The association between early introduction of tiny tastings of solid foods and duration of breastfeeding

The Word Health Organisation (WHO) recommends exclusive breastfeeding for six months and continued breastfeeding for at least two years or longer [1, 2].

It is well known that infant formula feeding increases the risk of breastfeeding cessation [3]. However, research has shown conflicting results regarding whether early introduction of solid foods, i.e. other sources of nutrition than breastmilk/formula, is associated with a shorter duration of breastfeeding. In the Swedish study [3], no association was found, while the study from the UK showed both an association and a dose–response effect [4]. In this context, it is notable that these two countries differ greatly in breastfeeding habits. In a Norwegian study, early introduction of solid foods was related to maternal sociodemographic factors, such as lower educational level, smoking and lower age [5].

Even though breastfeeding is associated with health benefits for both the mother and the child, breastfeeding recommendations in several high-income countries are in conflict with the WHO’s recommendation [1]. It is unknown how national recommendations affect breastfeeding. Sweden is considered a pro-breastfeeding country, and the breastfeeding incidence peaked during the 1990s when more than 40% of infants were exclusively breastfed for six months [6]. This was partly a result of a planned strategy to increase breastfeeding rates, namely the Baby Friendly Hospital Initiative [7]. However, the prevalence of exclusive breastfeeding for six months has decreased over the last few decades to 11% in 2019 [6]. One recommendation, in particular, in the national guidelines, has possibly had a significant impact on breastfeeding. Since 2011, the National Food Agency has informed parents that they can introduce tiny tastings (1 mL of solid food) from four months of age. The reasoning was that the amount was so tiny that it would not negatively affect breastfeeding. In Sweden, all children aged 0–5 years are offered health care services free of charge by the Child Health Service (CHS). CHS is available in all the 290 communities and aims to contribute to children’s physical, psychological and social health by promoting health and development, preventing illness, detecting emerging problems early on, and intervening when needed to optimise the child’s development. Due to a non-evidence-based belief that exclusive breastfeeding might delay and complicate the introduction of solid foods, the CHS had not recommended exclusive breastfeeding for six months. Based on this misunderstanding, the National Food Agency changed the national guidelines and added the introduction of tiny tastings [8]. This change has been utilised by the Swedish baby food industry, offering a range of products intended for infants from four months of age. Furthermore, the CHS continues to encourage parents to start providing solid food at four months, even when women express that they want to breastfeed exclusively for six months [9]. In the present study, we hypothesised that early introduction of solid foods, including tiny tastings, was associated with shorter duration of breastfeeding.

This retrospective study was a part of the longitudinal ‘Swedish Pregnancy Planning Study’ [10] and approved by the Swedish Ethical Review Authority, d.nr. 2010/085, with supplemental applications during the years. The aim was to investigate at what age solid foods, including tiny tastings, were introduced to Swedish infants as well as its effect on the duration of breastfeeding.

Antenatal clinics (n = 215) in ten (n = 10/21) regions in Sweden were invited to participate, and 153 (71%) agreed to participate. Women were asked to complete the questionnaires during registration at antenatal clinics in early pregnancy (Q1), in the third trimester (Q2) and one-year post-partum (Q3). The recruitment was conducted between 2012 and 2015. A total of 5,494 women were initially approached, out of which 4,969 women accepted participation. In the end, 3,389 completed and returned Q1. The first follow-up questionnaire (Q2) was sent to a total of 3,215 women, and 2,583 completed and returned the questionnaire. The second follow-up (Q3) was sent to 2,018 women, and 1,263 returned the questionnaire. A more detailed description of the procedure has been published previously [11]. Four of these questionnaires lacked an ID and could not be matched to previous questionnaires. For the current study, we also excluded women who had not provided data for all three questionnaires (n = 4), whose child was no longer alive (n = 3), and who provided data for an older sibling (n = 1). The final study sample comprises 1,251 women.

The self-reported questionnaires included sociodemographic questions about the mother (age, sex, previous children, country of birth, level of education and household income), the pregnancy (level of pregnancy planning, single/multiple pregnancy), mode of delivery (how it started, ended and if there was haemorrhage > 1000 ml), and the infant (birth weight, gestational age, sex, neonatal care, congenital states and twins). Furthermore, there was a detailed question about nutrition for the infant’s first year (0–12 months) “What kind of food did your child get during his/her first year?”: duration of breastfeeding, infant formula and introduction of solid foods including tiny tastings; see Additional file.

The main findings of this study were that half of all infants were fed with tiny tastings already in the fourth month and that the earlier the infant started with tiny tastings, the earlier they ate larger amounts of solid food. In the multivariate linear regression analysis, five factors were identified as having a negative effect on the duration of breastfeeding: the infant’s age upon introduction of tiny tastings, low maternal age, low level of maternal education, high maternal BMI and twin birth.

The Swedish recommendation to offer tiny tastings from four months of age contradicts the WHO’s recommendation [1], and its impact on breastfeeding has not been studied before. This study shows negative effects on breastfeeding duration. To recommend exclusive breastfeeding for six months could help to scale up breastfeeding and generate benefits besides those of the breastmilk itself, since breastmilk intake among children is associated with lower odds of consuming non-recommended foods, such as cookies, crackers and sweetened drinks [12, 13]. Instead, Nutrition Committees, such as the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition, continue to emphasise the introduction of solid foods from four months of age [14]. In line with the recommendation, the Swedish CHS informs mothers that it is important to start with solid foods when the child is four months old, even when women express that they want to breastfeed exclusively for six months [9]. Addition of solid foods before six months is common in many countries, with one common argument being that this protects against developing food allergies. However, research has not found evidence of any benefits from addition of solid foods before six months, nor any risks related to morbidity or weight change [15]. Another common concern about exclusive breastfeeding for six months is the risk for iron-deficiency anaemia. However, the risk can be successfully mitigated by delayed umbilical-cord clamping [16].

Conflicting advice and non-evidence-based recommendations have a negative effect on breastfeeding [6]. In many ways, it can be perplexing for women to breastfeed in a society that is not infused by a favourable attitude towards breastfeeding. Consequently, breastmilk substitutes have become a “multi-billion dollar industry” that has the opportunity to devote considerable financial resources, influencing women not to breastfeed [17]. Thus, our findings are consistent with previous literature.

This study investigated the impact of tiny tastings on the duration of breastfeeding. The results revealed that half of all Swedish infants taste their first solid foods during their fourth month, and that the earlier the tiny tastings were introduced, the shorter the duration of breastfeeding. It is difficult to influence most conditions that affect breastfeeding, for example, the mother’s educational level, BMI, age and if she has given birth to twins. In contrast, national guidelines can always be updated. Recommendations from the Swedish authorities should adhere to the WHO’s recommendation, which states exclusive breastfeeding for six months and partial breastfeeding for at least two years or longer [1].