Are puréed foods justified for infants of 6 months? What does the evidence tell us?

Abstract

Current guidance recommends that infants be introduced to solid foods from 6 months, an age at which chewing skills are rapidly developing. However, there is a general assumption that the first solid foods should be offered as purees. This article considers the rationale for this practice and presents evidence that, far from being either necessary or beneficial, insistence on pureed foods may contribute to feeding and health problems.

Full text

Are pureed foods justified for infants of six months?
What does the evidence tell us?
Gill Rapley, PhD
This document is the Accepted Manuscript version of a Published Work that appeared in final form in the Journal
of Health Visiting in June 2016, copyright © MA Healthcare, after peer review and technical editing by the
publisher. To access the final edited and published work see [http://www.magonlinelibrary.com/toc/johv/current].
Key Points
No need for pureed foods for infants of six months
No evidence to support the use of pureed foods at six months
The use of pureed foods may predispose to feeding problems
The use of pureed foods may predispose to health problems
Key Words
Infant nutrition physiology
Complementary feeding
Child nutrition
Childhood eating and feeding disorders

Are pureed foods justified for infants of six months?
What does the evidence tell us?
Abstract
Nowadays it is recommended that infants be introduced to solid foods from six months, an
age at which chewing skills are rapidly developing. And yet there is a general assumption
that the first solid foods should offered as purees. This article considers the rationale for this
practice and presents evidence that, far from being either necessary or beneficial, insistence
on pureed foods may contribute to feeding and health problems.
Introduction
The current worldwide recommendation regarding infant feeding is that infants should be
exclusively breastfed for the first six months of life. They should then be introduced gradually
to a nutritious diet composed of a variety of complementary foods, with breastfeeding
continuing for at least the first two years (WHO, 2002; WHO 2005; WHO/UNICEF, 2003).
This extended transition, which is also known as weaning, is recognised as a crucial period
for the development of life-long healthy eating habits (Oddy et al, 2003; Rich-Edwards et al,
2004; Owen et al, 2005; Horta et al, 2007; Ip et al, 2007; Quigley et al, 2007; Duijts et al,
2010; Li et al, 2014).
In practice, the age at which weaning begins varies across time and cultures, from less than
one month old to as late as two years (Dettwyler, 1987; Bentley et al, 1991; Jarosz, 1993).
Yet, whatever the age of the infant, the expectation in industrialised societies is that the first
complementary foods will be offered as purees. Thus, in 2010, although 25% of UK infants
did not experience ‘solid’ food until five months or older, only 4% were offered this food as
something they could pick up with their fingers (McAndrew et al, 2012). But where is the
evidence for this practice?
The evidence for the use of purees
An extensive search of the academic literature revealed many papers dealing with the timing
of complementary feeding (e.g. (Butte et al, 2002; Kramer and Kakuma, 2012) and the need
to offer a variety of flavours from the outset (e.g. Gerrish and Mennella, 2001; Maier et al,
2008; Mennella et al, 2008). The majority of these papers make only a passing reference to
the fact that the first foods were pureed, and offer no justification for this choice – even
where the infants concerned are nearer six months than four. A smaller number of studies
has been concerned with the age at which ‘lumpy’ foods should be introduced (e.g.

Northstone et al, 2001) but, again, the initial use of purees seems not to have been
questioned. Other than recent papers concerned with ‘baby-led weaning’ (BLW), none were
found that challenged this practice and none that provided support for it. On the contrary, a
wider search of the literature revealed compelling evidence against offering pureed foods.
This evidence is related to three key areas: the requirements for the acquisition of chewing
skills, the role of food format and presentation in the development of food preferences, and
the effects of pureeing on food.
The development of chewing
One rationale commonly offered for the use of purees is that the infant has to ‘learn to chew’.
Indeed, there is an implication that pureed foods are necessary for this learning to take
place. However, this belief is not borne out by the literature. The average full-term newborn
infant has innate reflexes that enable her/him to attach and suckle at the breast or on a
bottle teat, drawing in liquid food and swallowing it. By four months the position of her/his
larynx allows more space within the oral cavity (Delaney and Arvedson, 2008), s/he can
‘mouth’ foods and is beginning to lose the innate tongue protrusion (or ‘tongue thrust’) reflex,
which spontaneously expels non-liquids. However, s/he is still not able to bite or chew. If
s/he is to be given foods other than breastmilk or formula, it follows that they must be in
liquid or semi-liquid form, so that the infant can use an adapted sucking movement to deal
with them.
By six months the situation is very different. At this age the infant has developed a range of
oral motor skills that allow her/him to manage foods that require chewing (Wickenden, 2000;
Naylor, 2001). The ‘tongue thrust’ reflex has disappeared and the infant is able to ‘munch’
food with an up-and-down movement of the lower jaw. In addition, s/he is beginning to use
her/his tongue in a lateral manner, enabling her/him to move food to the sides of the mouth
for chewing (Naylor, 2001). Between six and nine months the infant becomes able to collect
together a bolus of food on the tongue and move it deliberately to the back of the mouth for
swallowing. At the same time, s/he develops the ability to swallow independently of the
sucking movement (Naylor, 2001). What is striking is that these rudimentary biting, chewing
and swallowing skills do not need to be learnt; they appear as part of the infant’s natural
development whether or not s/he has prior experience with semi-solid foods (Naylor, 2001).
It is worth noting that the ability to make chewing movements is independent, not only of
experience with purees but also of the presence of teeth. Although the first teeth commonly
appear at around six months – the age when chewing movements are beginning – these
are incisors, which are for biting, not chewing. Premolars and molars do not normally appear

until after the first birthday. In the absence of teeth, anecdotal evidence suggests that gums
are effective for chewing all but the toughest foods. In a study by Carruth and Skinner
(2002), the mean age for being able to chew ‘firmer’ foods was ten and a half months, while
that for the eruption of the first molar was 15 months. By 20 months, all the children were
reportedly able to chew and swallow firmer foods, even though some still had no cheek
teeth.
Infants who are beginning to bite and chew require repeated opportunities to practise these
skills in order to become fully proficient in them (Illingworth and Lister, 1964; Archambault et
al, 1990; Northstone et al, 2001). Delaney (2010) found that experience accelerated the
development of chewing skills over and above what would be expected through maturation
alone, and showed that infants as young as eight months were able to manage a range of
textures more effectively than was previously thought to be the norm. She questioned the
accepted wisdom that experience with purees predisposes children to learn other oral skills,
suggesting that it may even delay the acquisition of those skills.
The development of food preferences
There is a wealth of research into the development of food preferences in infancy. We know,
for example, that infants who breastfeed tend to be more accepting of different flavours
during the weaning period than infants fed on standard infant formula (Forestell and
Mennella, 2007; Maier et al, 2008; Beauchamp and Mennella, 2009; Shim et al, 2011). In
addition, several studies (e.g., Maier et al, 2007; Mennella et al, 2008) have shown that,
when infants are repeatedly fed an individual flavour, they acquire an apparent liking for that
flavour. However, in spite of the known link between taste and texture in the perception of
flavour (Ganchrow and Mennella, 2003), the role of texture in food acceptance has rarely
been studied in children under one year, and never in relation to the first non-milk foods.
Northstone et al (2001), Coulthard et al (2009) and Northstone and Emmett (2013) examined
the impact of the timing of the move from purees to lumpier textures on the range of foods
children were willing to eat at 15 months, two years and seven years, but the possibility that
the need for this move could be eliminated, through the use of chewable foods from the
outset, has not been explored.
The potential importance of the visual attributes of the first ‘solid’ foods has, similarly, not
been examined. Much of the research into the development of food preferences focuses on
the number of times an infant or child is ‘exposed’ to a new food. However, the nature of the
‘exposure’ varies according to the focus of the study and the ages of the participants: In
utero, exposure occurs passively, via the smell and taste of the mother’s amniotic fluid

(Cooke and Fildes, 2011). For the young infant, ‘exposure’ means the active introduction of a
few drops of liquid, a flavoured drink, or a ‘bite’ of (semi-solid) food directly into her/his
mouth, via a bottle teat or spoon (e.g., Desor et al, 1973; Crook, 1978; Harris et al, 1990;
Mennella et al, 2008; Mennella et al, 2009), an experience that comprises taste, intra-oral
texture and that element of smell which is experienced inside the mouth. In research into the
responses of older children the term ‘exposure’ is used variously to mean opportunities to
see, smell and/or taste food before deciding whether to eat it (Sullivan and Birch, 1990;
Wardle et al, 2003; Williams et al, 2008; Hausner et al, 2012). There appear to be no
grounds for assuming that such dissimilar experiences are equally influential for the child
and yet they are discussed as if they are interchangeable (Cooke, 2007).
Food neophobia, or the reluctance to eat unfamiliar foods, is generally accepted as a normal
phenomenon during the pre-school years, emerging as the child becomes mobile, peaking
soon after the second birthday, and gradually dwindling thereafter (Cashdan, 1998; Cooke et
al, 2003; Nicklaus, 2009). To children in this age group, the appearance of a food (especially
its colour and shape) is key to whether they perceive it as ‘new’, whether or not they are in
fact already familiar with its taste (Carruth et al, 1998; Zeinstra et al, 2010). In studies of
children in the two-to-five-year age group the importance to the child of visual inspection is
tacitly acknowledged, in that the food is usually presented on a plate for her/him to eat or
not, as s/he chooses (Carruth et al, 1998; Dovey et al, 2008; Zeinstra et al, 2010). However,
with a few exceptions (e.g. Mennella et al, 2008), studies involving younger infants appear to
side-step the possible impact of the food’s appearance, both by presenting it on a spoon
directly to the mouth (Maier et al, 2008), thereby effectively preventing the infant from
examining it, and by offering it as a puree – a format that offers few visual clues to its
composition.
Dovey et al (2008) explain the gradual decline in neophobia by the fact that the older a child
gets the fewer foods are new to them. If this reasoning is applied to the period during which
neophobia is increasing it follows that a change in the appearance of previously familiar
foods – making them appear ‘new’ – has the potential to exacerbate the problem. Thus,
while one or more ‘blind’ intra-oral exposures to a pureed food may indeed make an infant
more likely to accept that food when it is presented in the same way on a subsequent
occasion (Maier et al, 2007; Mennella et al, 2008), there is no guarantee that s/he will be
equally willing to eat it if given the chance to inspect it – nor that s/he will accept it in a
different format.
We do not know at what age the appearance of food may start to be important but the work
of Wright et al (2011) and Brown and Lee (2011) suggests that the establishment of links

between the taste, texture and appearance of food may be possible for infants as young as
six months. It follows that the beginning of weaning may be a crucial period not only for the
acceptance of new flavours but for building a store of visual references with which new foods
can be compared. It may be no coincidence that the period during which neophobia is
increasing commonly coincides with the move away from pureed foods towards food
presented in the same way as eaten by the rest of the family. Infants who are familiar with a
pureed food – whether via flavour, appearance or both – may need to begin the
familiarisation process afresh when ‘table’ foods are introduced.
‘Picky’ eaters commonly reject food on the basis of its appearance (Werthmann et al, 2015).
Not only may a puree itself deter the child visually, pureeing also reduces the diversity of
appearance that exists naturally between foods. This can lead to inaccurate deductions
about the nature of the food. Thus, an infant may reach excitedly for an orange-coloured
puree, only to discover that (being mango instead of carrot) it tastes very different from the
orange-coloured puree of yesterday. It is not difficult to see how children may decide to
reject, for example, all green foods, based on an unpleasant experience with one green
food. Some picky eaters are especially resistant to dishes in which several foods are mixed
together (Carruth et al, 2004a). This may be because mixing makes recognition of the
contents, whether by appearance, smell, taste or texture, even more difficult. Alternatively, it
may reflect a wariness induced by the common parental ‘trick’ of concealing disliked foods
within liked ones. As well as masking the nature of the constituents, combining foods into a
homogenous whole has the potential to hamper the operation of ‘sensory specific satiety’
(Rolls et al, 1981), which allows the individual to become sated in relation to one food while
remaining willing to eat a different food – something that is thought to be important for
ensuring a balanced intake of nutrients. The common practice of presenting infants with
several foods as a single puree may therefore have implications for health, as well as for
food acceptance.
Modelling, by parents or peers, has been shown to be effective in persuading children to eat
healthily (Brown and Ogden, 2004; Greenhalgh et al, 2009; Palfreyman et al, 2014), with
children as young as one year being positively influenced by others eating what appear to be
identical foods (Addessi et al, 2005; Shutts et al 2009). However this, too, relies on visual
clues that are denied to the infant who is presented with all her/his food in pureed form.
Werthmann et al (2015) found that children aged between 32 and 48 months were more
influenced by changes to the texture of a liked food than by alterations to either colour or
taste but how early such changes may begin to be important is not known. It is possible that
problems reportedly caused by the late introduction of lumpy foods (Northstone et al, 2001)

may be as much due to their unfamiliar appearance as to physical eating challenges
presented by their texture. All of this raises questions not only about the best time to
introduce table foods but about the wisdom of introducing foods as purees in the first place,
when complementary feeding begins at six months.
The effects of pureeing
Pureeing alters not only the appearance of food but also its cellular structure, thereby
affecting its textural properties and potentially increasing its viscosity (Waldron et al, 2003).
Viscous foods tend to adhere to the lining of the mouth, which may make them difficult to
manage intra-orally (Lucas et al, 2004). Delaney (2010) found evidence that purees are not
necessarily easily managed by infants and that their skills in this regard do not increase in
the way that those related to more solid textures do. She notes her surprise at these
findings, given the fact that “this texture is thought to be easy to chew” (Delaney, 2010: 71).
Pureeing affects the intensity and nature of the flavour of food, by allowing the dispersal, in
advance, of volatile elements that would normally be released gradually while chewing. It
therefore interferes with the way the individual experiences flavour (Wilson and Brown,
1997). A homogenous texture and the lack of a need to chew further detract from the
appreciation of flavour (Ganchrow and Mennella, 2003; Waldron et al, 2003) and preclude
the stimulation of other senses, thereby limiting the pleasure to be gained from eating
(Duizer, 2001; Spence and Shankar, 2010; Woods et al, 2010). Since enjoyment of eating
has been shown to be an important factor in children’s food choices (Skafida, 2013), the fact
that pureeing may reduce the potential for an enjoyable eating experience warrants
consideration.
Commercially prepared weaning foods may present an additional problem. As well as
lacking an equivalent nutrient value (Nazanin et al, 2011; Wright et al, 2011; Garcia et al,
2013), they rarely taste the same as home-cooked (pureed) versions of the same food
because of the effects of the processing to which they are subjected (Oey et al, 2008;
Kocadağli and Gökmen, 2014). This may result in them being difficult to identify by taste,
even for adults (Birch et al, 1998). Both Harris and Booth (2006) and Forestell and Mennella
(2007) have noted that it is possible that experience with commercial infant foods may hinder
infants’ acceptance of home-cooked foods, both pureed and ‘whole’.
Infants have been shown to be capable of regulating their own intake of food (Fox et al,
2006; Li et al, 2010; DiSantis et al, 2011; Brown and Lee, 2012). However, it is possible that
this ability may be disrupted if all the infant’s food is pureed. Chewing has been shown to
play an important role in appetite suppression in adults (French and Cecil, 2001; de Graaf,

2012), whereas runny foods are known to promote rapid swallowing (Gisel, 1991). In
particular, food that can be swallowed quickly makes it easier for a caregiver to override the
infant’s natural appetite control. Rapid transit of food through the mouth is the antithesis of
‘mindful eating’, which involves paying attention to the totality of the experience (Bays, 2009)
and allows the individual to become attuned to internal cues of hunger and satiety. Mindful
eating is recommended as a way for adults to avoid overeating (Wansink and Sobal, 2007;
Wansink, 2009; Beshara et al, 2013). It is possible that the encouragement of mindless
eating in infancy may be behind the apparently spontaneous reduction in intrinsic appetite
control seen in the preschool years (Rolls et al, 2000; Smith et al, 2013), through what Fox
et al have termed “interference with natural self-regulation” (Fox et al, 2006: S81).
As well as encouraging excessive intake, rapid oral processing of food may also impede
effective digestion, since it reduces the time available for the food to mix with saliva (Pocock
et al, 2013). It also allows less time for the appreciation of flavours (Zijlstra et al, 2009), albeit
that this may be considered an advantage if the food is disliked. Finally, over-reliance on soft
foods is thought to contribute to poor facial growth (Lieberman et al, 2004) and an increased
risk of dental, respiratory and aural problems (Corruccini, 1999; Kiliaridis, 2006;
Montgomery-Downs et al, 2007; Gibbons, 2012).
The argument for purees
In support of the use of purees, Reeves states that they are “ideal for being able to introduce
a known volume of food to the infant and provide essential nutrients” (Reeves, 2008: 108)
and that a diet containing both finger foods and purees “is the most likely to provide the
variety of foods and nutrients that a developing infant requires.” (Reeves, 2008: 109). This is
a view echoed by Caroli et al (2012). However, caregivers have yet to be shown to know
better than infants what their individual nutrient needs are at any one meal. Although Clara
Davis’s work from the 1920s (Davis, 1928) has been robustly challenged (Story and Brown,
1987; Strauss, 2006), no published studies exist that have disproved her claim that infants
and children are capable of choosing a balanced diet for themselves.
Reeves also asserts that “purees are an obvious transition food to bridge the gap between
liquid and solid foods” (Reeves, 2008: 108). Yet there appears to be no evidence that the
infant’s transition from a liquid diet to one that includes chewable foods requires her/him to
be offered foods that are themselves transitional in consistency. Stevenson and Allaire
(1991) have commented that the case for semi-solids is not proven but is based on child-
rearing beliefs and customs, while Reilly et al (2006) point out that many non-industrialised
cultures do not use ‘weaning foods’. Palmer (2011) notes that the belief that soft foods are

necessary may be perpetuated in part by the baby food industry, which has an interest in
encouraging parents to use commercially prepared products.
In a direct challenge to the belief that semi-solid foods are needed, the approach to the
introduction of solid foods known as ‘baby-led weaning’ (BLW) argues that the weaning
period need consist only of an overlap of liquid and chewable foods, during which the
chewable foods form a gradually increasing proportion of the diet (Brown and Lee, 2011;
Cameron et al, 2012), and that the changeover can be adequately negotiated by the infant
himself, as he becomes more proficient at chewing (Rapley, 2013). The available evidence
suggests that self-feeding with graspable foods is a viable alternative to the use of purees for
infants beginning weaning at six months (Wright et al, 2011; Cameron et al, 2012).
Discussion and conclusions
In recent years the majority of the research surrounding the period of complementary
feeding has focused on the timing of the introduction of new foods, based on perceived
nutritional requirements, the development of the gut and immune systems and, more
recently, the risk of allergy. The infant’s developing oral-motor abilities have largely been
ignored, with the result that the emphasis has been on the foods themselves and the
acceptance of new flavours, rather than on matching the consistency of the first foods to the
current eating skills of the infant. A search of the literature revealed no evidence to support
the routine use of pureed foods for normally developing healthy infants of six months.
Rather, the available research suggests that an insistence on purees at the beginning of
weaning may have negative consequences:
 Purees may be more difficult to manage for infants who are beginning to be able to
chew than are chewable foods. They may also impede the development of more
advanced oral-motor skills.
 Pureeing reduces the opportunity for infants to learn to recognise foods by their
appearance – and to trust their ability to do so. This may lead to wariness, both with
previously experienced foods, with the same foods in other formats, and with new
foods, potentially contributing to picky eating and neophobia. It also reduces the
opportunities for parents to model the eating choices they wish their offspring to make.
 Pureeing deprives infants of the opportunity to experience different textures and may
cause distortion of flavours. Either of these effects may impact on the enjoyment of
meals, either at the time, or when chewable foods are eventually introduced.

 Overuse of purees may have implications for health, both in infancy and later. Food
that can be swallowed quickly may contribute to excessive weight gain and less
efficient digestion, while persistent lack of chewing movements may contribute to poor
facial growth, and thence to adverse dental, respiratory and aural health outcomes.
Perhaps more worrying is the possibility that the routine use of purees in infancy may have
distorted our learning about the feeding of infants. For example, although not generally
acknowledged, the focus of research into the early development of food preferences has
been on infants’ reactions to pureed foods, rather than on their responses to food per se.
Thus, Coulthard et al (2014), on finding that infants introduced to solid foods after five and a
half months ate less of a novel puree than did those who had started solids before this age,
concluded that infants are less accepting of new foods when the start of weaning occurs at
or after six months than when it occurs earlier. An alternative explanation may be that six-
month-olds are simply less accepting than younger infants of new foods presented as
purees. Similarly, the work of Delaney (2010) raises questions about the accuracy of our
understanding of the normal development of oral-motor skills, since the majority of what we
know has been accumulated by studying infants who are being, or have been given, pureed
foods.
In summary, if purees are not necessary, and may even be harmful, we need urgently to re-
assess their routine use for infants who do not need them.
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