Science You Can Use: How many babies start solids before 4 months, and why? The CDC told us this week.

Baby_eating_baby_food“My pediatrician told me at our 4 month appointment, ‘if you don’t start her on solids before 6 months, she’ll never learn how to eat!’”

“Upon recommendations from WIC and my doctor I tried giving her baby food at four months.”

“Every time I tell the doctors I am breastfeeding they give me congratulations!  And at every visit prior to six months I was told to wait on solids as they will replace valuable nursing sessions.”

“They recommended that I start solids at THREE MONTHS. I refused.”

“I am happy to report that out physician is VERY pro-breast feeding. He encouraged me to wait longer (until 6 months or more) to introduce solids, and at every appointment we have had he has encouraged my continued nursing relationship (with my now 2 year old). I am blessed!”

-Your comments on our Booby Traps post on provider recommendations about the timing of the introduction of solid foods.

How many babies start solids before 4 months of age?

An estimated 40%, according to research released this week by the CDC in a study in Pediatrics.

The timing of solids introduction also varied significantly by feeding method.  Exclusively breastfed babies were the least likely to start solids before 4 months (24%), while mixed fed and exclusively formula fed babies started solids at nearly double that rate (50% and 53% respectively).

This paper, based on telephone interviews with 1,334 mothers across the country between 2005 and 2007, showed widespread use of solid foods far earlier than the American Academy of Pediatrics (AA) recommends.

The AAP’s 2012 breastfeeding policy marked an unequivocal shift from recommending solids introduction at 4 to 6 months to a solid 6 months.  So this data, collected between 2005 and 2007, represents the landscape prior to that change.

But even taking into account the 4-6 month prior recommendation, these infants were given solids too early – at ages younger than 4 months.  And other health authorities like UNICEF and the World Health Organization have been advising the introduction of solids in all countries no earlier than 6 months for some time.

What were the reasons that mothers started solids so early?  Mothers asked this and were given 12 choices.  These are the reasons that rose to the top:

  • “My baby was old enough.”
  • “My baby seemed hungry.”
  • “I wanted to feed my baby something in addition to breast milk or formula.”
  • “My baby wanted the food I ate.”
  • “A doctor or other health care professional said my baby should begin eating solid food.”
  • “It would help my baby sleep longer at night.”

The CDC also found that mothers who were exclusively formula feeding or mixed feeding were more likely to report that that their doctor recommended starting solids earlier.

If you’ve read our Booby Traps series you probably know why we’ve highlighted one of the above responses.  So let’s dig into that reason a bit here.

First, let’s review why six months of exclusive breastfeeding is important.  In its most recent policy, the AAP explains why six months is better than four:

Support for this recommendation of exclusive breastfeeding is found in the differences in health outcomes of infants breastfed exclusively for 4 vs 6 months, for  gastrointestinal disease, otitis media, respiratory illnesses, and atopic disease, as well as differences in maternal outcomes of delayed menses and postpartum weight loss…When compared with infants who exclusively breastfed for longer than 6 months, those exclusively breastfed for 4 to 6 months had a fourfold increase in the risk of pneumonia.

And now let’s look at the evidence about how this recommendation translates into practice.

As I wrote last year, mixed messages from health care providers is not a new phenomenon:

A survey of pediatricians conducted in 2004 found that nearly 30% of pediatricians routinely recommended the introduction of solid foods or formula for exclusively breastfed infants before 5 months of age.  This figure was unchanged since the prior survey in 1995.

So it’s not surprising that mothers get inconsistent messages about when to introduce solids, and this problem is not a new one.  Consider what mothers understand their pediatricians’ recommendations are on even more basic issues of infant feeding:

Data from the CDC’s Infant Feeding Practices II study show that only 34% of mothers believe that their doctor favors exclusive breastfeeding, and nearly an equal number (32%) said that they believed that their doctor had no preference for breastfeeding or formula feeding at all.

When it comes to the reasons why mothers get such poor advice, there is plenty of blame to go around.

As Dr. Kelley Scanlon, co-author of the study, commented in the New York Times, ““Clearly we need better dissemination of the recommendations on solid food introduction.  Health care providers need to provide clear and accurate guidance, and then provide support to help parents carry out those recommended practices.”

As Dr. Lori Feldman-Winter pointed out in my interview with her, pediatrician training is also part of the problem:  “Clearly, the lack of training [on breastfeeding] makes for pediatricians who are not supportive – particularly if mothers have problems, have poor attitudes, don’t think exclusive breastfeeding can work out for many women.”

And then there is the slow adoption of the World Health Organization’s growth charts.  Use of outdated growth charts, based on formula fed and mixed fed growth patterns, can make a normally growing exclusively breastfed baby appear to be slowing down, resulting in recommendations to supplement or start solids before six months.

I thought that this data also raises some interesting questions.  Why, for instance, would the rate of solids introduction for mixed-fed babies be essentially the same as for exclusively formula fed babies?  Did the exclusively breastfeeding moms delay solids introduction because of provider support or because they’d done their own research?  And are there cultural practices which underlie some mothers’ interest in starting solids early?

But the overall message of this study is that, when it comes to both the timing of solid foods introduction and the practice of six months of exclusive breastfeeding, we have quite a ways to go.

What was your experience with the introduction of solid foods?  Did your pediatrician recommend that you begin before 4 months?  Which of the reasons moms stated in this study reflect your experience?

Image credit:  Wikimedia Commons



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7 Responses to Science You Can Use: How many babies start solids before 4 months, and why? The CDC told us this week.

  1. Melissa says:

    Our pediatrician at our four month appointment said we could go ahead and start solid foods, but when I asked her about waiting and exclusively breastfeeding to 6 months, she said that was also a very valid option. We held off on introducing solid foods until 6 months and then started baby led weaning.

  2. trina says:

    My daughters pediatrician didnt seem supportive of breastfeeding at all. When I had supply issues she forced a botttle of formula in her mouth, then reccomended that I give her rice cereal in her bottle at 8 weeks because the formula wasnt staying down… I saw a lactation consultant ang got a different pediatrician. She’s 5 months and still nursing. chunky healthy baby that is EBF !

  3. Alex says:

    I am very confused by the whole idea of solids. I’m from South Africa, and I use public health facilities, and they are all very pro breastfeeding and strict about waiting until 6 months to start solids. When I was pregnant and in the first month or so of my baby being around, older family members would keep asking us when we were going to start solids and water and if I was still breastfeeding. We were adament to wait until six months. But after 4 months, our little boy was showing all the signs of being ready for solids, and he was always trying to grab our food and eat it. So we tried some pumpkin, just to see. He ate a little but not much, so we decided to wait a few more weeks. Then we tried some maize cereal (didn’t want to do rice cereal because of the arsenic) and he loves it. I also read an article about a new study that showed that EBF babies who started solids at 4 months had higher levels of iron, and that it was not necessarily provoking allergic reactions to start earlier and in fact it might reduce the risk of allergies. So its been a little over a week that we have been giving him cereal, he like it most days. I mix it with expressed milk and only give him a few spponfuls between milk feeds. Often he will nurse after he has his cereal. After reading this article, I am worried that we have started too early. He is advanced and the size of a six month old. Should we stop?

    • Tanya Lieberman, IBCLC says:

      Hi Alex,

      We agree – the conflicting advice you get from family and providers can make it a really tough to figure out when to introduce solids!

      As I mentioned, the basis for the AAP and others’ recommendations to wait for 6 months is based on research findings that waiting reduces the risk of gastrointestinal disease, otitis media, respiratory illnesses, and atopic disease. Best for Babes responded to the research you mentioned here: http://www.bestforbabes.org/messing-with-the-six-months-exclusive-breastfeeding-recommendation-hidden-boobytrap.

      The other issue is developmental readiness. While there is surely a range of normal and some babies are ready to start earlier than others, sitting up without support is one related skill that usually isn’t mastered until 6 months or later: http://kellymom.com/nutrition/starting-solids/solids-when/#developmental It sounds like you are aware of the possibility that early introduction of solids can diminish milk supply and are taking steps to minimize that. Whatever you decide, a final thought is to check out Baby Led Weaning, if you haven’t already.

      Tanya

  4. Bridget Palkow says:

    My Doctor is amazng. We see a D.O. He is so supportive of Breastfeeding. He encourages breastfeeding for as long as we can. My daughter will be 6 months old next week and everything is perfect. I wish more moms had supportive doctors. Good for the mom’s that do what they feel is right for their babies.

  5. Desiree Martinez says:

    I have a 4 month old who is EBF. I already planned to not give her solids until later than 6 months and her Dr agrees. Shes got so many rolls I LOVE it. LOL I’m trying to do my part and educate my friends who want to breastfeed. I love to breastfeed and I wanna be apart of helping others do so too. :)

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