Starting solid foods earlier than six months

Why start solids earlier than six months?

No major health group recommends starting solid foods before four months. Babies aren’t ready for solid foods at that stage, and starting solid foods that early may increase the risk of obesity and food allergies. Babies between four and six months with a high risk of peanut allergies may benefit from being given peanut-containing foods. On the other hand, starting solids at four months instead of waiting to six months can decrease the amount of breast milk a baby takes in and increase the risk of various health problems.  

A) Avoid starting solid foods before four months

No major pediatric or health group recommends starting solid foods before four months of age, because babies at that stage are not developmentally ready to eat them.

Putting cereal in the baby’s bottle will introduce solid foods early and is not recommended. 

Giving babies solid foods earlier than four months may increase the risk of the following:

  • Obesity (English 2019; Fewtrell 2017; Wood 2020)
  • Food allergies (Fewtrell 2017; Muraro 2014; Thorisdottir 2019)
  • Cow’s milk protein allergy (Zhang 2020)
  • Earlier weaning (Scott 2019)
  • Less healthy eating habits (EFSA 2019)

B) Reasons for starting solid foods between four and six months

Even if solid foods are started before six months, breastfeeding will still be the main source of a baby’s nutrition for most of the first year of life (Fewtrell 2017).

The number of children with food allergies has been increasing.There is some evidence that babies at high risk of peanut allergy may benefit from their introduction between the ages of four and six months. The recommendations on this vary as does the definition of high risk.

C) Evidence against starting solid foods before six months

In high-income countries, babies who are breastfed by healthy mothers exclusively to six months appear to grow just as well as babies who are given solid foods at four months (Fewtrell 2017; Kramer 2012; Wells 2012).

In low-income countries starting solid foods early may result in malnutrition. Studies of babies in Ethiopia and Bangladesh found that early solids resulted in more than a doubling in the number of underfed babies (Khan 2017; Nigatu 2019). Early solid foods appear to decrease the amount of breast milk that a baby takes in (Wells 2012).

Starting solid foods at four months instead of six may increase the baby’s risk of (Fewtrell 2017; Rippey 2020):

  • Infections:
    • Stomach infection and diarrhea (Richard 2018; Kramer 2003; Nigatu 2019).
    • Infection by parasites present in contaminated solid foods (Palmieri 2018).
    • Colds and ear infection.
    • Pneumonia (Richard 2018).
  • Fever (Nigatu 2019).
  • Cough, wheezing, and asthma (Lossius 2018).
  • Hard stools.
  • Having more feeding difficulties when older (Hollis 2016).
  • Being prescribed medication.
  • Obesity (Araújo 2019; Mannan 2018; Sirkka 2018).

One study (Gupta 2017) showed starting premature babies on solid foods before six months of corrected age increased the risk of hospitalization.

Mothers who start solids before six months may have their periods (menses) start earlier and thereby lose the contraceptive benefit of breastfeeding. They may also lose less weight.

Some authorities have concluded that there is not enough evidence to support routinely giving eggs or peanut products before six months to prevent allergies (SACN 2017; SACN 2018).

References

Araújo CS, Costa PRF, Queiroz VAO, et al. Age of introduction of complementary feeding and overweight in adolescence and adulthood: A systematic review. Matern Child Nutr. 2019 Feb 15:e12796

English LK, Obbagy JE, Wong YP, et al. Timing of introduction of complementary foods and beverages and growth, size, and body composition: a systematic review. Am J Clin Nutr. 2019 Mar 1;109(Suppl_7):935S-955S
 
European Food Safely Authority (EFSA) Panel on Nutrition, Novel Foods and Food Allergens. Scientific Opinion on the appropriate age range for introduction of complementary feeding into an infant's diet. EFSA Journal 2019;17(9):5780, 241
 
Fewtrell M, Bronsky J, Campoy C, et al. Complementary Feeding: A Position Paper by the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) Committee on Nutrition. J Pediatr Gastroenterol Nutr. 2017 Jan;64(1):119-132  

Gupta S, Agarwal R, Aggarwal KC, et al.; Investigators of the CF trial. Complementary feeding at 4 versus 6 months of age for preterm infants born at less than 34 weeks of gestation: a randomised, open-label, multicentre trial. Lancet Glob Health. 2017 May;5(5):e501-e511
 
Hollis JL, Crozier SR, Inskip HM, et al.; Southampton Women’s Survey Study Group. Age at introduction of solid foods and feeding difficulties in childhood: findings from the Southampton Women's Survey. Br J Nutr. 2016 Aug;116(4):743-50
 
Khan MN, Islam MM. Effect of exclusive breastfeeding on selected adverse health and nutritional outcomes: a nationally representative study. BMC Public Health. 2017 Nov 21;17(1):889
 
Kramer MS, Guo T, Platt RW, et al. Infant growth and health outcomes associated with 3 compared with 6 mo of exclusive breastfeeding. Am J Clin Nutr. 2003 Aug;78(2):291-5.
 
Kramer MS, Kakuma R. Optimal duration of exclusive breastfeeding. Cochrane Database Syst Rev. 2012 Aug 15;(8):CD003517

Lessa A, Garcia AL, Emmett P, et al. Does early introduction of solid feeding lead to early cessation of breastfeeding? Matern Child Nutr. 2020 Jan 29:e12944

Lossius AK, Magnus MC, Lunde J, et al. Prospective Cohort Study of Breastfeeding and the Risk of Childhood Asthma. J Pediatr. 2018 Jan 31. pii: S0022-3476(17)31621-9
 
Mannan H. Early Infant Feeding of Formula or Solid Foods and Risk of Childhood Overweight or Obesity in a Socioeconomically Disadvantaged Region of Australia: A Longitudinal Cohort Analysis. Int J Environ Res Public Health. 2018 Aug 7;15(8). pii: E1685
 
Muraro A, Halken S, Arshad SH, et al.; EAACI Food Allergy and Anaphylaxis Guidelines Group. EAACI food allergy and anaphylaxis guidelines. Primary prevention of food allergy. Allergy. 2014 May;69(5):590-601
 
Nigatu D, Azage M, Motbainor A. Effect of exclusive breastfeeding cessation time on childhood morbidity and adverse nutritional outcomes in Ethiopia: Analysis of the demographic and health surveys. PLoS One. 2019 Oct 2;14(10):e0223379
 
Noble LM, Okogbule-Wonodi AC, Young MA. ABM Clinical Protocol #12: Transitioning the Breastfeeding Preterm Infant from the Neonatal Intensive Care Unit to Home, Revised 2018. Breastfeed Med. 2018 May;13(4):230-236
 
Palmieri JR, Meacham SL, Warehime J, et al. Relationships between the weaning period and the introduction of complementary foods in the transmission of gastrointestinal parasitic infections in children in Honduras. Res Rep Trop Med. 2018 Jul 26;9:113-122
 
Richard SA, McCormick BJJ, Seidman JC, et al. Relationships among Common Illness Symptoms and the Protective Effect of Breastfeeding in Early Childhood in MAL-ED: An Eight-Country Cohort Study. Am J Trop Med Hyg. 2018 Jan 29

Rippey PLF, Aravena F, Nyonator JP. Health Impacts of Early Complementary Food Introduction Between Formula-fed and Breastfed Infants. J Pediatr Gastroenterol Nutr. 2020;70(3):375‐380
 
Scientific Advisory Committee on Nutrition (SACN). Feeding in the first year of life. London; 2018
 
Scientific Advisory Committee on Nutrition (SACN) and the Committee on Toxicity (COT). Assessing the health benefits and risks of the introduction of peanut and hen’s egg into the infant diet before six months of age in the UK; A Joint Statement from the Scientific Advisory Committee on Nutrition and the Committee on Toxicity of Chemicals in food, Consumer products and the Environment. London; 2017 [cited Mar 15, 2018]

Scott J, Ahwong E, Devenish G, et al. Determinants of Continued Breastfeeding at 12 and 24 Months: Results of an Australian Cohort Study. Int J Environ Res Public Health. 2019;16(20):3980. Published 2019 Oct 18. doi:10.3390/ijerph16203980 

Sirkka O, Vrijkotte T, Halberstadt J, et al. Prospective associations of age at complementary feeding and exclusive breastfeeding duration with body mass index at 5-6 years within different risk groups. Pediatr Obes. 2018 Apr 25
 
Thorisdottir B, Gunnarsdottir I, Vidarsdottir AG, et al. Infant Feeding, Vitamin D and IgE Sensitization to Food Allergens at 6 Years in a Longitudinal Icelandic Cohort. Nutrients. 2019 Jul 23;11(7). pii: E1690
 
Wells JC, Jonsdottir OH, Hibberd PL, et al. 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. 2012 Jul;96(1):73-9
 
Wood CT, Witt WP, Skinner AC, et al. Effects of Breastfeeding, Formula Feeding, and Complementary Feeding on Rapid Weight Gain in the First Year of Life. Acad Pediatr. 2020 Sep 19:S1876-2859(20)30507-6

Zhang JY, Zhou SM, Wang SH, et al. [Risk factors for cow's milk protein allergy in infants: a multicenter survey]. Zhongguo Dang Dai Er Ke Za Zhi. 2020 Jan;22(1):42-46