Weaning and childhood nutrition

Abstract

Suitable nutrition in children is critical to development. It has long been recognised that under-nutrition can lead to faltering growth, however, there is also increasing concern over the rising number of children who are overweight and classified as obese. Babies initially receive all their nourishment through exclusive milk feeding, either breast or bottle, but this soon becomes nutritionally inadequate and needs replacing with solid foods. This process of weaning onto a solid diet can be a stressful time for parents. Conflicting messages from family, friends and healthcare professionals make it difficult for parents to decide how best to introduce solid foods into their child’s diet. This article looks to provide an overview of infant nutrition with a particular focus on weaning and the current evidence surrounding the process.

The GP Curriculum and childhood nutrition

Clinical example 3.04: Care of children and young people lists the criteria that are felt to be required by GPs with regards to the care of children. It is expected that GPs have an awareness of disease prevention, well-being and safety in children and adolescents, including in the following areas:

Breastfeeding

Healthy diet and exercise for children and young people

Childhood nutrition

Good nutrition in children is of paramount importance as they go through phases of growth and development. Adequate nutrition is essential as infants and children have low nutritional stores but high nutritional demands. In 1992, Professor David Barker published a book called ‘The fetal and infant origins of adult disease’. The Barker hypothesis states that many chronic diseases of adulthood, such as obesity, cardiovascular disease, diabetes, osteoporosis, cancer and even ageing, originate in childhood, or even in the womb. One of the tenets of this hypothesis is that good diet is a crucial factor in producing healthy children who remain healthy into old age. A large body of research evidence published subsequently has supported this hypothesis. Healthy diet for children is therefore essential to ensure a healthier population into the future.

The requirements of children at different ages vary and infants require a greater amount of nourishment, per unit body size, than at any other time in childhood (Lissauer & Clayden, 2005). As well as poor nutrition potentially leading to faltering weight gain, over-nutrition is an increasing problem. In 2011 in England, 31% of boys and 29% of girls aged 2–15 were classed as overweight and 17% of boys and 15% of girls aged 2–15 were classed as obese (Public Health England, 2014). This is a significant increase from the levels seen in previous years. Therefore, it is essential for GPs to understand and disseminate an evidence-based approach to introducing solids to babies as the first step on a path to healthy eating habits throughout childhood and as an adult.

Age: 0–6 months

Currently the advice from the World Health Organisation (World Health Organisation (WHO), 2002) that has been adopted in the UK for nutrition in the first 6 months of life is for exclusive breastfeeding (Scientific Advisory Committee on Nutrition (SACN): Subgroup on Maternal and Child Nutrition (SMCN), 2003). This recommendation was based on a systematic review (Kramer & Kakuma, 2009). The main outcomes reported by the authors were that infants who were exclusively breastfed for 6 months experienced lower rates of morbidity from gastrointestinal infection and that no deficits were demonstrated in growth among infants from either developed or developing countries who were exclusively breastfed for 6 months.

However, more recently the findings of this review and the guidelines for exclusive breastfeeding have come under scrutiny. Fewtrell, Wilson, and Lucas (2011) have argued that the evidence supporting the WHO recommendations is insufficient. They argue that 7 of the 16 studies were from developing countries and 14 were observational, thus preventing proof of causality. They also argue that newer evidence, although still observational, suggest infants exclusively breastfed until 6 months (as opposed to 4–5 months) are more likely to develop anaemia and low serum ferritin. They also cite studies that suggest an increased risk of coeliac disease in babies exclusively breast fed until 6 months.

Much like the evidence for exclusive breastfeeding until 6 months, this newer evidence is weak and insufficient to prove causality. What it does seem to show, however, is that we currently do not know the best time to wean children.

The advantages of breastfeeding are more certain and are covered in depth in another InnovAiT article in this issue (Finnikin, 2015). These include protection from infections, such as gastroenteritis and ear infections, and maternal benefits, for example, reduced risk of breast and ovarian cancer (National Health Service (NHS), 2012). Therefore, breastfeeding should be encouraged for as long as possible in infancy.

Age: 6–12 months

After 6 months of age, milk, whether breast or formula, becomes an increasingly inadequate supply of nutrition. At this stage, solid foods need to be introduced.

Solid foods initially provide only a small proportion of the nutritional requirements of a growing baby but soon take over as the main nutritional supply. This is reflected in the Royal College of Nursing recommended milk requirements (Crawley & Westland, 2014) that suggest that 6-month-old babies should have four milk feeds of between 210 and 240 ml a day, whereas 10–12-month-old babies can be offered 100 ml at breakfast, 100 ml at tea and 200 ml before bed.

Weaning

Weaning is the term used to describe the introduction and establishment of solid foods in a baby’s diet. Although a subject of some debate, the current UK recommendation is to start weaning at 6 months.

Food can be introduced into a child’s diet in a number of different ways. The two most common styles of weaning are ‘spoon-feeding’ and ‘baby-led weaning’. Advocates of both argue the benefits of their style and point out weaknesses in the alternative option. Currently, there is no definitive evidence to recommend either approach over the other; which approach to adopt depends on the developmental stage of the child when weaning and parental preference.

Spoon-feeding

As the name suggests, weaning by spoon-feeding involves food being offered to infants with a spoon. First foods such as baby rice and cooked fruit and vegetables are pureed. The food that is offered becomes more textured and lumpy as children grow and become accustomed to moving food to the back of their mouths and swallowing. This is later followed by finger foods, for example, pasta and toast, at around 8–10 months. As children develop fine motor skills, they become more coordinated and gradually more involved and active in their own feeding.

Spoon-feeding is the traditional approach to weaning and has many popular advocates, for example, Annabel Karmel who has authored many cookbooks and guidebooks about weaning. The emphasis of this method is getting children used to eating a variety of flavours early, and then gradually introducing textures as their swallowing and chewing abilities develop. Parents who use this method successfully are reassured by knowing that their child is definitely eating some solid food from the start.

In 2012, spoon-feeding received some negative coverage after the publication of a study that suggested spoon-fed babies were fatter (Townsend & Pitchford, 2012). This study recruited 155 parents to undertake a questionnaire looking at infant feeding style, food preferences and body mass index. When they compared the spoon-fed group to the baby-led weaning group, they found that there was an increased incidence of obesity in the spoon-fed group, with 8 of the 63 children in the spoon-fed group classed as obese compared to 1 of the 63 in the baby-led group. Of note, three children in the baby-led weaning group were significantly underweight, but none in the spoon-fed group. However, this study was small and the majority of children in both groups were of normal weight. Furthermore, as a cross-sectional observational study it is also not possible to ascertain causality. Therefore, results should be interpreted with caution.

Spoon-feeding has long been a feeding style adopted by many parents and at present there is no clear evidence that it is detrimental to the health of children. It remains a popular, tried and tested way of introducing solids to babies.

Baby-led weaning

Baby-led weaning is a style of feeding based around providing babies with finger foods and allowing them to choose what they eat from the very start of the weaning process. Many parents feel this is an easier and less stressful way to feed their children and leads to less fussy eaters later in life. However, Townsend and Pitchford (2012) actually found no difference in the number of picky eaters whether children were weaned by this method or spoon-fed.

Advocates of baby-led weaning argue that spoon-feeding is an adaptation to feeding to allow introduction of solids at a non-physiological age (Wight, Cameron, Tsiaka, & Parkinson, 2011) and that, if weaning is to begin at 6 months, baby-led weaning is more appropriate.

A systematic review of the literature (Cameron, Heath, & Taylor, 2012) found that, although baby-led weaning will not suit all infants and families, it is probably achievable for most. Benefits identified include mothers reporting lower levels of restriction and decreased pressure to eat (Brown & Lee, 2011a). Unlike Townsend and Pitchford’s work, this paper also found no significant difference in weight between groups based on weaning style. Further work found that mothers had several positive experiences including more convenience, reduced cost and the belief that their child was enjoying eating more (Brown & Lee, 2011b).

The biggest weakness of baby-led weaning is the requirement of children to be able to pick-up food and feed themselves. The necessary skills needed include sitting up without support and a palmar grasp. The median age for acquisition of these skills is around 6 months (Lissauer & Clayden, 2005). However, in one study of 609 babies where parents were asked to report when their babies first reached out for food, 56% had done so by 6 months of age but 6% had not reached out for food by 8 months (Wight et al. , 2011). Another study found that 68% of children were reported to be grasping food with their hands at 4–6 months, but only 53% of children were eating foods that required chewing at 7–8 months (Carruth, Ziegler, Gordon, & Hendricks, 2004).

Although these studies do not mean that baby-led weaning is not a feasible feeding style, there is evidence to suggest that there are a group of infants for whom baby-led weaning may be, at least initially, inappropriate due to inadequate gross and fine motor development.

General information for parents

There are several resources available for parents to assist with the introduction of solid foods. This section will provide an overview of the general advice and recommendations for parents.

When to introduce solids

The current advice is to wait until 6 months of age before weaning. Despite this advice some parents will introduce foods earlier, partly due to the perception that their child ‘wants to be fed’. It is important to be aware that historical signs that a child may be ready to wean, including waking at night, wanting extra milk and chewing fists, are no longer considered as markers of readiness to begin eating solids (NHS, 2011). The current recommended signs that babies are ready for their first foods are:

Staying in a sitting position and holding their heads steady

Co-ordinating eyes, hands and mouth so that babies can look at the food, pick it up and put it in their mouths all by themselves

Ability to swallow foods; babies who are not ready will push their food back out, so they get more round their face than they do in their mouths.

It is interesting to note that the current recommendations would suggest weaning only at a point when both spoon-fed weaning or baby-led weaning are possible from a developmental perspective.

Style of weaning

No recommendations are made about the style of weaning. If parents approach you for advice on style of weaning, explain the pros and cons of each style and allow them to decide which suits them best.

First foods

The types of first food offered to babies are similar regardless of the weaning style adopted. Fruits and vegetables such as parsnips, potato, sweet potato, carrot, apples and pears that have been cooked and cooled are suitable first foods and can be prepared in sticks or mashed depending on the weaning style being used. The food initially needs to be soft enough that it can be squashed between the tongue and the roof of the mouth to avoid the risk of choking. In baby-led weaning, soft fruits, such as melon or peach, can also be offered in slices. Alternatively, if parents are spoon-feeding, baby rice can be mixed in with usual milk and flavoured with fruit or vegetable purees.

Follow-on foods

After the first-taste foods, cooked soft meats (such as chicken and fish) can be introduced, as can pasta, toast, rice and mashed hard-boiled eggs. Although not suitable as a primary milk source due to the insufficient amounts of iron, cow’s milk can be used in cooking from 6 months.

Parents should be advised to introduce allergens one at a time, so that if their child has a reaction to something, they can isolate what it is. There is no consensus or guidance about what order to introduce allergens to the diet. Key potential allergens include dairy products, gluten, egg, citrus fruits and nuts.

From 8–9 months, the amount of food that babies eat will gradually increase and will become a larger and larger proportion of their nutritional requirements. The aim by 12 months will be for babies to be eating three meals a day in addition to milk and healthy snacks. From 12 months of age, whole cow’s milk can be used in place of breast or formula milk.

Things to avoid

There are a few foods that need to be avoided during weaning due to possible risks to the health and development of babies (NHS, 2013). Salt and sugar should be avoided and the advice is to avoid adding these ingredients when cooking.

Babies’ kidneys cannot cope with excessive salt. It is important to emphasise to parents that often large amounts of salt are added to processed food, as this may not be readily apparent. It is wise to suggest that they do not offer their infant the food that they are eating unless they have prepared it from scratch. This is particularly important if parents intend to use a baby-led weaning approach and admit to eating a lot of processed food themselves; they may not realise how much salt they will give their child by feeding them what they are eating.

Added refined sugar should also be avoided to prevent infants developing bad eating habits later in childhood and adult life. There is no need for infants to have foods such as biscuits, cakes and sweets as a main part of their diet while weaning. Babies naturally prefer sweet tastes and giving them lots of refined sugar during weaning will encourage them to eat more of this type of food in later years (Buckley, Ziegler, Ho, Uetrecht, & Specker, 1998; NHS, 2014). Specifically, honey should be avoided in children under the age of a year, not only because of the high sugar levels, but because there is a risk of infant botulism.

Other foods that should be avoided for safety reasons are:

Shellfish: Due to the risk of food poisoning

Shark, swordfish and marlin: These fish may contain high levels of mercury that can affect the developing nervous system

Eggs: Can be given to babies over 6 months but must be fully cooked so that the white and yolk are solid to avoid the risk of salmonella infection

Whole nuts should be avoided in the under-fives to avoid choking; however, ground nuts or nuts chopped finely enough to not pose a choking risk can be offered.

Key points

Good nutrition in childhood is the key to development and growth

Poor nutrition can lead to both problems of being under- and over-weight in childhood and poor health in adulthood

Guidance on weaning children is not based on conclusive evidence and as such there is continued debate on when and how this should occur

The most common weaning techniques are spoon-feeding and baby-led weaning

Claims over the benefits of the different methods of weaning have not, as yet, been substantiated

What seems more important is that appropriate foods are offered and that parents are made aware of the foods that should be introduced and those that should be avoided

References

Barker

D. J. P.

(1992) The fetal and infant origins of adult disease, Oxford, UK: Wiley Blackwell.

Brown

Lee

(2011a) Maternal control of child feeding during the weaning period: Differences between mothers following a baby-led or standard weaning approach. Maternal and Child Health Journal 15(8): 1265–1271. doi: 10.1007/s10995-010-0678-4.

Brown

Lee

(2011b) An exploration of experiences of mothers following a baby-led weaning style: Developmental readiness for complementary foods. Maternal and Child Health Journal 9(2): 233–243. doi: 10.1111/j.1740-8709.2011.00360.x.

Buckley, D., Ziegler, P., Ho, M., Uetrecht, G., & Specker, B. (1998). Longitudinal study of sugar intake in infancy. Paediatric Research, 44, 418. doi: 10.1203/00006450-199809000-00029.

Cameron

S. L.

Heath

A.-L. M.

Taylor

R. W.

(2012) How feasible is baby-led weaning as an approach to infant feeding? A review of the evidence. Nutrients 4(11): 1575–1609. doi: 10.3390/nu4111575.

Carruth

B. R.

Ziegler

P. J.

Gordon

Hendricks

(2004) Developmental milestones and self-feeding behaviours in infants and toddlers. Jounral of the American Dietetic Association 104: s51–s56. doi: 10.1016/j.jada.2003.10.019.

Crawley, H., & Westland, S. (2014). Infant milks in the UK: A practical guide for health professionals. First Steps Nutrition Trust.

Fewtrell, M., Wilson, D. C., & Lucas, A. (2011). Six months of exclusive breast feeding: How good is the evidence? British Medical Journal, 342, c5955. doi: 10.1136/bmj.c5955.

Finnikin, L. (2015). Breastfeeding. Support a new mum today. InnovAiT. Epub ahead of print 27 January 2015. doi: 10.1177/1755738014559107.

10.

Kramer, M. S., & Kakuma, R. (2009). Optimal duration of exclusive breastfeeding (review). Cochrane Database of Systematic Reviews, 1, art. no.: CD003517. doi: 10.1002/14651858.CD003517.

11.

Lissauer, T., & Clayden, G. (2005). Illustrated textbook of paediatrics, second edition. Mosby.

12.

NHS. (2011). Introducing solid foods: Giving your baby a better start in life. Retrived from www.nhs.uk/start4life/documents/pdfs/introducing_solid_foods.pdf.

13.

NHS. (2012). Pregnancy and baby: Why breastfeed? Retrieved from www.nhs.uk/Conditions/pregnancy-and-baby/pages/why-breastfeed.aspx#close.

14.

NHS. (2013). Foods to avoid giving your baby. Retrieved from www.nhs.uk/Conditions/pregnancy-and-baby/Pages/foods-to-avoid-baby.aspx#close.

15.

NHS. (2014). Sweet as they are- how to avoid giving your baby a sweet tooth. Retrieved from www.nhs.uk/start4life/Pages/babies-avoiding-sugar-sweet-foods.aspx.

16.

Public Health England. (2014). Public health England. Retrieved from www.noo.org.uk/NOO_about_obesity/child_obesity/UK_prevalence.

17.

RCGP. Clinical example 3.04: Care of children and young people. Retrieved from www.rcgp.org.uk/gp-training-and-exams/∼/media/Files/GP-training-and-exams/Curriculum-2012/RCGP-Curriculum-3-04-Children-and-Young-People.ashx.

18.

SACN SMCN. (2003). Paper for discussion: introduction of solid foods, agenda item: 3.

19.

Townsend, E., & Pitchford, N. J. (2012). Baby knows best? The impact of weaning style on food preferences and body mass index in early childhood in a case-controlled sample. BMJ Open, 2(1), e000298. doi: 10.1136/bmjopen-2011-000298.

20.

WHO. (2002). Infant and young child nutrition. Retrieved from www.who.int/nutrition/topics/WHA55.25_iycn_en.pdf.

21.

WHO. (2003). Global stratergy for infant and young child feeding. Retrieved from http://whqlibdoc.who.int/publications/2003/9241562218.pdf?ua=1.

22.

Wight

C. M.

Cameron

Tsiaka

Parkinson

K. N.

(2011) Is baby-led weaning feasible? When do babies first reach out for an eat finger foods? Maternal & Child Nutrition 7(1): 27–33. doi: 10.1111/j.1740-8709.2010.00274.x.