The jury is not out on infant feeding and what is ideal for the baby, yet the desire to pathologize deviating from exclusive breastfeeding or the so-called “perfect” age to start solids is stronger than ever. Now it is the Centers for Disease Control and Prevention (CDC) that is doubling down on creating guidelines for already existing guideline’s guidelines and this pediatrician cannot take it anymore!
The framing of these messages do harm as they tend to be dogmatic and insist on solving problems we really don’t have in our society or at least not to the dramatic degrees they suggest. This unnecessarily pressures and adds stress to parents which detracts from the joy of the experience while erroneously insisting there is one right way to feed a baby.
Such are the misguided claims or stated intentions of a cross-sectional data analysis of 2009-2014 National Health and Nutrition Examination Survey recently published in the Journal of the Academy of Nutrition and Dietetics.
Let’s break down some fundamental flaws in this work:
#1 The premise
“In recent years, there has been some inconsistency in the recommended timing of the introduction of complementary foods to infants. The term complementary foods refers to anything other than breast milk and infant formula, both solids and liquids, that are needed when milk feeds alone are no longer sufficient to meet the nutritional requirements of infants.”
The word inconsistency implies wrongdoing for which there is likely no such thing. They go on to state that the American Academy of Pediatrics (AAP) recommends beginning at about 6 months while others advise 4-6 months and most experts agree not to start before 4 months (e.g. due to choking hazards, compete with vital nutrition from breast milk/formula, etc.).
Inconsistency and the paper’s statements require some unpacking and nuance. In reality, these groups are saying the same thing. Solids are not nutritionally relevant in the first six months of an infant’s life, all they need is breast milk or formula. In the second six months, they explode in development becoming more alert, aware, vigorous and replete with an ever coordinated system for sucking and swallowing. Then, they start taking in solids, steadily increasing their volumes as they decrease their breast milk or formula. Scents, smells, textures and the world around them become very stimulating. They increase their mobility and capacity to sit unassisted.
#2 A solution seeking a problem, ignoring many realities
“Despite using a broader definition of complementary foods, this analysis found a lower prevalence of early introduction in this nationally representative sample than previous studies that included only solids. However, many young children were still introduced to complementary foods earlier than recommended. Strategies to support caregivers to adhere to infant feeding guidelines may be needed.”
Previously it was reported in the U.S. that 20%-40% of infants are introduced to complementary foods prior to 4 months, while this report demonstrated 16.3% - a much lower value. Are “strategies” so necessary when 84% are uninvolved?
The premature conclusions made by drive by of data in a vacuum dismiss the variation in pace of development between individuals, cultural differences, need for bonding, and recognition that when infant’s even start in the 4 to 6 month mark they spit out more than they actually ingest. Babies follow their own pace and can be more advanced than others in certain milestones and at different times. Some demonstrate a greater readiness to start solids (e.g. excessively drool, get excited over parent’s foods, exhibit good head control) and parents can become more engaged with their child through this process. More often doing so just amounts to more work, so 6 months for nutritional and pragmatic purposes is more common for the start of solids.
When an infant is thriving, whether he initiates solids at 5 ½ or 6 ½ months is not a meaningful distinction.
Misperceptions in the community abound that using gripe water or sugar water and thickening feeds with rice cereal can help a fussy baby. Pediatricians repeatedly address the risks associated with these and other premature exposures, especially before age 4 months. The majority of breast milk or formula is water, so water is not typically recommended early on since it can fill the baby up with no nutritional value (among other reasons). Despite this, family and friends can exert tremendous influence and when compounded by lack of sleep or worry offer a task that holds promise. The fact it is a false promise is hard to suss out when desperate at 3 a.m.
#3 There can be medical reasons
There are situations that warrant fortification of feeds in infancy. Consider extreme prematurity or failure to thrive due to significant underlying congenital heart disease, to name a few.
The bottom line is infant feeding and successful growth and development are among the core tenets of pediatrics. Close monitoring so as to intervene before problems arise enables pediatricians to assess proportionate and appropriate growth, growth rate, physical, emotional and cognitive development. What and when to feed is determined by the parents in consultation with their child’s doctor who knows the complete clinical history and physical examination. A thriving infant should be a part of a thriving family, one-size-fits all policies contribute to the expense of it. It’s time the government stops parenting parents.