Monday, November 18, 2013

Bullshitometer: Rice cereal edition

Rice cereal is widely used in many countries as a first food for infants, either stirred into a bottle or mixed with breastmilk/formula and fed with a spoon. Hang around any discussion group with mothers of babies and you're sure to hear someone talking about how they plan to "skip the rice cereal" or "start giving baby rice." Debates on the subject can get very heated--astonishingly heated, really, when you consider that this is basically an innocuous-looking white powder that most babies probably only eat in very small amounts anyway.

Some people have been assured by their doctors that it is hazardous to give babies anything other than rice cereal as a first food. Other people believe that rice cereal is harmful, and that the only reason we are told to start with it at all is due to the machinations of the good old formulaandbabyfoodmilitaryindustrialcomplex. Still others hint that giving cereal is okay... as long as it's organic, or homemade, or brown/wholegrain, or is something other than rice. So, who's telling the truth? As there are so many claims that are made about rice cereal, I'll break them down into "In favor" and "Against." As you'll see, sometimes the bullshitometer verdict is of the "It Depends" variety.

Claims made in favor of rice cereal

Rice cereal will make your baby sleep longer at night
Bullshitometer verdit: Basically false
It appears that this particular myth is still doing the rounds. However, the sole randomized control study that I have been referred to found that cereal at bedtime makes no difference to babies' sleeping patterns. (If your baby has gastrointestinal reflux, however, it's a different story: see below.)

Only rice cereal should be given at first, because it's hypoallergenic
Bullshitometer verdit: False
Rice is one of the foods least likely to provoke an allergic reaction, so some parents find it a "reassuring" first food. However, it's a bit of a stretch to imply that this means parents should give rice first, or give nothing but rice for the first few months.

About 10 years ago, there was a spate of advice from medical bodies which basically told mothers and mothers-to-be to avoid foods associated with allergies--no peanuts during pregnancy, no eggs for baby until 12 months, etc. As far as I can tell, this advice was never based on any actual data, but rather on a vague sense of panic that Allergies Are Increasing And We Must Do Something About It. Since then, most of the "avoid allergens!" advice has been dropped, and the American Association of Pediatricians and Britain's National Health Service now state that other than a few exceptions like honey, there is no particular reason to delay any food beyond six months. For every (small, unsatisfactory) study which seems to indicate that delaying the introduction of wheat or egg reduces the risk of allergy, there's another (equally inconclusive) study which hints tantalizingly that early-ish introduction of the allergen in question might be better--see here and here, for example. When the EATS study results come out in 2015, we'll have a better idea. Till then, there seems to be no reason to stick exclusively to rice cereal in the early weaning stage.

Rice cereal is rich in iron
Bullshitometer verdit: True
Fortified rice cereal is a good source of iron; indeed, that's a large part of the reason why it's recommended by doctors. I discussed the importance of iron here. It's the fortification that gives baby rice its iron, by the way, so if you make your own "rice cereal" at home it won't provide the same benefit. Nor do many organic cereals, because generally if any food is fortified artificially it can't be called "organic."(NB: I am told that this is actually not the case in the US, so this may be one of those #regional things.)

Rice cereal helps with reflux
Bullshitometer verdit: Somewhat true
Thickening formula or expressed breastmilk with rice cereal is popular advice for helping babies suffering from acid reflux. A 2008 meta-analysis found that thickening feeds was helpful for reflux--although only moderately so.

Claims made against rice cereal

Rice cereal can cause constipation
Bullshitometer verdit: True
Rice cereal can indeed constipate some babies. This is sometimes attributed to its being white and refined, but the real culprit appears to be the iron with which it is fortified. It's the reason why "traditional" weaning regimes like that of Gina Ford include a lot of loosening fruits like prunes and pears.

Rice cereal is bland and taste of nothing (or even "Rice cereal tastes and smells disgusting")
Bullshitometer verdit: Sort of true, but...
I don't think anyone is ever going to claim that baby rice is as flavorful as, say, a plate of hummus or a Thai curry. That said, the rhetoric one sees about "How can people give their babies slop that tastes of wallpaper paste!?!" seems a bit unfair on poor old rice cereal.

For a start, there's surely room for both intensely and subtly flavored foods in our diets, and I doubt many parents give their babies nothing but rice. Plus... at the risk of pointing out the bleedin' obvious, rice cereal mixed with breastmilk tastes primarily of--surprise, surprise--breastmilk. Given that lactivists are so big on the idea that breastmilk takes on all these interesting flavors from the mother's diet and so on, it seems a bit odd to simultaneously insist that cereal mixed with breastmilk tastes of absolutely nothing. To make matters even more confusing, crunchy forums are full of mothers who say that rice cereal shouldn't be given because it's tasteless, yet consider rice cakes (for self-feeding) to be A-OK. I'm not sure what the reasoning is here--that rice magically acquires lots of exciting flavor when you puff it up and press it into a styrofoam disc? Given that rice itself doesn't really taste of anything, I feel confident saying that if a serving of breastmilk-mixed-with-cereal smells or tastes disgusting, it's probably something to do with the breastmilk. Unfortunately, some mothers' milk acquires fishy/metallic flavors when stored for any length of time.

One Dr. Greene, by the way, has made claims that rice cereal is not only bland but will give your child a lifelong preference for bland, starchy foods, based on the curious idea that the babies will "imprint" on the cereal, like a duckling fixating on the first moving object it sees. I think it makes sense to expose babies to lots of interesting flavors, but there is not a shred of evidence to support his idea that giving a baby any cereal whatsoever is going to do terrible things to their palate. Anyway, if you find cereal a little bland, there's nothing to stop you mixing it with other things.

Rice cereal is indigestible because babies can't digest grains until they are a year old/two years old/until their molars come through etc.
Bullshitometer verdit: False
The idea that we should avoid giving babies grains has become increasingly popular in the last few years in parallel with the rise of so-called "paleo" diets which limit the consumption of starchy cereals. A much-shared article from Food Renegade "Why Ditch The Infant Cereals?" is typical of this genre:
In order to digest grains, your body needs to make use of an enzyme called amylase. Amylase is the enzyme responsible for splitting starches. And, guess what? Babies don’t make amylase in large enough quantities to digest grains until after they are a year old at the earliest. Sometimes it can take up to two years. You see, newborns don’t produce amylase at all. Salivary amylase makes a small appearance at about 6 months old, but pancreatic amylase (what you need to actually digest grains) is not produced until molar teeth are fully developed! First molars usually don’t show up until 13-19 months old, on average. 
I do not have the time to go through every single scientific and historical error in the entire Food Renegade article, so, briefly: contrary to what Food Renegade claims, pancreatic amylase starts to be produced by infants from about one month of age, and is present in substantial amounts by a few months later. What's more, salivary amylase (which is present in your saliva) starts being produced from around birth and is at around two-thirds of adult levels by three months of age. Finally, expressed breastmilk itself is full of amylase. There's also evidence that breastmilk amylase continues to be active even when it's in your baby's stomach. Food Renegade claims that pancreatic amylase is the only one that will digest grains, but this is false; salivary, pancreatic and breastmilk amylase are all alpha-amylases and all will break down the starch in cereals.

If you're lactating and are feeling bored today, you can actually try this out for yourself: pump, and mix your freshly expressed milk in a bowl with enough rice cereal or flour to make a thick goo. Wait five minutes, and look at it again. It will have gone runny or sloppy, because the amylase in your milk is actually predigesting the starch in the cereal. Very young babies may have difficulty digesting cereal, but if your baby is four months or older you shouldn't need to worry.

Rice cereal is nutritionally void
Bullshitometer verdit: False
The iron with which infant rice cereal is fortified is useful to babies--especially since it's one of the few things they won't get from breastmilk. Rice cereal won't provide much else other than iron, true--but then, it doesn't really need to: breastmilk/formula meets all other nutritional needs except perhaps zinc.

Rice cereal in a bottle can cause choking
No TinyTears™ dolls were harmed in the
 making of this photograph
Bullshitometer verdit: Perhaps somewhat true
Cereal-thickened milk in a bottle is often said to be a "choking risk" for infants. Now... I am nitpicking a little, but the concern about thickened liquids is not choking but aspiration (choking = something completely blocking your windpipe; aspiration = something getting into your windpipe that shouldn't be there). OK, now I've got that off my chest (pardon the pun), what's the risk of aspiration from cereal in a bottle?

Well, not much, judging from a trawl through Google Scholar, which produced only discussions of cereal-thickened milk being used to prevent aspiration of milk. However, occasionally medical professionals have expressed a preference for alternative thickeners to cereal for this reason. The concern is that because the cereal forms irregular lumps in the milk, carers may be tempted to make the hole in the bottle teat excessively large to allow the milk to pass through, which in turn may cause excessive flow from the bottle, increasing the risk of aspiration. This may be a particular concern with breastmilk because the action of amylase makes the thickening action unstable and unpredictable. So some medical professionals now prefer thickening gels/carob bean gum, which are not broken down by amylase (see here). Hopefully these alternative thickeners will become more widely available; in the meantime, it seems wise for parents to feed thickened breastmilk with care, resist the temptation to make the teat hole too large, and never prop bottles.

Mmm…. red meat. Yum yum.
There are better sources of iron than rice cereal
Bullshitometer verdit: True, but...
You will sometimes hear people say that "The iron in rice cereal is poorly absorbed." This is sort of true, but needs to be understood in context. Only about 4% of the iron in rice cereal is absorbed, but that's because all non-haem iron is absorbed poorly, not because there's something uniquely crap about rice-cereal iron. Iron from beans, quinoa, peanut butter  etc. is also absorbed at around 4%. But because the infant cereal is fortified with so much iron, the absolute amount that the baby ends up getting is far higher than for these natural foods. The WHO guidelines specifically recommend iron-fortified foods on the grounds that without them, it may be difficult for babies to get enough iron in practice (see p.25).

Haem iron--the sort found in meat and eggs--is absorbed at a much higher rate, and there's loads of it, plus zinc which babies may also need. If parents have the time to prepare meat purees they should by all means do that, and pediatric authorities increasingly recommend meat as superior to cereal. Honestly, though, I can kind of see why doctors push the rice cereal. Rice cereal is inexpensive, easy and innocuous to feed, whereas not everyone has the time/inclination to make their own meat purees, and as for jarred meat-based babyfoods.... well, I think many parents understandably feel a bit reluctant to feed their infant shelf-stable liquidized meat products of indeterminate origin that smell rather like dog food. So if pediatricians just completely ditched the rice-cereal recommendations, I think what would actually happen is that a lot of babies wouldn't get either cereal or meat, and anemia would probably increase substantially as a result.

Rice cereal contains arsenic
Bullshitometer verdit: Contains a kernal of truth, but...
There has been a bit of concern in parenting circles about arsenic in rice cereal, ever since a Consumer Reports article on this subject back in 2012. I'll confess straight-up that I live in a country with a rice-based diet and the world's highest life expectancy, which probably biases my own views somewhat. So I'd like to hand this over to KevinMD and his excellent blog.

The Consumer Reports has some sensible advice and information about arsenic in general. But then the report goes all alarming, with a great big table showing the amounts of arsenic in some common rice products, the excessively high ones being shown in scary red font.

Here's the thing, though: in this table, "excessive" arsenic is defined as anything exceeding 5ppb, this being the Environmental Protection Agency's maximum permitted level for water (not rice or any foodstuff). As KevinMD points out, the reason why the levels for any-sort-of-contamination in water are set so incredibly low is because people drink many large cupfuls of fluid a day; any given foodstuff is consumed in far smaller amounts, so it doesn't make any sense to subject foods to the same standards. Of course, ideally nobody wants any arsenic in their food, but as the report itself points out, vegetables and fruits contribute more arsenic to our diets than rice; what's more, all foods contain tiny amounts of poisons/carcinogens--manmade and natural--and trying to completely eliminate them is futile.

For example: two of the rice-y foodstuffs that the Consumer Reports article comes down the hardest on are rice milk and brown rice syrup (a form of sugar). Here's the funny thing: I can remember when people were choosing rice milk as a healthy drink--because they were afraid of soya milk because of the phytoestrogens, and afraid of cow's milk because it was, well, cow's milk. And brown rice syrup was being lauded a few years ago as a healthy alternative to the dreaded high fructose corn syrup. Rice itself became more popular a few years back due to worries about gluten. If we now have to start avoiding rice because it's "bad," we'll have to eat more of something else instead...quinoa, perhaps, or sweet potatoes. Before long, there'll be a media scare story about each of those foods as well and we'll have to replace them with yet another food. And so on. We can either choose to live our lives constantly bouncing around from food to food in an effort to avoid the latest killer de jour, or we can take the approach that there is not a food on the planet that does not contain something that might kill you if you somehow contrived to eat several kilos of said food at a single sitting, and that the solution is to eat a varied diet with a little of everything. Same goes for babies. Same goes for rice cereal.

(For what it's worth, even the Consumer Reports article doesn't actually advocate that people stop eating rice or feeding it to babies altogether--that's just what some worried mums on the internet have been telling each other to do.)

Overall bullshitometer verdict
Overall, there doesn't seem to be any super-strong case in favor of or against rice cereal. It can be used for reflux (but other thickening agents may be slightly better); it can provide iron (but meat-based baby foods may be slightly better). There seems to be little evidence to support any of the other claims, either positive or negative.

Given this somewhat underwhelming reality, why do people talk about rice cereal as much as they do on the parenting boards? I'm guessing that it's because rice cereal has become one of those "materno-political" issues: when mothers say things like "We don't do rice cereal in our family" or "We're giving two servings of rice cereal every day just as the pediatrician tells us" they aren't really talking about the white powdery stuff itself, but are making a statement about what "type" of mother they are. If we took the time to look at the data and see how pallid the evidence is on either side, I reckon we'd all argue about these things less and parenting boards would be more peaceful places.

Further reading:
The Case for Rice Cereal: What it says.

Almost immediately after hitting "publish" I noticed, with mortification, that one of my favorite bloggers, Science of Mom, published her own blog post on starch/amylase in infancy about two weeks ago! I can only assure anyone who has spotted this that there was no copycat intention here--I have had a draft version of this post hanging around for months and kept meaning to finalize the damn thing and publish it, and having been busy with school choices the last couple of weeks I have not been able to keep up with my favorite bloggers at all. Anyway, I thoroughly recommend her fascinating post which looks at amylase in more detail than I am able to. Cheers. BFWOBS.


  1. Hi! I just ran across this post and wanted to say THANK YOU! I've been wanting to write something similar, but as you can see, I am too easily distracted by small details such as amylase and poor misunderstood starch. This is a great collection of myths and truths about rice cereal. I'm working on a chapter for my book about introducing solids. It is one of the most confusing areas of parenting, I think, and since nutrition is my field, it bugs the heck out of me. Anyway, thank you for your great posts! You're doing good work spreading accurate information. Maybe we can drown out a bit of the misinformation on the internet together:)

  2. Hey, thanks for the reassurance! I agree, solid foods seems to be one of the areas where there seems to be very little "solid" evidence (haha) and a whole lot of opinion. Looking forward to reading the book!

  3. This article wins! I don't understand the mommy boards. I've stopped going to them. You give rice cereal and don't cosleep OMG how could you have ever possibly even considered having children you selfish monster!?

  4. Nice article. I like the scientific approach! Rather than, as you put it, a statement about what 'type' of parent you are

  5. THANNNNKKKKK YOUUUUU! FINALLY some fact based, non biased evidence supporting why my mother-in-law needs to shut the hell up and let us parent how we parent! I would kiss you, my friend, you've made my day.

  6. So does you MIL support rice �� cereal or no? ��