Episode Transcript
Hi everyone, welcome to Clerkship Ready – Pediatrics – A podcast aimed at helping you excel during your clinical clerkship in Pediatrics! I am Erica Licari and I’m a pediatric resident at the University of Virginia and am planning to pursue a fellowship in allergy and immunology.
Because of that, I thought it would be very fitting to talk about something that comes up time and time again in the pediatric clinic – how to introduce complementary foods and potentially allergic foods into infants’ diets! This will be something parents will ask you many many questions about and they will often want to know: when to introduce pureed and solid foods, how to introduce these foods, in which order should they be offering these foods, and everything in between!
So what do we mean when we say “complementary” foods? Complementary foods is a catch all category, by which it is just defined as “all solid and liquid foods other than breast milk or infant formula”. Whereas potentially allergenic foods are things like eggs, peanut butters, nut butters, fish, shellfish, etc. We use the term complementary foods and solid foods interchangeably usually.
For a lot of parents, introducing new foods into their baby’s diet can be a scary feat – especially if this is their first child or if the parents have had experience with food allergies in the past. There is also a lot of misinformation on the internet about very specific ways that parents should introduce foods and strict guidelines that they should follow, so sometimes parents can be overwhelmed and worried they are going to make a mistake. It is important to keep this in mind when you are counseling them, because at the end of the day, introducing these foods does not need to be as complicated or scary as sometimes it can be made out to be.
As a general rule of thumb, the first time that we will start recommending the introduction of solid foods in the form of puree, is around the time an infant turns 4-6 months old – and that is only if the infant is able to demonstrate adequate head control in the office with us (which we assess for during their 4-month-old well child visit). Why this age? When thinking about both the organ development and the development of feeding skills, it is important to know that an infant’s renal and gastrointestinal systems can only start to metabolize complementary foods around the age of 4 months. And that an infant will usually develop motor and dental development skills to sufficiently chew and swallow foods around 6 months. Additionally, studies have found that introducing complementary foods too early can be associated with harmful health side effects. For example, a study published in 2011 found that introduction of solids (in formula fed babies) before age of 4 months was actually associated with a 6-fold increase in risk of obesity by age 3 years. However, this increased risk was not seen with the very early introduction of solids in breastfed babies, but something to keep in mind.
So, why is it important to introduce complementary foods into an infant’s diet? There are two main reasons I want to highlight:
1. The first is that breastmilk and infant formula do not contain all the nutrients a growing infant will need to continue growing and developing appropriately. This is specifically true, once the child is 6 months old. For example, one of the most common deficiencies that we see in children (and in infants) is iron deficiency, which is something we will talk about in a little bit. You can also learn more about iron deficiney anemia in the podcase episode 27.
2. The second reason is base on information from an important pediatric study called The LEAP study –
In 2015, A Randomized control trial was published in the new England journal of medicine that looked at the prevalence of peanut allergy in a cohort of atopic children (as a reminder atopic just means people who are prone to allergic conditions: such as seasonal allergies, asthma, food allergies, eczema)
The study included Infants age 4months to 11months that had a hx of severe eczema, egg allergy or both
The infants were randomly assigned to consume or avoid peanuts until age of 60 months (aka 5 years of age)
At the end of the study, the prevalence of peanut allergy in the group that avoided peanuts was 13.7%, whereas the prevalence of peanut allergy in the groups that consumed peanuts was 1.9%
This study had HUGE implications regarding the introduction of potentially high allergen foods into infant’s diets. More specifically, the findings from this study led to the recommendation that infants should be introduced to high allergen foods (as early as possible starting at age 4 months) in order to reduce the risk of developing a food allergy to them. And although this study focused on peanut allergy specifically, we have applied these findings to other allergenic foods such as egg, soy, shellfish, etc.
So, getting back to the main topic of today’s discussion: what do you do next when the 4 month old child comes into your office with adequate head control and you want to discuss incorporating solid foods into the diet? How do you counsel parents on how to start introducing these foods?
I personally like to go about this by thinking about introducing foods into two different frameworks:
1. The introduction of complementary foods
2. The introduction of potentially allergenic foods
So, in terms of the introduction of complementary foods:
- Both the AAP and the WHO recommend first offering a variety of single-ingredient foods (such as pureed vegetables, fruits, grains and meats). And these can be given in any order that parents desire
- It can be a safe bet to start with something like an iron fortified cereal
- Full term infants are born with iron stores that eventually become depleted by about 4-6 months of age. Formulas fortunately contain a small amount of iron that can help make up for this, however, it is important for infants to receive additional sources of iron through the foods that they eat. Moreover, this is extremely important in breastfed infants since breastmilk contains a very very small amount of iron. Because of this, recent pediatric guidelines have started recommending the supplementation of breastfed (or partially breastfed infants) with a pediatric multivitamin that contains iron at age 4 months in order to help with proper acquisition of iron.
- So this is important to keep in mind, because encouraging parents to provide their infants with an iron fortified cereal helps you increase both the baby’s iron stores while also encouraging the start of adding in complementary foods. We recommend mixing the infant cereal with formula or breastmilk in a bowl, to the point that it is soupy in consistency. It is important not to directly mix the cereals into a bottle (and then making the nipple size bigger) because this can actually be a choking hazard.
Many parents will ask if they can should introduce one new food per day, and while there is no strict guideline with this, we generally recommending only providing 1-2 new foods per day in case the child has an adverse reaction (this can help to narrow down the possibilities of what could have caused the reaction)
Additionally, many parents will ask if they need to wait a few days in a row between offering their child new foods. For example, a trend that I have seen is that many parents will provide their infants with pureed peaches for 3 days in a row, before moving towards providing pureed something like pureed squash for 3 days. This is not something that needs to be followed. Again, parents can introduce foods into their infant’s diet in any order they choose and in any time manner they desire as well. They do not need to be waiting a few days in between each introduction.
It is also important to remember that the main calorie source for these infants should still be coming from their formula or human milk, and that the introduction of these foods into their diet can be seen as “an added bonus” rather than taking the place of one of their bottles or breastfeeding occurrences. Because of this, we recommend providing infants with just a few teaspoons of each of these purees per day. They do not have to eat a full serving or an entire container of the purees.
And lastly, important foods to avoid include: honey (due to the risk of botulism), cow’s milk (we transition to cow’s milk instead of formula / breastfeeding at age 12 months but not prior. This is because it has a low absorbable iron content which can lead to iron deficiency anemia, and doesn’t have all of the nutritional value that infant’s need from breastmilk/formula). We also advice to avoid foods that can be choking hazards (such as whole nuts, grapes, popcorn, etc). We also always recommend first providing foods with a very smooth or soupy texture, and then start to advance the texture as the child grows.
Now, in terms of the introduction of potentially allergenic foods:
Like we mentioned before, the LEAP study that was published in 2015 had a MAJOR impact on the recommendations regarding introduction of potentially allergic foods
Prior to 2015, the recommendation was to delay introduction of these foods (especially in high risk children – aka children with other atopic conditions). For example, it had previously been recommended to introduce cow’s milk at 1 year of age, eggs at 2 years of age, and seafood, peanuts, tree nuts at 3 years of age. However, based on the results of the LEAP study, these recommendations have completely changed
Now the recommendation is to introduce these foods as early as possible (as early as 4 months) in order to reduce the risk of the development of a possible food allergy
In terms of the most common allergenic foods, the list usually consists of milk, egg, soy, wheat, fish, shellfish, tree nuts, sesame (with egg and milk being the two most common in young children)
- In terms of introducing these foods, it is recommended that these foods start to be added to the infant’s diet after the infant has tried and tolerated a few of the non-allergenic complementary foods (this is to make sure that the infant can tolerate non-allergenic foods first and foremost)
- For children with a history of atopy (or a family hx of atopy) it is recommended to start with a small serving of each of these foods, and then gradually increase the serving size as it is tolerated
- In terms of cow’s milk, we still recommended avoiding just plain cow’s milk in a bottle but instead can introduce other cow’s milk based products such as yogurts and cheese
When counseling parents on the introduction of these foods, it is important to review with them what a true “allergic reaction” will look like. For example, it is helpful to describe what a hive may look like. This is important, since many acidic fruits can cause a contact dermatitis like rash on the patient’s skin, which the parents may worry is an allergic reaction. Remember that a hive will usually be described as an erythematous raised area with a pale or whiteish center that comes and goes on many different areas of the patient’s body. Whereas, a rash that is from contact dermatitis is usually an erythematous flat area that may have papules, and stays in one spot.
With this is mind, it is important that you clarify with the family what a hive would look like vs what a contact rash would look like. Otherwise, patients can unfortunately get stuck down a rabbit hole where they are avoiding / eliminating certain foods from their child’s diet due to unclear “reactions” that their child had. When in reality, many of these reactions may have not been allergic (IgE) driven reactions.
This is incredibly important to bring up, since avoiding a food that was previously tolerated, can sometimes actually lead to the formation of a food allergy. This has a special title called “FA-PTF” aka Food allergy to a previously tolerated food”. Because of this, we want to make sure that parents do NOT start avoiding foods or eliminating foods from their infant’s diet due to confusion as to what type of skin reaction the patient may have had.
Additionally, as a side note related to this
- Many parents with children that have very bad eczema, will sometimes come to the office reporting that their child’s eczema has been exacerbated by “XYZ” food. And because of this, they will start eliminating that food from the child’s diet as well
- Again, we do NOT want this to occur, because as we just talked about – if you avoid a certain food, you can be at a greater risk of then developing an allergy to that food
Another common issue that arises once complementary and allergenic foods are introduced to the diet, is that bowel habits change
- It is very very common for parents to talk about how their baby’s stools have started to change in consistency and/or frequency after they implemented solid foods into their diet. Specifically, many parents will note that their babies are stooling less frequently or their stools appear to be slightly harder after they have introduced solids.
- In many cases, this change in stool may be directly associated with the types of purees that parents are providing their babies with
- For example, foods with bananas or rice cereals can have a tendency to constipate babies
- While other foods can soften stools or increase frequency of stools (such as the P foods: prunes, pears, peaches, apricots and apples)
- This is important to keep in mind, and I usually like to provide anticipatory guidance for families when I discuss implementing complementary foods, just so that they know that it is expected to see a change in their baby’s stooling patterns
So in summary, here are the 3 big take aways that I want you to remember from this podcast if nothing else:
1. We can first start introducing complementary foods into an infant’s diet around 4 months of age – as long as they demonstrate adequate head control in our office and don’t otherwise have any medical conditions that would interfere with their ability to safely swallow purees
2. Parents should start by offering a variety of single-ingredient foods (with iron fortified baby cereal as a great first option since infant’s iron stores that they are born with generally are depleted by age 4-6 months)
3. In terms of introducing potentially allergenic foods, it is important to introduce them early in order to decrease the risk of the potential development of a food allergy down the road, and to also make sure you provide parents with guidance as to what a true allergic reaction would look like so that they don’t start avoiding or eliminating foods from the infant’s diet prematurely.
