowing this helps parents understand why they don’t need to rush to introduce solids:

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Here's a link to the kellymom page on the calorie and fat content of common baby & toddler foods, where you can compare the calories in breastmilk and formula to those in common baby foods. There are 22kcals in one oz of breastmilk, and 20kcals in one oz of formula, but only 7kcals in one oz of cooked carrot. I think that knowing this helps parents understand why they don’t need to rush to introduce solids:

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Food Calorie content*
(kcal per ounce)
Fat content
(grams per ounce)

Milk

Applesauce

Beechnut (stage 1) applesauce

Beechnut (stage 2) applesauce

Beechnut (stage 3) applesauce

16

15

15

0

0

0

Avocado, raw

46

4.21

Banana

Squash

Carrots

Green Beans

Oatmeal

Baby oatmeal

(2 TBS dry cereal prepared in one oz water)

20

0.39

Peaches

Pears

Beechnut (stage 1) pears

Beechnut (stage 2) pears

Beechnut (stage 2) pears

20

18

17

0

0

0

Peas

Potatoes, baked

14

0.02

Rice cereal

Baby rice cereal

(2 TBS dry cereal prepared in one oz water)

20

0.24

Baby brown rice cereal

(2 TBS dry cereal prepared in one oz water)

30

0.22

Sweet potatoes

Yogurt

Yogurt, plain, whole milk

Yogurt, plain, low fat

Yogure, plain, skim milk

17

18

16

0.92

0.44

0.05

* Rounded to the nearest kcal
References:

Updated on Filed Under: Solid Foods

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Calorie and fat content of common baby & toddler foods * KellyMom.com

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Food Calorie content* (kcal per ounce) Fat content (grams per ounce) Milk Applesauce Beechnut (stage 1) applesauce Beechnut (stage 2) applesauce Beechnut (stage 3) applesauce 16 15 15 0 0 0 Avocado, raw 46 4.21 Banana Squash Carrots Green Beans Oatmeal Baby oatmeal (2 TBS dry cereal prepared in one