What are the guidelines for introducing solids to a 6-month-old infant during weaning?

Introduction of Solids at 6 Months: Evidence-Based Guidelines

Introduce solid foods at 6 months of age (not before 4 months) when the infant demonstrates developmental readiness, starting with iron-rich foods and including allergenic foods without delay. 1

Developmental Readiness Markers

Before introducing solids, confirm the infant has achieved these milestones:

• Good head control - the infant can hold their head steady without support 1, 2
• Ability to sit with support - can maintain sitting position in a high chair with assistance 1, 2
• Interest in food - watches others eat and reaches for food 2
• Disappearance of extrusion reflex - no longer automatically pushes food out with tongue 3

First Foods and Feeding Progression

Start with iron-rich foods as the priority since iron stores from birth are depleted by 6 months 1, 2:

Initial Foods (6 months)

• Iron-fortified infant cereals providing approximately 1 mg/kg per day of iron 3
• Iron-rich vegetables: broccoli, cauliflower, squash, carrot, white potato as smooth, thin purees 1
• Meats: finely ground beef, lamb, chicken, or fish 2
• Fruits and vegetables can be introduced alongside other foods 4, 1

Texture Progression

• 6 months: smooth, thin purees mixed with breast milk or formula 3
• 8 months: soft-cooked, bite-and-dissolve textures 1
• 12 months: modified family foods that are table-chopped, soft-cooked 1

The aim is to encourage normal textures for age and prevent long-term feeding problems 4

Allergenic Foods Introduction

Introduce allergenic foods (peanut, egg, dairy, wheat) at the same time as other complementary foods around 6 months without delay 1, 2:

• Standard-risk infants: introduce allergenic foods at home without specialist evaluation 1, 2
• Infants with mild-to-moderate eczema: introduce peanut-containing foods around 6 months at home 1
• Infants with severe eczema or egg allergy: evaluation by allergist may be warranted before introducing peanut 1

Introduction Strategy

• Introduce one new food at a time and wait at least 4 days before introducing another to observe for reactions 1, 2
• Foods should be given at normal concentrations (not diluted) to ensure adequate nutritional intake 4

Feeding Amounts and Frequency

Initial Amounts

• Start with 1-2 teaspoons per feeding, gradually increasing as the infant becomes familiar with eating solids 1, 2
• At 6-8 months: offer complementary foods 2-3 times per day 2
• At 9-11 months: increase to 3-4 times per day 2

Breast Milk/Formula Continuation

• Breast milk or formula remains the primary nutrition source throughout the first year 2
• Offer breast milk or formula first, followed by solids 2
• Continue breastfeeding alongside solid food introduction for as long as mutually desired 1, 2

Normal Responses vs. Warning Signs

Expected Normal Reactions

• Initial hesitation or refusal - may need 8-10 exposures to accept a new food 1, 2
• Facial expressions of surprise, confusion, or disgust - normal reactions to new tastes 1
• Small gagging episodes - occur as infants learn oral motor skills 1
• Mild stool changes - changes in consistency, color, and frequency are expected 1
• Small amounts of undigested food in stool - normal as digestive system matures 1

Warning Signs Requiring Medical Attention

• Persistent vomiting, especially projectile vomiting 1-4 hours after eating 1
• Severe diarrhea with blood or mucus 1
• Skin rashes, hives, or facial swelling occurring shortly after food introduction 1
• Respiratory symptoms - wheezing, persistent coughing, or difficulty breathing 1
• Lethargy or significant behavioral changes following food introduction 1

Foods to Limit or Avoid

Specific Restrictions for Certain Conditions

For infants with glycogen storage disease type I, limit or omit fruits, juice, and other sucrose-containing, fructose-containing, and lactose-containing foods 4. However, for healthy infants, these restrictions do not apply.

General Safety Guidelines

• Avoid honey before 12 months due to botulism risk 2
• Avoid whole cow's milk as main drink before 12 months 2
• Avoid added salt or sugar in complementary foods 2
• Limit juice and avoid sugar-sweetened beverages entirely 2
• Ensure appropriate textures to prevent choking hazards 1

Critical Pitfalls to Avoid

Delaying introduction of solids beyond 6 months increases risk of iron deficiency anemia, inadequate nutrient intake, growth deficits, and feeding problems 1, 3. The evidence is clear that waiting too long is harmful.

Delaying allergenic foods beyond 6 months does not prevent food allergies - in fact, early introduction between 4-6 months may help prevent food allergy, particularly for egg and peanut 1, 5.

Spoon-feeding, drinking from a cup, and introduction of table foods should follow normal feeding progression to prevent long-term feeding disorders 4. Any delays in this progression should be addressed immediately.

Special Populations

Infants with Severe FPIES to Cow's Milk or Soy

For these high-risk infants, supervised introduction of solid foods may be necessary, and consider starting with lower-risk vegetables before rice cereal 1, 3.

Infants on Parenteral Nutrition

Solids should be started at the usual recommended age for healthy infants where possible, limiting initially to foods least likely to have allergenic effect (rice, chicken, carrot) especially if there is intestinal inflammation 4.