Breastfeeding And Introduction Of Solid Foods: Does One Size Fit All?

Medicine is all about statistics. There are no absolutes unless the statistics are absolute, which rarely, if ever, happens.

Let’s look at two scenarios.

Scenario #1: In Melbourne, Australia, the prevalence of severe food allergy in children is 10%. If both parents are allergic, there is an 80% chance that any child will develop some type of allergy (food and/or inhalant). Parents of a food-anaphylactic child want to know the best way to reduce that risk in the next child. Australia, generally, has excellent standards of hygiene and health care.

Scenario #2: In any number of developing countries, and in certain indigenous populations of Australia, hygiene and health care are poor. Rates of infection, especially respiratory and gastrointestinal infections, are high in babies and children. Food allergy is not a high priority, and, indeed, possibly because of poor hygiene, the prevalence of food allergy is low.

Once we plug in these variables – hygiene, health care access, family history, infection rates – then it follows that one size does not fit all.

What are the current recommendations of various allergy associations in high allergy, good healthcare countries?

• Breastfeed exclusively for 4 months, if possible. There is no good evidence that avoidance of allergenic foods by the mother while breastfeeding reduces allergy in the child.
• Breastfeed, if possible, while introducing solid foods between 4 and 6 months.
• Breastfeed beyond 6 months depending on personal, cultural, nutritional, health and economic maternal and child variables.
• Formula feed if needed but this is a complex issue. Information on formula feeding and allergy can be obtained from this paper by Prof Mimi Tang of the Royal Children’s Hospital in Melbourne, and from ASCIA Australia.
• Introduce solid foods between 4 and 6 months of age. There is no good evidence that delayed introduction of solids beyond 6 months reduces food allergy. There is some evidence that the introduction of solids between 4 and 6 months reduces food allergy, although it is true that more longitudinal studies would be helpful. A variety of foods can be added sequentially, with a gap of two to three days. So-called high allergenic foods, containing cow’s milk or egg or peanut (ground, not whole peanuts!!), can be included. If the baby has an established allergy to a particular food, then clearly that food should be avoided.

Is the risk of diarrhoea and/or respiratory infection increased by formula rather than breast milk? Yes. Is the risk of such infection increased by solid foods? Probably not. Does the Australian baby have better access to prompt treatment of infections than babies in developing countries? Yes

I would encourage you to read the following references. They don’t all agree on when to introduce solids. You can look at the priorities of your own family situation and make up your own mind:

• Prof Mimi Tang from the Royal Children’s Hospital has written an excellent guide. She recommends introduction of solids at 4 to 6 months.
• ASCIA Australia is the peak allergy and clinical immunology society in Australia. It provides comprehensive information on its website. ASCIA recommends introduction of solids at 4 to 6 months while breastfeeding.
• A Clinical Report from the American Academy of Pediatrics reviews the literature (63 references) and provides guidance. It states that there is no evidence that delaying solids beyond 4 to 6 months reduces allergies. This is a long complex report.
• Finally, the Australian Family Physician has a good report on Feeding in the First Year of Life.
• The Australian Breastfeeding Association recommends exclusive breastfeeding for 6 months, as does the World Health Organisation, and I suggest that you read the advice of both of these organisations, as they (currently) differ slightly from allergy groups.

There are mixed messages on when to introduce solids. It will take time for a consensus by all organisations. As indicated above, I feel that a uniform approach may not be possible, but ultimately a risk-benefit assessment will develop. You can read media reports that highlight the confusion here and here. All groups strive for one outcome – a healthy babe