“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