Introducing Complementary Foods
Letters to LLLI
From: LEAVEN, Vol. 35 No. 6, December 1999-January 2000, p. 130
Ed. Note: We provide
articles from our publications from previous years for reference for our Leaders
and members. Readers are cautioned to remember that research and medical information
change over time.
Dear LLLI,
A few weeks ago, a mother
called me with questions about starting her breastfed baby on solid
foods. All went well until I started explaining LLL's suggested guidelines
about the order in which solid foods can be introduced to the baby.
The mother was skeptical about LLL's recommendation that meat be introduced
as a good second food, right after banana and sweet potato. To my surprise
and dismay, by the end of the call, I realized that I too was skeptical
about this particular recommendation.
While meat is highly
nutritious, it is also a highly allergenic food. In the 1997 edition
of the BREASTFEEDING ANSWER BOOK. (p 148), it is noted that foods which
can produce an allergic response (such as eggs, cow's milk, and citrus
fruits) should not be introduced until after the baby's first birthday.
If a mother follows LLLI s guidelines about introducing meat, the baby
would be exposed to a potentially allergenic food during the middle
of their first year.
Is meat truly an appropriate
food for a six-month-old baby? THE BREASTFEEDING ANSWER BOOK and THE
WOMANLY ART OF BREASTFEEDING point out that meat is high in protein
and iron, and certainly growing babies need those. However, in recent
years it has been found that human babies need less protein than was
previously thought, and that the iron in human milk is more easily absorbed
than iron from other sources.
I would like to be able
to explain LLLI's position with confidence, knowing that its recommendation
is well thought-out, up-to- date, and based on solid research. Please
share with us the reasons behind LLLI's recommendations on the introduction
of meat into the baby’s diet.
Celeste Land Vienna,
VA USA
Dear LLLI,
A mother of a three-and-a-half-month-old
baby called to ask if she could offer mashed banana during the day when
the baby's caregiver ran out of breast milk. The mother said she had
read this suggestion in a breastfeeding book.
I discussed strategies
to pump more milk and listened to her concerns. I also stressed that
breast milk is the food a baby needs to grow for the first year, with
solids as a slowly introduced supplement. I briefly mentioned watching
baby for signs of readiness, etc.
Imagine my surprise when
I found the breastfeeding book the mother had quoted was the 1997 THE
WOMANLY ART OF BREASTFEEDING: "If your baby is older than 3 or
4 months, and seems to need more milk than you can pump, consider asking
your doctor if you could start some mashed banana as a supplement instead
of introducing formula." (page 161)
Please help me understand
the thinking behind this statement. Do we believe early introduction
of solids to be better nutritionally than formula? Although breast is
best, isn't formula closer to meeting a baby's nutritional needs than
banana?
Joanne Green
Philadelphia PA USA
Dear Celeste and Joanne,
Thank you for your letters
and questions about the early introduction of meat to baby's diet and
the early introduction of solids as opposed to formula. To answer your
inquiries, we consulted with Judy Hopkinson, Ph.D., Associate Professor
of Pediatrics at Baylor College of Medicine and member of LLLI's Health
Advisory Council. Dr. Hopkinson agrees that the information stated in
both books is reliable and supported by research.
We need to remember that
the information given is for full- term healthy infants. Mothers of
infants who are premature, have a family history of allergy, or have
other health problems will want to check with the baby's health care
provider and adapt the LLLI information with specific advice for her
family. Drawing on the information provided by Dr. Hopkinson, I hope
the following will answer your questions.
Is it a good idea to
add meat to the breastfed baby's diet between four to six months?
The American Academy of Pediatrics
Committee on Nutrition states that when a baby's breast milk intake
is adequate, the order in which other foods are added to the infant
diet is not critical. A study published in Pediatrics (Dewey
1996) shows that the low protein in breast milk does not limit the growth
of exclusively breastfed infants. It is important to remember, however,
that when solid foods are introduced, the amount of breast milk a baby
consumes decreases. If protein, zinc, or other nutrients are not provided
in solid foods, the amount a baby receives from breast milk could be
insufficient for optimal growth during the weaning period. Therefore,
adding meat to the diet early in the weaning period may be beneficial.
Meat provides additional
protein, zinc, B-vitamins, and other nutrients which may be in short
supply when the decrease in breast milk occurs. A recent study from
Sweden suggests that when infants are given substantial amounts of cereal,
it may lead to low concentrations of zinc and reduced calcium absorption
(Persson 1998). Dr. Nancy Krebs has shared preliminary results from
a large infant growth study suggesting that breastfed infants who received
pureed or strained meat as a primary weaning food beginning at four
to five months, grow at a slightly faster rate. Dr. Krebs' premise is
that inadequate protein or zinc from complementary foods may limit the
growth of some breastfed infants during the weaning period. Both protein
and zinc levels were consistently higher in the diets of the infants
who received meat (Krebs 1998). Thus the custom of providing large amounts
of cereal products and excluding meat products before seven months of
age may not meet the nutritional needs of all breastfed infants.
Meat has also been recommended
as an excellent source of iron in infancy. Heme iron (the form of iron
found in meat) is better absorbed than iron from plant sources. In addition,
the protein in meat helps the baby more easily absorb the iron from
other foods. Two recent studies (Makrides 1998; Engelmann 1998) have
examined iron status in breastfed infants who received meat earlier
in the weaning period. These studies indicate that while there is not
a measurable change in breastfed babies' iron stores when they receive
an increased amount of meat (or iron), the levels of hemoglobin circulating
in the blood stream do increase when babies receive meat as one of their
first foods. Ultimately, however, there was no long-term benefit in
terms of iron levels from introducing meat products earlier than the
customary seven months.
It is important to remember
that one of the main factors that determine the amount of iron in later
infancy is birth weight. Infants whose birth weights are less than 3000
grams or about six-and-a-half pounds (whether term or premature) have
reduced iron stores at birth and appear to need additional iron earlier
(Dewey 1998). Mothers need to consult with a health care professional
about these infants' diets. Early introduction of meat products, the
addition of cereals, fruits, and vegetables supplemented with ascorbic
acid and iron, or commercially available iron supplements may be recommended.
The surest way to determine how well these supplemental measures work
is to continue monitoring the infant's iron levels.
There is a small risk of
allergic reaction to meat products. However, "the present knowledge
on meat digestibility and allergenicity are not enough to justify removal
of meat from a child's diet when there is risk but not clinical evidence
of allergy” (Restani 1997). Moreover, the risk of reaction can
be reduced even further by selecting less allergenic meats, (such as
turkey or lamb rather than beef or chicken), by cooking and thoroughly
blending them, or by using commercially processed (freeze dried or homogenized)
meat products. Introducing meat (or any other new food) before weaning
from the breast may reduce the likelihood of developing a food sensitivity
(Cummins and Thompson 1997).
In short, the amount of breast
milk a baby consumes decreases after solid foods are introduced. Important
nutrients most likely to be in short supply during the weaning period
include protein, zinc, iron, and B-vitamins. Meat is a very good source
of all these nutrients and, therefore, is an important part of the infant's
diet during weaning. The incidence of allergic reactions to meat is
minimal, and lower still when pureed varieties are used.
It is also important to remember
that when solids are first given to baby, it is as an introduction and
small supplement. Breast milk will still be the baby's primary nutrition
for quite some time. Solids are introduced individually about a week
apart and only in very small amounts. With this slow introduction, it
will be quite a while before baby is relying on solids for his/her basic
nutrition. Therefore, it is important that the foods which are given
provide the nutrients which are needed most for growth and health.
Vegetarian mothers are almost
always aware of their need for protein, iron, zinc, calcium and vitamin
B12 as well as adequate calories. Those who occasionally
add poultry or fish to their diets and those who are lacto-ovo vegetarians,
using milk and eggs in their diets, usually have no problems meeting
their needs for these nutrients. For vegans, who do not use any dairy
products, attention needs to be given to adequate sources of calcium.
There are also many non-animal foods that provide iron, calcium, and
zinc. Vegetarians may need supplements to get enough B12.
Vegetarians who want their children to eat as they do will need to be
aware of the same nutrient needs for their children. When starting solids,
single foods are given so that any sensitivities or allergies can be
noted.
A non-vegetarian mother who
is concerned about her baby having meat or poultry before one year of
age, or who is worried about a family history of allergy, could use
non-animal sources of protein until she feels the baby is ready for
meat.
When a mother is having
trouble pumping enough to satisfy her baby while they are separated,
is it acceptable to give the baby mashed banana instead of formula to
satisfy his hunger?
The addition of solid foods
between four and six months is appropriate, but it is important to distinguish
between adding solids because the baby is developmentally ready and
adding solids because the baby is not getting enough breast milk. Formula
is the usual replacement for inadequate breast milk in infancy, especially
for a baby who is not gaining well. However, in that situation the mother
needs to consult her doctor to determine what would be best to give
her baby.
In the case you mentioned,
it was appropriate to offer the mother tips on improving her pumping
techniques. Sometimes, too, the caregiver needs to be reminded that
a breastfed baby does not need to consume the same amount of human milk
as a formula-fed baby needs. The caregiver may be interpreting the baby's
need to be held and comforted as hunger. A mother who is having trouble
pumping may also need to be reminded to nurse often when she and the
baby are together to keep baby well nourished and to improve her milk
supply.
If baby is growing well and
nursing often when he and his mother are together, the suggestion given
in THE WOMANLY ART, to offer a small amount of mashed banana, could
tide baby over until the mother returns without introducing the potential
allergy risk of giving infant formula. The baby is not likely to take
enough mashed banana to interfere with his willingness to nurse, whereas
after several ounces of formula, the baby may not be interested in nursing
when his mother is available.
Thank you again, Celeste
and Joanne. Your questions have helped us all look at this topic and
gain added insight into starting solids and providing documentation
for those who might question the reasoning behind LLL's information.
Judy Minami
US Western Division Professional Liaison Coordinator and Editorial Advisor
Portland Oregon, USA
References
American Academy of Pediatrics,
Committee on Nutrition. On the feeding of supplemental foods to infants.
Pediatrics 1980; 65(6):1178-81.
Cohen, R. et al. Effects
of age of introduction of complementary foods on infants breast milk
intake, total energy intake, and growth: a randomized intervention study
in Honduras. Lancet 1994; 344: 288-93.
Cummins, A. and Thompson,
F. Postnatal changes in mucosal immune response: a physiological perspective
of breast feeding and weaning. lmmuno Cell Biol 1997; 75 (5):419-29.
Dewey, K. et al. Do exclusively
breast-fed infants require extra protein? Pediatr Res 1996; 39(2):
303-07.
Dewey, K. et al. Effects
of age of introduction of complementary foods on iron status of breast-fed
infants in Honduras. Am J Clin Nutr 1998; 67: 878-84.
Engelmann, M. et al. Meat
intake and iron status in late infancy: an intervention study, J
Pediatr Gastroenterol Nutr 1998; 26(1): 26-33.
Krebs, N. Research in Progress.
Beef as a first weaning food. Food and Nutrition News 1998; 70(2):5.
Makrides, M. et al. A randomized
controlled clinical trial of increased dietary iron in breast-fed infants.
J Pediatr 1998; 133(4): 559-62.
Persson, A. et al. Are weaning
foods causing impaired iron and zinc status in 1-year-old Swedish infants?
A cohort study. Acta Paediatr 1998; 87(6): 618-22.
Restani, P et al. Effect
of technological treatments on digestibility and allergenicity of meat-based
baby foods. Am Diet Assoc 1997; 376-82.
Stuff, J. and Nichols, B.
Nutrient intake and growth performance of older infants fed human milk.
J Pediatr 1989; 115(6): 959-68.
Page last edited Sun Oct 14 09:32:22 UTC 2007.
