Weaning Update
October 2010
Jane Shaw
Lead Paediatric Dietitian
Natasha Lloyd
Dietitian for Paediatric Services
Outline
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Introduction
Weaning Recommendations- The Evidence
Weaning Myths
Getting started and Moving On
Weaning the Pre-term Infant
Other Issues
Common Problems
By age one- where should we be?
When and how to refer?
Weaning…
...means introducing a range of foods gradually
until your baby is eating the same foods as the
rest of your family
What are your worst offenders?
These are ours!
• Pureed family foods- chicken nuggets,
beans and chips
• Meringue snowman used as a tethers in
young babies
• Sausage roll put into bottle of formula
milk
• Curry sauce in bottle
Breast milk
Birth
Progress on to
lumpier food faster
when solids
introduced nearer
6/12
First milk
Preterm Formula till 26 wks actual
age or stopped earlier if growth
between 25-50th C
2 years
Finger foods
1 year
„Sour „ veg before
9/12
Fe rich foods
7/12
weaning
17 weeks the
earliest for
weaning
6 months
Family food
3 meals & 3
snack
Cow’s milk as a drink, 500 -600ml/day
First milk can be used till 1 yr
corrected
Cow’s milk as a drink, 500 600ml/day
Vit D supplements for all– Abidec, Healthy start Vitamins, OTC
till 5
95% of infants should be 100% happy on the above
Why? Start Weaning
• Baby needs more than milk alone to meet
nutritional needs
• Extra energy, vitamin D and iron stores are
running low
• Helps to develop muscles required for speech
• Gives infants the opportunity to learn to like
new tastes and textures at a time that is
receptive to them
• It‟s the first step towards baby sharing in family
meals!
When? Background to
recommendations
• By 6 months (26 weeks) never before 17 weeks
(ESPHAGAN 2008)
4 months=17 weeks not 16 weeks
• Exclusive breastfeeding for around 6 months is a
desirable goal (ESPGHAN 2008)
• WHO and DH(2003) recommend that each infant
must be managed individually so that insufficient
growth and other adverse outcomes are not
ignored and appropriate interventions are provided
• EFSA (2009) reported no disadvantage to begin weaning
onto solid foods between 4-6 months compared to waiting
until 6 months
• DH (2004) states there is evidence of harm in late weaning
as it increases the risk of energy and nutrient deficiencies.
Iron deficiency anaemia and rickets are common in infants
weaned after 6 months
• Harris (2000) between 4- 6 months infants learn to accept
new tastes and textures relatively quickly
• Data from Bolling et al (2007) found 50% of babies in the UK
were given solid food between the ages of 4-6 months and
the other half before 4 months
When?
Reasons for not introducing solids before 17 weeks
• Immature kidneys- increased risk of dehydration
• Immature gut- more venerable to allergic reactions and
infections and a reduced absorptive capacity
• Solids can reduce the availability of nutrients in infant milk
• Limited neuromuscular co-ordination for safely taking solid
foods
Reasons for not delaying beyond 26 weeks
• Increased risk of nutrient and energy deficienciesNutritional problems can be encountered i.e. iron and
vitamin D deficiency- anaemia and rickets
• Less chance of food refusal
• Key developmental stages may be missed
Infant Readiness Cues
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Positioning
Behaviours
Oral Skills
Some factors may only be assessed or
developed once weaning has begun and their
absence should not deter an infants
progression with weaning
• Managing to clear the spoon with their lips; this develops
with experience
• Absence of tongue protrusion during feeding; this
disappears gradually with time
• Presence of teeth; they are not essential for chewing
When? Signs to start
• Can sit supported, able to hold their head steady
• Reaches and grabs accurately
• Wants to chew and is putting fists, toys and other
objects in their mouths
• Shows more interest in meal times and food
• Seeming hungry between milk feeds or
demanding feeds more often even though larger
milk feeds have been offered
• Consider on a individual basis- taking a flexible
approach to support mothers in their decisions to
optimise the infants nutrition
Taste Development
• Taste acquisition probably occurs in utero
with foetal swallowing of amniotic fluid
flavoured by the mothers diet
• Taste and smells via breast milk –enhances
later acceptance
• Term infants preference for sweet flavours
• 5-6 months preference for slight salt taste
thus developing taste sensitivity and easy
acceptance of tastes and something new
• By around 1 year of age familiar food
recognition is established
Taste Development continued..
• Neophobia is a normal response to new food
which the child may not view as safe to eat
• Neophobia can increase over the next few years
which can make it harder to encourage children
to try new things
• The acceptance of new food & flavours is still
possible but it may take more time, & is easier in
certain social contexts
Weaning Myths
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Most mothers introduce solid food by 6 months of age and not before 17 weeks.
FALSE 49% of mothers introduce solid foods before 16 weeks (Hamlyn et al 2002 &
Bolling et al 2001).
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“Solid foods will help baby to sleep longer at night”
FALSE. Research suggests comparable sleeping times (Heinig et al 1993).
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Waiting until 6 months affects babies‟ ability to chew.
FALSE. Misconception arising from old research based on infants with developmental
delay which was generalised for healthy infants.
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Waiting until 6 months can lead to fussy eating?
FALSE – Studies suggest no differences in appetite or food acceptance of infants started
on solids at 4 or 6 months (breastfed infants) (Cohen et al 1995)
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Babies need to explore tastes and textures before 6 months to help with speech
development and acceptance of a varied diet
FALSE. – Oral development (anatomy, reflexes and function) is considered to be
immature before 6 months; hence the weaning process may take a bit longer in younger
infants
Breastfeeding and Weaning
• Breastfeeding to continue throughout weaning
and beyond
• Exclusive breastfeeding for around 6 months is a
desirable goal (ESPGHAN 2008)
• Introducing gluten (wheat, rye, barley and oats)
while breastfeeding may reduce risk of coeliac
disease, type 1 diabetes and wheat allergy
How? Safety and hygiene
• Thoroughly wash all bowls and spoons for feeding in hot
soapy water and keep surfaces and chopping boards
thoroughly clean
• Hands – yours and baby
• Keep pets away from food areas and baby‟s feeding
equipment
• Don‟t save and re-use foods that your baby has half eaten
• Cooked food should not be re-heated more than once
• Cook all food thoroughly and cool it to a luke warm
temperature
• Wash fruit and vegetables
• Make sure baby is safely secured in their seat in an upright
position and never leave baby alone whilst they are eating
How? Being Prepared
• Make sure that you have all the correct equipment
to hand:– Appropriate seating i.e. highchair, bumbo seat,
on mum‟s knee (not in bouncy chair/ reclined)
– Fork for mashing
– Shallow plastic spoon, bowl and bib
– Babies usual milk
• Choose a day when you know you will have plenty
of time, be most relaxed and remove as many
distractions as possible e.g. turn off television
How? Feeding your baby
• Make sure baby is sitting upright and facing
forwards
• Try to keep meals to the same times each day
• Baby should not be tired or too hungry
• Always check the temperature of food before giving
it to baby
• Offer food during or after a milk feed
• Start with offering just a few teaspoons of food
once a day – follows baby‟s lead
• Let baby touch the food, spoon, bowl etc
NEVER force feed a baby
Getting Started- First Foods
• Cooked mashed vegetables and fruit e.g. carrot, sweet
potato, butternut squash, parsnip, swede and potatoes,
banana, pear or apple
Or baby suitable cereal made with baby‟s usual milk
• Do not add any salt or sugar to baby‟s food
• Baby still needs to have usual milk feeds along side
weaning foods
• Vegan and macrobiotic diets are not recommend for infants
Commercial v Homemade Foods
Points to Consider!
Homemade
Known contents
Chosen ingredients
Commercial
Mixed ingredients
Cheap
Added vitamins and minerals
(if not organic)
Need skills, Take time
Convenient
No added vits and mins
Expensive
Controlled change in
consistency
Consistency- stage one is very
fine, stage 2 mixed lumps and
fluid
Easy to fortify
Foods to Avoid
• Salty foods e.g. gravy, packet sauces, instant
mash, stock cubes, added salt
• Honey
• Raw eggs, raw shellfish
• Whole nuts
• High sugar foods – sweets, biscuits, cakes,
chocolates, fruit juices, additional sugar and fats
(these are NEEDED if child has poor growth)
• Low calorie foods e.g. low fat dairy foods, Quorn
(egg and fungi)
First foods
High allergen foods such as wheat, egg, fish,
citrus fruit, diary foods, do not need to be
delayed until after 6 months –no evidence
that this will reduce the likelihood of allergies
(ESPGHAN 2008)
Previous recommendations to avoid
wheat, eggs, fish, citrus fruit, fish,
milk products no longer evidence
based
Moving On
Once the infant is eating 2-3 times day and is competent in
eating solid food- a variety of foods from all food groups
should be included. Note Eatwell plate not suitable for
under fives
Advice for 6-12 months:
• Starchy foods- potatoes, rice, oats, pasta, bread, cerealsapprox 3-4 servings per day
• Fruit and vegetables- 3-4 servings per day
• Milk, cheese and yoghurt- demand feeds of breast milk or
infant formula (about 500-600mls day, plus some cheese
and yoghurt
• Protein foods- meat, fish, eggs, smooth nut products,
pulses such as lentils, dhal and hummus: 1-2 servings per
day, 2-3 for vegetarians
Finger Foods
• These can be offered when you first start weaning,
even if baby doesn‟t have many/ any teeth
• Provides chewing practice and encourages baby
to feed themselves
• Try:- banana, melon, pear, cooked green beans
and carrots, bread, breadsticks, small cubes of
hard cheese, toast
• Some infants are kept
on pureed food for too
long and those in the
ALSPAC study who
were not offered lumps
and finger food by 9
months were more likely
to be fussy eaters at an
older age compared to
those weaned
appropriately
(Coultard et al 2009, Northstone et al 2001)
Healthier snacks
Snacks
Soft fruits
Vegetables i.e. carrot sticks
(steamed), cucumber sticks,
steamed broccoli and
cauliflower,
Bread sticks, plain crackers
Malt loaf, tea cakes, crumpets
Cheese cubes, not strings
Humus
Small sandwiches
High calorie snacks
Chapatti/ biscuits/ toast or
bread/ fingers with jam,
peanut butter, cheese/ cream
cheese, chocolate spread
Buns, cakes, muffins,
doughnuts, scones with jam
and cream
Full fat yoghurts and fromais
frai with added cream
Suitable Drinks
• Breast/ formula milk for the main drink from birth to
1 year- Full fat cows milk is a suitable drink
thereafter
• First stage milk is fine from birth to 1 year- hungry
baby, follow-on and toddler milks not routinely
recommended
• Cooled boiled water can be given in warm weather
for babies, and offered with meals once baby is on
3 meals a day
• „Baby juices‟ unnecessary and tea, coffee, fizzy
drinks are not suitable
Choosing a Cup
• Introduce from before/ around 6 months
• Choose a cup that encourages baby to develop
a sipping action.
• Free flow cups or those without a lid are best.
• Avoid no-spill cups as these encourage
excessive sucking.
• Valve cups, cups with teats and sports bottles
not suitable.
• Aim for all drinks from a cup by 1st birthday
Weaning the Pre-term Infant
• WHO and DH guidelines do not account for preterm babies
• Joint Consensus statement on weaning preterm
infants by Neonatal Dietitians Interest Group (UK)
and Speech and Language Paediatric Dysphagia
Group (UK)
• Supporting evidence in Paediatrics and Child
Health 2009 19:9 page 405-414 C king
• Weaning from 5 – 8 months uncorrected, those
healthy prems born nearer term can be weaned
as a term infant
Progression through textures
(Preterm infants)
• Most preterm infants will progress normally through
the development of eating & drinking skills with
responsive input from parents
• Preterm infants who are more sensitive to change
and less able to feed themselves may benefit from
more gradual progression through the range of
textures
• Allowing infants to play with food as soon as they
show an interest will help the development of self
feeding skills using hands and fingers
• Progression to use of utensils can happen later
Progression through textures
(Preterm infants)
• More textured foods may be better accepted as
finger foods as the child has more control of what
goes into his/her mouth.
• Home cooked foods are easy to modify and control
in terms of consistency. Avoid smooth puree with
floating lumps
• It may be useful to alter texture and taste
separately.
• Exposure to the sight of food alone is not sufficient
• By 9 months uncorrected a preterm infant following
normal development stages is likely to benefit from
being introduced to lumps and finger food
Nutritional Considerations
(Preterm)
• Thriving prems treat the same as any healthy term
infant
• No greater risk of food allergy
• Good variety of home cooked foods
• Provide adequate protein, energy, iron and zinc
• Iron and vitamin supplements
• Appropriate schedule for weight monitoring
Preterm infants with additional
medical problems
• MDT approach – joint feeding clinic very helpful
• Neurological impairment – aspiration, swallowing difficulties
or oro –motor problems
• CLD – more problems co-ordinating sucking and swallowing
with breathing from breast or bottle but may find solids
easier, not to start solid before 5 months uncorrected without
a SALT assessment
• Limited or negative early oral feeding (tube feeding, GORD)
may develop sensory based feeding aversions
• GORD – medical management, thicken feeds may
compromise milk intake and ensure appropriate feeding
equipment being used
• Faltering growth – not a reason for early weaning, weaning
food not energy dense like milk feeds – refer to dietitian
Other considerations…
• Allergy intolerance
• Vitamin drops
• Baby led weaning?
Family history of allergy/intolerance
• No need avoid allergen because of family history
unless history of serve reactions
• Ideally these infants would be breast fed
throughout weaning
• No evidence that delaying until after 6 months
reduces risk
• Consider allergies or aversions?
• Some tests need allergen to be in diet in high
amounts to provide a positive- Can not get NHS
prescription without a confirmed proven diagnosis
Vitamins drops and
HEALTHY START
Department of Health recommends that all children under 5
Vitamins A & D for breast fed infants or for infants (up to 1 year
of age) taking less than 500mls of formula per day
Children from ethnic minorities who have darker skin, because
their bodies are less able to produce as much vitamin D.
Especially African-Caribbean and South Asian origin.
How accessed www.healthystart.nhs.uk
• In Rotherham now available from most local pharmacies for
maternal drops
Baby Led Weaning
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Seems to follow current weaning guidelines
Misses puree and mashed stage
Doesn‟t advocate using a spoon
Baby chooses from a range of finger foods
Family meals
Eating off high chair rather than plate
Where should we be…
By 1 year of age…
Eating 3 family meals a day
• Having 2 to 3 snacks or milky drinks approx 1pint
milk daily
• Switch to cows milk and not formula milk
• Should be using a cup and not a bottle
Common Problems
• Fussy Eaters
• Constipation
• Anaemia
Fussy Eaters
• Constipation, anemia or other medical conditions need to be treated
before trying to change eating behaviors
• Parents should not pressure, bribe or force feed their toddler
• Toddlers show clear behavioral signals when they have had enough to
eat
• Don‟t get stressed
• Create a positive/ appropriate environment
• Set a good example by enjoying a variety of healthy foods- sit and eat
with your child
• Encourage set meal times- routine
• Let child feed themselves- cut food into bite size pieces and expect
mess, don‟t clean up until the end of the meal
• Use lots of praise- ignore refusal
Fussy Eaters…
• Parents should not use one food as a reward for eating
another
• No multiple meals
• 10 plus rule
• Consider fluid intake? Too much fluid intake, either milk,
juice or squash, may reduce food consumption.
• Consider snacks?
• What parents food habits like?
• Involve in all aspects of meal i.e. preparation, food toys,
books
Remember appetites varyWhat they eat in a week not what they eat in a day!
Constipation
• Poor diet, overfeeding in infancy, dietary insufficient
dietary fibre or fluid intake, excessive milk intake,
faddy eating (vicious circle)
• Check family history
• Treatment of constipation usually requires a combination of
dietary, behavioural and medical interventions
• If the bowel is loaded with faeces disimpaction of the bowel
with laxatives is the essential first-line management
• Behavioural intervention should include advice on toilet
training
• Constipation can be prevented by attention to healthy eating,
adequate fluid intake, exercise and sensible toilet training
Constipation..
Diet - Parents should aim to:
• Offer six to eight drinks per day - one with each meal and
one in between meals or with a snack
• Include a fruit and a vegetable with the midday and
evening meals
• Include a starchy or cereal based food with each meal make it wholegrain sometimes
• Offer regular meals and only planned snacks – one snack
halfway between meals
• Make sure there is always time in the mornings for
breakfast - include some fruit or a wholegrain bread or
cereal
Iron Deficiency Anaemia
• Up to 89 per cent of toddlers aged one to three have iron intakes below
the recommended intake and toddlers with feeding problems are at
particular risk of IDA
• Even moderately low levels of haemoglobin, between 90-109g/l (910.9g/dl), can be associated with delays in cognitive and motor
development and behavioural problems
• At birth infants have sufficient iron stores to last for up to six months.
Preterm babies do not have these stores and so are vulnerable to iron
deficiency
• Breast milk provides all nutritional needs, including iron, for about six
months and then iron must be supplied by the weaning diet
• IDA is treated with an iron supplement and a healthy diet that includes
foods rich in iron and nutrients that promote iron absorption
• Prevention of IDA includes nutritional education for parents and carers
and ensuring adequate intake of iron rich foods
Iron Deficiency Anaemia
• There are two types of dietary iron:
well-absorbed 'haem' iron from meat and oily fish and
less well-absorbed 'non-haem' iron found in leafy
green vegetables, grains, pulses and beans
• Iron absorption is inhibited by dietary fibre, calcium,
phytates in flour and tannin in tea
• Vitamin C in fruit, vegetables and fruit juices enhance
intestinal iron absorption if consumed at the same time as
iron-containing foods.
Foods High in Vitamin C include: • blackcurrants • kiwi
fruit • citrus fruits • strawberries • mangoes • tomatoes
• peppers • potatoes • sweet potatoes
When to Refer?
Term infants/Preterm infants
– Feeding difficulties, Fussy eaters, Food intolerance or allergy, Faltering
growth, Obesity, Constipation, Anaemia, NG feeders, congenital and
neurological abnormalities that if not known to a Dietitian
Preterm infants
– To Dietitian
• Faltering grow, aversion reaction to the introduction of food and/or oral
stimulation, experience spillage of food from their mouths during feed times,
narrow range of foods for social, cultural or behavioural reasons
– To CDC for assessment
• poor head control is difficult to position or seat, Very sensitive to touch around
their mouth and face, falls asleep frequently when being fed
– TO SALT urgently
• Chokes persistently/ gags and/or vomits during eating or drinking, experience
spillage of food from their mouths during feed times, marked tongue thrust and
protrusion well into second half of first year
Contact Details
Paediatric Dietitians
01709 304384
Fax number:
01709 304292
Appointments and
referral follow-up
01709 304297
Prescribing
01709 307079
How to refer
Well completed CAF form
No need to phone to discuss prior
to referral we‟ll contact you
GP and consultants on fully
completed Dietetic referral form
No telephone referrals or written
letter
Any Questions?
Formula Milk Update
Prescribing for patients with Rotherham GP‟s
Jane Shaw
Deputy Manager Nutrition and Dietetics
Acute Services
Dietetic Enteral and Supplement
Prescribing
• Have prescribed on behalf of GP‟s since April
2007 and hold the budget
• Dietitian px on GP behalf and can only
prescribe what is in mimms
• Enteral feed and supplements
• Always managed to meet the budget
• Unlike surrounding areas that have up to a
15% over spend
Project Expansion in 2010
• In August 2010 PCT Board agreed to expand
the project
• So on the 1st September 2010 we took on:
– All baby formulae
– Gluten Free foods
– Low protein foods
– Metabolic products
• Only what in mimms
• Do not px colief or feed thickeners or
thickened fluids
What we have found so far…
• Lots inappropriate prescribing
– Stopped about half pre-upload to the computer system
– Number of 2 and 3 yrs on formula
– Even a 9 year old!
• About 10 infants on soya formula all unknown to
dietitians
• Nutriprem 2
– we carried 43 pts on the new system
– After checking on TPP only 15 need to on NP2
– Of the 15 remaining 1/3 have FTT and need urgent dietetic
review
Your role in the project
• If you review the patient and you feel
that the product not suitable anymore
and there is more than 4 weeks to
dietetic appt contact us so we can
adjust nutritional care plan
• Notify us of deaths
• We need partnership working
Prescribing contacts
01709 307079
Any Questions?