1. Introduction of Solids Joanne Kurtz, RD January 2016

2. Outline Age of introduction Updated Health Canada guidelines Prevention of allergies Nutrition tips

3. Case #1 Mother and father of 3 month old, breastfed baby boy report that he seems hungrier lately. Grandmother suggested adding rice cereal to bottle. They are wondering about introducing solids. What do you say??

4. If you start before 4 months: Baby may not be able to swallow from a spoon Baby may drink less breast milk, or even stop drinking it Results in less intake of protein, fat and other key nutrients Studies have shown increased risk of eczema at age 10, celiac disease, type 1 diabetes, wheezing in childhood, increased body weight in childhood (mostly observational) If you start after 6 months: Baby may not get all the vitamins and minerals required Increased risk of iron deficiency Baby may be slower at accepting and trying new foods and textures Baby may have difficulty chewing foods

5. 4 OR 6 MONTHS?? When…

6. Timing of introduction Cochrane Review (2012) 23 studies (mostly observational, 2 trials, half developing countries) No apparent risks in recommending EBF for 6 mths in both developing and developed countries 3 RCTs (2 Honduras, 1 Iceland) Starting solids 4 vs 6 months All had similar results Growth  no difference ( up to 3 yrs old) Energy intake  no difference (less breastfeeding, more solids) Nutrient Status  higher hemoglobin, hct, ferritin at 6 mths in 4 month group in all studies, but ferritin was adequate in both groups and # of babies with ID or IDA did not differ

7. Timing of introduction Risk of celiac disease (2 RCTs- 2014) 1.No difference between introduction of gluten at 4 mths vs 6 mths in high risk infants (5% developed celiac disease by age 3) 2.Delaying intro of gluten (6 mths vs 12 mths) delayed celiac disease but did not prevent it in high risk infants (by age 5, 16% had developed celiac disease in both groups ) Type 1 diabetes and intro of gluten No difference in rates of islet auto-immunity by age 3 with 6 mth or 12 mth intro of gluten

8. Timing of Introduction Allergies Reduced risk of allergies with earlier introduction (4-6 mths vs 10-12 mths or >12 mths) with egg allergies in low risk and high risk infants (cross sectional study, parental reporting, 2010). Similar results with wheat (observational, 2006). Early introduction (before 11 mths of age) and continued exposure is a safe and reliable way to prevent peanut allergy in “high risk” children in countries where peanut allergies are prevalent (RCT, 2014)

9. Timing of Introduction Intro at 6 months Benefits to the mother Convenience Cost? Delayed further may delay celiac disease Intro between 4-6 months May decrease risk of allergies No difference in: Growth Risk of ID or IDA Intake of energy Risk of type 1 diabetes

10. Readiness vs Age Signs that your baby is ready for solid food: Sitting up in a high chair and holding head up Showing interest in food Following food with his eyes Opening his mouth wide when he sees food coming Keeps food in his mouth and swallows it instead of pushing it out Consider corrected age Babies do not require teeth to start eating solids

11. Case #2 Amy has heard a lot about Baby-led Weaning in her mom’s group. She has a 5 month old girl. She asks your opinion on the Baby-led weaning approach. What is it and what do you respond?

12. Baby-Led Weaning Self-feeding with hand-held foods rather than being spoon-fed by parents, family meals Benefits: Fun for baby, energy self-regulation Reported improved eating habits, less stressful for parents (cross sectional, case control) Drawbacks: Hard to get enough iron rich foods Baby would not consume enough calories and nutrients Choking risk

13. Texture of Meats & Alternatives Lumpy, soft, tender cooked food Pureed not necessary Slowly, increase texture

14. +

15. Case # 3 Mother of a breastfed 10 month old began solids around 7 months. Baby has had most fruit and vegetables, Cheerios and Mum-Mums rice rusks. What nutrient would you most be concerned about?

16. Iron-Rich Foods

17. Iron-Fortified Infant Cereals

18. Case #4 A father and his 7 month old infant are in your office. Baby has severe eczema, older brother has an egg allergy. He is planning on avoiding eggs and peanuts until child is 3 years. Do you support him or suggest an alternate plan?

19. Food Allergies No need to wait

20. Toit, GD et al. Randomized Trial of Peanut consumption in infants at risk for peanut allergy. New England Journal of Medicine. February 2015 Early introduction (before 11 mths of age) and continued exposure is a safe and reliable way to prevent peanut allergy in “high risk” children in countries where peanut allergies are prevalent

21. 640 participants Criteria: 1.4-11 mths old (mean 7.8 mths) 2.Severe eczema or egg allergy (or both) Excluded: SPT>4mm Mild eczema SPT Negative (no wheal) SPT Positive (wheal 1-4mm) Skin Prick Testing (SPT) Consume Avoid (50) Avoid (243) Food Challenge 1 dose of 2 g peanut protein Food Challenge Incremental dose up to 3.9g peanut protein + +-- Avoid (1) Intent to treat Avoid (6) Intent to treat Consume (255) 6g peanut prot/wk Until 60 mths Consume (41) 6g peanut prot/wk Until 60 mths

22. SPT Negative (no wheal) SPT Positive (wheal 1-4mm) Consume Avoid 13.7% 1.9% Results 86% relative risk reduction 35.5% 10.6% Peanut allergy 70% relative risk reduction

23. Points to consider Excellent retention rate (98%) and adherence FFQ (7.7g peanut vs 0g) and peanut protein dust samples collected at 60mths Similar levels of prevention in white, black, Indian and Pakistani children Peanut allergy can still develop (6 kids) Did not address kids with no risk factors or strong likelihood of established peanut allergy Support for dual allergen hypothesis

24. OTHER NUTRITION CONSIDERATIONS Tips!

25. Honey Do not give honey until 12 months Risk of botulism - bacteria Water Offer water in a cup

26. Choking Ris ks Avoid small and round shaped foods Hot dogs, whole grapes and whole baby carrots Avoid whole peanuts and popcorn until 4 years old Avoid hard and sticky foods Spread nut butters thinly onto crackers/toast Avoid dry and stringy meat and poultry Always supervise babies and children while they are eating

27. Other Foods Babies and children don’t need juice No treats needed No special foods needed

28. Healthy Habits for Life Division of Responsibility YOU are responsible for WHAT, WHERE & WHEN your baby eats. YOUR BABY/CHILD is responsible for IF & HOW MUCH he/she eats. [Ellyn Satter]

29. More information Books Better Baby Food by Joanne Saab, RD & Daina Kalnins, MSc, RD It’s Not about the Broccoli by Dina Rose, PhD Books by Ellyn Satter Online Ottawa Public Health West Durham Family Health Team website  Videos on Feeding your Toddler Nutrition from Stork to Fork by Sarah Remmer, RD It’s not about Nutrition by Dina Rose, PhD Kristen Yarker Blog The Ellyn Satter Institute Website Science of Mom website

30. References Health Canada – Nutrition for Healthy Term Infants: Recommendations from 6-24 Months (2014) City of Ottawa -Public Health; Breastfeeding Basics (2009) Nutrition Resource Centre(NRC) -Best Start; Feeding your Baby From Six Months To One Year (2015) Cameron SL et al. (2012). How feasible is baby0led weaning as an approach to infant feeding? A review of the evidence. Nutrients, 4: 1575. Hummel, S et al. (2011). Primary Dietary intervention study to reduce the risk of islet autoimmunity in children at increased risk for type 1 diabetes. Diabetes Care, 34: 1301. Koplin, JJ et al. (2010). Can early introduction of egg prevent allergy in infants? A population based study. J Allergy Clin Immunol.126(4):807-13 Kramer, MS & Kakuma R. (2012). Optimal duration of exclusive breastfeeding: A Cochrane Review.

31. Lionetti, E et al. (2014). Introduction of gluten, HLA status, and the risk of celiac disease in children. New Engl J Med, 371: 14. Poole, JA et al. (2006). Timing of initial exposure to cereal grains and the risk of wheat allergy. Pediatrics, 117 (6). Norris, JM et al. (2003). Timing of Initial Cereal Exposure in Infancy and Risk of Islet Autoimmunity. JAMA, 290 (13). Toit, GD et al. (2015). Randomized Trial of Peanut consumption in infants at risk for peanut allergy,. New England Journal of Medicine. Vriezinga, SL et al. (2014). Randomized feeding intervention in infants at high risk for celiac disease. N Engl J Med, 371:1304-15. Wells, JCK et al. (2012). Randomized controlled trial of 4 compared with 6 mo of exclusive breastfeeding in Iceland: differences in breast-milk intake by stable- isotope probe. Am J Clin Nutr, 96: 73-79.

32. Thank You! Questions?