At what age and with what foods should solids be introduced to a baby's diet, and is baby-led weaning or purees recommended?

Starting Solids: Evidence-Based Recommendations

Timing: When to Start

Introduce solid foods between 4-6 months of age, with 6 months being the preferred target, ensuring your infant demonstrates developmental readiness including good head control and ability to sit with support. 1, 2

• Do not introduce solids before 4 months of age due to immature gastrointestinal and renal systems 1
• Do not delay beyond 6 months, as this increases risk of iron deficiency anemia, inadequate nutrient intake, growth deficits, and feeding problems 3, 1, 2
• Wait for developmental markers: good head control, ability to sit with support, and disappearance of the extrusion reflex 1, 2

First Foods: What to Introduce

Start with iron-fortified cereals or iron-rich foods (such as pureed meats), as infants need approximately 1 mg/kg per day of iron at this age. 1

Standard Risk Infants:

• Begin with iron-fortified rice cereal or other iron-rich foods like pureed meats 1
• Progress to fruits and vegetables in pureed form 2
• Two or more servings per day of iron-fortified infant cereal can meet iron requirements 1
• Introduce allergenic foods (peanut, egg, dairy, wheat) at the same time as other complementary foods around 6 months—do not delay these foods 2

High-Risk Infants (Severe Eczema or Food Allergies):

• For infants with severe eczema or egg allergy, evaluation by an allergist may be warranted before introducing peanut 2
• Rice is considered a higher-risk food for food protein-induced enterocolitis syndrome (FPIES) in these infants 1
• Consider starting with lower-risk vegetables (broccoli, cauliflower, parsnip, turnip, pumpkin) before rice cereal 3, 1
• Introduce one new food at a time and wait at least 4 days before introducing another to observe for reactions 2

Purées vs. Baby-Led Weaning

Start with smooth, thin purées mixed with breast milk or formula, then progress to thicker consistency as the infant develops oral motor skills. 1, 2

• Begin with 1-2 teaspoons and gradually increase as the infant becomes familiar with eating solids 2, 4
• Progress from pureed textures to more complex textures as oral motor skills develop 2, 4
• Most infants will naturally advance through texture stages as they mature 2
• While baby-led weaning has gained popularity, the evidence base is limited, with only one randomized controlled trial (BLISS study) examining a modified approach 5

Practical Feeding Progression:

• Months 4-6: Smooth, thin purees of vegetables high in iron; choose foods like broccoli, cauliflower, squash, carrot, white potato 3
• Month 6: Expand to fruits (blueberries, strawberries, apple, pear, orange) and continue vegetables 3
• Month 8: Introduce soft-cooked, bite-and-dissolve textures; add high-iron foods like lamb, fortified cereals, beef 3
• Month 12: Offer modified family foods that are table-chopped, soft-cooked 3

Critical Safety Considerations

Normal Responses (Reassure Parents):

• Initial hesitation or refusal requiring 8-10 exposures to accept new foods 2
• Facial expressions of surprise, confusion, or disgust 1, 2
• Small gagging episodes as oral motor skills develop 1, 2
• Mild stool changes in consistency, color, and frequency 1, 2

Warning Signs Requiring Medical Attention:

• Persistent vomiting, especially 1-4 hours after eating a specific food 2
• Severe diarrhea with blood or mucus 1, 2
• Skin rashes, hives, or facial swelling 1, 2
• Respiratory symptoms (wheezing, persistent coughing, difficulty breathing) 1, 2
• Lethargy or significant behavioral changes 1, 2

Common Pitfalls to Avoid

• Do not introduce rice cereal before 4 months, even if the infant seems "ready"—the gastrointestinal and renal systems are not sufficiently mature 1
• Do not delay beyond 6 months waiting for "perfect readiness"—this increases iron deficiency anemia risk 1
• Do not delay allergenic foods beyond 6 months in an attempt to prevent allergies—this strategy is not supported by evidence and may actually increase allergy risk 3, 2
• Introduce foods at normal concentrations, not diluted, to ensure adequate nutritional intake 2
• Ensure appropriate textures to prevent choking hazards 2

Special Populations

Premature Infants:

• Introduce solids around 6 months of chronological age (not corrected age), but not before 4 months 4
• Prioritize iron-rich and zinc-rich foods due to higher deficiency risk 4
• Follow the same developmental readiness markers as term infants 4

Breastfeeding Considerations:

• Continue breastfeeding alongside solid food introduction 2
• Breast milk or formula should remain the primary nutrition source during the first year 2
• Decreased milk intake is normal as solids increase, but should not be forced 2