Duration of Exclusive Breastfeeding
The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for "about" the first 6 months of an infant's life, followed by the introduction of complementary solid foods with continued breastfeeding. [1] The World Health Organization (WHO), as well as the United Nations Children's Fund (UNICEF) have set a global recommendation for "exclusive breastfeeding for 6 months (180 days)" followed by "nutritionally adequate and safe complementary feeding starting from the age of 6 months with continued breastfeeding up to 2 years of age or beyond." [2][3]
Neither organization supports prolonged exclusive breastfeeding beyond 6 months of age, with the WHO considering the too-late introduction of complementary solids to be of equal concern as the too-early introduction of solids.
In 2006, The Journal of Nutrition published a Mexican Cohort study on the implications of exclusive breastfeeding beyond 6 months. They found that infants in developing countries who were breastfed for longer than 6 months had an increased risk of developing Iron-Deficiency Anemia, particularly those whose mothers were also anemic. [4] These findings are supported by an AAP report published in 2010, where exclusive breastfeeding beyond 6 months was associated with an increased risk of Iron-Deficiency Anemia at 9 months of age. [5]
During the 3rd trimester, infants begin to store iron in their liver. These stores will satisfy the infant's iron needs for the first few months of life. Breast milk contains very low amounts of iron, but the iron that is in breast milk is bound to lactoferrin glycoprotein, making it incredibly bio-available to the infant. But by around 6 months, not only do infants begin requiring more iron, but their iron stores begin to deplete. Infants who are preterm, were born small for their gestational age, or who had immediate cord clamping are at an even higher risk of developing Iron-Deficiency Anemia in the second 6 months of life.
Food Before One: Is It Just For Fun?
With the growing increase in "Baby-led Weaning", a mantra has developed: "Food before 1 is just for fun." This is not entirely accurate. While BLW is considered to be a compatible method of infant feeding [6], care does need to be taken by parents to make sure that they are not unnecessarily delaying the introduction of solids, believing that food is of no nutritional value. Some infants, particularly those who are born premature or who have motor delays, may have nutritional requirements for solid foods before they possess the manual dexterity to self-feed. [7]
"This means it is also important that parents understand that a different approach may need to be taken for preterm infants or those with developmental delay, at least until they are able to effectively convey food to their mouth, and safely chew and swallow it, and also for those at increased risk of allergy; and perhaps during and following illness."*Nutrients. 2012. "How Feasible is Baby-led Weaning as an Approach to Infant Feeding? A Review of the Evidence."
Infant Rice Cereal
2. Use "responsive" weaning. Allow infants to self-feed soft foods, if they desire. Use a spoon or your own finger to feed mushed, pureed or soft foods to infants who have a desire to eat but do not have the motor skills to self-feed. Never force an infant to take food off a spoon or to finish a whole jar of baby food.
Many claims have been made about infant rice cereal, from it resulting in an increased risk of obesity, to diabetes, food allergies, as well as claims that it is nutritionally deplete, un-digestible, and unnecessary. Rice cereal is used by many pediatricians as a formula thickener for infants with reflux, and is believed by many parents to help a child last longer between feeds and even to sleep through the night. Clearly, what an infant is fed as a first food is of great debate.
The WHO recommends that all infant first foods should have a greater energy density than breast milk. They define the average caloric content of breast milk to be 0.8 kcal per gram (or 22 kcal per ounce). By this respect, infant rice cereal fits the bill. The Gerber Single Grain cereal contains 60 calories in 15 grams (4 kcal per gram). But concerns have been raised over whether feeding such a calorie-dense food is beneficial to an infant.
There has been some loose correlation between the early introduction of infant rice cereal and later obesity. One such study from the Journal of the American Medical Association (JAMA) found that mothers who introduce rice cereal prematurely are more likely to value their infants being "chunky", and are also more likely to use food as a rewards system for good behavior. This makes it incredibly difficult to differentiate between whether the increase in obesity is a result of complex feeding practices and behaviors or the actual nutritional content of the food being fed. [8]
The WHO recommends that all infant first foods should have a greater energy density than breast milk. They define the average caloric content of breast milk to be 0.8 kcal per gram (or 22 kcal per ounce). By this respect, infant rice cereal fits the bill. The Gerber Single Grain cereal contains 60 calories in 15 grams (4 kcal per gram). But concerns have been raised over whether feeding such a calorie-dense food is beneficial to an infant.
There has been some loose correlation between the early introduction of infant rice cereal and later obesity. One such study from the Journal of the American Medical Association (JAMA) found that mothers who introduce rice cereal prematurely are more likely to value their infants being "chunky", and are also more likely to use food as a rewards system for good behavior. This makes it incredibly difficult to differentiate between whether the increase in obesity is a result of complex feeding practices and behaviors or the actual nutritional content of the food being fed. [8]
Almost all the mothers in that study believed infant cereal to "fill their baby up" longer and to help them sleep longer. One of the first studies on rice cereal and infant sleep was also published in JAMA in 1989, finding that feeding infants rice cereal in a bottle "does not appear to make much difference in their sleeping through the night." [9]
On the other hand, the timing of cereal exposure may affect the risk of an infant developing islet autoimmunity (a marker for Type 1 Diabetes). Children who were exposed to rice cereal before 4 months and after 7 months had an increased risk of islet autoimmunity than those who consumed rice cereal within the window of 4-6 months. For those parents who want to use rice cereal, timing of initial introduction should be considered. [10]
What about gluten? Is gluten bad for babies?
Rice cereal is a gluten-free food, but as more and more parents shun the processed, boxed infant foods, it has become increasingly more common to see recipes for homemade porridge made from oats or other grains. One of the tenants of Baby-led Weaning is that an infant can consume pretty much any food (including bread) once they begin eating solids.
A study undertaken in 2005 looked at the incidence of Celiac Disease among children and whether or not it corresponded to the introduction of gluten-containing foods. Children exposed to gluten-containing foods in the first 3 months of life and also beyond 7 months of life were at an increased risk of developing Celiac Disease. But this increased effect was only noticed in children who were already at a higher risk of developing the disease in the first place (such as those were certain genetic factors or Type 1 Diabetes). The children who developed Celiac Disease were also less likely to be breastfeeding at the time of gluten exposure. [11]
A link between the introduction of gluten cereals and Celiac Disease was also noted by comparing countries with different rates of Celiac Disease with their cultural infant feeding behaviors. Infants in Estonia consume less gluten-containing cereal and have lower rates of Celiac Disease then infants in Sweden and Finland who consume more gluten-containing cereal. However, this study did not control for formula or breastfeeding, making the results difficult to apply to larger populations. [12]
Rice cereal is a gluten-free food, but as more and more parents shun the processed, boxed infant foods, it has become increasingly more common to see recipes for homemade porridge made from oats or other grains. One of the tenants of Baby-led Weaning is that an infant can consume pretty much any food (including bread) once they begin eating solids.
A study undertaken in 2005 looked at the incidence of Celiac Disease among children and whether or not it corresponded to the introduction of gluten-containing foods. Children exposed to gluten-containing foods in the first 3 months of life and also beyond 7 months of life were at an increased risk of developing Celiac Disease. But this increased effect was only noticed in children who were already at a higher risk of developing the disease in the first place (such as those were certain genetic factors or Type 1 Diabetes). The children who developed Celiac Disease were also less likely to be breastfeeding at the time of gluten exposure. [11]
A link between the introduction of gluten cereals and Celiac Disease was also noted by comparing countries with different rates of Celiac Disease with their cultural infant feeding behaviors. Infants in Estonia consume less gluten-containing cereal and have lower rates of Celiac Disease then infants in Sweden and Finland who consume more gluten-containing cereal. However, this study did not control for formula or breastfeeding, making the results difficult to apply to larger populations. [12]
What these studies suggest is that the ideal time to introduce gluten to an at-risk infant is between 4 and 6 months, and that mothers should also be breastfeeding at the time of exposure. [13]
Can Infants Digest Grains?
Another consideration that has been brought up is whether infants even possess the ability to digest grains. I've heard it repeated several times that infants cannot digest grains until 12-24 months old.
Another consideration that has been brought up is whether infants even possess the ability to digest grains. I've heard it repeated several times that infants cannot digest grains until 12-24 months old.
The enzyme primarily responsible for the digestion of grains is amylase. Amylase is produced both in the saliva and by the pancreas. Salivary amylase begins to digest starches while the food is chewed, and then pancreatic amylase is secreted after the food passes in to the duodenum (upper section of small intestine), further digesting starches. Salivary amylase is at 60% of adult levels by 3 months of life and 83% by 5 months. [14]
Despite its designation as "salivary" amylase, this enzyme also functions in the lower digestive tract. A majority of starch digestion occurs in the duodenum, but because the infant stomach has a higher ph than an adult stomach, the salivary amylase retains much of its digestive properties. It is thus proposed that the salivary amylase that mixes with the food will continue to digest the grains even after swallowed, compensating for lower levels of pancreatic amylase. Around 6 months the infant's pancreas begins producing more and more of its own amylase. [15]
Another feature in the digestion of grains in infants is the presence of mammary amylase. Mammary amylase is the amylase that is found in breast milk. It has been suggested that, like salivary amylase, much of the mammary amylase retains its digestive properties, aiding in the digestion of starches until the infant's own pancreatic juices can begin to mature around 6 months. [16]
The digestion of carbohydrates by infants is a complex process, involving more than just the presence of amylase. Colon micro flora, and other small intestine brush-border enzymes play a role, and there is no evidence suggesting that infants who are old enough to consume solid foods have any difficulty digesting starches. The full strength of pancreatic amylase is not reached until a child is between 5 and 12 years old. Given that most infants, and especially most children, are able to digest starches and complex carbohydrates without issue, we can deduce that the digestion of starches is much more complex than merely the presence or lack of pancreatic amylase. [17]
So then, what would be a reasonable plan of action for the introduction of solid foods?
1. Delay solids until at least 4 months, preferably 6 months.
1. Delay solids until at least 4 months, preferably 6 months.
2. Use "responsive" weaning. Allow infants to self-feed soft foods, if they desire. Use a spoon or your own finger to feed mushed, pureed or soft foods to infants who have a desire to eat but do not have the motor skills to self-feed. Never force an infant to take food off a spoon or to finish a whole jar of baby food.
3. Preterm infants or those who were born small for gestational age require special feeding care to make sure iron intake is adequate, especially after 6 months. An iron blood test is a simple procedure that can be done at your pediatrician's office, and can help you assess your child's unique iron needs.
4. If iron levels are low, the WHO recommends increased intake of iron-rich solid foods before relying on supplementation through drops or vitamins.
5. Breastfed infants should only be given iron supplements if they have iron-deficiency anemia (iron below 10.5) and are not consuming adequate food sources of iron (disclaimer: infants with Perinatal Crohn's Disease may have impaired iron absorption despite consumption of iron-rich foods)
6. There are no contraindications to consuming grains if a child is old enough to consume solid foods.
7. Families with an increased risk of Celiac Disease should introduce gluten between 4-6 months, while continuing to breastfeed.
References:
4. If iron levels are low, the WHO recommends increased intake of iron-rich solid foods before relying on supplementation through drops or vitamins.
5. Breastfed infants should only be given iron supplements if they have iron-deficiency anemia (iron below 10.5) and are not consuming adequate food sources of iron (disclaimer: infants with Perinatal Crohn's Disease may have impaired iron absorption despite consumption of iron-rich foods)
6. There are no contraindications to consuming grains if a child is old enough to consume solid foods.
7. Families with an increased risk of Celiac Disease should introduce gluten between 4-6 months, while continuing to breastfeed.
References:
1. American Academy of Pediatrics. 2012. "AAP Reaffirms Breastfeeding Guidelines"
http://www.aap.org/en-us/about-the-aap/aap-press-room/pages/AAP-Reaffirms-Breastfeeding-Guidelines.aspx?nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token
http://www.aap.org/en-us/about-the-aap/aap-press-room/pages/AAP-Reaffirms-Breastfeeding-Guidelines.aspx?nfstatus=401&nftoken=00000000-0000-0000-0000-000000000000&nfstatusdescription=ERROR%3a+No+local+token
2. World Health Organization. 2009. "Infant and Young Child Feeding"
http://whqlibdoc.who.int/publications/2009/9789241597494_eng.pdf
3. World Health Organization. 2001. "Guiding Principles of Complementary Feeding for the Breastfed Child"
http://www.who.int/nutrition/publications/guiding_principles_compfeeding_breastfed.pdf
4. The Journal of Nutrition. 2006. "Risk of Infant Anemia is Associated with Exclusive Breastfeeding and Maternal Anemia in a Mexican Cohort."
http://jn.nutrition.org/content/136/2/452.long
5. American Academy of Pediatrics. 2010. "Diagnosis and Prevention of Iron-Deficiency and Iron-Deficiency Anemia in Infants and Young Children."
http://pediatrics.aappublications.org/content/early/2010/10/05/peds.2010-2576.full.pdf+html
6. Journal of Maternal and Child Nutrition. 2010. "Is Baby-led Weaning Feasible? When do Babies First Reach Out and Eat Finger Foods?"
http://onlinelibrary.wiley.com/doi/10.1111/j.1740-8709.2010.00274.x/full
7. Nutrients. 2012. "How Feasible is Baby-led Weaning as an Approach to Infant Feeding? A Review of the Evidence."
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3509508/
8. Journal of the American Medical Association. 1998. "Maternal Feeding Practices and Childhood Obesity."
http://archpedi.jamanetwork.com/article.aspx?articleid=189952
9. Journal of the American Medical Association. 1989. "Infant Sleep and Bedtime Cereal"
http://archpedi.jamanetwork.com/article.aspx?articleid=514762
10. Journal of the American Medical Association. 2003. "Timing of Initial Cereal Exposure in Infancy and Risk of Islet Autoimmunity."
http://jama.jamanetwork.com/article.aspx?articleid=197392
11. Journal of the American Medical Association. 2005. "Risk of Celiac Disease Autoimmunity and Timing of Gluten Introduction in the Diet of Infants at Increased Risk of Disease"
http://jama.jamanetwork.com/article.aspx?articleid=200903
12. http://www.allattamentoalseno.it/lavori/L99.pdf
13. Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Chicago. 2007. "The influence of gluten: weaning recommendations for healthy children and children at risk for celiac disease"
http://www.ncbi.nlm.nih.gov/pubmed/17664902
14. American Journal of Maternal and Child Nursing. 2007. "The importance of exclusive breastfeeding in infants at risk for celiac disease"
http://ajcn.nutrition.org/content/39/4/584.full.pdf
15. Journal of Digestive Diseases and Sciences. 1987. "Role of salivary amylase in gastric and intestinal digestion of starch"
http://link.springer.com/content/pdf/10.1007%2FBF01300204.pdf#page-1
16. Journal of Pediatric Research. 1983. "Mammary Amylase: a Possible Alternate Pathway of Carbohydrate Digestion in Infancy"
http://www.nature.com/pr/journal/v17/n1/abs/pr19833a.html
17.Journal of Pediatric Gastroenterology & Nutrition. 1999. "Starch Digestion in Infancy"
http://journals.lww.com/jpgn/Fulltext/1999/08000/Starch_Digestion_in_Infancy.4.aspx
Thank you for this info! I was debating whether to delay grains but this helps me to understand everything much more clearer.
ReplyDeleteMy father had type 1 diabetes. My son turned 7 months yesterday and we have not yet given him rice cereal. Do you think it's too late?
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