Patient education: Starting solid foods with babies (Beyond the Basics)

SOLID FOODS OVERVIEW — Solid foods and liquids other than breast milk or infant formula are known as "complementary" foods. For most babies, these foods should be introduced around six months of age, as recommended by the American Academy of Pediatrics and the World Health Organization [1,2].

This article will review when and how to start giving complementary foods, including which foods should be avoided. Strategies for ensuring that the baby has adequate iron, fluoride, vitamin B12, and vitamin D to support healthy growth, bones, and teeth will also be discussed.

More detailed information about starting solids and infant nutrition, written for health care providers, is available by subscription. (See 'Professional level information' below.)

WHEN SHOULD MY BABY START SOLID FOODS? — This depends on your baby's age as well as their physical development.

Age — Most authorities suggest starting solid foods not before four months of age and preferably closer to six months of age (if the baby has also reached the developmental milestones described below). (See 'Developmental milestones' below.)

Reasons for waiting until your baby is at least four months of age include:

●Feeding only breast milk or infant formula until a baby is close to six months of age helps them grow at a healthy rate and possibly lowers the risk of infections in some settings.

●Introducing solid foods before your baby is four to six months of age may interfere with their ability to take in an adequate number of calories or nutrients. In other cases, the solid foods provide too many calories or an imbalanced diet.

●Younger babies do not have the coordination and/or skills to safely swallow solid foods, which could lead to aspiration (inhaling food/liquid into the lungs).

●Younger babies have a reflex (called the "extrusion reflex") that causes them to raise the tongue and push against any object placed between their lips. This reflex usually disappears between four and five months of age. Trying to spoon-feed a baby who still has the extrusion reflex can be a frustrating and difficult experience for both of you.

●Introducing solid foods earlier probably does not help your baby sleep better.

Reasons for not waiting longer than six months of age include:

●After six months of age, your baby may not get enough calories and other important nutrients such as iron from breast milk or formula alone; if you do not start adding solid foods to their diet, this can slow down their growth. Most babies start needing additional calories from solid foods after they double their birth weight and weigh at least 13 pounds (5.9 kg). This usually happens between four and six months of age.

●If you delay introducing solid foods beyond six months of age, your baby might be less willing to try them.

●Delaying introduction of solid foods does not help prevent the development of food allergies. For information about starting solid foods with babies at risk for allergy, see below. (See 'Food allergy concerns' below.)

Developmental milestones — The best time to start solid foods depends not only on your baby's age but also on their ability to sit up, support their head, and meet other developmental milestones. These guidelines apply to all children, including those who have delays with gross motor skills.

●To start solid foods – To start solid foods, your baby should be able to:

•Sit in a highchair or a feeding seat

•Have good head and neck control

•Show readiness for different textures of foods by placing their hands or toys in their mouth

•Lean forward and open their mouth when interested in food, and lean back and turn away when uninterested in the food or not hungry

In general, the preferred method for introducing solid foods is by spoon. This allows your baby to learn how to use their tongue, chew, and swallow.

●To advance textures of foods – Once your baby is eating a variety of pureed foods, you can begin to offer foods with more texture. Most babies are ready for more textured foods between six and eight months of age. You may offer very soft, lumpy, mashed, finely minced, or ground foods to your baby by spoon or by putting small pieces directly in their mouth.

●To start finger foods – When your baby is six or seven months of age, you can start offering some foods that they can eat with their hands. To eat finger foods, your baby should be able to sit independently, grasp and release food with their hands, chew food (even without teeth), and swallow foods with some chunks without choking. For some types of finger food, a baby will need to be able to grasp pieces between two fingers. Most babies can do this by 12 months of age.

Foods that are safe to offer as finger foods are discussed below. (See 'Foods with texture and finger foods' below.)

PRECAUTIONS

Foods and drinks to avoid — Certain foods should not be given to any child under 12 months of age, including:

●Cow's milk – As a liquid beverage, cow's milk (other than milk-based infant formula) does not contain adequate nutrients for a baby, especially iron. However, other cow's milk products, such as yogurt or cheese, can be used as complementary foods. Similarly, other animal milks such as goat milk do not provide the nutrients that a growing baby needs.

If you are feeding your baby formula and are concerned about the cost, talk to your baby's doctor or nurse about options including lower-cost (generic) infant formulas. Or, you can talk with the doctor or nurse about the possibility of switching your baby to whole cow's milk when they are approximately nine months old. If you do this, it's particularly important that they get plenty of iron in their diet. (See 'Iron' below.)

●Plant-based milks – Plant-based milks (other than soy-based commercial infant formulas) do not contain adequate protein, vitamins, or minerals for babies. Similarly, homemade formulas, including those made from a recipe that seems to be healthy, can be dangerous. Do not use a homemade formula unless the recipe has been closely reviewed by a pediatric dietitian.

●Choking hazards – Do not let your child have any foods that increase the risk of choking. A food is a choking hazard if it is hard or firm, round, and the size of a small child's airway. Examples include peanuts, tree nuts, whole grapes, raw carrots, hot dogs (whole or sliced in discs), or candies. Foods that are light enough to be easily inhaled by accident, such as popcorn, are also choking hazards. Do not give these foods to children until they are at least four years old.

●Honey – Honey is not recommended, due to the potential risk of exposure to a harmful bacteria toxin (botulism poisoning). (See "Botulism".)

Food allergy concerns

●Which babies are at higher risk for food allergy? – Some babies with no known risk factors develop food allergy, but this is uncommon.

The risk of food allergy is higher in babies with (in ascending order of risk):

•A parent who has allergic disease

•Mild to moderate eczema

•Known allergy to another food

•Severe eczema (highest risk) (see "Patient education: Eczema (atopic dermatitis) (Beyond the Basics)")

For babies in these risk groups, the timing of introducing highly allergenic foods is the same as for all babies, as discussed below.

●When to introduce highly allergenic foods – "Highly allergenic" foods are those that most commonly cause allergy. They include cow's milk products, eggs, peanuts, tree nuts, sesame, soy, wheat, fish, and shellfish.

•Initial foods – For all babies, experts recommend that caregivers introduce traditional supplemental foods (eg, cereals; pureed fruits, vegetables, and meats) beginning between four and six months. (See 'Types of complementary foods' below.)

•Allergenic foods – If your baby has no signs of allergy with the initial foods, you can introduce additional foods gradually, including highly allergenic foods [3]. Cow's milk can be introduced through yogurt and cheese; liquid cow's milk should not be given to any child until after age 12 months, because it does not have the nutritional value of breast milk or formula. Peanut and tree nuts can be introduced by spreading a thin layer of pureed peanut or tree nut butter on other foods or mixing with fruits or vegetables; whole peanut or tree nuts should not be given to babies, because of the choking risk. Sesame can be introduced by feeding hummus or tahini paste mixed into pureed foods. (See 'Foods and drinks to avoid' above.)

These recommendations are based on studies that evaluated the specific timing of introducing highly allergenic foods and the risk of developing food allergies [3,4]. The studies suggested that early introduction of highly allergenic foods may actually decrease the risk of food allergy [5]. Thus, experts no longer recommend the historical practice of delaying introduction of these foods to children with risk factors for food allergy. (See 'Types of complementary foods' below.)

●How to introduce highly allergenic foods – It is possible for an allergic reaction to occur the first time a child eats a particular food. The most common symptoms of an allergic reaction seen in babies are hives and/or vomiting.

We recommend giving highly allergenic foods to high-risk children in the following manner:

•Give your baby an initial taste of one of these foods at home, rather than at day care or at a restaurant.

•If there is no apparent reaction, you can introduce the food in gradually increasing amounts.

•Consult your child's health care provider if your child has signs of an allergic reaction after eating a food or has moderate to severe eczema that is difficult to control. An allergy evaluation may be suggested in these cases.

•Call for emergency help if your baby has symptoms of a severe allergic reaction, like trouble breathing or passing out. (See "Patient education: Anaphylaxis symptoms and diagnosis (Beyond the Basics)".)

(See "Patient education: Food allergy symptoms and diagnosis (Beyond the Basics)".)

TYPES OF COMPLEMENTARY FOODS — There is no one food that is recommended as the best first food for babies. Single-ingredient foods should be introduced first, one at a time, to determine if your child has an allergic reaction. If there is no sign of a reaction, you can introduce another single-ingredient food a few days later. Signs and symptoms of a food allergy include hives (skin welts) or other skin rash, facial swelling, vomiting, diarrhea, coughing, wheezing, difficulty breathing, weakness, or pale skin. Consult your child's health care provider if any of these problems occur. (See "Patient education: Food allergy symptoms and diagnosis (Beyond the Basics)".)

As you introduce solid foods, your baby will usually begin to take less breast milk or formula. If you are breastfeeding, you can continue to feed your baby "on demand." As your baby takes more solid foods, they will naturally take less breast milk or formula. By nine months of age, most babies are taking plenty of solid foods and approximately 20 to 30 ounces (600 to 900 mL) of formula or breast milk per day.

Cereal — Single-grain infant cereal is a good first complementary food because it supplies additional calories and iron. Oat, barley, or rice cereals are a good choice because these grains have a low risk of allergy. Rice cereal is fine occasionally but should not be used exclusively, because of concerns about contamination with arsenic. Wheat products (in cereal or other foods) may be offered by six months of age.

●How to prepare cereal – You can prepare infant cereal by adding breast milk, formula, or water. Initially, make a thin consistency, then you can make it thicker as your baby gets older and learns how to handle the solid food. At first, offer the cereal by spoon in small amounts (1 teaspoon [5 mL]) at the end of breast- or bottle-feeding. Spoon-feeding helps your baby learn to coordinate their mouth and swallowing movements, which might also help with future speech development. Gradually increase the amount of cereal, so that your baby is taking approximately 2 tablespoons (30 mL) two to three times per day by 8 to 10 months of age and four times per day by 12 months of age.

If your baby refuses or appears uninterested in the cereal, try again the next day using a thinner mixture. You might need to keep offering the cereal many times before your baby develops an interest in eating it.

●Cereal in a bottle – Do not add cereal to a bottle unless this is recommended by a health care provider as a treatment for gastroesophageal reflux (acid reflux). If you put cereal in your baby's bottle because of reflux, be sure to also give them cereal from a spoon to help them learn to eat that way. (See "Patient education: Acid reflux (gastroesophageal reflux) in babies (Beyond the Basics)".)

●Cereal and sleep – You might have heard that cereal can help your baby sleep through the night. However, studies suggest that giving cereal to a child who is younger than four to six months probably does not help them sleep better.

Pureed foods — Introduce single-ingredient pureed foods, including meats, vegetables, and fruits, one at a time, every few days. If your baby has no signs or symptoms of an allergic reaction, you can add a second food. The goal is to expose your baby to new flavors and textures of food. The amount that they eat is less important. The order in which foods are introduced (vegetable, fruit, or meat first) is probably less important than the texture and consistency of the food.

By the time your baby is eight months of age, they should be eating about two to three tablespoons of fruits and vegetables twice per day. Continue to offer a variety of fruits and vegetables, even if your baby prefers some more than others.

●First foods should be finely pureed, contain only one ingredient, and not contain additives (salt, sugar).

●Second foods are pureed or strained, often contain two or more ingredients (eg, fruit and grain, meat and vegetable), and should not contain additives (salt, sugar). Combination foods may be given after your child tolerates the individual components. Once thin purees are tolerated, thicker purees can be introduced.

●Third foods are usually combinations of food types, some of which have texture to encourage chewing. Some are seasoned with spices, although foods should not contain added salt or sugar. Chunkier blends often contain pureed food with small pieces of pasta, vegetables, or meat.

Prepared baby food — Storebought baby food in jars or pouches is one option. To avoid potential safety issues:

●You can serve baby foods at any temperature (cold, room temperature, or warm).

●Serve storebought foods from a bowl. Spoon the desired amount of food out of the jar, or squeeze out of the pouch into a bowl. Then, immediately refrigerate the unused baby food in its container to avoid spoilage. An open jar or pouch of baby food kept in the refrigerator should be discarded after two to three days.

●If you serve your baby the food directly from the jar or pouch, it may become contaminated. Discard the baby food jar or pouch and any food left in the bowl after the meal.

Preparing baby food at home — You may choose to make your own pureed baby food for a variety of reasons (eg, freshness, increased variety and texture, cost, etc).

When choosing and preparing foods at home:

●Use food safety precautions for preparation and storage to avoid food contamination and spoilage. Several resources provide guidelines for safe preparation of baby food at home (American Academy of Pediatrics [6]; United States Department of Agriculture [7]).

●Do not add salt and/or sugar to your home-prepared foods.

●Experts recommend waiting until at least four months of age to introduce solid foods (see 'Age' above). It's especially important to avoid giving home-prepared spinach, beets, green beans, squash, and carrots to babies younger than six months of age. These vegetables may contain enough of certain chemicals (nitrates) to cause a rare condition called methemoglobinemia, which reduces the amount of oxygen carried by the blood [8]. Older babies are less susceptible to this risk.

Foods with texture and finger foods — Between six and eight months of age, you can start to offer soft foods with textures. Then, by the time your baby is approximately six or seven months of age, you can offer them foods to eat with their hands. You can start with finely chopped, very soft foods (such as small pieces of soft fruits, vegetables, cheese, well-cooked meats, or cooked pasta) and foods that dissolve easily (such as baby crackers or dry cereal). When your baby is older, you can offer soft foods with more chunks, as long as they show no signs of choking.

As your baby learns to eat, they might gag from time to time as they try more textured foods or new flavors. Gagging is a reflex that helps protect the airway. As long as the gagging is brief and your baby does not appear to have any trouble breathing, you can allow them to continue to learn with new foods.

Always be careful to avoid any food that could cause choking. Common choking hazards are hot dogs, peanuts, tree nuts, grapes, raisins, raw carrots, round candies, and popcorn. Do not give these foods to children until they are at least four years old.

Fruit juice — You can introduce 100 percent fruit juice when your child is older than 12 months. Limit the amount to no more than four ounces per day because too much fruit juice can cause diarrhea, excessive weight gain, and tooth cavities. Before age 12 months, babies should have fruit purees as part of their complementary foods, but fruit juice is not necessary or recommended [9].

VITAMIN AND MINERAL SUPPLEMENTS — Some children require vitamin or mineral supplements:

Iron — Iron deficiency is the most common nutrient deficiency in the United States. The amount of iron required depends on your baby's birth weight and whether they were born prematurely.

●Premature babies – Premature and very low birth weight babies are at higher risk for iron deficiency. They should be given an iron supplement (in the form of multivitamin drops) beginning by two weeks of age and continuing until they are at least 12 months of age.

●Full-term babies – Babies who are breastfed need additional iron after four to six months of age. In some cases, they can get the iron from iron-rich complementary foods such as fortified infant cereal or pureed meats. An average of two servings (2 ounces of dry cereal per serving) of iron-fortified infant cereal per day is sufficient to meet a baby's daily iron requirement. If your baby does not eat this much cereal, they should get an iron supplement. (See "Patient education: Breastfeeding guide (Beyond the Basics)".)

Full-term babies who drink iron-fortified formula usually do not need any additional iron supplementation. Low-iron formulas are not recommended in any situation.

After your baby is taking solid foods, continue to give them iron-rich foods such as fortified baby cereal or meats at least once every day. At the same meal, also give them foods rich in vitamin C (eg, citrus fruits and juices, cantaloupe, strawberries, tomatoes, dark green vegetables). Vitamin C helps the body absorb iron.

Fluoride — Fluoride is a mineral often found in drinking water. Fluoride can reduce the risk that a young child will develop dental cavities. However, not all drinking water contains an adequate amount of fluoride.

A fluoride supplement is recommended for children starting at six months old if the fluoride level in the local water supply is low or if your baby is drinking only breast milk or ready-to-feed formula (ie, not from concentrate or powder) [10]. The United States Public Health Service recommends an optimal community drinking water concentration of 0.7 mg/L to prevent dental cavities [11]. Too much fluoride (from water or toothpaste) should also be avoided because it can cause white spots on the teeth (called "fluorosis"). In the United States, the Centers for Disease Control and Prevention provides information about community water fluoridation [12]. If you get your water from a well, you can have it tested to see how much fluoride it contains. If you use bottled water to prepare formula, check the label to see if it has fluoride. Most bottled water has very low levels of fluoride, so a fluoride supplement may be needed.

Vitamin B12 — The body requires a source of vitamin B12 to maintain blood cells. Meat, eggs, and dairy products are the only food sources of vitamin B12. Low levels of vitamin B12 can lead to anemia, developmental delay, and other problems.

If you breastfeed your baby and you follow a strict vegan diet, or a vegetarian diet with few or no eggs, this increases your baby's risk for vitamin B12 deficiency. In this case, your baby will require a multivitamin supplement that includes vitamin B12, at least until they are getting enough vitamin B12 from complementary foods. Adequate B12 is available in most nonprescription infant vitamin drops and in certain brands of nutritional yeasts, most ready-to-eat cereals, many meat substitutes, and some milk alternatives. Fortified soy milk is a good source of B12 for children.

Vitamin D — The body requires vitamin D to absorb calcium and phosphorus, which are essential minerals for the formation of bones. Inadequate levels of vitamin D in children can lead to a condition known as rickets, which causes bones to be fragile and to break easily. The risk for vitamin D deficiency is highest for children who are breastfed, were born prematurely, have darker skin pigmentation, or have limited sun exposure.

All babies, whether they are fed breast milk or formula, should be given a supplement containing 400 IU of vitamin D per day, starting within days of birth [13]. Vitamin D is included in most nonprescription infant vitamin drops. In some countries, it is possible to buy infant drops that contain only vitamin D. As an alternative to giving your baby vitamin D supplements, you can choose to take a high dose of vitamin D yourself (approximately 6000 international units or 150 micrograms per day). While there is some evidence that this is an effective way to fulfill your baby's daily vitamin D requirement, it should be done only under guidance from a health care provider. (See "Patient education: Health and nutrition during breastfeeding (Beyond the Basics)", section on 'Vitamin D'.)

Infant formulas available in the United States have 400 IU of vitamin D per 800 to 1000 mL (27 to 33 ounces), so the formula will provide adequate vitamin D if your baby drinks this amount of formula daily.

WHERE TO GET MORE INFORMATION — Your child's health care provider is the best source of information for questions and concerns related to your child's medical problem.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients and caregivers, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Weaning from breastfeeding (The Basics)
Patient education: Starting solid foods with babies (The Basics)
Patient education: Diet and health (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Food allergy symptoms and diagnosis (Beyond the Basics)
Patient education: Eczema (atopic dermatitis) (Beyond the Basics)
Patient education: Acid reflux (gastroesophageal reflux) in babies (Beyond the Basics)
Patient education: Breastfeeding guide (Beyond the Basics)
Patient education: Health and nutrition during breastfeeding (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Dietary history and recommended dietary intake in children
Poor weight gain in children younger than two years in resource-abundant settings: Etiology and evaluation
Introducing formula to infants at risk for allergic disease
Introducing solid foods and vitamin and mineral supplementation during infancy
Poor weight gain in children younger than two years in resource-abundant settings: Management
Poor weight gain in children older than two years in resource-abundant settings
Botulism

The following organizations also provide reliable health information.

●Medline Plus

(www.nlm.nih.gov/medlineplus/infantandtoddlernutrition.html)

●American Academy of Pediatrics

(www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Starting-Solid-Foods.aspx be )

●Women, Infants, and Children Works Resource Center

(www.wicworks.fns.usda.gov/resources/infant-feeding-tips-food-safety)

●Food Allergy Research & Education

(www.foodallergy.org)