Weaning UpdateOctober 2010

Jane Shaw

Lead Paediatric Dietitian

Natasha Lloyd

Dietitian for Paediatric Services

• Introduction

• Weaning Recommendations- The Evidence

• Weaning Myths

• Getting started and Moving On

• Weaning the Pre-term Infant

• Other Issues

• Common Problems

• By age one- where should we be?

• When and how to refer?

Outline

Weaning…...means introducing a range of foods gradually

until your baby is eating the same foods as the

rest of your family

What are your worst offenders?

These are ours!

• Pureed family foods- chicken nuggets,

beans and chips

• Meringue snowman used as a tethers in

young babies

• Sausage roll put into bottle of formula

milk

• Curry sauce in bottle

2 years6 months 1 year

wea

nin

g

Birth

Breast milk

Cow’s milk as a drink, 500 -600ml/dayFirst milk

Family food1

7 w

ee

ks th

e

ea

rlie

st fo

r

we

an

ing

Fe r

ich

fo

od

s

7/1

2

„So

ur

„ ve

gb

efo

re

9/1

2

Vit D supplements for all– Abidec, Healthy start Vitamins, OTC

till 5

3 meals & 3

snack

Fin

ge

r fo

od

s

Progress on to lumpier food faster

when solids introduced nearer

6/12

95% of infants should be 100% happy on the above

Preterm Formula till 26 wks actual age or stopped earlier if growth between 25-50th C

First milk can be used till 1 yr

corrected

Cow’s milk as a drink, 500 -600ml/day

Why? Start Weaning

• Baby needs more than milk alone to meet nutritional needs

• Extra energy, vitamin D and iron stores are running low

• Helps to develop muscles required for speech

• Gives infants the opportunity to learn to like new tastes and textures at a time that is receptive to them

• It‟s the first step towards baby sharing in family meals!

When? Background to

recommendations• By 6 months (26 weeks) never before 17 weeks

(ESPHAGAN 2008)

4 months=17 weeks not 16 weeks

• Exclusive breastfeeding for around 6 months is a desirable goal (ESPGHAN 2008)

• WHO and DH(2003) recommend that each infant must be managed individually so that insufficient growth and other adverse outcomes are not ignored and appropriate interventions are provided

• EFSA (2009) reported no disadvantage to begin weaning onto solid foods between 4-6 months compared to waiting until 6 months

• DH (2004) states there is evidence of harm in late weaning as it increases the risk of energy and nutrient deficiencies. Iron deficiency anaemia and rickets are common in infants weaned after 6 months

• Harris (2000) between 4- 6 months infants learn to accept new tastes and textures relatively quickly

• Data from Bolling et al (2007) found 50% of babies in the UK were given solid food between the ages of 4-6 months and the other half before 4 months

When?Reasons for not introducing solids before 17 weeks

• Immature kidneys- increased risk of dehydration

• Immature gut- more venerable to allergic reactions and infections and a reduced absorptive capacity

• Solids can reduce the availability of nutrients in infant milk

• Limited neuromuscular co-ordination for safely taking solid foods

Reasons for not delaying beyond 26 weeks

• Increased risk of nutrient and energy deficiencies-Nutritional problems can be encountered i.e. iron and vitamin D deficiency- anaemia and rickets

• Less chance of food refusal

• Key developmental stages may be missed

Infant Readiness Cues

• Positioning

• Behaviours

• Oral Skills

• Some factors may only be assessed or developed once weaning has begun and their absence should not deter an infants progression with weaning

• Managing to clear the spoon with their lips; this develops with experience

• Absence of tongue protrusion during feeding; this disappears gradually with time

• Presence of teeth; they are not essential for chewing

When? Signs to start• Can sit supported, able to hold their head steady

• Reaches and grabs accurately

• Wants to chew and is putting fists, toys and other objects in their mouths

• Shows more interest in meal times and food

• Seeming hungry between milk feeds or demanding feeds more often even though larger milk feeds have been offered

• Consider on a individual basis- taking a flexible approach to support mothers in their decisions to optimise the infants nutrition

Taste Development

• Taste acquisition probably occurs in utero with foetal swallowing of amniotic fluid flavoured by the mothers diet

• Taste and smells via breast milk –enhances later acceptance

• Term infants preference for sweet flavours

• 5-6 months preference for slight salt taste thus developing taste sensitivity and easy acceptance of tastes and something new

• By around 1 year of age familiar food recognition is established

Taste Development continued..

• Neophobia is a normal response to new food

which the child may not view as safe to eat

• Neophobia can increase over the next few years

which can make it harder to encourage children

to try new things

• The acceptance of new food & flavours is still

possible but it may take more time, & is easier in

certain social contexts

Weaning Myths• Most mothers introduce solid food by 6 months of age and not before 17 weeks.

FALSE 49% of mothers introduce solid foods before 16 weeks (Hamlyn et al 2002 & Bolling et al 2001).

• “Solid foods will help baby to sleep longer at night”

FALSE. Research suggests comparable sleeping times (Heinig et al 1993).

• Waiting until 6 months affects babies‟ ability to chew.

• FALSE. Misconception arising from old research based on infants with developmental delay which was generalised for healthy infants.

• Waiting until 6 months can lead to fussy eating?

FALSE – Studies suggest no differences in appetite or food acceptance of infants started on solids at 4 or 6 months (breastfed infants) (Cohen et al 1995)

• Babies need to explore tastes and textures before 6 months to help with speech development and acceptance of a varied diet

FALSE. – Oral development (anatomy, reflexes and function) is considered to be immature before 6 months; hence the weaning process may take a bit longer in younger infants

Breastfeeding and Weaning

• Breastfeeding to continue throughout weaning

and beyond

• Exclusive breastfeeding for around 6 months is a

desirable goal (ESPGHAN 2008)

• Introducing gluten (wheat, rye, barley and oats)

while breastfeeding may reduce risk of coeliac

disease, type 1 diabetes and wheat allergy

How? Safety and hygiene • Thoroughly wash all bowls and spoons for feeding in hot

soapy water and keep surfaces and chopping boards thoroughly clean

• Hands – yours and baby

• Keep pets away from food areas and baby‟s feeding equipment

• Don‟t save and re-use foods that your baby has half eaten

• Cooked food should not be re-heated more than once

• Cook all food thoroughly and cool it to a luke warm temperature

• Wash fruit and vegetables

• Make sure baby is safely secured in their seat in an upright position and never leave baby alone whilst they are eating

How? Being Prepared• Make sure that you have all the correct equipment

to hand:-

– Appropriate seating i.e. highchair, bumbo seat, on mum‟s knee (not in bouncy chair/ reclined)

– Fork for mashing

– Shallow plastic spoon, bowl and bib

– Babies usual milk

• Choose a day when you know you will have plenty of time, be most relaxed and remove as many distractions as possible e.g. turn off television

How? Feeding your baby• Make sure baby is sitting upright and facing

forwards

• Try to keep meals to the same times each day

• Baby should not be tired or too hungry

• Always check the temperature of food before giving it to baby

• Offer food during or after a milk feed

• Start with offering just a few teaspoons of food once a day – follows baby‟s lead

• Let baby touch the food, spoon, bowl etc

NEVER force feed a baby

Getting Started- First Foods

• Cooked mashed vegetables and fruit e.g. carrot, sweet potato, butternut squash, parsnip, swede and potatoes, banana, pear or apple

Or baby suitable cereal made with baby‟s usual milk

• Do not add any salt or sugar to baby‟s food

• Baby still needs to have usual milk feeds along side weaning foods

• Vegan and macrobiotic diets are not recommend for infants

Commercial v Homemade Foods

Points to Consider!Homemade

Known contents

Chosen ingredients

Cheap

Need skills, Take time

No added vits and mins

Controlled change in

consistency

Easy to fortify

Commercial

Mixed ingredients

Added vitamins and minerals

(if not organic)

Convenient

Expensive

Consistency- stage one is very

fine, stage 2 mixed lumps and

fluid

Foods to Avoid

• Salty foods e.g. gravy, packet sauces, instant mash, stock cubes, added salt

• Honey

• Raw eggs, raw shellfish

• Whole nuts

• High sugar foods – sweets, biscuits, cakes, chocolates, fruit juices, additional sugar and fats (these are NEEDED if child has poor growth)

• Low calorie foods e.g. low fat dairy foods, Quorn (egg and fungi)

First foods

High allergen foods such as wheat, egg, fish,

citrus fruit, diary foods, do not need to be

delayed until after 6 months –no evidence

that this will reduce the likelihood of allergies

(ESPGHAN 2008)

Previous recommendations to avoid

wheat, eggs, fish, citrus fruit, fish,

milk products no longer evidence

based

Once the infant is eating 2-3 times day and is competent in eating solid food- a variety of foods from all food groups should be included. Note Eatwell plate not suitable for under fives

Advice for 6-12 months:

• Starchy foods- potatoes, rice, oats, pasta, bread, cereals-approx 3-4 servings per day

• Fruit and vegetables- 3-4 servings per day

• Milk, cheese and yoghurt- demand feeds of breast milk or infant formula (about 500-600mls day, plus some cheese and yoghurt

• Protein foods- meat, fish, eggs, smooth nut products, pulses such as lentils, dhal and hummus: 1-2 servings per day, 2-3 for vegetarians

Moving On

Finger Foods

• These can be offered when you first start weaning,

even if baby doesn‟t have many/ any teeth

• Provides chewing practice and encourages baby

to feed themselves

• Try:- banana, melon, pear, cooked green beans

and carrots, bread, breadsticks, small cubes of

hard cheese, toast

• Some infants are kept on pureed food for too long and those in the ALSPAC study who were not offered lumps and finger food by 9 months were more likely to be fussy eaters at an older age compared to those weaned appropriately

(Coultard et al 2009, Northstone et al 2001)

SnacksHealthier snacks

Soft fruits

Vegetables i.e. carrot sticks

(steamed), cucumber sticks,

steamed broccoli and

cauliflower,

Bread sticks, plain crackers

Malt loaf, tea cakes, crumpets

Cheese cubes, not strings

Humus

Small sandwiches

High calorie snacks

Chapatti/ biscuits/ toast or

bread/ fingers with jam,

peanut butter, cheese/ cream

cheese, chocolate spread

Buns, cakes, muffins,

doughnuts, scones with jam

and cream

Full fat yoghurts and fromais

frai with added cream

Suitable Drinks • Breast/ formula milk for the main drink from birth to

1 year- Full fat cows milk is a suitable drink

thereafter

• First stage milk is fine from birth to 1 year- hungry

baby, follow-on and toddler milks not routinely

recommended

• Cooled boiled water can be given in warm weather

for babies, and offered with meals once baby is on

3 meals a day

• „Baby juices‟ unnecessary and tea, coffee, fizzy

drinks are not suitable

Choosing a Cup• Introduce from before/ around 6 months

• Choose a cup that encourages baby to develop

a sipping action.

• Free flow cups or those without a lid are best.

• Avoid no-spill cups as these encourage

excessive sucking.

• Valve cups, cups with teats and sports bottles

not suitable.

• Aim for all drinks from a cup by 1st birthday

Weaning the Pre-term Infant

• WHO and DH guidelines do not account for pre-term babies

• Joint Consensus statement on weaning preterm infants by Neonatal Dietitians Interest Group (UK) and Speech and Language Paediatric Dysphagia Group (UK)

• Supporting evidence in Paediatrics and Child Health 2009 19:9 page 405-414 C king

• Weaning from 5 – 8 months uncorrected, those healthy prems born nearer term can be weaned as a term infant

Progression through textures (Preterm infants)

• Most preterm infants will progress normally through the development of eating & drinking skills with responsive input from parents

• Preterm infants who are more sensitive to change and less able to feed themselves may benefit from more gradual progression through the range of textures

• Allowing infants to play with food as soon as they show an interest will help the development of self feeding skills using hands and fingers

• Progression to use of utensils can happen later

Progression through textures(Preterm infants)

• More textured foods may be better accepted as finger foods as the child has more control of what goes into his/her mouth.

• Home cooked foods are easy to modify and control in terms of consistency. Avoid smooth puree with floating lumps

• It may be useful to alter texture and taste separately.

• Exposure to the sight of food alone is not sufficient

• By 9 months uncorrected a preterm infant following normal development stages is likely to benefit from being introduced to lumps and finger food

Nutritional Considerations

(Preterm)

• Thriving prems treat the same as any healthy term infant

• No greater risk of food allergy

• Good variety of home cooked foods

• Provide adequate protein, energy, iron and zinc

• Iron and vitamin supplements

• Appropriate schedule for weight monitoring

Preterm infants with additional

medical problems• MDT approach – joint feeding clinic very helpful

• Neurological impairment – aspiration, swallowing difficulties or oro –motor problems

• CLD – more problems co-ordinating sucking and swallowing with breathing from breast or bottle but may find solids easier, not to start solid before 5 months uncorrected without a SALT assessment

• Limited or negative early oral feeding (tube feeding, GORD) may develop sensory based feeding aversions

• GORD – medical management, thicken feeds may compromise milk intake and ensure appropriate feeding equipment being used

• Faltering growth – not a reason for early weaning, weaning food not energy dense like milk feeds – refer to dietitian

Other considerations…

• Allergy intolerance

• Vitamin drops

• Baby led weaning?

Family history of allergy/intolerance

• No need avoid allergen because of family history

unless history of serve reactions

• Ideally these infants would be breast fed

throughout weaning

• No evidence that delaying until after 6 months

reduces risk

• Consider allergies or aversions?

• Some tests need allergen to be in diet in high

amounts to provide a positive- Can not get NHS

prescription without a confirmed proven diagnosis

Vitamins drops and HEALTHY START

Department of Health recommends that all children under 5

Vitamins A & D for breast fed infants or for infants (up to 1 year of age) taking less than 500mls of formula per day

Children from ethnic minorities who have darker skin, because their bodies are less able to produce as much vitamin D. Especially African-Caribbean and South Asian origin.

How accessed www.healthystart.nhs.uk

• In Rotherham now available from most local pharmacies for maternal drops

Baby Led Weaning

• Seems to follow current weaning guidelines

• Misses puree and mashed stage

• Doesn‟t advocate using a spoon

• Baby chooses from a range of finger foods

• Family meals

• Eating off high chair rather than plate

Where should we be…

By 1 year of age…Eating 3 family meals a day

• Having 2 to 3 snacks or milky drinks approx 1pint

milk daily

• Switch to cows milk and not formula milk

• Should be using a cup and not a bottle

Common Problems

• Fussy Eaters

• Constipation

• Anaemia

Fussy Eaters• Constipation, anemia or other medical conditions need to be treated

before trying to change eating behaviors

• Parents should not pressure, bribe or force feed their toddler

• Toddlers show clear behavioral signals when they have had enough to eat

• Don‟t get stressed

• Create a positive/ appropriate environment

• Set a good example by enjoying a variety of healthy foods- sit and eat with your child

• Encourage set meal times- routine

• Let child feed themselves- cut food into bite size pieces and expect mess, don‟t clean up until the end of the meal

• Use lots of praise- ignore refusal

• Parents should not use one food as a reward for eating another

• No multiple meals

• 10 plus rule

• Consider fluid intake? Too much fluid intake, either milk, juice or squash, may reduce food consumption.

• Consider snacks?

• What parents food habits like?

• Involve in all aspects of meal i.e. preparation, food toys, books

Remember appetites vary-

What they eat in a week not what they eat in a day!

Fussy Eaters…

Constipation• Poor diet, overfeeding in infancy, dietary insufficient

dietary fibre or fluid intake, excessive milk intake, faddy eating (vicious circle)

• Check family history

• Treatment of constipation usually requires a combination of dietary, behavioural and medical interventions

• If the bowel is loaded with faeces disimpaction of the bowel with laxatives is the essential first-line management

• Behavioural intervention should include advice on toilet training

• Constipation can be prevented by attention to healthy eating, adequate fluid intake, exercise and sensible toilet training

Constipation..Diet - Parents should aim to:

• Offer six to eight drinks per day - one with each meal and one in between meals or with a snack

• Include a fruit and a vegetable with the midday and evening meals

• Include a starchy or cereal based food with each meal -make it wholegrain sometimes

• Offer regular meals and only planned snacks – one snack halfway between meals

• Make sure there is always time in the mornings for

breakfast - include some fruit or a wholegrain bread or cereal

Iron Deficiency Anaemia

• Up to 89 per cent of toddlers aged one to three have iron intakes below the recommended intake and toddlers with feeding problems are at particular risk of IDA

• Even moderately low levels of haemoglobin, between 90-109g/l (9-10.9g/dl), can be associated with delays in cognitive and motor development and behavioural problems

• At birth infants have sufficient iron stores to last for up to six months. Preterm babies do not have these stores and so are vulnerable to iron deficiency

• Breast milk provides all nutritional needs, including iron, for about six months and then iron must be supplied by the weaning diet

• IDA is treated with an iron supplement and a healthy diet that includes foods rich in iron and nutrients that promote iron absorption

• Prevention of IDA includes nutritional education for parents and carers and ensuring adequate intake of iron rich foods

Iron Deficiency Anaemia• There are two types of dietary iron:

well-absorbed 'haem' iron from meat and oily fish and less well-absorbed 'non-haem' iron found in leafy green vegetables, grains, pulses and beans

• Iron absorption is inhibited by dietary fibre, calcium, phytates in flour and tannin in tea

• Vitamin C in fruit, vegetables and fruit juices enhance intestinal iron absorption if consumed at the same time as iron-containing foods.

Foods High in Vitamin C include: • blackcurrants • kiwi fruit • citrus fruits • strawberries • mangoes • tomatoes • peppers • potatoes • sweet potatoes

When to Refer?Term infants/Preterm infants– Feeding difficulties, Fussy eaters, Food intolerance or allergy, Faltering

growth, Obesity, Constipation, Anaemia, NG feeders, congenital and neurological abnormalities that if not known to a Dietitian

Preterm infants– To Dietitian

• Faltering grow, aversion reaction to the introduction of food and/or oral stimulation, experience spillage of food from their mouths during feed times, narrow range of foods for social, cultural or behavioural reasons

– To CDC for assessment • poor head control is difficult to position or seat, Very sensitive to touch around

their mouth and face, falls asleep frequently when being fed

– TO SALT urgently• Chokes persistently/ gags and/or vomits during eating or drinking, experience

spillage of food from their mouths during feed times, marked tongue thrust and protrusion well into second half of first year

Contact DetailsPaediatric Dietitians

01709 304384

Fax number:

01709 304292

Appointments and

referral follow-up

01709 304297

Prescribing

01709 307079

Well completed CAF form

No need to phone to discuss prior

to referral we‟ll contact you

GP and consultants on fully

completed Dietetic referral form

No telephone referrals or written

letter

How to refer

Any Questions?

Formula Milk Update

Prescribing for patients with Rotherham GP‟s

Jane Shaw

Deputy Manager Nutrition and Dietetics

Acute Services

Dietetic Enteral and Supplement

Prescribing

• Have prescribed on behalf of GP‟s since April 2007 and hold the budget

• Dietitian px on GP behalf and can only prescribe what is in mimms

• Enteral feed and supplements

• Always managed to meet the budget

• Unlike surrounding areas that have up to a 15% over spend

Project Expansion in 2010

• In August 2010 PCT Board agreed to expand the project

• So on the 1st September 2010 we took on:

– All baby formulae

– Gluten Free foods

– Low protein foods

– Metabolic products

• Only what in mimms

• Do not px colief or feed thickeners or thickened fluids

What we have found so far…

• Lots inappropriate prescribing – Stopped about half pre-upload to the computer system

– Number of 2 and 3 yrs on formula

– Even a 9 year old!

• About 10 infants on soya formula all unknown to dietitians

• Nutriprem 2 – we carried 43 pts on the new system

– After checking on TPP only 15 need to on NP2

– Of the 15 remaining 1/3 have FTT and need urgent dietetic review

Your role in the project

• If you review the patient and you feel

that the product not suitable anymore

and there is more than 4 weeks to

dietetic appt contact us so we can

adjust nutritional care plan

• Notify us of deaths

• We need partnership working

Prescribing contacts

01709 307079

Any Questions?