Introducing Solid Foods to Infants

1. Introducing Solid Foods to Infants Nathan R. Harmon, D.O.

2. Definition The AAP defines �Complimentary� foods as any food which reduces the intake of breast milk Thus, Solids are �complimentary� Thus, Solids are �complimentary�

3. Strength-of-Recommendation Grades Strength of recommendation Basis for recommendation A Consistent, good-quality patient-oriented evidence* B Inconsistent or limited-quality patient-oriented evidence* C Consensus, disease-oriented evidence,* usual practice, expert opinion, or case series for studies of diagnosis, treatment, prevention, or screening *-Patient-oriented evidence measures outcomes that matter to patients: morbidity, mortality, symptom improvement, cost reduction, and quality of life. Disease-oriented evidence measures intermediate, physiologic, or surrogate end points that may or may not reflect improvements in patient outcomes (e.g., blood pressure, blood chemistry, physiologic function, pathologic findings). From American Family Physicain, most of what is discussed today is considered AFrom American Family Physicain, most of what is discussed today is considered A

4. Assessing Quality of Evidence Level 1: good-quality, patient-oriented evidence Validated clinical decision ruleSR/meta-analysis of high-quality studiesHigh-quality diagnostic cohort study* SR/meta-analysis or RCTs with consistent findingsHigh-quality individual RCT�All-or-none study� SR/meta-analysis of good-qualitycohort studiesProspective cohort studywith good follow-up

5. Level 2: limited-quality patient-oriented evidence Unvalidated clinical decision ruleSR/meta-analysis of lower quality studies or studies with inconsistent findingsLower quality diagnostic cohort study or diagnostic case-control study SR/meta-analysis of lower quality clinical trials or of studies with inconsistent findingsLower quality clinical trialCohort studyCase-control study SR/meta-analysis of lower quality cohort studies or with inconsistent resultsRetrospective cohort study or prospective cohort study with poor follow-upCase-control studyCase series

6. Level 3: other evidence Consensus guidelines, extrapolations from bench research, usual practice, opinion, disease-oriented evidence (intermediate or physiologic outcomes only), or case series for studies of diagnosis, treatment, prevention, or screening SR = systematic review; RCT = randomized controlled trial. *-High-quality diagnostic cohort study: cohort design, adequate size, adequate spectrum of patients, blinding, and a consistent, well-defined reference standard. �-High-quality RCT: allocation concealed, blinding if possible, intention-to-treat analysis, adequate statistical power, adequate follow-up (greater than 80 percent). �-In an all-or-none study, the treatment causes a dramatic change in outcomes, such as antibiotics for meningitis or surgery for appendicitis, which precludes study in a controlled trial. Evidence here is level 2 and 3Evidence here is level 2 and 3

7. Goals When to introduce complimentary foods Reasons/Evidence behind proper timing How to be successful Other pearls

8. Case Two Family practice residents are thinking of introducing solid foods to their first child, who is now 5 months old. They realize that they know little about pediatric nutrition, and have had different advice from their parents versus their pediatrician.

9. Case Their parents tell them to give rice cereal as early as possible to help the baby sleep through the night. (They gave us cereal as early as 3 months old!) Their pediatrician gives very different advice��.

10. Criteria for When to Introduce Solids Age: 4 to 6 months Too Early Too Late Proper Motor skills (neurodevelopment) Sit with support Good head and neck control Truncal Control Extinguishing of Extrusion Reflex Too Early -- Solids before 2 months can lead to inadequate energy/nutrients -- Increased renal solute load can be harmful --Increased risk of developing food allergies (more later) Too Late --after 6 months, may delay growth due to inadequate calorie intake, Risk of iron deficiency in Breast fed infant (term baby�s iron stores are depleted by 6 months), Can lead to delayed oral motor function or solid food aversion Motor Skills --Truncal Control � can push up from the prone position onto elbows --Extrusion reflex � see next slide By 5-6 months, infants can indicate desire for food by opening mouths and leaning forward, or indicate disinterest or Satiey by leaning back and turning away. Too Early -- Solids before 2 months can lead to inadequate energy/nutrients -- Increased renal solute load can be harmful --Increased risk of developing food allergies (more later) Too Late --after 6 months, may delay growth due to inadequate calorie intake, Risk of iron deficiency in Breast fed infant (term baby�s iron stores are depleted by 6 months), Can lead to delayed oral motor function or solid food aversion Motor Skills --Truncal Control � can push up from the prone position onto elbows --Extrusion reflex � see next slide By 5-6 months, infants can indicate desire for food by opening mouths and leaning forward, or indicate disinterest or Satiey by leaning back and turning away.

11. Review When introducing solids, the parent should wait until A. They are exhausted and just want to baby to sleep through the night (i.e. as early as possible) B. The Baby has good truncal control, no extrusion reflex, and can sit with support.

12. Extrusion Reflex