The latest weaning guidelines

The World Health Organization (WHO) advocates exclusive breastfeeding for the first six months². This advice forms the basis of current Department of Health (DH) recommendations³. However, the WHO guidelines provide a global positioning statement on weaning, primarily to ensure that infants in the developing world receive the full nutritional, health and bonding benefits of breastfeeding¹; there is debate as to how relevant the recommendations are for the developed world.

Organisations such as the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN)⁴ and the American Academy of Pediatrics advocate a more flexible approach to weaning healthy term infants⁴. Their recommendations suggest a wider window of weaning (between four and six months) and advocate that parents introduce a broad range of foods, from an earlier age^{4, 5, 6}.

When should weaning start?
Between 4 and 6 months: The DH recommends that weaning should preferably be commenced at six months but no earlier than 17 weeks³. Robust clinical data on the optimal window for weaning indicate that solids should be introduced between four and six months, at a time suited to the individual baby’s development (as advocated by ESPGHAN)⁴. Solid foods should never be given before 17 weeks, because younger babies are at greater risk of developing coeliac disease or gluten intolerance^{7, 8}. UK recommendations state that weaning should not occur before 17 weeks.

No later than six months: all infants should start taking solids by six months (26 weeks); babies in whom weaning is delayed beyond this often find it difficult to accept lumpy foods^{9, 10.} However, there is no clinical evidence that delaying weaning until six months offers specific clinical benefits³. Data that confirm when is the best time to introduce solids are urgently needed. Six months is an important age when infants begin to learn the side-to-side tongue movement that is the start of the chewing process. By moving food in this manner, infants make the sides of the mouth less sensitive to touch – a learning point that only occurs if lumpy solids are given.

After the age of one year, if infants have not experienced lumpy solids they are likely to become ‘orally defensive’: they become reluctant to have lumps in the mouth and refuse to have any food in the sides of the mouth. Children who are introduced to lumpy solids late, even if purées were introduced at the correct time, are more likely to be fussy about foods and textures in later childhood^9-11.

First foods for taste
The initial goal of weaning is not to satisfy nutritional needs: the aim is for a baby to get used to the sensation of food that is not free-flowing – that requires a different mouth action and comes on a spoon or on fingers. By doing this, when a baby does need additional nutrients to those provided by breastmilk, he/she is able to tolerate them.

In the first weaning stage a baby should consume different foods that stimulate and desensitize the inside of the mouth¹¹. A baby’s mouth is very sensitive to touch from birth and he/she needs to experience different textures (and feeding utensils) within the mouth. Those who do not experience oral feeding at the right developmental (rather than physical) age are more likely to refuse foods in later infancy.

Taste and variety
The first weaning stage is a sensitive time in the development of taste⁵. Babies who receive a wide range of foods during this period appear less likely to experience extreme faddiness: even those who later become neophobic usually pass through this phase without long-term effects¹²

• Start with purées, mixed with breast or formula milk. Offer a few teaspoons once daily, when the baby is not overtired/ over-hungry.
• All tastes should be tried, including bitter/sour foods. Given early and often, infants usually learn to like different tastes, have healthier varied diets and show less preference for sweet or salty tastes in later childhood and adulthood⁴.
• New food groups* should be added (one at a time every 2–3 days) to the range of foods being given: if reactions occur, causes may be more easily identified.
• Fish, eggs and gluten may be given at 26 weeks³: this approach does not increase risk of atopy/eczema^{5, 13, 14}.

Foods requiring caution
Recent studies looking into the timing of the introduction of solid foods and development of childhood atopic disease have prompted countries such as Australia¹⁵ and the USA⁵ to revise their guidance on when allergenic foods should be introduced.

These guidelines state that there is no convincing evidence that delaying the introduction of allergenic foods reduces the risk of allergy; indeed some observational studies indicate allergies may be more likely if these foods are withheld^{5, 13, 14}. Unnecessary dietary restrictions also mean that children may not receive adequate levels of key micronutrients found in specific food groups¹⁶.

To reduce the risk of coeliac disease^{15, 17} or type 1 diabetes¹⁸, gluten should not be given too early (never before four months) or too late (after six months)¹⁹; the DH advice is currently not before 26 weeks³. Gluten containing foods are best introduced gradually, ideally while the baby is still receiving breastmilk⁴.

Babies under 12 months old should not consume honey unless it has undergone specific high-pressure, high-temperature industrial treatment to deactivate Clostridium botulinum spores²⁰.

Consistency
Stage 1: 4–6 months
Start with very fluid purées (consistency of thin cream) that contain fruits, vegetables and/or baby rice products. Commercial foods suitable for Stage 1 weaning may also be given. To create the correct consistency, mix purées with the baby’s usual milk. Changes in texture and consistency should be made at a pace suited to the individual, so that for hungrier babies the calorie content can increase more rapidly, as purée becomes mash.

When weaning begins at six months, the puréed phase should be short. Older infants should move on to mashes/soft finger foods more quickly to ensure that normal feeding behaviours develop^{21, 22}.

Babies should be encouraged to self feed using their hands and their own plastic spoons as soon as they show interest. Parents should expect play – and mess!

Stage 2: 7–9 months
By around seven months, all babies should be eating mashed food (small, soft lumps). If a baby finds it difficult to tolerate lumpier consistencies, parents should offer bite-and-dissolve foods or soft mashes that disperse in the mouth (e.g. potato). These make it easier for the baby to cope with changing textures. Soft finger foods should be given, and commercially prepared foods that are suitable from Stage 2, but avoid hard non-dissolvable foods (including under-cooked or raw foods given in sauces, meat pieces in gravy) which are difficult to chew.

Foods for good nutrition
Once a child learns how to deal with the sensations of eating and consumes more than he/she ends up wearing (around six months), foods from all nutritional groups should be given (to download Table, `Developmental stages of weaning` click here). The content of the diet is now important.

Breastfeeding should continue beyond six months if this suits the mother and baby. Although breastmilk contains adequate iron for younger babies, other sources of iron should be introduced into the older infant`s diet, so check that parents are giving enough iron-rich foods. If parents do not wish to give red meat and other dietary sources of iron seem limited, consider suggesting that home made sauces and breakfast cereals are made with formula or follow-on milk. This may provide a nutritional ‘top-up’ until a wider variety of iron-rich foods are consumed²³. Breastfeeding should continue for as long as the mother and baby want to, as it continues to provide bonding and health benefits.

Full fat cows` milk is permitted in small quantities, after six months, when mixed with other home-cooked foods. However, a broader range of nutrients are found in formula, follow-on (suitable from six months) and growing-up milks (for toddlers). These fortified milks are suitable for older babies and toddlers who are no longer breastfed, or to supplement continued breastfeeding, especially in those who do not follow a varied diet. Certainly, cows’ milk is an inappropriate main drink before 12 months, primarily due to its high sodium content and low iron content.

Vitamin A and D supplementation is recommended for all babies from six months until 3–5 years of age unless they are consuming over 500ml of formula²⁴.

Stage 3: 10–12 months

Chopped foods should have been introduced and the variety of items offered should be increased (e.g., crackers, crunchier breakfast cereals, chopped grapes or fruit pieces). As solids become established and their nutritional importance increases, daily milk intake should not exceed 600ml.

Stage 4: 12+ months

Foods should be of comparable texture to adult foods, with no added salt or sugar. Up to 600ml milk (or three servings of dairy foods) should be consumed daily: growing-up milks provide an alternative to unmodified cows’ milk. Breastfeeding may continue.

If milk feeds are not reduced, a child risks becoming a ‘milkaholic’. Heavy reliance on milk (over 700–800ml per day) restricts appetite and limits the overall nutritional value of the diet – particularly its iron content. In children who continue to eat well, excess milk consumption may also heighten the risk of overweight/obesity.

Commercially prepared foods
Parents can be misled by foods that are marketed for families and given to very young children, but which are suboptimal for weaning. Ingredients and manufacturing processes used in commercially prepared baby foods (foods specifically for up to 36 months) are regulated by strict government guidelines, however, numerous ‘family’ foods used for weaning are not covered by this (e.g. many breakfast cereals, yogurts, fromage frais). Their ingredients would often be restricted if they were specifically produced for children under 36 months.

This does not mean that family foods like yogurts are unsafe for weaning, but parents should read the labels of any foods they intend to use when weaning. Foods with added salt or sugar, or foods naturally high in sugar, should be avoided: infants between 7 and 12 months should have no more than 1g salt per day (rising to 2g per day in the second year)²⁵. Ready meals, soups, stock cubes, gravies and sauces usually contain too much salt for the weaning diet. Parents should be encouraged to make their own weaning foods. However, commercial baby foods can make a useful contribution to the process and can be given alongside (or mixed with) home prepared ingredients. They provide a convenient way for parents to introduce new tastes and textures. Such foods do not always need to be refrigerated or heated, and therefore are of use when safe food storage is difficult.

Trying new foods, a life experience!
Weaning is an ongoing process – most adults still try new foods. But weaning a baby provides the ideal opportunity to encourage the whole family to eat more fish, vegetables and wholemeal bread. All too often vegetables and fruits are abundant in the initial weaning phase, only to be dropped as babies eat the diet of their parents/older family members.

Sadly, evidence from food diaries shows that by a baby’s first birthday, his/her diet is often nutritionally inferior to that offered a few months previously. Instead of replacing fruit purées with fresh fruit, older babies start having cake and biscuits instead. The wide array of vegetables given at six months makes way for baked beans and frozen potato products²⁶. Weaning should be the start of a process where adults show children the wonders and delights of new tastes and textures, but the process of offering healthy, varied foods should progress throughout life.

Click here to view `Weaning Dos and Don`ts for parents`




This article was originally published in the Journal of Family Health Care Bulletin. Vol 19. To download a PDF of the original article click here




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