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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.

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