Pediatrics, the official journal of the American Academy of Pediatrics, recently released an article finding 40 percent of mothers introduce solid foods to their infants before the minimum recommended age of four months, an increase from previous estimates of 20 - 30 percent. (Both the American Academy of Pediatrics and the World Health Organization recommend exclusive breastfeeding for about 6 months.)
The harm caused by premature introduction of solid foods to an infant’s diet is two-fold. First, babies younger than four months are developmentally unable to swallow solid food due to the extrusion reflex (pushing food out with the tongue) and their lack of necessary throat muscles. Early introduction to solid foods can lead to abdominal bloating, constipation, skin rashes and diarrhea in babies who do not yet produce sufficient enzymes necessary to break down food. Researchers have suggested that early introduction of solids may increase the risk of chronic diseases, such as diabetes, obesity, eczema and celiac disease. Second, the consumption of solid food means a baby will consume less nutrient-dense breast milk or formula, which has everything a baby nutritionally needs. The benefits of breast milk go beyond proper nutrition — the consumption of breast milk has also been found to reduce the risk of respiratory and ear infections and sudden infant death syndrome.
The Pediatrics study found mothers who engage in early feeding of solid foods are likely to be younger and unmarried, have a lower level of educational attainment and lower income, and likely participating in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC). All these characteristics are also associated with a decreased likelihood of breastfeeding. Infants fed solid food early are more likely be formula fed (and therefore not reaping all the benefits of breast milk), and are getting less formula than they need due to solid food replacement. Low-incomes and low-educational attainment are currently associated health disadvantages, and early introduction of solid foods could be contributing to health disparities.
The WIC program was designed to prevent these early childhood deficiencies by providing federal grants to states for supplemental foods (including formula) and nutrition education for low-income pregnant and postpartum women, and to infants and children up to age five who are found to be at nutritional risk. WIC emphasizes the benefits of breastfeeding by requiring all staff counseling WIC clients understand the benefits of breastfeeding and “encourage, educate, and support women in their breastfeeding decisions.” WIC also incentivizes breastfeeding by providing more benefits to those women who breastfeed. These additional benefits enhance the mother’s nutrition while indirectly promoting the infant’s wellness.
Unfortunately, the WIC program does not currently emphasize counseling about the risks of introducing solid foods too early. One policy change that could address the prevalence of early solid food introduction is for the WIC program to require all staff be educated about the risks and that staff counsel mothers about those risks. Such efforts could be incorporated into existing programs that promote breastfeeding, especially in light of the fact that formula feeders are more likely to introduce solid foods before four months.
The WIC Nutritional Risk guidelines were overhauled in 2006 with the introduction of the Value Enhanced Nutrition Assessment (VENA), a comprehensive nutrition assessment now used by all state agencies to uniformly evaluate whether an individual is at nutritional risk and thus eligible for WIC. However, VENA Guidance uses the same data collection of infant nutrition for all infants (aged zero to twelve months). Specialized questions drafted for children younger than six months may help staff identify early feeders and start a dialogue about what is nutritionally appropriate for the child.
Mothers and their children would benefit from increased and more targeted discussion and education about nutrition. However, one impediment to increasing the number of conversations with mothers about appropriate feeding practices is that under current regulations states are permitted to certify an infant younger than six months for WIC benefits up to when they are one year old. Therefore, a one-month old certified for WIC benefits may not be re-evaluated until after she is a year old — well past the time the infant is introduced to solid foods. Lumping all of this discussion into one consultation with potentially no re-assessment between the ages of one month and twelve months means that state agencies may miss the early solid food introduction entirely. Requiring mothers of young infants to re-certify for benefits between the ages of four and six months would allow staff to have clearer, more directed conversations about when it is nutritionally appropriate to introduce solid foods to their baby, both initially when they certify and then again when it is age-appropriate to begin the transition to solid foods.
Increased discussion and education could also help dispel confusion about what food is appropriate for a child’s age. The need for additional parent education is highlighted by the Pediatrics study findings that early feeding of solid foods occurred because of a mother’s perception of readiness, wanting to feed something in addition to breast milk or formula, and a perception that the baby is interested in solids. Even though babies younger six months do not receive any "baby food" under WIC, mothers qualifying for WIC benefits receive foods such as milk, juices, fruits and veggies, and breakfast cereals for themselves, which they might believe are appropriate to feed to their baby.
The Affordable Care Act (ACA) may also provide opportunities to improve infant nutrition. The ACA includes a provision to provide better coverage for breast pumps, which may help promote breastfeeding in the future. Making breastfeeding more accessible to mothers who return to work or otherwise must use a pump could work to reduce the introduction of solid foods too early.
The findings of the Pediatrics study present the opportunity to improve our laws, policies and programs to better serve public health. The revelation about the wide-spread early introduction of solid foods for those most likely to be nutritionally at risk suggests that WIC would be well suited to addressing this problem.
This blog was prepared by Anna Johnston, Public Health Law Clinic student at the University of Maryland Carey School of Law, home of the Network for Public Health Law -- Eastern Region.
The Network for Public Health Law provides information and technical assistance on issues related to public health. The legal information and assistance provided in this document does not constitute legal advice or legal representation. For legal advice, readers should consult a lawyer in their state. This blog post does not represent the views of the Robert Wood Johnson Foundation.