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Weaning infants onto solid food

Key learning points:

 - Current advice and recommendations regarding weaning

 - Achieving adequate nutrition in weaned and weaning infants

 - Establishing a healthy relationship with food from a young age

Complementary feeding or weaning is a learning process and progresses with the introduction of a wide range of new tastes and increasingly complex textures so that infants are eating minced and chopped nutritious family foods and sipping drinks by 12 months of age. 

Why wean?

Introducing solid foods alongside milk feeds: 

 - Provides extra energy (calories) and nutrients when breast milk or infant formula no longer supply them in sufficient amounts to sustain normal growth and optimal health and development.

 - It also gives infants the opportunity to learn to like new tastes and learn to manage new textures at a time when they are receptive to learning to like them.

As their feeding skills develop, infants begin to eat larger quantities and the number or volume of milk feeds can slowly decrease. 

Good progression through the weaning stages occurs when mealtimes are enjoyable positive experiences, and the risk of later feeding problems reduces.

Ideally breast milk should continue as the main milk drink throughout weaning as this may reduce the risk of food allergies and coeliac disease, although further research is needed in this area.1,2 The age of the infant when solid food is introduced has no effect on the incidence of these conditions.3

When to begin 

Infants all develop at different rates and healthcare professionals need to support parents to decide when their individual infant is ready to wean. Oromotor skills to support weaning onto solid food are noticeable in infants between three and six months of age.4

Within Europe, national recommendations vary from country to country, with most recommending beginning weaning between four and six months of age.3 The UK Department of Health recommend that term infants should be considered individually and should begin around six months (or 26 weeks), but not before four months (or 17 weeks). Parents tend to choose to wean male babies and larger infants earlier than smaller and female babies.5 Larger babies are growing more quickly and tend to be ready for more than just milk at an earlier age. 

Developmental signs that suggest that an infant is ready to accept solid foods are:

 - Ability to sit with support and have good head and neck control.

 - Putting toys and other objects in the mouth.

 - Watching others with interest when they are eating.

 - Seeming hungry between milk feeds or demanding feeds more often, even though larger feeds have been offered.

Night-time waking and crying are not necessarily signs of hunger at this age, as sleeping patterns change and infants that are more easily roused may begin to wake during the night. Many parents hope that weaning will help their infant sleep through the night, but no evidence supports this optimistic theory.

There are no disadvantages to beginning any time between four and six months, and at this age infants learn to accept new tastes and textures relatively quickly. Parents and carers report more problems the later they start.6

Progression

Infants only learn to develop their feeding skills and accept and enjoy new tastes and textures if they are given the opportunity to try them. Infants kept on pureed or smooth foods for too long and not offered lumps and finger foods before 10 months are more likely to be fussy eaters at the age of three years compared to those that progress through the weaning stages appropriately.7 

As their feeding skills develop, infants will eat more food and need less milk. This varies from infant to infant, so set portion sizes are not appropriate. 

The majority of infants regulate their intake of both milk and solid food to their energy needs. 

However parents may be disappointed and frustrated when their infant eats less than they expect and they need a lot of reassurance to allow their infant to decide when he/she has had enough food or enough milk to drink.

Positive feeding environment

Feeding infants in a positive and responsive environment allows them to eat to their appetite and enjoy mealtimes. 

When infants who are coerced or forced to eat more than they need the meal becomes a negative experience for them. In addition they may gain weight rapidly and cross centiles upwards on their growth chart. Excess weight gain in infancy is a risk factor for future obesity.8

Components of a responsive feeding environment include: 

 - Infant sitting with support for both back and feet.

 - Infant and carer facing each other.

 - Pleasant and positive interaction between infant and carer.

 - Allowing infant to set the pace and follow his cues.

 - Having food where the infant can see it and allowing infant to touch and play with food.

 - Offering finger foods from early weaning.

 - No distractions, such as TV or toys, so that the infant can concentrate on eating.

 - Use bibs, cloths, plastic sheets or newspaper to 'contain' mess so that it can be more easily cleaned up at the end of the meal.

 - Stopping feeding when the infant indicates they have had enough.

Following infant cues 

When happy to eat more food infants will: 

 - Open their mouths to accept a spoon of food.

 - Pick up food and put it in their mouth themselves.

When they have had enough they will:

 - Keep their mouth shut when food is offered.

 - Turn their head away from food offered.

 - Put their hand in front of their mouth.

 - Push away a spoon, bowl or plate. 

 - Hold foods in their mouth and refuse to swallow.

 - Spit out food repeatedly.

 - Cry, shout or scream.

 - Try to climb out of their high chair.

 - Gag or retch.

When offered a new taste or texture infants may show surprise and be reluctant to take more at that meal. However if new tastes are offered repeatedly, infants will learn to like that taste as they become more familiar with it. Parents often give up offering new foods if they assume that their infant doesn't like that food, but this narrows down the range of foods the infant has the opportunity to learn to like. By persevering in offering small tastes of a new food every few days the infant will have the opportunity to learn to like that food.9,10

Infants that are able to see and to play with their food at mealtimes learn more about it and develop a positive relationship with food. Finger foods give this opportunity, but touching and playing with soft foods in their bowl is also important. Some parents find the mess involved hard to accept and may need to be encouraged to allow this important part of infants' learning experience. 

Offering finger foods and allowing infants to have their own spoon with which to try feeding encourages the development of self feeding skills. Infants who are encouraged to self feed will feel more engaged in the feeding process and will be less likely to want to end the meal because they have become bored. 

When infants join in family meals they learn to like the taste of family foods. They also develop their own feeding skills by watching and copying other family members' eating habits. 

Although offering only finger foods to infants has been promoted in recent years as 'baby-led weaning,' there is no evidence to support the energy and nutritional adequacy of this method11 and healthcare professionals should not recommend it. 

Gagging and coughing 

When learning to manage new textures, infants may gag or cough back food that needs more chewing. This is part of the learning process and no need for parents to panic; the infant just needs more experience to cope easily with that texture. Infants who repeatedly gag may need further assessment from a speech and language therapist.

Balanced Nutritious Weaning 

A variety of foods from all four food groups will provide the range of nutrients required for growth and development. 

Family foods and home cooked foods are preferable as their taste and texture is more variable than the very uniform commercial baby foods. 

Foods to limit: Liver - limit to once per week.

Foods to avoid: Added sugar and salt; honey; juices and sweet drinks; undercooked eggs, meat and fish; unpasteurised cheeses, marlin, swordfish and shark; soft round foods or whole nuts that are a choking hazard

Drinks 

Breast milk or formula milk should continue as the main milk drink until 12 months of age. Introducing cows' milk as the milk drink before this age increases the risk of iron deficiency anaemia. 

Cups of water can be offered with meals once infants are eating thickly mashed food. Non-valved cups are preferable as they allow the infant to learn to sip. 

Fruit juices damage teeth and are not necessary as sufficient vitamin C comes from milk feeds and fruits and vegetables.  

Vitamin supplements

Policies vary locally but the Department of Health12 recommend that all infants begin a vitamin A & D supplement.

Breastfed infants should begin from six months if their mother was well nourished during pregnancy. If there is any doubt about a mother's vitamin status during pregnancy then breastfed infants should begin this supplement at one month of age. 

Formula fed infants should begin taking a supplement once they are over six months and drinking less than 500mls formula per day. This is because infant formula is supplemented with vitamins A & D. This is usually about 11-12 months.

Food Allergy

Infants are at higher risk of allergy if they have a parent or sibling with eczema, asthma, hayfever and/or food allergies. Ideally for these infants, as for all infants, breastfeeding should continue throughout weaning and the highly allergenic foods should be introduced one at a time so that any reaction to these foods can be noted.

The highly allergenic foods are: 

 - Cow's milk.

 - Egg.

 - Nuts.

 - Fish and seafood.

 - Wheat.

 - Soya.

 - Sesame seeds.

 - Lupin.

 - Celery.

 - Mustard.

There is no evidence to delay introducing these foods beyond specified ages as was previously advised. It may be that when these foods are introduced early while still breastfeeding, food allergies are less likely. More research is needed in this area before more specific recommendations can be made. 

 

References

1. Scientific Advisory Committee on Nutrition and Committee on toxicity. 2011. Timing of introduction of gluten into the infant diet. Available at: www.sacn.gov.uk/pdfs/sacn_cot_statement_timing_of_introduction_of_gluten... (Accessed 10/03/12). 

2.Agostoni C, Decsi T, Fewtrell M, Goulet O, Kolacek S, Koletzko B, Fleischer Michaelsen F, Moreno L, Puntis J, Rigo J, Shamir R, Szajewska H, Turck D, van Goudoever J. Complementary Feeding: A Commentary by the ESPGHAN Committee on Nutrition Journal of Pediatric Gastroenterology and Nutrition 2008;46:99-110.

3. European Food Safety Authority (EFSA) Panel on Dietetic Products, Nutrition and Allergies (NDA) Scientific Opinion on the appropriate age for introduction of complementary feeding of infants. EFSA Journal 2009; 7(12):1423;38.

4. Carruth BR, Skinner JD. Feeding Behaviours and other Motor Development in Healthy Children (2-24 months). Journal of the American College of Nutrition 2002;21(2):88-96.

5. Wright CM, Parkinson KN, Drewett RF. Why are babies weaned early? Data from a prospective population based cohort study Archives of Disease in Childhood 2004;89:813-81. 

6. Diet and nutrition survey of infants and young children (DNSIYC). 2011. Available at: http://transparency.dh.gov.uk/2013/03/13/dnsiyc-2011.

7. Northstone K, Emmett P, Nethersole F and the ALSPAC study team. The effect of age of introduction to lumpy solids on foods eaten and reported feeding difficulties at 6 and 15 months. J Hum Nutr Diet 2001;14:43-54.

8. Reilly JJ, Armstrong J, Dorosty AR, Emmett PM, Ness A, Rogers I, et al. Early life risk factors for obesity in childhood: cohort study. BMJ 2005;330:1357-1359.

9. Birch LL. Development of food acceptance patterns in the first years of life. Proc Nutr Soc 1998;57(4):617-24

10. Maier A, Chabanet C, Schaal B, et al. Food-related sensory experience from birth through weaning:Contrasted patterns in two nearby European regions. Appetite 2007;49(2):429-40.

11. Wright CM, Cameron K, Tsiaka M, Parkinson KN. Is baby-led weaning feasible? When do babies first reach out for and eat finger foods? Maternal and Child Nutrition 2011;7: 27-3.

12. Department of Health. Weaning and the weaning diet. Report on health and social subjects no 45. London: HMSO; 1994.