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Weaning practices have changed frequently over the years...

…whether due to trends or in response to new evidence – leaving families and sometimes health professionals unsure of the latest guidance. Yet age-appropriate weaning remains vital for helping children to prevent allergies, lowering the risk of obesity, contributing to development, and fostering independence. Given their significant interaction with parents of young children, health visitors and other community practitioners are well placed to give the most up-to-date advice on weaning.

 

This module will:

  • Examine how age-appropriate weaning can contribute to child health
  • Discuss official advice on weaning, also called complementary feeding
  • Look at the steps involved in successful introduction of complementary feeding, including which foods and textures to introduce when
  • Consider how to tackle problems arising during weaning, such as pressures around the timing of food introduction, avoidance of certain foods, fussy eating, or poor cooking skills
  • Address common food myths which lead to confusion amongst families

 

IMPACT ON WEANING ON CHILD HEALTH

The purpose of weaning is to meet the increased energy and nutrient needs of growing infants while contributing to their development of social and physical skills (e.g. chewing, swallowing, holding, feeding and speaking).

Early introduction of complementary foods prior to 17 weeks presents risks to the infant as the gut, kidneys and immune systems are underdeveloped[1]. There is some evidence that the risk of obesity may be higher in infants weaned too early[2,3],  with theories proposing that high protein diets early in life stimulate the number and size of adipose (fat) cells leaving the infant more susceptible to fat gain later. A meta-analysis found evidence to link bottle feeding, maternal smoking, birth weight and early weaning to an increased risk of childhood obesity[4]. Inappropriate weaning can also lead to choking as the young infant is less able to sit upright.

In a similar way, late or slow introduction of complementary foods could risk delaying normal development. Anecdotal evidence suggests that children who remain too long on fine pureed foods may take longer to develop oral motor skills or accept different flavours and textures. However, there has been little research on this.

In contrast, age-appropriate weaning is in tune with the development of the gut and immune systems[5], and offers foods which challenge infants’ oral skills and taste buds.

 

WHAT THE EXPERTS SAY

Since 2003, official UK advice has been to encourage exclusive breast feeding (or breastmilk substitute where the mother is unable or unwilling to breastfeed) until infants are around six months of age[6]. The advice was based on a report from the World Health Organisation which found optimal infant health and development when the introduction of complementary foods was delayed until this time[7].

Research shows that 75% of parents introduce complementary foods before six months[8], with 10% weaning at 3 months or earlier, even when they have been encouraged by healthy visitors and other community practitioners to follow guidance[9]. This can present a dilemma for healthcare professionals when faced with an infant who has been weaned too early and will require careful handling, including a discussion between the professional and the family to understand their circumstances and assess the weight, health and readiness of the infant.

 

THE WEANING JOURNEY

When starting weaning at 6 months, it is appropriate to rapidly progress from smooth to rough purees and finally onto soft whole foods with around a week spent at each texture stage. Infants weaned between 4 and 6 months may need to spend longer at each texture stage as their motor skills will be less developed.

Eating requires skills which most adults take for granted. An infant needs to be able to swallow food, chew, manipulate their tongue inside the mouth, and have enough jaw strength to break up and grind food, with or without teeth. This is why smooth, thick purees are an excellent first weaning food.

Parents are often alarmed about their babies gagging during feeding. This is because the pharyngeal reflex or gag reflex in infants is in the back of the throat and can be easily stimulated by touching the roof of the mouth or the back of the tongue[10]. As babies get older, the gag reflex moves further back in their throat allowing food to be moved around the mouth without activating it. It takes some children longer than others to outgrow a sensitive gag reflex, which is why smooth textures are advisable to begin with.

UK Government Advice

  • Exclusive breastfeeding from birth until weaning, at around 6 months, is optimal.
  • Infants should not receive complementary foods before 17 weeks of age.
  • Infants should be considered individually as they develop at different rates.
  • High allergen foods, e.g. egg, fish, dairy foods and gluten-containing cereals, can be introduced after 6 months
  • Preterm infants may need to be weaned later than term infants.

 

AGE APPROPRIATE WEANING FOODS

The table below shows which foods are suitable at the different stages of weaning. However, some foods should be avoided completely as they represent a hazard, e.g. honey due to the risk of spores, whole nuts due to the risk of choking, unpasteurised milk and cheese due to the possible presence of food poisoning bacteria (e.g. listeria salmonella and E.coli) and certain fish (shark, marlin and swordfish) as they can contain high levels of mercury.

There are broadly three stages of weaning taking an infant up to a year when they should be enjoying regular family meals. Progression from stage 1 to 2 should be fairly rapid – i.e. a few weeks – when the introduction of complementary foods has been delayed until 6 months, as recommended. However, as each infant is different, progression has to be tailored to the individual. The most important factor is to introduce a growing variety of tastes and textures to encourage a broad-based diet for the future. New research shows that promoting a ‘vegetables first’ message can help infants to develop liking for these and support better eating habits in childhood.

TABLE

 

TACKLING WEANING ISSUES

The route to successful weaning can be bumpy and some families will need extra support. A common theme is the pressure placed on many parents by family or friends to wean early – prior to 4 months – in order to satisfy perceived hunger or to encourage an infant to sleep through the night. Parents can be reassured that frequent feeding is normal in the first few months of life and that early weaning does not prevent night waking. Indeed, weaning too early could lead to health issues.

Other parental concerns include which foods to introduce first and there may be a tendency for cautious parents to stick with fruit purees and baby rice overly long. If weaning has commenced after 6 months, most infants can happily cope with a rapid progression onto lumps, pieces and family-type meals. Inexperienced parents may be alarmed if their infants choke or gag, and reassurance can be given about this, as well as tips to reduce the risk such as providing soft foods, removing fruit skins initially and cutting foods into small pieces.

Basic cooking skills and restricted income are barriers to successful weaning onto a healthy diet, particularly if the family relies on convenience or take-away foods. Support will be needed from health visitors and other professionals to improve parental skills around meal planning, safe food storage, food budgeting and simple meal preparation. Parents on low incomes may need reassurance that home-made meals are just as good as baby jars.

Research shows that infants and young children may need to be offered new foods up to 10 times before they accept them[12]. Therefore, food refusal is common and parents should keep trying to introduce new tastes and textures, particularly before the age of 1 year when neophobia (fear of new foods) can peak[13] . Eating with other family members or sharing a plate with a parent or sibling can encourage fussy eaters to try new tastes. Breast-fed infants seem to display less neophobia perhaps because they sample a range of flavours in breast milk as a consequence of the maternal diet[14].

Figure 1[15] below visualises the different risk factors for neophobia.

Figure 1[15]:

CP WEANING FIG 1

 

Baby-led weaning (BLW)

This involves presenting infants aged around 6 months with titbits of soft food and encouraging them to feed themselves . BLW can lead to choking if certain foods, such as apple, are given . However, this can be overcome with practice modifications . Breast or bottle feeding should continue as it may take some time for infants to eat enough food to meet their energy and nutrient needs. BLW is not for everyone and parents may prefer the more traditional route of purees.

 

CONCLUSIONS

Weaning advice needs to remain appropriate for the infant’s stage of development and the family’s circumstances while maximising nutritional and health benefits. There are many different ways to wean successfully but a key point is to progress steadily towards a varied diet once the infant has indicated readiness to go beyond milk feeding. Health visitors and other community practitioners have a unique role in delivering evidence-based practical advice on weaning, as well as helping to sort fact from fiction (see below).

 

Fact or fiction?

Introducing complementary foods before 6 months is dangerous.

FICTION: as long as weaning doesn’t commence prior to 17 weeks, there is little evidence of negative health consequences, especially for breast-fed infants. Health visitors should promote weaning at 6 months where possible. Where earlier weaning is desired by parents, guidance can be given after assessing the infant’s readiness.

Dairy foods should be delayed until 1 year of age due to risk of allergy.

FICTION: only cow’s milk needs to be restricted as a drink until 1 year and that is due to the low iron content. Fromage frais, yogurt, cheese and cow’s milk in foods are all perfectly acceptable from 6 months as long as they are low in added sugars.

Babies shouldn’t be given red meat as it is too rich.

FICTION: From 6 months, babies can benefit from the haem iron content of red meat which is well-absorbed by the body.

Infants need vitamin supplements.

FACT: The Department of Health recommends that all children aged 6 months to 5 years are given a supplement of vitamin A, C and D. Breastfed babies should receive a vitamin D supplement from birth.

 

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Have you completed our first module, Vitamin D status of young children? Click here to learn more.

 

References

[1] Wright C et al. (2004) Why are babies weaned early? Data from a prospective population based cohort study. Archives of Disease in Childhood 89: 813-16.

[2] Sloan S et al. (2008) Early weaning is related to weight and rate of weight gain in infancy. Child Care & Health Development 34: 59-64.

[3] Wang J et al. (2016) Introduction of complementary feeding before 4months of age increases the risk of childhood overweight or obesity: a meta-analysis of prospective cohort studies. Nutrition Research 36: 759-70.

[4] Weng SF et al. (2012) Systematic review and meta-analyses of risk factors for childhood overweight identifiable during infancy. Archives of Disease in Childhood 97: 1019-1026. http://adc.bmj.com/content/97/12/1019.long

[5] British Nutrition Foundation (2015) Factsheet: Weaning your baby www.nhs.uk/ipgmedia/national/british%20nutrition%20foundation/assets/weaningyourbaby.pdf

[6] NHS Choices (2015) www.nhs.uk/conditions/pregnancy-and-baby/pages/solid-foods-weaning.aspx

[7] World Health Organization (2003). Global Strategy for Infant and Young Child Feeding. World Health Organization; Geneva, Switzerland.

[8] Department of Health (2013) Diet and nutrition survey of infants and young children, 2011. London: DH. www.gov.uk/government/publications/diet-and-nutrition-survey-of-infants-and-young-children-2011

[9] Moore AP et al. (2014) An online survey of knowledge of the weaning guidelines, advice from health visitors and other factors that influence weaning timing in UK mothers. Maternal & Child Nutrition 10: 410-21.

[10] Babycentre website www.babycenter.com/0_gagging-in-babies_9197.bc

[11] First Steps Nutrition Trust (2016) Good food choices and portion sizes for 1-4 year olds. www.firststepsnutrition.org/pdfs/Good_food_choices_and_portion_sizes%201-4_for_web.pdf

[12] Sullivan SA & Birch LL (1994) Infant dietary experience and acceptance of solid foods. Pediatrics 93: 271-7.

[13] Birch LL & Doub AE (2014) Learning to eat: birth to age 2 y. American Journal of Clinical Nutrition 99: 723S-8S.

[14] Shim JE et al. (2011) Associations of infant feeding practices and picky eating behaviors of preschool children. Journal of the American Dietetic Association 111: 1363-8.

[15] Wardle J & Cooke L (2008) Genetic and environmental determinants of children’s food preferences. British Journal of Nutrition 99:S15-S21. http://discovery.ucl.ac.uk/168680/1/download2.pdf

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