1: Starting Complementary Food

What is Complementary Feeding?

Complementary feeding means giving solid foods to babies along with breast milk or formula. Infants grow fast! As they get older, their nutrient and calorie needs also increase significantly. Breast milk and formula alone cannot keep up with those needs, so solid foods are important too.

Guidelines for Complementary Feeding

Each organization has slightly different recommendations for when to start introducing solid foods. Here is a chart on the different recommendations, and the handout below has more information on individual organization recommendations.

Key Take-Aways

Start feeding solid food around 6 months old and not before 4 months
Introduce one new food at a time
Start with pureed food 2-3 times per day and move up in texture as baby develops
Include all of the food groups in the baby's diet while avoiding high added sugar and salt food
Never give raw milk products to your baby

Vital Nutrients

Infants need macronutrients to thrive! Below are the three macronutrients' infants need:

Carbohydrates
Protein
Fat

Carbohydrates

Most important for energy and main fuel source for the brain
Babies grow a lot in the first year and need a lot of energy to keep up
Examples
- - Cereals, grains, fruits, vegetables, breads

Protein

Building blocks for muscles and cells
Helps different body parts function and is vital for growth
Examples
- - Meats, fish, cheese, eggs, dairy, nuts, seeds, beans

Fat

High in energy
Help absorb some vitamins
Omega-3s fats are good for brain health and fat helps protect organs and cells
Examples
- - Fish, oils, butter, avocados, olives, nuts, seeds

Vital Nutrients Handout

Other Vital Nutrients

There are also vital micronutrients (vitamins and minerals) that are important for a developing baby. Here are some of the most important to infants:

Iron
Calcium
Iodine
Vitamin D

Iron

Plays a vital role in making blood cells to help your baby get oxygen to every part of their body!
0 to 4-6 months: Iron needs are met through breastmilk and/or formula
6-12 months: Babies need about 11 mg of iron per day.
Dietary sources: spinach, iron-fortified cereal, red meat

Calcium

Important for making strong bones, hormones, and muscle and nerve function!
0 to 6 months: Calcium needs are met through breastmilk and/or formula.
6-12 months: Babies need about 260 mg of calcium per day.
Dietary sources: Milk, cheese, tofu, nuts, fish

Iodine

Iodine is important for hormone production and cell growth!
There is new research coming out about how important iodine is!
0 to 6 months: Iodine needs are met through breastmilk and/or formula.
6-12 months: Babies need about 130 mcg of iodine per day.

Dietary sources: seafood, seaweed, milk, eggs

Iron, Calcium, and Iodine for Breastfed Babies

For exclusively breastfed babies, the introduction of Iron, Calcium, and Iodine-rich foods by 6 months is extremely important to prevent deficiency. The daily nutrient intake for babies who are formula-fed should consider the nutrients from the formula along with the solid food consumed. The nutrient information for the formula the baby consumes can be found on the food label on the back of the can.

Vitamin D

Vitamin D helps the immune system function and helps make strong bones!
0 to 12 months: Babies need 400IU per day.
- - Breast milk alone does not provide enough, so many babies may need a supplement. Ask your doctor.
  - Formula usually has vitamin D added. Because of this, formula-fed babies may not need supplementation (check the nutrition labels of the formula).
  - Once babies start eating solids, they should consume vitamin D-rich foods

Dietary sources: seafood, dairy, eggs, mushrooms

Vitamin D for Breastfed Babies

For exclusively breastfed babies, please consult with your pediatrician regarding vitamin D supplementation since vitamin D level is low in breastmilk. For formula-fed babies, the daily intake of vitamin D should consider the intake from formula (check the labels) and solid foods.

Signs of Complementary Feeding Readiness

Below are a few signs that the child might be ready for complementary feeding. It is important to note that every baby is different and there is no set age for when you should start complementary feeding.

If your baby is able to sit up with or without support, hold a spoon, and shows interest in the food you are consuming, these are signs of complementary feeding readiness.

Stops or reduces the "Toung thrust" reflex

This baby is displaying the reflex. He is not ready.

Shows interest in food and opens mouth to eat

Can sit up on their own and stay up with support

Infant can hold a spoon (voluntary palmar grasp)

Risks of Wrong Timing for Feeding

Feeding too Early

Increased risk of choking
Feeding before 4 months can put them at risk for abnormal weight gain as a baby and in early childhood
Babies lack proper enzymes to break down food, which can cause a GI obstruction or pain

Feeding too Late

Increased risk of underfeeding, malnutrition, and weight loss
Increased risk of developing lifelong food allergy (especially after 6-7 months)
May not develop skills associated with eating, which may require speech-language pathologist intervention in the future

Initiating the First Feed

How to Initiate the First Feeding

Start with half a spoonful of food
Talk to the baby about what is happening

Tips for the First Feeding

If the baby is getting frustrated because they are hungry, try to give a little formula/breastmilk first then switch to food. Feed them the food, then finish with formula/breastmilk
Do not force food into their mouth if they turn away or cry
The first few times, more food might end up ON them, then IN them. This is normal - just start with a little and increases as they become better at swallowing

Introduction of Allergenic Foods

Below are the top 9 common food allergens in the United States. Research findings support feeding these allergens along the solid food introduction process.

Should you wait on giving allergenic food?
- - No! Research shows that introducing food allergens early (between 4-6 months) is vital to prevent the development of allergies.
Should I avoid giving allergenic food if their sibling has allergies?
- - No! Research shows that siblings of those with allergies can still be introduced to allergens. Be careful to avoid cross-contact to prevent accidentially giving the allergen to your other child.
Should I wait between foods?
- - Current guidelines suggest waiting 3-5 days between new foods. Some new research is suggesting that this may not be needed but the guidelines have not changed yet.
Should I avoid feeding allergens if my infant has eczema?
- - No! Recent research suggests it is beneficial to try allergenic food when your child is between 4-6 months of age even if the child has eczema.

References and Resources

Complementary feeding-Global. www.who.int.
Infant and young child feeding. World Health Organization. Accessed August 26, 2024. https://www.who.int/news-room/fact-sheets/detail/infant-and-young-child-feeding
Samady W, Campbell E, Aktas ON, et al. Recommendations on Complementary Food Introduction Among Pediatric Practitioners. JAMA network open. 2020;3:e2013070. doi: 10.1001/jamanetworkopen.2020.13070
Fleischer DM, MD, Spergel, Jonathan M., MD, PhD, Assa'ad AH, MD, Pongracic JA, MD. Primary Prevention of Allergic Disease Through Nutritional Interventions. The journal of allergy and clinical immunology in practice (Cambridge, MA). 2013;1:29-36. DOI:https://doi.org/10.1016/j.jaip.2012.09.003
Infants. USDA MyPlate Nutrition Information for. Accessed August 26, 2024. https://www.myplate.gov/life-stages/infants#:~:text=Complementary%20foods%20are% 20foods%20other,zinc%2C%20particularly%20for%20breastfed%20infants
Samady W, Campbell E, Aktas ON, et al. Recommendations on Complementary Food Introduction Among Pediatric Practitioners. JAMA network open. 2020;3:e2013070. doi: 10.1001/jamanetworkopen.2020.1307
Nutten S. Proteins, Peptides and Amino Acids: Role in Infant Nutrition. Nestle Nutrition Institute workshop series. 2016;86:1. https://doi.org/10.1159/000442697
Iron needs of babies and children. Paediatrics & child health. 2007;12:333-334. doi: 10.1093/pch/12.4.333
Gavin ML, ed. Calcium (for parents) | nemours kidshealth. KidsHealth. February 2021. Accessed August 27, 2024.https://kidshealth.org/en/parents/calcium.html#:~:text=a%20calcium%20supplement.-,Ba bies,mg%20of%20calcium%20a%20day
Chiang KV, Hamner HC, Li R, Perrine CG. Timing of Introduction of Complementary Foods- United States, 2016-2018. MMWR. Morbidity and mortality weekly report. 2020;69:1787-1791. DOI: http://dx.doi.org/10.15585/mmwr.mm6947a4
Ghirri P, Lunardi S, Boldrini A. Iodine supplementation in the newborn. Nutrients. 2014;6:382-390. doi: 10.3390/nu6010382
Vitamin D. Centers for Disease Control and Prevention. July 22, 2021. Accessed August 27, 2024. https://www.cdc.gov/nutrition/infantandtoddlernutrition/vitamins-minerals/vitamin-d.htm l#:~:text=When%20Does%20My%20Child%20Need,of%20vitamin%20D%20each%20d ay
Stephen A, Alles M, De Graaf C, et al. The role and requirements of digestible dietary carbohydrates in infants and toddlers. European journal of clinical nutrition. 2012;66:765-779. doi: 10.1038/ejcn.2012.27
Infant Food and Feeding (aap.org)
Brown JE, Lechenberg E, Murtaugh MA, et al. Nutrition through the life cycle. 7th ed. Cengage Learning; 2017
Milner JA, Allison RG. The Role of Dietary Fat in Child Nutrition and Development: Summary of an ASNS Workshop. The Journal of nutrition. 1999;129:2094-2105. https://doi.org/10.1093/jn/129.11.2094
Borowitz SM. First Bites-Why, When, and What Solid Foods to Feed Infants. Frontiers in pediatrics. 2021;9:654171. doi: 10.3389/fped.2021.654171
Chan, E.S., Abrams, E.M., Hildebrand, K.J. et al. Early introduction of foods to prevent food allergy. Allergy Asthma Clin Immunol 14 (Suppl 2), 57 (2018). https://doi.org/10.1186/s13223-018-0286-1
Introducing solid food. Pregnancy, Birth and Baby. Accessed August 29, 2024. https://www.pregnancybirthbaby.org.au/introducing-solid-food#:~:text=They%20don’t% 20know%20how,also%20risk%20your%20baby%20choking
Ha EK, Lee SW, Kim JH, et al. Associations between Delayed Introduction of Complementary Foods and Childhood Health Consequences in Exclusively Breastfed Children. Nutrients. 2023;15:3410. doi: 10.3390/nu15153410
Abeshu MA, Lelisa A, Geleta B. Complementary Feeding: Review of Recommendations, Feeding Practices, and Adequacy of Homemade Complementary Food Preparations in Developing Countries- Lessons from Ethiopia. Frontiers in nutrition (Lausanne). 2016;3:41-41. https://doi.org/10.3389/fnut.2016.00041
Starting solid foods. HealthyChildren.org. January 16, 2018. Accessed August 29, 2024. https://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/Startin g-Solid-Foods.aspx
Food Allergies: The “Big 9” | Food Safety and Inspection Service. Accessed August 29, 2024.
Abrams EM, Becker AB. Food introduction and allergy prevention in infants. Canadian Medical Association journal (CMAJ). 2015;187:1297-1301. doi: 10.1503/cmaj.150364
Babies with existing allergy or a family history of allergy. Prevent Allergies. April 23, 2024. Accessed August 29, 2024.
Experts question need to wait days between introducing new solid foods to Infants | Lurie Children’s. August 17, 2020. Accessed August 29, 2024. https://www.luriechildrens.org/en/news-stories/experts-question-need-to-wait-days-betwe en-introducing-new-solid-foods-to-infants/.
Eczema and food allergy. Prevent Allergies. September 25, 2023. Accessed August 29, 2024. https://preventallergies.org.au/eczema/eczema-and-food-allergy/#:~:text=Listen,result%2 0in%20better%20eczema%20control.
Chiang KV, Hamner HC, Li R, Perrine CG. Timing of Introduction of Complementary Foods- United States, 2016-2018. MMWR. Morbidity and mortality weekly report. 2020;69:1787-1791. DOI: http://dx.doi.org/10.15585/mmwr.mm6947a4
. Introducing solid food. Pregnancy, Birth and Baby. Accessed August 29, 2024. https://www.pregnancybirthbaby.org.au/introducing-solid-food#:~:text=They%20don’t% 20know%20how,also%20risk%20your%20baby%20choking

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