The purpose of introducing solid foods alongside an infant’s milk feeds is to:
From 1994 the age range of 4-6 months was considered ideal to begin weaning term infants onto solids (Department of Health 1994). However this was largely mis-interpreted by many Health Care Professional (HCPs) to mean that infants should all begin weaning at 16 weeks of age.
The World Health Organization (WHO) recommended in 2001 that exclusive breastfeeding should continue until 6 months of age to protect infants from morbidity and mortality that is associated with gastroenteritis.
Following the WHO recommendations in 2001 there has been considerable debate over the ideal age to begin weaning healthy term infants (Platt 2009, Agostoni et al 2008, Fewtrell et al 2007, Foote & Marriott 2003). Gastroenteritis is common in developing countries and is associated with the introduction of formula and complementary foods. Many have questioned whether the WHO recommendation applies to developed countries where the risks from episodes of gastroenteritis are minimal (Fewtrell et al 2007, Foote & Marriott 2003, Lanigan et al 2001). The debate remains over whether some infants who are not weaned until 6 months may be at risk of micronutrient deficiencies (Lanigan et al 2001, Butte et al 2002).
The 2001 World Health Organization’s global strategy for infant and young child feeding revised its guidance and recommended exclusive breastfeeding for the first six months of life. The WHO recommendation applies to populations and it is acknowledged in the document that exclusive breastfeeding to six months could lead to iron deficiency in susceptible infants, and growth faltering and other micronutrient deficiencies in some infants.
In 2001 The UK Scientific Advisory Committee on Nutrition (SACN) reviewed the evidence from the 2001 World Health Organization’s global strategy for infant and young child feeding and advised that:
‘there is sufficient scientific evidence that exclusive breastfeeding for 6 months is nutritionally adequate’. However SACN ‘noted that early introduction of complementary foods is normal practice in the UK and that mothers do this for many valid personal, social and economic reasons’. SACN ‘therefore recommended that there should be some flexibility in the advice, but that any complementary feeding should not be introduced before the end of 4 months (17 weeks)’
The Department of Health issued a statement on breastfeeding (12/05/03): ‘Breastfeeding is the best form of nutrition for infants. Exclusive breastfeeding is recommended for the first six months (26 weeks) of an infant’s life as it provides all the nutrients a baby needs.’
Both the recommendations from the WHO and from the Department of Health (DH) England, in 2003 were population recommendations. Both organisations recommended that each infant must be managed individually so that insufficient growth and other adverse outcomes are not ignored and appropriate interventions are provided.
The European Society for Paediatric Gastroenterology, Hepatology and Nutrition and the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition reviewed the literature on complementary feeding for healthy term infants in 2008 and recommend that:
Exclusive breastfeeding for around 6 months is a desirable goal
*Foods containing gluten are wheat, rye, barley and oats. These cereals are present in bread, wheat flour, some breakfast cereal and rusks.
In developed countries there are no reported disadvantages to beginning weaning onto solid foods between 4 and 6 months compared with waiting until 6 months (EFSA 2009).
A recent study of hospitalisation rates due to gastroenteritis or respiratory tract infection in the UK showed that these rates were higher in infants fed on infant formula compared to infants being breastfed but were unrelated to the age at which term infants, regardless of their milk feed, are weaned onto solid food (Quigley et al 2009). This study questions the findings by Forsyth in 1993 that respiratory rates of infections were higher in those weaned before 8 weeks compared to those weaned after 12 weeks (Forsyth et al 1993). Platt argues that there is no evidence of harm even within populations that begin weaning within a few days of birth (Platt 2009).
There is a five-week gestational age range of term babies (born between 37 and 42 weeks gestation) and babies grow and develop at different rates. This means some infants will be ready to begin weaning at an earlier postnatal age than others rather than all being ready on one postnatal day (Platt 2009). Mothers usually begin weaning large infants and male infants earlier than others (Wright et al 2004). In practice the developmental signs that suggest that an infant is ready to accept solid foods are:
Many parents perceive that their baby is ready to begin weaning earlier than 6 months (Bolling et al 2007, Fewtrell et al 2003, Foote & Marriott 2003). In the UK about 50% of babies are given solid foods between the ages of 4 and 6 months – the other half are given solids before 4 months (Bolling et al 2007).
Weaning is a learning process and infants will only learn to accept and enjoy new tastes and textures if they are given the opportunity to try them. Some infants are kept on smooth foods for too long and those in the ALSPAC study who are not offered lumps and finger foods by 9 months were more likely to be fussy eaters at an older age compared to those that were weaned appropriately (Coultard et al 2009, Northstone et al 2001).
The type and texture of foods to be introduced at each weaning stage:
|Stage||Age guide||Skills to learn||New food textures to introduce|
|1||Begin by 6 months, but not before 4 months (17 weeks)||– taking food from a spoon- moving food from the front of the mouth to the back for swallowing- managing thicker purees and mashed food||Smooth purees Mashed foods|
|2||6 – 9 months||– moving lumps around the mouth- chewing lumps- self-feeding using hands and fingers- sipping from a cup||Mashed food with soft lumpsSoft finger foods
Liquids in a lidded beaker or cup
|3||9 -12 months||– chewing minced and chopped food- self-feeding attempts with a spoon||Hard finger foodsMinced and chopped family foods|
Adapted from Clinical Paediatric Dietetics 4th ed Shaw 2015
Once infants are competent in eating solid food, a variety of foods from all 4 food groups should be included daily in the weaning diet to provide the range of nutrients they need. Ideally these foods should be the nutritious family foods that infants will be expected to eat during their toddler years.
The 4 food groups are:
There is no evidence to support weaning these babies differently. However it is prudent to introduce high allergen foods one at a time so that any reaction can be attributed to the newly introduced food.
Each premature baby (born before 37 weeks gestation) should be considered individually and some time between 5 to 8 months after their actual birth date is likely to be the best time to begin weaning (King & Aloysius 2009, King 2009). Many of the organ systems develop precociously following preterm delivery and it is considered safe to wean preterm infants at this time even though their age may be less than 4 – 6 months after their EDD. The majority may benefit from delaying until after 3 months from their EDD; this will allow more time for the development of motor skills which are desirable for safe transition to solid foods eg head control (van Haastert et al 2006, King 2009). All young babies, especially those born prematurely, need back and head support when they are fed to minimise the risk of choking.
As growth and nutritional status can be issues in this group, careful attention is needed to supply a diet of sufficient nutrient density and variety. They often need vitamin, mineral, and sometimes protein and energy supplements – particularly those that are breastfed.
In addition it is important not to miss the opportune times when the introduction of textures and flavours are more easily accepted.
Breastfeeding is the best form of nutrition for healthy infants and can provide complete nutrition for the first 6 months (26 weeks) of life for some infants.
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