FIRST FOODS NEED TO BE NUTRIENT DENSE AND VARIED
For the first time ever, the 2020-2025 edition of the Dietary Guidelines for Americans (DGA) includes guidance for feeding infants and toddlers from birth to 24 months old.1 These evidence-based guidelines emphasize the vital role that foods rich in iron and zinc, including meat, play in meeting nutrient requirements in the early years.
The unique nutrient matrix of iron-rich red meat, such as beef, makes it an ideal first complementary food to help meet an infant's nutrient needs.
Exclusive breastfeeding is recommended as the ideal source of nutrition for infants during the first 6 months of life, with continued breastfeeding until 12 months old and beyond.1–3 Starting at approximately 6 months old, it is critical to introduce nutrient-dense complimentary first foods to meet growing nutrient demands.1
“Children in this age group consume small quantities of foods, so it's important to make every bite count.”– DGA, 2020-20251
Consistent with the DGA, the American Academy of Pediatrics (AAP),3 the National Academy of Medicine,4 and the World Health Organization5 also emphasize the importance of nutrient-dense first foods rich in iron and zinc, including meat, starting at or approximately 6 months old.
A key goal of complementary feeding is offering the right nutrients, in the right foods, at the right time for optimal development.
Healthy full-term infants are born with sufficient stores of iron for approximately the first 6 months of life.1 The iron in human milk is low in concentration but is absorbed to a higher degree (20%-50% vs 10%-20%) than infant formula.6,7 Iron requirements drastically increase around 6 to 7 months old, increasing from 0.27 mg/d to 11 mg/d (Figure 1).8 Therefore, starting at approximately 6 months old, all infants, particularly breastfed infants, need to eat iron-rich complementary foods to provide adequate sources of bioavailable iron.
“In the United States, an estimated 77 percent of infants fed human milk have inadequate iron intake during the second half of infancy, highlighting the importance of introducing iron-rich foods starting at age six months.” – DGA, 2020-20251
Bioavailability of iron differs greatly among different food sources. Unsurprisingly, human milk is the most bioavailable food source, with approximately 50% bioavailability. Heme iron sources have approximately 20% bioavailability, and nonheme iron sources have approximately 5% bioavailability.9 Therefore, it is important to provide nutrient-dense food sources with high bioavailability, along with food sources such as vitamin C–rich foods to enhance iron absorption to achieve the most absorbed iron.
The Feeding Infants and Toddlers Study (FITS) is the largest survey of dietary intakes of infants and young children in the United States and has been conducted in almost 6000 families in 2002, 2008, and 2016.10 The FITS data identified iron as commonly underconsumed relative to the recommended dietary allowance among infants in the United States.11 On the basis of trends seen in the FITS data, more mothers are breastfeeding their infants and are continuing to breastfeed longer.12,13 Although improvements in the initiation and duration of breastfeeding are positive public health outcomes, these trends underscore the need for parents to focus on feeding nutrient-dense, iron-rich complementary first foods, such as meat and fortified infant cereals because human milk is low in iron and infants will have mobilized much of the hepatic iron stores accumulated prenatally.3,6 The AAP recommends that infants who are not breastfed or are partially breastfed should receive an iron-fortified infant formula containing between 4 and 12 mg/L of iron from birth to 12 months old.14 Infants receiving iron-fortified infant formula have more protection from iron deficiency between 6 and 12 months old. However, when researchers examined the 2016 FITS data for iron consumption and considered the estimated bioavailability of dietary iron sources to evaluate the proportion of infants whose calculated total daily absorbed iron fell below recommended amounts, they found that approximately 20% of exclusively formula-fed infants did not have enough absorbed iron to meet recommended amounts to support growth and erythropoiesis.9
Although human milk is initially high in zinc that is readily absorbed, the concentration declines during the first 6 months of lactation.1 In the United States, more than half (54%) of breastfed infants have inadequate zinc intakes between 6 and 12 months old.1 Thus, starting at 6 months old, it is also important to prioritize zinc-rich complementary foods, such as meats, beans, and zinc-fortified infant cereals.
Data from FITS showed that, in 2016, approximately 80% of exclusively breastfed 6- to 9-month-old infants did not get enough iron to meet their requirements.11 Although approximately 70% of toddlers aged 12 to 24 months consumed meat on a given day, the meats consumed most often were not the best sources of iron, with chicken and hotdogs among the top choices. Only 10% of 12- to 24-month-old toddlers ate beef.12 When considering the bioavailability of dietary iron sources, researchers found that 96% of exclusively breastfed infants and 72% of infants fed a combination of human milk and formula did not meet recommended iron absorption levels for growth and erythropoiesis at 6 to 12 months old.9 They also found that chicken and turkey were the top foods among meat sources for iron intakes but that these foods contribute relatively little heme iron and therefore did not improve the total absorbed iron used by the body. Therefore, they recommended increasing the proportion of heme iron obtained from red meat such as beef into the diet.
A variety of first foods is critical. Providing a variety of foods allows for further nutritional adequacy, diminishes impact of contaminants, and exposes children to more flavors, colors, and textures.15 Food variety and repeated exposure also allow more opportunities for the infant to become familiar with foods that were previously rejected and continue to support food acceptance.16 In addition, variety can be achieved within all ranges of family preferences, cultural traditions, and budgetary considerations.1 The DGA supports a variety of protein foods for children younger than 2 years by including meats, poultry, eggs, seafood, nuts, seeds, and soy products, which are important sources of iron, zinc, protein, choline, and long-chain polyunsaturated fatty acids.1 Healthy, nutrient-dense foods should be prioritized over processed meats and foods.
RED MEAT CAN SUPPLY CRUCIAL NUTRIENTS FOR GROWTH AND DEVELOPMENT
Compared with other meats such as poultry, lamb, and pork, or other protein sources, such as seafood, nuts, beans, and soy, red meat such as beef is higher in iron zinc, choline, vitamin B12, and vitamin B6. Chicken and turkey are the most commonly consumed meats among infants and toddlers according to the 2016 FITS data, and other nonmeat proteins consumed were cheese, eggs, yogurt, and nut butters,11 all of which are lower in iron and zinc than meat.
One to two ounces of meat per day meets iron requirements for healthy infants 6 to 12 months old and toddlers up to approximately 3 years old.3,17,18
Because of nutrient density, a small amount of red meat per day meets nutrient needs. An ounce of meat per day is approximately 1 small meatball, a small slice of steak, or approximately 2 tablespoons of ground beef, shredded pot roast, or lean pork (Figure 2). A nutrient comparison of commonly consumed first foods is shown in the Table. However, it is important to note that the higher level of iron added to infant cereals is due to the lower bioavailability of supplemental iron compared with heme iron in animal-sourced foods.9 In addition, red meat uniquely supplies iron and zinc and is the only food that offers a high bioavailable source of both, unlike fortified cereals.20 Furthermore, studies show infants accept red meat such as pureed beef just as well as infant rice cereal as a first complementary food.20
Nutritional Comparison of Commonly Introduced First Foods for Infants and Essential Nutrients for Healthy Early Development
|30 g (Approximately 1 oz or 2 tbsp)
||Infant Cereal, Rice
||Infant Cereal, Oatmeal
|Total fat, g
|Vitamin B12, μg
|Vitamin B6, mg
Among commonly introduced first foods, there is variability in key nutrient composition. Attention should be given to foods that provide iron, zinc, choline, and vitamin B12 for important growth and development in early childhood. Emphasizing variety to meet nutritional adequacy is key, such as including vitamin C–rich foods to enhance nonheme iron absorption of plant foods.
Nutritional values based on 30 g (approximately 1 oz or 2 tbsp) of foods before being pureed (ie, with no added liquid).19
METHODS OF SOLID FOOD INTRODUCTION: ADAPTING ALL METHODS TO MEET PARENT AND INFANT PREFERENCES
Although most infants traditionally have been spoon-fed by their parents, baby-led weaning has become increasingly popular for the past decade. Although the term baby-led weaning is relatively new, first coined by Gill Rapley in 2008,21 it is actually a centuries-old, natural approach to letting infants learn to self-feed age-appropriate foods. Baby-led weaning embraces all textures, including purees when preloaded by the parent onto a spoon and given to the infant to put into their own mouth.
Parents do not have to choose only 1 method. Using a combination of parent-led and baby-led weaning methods is a practical and common way to begin feeding infants first foods.
A concern with baby-led weaning is if it can meet the infant's nutrient needs. Most infants in the first months of complementary foods may only suck on foods and not necessarily swallow them. The BLISS (Baby-Led Introduction to SolidS) study took parent concerns about choking and iron adequacy under review to evaluate a modified baby-led feeding approach.22 The BLISS study began as a 12-week pilot study of 23 families and was further expanded to a large randomized controlled trial of 206 families.23 The BLISS pilot study showed that educating parents about the importance of iron-rich first foods and what foods are high in iron can influence their early feeding practices. Parents following the BLISS baby-led feeding approach, which was modified to address iron concerns, were more likely to introduce foods containing iron during the first week of complementary feeding.22 They also offered their infant more servings of iron-containing foods at 6 months old (2.4 vs 0.8 servings/d) compared with parents following a regular baby-led approach who did not receive advice regarding iron-rich foods.
The follow-up BLISS study concluded that when parents received advice to offer foods high in iron with each meal, a baby-led feeding approach did not appear to increase the risk of iron deficiency in infants compared with a traditional spoon-fed approach.23 Rowan et al24 also confirmed that, among 180 families using either a baby-led feeding approach or a traditional spoon-fed approach, infants in both groups had similar exposure to iron-containing foods, helping families to understand that both methods can be safely and successfully used. Feeding issues such as swallowing difficulties are experienced by as many as 25% to 40% of normally developing children and 85% of those with developmental delay.25,26 By 6 months old, infants can put a spoon in their mouth independently, progressing to dipping a spoon into food by 9 months old. Foods made at home such as ground beef can be blended to puree consistency by adding either expressed human milk or infant formula and offered starting at approximately 6 months old. When infants show proficiency with purees of different thicknesses, they can quickly move on to eating soft foods they can grasp with their hand.
Choosing tender cuts of red meat such as sliced tenderloin or sirloin, or those that are slow cooked such as beef chuck roast that can be shredded and served to the infant, is an easy way to provide nutrient-rich meats to infants on a variety of budgets. These foods are easily grasped by either palmar or pincer grasp and are appropriate for infants starting at 6 months old with baby-led weaning or by 8 to 9 months old with traditional feeding.
PRACTICAL WAYS TO SUPPORT PARENTS IN STARTING SOLIDS WITH THEIR INFANT
Parents are both excited and overwhelmed when they first introduce complementary foods to their infants. Nutritional value, safety, and taste are top of mind and among the most important considerations as parents feed their infants and young children according to a recent survey.27 Parents value red meat as a source of protein and iron, and a food their family likes to eat, but have concerns about choking. Market research suggests introduction of beef into a child's diet by parents is slow until approximately 18 months old, and only 34% of infants have been offered beef by 12 months old.27
Parenting is a vulnerable experience, and infant feeding is messy. The introduction of complementary foods is one of an infant's earliest educational experiences, learning to enjoy foods with new tastes, textures, and colors.
Recently, concerns have arisen about heavy metals such as arsenic, lead, and mercury in commercial baby food.15 Heavy metals can get into the food supply from the soil they are grown in and/or through commercial processing; therefore, organic foods often contain similar levels of heavy metals as nonorganic foods.15 Rice cereal is a common first food for infants; however, rice tends to absorb more arsenic from groundwater than other grains. The AAP recommends that exposure to heavy metals from all sources could be minimized by selecting a variety of fruits, vegetables, grains, and lean protein.15 The AAP also suggests making homemade baby food, which can be cost-effective and be made into many different textures, allows parents to choose the ingredients, and avoids potential contaminants from commercial processing and packaging.15 Including lean proteins, such as red meat, as a choice for homemade baby food is easy to accomplish across a range of textures from pureed to table food.
One of the most common concerns about infant feeding is choking. Emerging research suggests that a baby-led approach can be as safe as the traditional parent-led method and does not increase the risk of choking.22,28,29 To avoid choking, the AAP recommends giving infants foods including meat that are soft, easy to swallow, and cut into small pieces.30 The BLISS study found that when parents received advice on how to minimize choking risk, infants fed using a baby-led approach were not at a higher risk of choking than those fed with a more traditional parent-let method.29 An earlier BLISS pilot study showed that when parents received advice about how to reduce choking risk, they were less likely to offer their infant high–choking-risk foods at 6 months old.22 These findings underscore the need to educate parents about choking hazards and that choking can be avoided with a baby-led approach.
Because family meals often influence foods provided to infants and young children, a focus on variety for all family members is important to meet nutritional adequacy within calorie needs. Parents should begin modeling healthy behavior even when their children are quite young. Introducing a wide variety of food sources to infants and young children as part of the family meal offers opportunities to provide nutrient-dense foods.31 In practical terms, variety is providing different food sources throughout the day and throughout the week, such as red meat for iron, seafood for zinc, fruits and vegetables for vitamins A and C and fiber, whole grains for potassium and fiber, and dairy foods for calcium. Recognizing that small stomach capacities of infants and young children equate to smaller portion sizes to meet nutrient needs, an emphasis on nutrient-dense foods for the entire family sharing the meal is a useful strategy for all family members.
New DGA for infants and children younger than 2 years confirm that, starting at approximately 6 months old, it is critical to introduce nutrient-dense first foods to meet an infant's nutrient needs for growth and development, making every little bite count. Commonly enjoyed by most American families, nutrient-dense meat is particularly well suited for early introduction as one of an infant's first foods. Parents can help instill healthy habits by modeling enjoyment of a variety of nutritious foods as a family.
The authors thank Brooke Vyvlecka for her assistance with food preparation and photography of the beef meals.
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