Dr. Greenes's Feeding Advice for Infants

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Should I give breast milk or formula to my baby?

You must feed your baby! This is very important. Whether you give breastmilk, formula, or both to your baby, however, is not nearly so important. Both breastfed and formula-fed babies grow up to be healthy children and adults.

Professional organizations of health experts, such as the American Academy of Pediatrics (AAP) and the World Health Organization, recommend breast milk as the preferred form of feeding for infants. The AAP recommends that babies be breastfed until they are at least 12 months old.

If breastfeeding is working well for mother and baby, it is appropriate to continue breastfeeding throughout infancy. However, if it is not working well, or if the mother finds it difficult or unpleasant to breastfeed, formula is a fine option.

In my opinion, it is very important that you enjoy your infant and be good to yourself during your child's infancy, both for your own well-being and so that you can be your best as a parent. In some cases, breastfeeding starts off difficult but gets easier after the first several days. So, we often encourage new mothers to be patient and keep trying for the first couple of weeks. But if the situation does not improve, you should not breastfeed if it is making you miserable! I am happy to talk with you more if you have questions about this choice.

When should I begin solid (complementary) foods for my baby?

The American Academy of Pediatrics (AAP) recommends that breastfed babies be fed breastmilk exclusively until 6 months of age. There is evidence that if babies start solid foods earlier, they are more likely to wean off breastmilk earlier.

There is some concern that starting solid foods before 4 months of age may lead to an increase in the risk of certain problems later in life, such as diabetes, food allergies, and celiac disease. While there is still uncertainty about this, it seems reasonable not to start solids before 4 months.

It is also probably best not to wait much beyond 6 months of age to start solids. Part of the goal of infant feeding is to enable babies to learn to accept the taste and texture of solid foods. If babies delay this process until very late in infancy, they may miss the usual "developmental window" and perhaps be more likely to develop aversions to solid foods or other feeding difficulties.

In general, it is best to delay solid foods until your baby can sit upright (with support), so as to minimize the risk of choking (it's hard to eat and swallow lying down!). Also, some young babies have a tongue-thrust reflex that interferes with eating. If your baby sticks her tongue out every time you bring a spoon to her mouth, you may need to wait a few weeks and try again later.

What foods should I give first?

The most important issue is texture. You want to be careful to prevent choking!

You should start with very thin purees that don't require any chewing and that are unlikely to lead to gagging. Most families use "Stage 1" baby foods such as pureed vegetables and fruits. Powdered infant cereals, mixed with water, breastmilk, or formula, are another popular choice.

Once your baby has mastered the art of eating these foods with a spoon and has proven her ability to swallow these foods without gagging, you can consider advancing to chunkier "Stage 2" baby foods. Often, these Stage 2 foods include meats and grain products.

If your baby does really well with these chunkier baby foods as well, she might then be ready for tiny pieces of table food. Usually babies are at least 8 or 9 months old before they get to this stage. You should be very careful about choking, beginning with foods that "melt in the mouth" or with tiny shreds of food that don't require chewing.

Aside from issues of texture, the order in which you introduce foods probably does not really matter. Traditionally, pediatricians have recommended cereals, then vegetables, then fruits. (The theory was that you should delay sweeter foods till last, so that you don't "spoil" the baby early on.)

But some experts recommend we give infants meats early on, because they are more nutritious than cereals. Really, whatever order you choose is OK. As you plan your baby's meals, it is reasonable to aim for a balance of the various food groups, in the same way you would for an older child or adult. (That is, give some fruits, some vegetables, some grains, some meat, some milk.)

You can engineer your child's diet a little. If your child is a big milk drinker, hold off on the milk and give solid foods first at mealtime. On the other hand, if your child loves to eat solids and is losing interest in milk, you can offer milk first, before offering a meal.

How much food should I give?

This is a hard question to answer, because babies vary quite a bit in how quickly they learn to accept solid foods and in how much they like to eat. Also, it can be hard to quantify how much your baby is eating, since so much of the food will end up on her face or on the floor (or in her hair, or on your shirt, etc.!).

In general, it makes sense to start with a small quantity (perhaps a couple of teaspoonfuls) and to see how it goes. If your baby finishes everything on her plate, you can offer more. Aim for variety, giving some of one food and some of another, so that your baby learns to accept different tastes and textures.

If you want to estimate calories, it may be helpful to know that infants typically take about 45 calories per pound per day. So, a 20 lb. baby would be expected to take about 900 calories a day. Breast milk and formula each contain 20 calories per ounce. So, if your baby takes 30 ounces of milk per day, she is getting 600 calories from her milk intake.

To minimize your time, effort, and expense, you will probably want to start with just one meal a day. Once your baby gets good at eating, you can move on to adding a second and then a third meal. It is reasonable to move towards the same type of meal schedule that you or your older children follow.

You will probably find that your child's milk intake decreases as her solid food intake increases. This is natural and expected. Often, bottle-fed babies are taking about 32-36 ounces of milk per day at 6 months of age, before they start solids. These same babies may be taking only about 16-24 ounces of milk by 12 months of age.

Are there foods I should avoid for my infant?

Yes. We recommend avoiding foods that contain potential toxins. Infants younger than 1 year of age should not eat honey, because honey can contain botulinum spores, which cause botulism.

Also, parents should be careful about fish that contain mercury, such as swordfish or tuna. In general, it is probably best to avoid these types of fish for infants, or at least, not to give them more often than once a week or so.

Cow's milk is not dangerous in small quantities. Milk products like yogurt and cheese are fine for infants older than 6 months of age. Even an occasional bottle of cow's milk would be OK.

However, I do recommend that your baby be given either breast milk or formula as his main drink until 12 months of age. Cow's milk does not contain iron, and in fact, exposure to cow's milk protein can lead to blood and iron loss in the gastrointestinal tract. So, babies who are fed exclusively cow's milk can become severely iron deficient. Even though formula contains cow's milk, it is fortified with iron, which effectively prevents the development of iron deficiency.

Some parents seem to take pride in avoiding exposure to formula during their baby's infancy. They sometimes ask if they can wean from breastmilk directly to cow's milk in later infancy (for instance, at 10 months of age). While this may be acceptable for some babies, I see no advantage in taking this approach. I think formula is a safer option than cow's milk for babies until they are 12 months old.

What about allergen exposure?

It is probably best to give allergenic foods early, as early exposure seems to reduce the risk of the child developing food allergy. For this reason, the American Academy of Pediatrics recommends that potentially allergenic foods such as peanuts and egg be introduced between 4 and 11 months of age.

In the past pediatricians thought that it was best to delay introduction of foods that contain potential allergens. The thought was that infants who were exposed to these foods early in infancy might be more likely to develop food allergy.

As more scientific evidence has accumulated, however, it appears that the reverse is true. Babies who are exposed to allergens in infancy actually are less likely to develop food allergy! This makes sense, because in general, we understand that people can be desensitized to allergens through frequent small exposures to the allergens.