Food is served or What parents need to know about introducing complementary foods

Experts have not yet come to a consensus on what should be called complementary feeding. Only one thing is certain: complementary feeding is the first step towards “adult” food. At the same time, foreign pediatricians are unanimous that we are talking only about thick food, which is given from a spoon. Domestic doctors also include liquid products in this concept - kefir and milk, believing that complementary feeding is independent nutrition, replacing first one and then several breastfeedings. This distinguishes complementary foods from nutritional supplements that a baby receives in addition to breast milk. Such food additives include fruits, cottage cheese, yolk, vegetable and butter.

Product order

The following sequence of introduction of complementary foods is proposed.

• Vegetables at 6 months.
• Porridge on water (oatmeal, buckwheat, corn) at 6.5 - 7 months.
• Fruit puree, yolk at 8 months.
• Milk porridge at 8 - 9 months.
• Meat puree at 9 months.
• Meat by-products at 9 – 10 months.
• Kefir, cottage cheese, yogurt at 9 - 10 months.
• Fish at 10 months.
• Juice at 10-12 months.
• Berry purees at 12 months.
• Meat broths at 12 months.

The introduction of vegetable oil (olive, sunflower) into purees and porridge is allowed from 6 months: the scheme is from 1 drop with a gradual increase to a volume of 1 teaspoon. The introduction of butter begins at 7 months: the scheme is from 1 g to 10 g in porridge.

For children who are fed with artificial formula, the scheme for the first complementary feeding is similar, with the exception of a few points. For these babies, it is better to introduce complementary foods from 5 months, because formula milk does not provide the little body with all the “building material”. The introduction of complementary foods differs only in the timing: vegetable purees and cereals are introduced a month earlier.

Introduction of complementary feeding to children of the first year of life

For a long time in our country there were legal provisions on the early introduction of complementary feeding from 3 weeks of a child’s life. The rationale for this was the statement about the need for early subsidies of vitamins, dietary fiber and fiber in order to improve digestion. This system of introducing complementary foods was determined by the very wide spread of artificial feeding, which was mainly not adapted to human milk (bifido-kefir, rice or buckwheat, from industrial mixtures - “Malyutka” or “Baby”). They included unchanged cow's milk protein, carbohydrates were mainly sucrose and glucose, and fats were a mixture of saturated and unsaturated mostly long-chain fatty acids. Against this background, children very often developed enzymopathies, disorders of intestinal microbiocenosis, allergic dermatitis, anemia and rickets. To reduce the negative impact, it was proposed to introduce products very slowly (starting with drops - as if “preparing” the intestines) and very early - to replace the main milk formula as quickly as possible.

The scheme for introducing complementary foods was as follows: starting from 3 weeks, it was proposed to introduce juices (drops), then vegetable broth, gradually adding one component at a time in order to “accustom” the child to these products. At 2 months, fruit puree was introduced, at 3 months, kefir, at 4 months, porridge, at 5 months, vegetable puree and cottage cheese, then an egg, and at 7 months, meat and cookies.

And if the alternation of complementary foods and the speed of their introduction in the second half of the year in children of the first year of life differed slightly in different countries, then such an early introduction of complementary foods in the first half of the year had no analogues in the world. Epidemiological studies conducted at the initiative of WHO in 1999–2002, aimed at identifying the causal factors in the prevalence of gastroenterological, allergic, and immunological diseases among children and adults, found that one of the leading causes of the development of these diseases is the early introduction of complementary foods.

Modern guidelines regarding the introduction of complementary foods are based on the study of the physiology of the development of the child’s organs and systems, his readiness to accept new food.

Timely introduction of properly selected complementary foods helps promote health, improve nutritional status and physical development of infants and young children during the period of accelerated growth and maturation.

During the entire period of introduction of complementary feeding, mother's milk or formula replacing it should remain the main product consumed by the infant.

The gradual expansion of the child’s diet and the addition of mother’s milk (or its substitutes) with complementary feeding products is due to:

• the need to replenish the deficit of energy and a number of nutrients (protein, iron, zinc, etc.) that occurs in the body of a growing child, the supply of which with breast milk or substitutes becomes insufficient after 4–6 months;
• the feasibility of expanding the diet with plant components, various types of carbohydrates, fatty acids of vegetable oils and microelements;
• the need to include in the diet denser food than milk for the development of the digestive system, chewing apparatus and stimulation of intestinal function.

Complementary feeding products can be divided into two categories. Transition foods are complementary feeding products specifically designed to meet the specific nutritional and physiological needs of the infant. Food from the family table, homemade food are complementary feeding products that are introduced into the diet of a young child and are similar in composition to those products consumed by the rest of the family.

The ability to consume solid foods requires maturation of the neuromuscular, digestive, urinary, and immune systems.

Up to 4 months, infants do not yet have the neuromuscular coordination necessary to form a bolus of food, move it into the oropharynx and swallow, so introducing semi-solid food before this time is not physiological. Further stages of development of neuromuscular coordination in infants and the relationship with the possibility of introducing various complementary foods are presented in the table.

Digestion and absorption. The introduction of complementary foods is advisable only after gastric, intestinal and pancreatic digestive enzymes have fully matured. In different children, depending on the degree of morpho-functional maturity and hereditary factors, enzymes begin to fully function at different times, but not earlier than 4 months. That is why the early introduction of complementary foods is associated with the appearance of intestinal dysfunction.

Renal function. Renal solute load refers to the total amount of solutes that must be excreted by the kidneys. These are food components that are not transformed during metabolism - mainly electrolytes: sodium, potassium, chlorine, phosphorus, which were absorbed in excess of the body's needs - and the final products of metabolism, in particular nitrogen compounds. The potential solute load on the kidney is endogenous and dietary solutes that must be excreted in the urine. It is defined as the sum of four electrolytes (sodium, chloride, potassium, phosphorus) plus solutes derived from protein metabolism, which typically account for over 50% of the potential load on the kidneys.

Breast milk has the lowest potential load of “osmotically active substances” on the kidneys - 93 mOsmol/l, infant formula - 135 mOsmol/l. When complementary foods are introduced, the load increases two or more times. The formation of renal function occurs at approximately 4 months, and in children who have suffered chronic intrauterine or postnatal hypoxia, at a later date (approximately 6 months). Thus, from this point of view, introducing complementary foods after 4–6 months is safe.

The immune system. The immature intestinal mucosa of infants is extremely susceptible to the action of enteropathogenic microorganisms and is sensitive to antigens contained in food. In the first months of life, when the intestinal immune system is not yet developed, nonspecific protective factors, which include breast milk, play a decisive role in maintaining the health of the child. In addition, during this period of a child’s life, the intestinal wall is highly permeable to macromolecules, primarily food allergens. Under the influence of lymphocytes and partially hydrolyzed immunoglobulin G of breast milk, the intestinal lymphoid system (GALT - Gut associated lymphoid tissue) matures, which is not only the main protective factor, but also reduces the permeability of the intestinal wall. Potential antigens include soy proteins, gluten, cow's milk proteins, eggs, fish, etc. Thus, the earlier these products are introduced, the higher the risk of antigenic exposure.

Particular attention should be paid to the fact that such an antigen may be soy protein, mixtures based on which are now often prescribed when skin changes appear, regardless of their genesis. Soy-based formulas should be prescribed only if there is intolerance to cow's milk protein and with mandatory monitoring of the child's individual reaction.

Introduction of complementary feeding in children of the first year of life

When introducing complementary foods to children in the first year of life, a number of provisions should be taken into account.

• Each child may have an individual tolerance reaction.
• The timing of each introduction of complementary foods may vary for each child within 1–2 months.
• During the period when a child is sick, he experiences severe “intestinal colic”, i.e., before 4 months, the introduction of complementary foods is extremely fraught with “breakdown”.
• With natural feeding, the timing of introducing complementary foods can be shifted by 2 months and new foods can be introduced after 6 months.

The timing of the introduction of complementary feeding in our country is still somewhat different from global norms and WHO recommendations. Thus, WHO recommends not introducing complementary foods until 6 months, and after 6 months adding new foods to the diet fairly quickly. Domestic experts (I. Ya. Kon et al., 2000) recommend introducing the first complementary foods from 4 months and at a slower pace. Apparently, it is inappropriate to consider the timing of the introduction of complementary foods as a kind of dogma. The individual characteristics of the child should be taken into account. Thus, if breastfeeding, the mother has a desire for long-term lactation, and the child has good physical and psychomotor development, complementary foods can be introduced from 6 months. With artificial feeding, it may be advisable to maintain the introduction of new foods from 4 months. If there is an allergic predisposition in the family or manifestations of dermatitis in the child, the introduction of complementary foods can be slightly delayed, as, for example, with long-term unstable stools or a late start of enzymes.

The first complementary foods are fruit juice and puree. In Russia, this is traditionally applesauce, preferably from a slightly “poached” apple: it contains less extractive substances. It is desirable that the apple is green or yellow. You can also use “industrial” purees, especially in the winter and spring. They are no less healthy and contain essential vitamins and dietary fiber. Juices contain extractive substances that have a more active effect on the intestines. The question of what to introduce at the beginning - juice or puree - can be decided individually. The next fruit could be a banana, then apricot, prunes (all in the form of puree). It is very good to use combinations - apple-zucchini or pumpkin. At 4 months these products are almost safe, but at 1–1.5 months they are very likely to cause allergic reactions, skin manifestations or increased abdominal pain.

Fruit, fruit-vegetable and vegetable purees and juices can be prepared from one or two types of fruit, or from a mixture of fruits and vegetables. Juices can be clarified and with pulp. Juices with pulp are introduced later than clarified ones, although they contain plant fibers that stimulate intestinal motility and can be used as a way to treat constipation.

Basic rules when using juices.

• The label should indicate the minimum age at which the juice can be given, but older children can start giving it.
• You should always start with juices containing one fruit or vegetable. It is not recommended to start with grape, carrot, or exotic fruit juice.
• It is impossible to simultaneously introduce several types of juices, since in this case it is difficult to determine which juice the child developed a particular reaction to. You should start introducing juice with minimal volumes, while carefully monitoring the child. It is necessary to monitor whether there are any changes in stool, increased abdominal pain, or redness of the skin. If these symptoms appear, this type of juice should be discontinued. The reaction to juice may appear delayed, as its volume increases. The next type of juice can be given to the child only after the previous one has been completely mastered. The later you start introducing juices (no earlier than 4 months), the fewer negative reactions.
• After introducing single-component juices, you can begin to include multi-component juices in the diet, but it is better to do this after 6–7 months. Tomato and grape juices most often cause negative reactions, so it is better to start giving them to your baby by the age of one year. Juices from wild berries and oranges are also useful. It is better to use apricot, pear, and plum juices.

Fruit and vegetable purees can contain only fruits and vegetables, or their combinations with formative components - starch, flour, thickeners. Fruit purees can be single- or multi-component. The principles for introducing purees are the same as for introducing juices.

Fruit purees can be of varying degrees of homogenization - completely crushed, finely and coarsely ground. This division corresponds to the stages of introducing foods and preparing the child to eat solid food. In addition to pure fruit or vegetable purees, there are currently combination products on the market, for example with the addition of yogurt or cereals. You need to start giving them at a time corresponding to the period of introduction of the second component, i.e. during the period of inclusion of fermented milk products in the diet - in the first case, and porridge - in the second.

Fruit and vegetable dishes are always tastier, sweeter and are introduced as fruit puree.

Later, less tasty vegetable purees are introduced, to which the child must be introduced more gradually. When introducing them, it is necessary to take into account the composition, as well as the child’s individual reaction to the composition of the puree. When introducing vegetable purees, you should start with those that consist of a minimum amount of vegetables; gradually introduce purees with a more complex and coarsely crushed composition. We are talking about puree from zucchini, pumpkin, sweet potatoes, then puree from carrots, peas and other legumes, cabbage is added to them. Lastly, after 9–10 months, purees containing tomatoes, onions, and spices are introduced. Usually the puree contains vegetable oil, so it should not be added additionally.

Porridge is an important complementary food that should be added to the diet after fruit purees and juices. All cereals are divided into dairy and non-dairy, and also containing one grain or several grains; it is possible to include fruit and vegetable additives. In the presence of these additives, complementary feeding refers to cereals, and not fruit purees.

Industrially produced milk porridges are mostly instant, that is, they do not require cooking. When diluted with water in the ratio indicated on the box, the result is a porridge containing a milk component in the form of an appropriate mixture produced by this company, or less often - in the form of cow's milk powder.

The packaging of some cereals states that they are “gluten free.” Gluten, or gluten protein, is found primarily in grains. It can cause damage to the lining of the small intestine, leading to decreased absorption, increased bowel movements, wasting, and anemia. This condition is called celiac enteropathy or gluten-sensitive celiac disease. Gluten is a mixture of proteins found in grain products. The gliadin fraction of gluten is toxic to the intestinal epithelium. The largest amount of gliadin is found in wheat.

True celiac disease is a fairly rare disease. However, a late start of small intestinal enzymes may also affect gluten-digesting enzymes. In this case, not only clinical intestinal manifestations occur, but physical and psychomotor development may also be delayed. A direct connection has been established between the time of introduction of complementary foods and the clinical manifestations of celiac disease. At the same time, in most children, the introduction of gluten-containing products after 6 months no longer causes these changes. Moreover, even in children with primary celiac disease, late introduction of gluten-containing products causes a delayed development of the clinical picture. The latter is quite important, since during a particularly vulnerable period of accelerated physical development there are no obstacles to the child’s nutrition and growth. Therefore, it is better to start the first introduction of cereals with gluten-free products; you should also not start giving whole cereals after the 6th month of life.

Traditionally, Western companies use rice, wheat flour, less often - oatmeal, semolina and very rarely - buckwheat. This is explained by the fact that in the West these cereals are considered the most important for babies, and the purpose of porridges begins with them.

In Russia, it is customary to begin introducing this type of complementary food into the diet with porridge made from buckwheat and oatmeal. The production of porridges from these cereals is a tribute to the traditions of our country, and they are produced mainly for sale in the CIS.

It is known that corn flour causes allergic reactions less often than others, and rice flour contains the largest amount of essential vitamins. Rice flour for baby food is usually prepared from uncrushed rice, so these cereals do not have the property of slowing down peristalsis and do not provoke the development of constipation in children. Therefore, industrially produced porridges made from rice flour can be recommended to all children, even those with a tendency to slow down the evacuation of feces, while homemade rice porridge from ground crushed purified rice can provoke a slowdown in peristalsis. Oatmeal, on the contrary, enhances peristalsis and promotes better evacuation of bile.

Porridges made from several grains in combination with fruit fillings are best introduced closer to the year. This primarily applies to porridges with honey, chocolate, cocoa, nuts and wild berries.

Meat and fish are introduced at 7–8 months, usually in combination with vegetables. The child begins to give the meat in chopped, beaten form, gradually moving to larger pieces turned through a meat grinder or finely chopped - taking into account the child’s capabilities. The child should not choke on food so that a negative reflex to food does not develop. It is better to start with low-component meat and vegetable purees or pure meat purees, which are added to the vegetables familiar to the child. In Russia, potatoes, cabbage, zucchini, pumpkin, and turnips are traditionally used. Carrots must be administered very carefully. Particular attention should be paid to the use of tomatoes - children under 1 year of age tolerate them quite poorly: they can provoke eating “breakdowns”. The addition of onions and spices should also be treated with caution.

You can use any meat - beef, veal, turkey, rabbit, lean pork, chicken. It is necessary to introduce different types of meat gradually, taking into account the child’s food preferences and monitoring his condition.

At 6–8 months, cottage cheese and fermented milk mixtures are introduced. Children with rickets and anemia can start giving these products earlier - from 5 months.

At 8 months, bread or cookies are introduced, which are usually added to cottage cheese and mixed with fruit puree.

If family members are not allergic to it, it is better to include yolk in the diet starting from 10–11 months; during the same period, you can start giving weak broths.

Thus, in the first 6 months the child is almost not “loaded” with unfamiliar food, while in the second half of the year all the necessary ingredients can be introduced quite quickly.

All new food must be included in the diet gradually, one component at a time. If a negative reaction occurs, this type of complementary food or its constituent product is “removed” from the diet for at least 1 month.

The child’s diet should be structured in such a way as to form a reflex in him: breakfast (usually porridge), lunch (vegetable puree, then puree with the addition of meat and broth), afternoon snack (cottage cheese with cookies and fruit puree), dinner (yogurt, milk or porridge). It is advisable not to give the baby anything between feedings. If the baby is breastfed or is accustomed to some kind of formula, then perhaps after any type of complementary feeding he will need a little of his favorite product.

So, the following sequence of introducing complementary foods is recommended:

4–6 months - fruit purees and juices;

5–6 months - vegetable puree;

6–7 months - porridge;

7–8 months - meat; fish - after 10 months;

8–9 months - cookies, cottage cheese, kefir;

10-11 months - yolk, broth.

You can initially introduce porridge, and then vegetable puree. Cottage cheese for medical reasons (rickets, anemia, malnutrition) begins to be administered at 5–6 months. For persistent constipation, from 4 months you can include fermented fermented milk mixtures or kefir in your diet.

E. S. Keshishyan , Doctor of Medical Sciences, Professor of the Moscow Research Institute of Pediatrics and Pediatric Surgery, Moscow

First porridge

If the child's weight is significantly less than normal, WHO recommends starting complementary feeding with non-dairy cereals. For infants, porridges are prepared only as non-dairy, unsalted, semi-liquid, and absolutely uniform in consistency. The first porridges are prepared from cereal flour (sorted and washed cereals are thoroughly ground and crushed).

The following sequence of introduction of cereals is proposed: buckwheat, rice, corn, oatmeal, semolina. It is recommended to cook semolina porridge only once a week, because it contains practically no nutrients, but is rich in gluten, which can cause problems in the intestines. Proportion for preparing the first porridge: 5g of cereal flour per 100 ml of water. After cooling the finished porridge slightly, chop again. You can add 1-2 drops of vegetable oil or a little expressed breast milk to the finished porridge.

From the age of 9 months, the infant's nutritional system involves multi-component porridges, from products already well known to the child. You can now add vegetables and fruits familiar to your baby to the porridge. At 9 months you are allowed to prepare pearl barley and millet porridge for your baby. And by 10-11 months, porridge on water will be an excellent addition to meat and fish meatballs and steamed cutlets.

Vegetable complementary foods

The first purees are prepared from one vegetable.

The order of introducing vegetables into complementary feeding for infants is suggested as follows: zucchini, cauliflower, pumpkin, potatoes, carrots, green peas, beets. These vegetables are introduced during the baby's 6-9 months. After 1 year, you can give your child cucumbers, eggplants, tomatoes, sweet peppers, and white cabbage. After preparing the puree, make sure that the mass is completely homogeneous, there are no fibers or small particles, and the consistency is semi-liquid. Don't add salt. Add 1-2 drops of vegetable oil or expressed milk.

If a child refuses vegetable complementary foods, discontinue this product for 1-2 weeks. Try temporarily replacing it with another one and return to it after a while.

How is readiness for complementary feeding determined?

Psychological and physiological readiness for new food is distinguished.

1. Psychological readiness is expressed in the fact that the baby begins to be interested in adult food, reaches out to it, wants to try it;
2. Physiological readiness is associated with the characteristics of the body and the need to expand the diet in order to obtain more nutrients.

Among these signs:

• the child can sit independently or with minimal support (read: When does a child begin to sit);
• he holds his head confidently;
• he often asks for the breast (as if he is no longer full of milk);
• the reflex of pushing out food with the tongue weakens;
• The baby's weight has doubled since birth.

All signs should be taken into account comprehensively, especially the combination of psychological and physiological readiness.

Meat feeding

From the age of 9 months, the first meat purees are recommended for babies. It is recommended to prepare first courses from lean meats: rabbit; quail; turkey; chicken.

It is recommended to introduce complementary foods for a 6-month-old baby in the morning.
This will allow you to track the child’s reaction to an unfamiliar product before going to bed at night: whether there is a rash, bowel dysfunction, anxiety in the baby, or excessive regurgitation. It is better to give vegetables or porridge first, and then feed with breast milk or formula. Gradually, porridge and a vegetable dish will replace one full feeding. The dish must be warm and freshly prepared. Gradually, by the age of 1, your baby will develop taste preferences. You will know what foods he enjoys eating. In the meantime, try to fully expand your child’s diet with the foods necessary for growth and development. Be healthy!!!

Why can’t the table be considered universal?

Let's talk about some points again:

1. WHO has only general recommendations on how complementary feeding should be structured and at what age it should be introduced;
2. There is no current or WHO-developed complementary feeding table. This is the invention of a very specific mother, who rewrote the usual pediatric scheme for introducing complementary foods, making it more detailed, breaking it down into products;
3. Introducing complementary foods according to this scheme and with such a volume of complementary foods leads to 7-8 months. child to a complete refusal of complementary feeding and disturbances in the child’s nutrition.

What other mistakes can be found in complementary feeding schemes?

• There is no consideration of the individual characteristics of children;

For example, if a child does not have any digestive disorders and is gaining weight well, then complementary feeding, as a rule, starts with vegetables. This is the most common option.

But if, on the contrary, the baby is underweight, then many pediatricians recommend introducing porridge first, and only then: vegetables, meat, and dairy products.

• The volume norms for vegetables and porridge on the 7th day of complementary feeding for each product are up to 180 grams.

This number is far from reality. Few children at 6-7 months will be able to cope with this volume.

Do not put pressure on your baby to feed this entire amount, otherwise you will create a serious burden on his digestive system. Offering him several smaller dishes may be more effective.

• The table of sequential introduction of products is concentrated within the framework of pediatric complementary feeding, according to which pureed products are first given in small portions, then, as you get used to them, their quantity gradually increases and the consistency becomes thicker.

Until one product is brought to the required volume, the other is not introduced.

For more than 10 years I have been teaching mothers how to introduce complementary foods according to the child’s natural needs. This involves introducing the baby to food based on his interest in it and readiness for complementary feeding.

The products are not mashed into purees, but given in very small pieces. The child is not prepared with separate dishes, but is offered what adults eat.

The purpose of such complementary feeding is not to feed him to satiety, but to form a stable interest in food and correct eating behavior. Read more in the article: Pedagogical complementary feeding.

The introduction of complementary feeding according to WHO implies careful introduction of complementary feeding, without reducing breastfeeding. This is exactly the approach we learn in the ABC of complementary feeding course.