Starting Solids According to Research

An interview with Kim Grenawitzke of Solid Starts answering all of your questions about starting solid food with your baby

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Dr. Cara Goodwin: Hi everyone! Welcome to the Parenting Translator newsletter and podcast. I'm Dr. Cara Goodwin and today I am here with Kim Grenawitzke of the Solid Starts team, which is one of the, if not the, most popular feeding Instagram sources. They have an incredible team of professionals that puts out resources for parents related to feeding infants and toddlers. Kim is a pediatric occupational therapist, a feeding and swallowing specialist, and an international board certified lactation consultant. Kim, I'm so excited to have you here. I really wanted to interview someone from Solid Starts because feeding infants and toddlers is so confusing and even the research doesn't always give us clear answers. Could you introduce yourself and tell us a little bit about Solid Starts and what kind of resources you provide for parents?

Kim Grenawitzke: I'm so excited to be here as well. My experience has mostly been in pediatric acute care and some large high acuity children's hospitals working specifically with kids in and out of the NICU and the cardiac ICU. In addition to my hospital work, I've also done some in-home and pediatric rehabilitation care too. I've worked the spectrum of the most medically complicated kids to just kids in home learning to eat like all of our kids do. 

I got involved with Solid Starts in late 2019, early 2020. If you're not familiar with Solid Starts yet, it has turned into an almost 3 million strong group of families that are learning to feed their babies and toddlers. Solid Starts provides educational material and content for families that touches on starting solids, regular developmental toddler selectivity, and then the dreaded picky eating that I know people are always worried about for their older kids. We also recently just launched a Professionals Portal. So we're providing continuing education materials for physicians, nurse practitioners, feeding therapists, dieticians, anyone that's working in the pediatric feeding space. 

The other thing that we have is a really cool free app that you can use to look up how to cut food for your baby at any age. Just download it on your phone and you can search avocado and it shows you exactly how to serve it safely. All of those entries have been reviewed by not only us from a feeding and swallowing perspective, but also from our dietitians and our medical team to make sure that everything is appropriately served in regards to nutrition for your baby. There are lots of really cool resources on our website and our app.

Dr. Cara Goodwin: Thank you so much for going through all that. I love that so much of what you offer is free because a lot of us parents don't have a lot of money to spend on all these resources. There's just a lot of free information on your website that I think is really helpful to parents. First I want to ask you, how do you know when your child is ready to start solids? I've looked at a lot of this research talking about the four versus six months debate. When exactly do you start solids? What do you recommend? I know the research is a little mixed on this.

Kim Grenawitzke: There is really poor literature to support most of the things that we do in the pediatric world, especially when it comes to feeding. There's a lot of talk that babies are ready to start solid foods at a certain age, but that's actually outdated advice. There's really no good literature to support a specific age of introduction. The World Health Organization, the AAP, and the American Academy of Family Physicians have now transitioned to recommending looking for signs of readiness. Those signs of readiness tend to show up around six months of age. 

The three things that you're looking for are 1) the ability to sit with minimal support. When you put them in their high chair or you sit them in your lap and they're not tumbling over or falling forward. You want them to be able to maintain their head and neck upright, which is important for chewing and swallowing. 2) You want them to be able to bring their hand to their mouth when they're sitting, which is important for self-feeding. 3) Most importantly, you want to make sure that they're interested in food and meal times. If a baby's not interested in eating, they are turning their head and their pursing their lips, it’s really, really easy to force feed them. We can get into this a little bit later if we start talking about picky eating, but you want meal times to be a reciprocal relationship where the baby's really interested and engaged and you as the parent are just presenting the food for them. 

Allowing them to take control of that from the very beginning is one of the ways that we pave the way to really have happy meal times moving forward. One of the things that we hear about a lot is that the tongue thrust reflex should be gone. If you have a really young baby and you touch their tongue, you'll see they kind of stick their tongue out to push things out. Believe it or not, there is zero literature to support the fact that tongue thrust reflex needs to be gone to start solids. In the context of spoon feeding, the reflex would be a nuisance because if you tried to spoon feed purees, the tongue thrust would just push the puree out of the baby's mouth so they wouldn't really even have the chance to learn how to move the food around and swallow it. But if you're working on introducing finger foods and self feeding, that tongue thrust reflex actually doesn't really get in the way. And if anything, it's helping the baby stick their tongue out to kind of lick the food and explore it. The thing that's also not mentioned is even if the reflex is gone, that's a motor pattern that they do over and over and over again for six months. They're still going do it even after the reflex is gone. If we actually waited for that to be gone completely, we'd be introducing solids really, really late. So again, around six months of age is when they're showing these signs of developmental readiness that tell us that they can actually engage in the activity and that they have the motor skills to safely chew and swallow.

Dr. Cara Goodwin: That is so helpful to know. I hadn't heard that about the tongue thrust reflex. That's really interesting.

Kim Grenawitzke: The only other thing that is important to keep in mind is that there are a lot of pediatricians or medical professionals that might talk about starting solids at four months old for the nutritional benefit. But when you look at the literature, there's actually no nutritional benefit of starting solids at four months versus six months even when they look at iron stores. In babies that started earlier versus at six months, there's no difference in those two groups. There are very, very few circumstances that starting before developmental readiness is a good idea. In those situations, it's typically medically complicated kids with different nutritional needs that are being managed by a whole team of professionals.

Dr. Cara Goodwin: That is so helpful to know. When your child does seem developmentally ready, what would you suggest to offer as a first food? A lot of us have heard from grandparents or maybe even old school pediatricians to start with rice cereal. That's an old tradition, but what about rice cereal, fruits, vegetables? Where do you start with this?

Kim Grenawitzke: There are so many incredible options for a first food and the secret is that there really is no perfect first food. You want starting solids to be a memorable special experience for your family. Think about foods that are important to your baby or your culture. With my first daughter, when we started solids, we did pineapple for her first food because I felt her move for the first time when I was eating pineapple. And my second daughter, we started with fajita steak and veggies because we had recently moved to the Midwest from California and it felt like we were introducing her to a small taste of my Southern California roots doing a Taco Tuesday with her. 

But getting into the nitty gritty, you do want to look for something that's densely nutritious, easy for baby to self-feed, and low risk for choking. Now keep in mind no one food is going to be like perfect home run hitting all these things. We just want to introduce our baby to variety over those first few months of introducing solids. So when it comes to nutrition, food that is high in protein and fat and carbohydrates are all beneficial. Things like iron-rich foods with zinc, calcium and omega-3 fatty acids are also very good. Next, you want something that's easy for your baby to self-feed, so you want them to be able to pick it up off the tray. The research is relatively clear in both the pediatric and actually the adult geriatric population that choking risk significantly decreases when a patient or a person is feeding themselves. This research started in nursing homes because they found that nursing home residents would choke less when they were feeding themselves. This research has now luckily carried over to the pediatric population as well, showing that when babies and children feed themselves, their choking risk decreases. 

Our six-to nine-month-old babies really can only use a gross grasp [translation: the gross grap involves wrapping the fingers around and holding the food against the palm]. They really can only pick up big things with their hands. They don't have a pincer grasp [translation: picking up an object with their thumb and index finger in a pinching position] to pick up small pieces of food. We want that food to be kind of stick-shaped and able to fill up their entire palms so they can pick it up and bring it to their mouth.

And then finally, you want to avoid foods that are choking hazards. So things like whole grapes, cherry tomatoes, and whole nuts, but I don't think any parent would really go for that as a first food anyway. 

The feeding therapist in me tends to lean towards something that's going to build oral motor skills. So I love something like a food teether, which is something that's a long resistive stick of food that's going stimulate all the reflexes in their mouth. So it's going to stimulate their tongue lateralization reflex, the one that makes their tongue move side to side and stimulate their gums to kind of build that munching pattern. The beauty of these resistive food teethers is they don't break apart in the mouth. They're completely unbreakable. So you get tons and tons of practice with chewing skill without having any demand of really needing to manage anything in the mouth. But again, no food is a home run and pretty much all family foods can be modified to be safe. So my heart always says, go for something that's special and means something to you. But of course, consider things like nutrition. 

I do want to touch on rice cereal quickly because it was a logical recommendation before we knew a lot more about nutrition and child development because it's bland, it's not allergenic, it's similar in texture to milk in a lot of ways, except it's just slightly thicker and it's fortified to be high in iron. But as our understanding of nutrition and digestion and feeding skill development has progressed over the last 50 years, rice cereal is really not the logical recommendation anymore. First, there's no research to support the idea that babies need bland food. And if anything, literature actually supports offering babies tons of different flavors during that 6- to 12-month window so they build tolerance and interest in those fun flavors. Rice cereal is also quite constipating. Any parent that has started solids with their baby already knows that when they start doing solid food, their poop is already super weird. The last thing we need to do is block them up even more. Rice cereal is very, very constipating, especially when given in large amounts. When they're sucking it off of a spoon, almost like a milk feed, you can get a lot of rice cereal in a baby, which is really going to stop them up. Then most importantly, it does have arsenic. So if we can avoid that, that's a great thing to avoid. 

The recommendation generally now is to focus on variety. If you do want to offer rice cereal in small amounts, go for it, but it's definitely not the necessary. The other thing that you asked about is vegetables versus fruit and what do you need to do? Is there a certain order? And there is no research to support the idea that you have to give vegetables before fruits or you have to introduce food in any sort of order. The thought was that if you introduce fruits first, your baby's only going to want fruits and they're never going to want vegetables, but that's actually not supported by the literature. We do know that babies have a propensity for sweet foods because milk is sweet and basically that has driven them to go for their food source evolutionarily. Bitter tastes were associated with poisonous plants, so it's common for show an interest and a preference in sweet foods and then avoid or be a little bit more cautious about bitter ones, totally just based on biology. So it's going to occur no matter when or how you introduce those foods. But the goal is just to provide opportunities for your baby to be exposed to all of those flavors. So you can introduce strawberries in the morning and kale at lunch, and that's great. It does not have to be in any sort of order. Don't stress if you've given something sweet and then given something bitter after the fact. There is some literature that's talking about, there is some studies that have shown when a baby is only offered vegetables during the six to nine month window, they have a higher volume of vegetables eaten after the nine months, but there's no difference in whether the baby's like or perceived to like the vegetables. It might just be, the fact that they're just exposed to more during that six to nine month window, as opposed to the fact that they like it more because they were given it first. So that's just not great research, but again, really no reason to go one way or the other.

Dr. Cara Goodwin: That is just a wealth of information. I love the idea of the food teether. What are some examples of that?

Kim Grenawitzke: A favorite of mine is a mango pit. Take the mango, cut all the flesh off of it, and you have this hard thing that a baby can hold. It can be a little slippery, so you can roll it in some ground oats or some ground seeds to give them a little bit more grip. But that's a great thing that they can just pick up on their own and bring it up to their mouth and start gnawing on it. It also gets you like five minutes of quiet, which when you have a very full house, I'm sure you're looking for five minutes of quiet here and there. You can take a piece of meat and cut all the meat off. So like a bone-in pork chop, cut all the meat off and let them use the bone. A spare rib can be great too. What we did with my daughter was a pineapple core. After you've cut all the pineapple off of the pineapple, you can just give them the center of the pineapple. A super, super thick carrot. So I'm talking like bigger than an inch diameter. A really, really wide fat carrot. Anything that you as an adult really wouldn't be able to bite through unless you put it back on your molars and like really chomped in, or you physically couldn't like a bone.

Dr. Cara Goodwin: That's very helpful. I'm definitely going to try that with my new baby. Is it true that you should only introduce one food per week? I remember following that religiously with my first and then with my second. So is that something that parents should be careful about? Just introducing one food per week?

Kim Grenawitzke: This is one of those old recommendations that is not based in any sort of research. It’s how it's always been done type thing.  If we only introduced one food each week, a baby would only get 24 to 30 new foods during that six to 12 month period. Research solidly supports exposure to a wide variety of new foods in those first few months of solids. So you definitely do not have to only do one new food a week.

Dr. Cara Goodwin: What about if it's a potential allergen? Should you be careful about introducing potential allergens? When should this happen and what should you look for with a potential allergic reaction?

Kim Grenawitzke: First it's important for me to point out that I'll speak to allergen introduction from my experience as a feeding therapist and my work with incredible pediatric allergists in my practice. But with that said, I'm not a full expert in this area. In 2015, there was a study called the LEAP study that showed that early introduction of peanuts specifically to at-risk babies could actually decrease the risk of developing an allergy by as much as 81%, a huge decrease in allergy. The study was telling us that delaying the introduction of peanuts could actually increase the likelihood of peanut allergies in children. This study was extrapolated to a variety of other foods and the research is the highest quality for peanut and egg. Pediatricians and allergists now recommend introducing pretty much all of the most common allergens before your baby's first birthday. 

Before you start introducing them, it's important to know if your baby does have an increased risk of food allergy and the two things that you're thinking about there are severe eczema. A lot of babies have a little bit of eczema like in the creases behind their knees and in their elbows, but severe eczema, especially that that's being treated by a doctor already is a risk factor for food allergy as is an allergy to another food. So if you have a baby that has a milk allergy already, or if you start introducing foods and they show an allergic reaction to one food, that does unfortunately increase their risk of being allergic to something else. In that case, it's important to talk to your pediatrician and potentially an allergist just about coming up with a plan. 

For the vast majority of babies though, you just want to start small. You can even start with like an eighth of a teaspoon if that makes you feel better. You want to offer allergens early in the day so you can watch your baby for any potential reaction. You just want to introduce one food allergen at a time. So for example, don't like mixed peanut butter with yogurt when you're first introducing, because those are two allergens and you wouldn't be able to tell which one was the culprit of the allergic reaction if you had it. A few days of daily ingestion is typically enough to establish that your child is tolerating that food but that doesn't mean that you have to only introduce that food. If today you introduce peanut butter in the morning, you can still serve strawberries at lunchtime. That's totally fine. You just don't want to mix a whole bunch of allergens in the same day. 

After you've safely introduced those allergens, you just want to keep them in the diet. The majority of the literature tells you two to three times per week, but I feel like that would make us all go crazy as parents to think all nine allergens two to three times a week. That's so much work. The literature says two to three days a week because that's what the studies looked at. Most allergists will tell you if you can get each allergen in once a week, that's awesome. The one allergen you have to worry about less is shellfish. The literature on introducing shellfish early in regards to preventing allergy is very poor, if any. Actually many shellfish allergies don't develop in childhood. So if shellfish is not something that you serve to your family on a regular basis, don't stress about giving it to your baby. A lot of shellfish is also really high in sodium and we'll talk about that in a little bit, but don't stress too much about shellfish. 

Symptoms of an allergic reaction, you have mild versus severe. Your mild symptoms are things like sneezing, itchy runny nose, a baby kind of like scratching the inside of their mouth, which would make you think that their mouth was itchy, a few isolated hives or a baby itching, and then maybe sometimes some mild nausea or GI discomfort, so a little bit of retching, gagging. If you see any of these things, stop feeding that food and contact your pediatrician so they can help you to make a plan as to what to do. A lot of times they'll say, let's go ahead and introduce again. Other times they'll have you stop because many times introducing an allergen on the second round is actually a worse reaction than the first. 

Now a more severe reaction is something like shortness of breath, wheezing, like your baby looks like they're struggling to breathe, they're starting to get pale, their skin tone is changing, severe swelling, especially in the lips and the eyes, anywhere on the face or their tongue, widespread hives that cover their body or more than one area of their body. A lot of times you'll see if you take their onesie off, it'll be like spreading up their belly. You will see lots of vomiting or just overall tiredness and lethargy. A baby that seems really off. In that case, you do want to call emergency services immediately and tell them that your child is having a severe allergic reaction so they can manage that. In that case, you absolutely want to get in touch with your medical provider after that and probably a pediatric allergist to make a plan.

Dr. Cara Goodwin: I think that makes parents feel a lot more comfortable just knowing what to do and what to look for when they see an allergic reaction. Something else parents worry about a lot when introducing solids is whether the child is getting enough? Are they getting enough milk whether it's breast milk or formula? Are they getting enough solids? How do parents know especially when so much of the food ends up on the floor or on their face? How do we know if they're getting enough? How do we know if when we're feeding them they're still getting enough of the milk that we know is an essential nutrient?

Kim Grenawitzke: I think feeding your baby is one of the first times as a parent we have to learn to let go and trust our babies, right? It's so impossible and it's so challenging, but this is a really great time to just start to believe that your baby knows how their body feels. Keep in mind that your milk feeds are the most crucial nutritional component of your baby's diet. Even after starting solids you really don't want to see any decline or change in the amount your baby nurses or in the amount of the bottles they're taking. From six to nine months especially, so those first few months of trying foods your milk feeds really should be essentially the same. You don't want to see any drops at all. We tend to tell families to offer their milk feed first, wait 30-45 minutes and then do your solids meal. That way they're getting the nutrition from the milk feed, which is the important part. Then you're also making sure that they don't come to the table super hungry because we're asking them to do something really challenging by learning to pick up food, learning to chew. It's hard, so we want them to be in a good mood. None of us like to show up anywhere hungry, let alone a baby that's trying to do something brand new. Any amount of solid food that's consumed is just a cherry on top. If you can try to remind yourself that their nutrition is coming from their milk feeds and what they eat from food doesn't matter, I think that most parents would feel so much less stressed about solids. 

If you see that your baby is having a pretty big decrease in the amount of milk feeds before 9 to 10 months, you're probably giving too much solid food. You really do want to prioritize the milk feeds over solids until at least nine to 10 months. Around 9 to 10 months, a lot of times babies will start to slowly wean their milk feeds on their own and they'll start to eat more table food. If your baby is not that baby, that's okay. Some babies don't do this until closer to 12 to 15 months, and that's also very, very normal. Most babies are pretty much completely on solid foods by somewhere between 15 to 18 months with bottles and nursing sessions as supplement at that point. If for any reason your medical provider has encouraged you to prioritize solid food over milk feeds, it's our medical team's strong recommendation that you ask them more questions about why. Milk feeds are complete nutrition. They offer the baby everything they need in regards to nutrition and hydration. All of those little extra micronutrients that they get from table food are a plus. But prioritizing table food during this period typically is not great for weight gain or development. If your doctor is pushing that, just ask questions, is this something you're recommending specifically for my baby, or is this something you recommend for all babies? And can you just tell me a little bit more about that? Again, do your best to not worry about how much table food they're eating. It really doesn't matter. 

People ask me all the time how much my 9-month-old is eating and I'm like, I have no idea. Whatever she doesn't eat, I package up and I'm going to have for lunch today. Because with every experience she's feeding her brain, not necessarily her stomach.  She's building skills. She's learning about the family meal. She's having fun at the table. That's what matters. I don't care about the amount. If your baby's in that young toddler stage and is still not eating a lot of table food, that's when we might want to dig in a little bit more. But in the baby stage, do your best to just think about food is for learning, food is not for consumption They're getting what they need from their milk feeds. If every parent could prioritize that a little bit, I think there'd be a lot less stress at the table overall.

Dr. Cara Goodwin: Yes, I totally agree. I think just knowing that breast milk or formula is what they really need, that's so helpful to parents. Something else parents worry about a lot, I know I've worried about, especially with breastfed babies, is are they getting enough iron? As children, as breastfed babies in particular get older, they need to have solid foods as a source of iron. How do you know that your baby is getting enough iron and when should you be concerned?

Kim Grenawitzke: First I want you to think about the fact that all babies have different nutritional needs that depend on their birth history or pregnancy history. I was anemic and both of my pregnancies had to have iron infusions because my iron levels were low. So my babies are going to be predisposed to lower iron levels later on. Medications like reflux medications can also get in the way of iron absorption in the body. So every baby is a little bit different in terms of their iron needs and how their body absorbs iron. With that being said, you could do everything right and there could be iron-rich food in every single meal and your baby eats it like a champ and they still may end up with some low iron levels when it's tested by the pediatrician. Try to remind yourself that some things are just how your baby's body works and we can't control it perfectly. But to best support their iron needs, you just want to offer iron-rich foods at most meals. So even a few bites is great. Things that we're thinking about here are like beans, nuts and seed butters, tofu, tempeh, meats, cooked leafy greens, iron-fortified cereals if you're interested. And you can also do iron fortified pastas, things like that. Lentils are great or even just cooking stuff in a cast iron skillet can be great for extra iron in the food. 

Also keep in mind that the recommended daily values of iron that are, at least in the United States, are based off of the idea that infants are getting the majority of their iron from fortified infant cereals. Those iron sources are non-heme iron. Non-heme iron is harder to be absorbed by the body. Those recommendations are higher. If a baby was getting more heme iron sources, those recommendations would most likely be a little bit lower. If you have a variety of iron sources in the diet, you're getting a lot of different varied forms of iron and giving the baby's body a lot of opportunity to absorb that. Remember that consumption is typically low in the beginning, so you're just exposing and giving them opportunities to like get some of that iron in them. Even sucking on a piece of steak is giving them some exposure to iron and they are getting some there. If your baby is growing, if they are energized, if they're showing curiosity and engagement in their environment, they're most likely getting the iron that they need. They're also going to get screened at the pediatrician's office sometime between 9 and 12 months. Everywhere you live has a little bit of a different process. My first daughter was screened at nine months. In Michigan where I live now, they don't do the screening until 12 months. Your medical provider will give you recommendations if they feel that you need to do an iron supplement. If you're worried though, talk to your pediatrician. If they do end up needing an iron supplement, like I had said before, you are not a failure as a parent. This is not a reflection of your ability to care for your child. It is just how their body absorbs the iron. 

I worry sometimes about things like iron because if you get into the mindset of I really need to get my baby to get all these iron-rich foods, it's really easy to start pressuring your baby to eat. It's really easy to be forcing them to take another bite or mixing up that really yucky iron supplement in some sort of puree to try to get it in them because you're so worried about these iron levels. If you're at that level of anxiety about iron, please, please discuss this with your pediatrician because if they can decrease your worry about it and you can keep a low pressure eating environment for your baby, that's how we're going have a healthy foundation at the table. The least amount that we can force and push the better. There are some symptoms of low iron that are interesting for parents to know. So if you find that your baby looks really pale all the time, if they have really poor sleep, especially restless sleep, so lots of like kicking and moving around a lot, super irritable, if they have really poor appetite or just overall fatigue, those can be some signs of low iron and again it's worth asking your pediatrician about it.

Dr. Cara Goodwin: I love how you make the point that parent anxiety has a big impact, so to be aware as a parent how am I feeling about this? Am I starting to get anxious because that will impact your child? Making sure that we're knowledgeable about what our children need, but we don't worry about it to the point that we are creating anxiety.

Kim Grenawitzke: Because what we bring to the table matters in the same way that if we show up to a dinner with our husband and we're in a crappy mood, we're going to set the whole tone of that dinner in a very different way. Think about what you bring to the table.

Dr. Cara Goodwin: Another source of parent anxiety with feeding your kids is salt or sodium. I've heard before, do not give your child under one any foods with salt or sodium. But, a lot of times I will give my infant what the rest of the family is eating. And we like a little bit of salt in the food. Personally, I actually like more than the average person so I've worried about it. Can you give added salt or sodium and how do you know if it's too much?

Kim Grenawitzke: There's a lot of fear mongering out there about sodium. I feel like this is one of those things that people love to like throw the hammer down and you can never expose your baby to sodium. Well, guess what? Breast milk and formula both have sodium in it. Babies in the hospital have IVs that have sodium in it. In order to get sodium poisoning, the amount of sodium your baby would have to consume is just outrageous. There's no way that that's going to happen in a typical eating situation. Babies can have salt in moderation. We tend to say salt your food afterwards. Make your dish, is there some salt in your dish? Potentially.  Last night we had enchiladas and obviously in the sauce, there's some sodium. And that's okay. My nine-month-old shared that with us. My husband and I added a little bit of salt after the fact. In reality, what we know about sodium is that it can prime your palate for enjoying saltier foods. So if your baby is exposed to a lot of sodium early, and this also is the case for toddlers too, and we do know that most toddlers in the United States are given way too much sodium and too many salty snacks. 

We know that, when babies are exposed to more sodium, their palate then enjoys saltier food. If we build a palate of a baby and a child who likes saltier food, then their diet is likely to consist of more salty food moving into childhood, teenagehood, and adulthood. When adults eat more salty food overall, that can set them up for health problems later on in life, like hypertension, heart disease, stroke, etc. So limiting sodium in your diet early on is kind of a long game strategy for health. It's also hopefully priming the palate for liking a wide variety of foods that are not super, super salty. The benefit of sharing the food with your baby is paramount. I cannot speak more to how important it is to actually share your family food with the baby. If there's some salt in your dish, it's okay. Just don't go overboard. You don't need to add salt to baby's food. You can always balance out your child's food during another meal. If they have something that's kind of high in sodium, one meal, the next meal, just go with something that doesn't have sodium at all, if you want to be a little bit more balanced about it.

Dr. Cara Goodwin: That's so helpful to know that it's like not an all or nothing thing. So what about added sugar? A lot of us try to avoid like super sugary foods with babies under 12 months, like cake and cookies. But I was looking at my kids' yogurt the other day and I'm like, oh, that's like a lot of added sugar. How should you think about sugar with babies under 12 months?

Kim Grenawitzke: The funny thing about these kid foods that are branded for kids, like the kids' yogurts and the kid stuff, all have added sugar and they're all more expensive. It's so crazy. If you look at the grocery store, you can like buy an entire tub of yogurt for half the price of the like silly kid, branded extra sugary yogurt. But it makes sense, right? Because the sugar in many ways is addictive. Our brains and our bodies really, really love that sugar. So in general, the AAP, recommends delaying the introduction of added sugar until two. So that doesn't mean you need to avoid everything that has sugar in it because fruit, for example, has natural sugars, but fruit also has fiber and other nutritional benefits that kind of balance out that sugar. But in general, delaying the introduction of added sugar, so things like cakes and cookies is ideal. In theory, the idea here is that we're hoping to help babies and toddlers develop preferences for unsweetened food. 

If your baby gets used to eating regular plain Greek yogurt, hopefully by the time they're two or three, eating regular plain Greek yogurt is something they enjoy and they're not always requesting the sugar-sweetened stuff. Same thing with cereal, giving plain O cereal versus giving cereal that's sweetened. Hopefully you're developing a palate where they enjoy the stuff that's doesn't have added sugars. The research on this is not great, but it's emerging. Like I had mentioned earlier, the preference for sweets is built in. So there's really nothing that we can do to change that. It's just how our bodies and evolution has set us up. Breast milk is innately sweet. Clearly babies like sweet to begin with. But there is research out there that says that children are going to prefer sweets to the level at which they have been exposed. If they're exposed to foods that are super, super sweet, they're likely going to have a sweeter preference palate versus those that have had foods that are a little bit less sweet, they're most likely going to be interested and prefer that level of sweetness. If you can avoid the yogurt that has added sugar, that's great, but if that's what you have, it's what you have. Most pediatricians will tell you under 12 months, try to avoid it altogether. 

Has my daughter had a taste of ice cream? Absolutely, it's okay. It's all about balance and enjoying things. Like, Fourth of July rolled around and my toddler had a popsicle. Did the baby get a little taste of it? Absolutely, I'm not losing sleep over it. Every baby or most babies have a really sugary cake on their first birthday and it's okay. In the same way that we're trying to limit sugary consumption for toddlers and older children, just because we know the benefits of lower sugar intake on our health. Focusing on not doing lots of sugar for your baby is also great too, but again, not something that you need to stress about. I just want parents to be less stressed about restrictions with what they can give their baby.

Dr. Cara Goodwin: I love that balanced approach that really helps to reduce the anxiety to think that it's not all or nothing. It's really all about balance and moderation just like how it is with our own eating, you know. This might sound like a random question, but I've seen a lot of influencers and people on social media say you need this one particular expensive high chair. What should you look for in a high chair? Does the high chair matter? Do you really need like a foot plate? What should you look for?

Kim Grenawitzke: When it comes to seating, you can sit your baby on the floor or on your lap with their back against you and that's completely fine and safe. If you do not have the space, if you do not have the finances, if getting a high chair for any reason is out of your grasp, it is 100% okay to sit on the floor or sit with your baby on your lap and they are safe. When it comes to a high chair though, if you're going to buy one, I prefer to recommend having babies sitting completely upright. I do like a foot plate and I also like a removable tray. A lot of the chairs on the market have like a big fluffy back, they look super comfortable, and they also have a recline feature. If you need to recline your baby for any reason, they are not safe for eating solids. Being reclined even slightly increases the risk of food going into the breathing tube or aspiration and it also increases choking risk. It also makes it very easy to dump food in your baby's mouth. Because if they're reclined, you're coming at them and you're essentially pouring it in their mouth if you're spoon feeding them. It's also really hard for a baby that's leading backwards to physiologically get their hands to their mouth. 

Sitting very, very upright is key. Even if you have a chair that doesn't support them completely upright, you can always put towel rolls or blankets behind them to help them sit upright. I like to tell parents to go to the side of the chair and look at your baby's hips. and you want to look at their hips being directly in line with their shoulders. So that tells you that their back is completely upright. That's going to set them up for the best chewing, swallowing and safety. Now, do you need a footplate? Is your child going to choke and never eat well if you don't have a footplate? No, that's not the case. But having a footplate can improve a baby's stability in sitting and a lot of times it helps them sit for a longer period of time. So in the same way that if you're sitting with a bar stool and your feet are hanging, you feel a little unstable, it feels weird if you don't have something to rest your feet on, and that's because it provides stability for your entire body. When a baby has a foot plate and they can bear weight into that foot plate, they also have more support for their entire body. It gets them in a position where again their arms can be used flexibly but also the small muscles in their mouth and the small muscles that they use for swallowing are the best supported. In the therapy world, we like to say what happens at the hips happens at the lips, so that foot plate provides support for the hips which then can provide support for the mouth being able to do all these really creative and flexible things that we need it to do when chewing. Also, a lot of times if a baby is super wiggly and doesn't want to sit for a long time, the foot plate provides more stability and helps them stay seated a little bit longer. 

Full disclosure, my kids have absolutely sat in hanging high chairs without a stool underneath them. They've sat in high chairs at restaurants and they're completely safe and fine, but there are especially some babies that are maybe a little bit lower tone, they're a little bit less strong and that foot plate really does make a difference. That's one of the things that when a family tells me their child's just not doing so well with solids, that's one of the things I like to look at first. 

I also like a tray or a high chair that has a removable tray, so you can pull the baby right up to the table. Babies learn by watching us. A baby that's in a high chair away from the table a lot of times is like, what am I doing? I don't really care about this food. But if you take the high chair tray off and you pull them right up at the table and they can watch everybody else eating, they're like, wow, this is really cool. I want to do what sister's doing. I want to do what mom's doing. I want to do what dad's doing. That modeling is really, really important. When your baby gets to be a toddler, holy cow, they need to be at the table because otherwise they're going to be off doing their own thing. A lot of the chairs on the market are convertible, so for money saving options, I love telling families to get one that transitions into a toddler chair so that you don't have to buy a booster seat, you don't have to buy other things. It's great to have something that you can transition. 

Then the mom in me is like, get something that's easy to clean. I can't tell you how many times we've taken the high chair outside and just sprayed it down with a hose because it's covered in yogurt or covered in stuff. Things that have straps that are made of fabric and you can't wipe them down with lots of crevices. Definitely not a chair that I'd want to buy.

Dr. Cara Goodwin: That is such good advice. I'm just thinking of cleaning my own high chairs. It’s kind of a disaster.

Kim Grenawitzke: It's gross and no matter how well you clean your house, there's ants, like it's just impossible to like keep it clean.

Dr. Cara Goodwin: I have three dogs and I always wonder how people who don't have dogs do it because they clean everything from underneath as well and it’s such a nightmare to have to clean the floor.

Kim Grenawitzke: Just know that anybody that does have a dog, your dog's going gain like 10 pounds when your baby starts solids so just prepare accordingly for how much food you offer them.

Dr. Cara Goodwin: So, so true. All of a sudden the dogs come around on the baby. They hated the baby for six months and then they start loving the baby.

Another source of parent anxiety is how do you tell the difference between gagging and choking? I think all of us who have fed a baby have seen gagging and it's scary. You're just sitting there thinking, do I intervene? So how do you tell the difference between gagging and choking and how do you know when to get really worried?

Kim Grenawitzke: Gagging and choking are technically two completely different physiologic mechanisms in terms of like what's happening inside. They present really differently. But when it comes to eating, almost everything that looks not perfect or not right is thrown into this bucket of choking. A baby coughs and it's like, they're choking or a baby gags and they're choking. Everything gets tossed into this bucket. 

Gagging itself is a protective reflex. Just like when the doctor hits your knee and your leg kicks out, gagging is also a reflex in the same way. It's a rhythmic contraction of your food tube, your pharynx. So the idea is that it's getting stuff out of your stomach or getting stuff out of your mouth. And the brain gags when starting solids because things are different and they're like a surprise. So up until the time you start solids, all the brain knows is thin, watery milk. And then something new gets in their mouth, whether it's rice cereal, puree, or banana. And they're like, wait, this isn't right. I'm going to gag because I don't think this should be here. So it's kind of the body's protective response to keep stuff out. So typically with gagging, you see an open mouth, you see a cupped tongue. So the tongue looks like a U shape. Sometimes you'll see like a forward thrusting of the head and the body. You might hear retching sounds or like a eh, but sometimes gagging is silent or they're not making much noise at all. Most of what you see when a baby is starting solids is gagging. Now choking on the other hand is a different scenario. 

Choking is a complete or a partial blockage of the breathing tube. In our throats, we have two tubes, one for breathing, one for food. Choking in the way that is colloquially understood is when the breathing tube is blocked. Something is in the breathing tube and the baby or the child or the adult is unable to breathe. By definition, it's silent. You may hear some wheezing as air tries to escape past that thing that's blocking the breathing tube. But choking is a medical emergency and you do need to call 911 immediately if that does occur. With choking, the baby will not be able to cry. They will not be able to cough. They're not going to  be able to breathe. You may see tugging in or tugging back as opposed to gagging, which is typically a forward kind of thrusting in motion. You may hear some high-pitched sounds or wheezing, and in really severe cases, you'll see skin color changes as the baby's not getting oxygen. Now keep in mind if the baby is coughing, they're not choking, because if they're coughing, air is flowing, and choking means that the tube is blocked. So every parent, no matter how you start solids, should be trained in choking rescue not only because food is offered, but because babies, especially under the age of one, are more likely to choke on non-food items. 

My nine-month-old right now is all over the place. I found her in the coat closet the other day. If you have a toddler and there are Barbie shoes on the floor or rubber from the sole of your shoe or the stopper off the doors. These are the things that we worry about because your 9- or 10-month-old baby is crawling all over the place and that baby is going to put those things in their mouth. So it's very, very risky if you're not prepared in case of an emergency.

Dr. Cara Goodwin: That is so true, especially if you have an older child. I feel like little things are just everywhere. You have to be so careful.

Kim Grenawitzke: I found my nine-month-old with stickers all over her fingers yesterday, from my toddler, of course, and that could easily go in her mouth quickly.

Dr. Cara Goodwin: Yes, it's definitely so scary.

So what about introducing water? When do you introduce water? What kind of cup should you use? I feel like there's a lot of confusion around that.

Kim Grenawitzke: There's lots of varied opinions on water. Most of the medical institutions agree that water can be introduced in small amounts once you start solids. The AAP says up to eight ounces a day. We tend to recommend a little bit less because water can decrease a baby's interest in drinking breast milk or formula, which we know is the most important thing for them to be drinking. But giving small amounts of water is great for constipation, it's great for digestion, and it's great for a baby to learn how to drink water from a cup and a straw. We tend to prefer an open cup and a straw cup. There's a lot of drama and discussion out there about sippy cups and valves and all these things. The literature is not great to tell you that any of these things should or shouldn't happen. 

We tend to recommend a cup and a straw because these are things that your baby is going to use moving forward in their life. A sippy cup is an expiration skill. They need it for a short period of time, then they move on. It's a skill set that they don't need for a very long time. If they learn to drink from a sippy cup and they don't learn from a cup or a straw, it might be a little bit challenging to transition to that skill later. So if you want to use a sippy cup, go for it. Just use that as one of the cups that you introduce. When it comes to an open cup, just go with something small. You only want to offer them a one or two ounces at a time because you're going to get spills everywhere. Even like a little shot glass can be great or a little yogurt cup, a little plastic cup can be awesome. You do not have to spend a ton of money on something fancy. I'm a big fan of anything that has a little bit of give so you can squeeze it a little bit because squeezing the cup helps bring the water up the straw. 

Our 6- to 9-month babies tend to be really good at straw drinking right off the bat because they're used to sucking from a bottle or from a breast and so it's super easy for them to pick up that skill. If your baby's a little bit older and you haven't introduced a straw yet, that's okay. It might just take a little bit more practice. But the American Dental Association does recommend getting rid of sippy cups in early toddlerhood. So again, if you're using them, please don't stress about it, it's absolutely okay. You have not ruined your baby's oral motor skills or their oral facial development. But just balance that out with using straws and cups because those are also things that they need for life.

Dr. Cara Goodwin: That's such a good point that I hadn't thought of that eventually you don't really use sippy cups. You're not going to be using a sippy cup as an adult.

You have just given us such incredible information. I have one more question. Is there anything else we can do in feeding in the first year to reduce the risk of picky eating in later years? I think all of our goals are just please, please, please don't be a super, super picky eater. Is there anything else we can do that can reduce that risk?

Kim Grenawitzke: Despite what anybody says, we truly believe that there are things that you can do. There are things that we can control. Keep in mind that picky eating is multifactorial, right? Like temperament plays a huge part in this. If you have a highly sensitive child, they're probably going to be more predisposed to being more selective with their food as opposed to a baby that's more of a dandelion and is easier, more easygoing. You can set up the environment to help them be exploratory with food anyway. The first thing that we can do is always be responsive to our baby. Listen to their cues. If they say no, if they stop, if they push food away, listen to what they're saying. Try not to override their hunger and tiny cues. If they communicate that they're done, it's okay. End the meal. There's no reason to distract them, put on a TV, force feed them, trick them. Just serve the food, let them engage, and listen to the ways that they're communicating, whether they're interested or not. 

If you can serve them the family meal or parts of your family meal from the beginning, do it. Making oatmeal for your baby while you're having toast and coffee doesn't seem daunting, but when you have a three-year-old and a five-year-old and an eight-year-old and everybody's running around and it's 5.30 p.m. and bedtime is looming, making different dinners for every single kid is a lot of work. If you get into the habit of yourself of making one meal and serving one meal and that's it and not doing any short order cooking, that's going to teach your baby that this is what's offered. I have the choice to eat it or not. Offering your baby something different than what you're eating is probably what I would consider the slipperiest slope to picky eating. Because you get to a point of when do I stop serving special food to my baby. If your baby gets used to the fact that if I just don't eat what's served, I get something else, they learn pretty quickly to not eat the chicken and mashed potatoes that you gave them and to throw a fit until they get the yogurt and berries or whatever it is that is their preferred food. 

There is a strong research to support that when a parent eats the same food as the child, there's less food refusal. Doing that from the beginning is really, really important. If your baby doesn't like what's offered, that's okay. They have milk feeds. If they refuse the meal altogether, that's okay. They have milk feeds. Set the habit up in yourself and during your meal times that you serve the family meal, they eat it or they don't, and you move on with your day.

I think most importantly, and I know you've talked a lot about parenting styles on your platforms, permissive parenting and authoritarian parenting are the two parenting styles that are associated the most with picky eating. Setting boundaries, but having empathy is what you want to do from day one. Introduce your food, express that you understand that this is a hard skill that they're trying to learn, but hold your boundaries as to what's okay at your meals and what's not. Make the table a place your baby wants to be. We talk a lot about channeling dinner party vibe. Make it a fun place and then if your baby doesn't eat, that's fine, move on with your day, try not to stress about it. And if you have that perception from the moment you start solids, when they become a selective toddler, as all of them do, you're going to see much shorter selective toddler phase than you would if you started catering specifically to your baby and not setting those boundaries early. I feel like I went down a little rabbit hole on that, but this is something I feel really passionately about.

Dr. Cara Goodwin: I love this like low-anxiety, low-fuss approach to it because it's also easier.

Kim Grenawitzke: We have lots of resources for families depending on what direction you want to go. If you are a parent that wants specific directions, like on Monday I'm going to serve this and on Tuesday I'm going to serve this, we have that for you. We have something called the 100 Days Guide, which literally gives you food ideas and recipes for the first 100 days of starting solids. For me in my house, I'm more like, I make the family meal and I share it with the baby and I use our app or I use our database that's free to look up how to prepare those foods for my baby. If you're a little bit more concerned about nutrition or you really do want to focus on that, we have a great guide with 50 fantastic first foods for your baby. That will give you ideas of things that you can serve, but it's less prescriptive than the 100 Days Guide. You can take this so many different ways, but the goal is to just feel good about serving the foods that you love to your baby and to enjoy it.

Dr. Cara Goodwin: I love how simple you make it seem and that it doesn't have to be this big scary thing that all of us face starting solids.

This has just been so incredible. You've given us so much information. I cannot thank you enough. Can you tell us one last time where to find more information for parents who are starting solids and what kind of resources are have available?

Kim Grenawitzke: Follow us on Instagram at @solidstarts. We also have a really robust website with tons of articles if you want to deep dive into any of these topics, as well as guides and courses and that's www.solidstarts.com. Any of our resources, so our guides, our courses are completely free if you have economic need. You just have to search economic need on our website. There's a form you fill out and you can request any of our resources completely free, no questions asked. We want to make sure that everything can be available to any parent that needs it. So go ahead, check out our website, check out our Instagram and reach out if you need us. We're happy to help. We're really excited about forming healthy, happy relationships at the table.

Dr. Cara Goodwin: I love that. This has just been so incredible for any parents that are starting solids. I cannot thank you enough for all of this information and thank you so much for your time and for being here.

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Welcome to the Parenting Translator newsletter! I am Dr. Cara Goodwin, a licensed psychologist with a PhD in child psychology and mother to four children (currently a newborn, 3-year-old, 5-year-old, and 8-year-old). I specialize in taking all of the research that is out there related to parenting and child development and turning it into information that is accurate, relevant, and useful for parents! I recently turned these efforts into a non-profit organization since I believe that all parents deserve access to unbiased and free information. This means that I am only here to help YOU as a parent so please send along any feedback, topic suggestions, or questions that you have! You can also find me on Instagram @parentingtranslator, on TikTok @parentingtranslator, and my website (www.parentingtranslator.com).

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