“Dr. Tim Noakes, a well-respected physician, scientist and author in South Africa, recently had medical license under review after he used Twitter to tell a parent an infant could be weaned onto a low-carb, high-fat diet.

Thankfully, Noakes was found not guilty of misconduct on April 21.

Clearly this is a story of politics and big business, but it did get me thinking: What is the proper schedule for food introduction for babies?

What comes first, and why? Cereals? Veggies? Meats?

Is Dr. Noakes onto something?

Current Recommendations

The American Academy of Pediatrics (AAP) recommends starting babies on single-ingredient foods. While the AAP gives alternatives, it does suggest that fortified cereals are a good traditional first choice because they are easy to digest, have a low risk of allergy and are iron fortified. The American Academy of Allergy, Asthma and Immunology also recommends single-ingredient foods but seems more flexible with recommending cereals, vegetables or fruits.

Cereals are recommended first for two main reasons: They are low-allergenic foods and they are iron fortified. Cereals rarely cause an allergic reaction.

Food allergies have exponentially increased over the last decade, which has led to a great deal of research and many changes in guidelines specifically related to the inappropriate delay of allergenic foods in babies. We used to think that holding off on foods such as peanuts helped prevent food allergies, but research now shows the opposite. Starting food such as peanuts earlier actually leads to fewer allergies. While it seems reasonable to give your child a first food like rice cereal that rarely causes an allergic reaction, it might not be the answer to reducing food allergies. Babies might do better if they are given many different foods and are exposed to different allergens early. What if serving boxed, processed, fortified baby cereals is actually contributing to the current allergy epidemic? Could chemicals in the process of making boxed cereal actually lead to allergies?

“Could chemicals in the process of making boxed cereal actually lead to allergies?”

Baby cereals are iron fortified—which means they have iron and other minerals added to them. Babies at 4-6 months are often low in iron, as the iron stores they had from mom have weaned down. Iron deficiency is the most common nutrient deficiency in the United States. In fact, pediatricians routinely check hemoglobin at the nine-month well-child visit to screen for this common deficiency. Anemia in babies can cause long-term, permanent damage to neurodevelopment.

The AAP lists high-iron foods in its policy statement “Diagnosis and Prevention of Iron Deficiency and Iron-Deficiency Anemia in Infants and Young Children (0–3 Years of Age),” and while commercially fortified cereals are on the list, so are meats, vegetables and beans.

In the U.S., most pediatricians have traditionally recommended starting with fortified baby cereal, then veggies and fruits, then finally proteins such as beans and meats.

Global Recommendations

Are we the only ones giving fortified baby cereals to babies first?

As it turns out, parents in many countries actually give grains first, but most do not serve grains as a single ingredient. Most give them as a part of a cooked mixture with other foods such as veggies and meats.

Khichidi, a mixture of rice, lentils and vegetables, is a common first food in India. In Japan, okuizome—a mix of rice, fish, octopus and pickled vegetables—is often babies’ first food. In Jamaica they introduce babies to fruit first. In Kenya, babies start with sweet potatoes. In Vietnam, they start with broths with fish sauce, pork bone, shrimp and vegetables. And in France, babies are introduced to vegetables, soups and cheeses—but never boxed cereals.

Babies around the world start with all sorts of different first foods.

The History of My Recommendations

I graduated from medical school in 1998. I received my pediatric residency training from 1998 to 2001. I learned to start with rice cereal, then introduce vegetables one by one, then fruits. Once babies had demonstrated that they could tolerate single-ingredient foods and were ready to move on to finger foods, I recommended proteins such as lentils, then meats. I recommended delaying the high-allergy foods egg whites and nuts until after age 1.

Three things changed my recommendations over the last 15 years.

1. Arsenic—In 2012, Consumer Reports reported a high incidence of arsenic in rice. While I think it’s reasonable to eat rice occasionally, I don’t think it’s reasonable to give it to a developing brain as its first food two to three times per day. So I stopped recommending rice cereal to babies and switched to other fortified grains.

2. American Academy of Allergy, Asthma and Immunology Recommendations (2013)—The recommendations came in response to the high levels of allergies with peanuts and other allergenic foods, and they were quite flexible with regard to which foods to introduce first. After these recommendations were issued, I started having families decide what first single-ingredient food to start with—preferably real vegetables, then real fruits, not cereals.

3. Processed foods and sugars—It’s an epidemic. Finding real foods—foods that are not in a box or package—has become a challenge. The food on the edge of the grocery store is the key. Processed foods have led to a drastic rise in chronic disease, especially diabetes and heart disease. These chronic diseases have specifically been linked to the quantity of sugar we are eating. Knowing the role sugar and processed foods are playing in this disease crisis, I have encouraged my patients to eat real foods and serve them to their infants whenever possible.

My Current Recommendations

So what do I recommend now, and is Dr. Noakes onto something?

Of course he is. Meats have iron and have never been shown to be highly allergenic, and nuts have now been shown to be less allergenic if started early rather than delayed (nut products, not actual nuts; babies would choke on an actual nut).

Basic human nature and common sense also suggest something from the earth is probably better than something out of a box.

  1. Vegetables—Vegetables are a good choice as a first food. Select single-ingredient options and serve one at a time.

  2. Fruits—I still introduce single fruits after vegetables. I understand that children will eventually develop the taste for both vegetables and fruits, but it can’t hurt to wait on the sweet foods. It would be reasonable to wait on fruits until after meats, lentils and fish, too. Avocados are a great early food.

  3. Meats or lentils—I currently recommend both after vegetables and fruits, but I cannot fault anyone who wants to introduce them first. Serve pureed, of course; you can’t have baby choking. Meat and lentils are highly nutritious, and neither has been shown to be a highly allergenic food.

“Meat and lentils are highly nutritious, and neither has been shown to be a highly allergenic food.”

  1. Fish (not shellfish) and cooked fish (salmon)—While I get a little nervous about “fish” because some are more allergenic, salmon is not. It’s also a highly nutritious food. I currently recommend its introduction after vegetables and fruits, but I would not fault anyone who chose it as a first food.

  2. Nuts and eggs—Both are still considered allergenic foods (note again: pureed/blended; whole nuts present a choking risk). I would stick to the American Academy of Allergy, Asthma and Immunology recommendations to introduce them after the introduction of some vegetables and fruits. Consult with your pediatrician if your child has atopic dermatitis or other risks.

  3. Grains—Ah, what do we do with grains? On the one hand, grains are fortified and have decreased the incidence of anemia. On the other hand, they are processed and come out of a box. In the last several years, I have had many patients chose to delay the introduction of grains, just like the French. These patients have given their babies iron-rich real foods such as meats, vegetables and lentils. So if you are able to provide nutritious foods that are high in iron, then delay grains until after the introduction of other real foods. When you do introduce grains, introduce real grains such as quinoa—not grains out of a box. Furthermore, ensure you get the anemia test at the nine-month check-up to confirm that your baby is not iron deficient.

Above all, be mindful. Know what you are putting into your baby and why. Avoid processed foods and sugar as long as possible.

I’m thrilled the forward-thinking Dr. Noakes has been cleared of any wrongdoing. On my first day of medical school, our professor told us that half of what we learn in medical school will change over our lifetime. I saw that when the human genome was mapped, and I am seeing that change now. Wise physicians do not subscribe to dated recommendations but constantly evaluate new research to ensure the health of every patient. I predict our current recommendations for feeding infants will change to fall more in line with Dr. Noakes’ recommendations in the future.

About the Author: Founder of Coast Pediatrics Del Mar and Coast Pediatrics Carmel Valley, Shakha Gillin, MD, FAAP, has been a pediatrician since 2001. She attended the University of California-San Diego for her undergraduate education and for medical school. She did her residency at the University of California-Irvine and was the chief resident at Miller Children’s Hospital in Long Beach. She has worked in private practice in Southern California and at the Rady Children’s Hospital Emergency Department. Dr. Gillin has a special interest in preventative care and creating healthy, active lifestyles for children in particular. San Diego Magazine recognized her as a “top doctor” from 2006 to 2016.”




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