WHAT FOODS FIRST?

What nutrients do infants need?

A good way to think of this question is “which nutrients do we need to add to baby’s breast milk or formula diet first?”  At six months or so, a baby’s growth needs begin to outstrip the nutrients they can get from breastmilk or formula.  They need additional protein, iron, zinc, and B vitamins.  Breastfed babies can also develop a vitamin D deficiency if they don’t receive a supplement, and for all babies, vitamin C helps with iron absorption.

This chart shows the nutrients baby needs and infant-friendly foods that contain them:

 Infant-Friendly Food Sources for Needed Nutrients

Nutrient                                                                Food Source

Protein                                                    Lean meats, cereal, beans, eggs

Iron                                                     Iron-fortified cereal, meats, green vegetables

Zinc                                                    Fortified cereal, meats

Vitamin A                                           Yellow vegetables

Vitamin C                                           Fruits, broccoli, leafy green vegetables, tomatoes

Vitamin D                                           Sun exposure, fortified cereal, egg yolk, cod liver oil

DHA                                                    Eggs, fish (e.g., salmon)

          Note: Iron, vitamins, and DHA are also available as infant drops.

Super Cereal

For most infants, an excellent food to begin with is iron-fortified cereal. In addition to the protein, zinc and iron in fortified cereal, it gives infants a great opportunity to learn to use their tongues to move the cereal from the front to the back of their mouths, and then to swallowing. 

 Start by mixing one part cereal with three or four parts breastmilk or formula to create a very thin consistency.  Then gradually (over a week or so), reduce the amount of fluid to two parts to thicken up the cereal a bit. 

The usual cereal to start with is rice because relatively few babies develop an allergy to it.  However, rice does sometimes cause constipation in some babies.  For them, assuming they do not have celiac disease in their family, we sometimes start with barley or oats (see the post on introducing foods to potentially allergic babies).  If your baby has a constipation problem, and we don’t want to try other cereals because of gluten, then we can start with protein rich vegetables, usually the yellow or orange ones first because abies routinely like them and they are well tolerated.

Caution—One new food at a time to monitor allergic reactions. 

This is really important:  Only introduce one new food at a time to your baby, then wait three to five days to see if the baby has a reaction to the new food before introducing a new one.  For <potentially allergic infants>  we wait five to seven days.  For example, if you are introducing squash, start with a small amount on the first day, and build up to a full portion by the third day and continue with squash for two more days giving us five days in total (extend the cycle to seven days for potentially allergic infants).  This gives us five (or seven) days to see if baby develops a rash or other reaction to the food.  See my post <Monitoring Baby’s Reactions to New Foods> for more on this topic.

NEXT— What solid foods should we introduce to baby first? – Beyond Cereal

INTRODUCING SOLIDS--WHEN? AND WHY THEN

Four to six months – in general

Everyone, from your yoga instructor to your mother, has a clear idea of when its best to introduce solid foods to your baby’s diet.  The American Academy of Pediatrics’ guidelines state that solid foods are best introduced at four to six months of age for most babies.  I support those guidelines. 

However, the reason they are called “guidelines” and not “unbreakable rules” is because there are some very good reasons to stray from the guidelines based on the baby’s situation.  Potentially allergic infants who are not breastfeeding should get solids a bit later than the guidelines call for.  Babies with reflux should start solids a bit earlier.  What to feed and in what order also is dependent on your baby’s situation – but that’s another post.

Why four to six months matters

Most babies double their birth weight reaching approximately 13 pounds in the first four to six months.  During that time, breastmilk with added vitamins (and added fortifier if the baby was premature) or a good commercial formula with added vitamins provides all of the nutrients, vitamins, calories and minerals your baby needs for that first crucial growth sprint. 

But after that first growth sprint, your baby’s needs start to outstrip the nutrients he can derive from just human milk or formula.  He will often still seem hungry even though he breastfeeding 8 or 10 times per day or drinking over 32 ounces of formula (and keeping it all down).  So nutritionally, four to six months is when most babies need to begin solids.

Developmentally, at five or six months of age babies are muscularly better suited for solid food.  They are sitting well enough to support their head. They can lean forward when they want to eat and turn away when they are full or just not interested in food.  They also can start using their lips to pull food off spoons, and they can move the food from the front of their mouths to the back in or to swallow(lessening the risk of choking or breathing the food).  Lastly, their extrusion reflex – sticking out their tongues to push anything odd (including solid food) out of their mouths--disappears at four or five months old.  Alas, the loss of the extrusion reflex doesn’t necessarily mean the end of spitting out food – just that your baby is now deciding to do it on his own.

During the first 6 months, the baby’s intestinal tract is also maturing in ways that can help lessen the development of food allergies.  Dr. Allan Walker has established that before six months of age, large protein molecules can penetrate the surface of an infant’s intestines.  When this happens, the infant can become sensitized to penetrating proteins, which could allow food allergies to develop.  Dr. Walker’s research has shown that after six months of age, the cells of the infant’s intestines knit tightly together and form a more effective barrier to the potentially allergy causing proteins.  Not every infant is susceptible to developing food allergies in this way, but in my view, its yet another reason to hold off on solid foods until baby is four to six months old as recommended by the guidelines of the American Academy of Pediatrics.

Next-  Is my baby a “potentially allergic infant?”

EXPRESSING AND PUMPING BREASTMILK

Believe it or not, hand expressing is actually an effective method of retrieving the breastmilk your body produces. This can be done in place of pumping or afterwards, often with several extra ounces collected. Begin at the upper portion of your breast and gradually massage downwards until your fingers are squeezing around your areola and nipple. some mothers find it is most productive to do this as they lean over.  You can also watch this technique visually on either of two videos.

• “Hand Expression of Breastmilk,” 2012, http://newborns.stanford.edu/Breastfeeding/HandExpression.html
•  Ameda, “Your Baby Knows How to Latch On,” 2010,  http://www.ameda.com/resources/video                                        

Most mothers find it easier and more efficient to rely on electric pumps that are far more effective than hand suction pumps. These can be easily cleaned (and should be) following each feeding according to the manufacturer's instructions.

For many mothers, the concern isn't which technique to use or how to combine them, but rather, how to start the flow (and sometimes how to find the time). The issue of finding the time and place to feed shouldn't be an issue at least in the US, with federal law now requiring employers to provide a comfortable, private space (other than a bathroom) as well as the time for a mother to pump and store her breastmilk.

That reassurance often helps since anxiety and stress can interfere with production. But beginning the process can be difficult for some moms since the baby isn't there to stimulate the flow. If possible, time your pumping or expressing to when you are feeling full.  A picture or even pleasant thoughts of the baby often helps a letdown response develop. A warm compress, gentle massage, or a few minutes of quiet and relaxation will usually help you begin. and then follow w the guidelines in our What to Feed Your Baby or our blogpost on collecting and storing that precious breastmilk.

BREASTMILK SAFETY AND STORAGE

The good news is that breastmilk can be stored safely for months (and that there is not bad news). You just have to know how to store the milk safely. Especially since many mothers are breastmilk goddesses with abundant production, exceeding what their babies can drink. And so many others are returning to work while they are still breastfeeding (and federal law requires employers to provide adequate facilities so mothers can pump and store the natural resource they produce).  

Once pumped while at work, the milk can be placed temporarily in an insulated cooler with ice packs. Then the milk can be transferred to the refrigerator or freezer, and left there for days or months (as you can see from the table). To make sure you stay within bounds, it's important to label the bag or bottle.

There is a debate, which is better. Most experts prefer plastic bags, since they are concerned that the immune-active cells in breastmilk will layer against glass bottles and be lost. But recently, some breast milk banks have returned to bottle storage. Either way, remember to swirl the milk so that the fat mixes in with the rest and leave enough room in case the milk expands when it freezes.

Storage Guidelines for Breast Milk

Location             Temperature                    Duration                       Comments

Countertop          Room temperature           6–8 hours                  Must be covered

Insulated cooler   5–39°F or –15–4°C             24 hours                  Keep with ice packs

Refrigerator             39°F or 4°C                         5 days           Keep at the back of fridge; 

Freezer compartment of refrigerator

                                 5°F or –15°C                      2 weeks             Store at back of freezer

Freezer compartment of refrigerator with separate doors

                                  0°F or –18°C                 3–6 months   

Deep freezer          –4°F or –20°C               6–12 months

Source: Bailey Koch, RD, CSP

Thawing Breastmilk

It's also important to know how to thaw and warm breastmilk to room temperature. Microwaves can create hotspots with the milk, so MICROWAVES SHOULD NOT BE USED. Instead, breastmilk should be thawed overnight if possible and then the container should be placed in a warm water bath until the milk returns to room temperature, so the baby can drink it safely.

Once the breast milk is thawed, it can be saved for up to 24 hours in the refrigerator. It should not be refrozen. So to limit any waste, breastmilk goddesses might want to store the milk in 2 -4 oz portions. 

SUGAR-SWEETENED BEVERAGES (JUICE, SODAS AND SUCH)

SUGAR-SWEETENED BEVERAGES

How about a little quiz for a change? (Actually, you take the quiz every time you buy one at the grocery or gas station or when you offer one to your child).

Let's start with the basics: what are sugar sweetened beverages and what beverages do they include? That's easy, right? They are the liquids that have sugar added, whether its sucrose (table sugar), juice concentrates or high fructose corn syrup, which we'll discuss shortly. And they're found in soft drinks (sodas), fruit drinks, sweetened tea and lemonade. Did you also include sports drinks and lemonade?

How much of these beverages do we drink? Enough that they represent 12-13% of the daily calories adults and adolescents consume. That represents a 230% increase in soft drinks and 170% increase in fruit drinks over the 25 years from 1977-2002.

How much sugar is that? In a 12 ounce can of soda, you drink 10 teaspoons of sugar. How much do you think is in fruit juice? Apple juice has exactly the same amount--and grape juice actually has 50% more--and that's the natural kind--without any sugar added.

Fluid Calories and Nutrients (per 8 Ounces)

                                       Calories     Sugar (g)     Protein (g)             Other Nutrients

Water                                0                0                   0                          Water itself

Milk                                 160            1 2                  8                   Vitamins A and D. Ca, P

Apple juice                     105            26                  0                           Vitamin C

Grape juice                    160            58.5               0                           Vitamin C

Carrot juice                      43            10                   1                  Vitamins A and C, minerals

Celery juice                      40             5                   1                      Vitamin C, minerals

Sports Drinks                   50           10-14               0                   Sodium and potassium

Coca Cola                         94            26                 0                                Water

g = grams

So why do so many people drink so much? Lots of reasons. The sweet taste is very appealing, and new research looking at brain scans shows that carbonation actually changes the way brain centers process the sensation of sweetness and that may make you want more. Second, they are relatively inexpensive--and all the supersizing far exceeds the 8 ounce suggested serving. And behind it all is the massive advertising--700 billion dollars in 2000, just to make you want specific soft drinks.

Why are the SSBs, as they're called, so bad for you? The extra calories are bad enough especially since they aren't accompanied by any nutrients (please refer to the table again), but worse, the high fructose corn solids bypass some of the digestive processes and get metabolized into fat.

But that's adults, isn't it? Actually, a new study shows that 2-5 year olds who drink more SSBs have significantly higher BMIs than those who don't drink the SSBs (J Pediatrics 2013: pages 413-20).

Bottom Line: Far too many calories come from SSBs and this is particularly detrimental when they have high fructose corn syrup added.