Introducing Solids with Dr Golly – A Review of Global Literature & Recommendations

Introduction

In recent years, the timing of the introduction of solids has become a hot topic; it’s emotionally charged, a significant change for babies and parents, and there’s an excess of conflicting advice.

Parents need to feel empowered and confident, so that when they do start to introduce solids to their child, their child absorbs that confidence.

This increases the likelihood of a successful introduction to solids, setting the child up for a positive relationship with food; the way it should be.

In this article, I will highlight the latest guidelines and research (existing and emerging), as well as cultural practices across the globe and drive a common-sense approach.

For a topic that has become unnecessarily complicated, I want to simplify my advice down to 3 main statements:

1. You will receive abundant advice and countless recommendations from many people and resources, so it’s important to sift through the noise and remember that there is ONE single person – the most important person – who decides when solids are due, and that person is your baby. Children are brilliant communicators and if we learn to interpret them better, we can see when they’re telling us that it’s time for the introduction of solids, or they’re not yet ready.
2. I’m pro-breastfeeding – this is not for debate. BREAST MILK IS THE BEST MILK. But exclusive breastfeeding runs a course. The continuation of exclusive breastfeeding should never come at the cost of the mental/physical wellbeing of the baby or mother.
3. The high incidence of anaphylaxis and allergies in countries like Australia (1/10 infants) means that minimising allergy risk is a significant factor to consider.

There’s no room for shaming here.

I love that people are passionate when discussing this topic, but passion all too often turns to aggressive commentary.

There is no room for this.

If the health of the baby is the agreed #1 priority, then the natural extension of this is the health and wellbeing of the parents. We all want the same thing, we’re on the same team.

If you’re responding or commenting, please be mindful of your language; be respectful.

Read blogs and articles in their entirety, as everything exists in context.

Every baby is different – and every family needs to make individualised, personal choices.

There is no room in this space for shaming people.

• Be respectful that not all mothers can exclusively breastfeed.
• Be respectful that not all families can breastfeed, period.
• Be respectful that there are scenarios that don’t allow for exclusive breastfeeding, like limited parental leave, for example.
• Expressing is easier said than done, not to mention logistically challenging for some women returning to certain workplaces.
• Be respectful that bottle rejection can occur in breastfed babies.

I want to empower parents and have relevant conversations around starting solids. Minus the hyperbole and shaming.

I will present conversations with leaders in their fields.

• We will look at global literature & recommendations
• We’ll explore Australian guidelines & recommendations
• We’ll talk to paediatric allergists
• We’ll talk to paediatric gastroenterologists
• We’ll talk to paediatric dieticians & nutritionists
• We’ll talk to lactation consultants
• We’ll talk to paediatric physiotherapists

What are the goals of introducing solids to a baby?

1. Learning to eat (this is a learned skill that improves with practice) and promoting fine motor development
2. Increasing their total calorie intake to facilitate longer sleep (if desired)
3. Experiencing new tastes and textures
4. Helping with speech, teeth and jaw development
5. Having fun
6. Exposing the immune system to new proteins, which decreases food allergy incidence

When do you start your baby on solids?

My advice is the same as it’s always been.

Don’t look at the calendar, look at your baby – they will tell you.

Remember there is NO right or wrong answer here; child development is a fluid process and every family and baby is different – for most babies it will be somewhere between 4-6 months.

From approximately 4 months of age, start looking for – and recognising – the signs of evolving readiness.

These include:

• more frequent night waking and catnapping during the day
• your baby watching you more intently when you are eating and seeming more interested
• reaching for food as you try to eat
• opening their mouth when you offer them something to hold
• putting objects in their mouth more often
• have lost the tongue-thrust reflex that pushes food back out of the mouth

Babies do NOT need trunk control (sitting independently) to be able to start solids, you may be waiting up to 9 months for this. They can be safely fed in a ‘fitted’ high-chair, parent’s lap, etc.

What they do need is good head and neck control. Their head shouldn’t be ‘toppling’ around or slumping forward. There is a safety risk if their head is slumped then this can increase the risk of choking.

Remember, solids from 4-6 months are considered ‘complements’ to milk, not a replacement. Breastmilk or formula will still be the most important part of their nutritional intake.

The introductory period is an opportunity for baby and parents to learn about:

• different smells, textures and flavours,
• develop coordination,
• as well as exposing them to important allergens.

As you work towards 12 months, it will slowly shift to food being the primary source of nutrition.

What are the global guidelines for starting solids?

Now, this is when it can get a bit complicated – and I empathise with parents who find this confusing or frustrating.

In my opinion, the global and national bodies need to update guidelines based on current literature and be more aligned in their advice to simplify this for parents and healthcare professionals.

A quick of the overview before we get started:

1. Breastfeeding offers many health benefits to both mother and child. The benefits are likely to be amplified by prolonging breastfeeding. However – the addition of formula and/or solids in a breastfed baby do NOT undo any of the physical or emotional benefits of breastfeeding, which means that strictly exclusive breastfeeding isn’t obligatory.
2. Interpreting studies on breastfeeding is often problematic because of so many confounding factors (Ip, Chung et al 2007) – meaning there are so many factors that can’t be properly controlled for. Breastfed babies don’t just differ on how they are fed, but in practically every other way you can imagine (Kiefer, 2015):
   • pre/postnatal health,
   • maternal nutrition,
   • maternal education,
   • maternal IQ,
   • maternal mental health,
   • socio-economic status,
   • access to healthcare,
   • quality of healthcare,
   • environmental safety,
   • race, culture and
   • availability of childcare.
3. There is never going to be a complete body of evidence on the subject of breastfeeding or exclusive breastfeeding as true randomised controlled studies (RTCs) – the gold standard in academia – that involve halting breastfeeding would be unethical – as a paediatrician, I’d never want this to happen.

The debate over how long to promote exclusive breastfeeding rages on.

Some promote exclusive breastfeeding for 4 months EB4.

Many promote exclusive breastfeeding 4-6 months EB4-6.

And some promote exclusive breastfeeding 6 months EB6.

The World Health Organisation (WHO) updated their original EB4-6 advice to encourage EB6 in 2002, based largely on a paper by a seminal paper and systematic review by a researcher named Michael Kramer (Kramer, Kakuma 2002).

…But the international response was highly varied.

Only 8 out of 22 European Union member states adopted the advice and while the American Academy of Paediatrics followed suit only in 2022, they supported EB6 loosely, using confusing wording – like ‘approximately 6 months’ and ‘if mutually desired by mother and infant’ which only serves to complicate the recommendation ​​(Meek & Noble 2022).

Australia’s National Health and Medical Research Council (NHMRC) adopted the WHO recommendations in 2003 but interestingly, in 2012, authors at The Australian Family Physician journal recommended to immediately soften recommendation language from EB6 to EB4-6 (Symon & Bamman 2012).

So how aligned are these recommendations with actual practice in the community?

For context, The Australian National Infant Feeding Survey (ANIFS 2010) showed that although 96% of babies were breastfed after birth, 15% of mothers were exclusively breastfeeding 5 months later. A more recent 2018 national survey estimated that 61% of children were exclusively breastfed to 4 months of age and 29% to 6 months of age (AIHW 2022).

In terms of papers showing benefits of EB6 over EB4-6, probably the cleanest study came out of a key 2001 paper from Belarus (Kramer, Chalmers et al 2001). Belarus was considered an ideal setting to be extrapolated for both developing and developed nations, as by the mid 1990’s there was access to clean water, health services and nutrition BUT the hospital environment was similar to a 1950’s setting and not actively promoting breastfeeding (it’s hard to comprehend this in our current hospital care). Kramer and his colleagues used an experimental intervention to increase the duration of exclusive breastfeeding and showed that it decreased the risk of gut infection and eczema in the first year of life.

These results are important, but need to be interpreted with care.

To illustrate this point, the UK Millennium Study (Quigley, Kelly & Sacker 2007) showed a gastroenteritis hospital admission rate reduction from 1.1% to 0.5% of babies, hardly significant figures. Of further interest is the fact that the risk of infections related more to the age of introducing formula, than the age of introducing solids.

In my opinion, current literature does not provide a convincing argument as to why exclusive breastfeeding is necessary to facilitate the many benefits of breastfeeding in developed nations.

Breastfeeding yes – exclusive breastfeeding? Not necessarily.

What do the global recommendations suggest?

1. The Australasian Society of Clinical Immunology and Allergy (ASCIA); Australia’s allergy governing body, recommends introducing complementary foods (including allergens) in the window of 4-6 months.
2. Australia’s Raising Children’s Network and The Australian Breastfeeding Society recommends around 6 months and not before 4 months.
3. The European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) in their position paper recommends – complementary foods should not be introduced before 4 months but should not be delayed beyond 6 months (Fewtrell, Bronsky, Campoy, Domellöf 2017)
4. The American Academy of Paediatrics – introduce solids at approximately 6 months not before 4 months
5. The National Health and Medical Research Council (NHMRC) most recent recommendations include the vague caveat that although exclusive breastfeeding to around 6 months of age is recommended, more evidence is needed to identify any subgroups that require earlier introduction of solid foods. Around 6 months should be regarded as a population recommendation.
6. The WHO initially advised 4-6 months but toughened their stance in 2002 due to Kramer’s systematic review. What’s frustrating for me is that Kramer’s advice was taken in parts, not holistically – with crucial parts not transplanted alongside the overarching advice. Kramer recommends EB6, ‘although, infants should still be managed individually so that insufficient growth or other adverse outcomes are not ignored and appropriate interventions are provided’ – though this does not appear on WHO guidelines.

Kramer’s results were largely based on the aforementioned Belarusian study, for context again, 43% of children were exclusively breastfed at 3 months; just 8% at 6 months.

Blanket rules have no place in paediatrics, or anywhere in healthcare for that matter.

One can’t have a single approach for all babies, for all families. In developing countries, the landscape demands a different approach.

EB6 is certainly advisable as an overall protective measure, in a country with:

• poor sanitation,
• limited postnatal breastfeeding care and education,
• poor breastfeeding infrastructure e.g. maternity leave
• contraception access challenges, where delayed menstruation is a relied-upon contraceptive measure
• little regulation around predatory formula marketing.

As a paediatrician, I look at the holistic picture.

A baby exists within concentric rings; mother, family, society.

With this approach, there are 4 things to consider when initiating solids:

1. Allergies (aim to reduce long-term risk),
2. Biome (gut health, maturity) and
3. Behaviour (including sleep).
4. A breastfeeding mother’s wellbeing

1.0 Allergies are on the rise

The allergy factor in this debate of when it comes to starting solids early is compelling.

Allergy incidence has been climbing over the last couple of decades (Harrison, Giovannini et al. 2020) with Australia unfortunately leading the charge.

The reasons for this are not well understood.

Allergies are multifactorial conditions, which means there are many reasons why and how sensitivities come about.

Research exists linking allergies and food sensitivities increasing and decreasing to a variety of factors including but not limited to: age of introduction, family history, environment, ethnicity (particularly parents of Asian heritage), pets, siblings, wheeze, asthma and eczema (Koplin, Dharmage et al 2012; Peters, Allen et al 2015).

The rising incidence of food allergies in developed countries, has a significant public health impact; 1 in 10 Australian infants have some form of food allergy.

Serious allergy (anaphylaxis) can greatly hinder the quality of life for both children and parents and put enormous strain on education and health systems.

There’s no reliable cure currently. The best we can do is avoid triggers (not an easy task, just ask any parent of an anaphylactic child) and arm ourselves with costly and in recent times hard to acquire adrenaline auto-injectors (EpiPen, AnaPen) (Shaker & Greenhawt 2019) – although there is a glimmer of hope with emerging immunotherapy treatment (Mori, Giovannini et al. 2021) but it’s by no means standardised treatment right now.

Some EB4-6 proponents draw attention to the correlation between the rise of allergies timing with the WHO changing guidelines from EB4-6 to EB6. I think this is alarmist and draws a long bow. As we know well, most families do not follow these guidelines and introduce solids well before 6 months. Indeed after the Australian allergy testing recommendations were updated in 2016 there was a 3 fold increase in the early introduction of peanuts (Soriano, Peters et al 2019).

And while there’s much we have to learn about allergies – the current science leaves no debate about one thing: introducing allergens early reduces the long-term risk of food allergy and coeliac disease (Du Toit, Katz, Sasieni, et al 2008; Du Toit, Roberts et al. 2015; Prescott, Smith, Tang, et al. 2008; Martino, Prescott 2010; Koplin, Osborne, Wake 2010; Norris, Barriga, Hoffenberg et al. 2005; Poole, Barriga, Leung et al. 2006), and has decreased or plateaued the rate at which they were previously rising in developed countries (Soriano, Peters et al. 2022). The latest evidence is pointing strongly to the introduction window of 4-6 months (Halken, Muraro A et al. 2022; Skjerven, Lie, Vettukattil 2022).

The time of introduction is definitely a risk factor when it comes to paediatric allergies, and like management of eczema, should be addressed as it is something we can do to minimise the rate of allergic reaction.

I’m a big advocate for the 4-6 month window for introducing allergens, as you can:

• test/trial without the stress of a countdown clock
• you’re less worried about volume intake more broadly (you’re just playing & having fun) and
• generally this is a time when many babies will still be at home with a primary carer which can make day testing/observing all the more easy.

The 4-6 month window is the time frame used in many of the large randomised control trials (RCTs) so that’s where the evidence points to, but it’s important NOT to stress if you haven’t tested all your allergens by 6 months, there’s a great deal of evidence pointing to significant decrease in allergies any time prior to 12 months.

And if you’re starting nice and early there’s no need to worry, any time after 4 months is fine – a systematic review of relevant studies provided to the European Commission by the European Food Safety Authority reported no evidence of benefit in withholding complementary foods beyond 4 months (Fewtrell, Bronsky, Campoy, Domellöf 2017). The European Academy of Allergy and Clinical Immunology (EAACI) recommends introducing egg & peanut specifically in the first 4-6 months of life (Halken, Muraro A et al. 2022), and the The Australasian Society of Clinical Immunology and Allergy (ASCIA); Australia’s allergy governing body, recommends introducing complementary foods (including allergens) in the window of 4-6 months.

So when it comes to allergens, I recommend ideally testing them between 4-6 months with the aim to get them all in by 12 months – always responding to your child’s signs of readiness.

For more information on this see my blog – Starting solids and Testing Allergens.

Another great resource is the NIP Allergies in the BUB website – PreventAllergies.org.au.

2.0 What about gut health, maturity and the microbiome?

I sat down with Dr Rebecca Winderman (Paediatric gastroenterologist and director of Paediatric Gastroenterology at Jamaica & Flushing Hospitals in Queens, NY). Rebecca utilises an holistic, integrative approach to general and gut health – when she realised many young people were seeking advice on TikTok, she decided to be present – she’s known affectionately as the dancing poop doc @kidsgastrodoc – you can listen to our full 45 minute conversation here.

I also met with Dr Barry Lischitz, consultant in paediatric gastroenterology and nutrition, whose experience extends from South Africa, to New York City and Australia (no wonder when he’s not working, he’s running ultra-marathons!).

Their thoughts were clear and unequivocal.

There is no evidence that introducing solids between 4-6 months causes any gut damage; leaky/open gut is an exaggerated notion (unless it’s in the context of severe gastrointestinal disease).

There is a great deal of rhetoric and hyperbole regarding the introduction of solids, citing gut immaturity and long-term biome risk. Big words, but very little science behind them.

That’s not to say that gut health and a healthy microbiome aren’t incredibly important and something we shouldn’t focus on. Over the last 2 decades, abnormalities in gut biome have been linked to just about every possible health outcome.

Gut biome is said to be responsible for both the production of health and the destruction of health.

BUT what is gut biome?

Gut biome is a community of organisms, for simplicity we say a community of bacteria.

There are:

1. Bad Bacteria: Some gut bacteria are associated with disease
2. Good Bacteria: which are actually extremely important for your immune system, heart , weight (Fu, Bonder et al 2015), mental health (Clapp, Aurora et al 2017) and many other aspects of health.

Our job is to feed the good bacteria and starve out the bad bacteria. The food you eat affects the diversity of your gut bacteria.

Dr Winderman talked at length that the first 3 years are critical for establishing a healthy gut and healthy eating patterns. Parents should not get obsessed with the day they start solids or the first sip of formula milk, but instead need to have a focus on overall eating. She’s also a huge advocate for any breastfeeding until the age of 2 (but understands this isn’t possible for many families).

Separate to starting solids (but still really interesting) she’s not big on adding probiotics, but rather prefers foods naturally rich in probiotics i.e. yoghurt.

What do we feed our babies to promote a healthy gut/gut biome?

Dr Winderman is very relaxed about WHAT we feed babies – her big thing is ensuring babies and kids eat the rainbow – with plenty of plant based fibre sources. The latest research agrees with this too. Dietary diversity and high fibre intake seems to have the greatest impact on the gut microbiome as solids are introduced (Homann, Rossel et al 2021).

…And if you can leave food on the bench for a couple of days and it doesn’t spoil …it probably means it’s not got enough natural biome to keep little (or big) guts healthy.

Of-course, one wouldn’t suggest offering a 5-month-old baby highly complex foods; you won’t find a paediatric nutritionist/dietician or paediatrician who recommends this practice. Simple foods, unflavoured, unsalted.

The one gastro-connected finding in research was mentioned earlier: that the risk of gastroenteritis requiring hospital admission is reduced in exclusively breastfed babies. Recall, this drop in incidence went from 1.1% to 0.5% in the UK Millennium Study. Also, the risk of infection relates more to starting formula, than starting solids (Quigley, Kelly, Sacker, 2009).

One of the many benefits of breastmilk from the breast is it’s completely sterile. As soon as breastmilk is expressed, formula, solids or sips of water are offered – sterilisation and hygiene have to be a priority.

Changes to a babies poo:
One common question I get a lot relates to constipation and the changes in a baby’s stool after starting solids.

It should come as no surprise that stools change with the introduction of solids, just as anybody’s stools would change – at any age – when their diet changes; think travelling abroad.

While it’s wise to avoid foods that tend to constipate, it’s not the gut biome that isn’t coping, it’s the large bowel that hasn’t learned to move through harder stools, not to mention possible low water intake. The solution here is to remove offending foods and use softening ingredients, not to delay solids entirely.

3.0 Starting solids and sleep

There’s a lot of conflicting advice from government and regulatory bodies when it comes to starting solids and the link to sleep.

In my paternal and clinical experience, I know that a hungry baby will wake more frequently for food, disrupting sleep.

It’s a commonly held belief among parents that introducing solids (when a baby is showing signs of developmental readiness) will help babies sleep better. Thankfully, there are a number of studies that have confirmed this (Perkin, Bahnson, Logan et al. 2018; Clayton, Li, Perrine, Scanlon 2013; Alder, Williams, Anderson, Forsyth, Florey Cdu 2004; Scott, Binns, Graham, Oddy 2009).

There remains much conflicting advice from professionals, pundits and healthcare services when it comes to the link between calories and sleep. Some even say that introducing solids prior to 6 months will impact sleep negatively. Cue the fear-mongering.

Many reference the Davis Area Research on Lactation, Infant Nutrition, and Growth study, (DARLING Study, Heinig, Nommsen, Peerson et. al. 1993), but given this was a small, non-randomized study of 105 babies nearly 3 decades ago, I’m inclined to search for more evidence of what appears so evident in clinical practice.

Brown & Harries (2015) found that increased calories throughout the day led to less night feedings. Not to half-report the findings, they found fewer night feeds but not night wakings – this is more habitual and a different issue, there’s plenty of tips in my other content on how to deal with this.

The most recent, decent study I found (Perkin, Bahnson, Logan et al. 2018) concluded: ‘In a randomised clinical trial, the early introduction of solids into the infant’s diet was associated with longer sleep duration, less frequent waking at night, and a reduction in reported very serious sleep problems.’

If you’ve come across more recent and/or compelling research on any of the above, please forward it to me at [email protected] – I am eager to broaden my knowledge; this topic needs all players to listen to all points of view, and I will always listen to yours.

4.0 The topic not getting enough attention – a mother’s well-being

What stood out from the 2018 Perkins paper, was the language used in the findings:

• ‘most clinically important, very serious sleep problems, which were significantly associated with maternal quality of life.’

The breastfeeding mother was the one impacted the most significantly by the reported serious sleep problems by the group not receiving solids.

In my practice I see so many women breaking in half trying to meet the ideals of the ‘perfect mother’ – and for some women, exclusive breastfeeding for myriad reasons, just isn’t possible for 6 months to meet the caloric requirements of their baby.

Symon & Bamman (2012) wrote a seminal paper published in the Australian Family Physician that’s as true now as it was a decade ago – entitled ‘Feeding in the first year of life: Emerging benefits of introducing complementary solids from 4 months.’

There are 2 key paragraphs that resonate with me, as a father, husband and practising physician. Verbatim:

• “Advice to EBF6 commonly contains the statement that the supply of breast milk will respond to the demand and that ‘virtually all mothers’ are able to exclusively breastfeed successfully given appropriate support. Caring for women with newborn babies on a daily basis, it is clear to me that, for many women, their milk supply on some days may not meet the total nutritional needs of their child. Many women genuinely try to breastfeed exclusively without success and often feel disappointed and distressed at their failure.In primary care, the lead author finds that the large majority of women seen for antenatal or postnatal care are aware of the recommendation to EBF6. The promotion of EBF6 as a policy may risk the useful partial breastfeeding of those women, who – for biological or psychosocial reasons – are unable to provide a larger volume of milk. The benefits of breastfeeding can often be maintained by the addition of complementary feeding that provides the necessary calorie intake for the child.”

This is everything I see everyday succinctly phrased – allowing women the option of mixed feeding and complementary feeding, allows breastfeeding to be maintained for longer – which, when desired and possible, is absolutely what we want!

If you’ve introduced solids before 6 months, you are not alone

Results from the 2010 Australian National Infant Feeding Survey (the latest research) show that 96% of mothers in Australia start breastfeeding – it’s some of the highest rates in the developed world and we should be incredibly proud of this.

However, other Australian studies have found that 50% of mothers have introduced solids by 4 months of age, and 90% of mothers feed solids before 6 months (Scott, Binns, Graham, Oddy 2009). EB6 proponents should take note.

In my experience the pressure to ‘exclusively breastfeed’ to a specific day, with no caveats, places wanton pressure on families (mothers in particular).

Further to this fact, introducing solids can absolutely be achieved while maintaining breastfeeding. In my experience, I find mothers actually continue breastfeeding longer, when solids are introduced in this window.

If we focus on the health of the baby and mother and ensure public and workplace policies follow suit, the number of families breastfeeding at some level to 12 months would sky rocket.