Letters from Maine

Not so fast


Last week I found a story in the New York Times about a recent study by Centers for Disease Control and Prevention epidemiologists on the introduction of solid food to infants. Although the study was widely reported by other media outlets, it took me more than a week to discover the original journal article ("Prevalence and reasons for introducing infants early to solid food: Variations by milk feeding type [Pediatrics 2013;131:e1108]). The authors reported that 40% of the 1,334 mothers surveyed fed their babies solid food before 4 months of age, and 9% started as early as 4 weeks.

The mothers who introduced solids prior to 4 months were more likely to be young, less educated, and unmarried. The reasons that mothers gave were that they felt their baby was old enough, or seemed hungry, or they felt their infant would sleep longer if given solids. More than 50% of the mothers who introduced solids early replied affirmatively to the statement, "A doctor or health professional said my baby should begin eating solid food."

Like most surveys of this type, the results should come as no surprise to primary care pediatricians who see families from a broad mix of socioeconomic backgrounds. I also suspect that the investigators would have reported similar results had the study been performed 20 years ago. I think it’s risky to interpret their current results from such a small sample. What troubles me more is that some of the media reports I read as I hunted for the original article suggested that physicians and other health care providers aren’t doing a good job of educating and supporting young mothers. I suspect that there are few health care providers who have somehow navigated their training without hearing the good word about the introduction of solids. But the rest of us have gotten the message and are doing our best to see that our patients benefit from it. I wonder what the result would have been had the question been presented as two separate statements, one worded "should ..." and the other "was okay to start solids."

It is interesting that the mothers who were feeding only formula were more likely to report that a health care provider told them to start solids early than those who were solely breastfeeding (61.4% vs. 50.8%). This might suggest that the early introducers weren’t listening to the professional advice from the beginning.

Of course we could always do a better job, but I suspect the authors, who are epidemiologists, may be underestimating the strength of the current that primary care pediatricians are swimming against. They reported that just under 20% of the early introducers responded that relatives or friends told them that their babies should be eating solids. They did acknowledge that economics and lack of education are major contributors to the problem. But I think they are underestimating the strength of the grandmother factor. Even in stable, economically secure, two-parent families, grandparents, aunts, and uncles often provide unsolicited advice on feeding the newest buds on the family tree. But when a mother is unmarried and poor, it is very likely that a grandmother has significant influence over the food choices. It is difficult to contradict a grandmother’s advice, and even more difficult if she doesn’t attend the office visits.

For the better-educated mother who is nursing her baby, a dwindling milk supply that often comes with the return to work creates other pressures to add solids that must be considered. Given the choice between the expensive expletive (the f-word) and a few solids, the latter may seem to be (and arguably could be) the better choice. If I see a baby at his 4-month visit who had been offered a couple of spoonfuls of cereal the week before, am I going to climb on my soapbox? No, I am going to urge the family to take it slow and move on to other issues that are troubling them.

One of the best ways to avoid the whole situation is to make it very clear during the first few weeks of life that we feed our babies so they will grow, not so they will sleep better. By separating sleeping from eating, children are less likely to be overfed and their parents, sleep deprived.

Six months has always seemed to me to be an unreasonable target for us to set as a universal target for the introduction of solids. Common sense and individualization result in a better outcome. The recent evidence about late introduction of solids and the increased risk of allergy and celiac disease should make us all think more broadly as we craft our advice.

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