Psychological factors on weaning decisions

When to wean
Weaning onto solid foods should take place at the time when the infant starts to signal hunger to the mother. This usually occurs between the ages of four and six months, when breast or formula milk may not be providing sufficient calories for the infant. A young infant can regulate intake to meet its energy needs¹ – breastfed babies do this all the time, and so from an evolutionary perspective - the infant must be able to signal that energy needs are no longer being met, and this is the time when it is appropriate for the infant to move onto solid food.

The behaviours that mothers report as showing that the infant needs weaning food, and use to determine the age at which they wean, are usually those of:

• waking at night when they had slept before
• crying in between feeds when feed times had already been established
• sucking their fists²

Infants of this age will also show an interest in what others are doing and eating because they have reached the age at which they start to imitate others.A sensitive mother, who is confident that she can read her infant`s signals of hunger, is likely to respond by starting her infant on weaning foods, at about the time when the introduction of weaning food is often advocated or recommended.

What can go wrong with this process?
Some mothers may introduce solids, not in response to a change in their infant`s behaviour, but to attempt to get their infant to sleep through the night, or to go longer between feeds in the first instance. In these cases, a mother may well introduce solid foods before the infant is signalling nutritional need. Mothers who introduce solids earlier than four months are likely to be those who are younger, from a lower socio-economic group, less well-educated and more likely to be bottlefeeding<sup>3</sup>. These mothers may well start the process by adding food to the bottle, and may well see moving their infants onto solids as a developmental milestone, rather than acting in response to their infant`s need. Moving the infant on, to them, shows that their infant is progressing well through the developmental stages.

Moving the infant onto family foods is also seen as a progression, even though the family foods that they are feeding to their infants are not those that would necessarily be recommended. We often suggest that mothers start weaning with puréed or mashed family foods. However, family foods might not be appropriate for the infant and unlikely to meet the nutritional needs of the infant. If chips are part of a family`s staple diet, then puréed chips will be given to the infant.

Many mothers are confused therefore about the advice that they are given – family food is advocated, and this will give an infant a preference for the foods that the rest of the family eat – but do we want to have toddlers who only eat pizza and chips? What needs to be done is to educate these mothers into providing healthier meals for the whole family as well as the infant.

At the other end of the anxiety continuum are those mothers who have read so many booklets on weaning the infant, with so much conflicting information given to them, that they are terrified of introducing practically any food apart from very bland rice or cereals. These mothers often report in clinic that they rely on commercial baby food because they know that these foods must be safe for the infant, and that they are not sure which of the foods that they might prepare at home can be given to the infant.


Introducing puréed foods

Why introduce purées from a spoon?
Infants` tongues are very hypersensitive after birth, but become less so as they begin to mouth objects. Allowing a spoon into the mouth helps this process along. Using the spoon and starting the weaning process with puréed food also allows the infant to use the oral motor skills that have already developed, or are present at birth^4,5. Swallowing purées is done in the same way as swallowing liquids, the food is pooled in the tongue and then passes over the back of the tongue to be swallowed. The infant is less likely to gag or choke using this oral-motor movement than they are if they try to use the more complex skills involved in processing more solid textured food. The infant is gradually building on the skills that they already have, and puréed weaning foods can be safely introduced in the 4 to 6 month period.

Why introduce fruit and vegetables?
Infants are born with a preference for a sweet taste. Preferences for all other tastes have to be learned⁶. The infant doesn`t need to take large amounts of the new food to learn to like the taste, a little given often is better. The taste of many fruits and vegetables tend to be sour or bitter, so the infant has to learn to like these tastes. There are some research studies that show that it is easier to get an infant to accept one of these `new` tastes in the period between 4 to 6 months^7,8. If an infant accepts a taste readily then the mother is more likely to continue to feed the infant that food, and continue to give the child that food into later childhood. Early introduction of fruit and vegetables is more likely to mean that older children will eat fruit and vegetables^9,10.

Why introduce single tastes?
Adults usually eat foods as single tastes, we tend not to make all of our food into soups or stews. The infant needs to learn the taste of each individual food so that this preference will carry over into later childhood and to adulthood. Some mothers tend to think that, if a flavour of a food is too strong, it is best to try and disguise it with a sweeter flavoured food. They will perhaps mask the taste of broccoli with that of carrot (which is a sweet root vegetable). Because the infant accepts the sweeter mix more readily the mother tends to be pleased that the infant is eating broccoli in some form. Unfortunately, eating one food that is disguised in other foods does not mean that the food will be accepted when it is presented by itself.

What can go wrong with this process?
When being introduced to new foods, the infant can seem to spit foods out. This is because the infant is learning to handle a different texture from the milk diet and is getting used to the feel of a spoon in the mouth. The food is a different consistency from milk so the infant has to get used to the tongue movement that is needed to get the food to the back of the mouth. This means that some food will go to the back of the mouth, but some food will also come to the front of the mouth. Mothers may see this spitting out as an indication of dislike, and stop feeding the infant. Because, infants are born with a preference for a sweet taste and have to learn to get used to all other tastes (salt, bitter, sour and their combinations), the normal infant response to a new taste is to pull a face. These grimaces can be quite extreme when the food is slightly bitter or sour. Mothers, who do not realise that their infant will respond in this way, might then stop feeding the infant those foods that have a new or stronger taste, and return to blander and sweeter foods to continue the weaning process.

In addition, mothers, who themselves dislike certain foods or food tastes, may start to introduce them to their infants, but as they do so pull disgust faces. This signals to the infant that the food should not be tasted. Of course, other mothers may not even try to introduce foods that they themselves do not like, and they may not like them because they themselves have not eaten them as a child, which brings us back to the healthy family diet.

The second stage - lumpy solids
Mothers like to progress onto the next stage of weaning, and think that the next stage should be a purée with lumps in it. Perhaps this is because traditionally, baby food companies have produced this type of food as a second stage baby food, although they have now largely rectified this problem. However, this combination of textures is probably the most difficult for an infant to cope with. In order to process lumps in liquid the infant has to move the lumps to one side with the tongue, swallow the liquid, then move the lumps back to the centre of the mouth with the tongue in order to mash the lumps on the top of the mouth and then swallow them^4,5.

An easier second stage in weaning food is that of a consistent textured soft mash. This gives the infant the feel of texture in the mouth, but is easier to process. The food can be mashed against the top of the mouth and swallowed in one movement.

What can go wrong with this process?
This process is quite difficult for an infant if the food given is lumps in liquid, and what often happens is that the infant swallows the liquid and the lumps all together, the lumps stick on the back of the tongue, and the infant gags and chokes in an attempt to clear the lumps from the hypersensitive back of the tongue. Adults can experience the same feeling when they try to swallow a medication tablet whole, with water; it often doesn`t quite go down and has to be coughed back up.

If mothers see their infant `choking`, then they are likely to stop the progression of textures and return to feeding their infant puréed food. More experienced mothers know that their infant will gradually learn to cope with lumps, and that the gagging and choking will just be a passing phase.

Those mothers who do delay the introduction of more solid foods to their infants make it more difficult for the infant to learn to cope with anything more solid, including finger foods. The process of processing solid food in the mouth is one that has to be learned. There is an easier period to introduce solid foods, and this is before the end of the first year⁶. After this time infants become more defensive about putting solid foods into their mouth, and the sides of the mouth remain hypersensitive to any tactile experience. Children who have not gained the experience of dealing with solid textured foods tend to prefer food that is easier to eat, such as yoghurts and soft crisps. This is especially true of those children who tend to be more sensory sensitive anyway. These are children who are reluctant to get their hands dirty, and who dislike having their faces washed and teeth cleaned. So, for these children, it is especially important to introduce solid foods before the end of the first year.

The third stage - finger foods
These can be given from about the age of seven months or so, but once again these foods come with their own problems. The first finger foods should ideally be `bite and dissolve`, that is, once they are in the mouth, the saliva softens the food and breaks it down into a manageable mash. This texture allows the infant to have the experience of a lump of food in the mouth which is easy to process. With harder lumps, the infant has to move the food to the side of the mouth and break the food down with teeth or gums, this is a more complex movement than is needed for bite and dissolve foods. So the progression should be, bite and dissolve first, with a progression to harder textured foods that needs more chewing. Meat is the most difficult texture for an infant to cope with.

What can go wrong with this process.
Again, as with second stage baby food, the infant is likely to gag and `choke` when these foods are first introduced. More anxious mothers will then stop giving the food to the infant and revert to more puréed textures. However, the earlier an infant is introduced to solid or lumpy foods, from six months, then the less likely it is that food refusal and food fussiness will occur in later childhood¹¹.

Mothers may also give family foods as finger foods and be happy that their infant has progressed onto real adult food, but this may mean that the infant is given chips or pizza, but not pieces of fruit or vegetables.

Also at this stage, when the infant is beginning to self-feed, it is very important that the mother does not worry about her infant getting messy. The messy process helps to desensitize the infant, who will get less worried about the feel of food on hands and face. The infant also learns to enjoy food and cannot, of course, tackle such necessary foods as fruits without getting messy. Mothers who are worried about cleanliness and tend to be rather obsessive, or obsessively anxious, avoid letting their child get messy. This means, not only do they clean them as soon as any food gets on their face and hands, but also they won`t give foods that make a mess.

The mealtime
Weaning foods are best introduced when neither the mother nor the infant are stressed (if such a time exists). So foods should be given when the infant is more alert, and between feeds, or after having some of a milk feed. The infant needs to be in an appropriate baby chair, so that the mother can see the infant`s face. Small amounts of food should be offered, with the emphasis on the experience rather than the amount that the infant takes. This is a learning process. Infants after the age of four months can signal their preferences and their hunger levels. The infant might be slow to accept food at first, and wary of new tastes, but if the mother is not worried about the amount of food that the infant takes, then the pace of the mealtime can be determined by the infant.

What can go wrong with this process?
The infant will signal food refusal by closing his or her mouth, and turning the head away. It is acceptable to try with the spoon a few times after the infant shows these behaviours. However, if a mother keeps trying, when the infant clearly continues to refuse the food, and tries to push the food into the infant`s mouth, then food refusal behaviours will become more extreme. Eventually, an infant who has been force-fed, will start to cry when they are placed in the baby chair, and the mother will come to dread the mealtime. A mother who is already anxious or depressed after the birth of her baby is more likely to get this process wrong¹². Anxious mothers tend not to be able to think of ways around a problem, but tend instead to continue with the strategy that they are using; they are, therefore, more likely to force-feed the infant. This means that an anxious or depressed mother, is more likely to have an infant that refuses food in the weaning stage. Unfortunately, giving advice that weaning should be stopped and continued at a later date, often means that the problem gets worse rather than better. If mothers leave the introduction of foods too long they miss the sensitive periods – the windows of opportunity – and the introduction of foods becomes more difficult, rather than easier. It might be a good idea to stop the weaning process for a week or so, but then to restart it, giving the mother clear advice about concentrating on the experience of the food, starting with sweet foods, and an easy texture, not worrying if the infant appears to spit the food out, and allowing the infant to pace the mealtime.

The role of the Healthcare Professional
The Healthcare Professional needs to be aware of mother`s anxieties about weaning, and the infant`s role in determining what and how much is fed. Advice on weaning is often concentrated around what foods to give, or more often, what foods not to give. The time points at which the mother is most likely to have problems in the process of weaning, are the transition times:

• starting the whole process
• the transition from purée to more textured foods
• the introduction of finger foods

Those mothers who are most likely to have difficulty with the weaning process are those who are anxious and depressed, or obsessively clean about the house.

Those infants who are most likely to have problems with the weaning process are those with a small or poor appetite, or those who are tactilely hypersensitive; these tend to be the more irritable and less easily settled infants. With these infants, if weaning does not start well then the suggestion that the process should be delayed needs careful monitoring.

Some advice that we all give - that is, to introduce family foods – is not always the best advice.

Healthcare Professionals have an important role in helping with the entire family`s diet; vegetables and fruit need to be part of this if the infant is going to learn to eat them.

References

1. Harris, G. (2000). Developmental, regulatory and cognitive aspects of feeding disorders. In A. Southall and A. Schwartz (eds.) Feeding Problems in Children. Oxon: Radcliffe Medical Press.
2. Harris, G. (1988). Determinants of the introduction of solid food. Journal of Reproductive and Infant Psychology, 6: 241-249.
3. Bolling K, Grant C, Hamlyn B et al. (2007) Infant feeding 2005. A survey conducted on behalf of the The Information Centre for Health and Social care and the UK health departments by BRMB Social Research, London; The Information Centre.
4. Mason, S.J, Harris, G.& Blissett, J. (2005).Tube feeding in infancy: Implications for the development of normal eating and drinking skills Dysphagia 20, 1 : 46-61.
5. Giesel, E.G. (1991). Effect of food texture on the development of chewing of children between six months and two years of age. Developmental Medicine and Child Neurology, 33, 69-79.
6. Harris, G. (1993). Introducing the infant`s first solid food, British Food Journal, 95(9), 7-10.
7. Birch, L.L, Gunder, L., Grimm-Thomas, K. & Laing, D. (1998). Infants consumption of a new food enhances acceptance of similar foods, Appetite, 30, 283-295.
8. Harris, G, Thomas, A. & Booth, D.A. (1990). Development of salt taste in infancy, Developmental Psychology 26(4), 534-538.
9. Skinner, J. D, Carruth, B. R., Bounds, W., Ziegler, P.J. & Reidy, K. (2002). Do food-related experiences in the first 2 years of life predict dietary variety in school-aged children? Journal of Nutritional Education & Behaviour, 34; 6: 310-315.
10. Wardle, J, Cooke, L.J, Gibson, E.L, Sapochnik, M., Sheiham, A. & Lawson, M. (2003). Increasing children`s acceptance of vegetables; a randomised trial of parent led exposure. Appetite, 40; 2: 155-162.
11. Northstone, K, Emmett, P, Nethersole, F. and the ALSPAC study team (2001). The effect of age of introduction to lumpy solids on foods eaten and reported feeding difficulties at 6 and 15 months. Journal of Human Nutrition and Dietetics, 14, 43-54.
12. Coulthard, H & Harris, G. (2003) Early food refusal: the role of maternal mood. Journal of Reproductive and Infant Psychology, 21,4, 335-345.