Puréed dogma

The latest absolute and utter no-no for parents (or maybe not the latest – I am, as usual, some weeks months late with getting round to commenting on this, and in the parenting world that’s plenty of time for some totally new thou-shalt-not to have emerged) is, apparently, feeding babies puréed food.  I kid you not.

A post from Emily (whose blog has first been abandoned and then hacked, so I’ve had to take out the direct link) alerted me to this article by Gill Rapley and the BBC on the subject.  I phrase the latter part of that sentence in the way I do because I have learnt never to underestimate the ability of the media to mangle anything anybody has to say on any subject ever, and it is thus quite possible that whatever Rapley originally said was a lot more reasonable and the scary spin on it is courtesy of the BBC.  However, regardless of where, precisely, the blame lies, Rapley and the BBC between them seem to have come up with an article likely to strike fear into the hearts of any parents who’ve ever dared smush a fork into their babies’ food.

Having kicked off with that meaningless old standby of a criticism, ‘unnatural’ (in what sense?  In the sense that spoons and forks don’t grow on trees in the rainforests?), the article continues thusly:

‘Spoon-feeding babies pureed food is unnatural and unnecessary, a childcare expert has warned.  Gill Rapley, deputy director of Unicef’s UK Baby
Friendly Initiative said feeding babies in this way could cause health
problems later in life.  …She said: "In 2002 the World Health Organisation backed
research that found breast or formula milk provided all the nutrition a
baby needs up to the age of six months.  That research said feeding a baby any other food during
the first six months would dilute the nutritional value of the milk and
might even be harmful to the baby’s health." ‘

Since this lacks in specificity what it provides in alarmism, I’ll now attempt a look at the actual facts behind all this gloom and doom.  What, exactly, has research shown about the effects of starting solids before six months?

The first question to clarify here is: How far before six months?  There are excellent reasons why we’ve moved away from the old practice of trying to get babies to eat solids in the first few weeks (very small babies lack either the co-ordination to chew and swallow anything that isn’t liquid or the digestive enzymes to deal with it if it does make it down to their gut), but these have been well accepted for a long time, and, prior to all this new fanfare about waiting till six months, four months had been the advised age for as long as I can remember.  (And, thanks to my odd and eccentric childhood spent indulging my passion for reading childcare books, ‘as long as I can remember’ goes back a fair few decades.  I definitely remember reading the wait-until-four-months advice from Penelope Leach in the early 80s – granted, it was probably avant-garde then, but I think it’s well established now.)  All the books that haven’t caught up with the six month advice say to wait at least until four months.  The instructions on all the commercial baby food jars say from four months onwards.  I don’t think the burning question here is whether we should be waiting till six months as opposed to giving babies solids in their first few weeks.  It’s how waiting until six months to start solids compares to starting between four and six months.

This is not, by the way, to say that I believe all parents were faithfully following the wait-until-four-months advice; I have no doubt that there are going to be a few parents around ignoring everything any expert has to say and spooning purées into babies far younger than four months in accordance with that good ol’ traditional parenting principle of "My Mother Did It This Way And We All Turned Out Just Fine".  However, I suspect that those are precisely the parents who aren’t bothered by this sort of article because they really couldn’t care less about anything Gill Rapley or the BBC have to say on the subject.  The parents who are affected by articles like these are the parents who are trying to follow the expert advice and do what they believe to be the right thing for their babies, and who are caught off-guard whenever the advice changes.  So, for any parents who followed the old advice about four months and are now left worrying about what dreadful unspecified harm they’ve done to their babies through not waiting those crucial extra two months, here’s a discussion of the available research.

(This is where I start getting all technical and wordy and going on and on about studies and statistics and analyses.  Sorry.  I’ll try to keep it as straightforward as possible – feel free to yell loudly at me if I don’t.)

The available research consists of a number of studies which have compared breastfed babies who first received solids and/or formula supplements at four months with babies who were kept on breastmilk alone until six months.  The first thing to note here is an important difference between this focus and the thrust of the comments in the BBC article.  While Rapley’s comments seem to imply that the problems are specifically with starting solids and that they apply to both breastfed and formula-fed babies, all the research so far is in babies who were previously fully breastfed.  There is no research that I’ve ever seen that compares the effects of starting solids at four months versus starting at six months in babies who are already getting formula as well as/instead of breastmilk.  And although the standard advice has worked on the assumption that the results from the studies of exclusively breastfed babies can be applied to formula-fed or mixed-fed babies, this simply isn’t a valid assumption. 

Ideally, of course, all babies would be exclusively breastfed for at least the first few months.  However, given that this is very far from the current situation and that most babies are already getting at least some formula regularly by the age of four months, how applicable is the available research to the majority of babies whose parents are going to be reading this article?  The answer is, of course, that we don’t know.  We don’t know whether the research can be applied to mixed-fed or formula-fed babies at all.  While the general comments I made above about not starting solids in the first few months will still apply, what we don’t know is whether there are any added disadvantages for these babies in starting solids a bit earlier than that magic six-month mark.

But, with regard to babies who are exclusively breastfed, what does the evidence show? 

The studies to date have explored a variety of outcomes – various growth measures, likelihood of anaemia, and incidence of various symptoms of infection.  Most of them found no differences between the two ages in terms of effects on the babies.  This is actually an important and useful finding, since it means we can now dispense with the opposite problem – parents being told (as they were up until the updated advice came out) that they have to start solids at four months because babies need the extra food to grow.  We now know that that isn’t true.  Babies will grow perfectly well on nothing but breastmilk for the first six months – or formula, if exclusive breastmilk isn’t an option for whatever reason – and starting solids early gives babies no extra advantages in terms of growth.  Which is knowledge that can potentially save parents a large amount of trouble.  (One factor that tends to get overlooked in all the hoo-ha about unspecified but dire adverse effects on health from starting solids too early is that there are practical advantages in what is now known as baby-led weaning.  Trying to spoon purée into a propped-up four-month-old, and then clear up afterwards, is a pain, and those carrot stains are the very devil to get out of baby clothes.  Waiting until your baby is old enough to sit up, grab pieces of food, and stuff them into his own mouth, and then giving him a few pieces of stuff cut to an appropriate size that he can practice eating for himself, strikes me as likely to be a whole lot easier; and the reports I’ve heard from people who’ve tried this method seem to bear this out.)

However, although it’s very nice to know that we can now wait until six months if we want to, that in itself doesn’t add up to this message about how we must wait until six months or we’ll be Harming Our Babies.  So, let’s look further.  What studies have actually shown differences in outcomes for babies who wait until six months as opposed to babies who start something other than breastmilk at four months?  So far, there seem to be three. 

Two of these studies, carried out in the Honduras, found that babies kept exclusively on breastmilk for six months crawled a few weeks earlier than babies in whom purées were introduced at four months.  Whether this adds up to a blind bit of difference in terms of long-term development is unknown and debatable, but I suppose it might be nice for the sort of mother who likes boasting about her children’s achievements.  For the most part, these studies didn’t find any other differences between the two groups. 

I say ‘for the most part’ because one of those studies did find that the group who started solids at four months were found to have higher haemoglobin levels and iron stores, on average, than the group who were kept on exclusive breastmilk until six months.  However, although I mention this for the sake of completeness, it turns out that this doesn’t detract from the wait-until-six-months advice – further research shows that iron supplements from four months are actually a better way of dealing with this problem than iron-fortified purées, probably because babies this young can digest supplements more easily than purées.  It’s also worth noting that this study was done in the Honduras, in an area where nutrition was poor and the mothers were more likely to have iron deficiency before the birth of their babies, resulting in lower iron stores for the babies at the time they were born; this risk may not apply at all to babies born to well-nourished women in the First World.  In fact, there is some evidence that the reverse may be true.  Plus, the actual differences found were not great enough to result in a greater proportion of babies actually becoming anaemic, and didn’t seem to be a particular problem for babies who were normal weight at birth.  All things considered, this research probably isn’t even an issue for First World babies except in fairly rare cases; if you have a four-month-old baby who has been exclusively breastfed so far, for heaven’s sake don’t start assuming you need to rush for the iron supplements, let alone the purées.  Once again, most babies seem to be fine on breastmilk until six months, iron levels and all.

Of course, this also means that four months and six months are still coming out neck and neck as far as age of starting solids goes.  What else does the research show?

The tie-breaker (ding ding ding! We have a winner!) is a study published in early 2006, which compared rates of pneumonia and ear infections in babies who were fully breastfed until six months and babies who were fully breastfed until four months and then started some formula, solids, or both on a regular basis.  (Babies who got nothing but breastmilk on a daily basis were counted as fully breastfed even if they’d had occasional formula supplements in the past – a sensible point that probably makes the study more widely applicable.)

The study found a difference in reported rates of pneumonia between the two groups of babies.  (That may need a mite of clarification.  Data on feeding methods and disease rates were obtained
from the results of a national survey, the NHANES questionnaire – I
haven’t been able to find a copy of the questions asked, so I don’t
know how strictly ‘pneumonia’ was defined, and thus can’t rule out the possibility that it
may cover a lot of what, strictly speaking, would have been better
described as nasty chesty colds.)  Also, although there was no difference between overall rates of ear infections, the babies who started formula or solids at four months were more likely to suffer from frequent ear infections (more than three).

What were the actual numbers involved, in terms of increased chance of getting pneumonia for a baby who’d started something other than breastmilk at four months rather than waiting till six months?  According to the numbers in the abstract the extra risk was around 1 in 20, but this is actually a bit misleading since these were the unadjusted figures.  (Results from a study like this can be affected by what are called confounding factors – for example, it may be that smokers are more likely to use formula rather than breastfeed and that their babies are more likely to develop chest problems because of the smoking, or that women with babies in day care are less able to keep breastfeeding and that their babies are more likely to catch infections due to being in day care.  Factors like these can obviously affect the results by showing an association between earlier weaning and adverse outcomes that’s actually due to reasons other than the earlier weaning.  However, where these confounding factors are known there are ways of adjusting for their effect in the study results; and, therefore, the most accurate figures in this sort of study are the ones that have been adjusted for all the confounding factors known.)

(Sorry.  To avoid confusion for any US readers, I should clarify that in the above paragraph, and anywhere else where the word happens to come up in this post, I’m using ‘weaning’ in the British sense of meaning ‘initial introduction of solids in a baby still getting baby milk’, rather than in the American sense of stopping breastfeeding.  I was trying to avoid the word for fear of causing confusion, but typing out ‘starting something other than breastmilk’, or phrases to that effect, just became too much of a hassle.)

The study did give the adjusted figures, but, unfortunately, gave them in a different format that isn’t as easy to interpret – the odds ratio.  This is a measure of how much more likely a baby from one group was to develop pneumonia compared to a baby from the other group.  In this case, it tells us that the babies weaned before four months were more likely to get pneumonia than the babies fully breastfed until six months.  However, it is not possible to tell from an odds ratio what the actual risk is.  I tried working it out for myself from the raw data given in the article, and, by my calculations, the risk is 1 in 40 – in other words, of the babies fully breastfed until four months and then started on solids, you would expect approximately an extra 1 in every 40 to catch pneumonia compared to babies who are fully breastfed until six months.  Between my appallingly poor arithmetical skills and my calculator’s failing battery I’m not sure I’d recommend depending too much on the precision of that figure, but I figure it’s probably at least ballpark.  So, although the chances of benefit aren’t that great, it certainly seems that some babies benefit from the extra delay in weaning.

There’s also the question of whether there might be benefits that are as yet unproven simply because we haven’t done the studies (which, of course, does work both ways – theoretically, there could also be disadvantages that we have yet to discover).  One question that has been asked is whether the extra time on nothing but breastmilk might also decrease the chances of getting tummy bugs.  There have not yet been any studies specifically comparing the risks of weaning at four months and the risks of weaning at six months with regard to this issue, but one good-quality study that compared weaning at three months to weaning at six months found an increased rate of episodes of diarrhoea in the three-month group.  The chances of getting diarrhoea as a result of weaning that bit earlier was around 1 in 40.  This doesn’t prove that weaning at four months would increase the risk of tummy bugs compared to weaning at six months (and, if there is any increased risk, presumably it would be correspondingly less than the risk of weaning at three months), but it’s quite possible.

So, to sum up the story so far – if you have a fully breastfed baby and hold off on giving him anything other than breastmilk until he’s six months then he will have a slightly smaller risk of pneumonia, of being plagued with frequent ear infections, and possibly of tummy bugs, than he will if you start solids at four months.  He will also, as Rapley points out, be at less risk of bouts of constipation, which is one of life’s nuisances that it’s nice to be spared if possible.  You’ll be spared either the trouble of making tiny quantities of purée or the cost of buying jars of the stuff.  You’ll also be spared all the hassle of trying to spoon semi-solid gunk into a baby too young to sit up properly, and of cleaning up afterwards.  And your child’s clothes will be spared a lot of ugly stains.  All in all, I’d say it sounds like a pretty compelling case – all other things being equal, I’d say that there are indeed good reasons to wait until six months before starting solids.

I would not, however, say that there are good reasons to scare parents silly with alarmist articles suggesting that parents who’ve started solids earlier have in some way damaged their babies.

The advice about waiting until six months before starting solids is at least based on some evidence.  (Which, I might add, is more than was the case when that advice was first given out.  The WHO report Rapley mentioned came out, as she says, in 2002 – the research about increased rates of diarrhoea where solids were started at three months was available then, and they extrapolated from that, but at the time there was no research available showing any benefit for six months over four months.  Which did not stop the government and health visitors from collectively presenting six months as The New Parenting Gospel.) 

However, I’m not too impressed by a vague phrase like ‘might be harmful to the baby’s health’ to refer to earlier weaning – too scary, too open to being embroidered by parental imagination into worst-case scenarios.  I’d far sooner see parents given a brief summary of the facts so that we can weigh matters up for ourselves.  What the organisations who give out this sort of health message regularly fail to take into account is that people don’t make health-related decisions in a vacuum.  There are all sorts of other factors that may influence our decisions; and there are a myriad of reasons why a decision that may not,strictly speaking, be the best one purely from the health perspective may still be the best one for that person in that situation.  Instead of simply telling us that we ‘should’ do things one way or another, why not trust parents enough to tell us about the evidence so that we can take it into account when making our own decisions?

But the biggest problem is that the article doesn’t stop there.  It also leaves us with the message that purées are somehow inherently harmfulthat there’s something wrong with feeding babies puréed food even once they’ve reached the grand old age of six months.

"After six months, Mrs Rapley said babies were capable of taking food into their mouths and chewing it.  Therefore, feeding them pureed food at this time could delay the development of chewing skills."

I suppose it could – after all, the more we practice a skill the better we get at it, and so it sounds plausible that a baby who mostly gets puréed food could be slower to grasp the essentials of chewing than a baby who spends that time working on masticatory skills.  So…. freakin’… what?  Exactly why should the precise age at which a child masters chewing skills matter?  Is this a race?  Are these babies under a deadline for sitting their Chewing Exams?  Is this some vital new part of the National Curriculum of which I was hitherto unaware?

Baby-led weaning is a new enough concept in this country that almost every person you know will have been weaned onto puréed foods back in their own weaning days.  How many people do you encounter who are having difficulty with chewing solids because of having missed out on the practice in their first year of life?  I’d say we have compelling evidence that, purées or no purées, kids do eventually pick up the general idea of what’s involved in chewing.

However, parents who’ve realised this for themselves, or who just don’t care all that much about whether their baby’s chewing skills are keeping up with those of the Jones’s baby, don’t get off scot-free – the article then falls back on taking the tried-and-trusted allusions-to-unspecified-future-risks line.

"Mrs Rapley argued that babies fed pureed food had little
control over how much food they ate, thus rendering them vulnerable to
constipation, and running a risk that they would react by becoming
fussy eaters later in life"
the article tells us.  And in case that didn’t make it sound quite scary enough, the opening paragraphs get even vaguer on the subject: "Gill Rapley, deputy director of Unicef’s UK Baby Friendly Initiative said feeding babies in this way could cause health problems later in life."

"There’s an article on the BBC website," I told my husband, "saying that feeding babies puréed foods might cause them to have health problems later in life."

"Well," Barry replied "it might cause Satan to rise up out of the bowels of the earth and take over the world.  But unless you’ve any evidence for that…"

Rapley, as far as I know, doesn’t.  (For the health problems, I mean.  Well, I think it’s probably a reasonable assumption that she doesn’t have any evidence for Satan-invoking potential either, but that wasn’t what I wanted to comment on.)  At any rate, I have heard no mention of actual research on the long-term effects of baby-led weaning vs. other methods, and the only research that I can find mention of Rapley having done is her Masters’ degree, necessarily a short-term project.  And, since the whole idea of Baby-Led Weaning as a specific concept only developed in recent years, I really doubt that there have been any follow-up studies on the correlation between quantity of purée consumption in babyhood and degree of food fussiness later in life.  Rapley and the BBC are welcome to theorise about this all they want, but it would be appropriate to be clear about the fact that we don’t, currently, have a shred of evidence for or indeed against this theory.

All this, of course, goes back to the general OneTrueWay attitude to parenting.  There is, it seems, no middle ground between mandatory and forbidden when it comes to advising parents.  After years of experts telling parents that they had to start solids at four months, someone discovers that actually they don’t.  So does the advice to parents change to "It’s fine to wait until six months if you want to.  Feel free to decide for yourself."?  No.  It changes into another ‘must’.  Another Commandment From On High that we are all supposed to follow blindly until the advice changes again.

What effect does it have on parents when theories get handed out as if they were proven fact?  It promotes worry and guilt, and it damages trust.  When parents are continually told that innumerable minor things that they’ve done or are thinking of doing are harmful to their babies, that damages the trust that they have in their own abilities to parent.  And, for those parents who are strong-willed enough to resist this erosion of their confidence, the inevitable result is that it instead damages the trust they are willing to place in experts.  Which means that when genuinely evidence-based advice comes out, it’s more likely to be widely ignored because parents are so disillusioned by the times they’ve been told they absolutely must/must not do something only to have the advice switch 180 degrees on them.

To summarise the actual evidence on feeding babies solids and what my husband once referred to as ‘smusheds’; Most parents will find that there are good practical reasons for leaving the introduction of solids until such time as their baby is sitting up and grabbing them for himself.  A few babies will also avoid chest infections or ear infections as a result of waiting the extra time.  If you’ve got a four-month-old baby and are wondering when to start them on solids, those are the benefits of waiting.  But if you’re a parent who did start solids earlier than six months and/or (gasp) fed your baby purées and, following that article, have been anxiously wondering what terrifying consequences you may have stored up for your apparently healthy happy baby, then worry no more.  You may well have done irreparable harm to your baby’s clothes with all those orange mushes, but there’s not a shred of evidence that you’ve done any harm to your baby.

Advertisements

8 Comments

Filed under Sacred hamburger

8 responses to “Puréed dogma

  1. That was well written. I think those sorts of articles are so damaging to parents confidence. The advice changed changed from 4-6mnths to 6mnths between my babies. I was exclusively breastfeeding and got to the stage where my babies needed something more (ie I wasn’t coping with two hourly feeds day and night and they stopped gaining) and after alot of research chose first tastes over formula. To me this made sense and worked yet since then I’ve seen (on parenting forums) breastfeeding Mums feeling like failures and being told they have to introduce formula because their not quite 6mnth old babies aren’t gaining weight and are too young to wean.
    I’m sure it won’t be too long before they start blaming obesity, adhd and gang shootings on early weaning and pureed foods.

  2. beth

    I had two thoughts when reading this:
    1) Everyone seems to ignore what I considered a huge reason to delay weaning — breastfed baby poop smells a lot better before weaning. I had heard rumers of this and found it strongly confirmed with my two kids — if you exclusively breastfeed, diapers aren’t as awful. I spent six months wondering why people bothered with those air-tight diaper holder thingies (genies?), and then I found out.
    2) How do you think new information should be presented? I read the article and I didn’t find it scary at all. Are there really parents out there who would walk away from it consumed with guilt over starting food or the wrong consistency of food too early? It seems to me that a bigger issue is why people are so desperate to feel guilt; is it because parents feel so out of control that they want to control everything? I think new parenthood is a time when many people do feel lost and overwhelmed, and maybe people react by overreacting to every piece of news. But it’s hard to imagine how news of a changing idea could be presented that woudn’t be interpreted as a slam by these vulnerable parents.
    For the record, my first started pureed foods and formula at six months, although he was still primarily breastfed, and my 2nd refused pureed foods at 5 1/2 foods and started in on little things he could grab. So I don’t know if I would feel bad or not at this news if I hadn’t had my guilt-gland removed somewhere along the line.
    Beth

  3. Ruth

    lay off the poor old media!

  4. nuala

    I think Lucy brings up a good point. The idea there is something wrong with an otherwise healthy baby who isn’t gaining weight as fast as the first few months is still far too prevalent. As long as this is seen as a ‘problem’ that needs fixing[1], the time of solid starting will be fraught with baggage it doesn’t deserve. My daughter is now a year old so my peers should have been dealing with Health Visitors who understand that breastfed babies follow a different curve, but I still know 5 or so mothers who were pushed into either supplementing with formula or starting solids ‘early’ for no reason other than the charts. This is, IMO, a huge problem within the NHS – and one you’ve touched on before – the people who are supposed to help mothers often don’t know enough about breastfeeding.
    I avoided this pressure completely by stopping weighing my daughter after the first 3 months. The only people who were upset by this were the grandmothers who liked knowing how much she weighed. But I found it very freeing to have no idea how she was ‘gaining’. We then went onto BLW which mostly worked for us especially the laziness aspect.
    [1]I’m leaving aside the frequent feeds component as how much is too much is so variable depending on the mother and the baby and each of us needs to be left alone to decide that for ourself.

  5. Constance

    This was fascinating and fun as well. Whoever would have thought that pureed food could cause such emotional ructions. Your intercalated [spelling?] year of stats and analysis was a good investment. XXM

  6. Clare Wilson

    Thank you for this insightful summary of the evidence on the four-months versus six-months debate.
    Actually though, the main message I took from the Rapley coverage was not that she was highlighting the four-versus-six issue, but that she was saying whatever age you start weaning, and whatever their current age is (e.g. even if we’re talking about a ten-month-old here) you shouldn’t give purees, you should only give them solid food they can chew up for themselves.
    Clare

  7. Jeni

    What I find interesting is the number of people I’ve come across who usually rely on good research to explain their way of parenting who now seem not the least worried that Gill Rapley has produced none. Websites have sprung up everywhere with advice on blw with no expertise on safety – some which actually contradict the advice in Rapleys article and current safety advice. And if one more person smugly claims they aren’t force-feeding their baby but puree users are, well… Thanks Sarah for once again bothering to actually do the research and making sense of it all.

  8. Would this
    http://www.cdc.gov/nchs/nhanes/questexam.htm
    have the questions you were looking for (couldn’t be bothered to read all the subscales!)

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s