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We spent some time with Dr. Moore-Ostby of Indy Direct Docs to answer questions about starting solids. You can watch our live interview at the end!
Dr. Moore-Ostby is a board-certified pediatrician and has been in practice for ten years. She is also a IBCLC and a postpartum care physician. Everything stated in this article is not specific medical advice, but general medical counsel, knowing there might be specifics in each case that makes a difference.
"When to start solids, how much, how often?" Six months - it's not a magical number. You can start around six months. We've learned a lot about gut health so six months is correct, whether breastfed or formula fed. Even around five months, they are watching you eat and it's something they need to do developmentally, but six months is better. That alone doesn't say they are truly ready. They just want what you have, whether it's food or not. Before six months, they are getting the nutrients they need from breastmilk or formula. If your baby was premature or has certain medical issues, your baby might need an iron supplement. The stores that babies are born with start to die off around six months, so when you do start solids, it's important to focus on iron-heavy foods.
"My daughter's pediatrician is making us feed her oatmeal with a spoon, along with breastmilk and formula. She is five and a half months old, four months adjusted." It's difficult with premies because at some point, I don't worry about how they are adjusted. In general, she can start solids at six months. When I was first trained, I always used to say start with cereal with a spoon, but I don't say that anymore. There isn't evidence stating that the thin to thicker approach is needed. A reflex that baby is born with, sticking their tongue out when something is in their mouth is a natural reflex. If a baby still does that, that baby isn't ready for solids. I personally don't push cereal across the board anymore. Rice cereal used to be the standard but now I suggest oatmeal, due to high levels of arsenic and constipation. Oatmeal is fortified with iron which is a good option for baby. I don't care if most of my patients skip it. They might be suggesting it for iron or calorie fortification too. It might be worth asking the pediatrician to explain their reasons. Don't be nervous to ask your doctor. Some pediatricians say to start certain colors of food and that is not supported by evidence.
"What if they don't like puréed foods? 90% of the time she is gagging like she is going to throw up. She is seven months old and likes wafers." The gagging might mean she truly does hate it. It also might just be her gag reflex. Babies have a gag reflex that is farther up than ours is. That is to protect them from food getting too far back in their mouth and blocking their windpipe. The wafers might be okay because it is in the front of her mouth and the purées are going too far back, triggering the gag reflex. You don't have to do purées first. You can do baby led weaning, which means skipping all purées and eating foods they can hold. There is zero evidence or data that shows either method to be superior. Seven months old is still early and remember you may need to offer a certain food 15-20 times for them to accept it. I'm a grown up and have a pretty decent diet and still have certain textures that I don't favor, like oysters. Or take wine for instance. I didn't really love it the first few times but after I tried it more, I started to like certain types. We have to remember that Baby is building their palette. That doesn't mean force Baby to feed it because that could cause an aversion. Just put it on their high chair and let them have fun with it. It's might be messy but that's how babies learn - it's called sensory play. They will accept it better if they can touch and feel it. It's not you forcing it with a spoon, it's letting them take the lead. You can try the Grabease All Over Bib to reduce the mess.
"My best friend has a thirteen month old who hates everything but the bottle." I start bringing this up by the nine month visit. If we don't get rid of the bottle between 13-15 months, it gets really hard to get rid of. I tell my patients once baby is over six months, you can give them a sippy cup of any kind with an ounce of water in it. As soon as they are capable of drinking out of it, you can ditch the bottle. Just keep offering different kinds of sippy cups. At 13 months, they need about two to three 6 ounce cups per day of cow's milk. If your child hates milk, you don't have to drink it, but make sure you have enough yogurt and cheese in their diet. If your child is refusing milk, you can mix breastmilk or formula into the milk and increase the amount of milk over the course of a few weeks. This goes the same if your child doesn't like water. You can water down the milk and increase the amount of water over the course of a few weeks. The biggest problem I have with milk in toddlers’ diets is that they are getting too much. They only need about 20-24 ounces per day. If they are getting more than that, you risk lowering their iron levels and anemia. Milk decreases how well your food binds and goes into the body. Iron is the building block of heme which is the building block of hemoglobin which is the building block of red blood cells that helps carry oxygen to your brain and body. That's why at one and two year old check up, we finger prick to check their hemoglobin. Iron deficiency effects growth and brain development.
"How much to feed with solids: overfeed vs. not enough?" One question I get a lot is if "food before one just for fun". Food is never just for fun. It does start at six months more just for fun since the majority of their nutrition is coming from breastmilk or formula. They are barely going to eat anything at six months. You can start with an ounce of food, they will make a mess or drool it out. It's important to follow their cues. Babies learn how to pace themselves by breastfeeding or paced bottle feeding and learn when they are full. Maybe you start your 6-8 month old with a spoonful at lunch or dinner time and increase it to a few more spoonfuls. As they get more into eating more food, you will see their milk intake decrease.
"For 12 month old who primarily has had bottle, should purées be offered? He has 8ish teeth." I don't care if they have teeth or not. We are not giving them big bits of chicken. They might get crumbled or shredded chicken. Honestly, whether I give purées or baby led weaning, it has nothing to do with teeth. Just give a variety of purées and graduate to chunks as you go. You can go down the mommy rabbit hole with all of the things that you "should do", but each kid is different but it's important to offer them different foods. You don't have to do purées or baby led weaning, you can do both. Don't stress so much. It's important to expose them to different textures, colors, tastes, a little bit of salt and seasoning. You go with your comfort zone. If watching your child gnaw on a piece of zucchini gives you a heart attack, maybe don't go with baby led weaning.
"Exclusively-breastfed baby has a milk sensitivity. Should I slowly introduce dairy now that he is ready to start solids?" Again, this should be tailored to each specific child so I can't give specific medical advice. My first question would be - has someone told you that your child is lactose intolerant - because that is not a thing in infants. If that's what you've been told, I would double check with your doctor. If you are told this is a milk protein allergy, it's not very common but is possible. It's not an allergy that causes hives or other common food allergy reactions. This has to do with cow’s milk that the lactating parent has in their diet and passes to the baby through their milk. That is the type of allergy that causes inflammation in the lining of their intestines. This can lead to fussiness, belly pain and blood in their stool. When we have a milk protein allergy, which can be over and under diagnosed, we have to eliminate cow’s milk protein from their diet. If they are on formula, they need a soy formula or protein-hydrolyzed formula. Or if you're breastfeeding, you need to remove dairy or soy from your diet. All allergies can appear at any age and have the potential to be outgrown. The cow’s milk protein allergy is often outgrown. Sometime after they are 8 months old, they can be reintroduced to milk and do okay. You should talk to your doctor about seeing an allergist or a gut specialist and about when to introduce again. It's hard to know when it's the best time. Seven months is still early but you should check with your doctor. Until then, try solids that don't have dairy in them.
"What is the correct temperature to serve food?" It doesn't matter if it's hot or cold, we just don't want it to be hot enough to burn them. I am very cautious with microwaves because they have hot and cold spots. If you microwave baby food, stir it carefully and test the temperature throughout before serving.
"Foods to start with and foods to avoid?" The rainbow colored plan is too hard. We used to tell people to avoid allergenic foods under a certain age, like eggs, strawberries and nuts. We know now it's not true. Sometimes data changes over time and can even change back. Science didn't lie to you, it just learned more. What we now know is that there just isn't a good basis that says to wait until later. Avoiding allergens can increase their chance of having an allergy. Giving them frequent exposure to allergenic foods has some chance of decreasing their chances of developing a food allergy. I recommend giving your baby everything. One new food every three days is reasonable to a point, but at the same time it's hard because it's only ten foods a month. Eggs, fish, strawberries, nuts - give them to your child! There is one food that you should avoid before one and that's honey, unless it's baked. Honey can have botulism spores in it and our gut has enough acids that we can denature the spores and they won't cause disease. Infants don't have that acid until around 12 months. You don't have to give them a spoonful of peanut butter because that's a choking hazards, but you can give them a little bit or mix into the baby food. If your child has eczema, then we do recommend seeing an allergist to get tested before you introduce nuts. If you have food allergies in your family, talk to your doctor. I've seen powdered peanut butter to put into your child's bottle - please do not do this! You can wait until six months to introduce allergenic foods. So back to foods to start with. I want you to start with high-iron foods: meats of any kind, fruits, vegetables, leafy greens vegetables, a little bit of citrus fruit. If you're cooking foods yourselves, cook with the old school cast iron because it leaches a little bit of iron into the food. You can even add a cast iron fish when cooking pasta to get extra iron into your food.
Let me talk for 30 seconds about juice. Babies might need a Vitamin D supplement until one. Juice is not necessary, EVER. When I do drinks, it's two to three cups a day of cow's milk and water. After six months, I give babies sips of waters. By the time they are one, 1-2 ounces of day is ideal. Before one, their kidneys are not mature enough to handle extra water. That can end up causing low sodium levels in their blood that can lead to seizures, brain swelling and even death. I have had patients who gave their babies certain teas to treat a sickness. Their kidneys cannot handle it and could kill them. Under six months, breastmilk or formula, mixed properly, are the only two things babies need to drink. I understand that diluting formula may seem like a good option for cost reasons, but this can lead to a sodium imbalance. After 6 months, you can give them sips and at 9-12 months, 1-2 ounces per day is fine and it gets them used to drinking water. You do not need to flavor the water. If you start flavoring it early, they may not ever drink water. Juice, even when it says "no sugar added", is not good. To make apple juice, they take apples, squeeze them, they throw away everything that is good, and keep the liquid that has all of the sugar in it. Juice is terrible for our children. They are going to get way too much sugar and as they start to get teeth, it will start to rot their teeth. I have seen 18 month olds with crumbling teeth due to juice. If you are going to give it, as a pediatrician this is my advice. You do not want to give it as a drink to be sipped on throughout the day because you're bathing their teeth in sugar. Just give a few ounces in a cup for 20-30 minutes and whatever they drink in that timeframe is it.
We love Big T NYC Little T organic, caffeine-free kids' tea. If you are wanting another option besides water, you can buy this by the tin for a pitcher or in a box to make one cup at a time. You can add lime juice to add more flavor!