The age of weaning, practice and practicalities

The recommended age of weaning is at six months, but many parents, for a variety of reasons, may wish to wean earlier^2,3,4. The earliest age at which solids should be introduced is four months or 17 weeks⁵. This applies for all normal healthy term infants, whether breastfed, formula-fed or combination-fed (i.e. breast and formula-fed). The DH also states that if a mother chooses to introduce solids before six months, she should be fully supported by her Healthcare Professional. The general advice available in the public domain has an emphasis on communicating the six months` age of weaning recommendation, and rarely in conjunction with reinforcing to parents that they should have Healthcare Professional (HCP) support. All babies are different, and parents should be advised to discuss their baby`s needs with their Health Visitor or GP.

Current guidance on weaning is based on the COMA report on Weaning and the Weaning Diet⁶, with the exception of the age recommended. Introducing weaning food early (prior to 17 weeks) into an infant`s diet is discouraged because the infant has not fully developed neuromuscular coordination which allows the infant to form a bolus and eat solid food – at a time when they should be fed only milk. The kidneys are not fully mature before 17 weeks, nor will the baby have achieved gut closure. This means that the gut will be particularly `porous` to intact proteins entering the bloodstream during this time, which may contribute to an increased risk in allergies and infections. Early introduction of solid foods may also reduce the absorption of nutrients from breastmilk⁷. Weaning too early has been associated with an increased rate of minor morbidity, and may also jeopardise the continuation of breastfeeding. On the other hand, a delay in weaning has been associated with malnutrition, neuromuscular effects and feeding problems⁸.

Current trends in weaning practices
Only 2% of mothers are following DH guidelines to delay weaning onto solids until 26 weeks⁴. However, despite this a recent national survey has shown a marked trend towards mothers introducing solids later. This suggests that parents are more aware of the recommendations, particularly not to wean before 17 weeks (4 months). (See Figure 1).

Figure 1. This shows a trend towards mothers introducing solid foods later. In 2005 only 51% of mothers introduced solid foods by 17 weeks, as opposed to 85% of mothers in 2000⁴.



Despite the recommended age of weaning being 26 weeks and not before 17 weeks, the average age of first weaning onto solids in the UK is 19 weeks, with 1 in 10 mothers commencing weaning before 13 weeks⁴. If an infant has had rapid weight gain in the first six weeks, they are most likely to be weaned early alongside their parents` perception that they are still hungry⁸.

Common signs that indicate that infants are ready to wean, as reported by mothers, include the baby showing an interest in food and the baby is no longer satisfied or is still hungry⁴. Women who introduced solids before 12 weeks hoped that their infant would settle more easily after the introduction of solids and that they would sleep through the night. Some continued to give the infant solids as the baby was settled and content on them – and seemed to enjoy them¹⁰. First time parents have been reported to introduce solids too early, possibly because they feel insecure when interpreting the infants behaviour¹¹ due to lack of experience, or they are following contradictory advice from friends and family?

Multicultural weaning practices
Healthcare Professionals working with clients from multi-cultural backgrounds may observe differences in weaning practices. Infant feeding practices also differ between families in the UK and their country of origin. For example, in a study to investigate the reasons for adherence or nonadherence to guidelines by Pakistani mothers living in England and Pakistan, 73% of mothers in Pakistan breastfed compared to 24% of mothers in England¹². With regards to weaning practices, mothers in Pakistan demonstrated more confidence in weaning practices – which was attributed to advice from relatives and experiences with other siblings. Mothers in England and Pakistan both requested additional HCP advice in order to improve weaning practices of the infants. This may be extrapolated to other cultures, as there is an indication that most families are receptive to weaning and breastfeeding advice¹¹.

Mothers from minority ethnic backgrounds in the UK introduce solids later on average than white mothers, with 83% of white mothers introducing solids by five months. In comparison, around 70% of mothers from Asian, Black, Chinese and other ethnic backgrounds have weaned by this stage. Mothers from Chinese and other ethnic backgrounds are the least likely to have introduced solids by 17 weeks (40% compared with 53% of white mothers)⁴.

Problems with late weaning
There is a window of opportunity in which weaning should commence, including progression through textures and flavours, and missing this (i.e. late weaning) is not ideal for an infant`s development.

The problems that have been associated with late weaning include¹³:

• Problems later with different tasting food
• Problems coping with lumps as the infant has missed out on critical phases for textures and developing eating skills from 4-6 months. Establishment of coping with lumps is from age 6-8 months
• As a consequence of late weaning, the infants tend to eat non-lumpy food, with a puréed consistency without progression through textures and consistency
• As the infants have not been introduced to solids, they tend to consume milk for longer whilst displacing solids. For example, the average milk intake in Bangladeshi infants at 18 months being 600ml, twice that of the recommended milk intake at that age.

Influences on age of introduction
Mothers who introduced weaning foods later tend to be guided by their HCP advice such as the Health Visitor and written sources. However, those who wean early are more likely to be influenced by informal advice from friends and family, as well as subjective criteria such as whether they consider their baby to be sufficiently satisfied with milk feeds, and their own previous experience⁴.

Conflicting information regarding weaning
There seems to be some conflicting data regarding the health consequences of early weaning on infants` health. Although minor morbidities have been reported⁸ with introduction of solid food too early, it is also considered as a risk factor for infants at high risk of developing allergic disease¹¹; including a predisposition to atopic dermatitis for preterm infants at 12 months post-term¹⁴. Moreover, the reverse, that delayed introduction of solids might help prevent allergies is equally unfounded¹⁵. There was no evidence of a protective effect of the late introduction of solids for the development of Atopy – including Atopic Dermatitis. Parents may also be privy to this conflicting data as it is published in the public domain, with some researchers suggesting, or challenging the current weaning recommendations for developed countries such as the UK³. Despite the conflicting information available on the effects of early weaning, parents should be supported and reassured that not all babies are the same and should be managed individually according to their needs.

Some parents are not aware of basic infant nutrition, and HCPs are advised to continually work at improving parental understanding. This may be achieved through the health visits which infants undergo in the first year of life. Perhaps adoption of fact sheets that have been shown to be best practice, from reputable sources can be adapted into standard patient education. HCPs currently spend time dealing with iron deficiency and feeding difficulties – it may also be worth bearing in mind that these problems may be traced to poor weaning practices¹³ therefore the issue may be addressed through education to minimise the risk of malnutrition and feeding problems.


Recommendations on the age of weaning:

• Exclusive breastfeeding is recommended for the first six months of life
• Weaning (not before 17 weeks). To optimise all infant`s nutrition, all mothers should be supported by their HCPs, including those who choose to wean before six months
• Breastfeeding or infant formula feeding (or a combination of both) should continue beyond six months along with appropriate weaning foods.

The issues surrounding the age of weaning recommendations and guidelines sometimes have conflicting advice, and individual circumstances and cultures all have a bearing. For the parents and caregivers, it may not be simple - and the age of weaning may be another area of anxiety for which they need additional HCP support.

For more information visit (click each link to access)

Cow & Gate Weaning Foods
The Infant and Toddler Forum website

For parents - for practical advice and information and advice weaning and suitable products, visit the Cow & Gate website using this link:

Cow & Gate parents website – information and advice about weaning


References

1. WHO. WHA54.2. Agenda item 13.1. Infant and young child nutrition
2. Fewtrell M et al. Arch Dis Child Neonatal Ed. 2003;88:F296-F301
3. Foote KD & Marriott LD. Arch Dis Child 2003;88:488-92
4. Bolling K et al. Infant Feeding Survey 2005
5. Department of Health 2003. Infant Feeding Recommendation
6. Department of Health 1994. Weaning and the Weaning Diet. Report on Health and Social Subjects 45. HMSO, London
7. www.sacn.gov.uk/pdfs/smcn_03_08.pdf (accessed 30.09.07) p4
8. Wright C et al. Arch Dis Child. 2004;89:813–816
9. Scientific Advisory Committee on Nutrition. Introduction of solid foods SMCN/03/08
10. Alder EM et al., BJN 2004;92:527–531
11. Mikkelsen A et al. J Pediatr Health Care 2007;21(4):238-44
12. Sarwar T. J Hum Nutr Diet 2002;15(6):419-28
13. Harris RJ. Arch Dis Child 2004; 89(2):154-8
14. Morgan J et al. Arch Dis Child 2004;89(8):728-33)
15. Zutavern A et al. Arch Dis Child 2004;89:303-308.
16. Complementary Feeding: A Commentary by the ESPGHAN Committee on Nutrition. J Ped Gastr & Nutr 2008; 46:99-110.