The "when to wean" debate earlier this year generated plenty of interest, but confusion still reigns. Leading dietitianDr Carina Venterweighs up the evidence to provide reassuring and practical advice firsttaste

Dr Carina Venter  

Senior Allergy Dietitian, The David Hide Asthma and Allergy Research Centre, Isle of Wight NIHR Post Doc Research Fellow, University of Portsmouth  The main aim of weaning is the introduction of solid foods into an infant's diet to ensure optimal nutrition, accomplish developmental milestones and set life-long healthy eating habits. The topic of weaning has been much debated recently, not surprisingly leaving healthcare professionals and parents with some questions.


When to wean?  

For busy families, weaning also has a practical aim: to introduce a variety of foods gradually to an infant's diet alongside their usual milk until they are able to eat the same healthy foods as the rest of the family1. The issue of when to wean has been widely debated2,3. In 1994, the COMA report recommended that: "The majority of infants should not be given solid foods before the age of four months and a mixed diet should be offered by the age of six months"4. 

The World Health Organisation started their consultation in 2001. Their recommendation followed in 2003, namely that the sole source of nutrition for all babies up to the age of six months is breast milk and babies should not be given solid foods up to that time5 (see Box 1). This was endorsed by the SACN6 and the DH issued their first statement in May 2003 stating: "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 baby needs"7. However, they acknowledged that infants develop at different rates and that the advice needs to be tailored to each infant's individual needs. A slightly more flexible wording is used in the more user friendly DH information booklet, ie: that "the introduction of complementary foods should start around six months of age"8,9.
The latest weaning guidance from the Paediatric Group of the British Dietetic Association reflects the SACN6 stance regarding the need for flexibility around the time of introduction of solids foods, although solids should never be introduced before 17 weeks (four months) of age10. Once the child is six months old, weaning should commence, and it is important that this is not delayed "there is an increased risk of food refusal if the introduction of solids is delayed, particularly beyond nine to 10 months of age"11,12.
Infants all develop at different rates and rather than debating a specific time of weaning for all, it should be appreciated that infants will be ready for weaning during a "window" period of time (most probably between four to six months of age) - just as full term babies are born over a window period of time (37 to 42 weeks)13.

Box 1: Definitions of exclusive breastfeeding and weaningExclusive breastfeeding, based on the WHO definition, refers to: The practice of feeding only breast milk (including expressed breast milk) and allows the baby to receive vitamins, minerals or medicine.

Water, breast milk substitutes, other liquids and solid foods are excluded.

http://www.who.int/nutrition/topics/infantfeeding/en/
The DH recommends on their NHS Choices website9, available to all, that there are three signs which together show that an infant is developmentally ready for the introduction of solid foods. These are:

● The infants stays in a sitting position and holds his/her head steady

● The infant co-ordinates his/her eyes, hand and mouth so that they can look at the food, pick it up and put it in his/her mouth all by themselves.

● They can swallow food. Babies who are not ready will push their food back out.
The DH further warns9 that other signs that could be mistaken for an infant being ready to receive solids are:

  • Chewing their fists.
  • Night waking when they have previously slept Through
  • The infant wants extra milk feeds. NB: This guideline differs somewhat to that indicated by the Paediatric Group of the BDA10.

Age-appropriate weaning foods   firsttaste2

First weaning foods should include commonly used baby foods such as baby rice, vegetables and fruit, with the texture variable and dependent on the age of weaning14. Both the DH and Health Scotland recommend that certain foods should not be given up to six months if weaning commences before that time for ALL infants (Box 2). This advice is however questioned by the Paediatric group of the BDA stating that recent evidence and guidelines from the ESPGHAN committee 15 indicate that potentially allergenic foods such as egg, fish, and milk used in foods and cooking, cheese, yoghurt, wheat and other gluten containing cereals do not need to be delayed until a certain age. The DH do not intend to change their advice, until the results of the review by SACN looking into the appropriate timing for introduction of solid foods for both breastfed and formula-fed infants and foods to avoid before six months of age, are available16.


Importance of different tastes and textures

Weaning is an important time for families as it provides the ideal opportunity to introduce the infant to a variety of tastes and textures, which forms the platform for later eating habits, ensuring a varied and balanced nutritional intake. Infants who have missed important flavour and texture milestones may become faddy or difficult feeders later on in childhood and this may persist into adulthood18,19. The recommendations from the Paediatric Group of the British Dietetic Association10 and the DH7 with regards to textures should be followed at all times.

 

Common parent query 1
I am from an allergic family and would like to know when I can start to give my baby the allergenic foods, such as egg, fish and nuts?
The following advice only applies to babies who are born into families with allergies such as asthma, eczema, hay fever and food allergies: The information was copied with permission (authors C.Venter and K.C. Grimshaw and former chair of the BDA FAISG, R. Meyer), from the consensus statement from the Food Allergy and Intolerance Support Group Position Statement: Practical Dietary Prevention Strategies for Infants at risk of developing Allergic Diseases25 A recent EU Directive lists 14 foods or food additives identified as being the source of the majority of adverse food reactions. These are; peanuts: tree nuts, sesame seed, mustard seed, cow milk, eggs, fish, shellfish, soy, wheat, celery, lupin, molluscs and sulphites. The foods on this list may be introduced from the age of six months.  

The Food Allergy and Intolerance Support Group of the BDA recommends that they are introduced in food categories, starting with a small amount and introducing no more than one new allergenic food at a time and allowing at least three days between each new food group in order to enable easy identification of any resulting reactions. The food categories include wheat, well-cooked egg, cows' milk (as part of the diet rather than the sole source of nutrition), fish, shellfish and soy products. By the age of 12 months, all the major high-risk foods should have been introduced. Peanuts can be introduced into the diet of high risk infants after discussion with a GP, health visitor or medical specialist that it is safe to do so. There is no research evidence to support delayed weaning of major allergenic foods beyond six months, and it is possible such a delay could adversely affect the development of food allergies). The advice is, unless there is a good reason not to, it is better to give the food at an appropriate stage in weaning rather than hold back. These guidelines are not applicable to infants who already have a suspected or proven food allergy, or any other allergic disorder such as eczema or asthma. Such infants require individual assessment and advice by an allergy specialist." For further references of this section - please see the BDA position statement.

 firsttaste3

Suitable textures

The texture "ladder" that infants should climb includes runny/pureed, mashed, lumpy, chewy/chopped and crunchy foods17 (Box 3). However, where an infant will start on this ladder will depend on the age that solid foods was introduced. From around six months, infants can also start to eat finger foods in addition to the other textures that they are managing. The use of baby-led weaning is another point of huge debate amongst healthcare professionals dealing with young infants. However, according to Wright et al., baby-led weaning20 is probably feasible for a majority of infants, but could lead to nutritional problems for infants who are relatively developmentally delayed.

Suitable flavours

Infants should be offered a variety of fruit and vegetables to start with followed by cereals, dairy foods and meat, chicken, and alternatives. By one year of age, the infant's diet should consist of the following foods:

● fruit and vegetables

● bread, rice, potatoes, pasta and other starchy foods

● meat, fish, eggs, beans and other non-dairy sources of protein

● milk and dairy products (in addition to breast milk and infant formula feeds.

Seasonality  

National1 and Dietetic Organisations21 recommend the use of seasonal fruits and vegetables where possible, as they tend to be less expensive and tastier. The website www.eattheseasons.co.uk provides useful information on the UK's seasonal foods.

Organic foods  

Many parents believe that their babies should only be fed organic foods and feel guilty when they can't afford them. Community health professionals should reassure parents that giving their child plenty of variety in terms of fruit and vegetables is most important. The Food Standards Agency address this by offering reassurance that organic and conventional food meets the same legal food safety requirements. Parents may still choose to buy organic fruits, vegetables and meat believing them to be more nutritious than other non-organic foods. However, the balance of current scientific evidence does not support this view22. This is because nutrient levels in food vary and are dependent on many different factors including freshness, storage conditions, crop variety, soil conditions, weather conditions and how animals are fed. Processed foods, including organic, have a nutrient content that is dependent on the nutrient content of ingoing ingredients, recipe and cooking methods. The impact of processing on nutrient levels will be the same for products made from organically and conventionally produced ingredients.

Processed foods  

In terms of convenience, many parents find bottled jars a huge help and some babies may even prefer them to homemade versions as the texture in jars/bottles can be smoother than homemade purees. Although the use of commercially prepared baby foods shouldn't actively be discouraged, home cooking should be promoted, as overdependence on commercial products may prevent a baby from transitioning onto a range of textures, tastes and family meals. Parents should also be advised to limit or discourage their infants from sucking on feeding pouches as these may stop them from using utensils and texture milestones may be missed.

Foods versus milk  

Another concern parents often have is reduced milk intake by the baby as their intake of solid foods becomes more established. Fluid requirements (supplied mainly by breast milk or infant formula) are 885ml (30fl oz) for an average weight three month old baby or 115ml (3fl oz) for an average weight six month old infant. This fluid requirement roughly stays the same for babies up to 12 months, but only about 500 to 600ml (17 to 20fl oz) of the total fluid requirement should be provided by breast milk or formula milk.

Weaning: one step closer to family meals firsttasteb3

Although weaning is an exciting time for parents, it can also be very confusing due to conflicting advice. In general, weaning can start between four to six months, acting on the cues provided by the baby. As weaning progresses, the intake of milk, either breast milk or formula milk, will reduce. Parents should aim to provide the baby with a varied diet by the age of 12 months and use meal times as an ideal opportunity for the family to eat together and socialise.  


This is to allow for the fact that other foods and fluids become important in the baby's diet and as the weaning diet increases in variety and volume the intake of breast milk and formula milk will gradually reduce. Some parents decide to change over from a first or second stage milk to follow-on formulas once the baby reaches six months of age. Parents who prefer not to should ensure their baby eats a varied diet, with sufficient amounts of high calcium and high iron foods - as recommended by the DH in their bottlefeeding booklet23 .

Vitamin supplementation  

For those babies over six months of age drinking less than 500ml (1 pint) of follow-on milk, the DH4, and NICE24 recommend that they should be given vitamin drops containing vitamins A and D. It's especially important to give vitamin drops to children who are fussy about what they eat, children living in northern areas of the UK and those of Asian, African and Middle Eastern origin24. Breastfeeding mothers should continue to take their Vitamin D supplementation (10 ug/day) for as long as they breastfeed and breastfed infants over six months of age need to take a supplement containing 7mcg vitamin D/d in addition to vitamin A. Infants who are breastfed and whose mothers did not take their vitamin D supplementation during pregnancy may have low stores at birth and supplementation (7ug/day) of these infants should start at one month24. NICE guidelines24 states: "Health professionals should offer the maternal Healthy Start vitamin supplement (folic acid, vitamins C and D) to pregnant women who are (or who may be) eligible. GPs and health visitors should offer children's Healthy Start vitamin supplements (vitamins A, C and D) to all children aged from six months to four years in families receiving the Healthy Start benefit." 

Common parent query 2
When can I start using "doorstep" milk?

Full cream cow's milk can be introduced as a main drink from one year of age, but can be used in cooking and on foods from six months. Semi-skimmed milk and lower fat dairy products can be introduced from two years of age4.

References

1. Health Scotland. Fun First Foods: An easy guide to introducing solid foods. 2011 http://www.healthscotland.com/uploads/documents/16605- FunFirstFoods.pdf [Accessed Sept 2011]
2. Fewtrell M, Wilson DC, Booth I, Lucas A. Six months of exclusive breast feeding: how good is the evidence? BMJ 2010; 342:c5955
3. Renfrew MJ, McGuire W, McCormick FM. When to wean. Analysis article on breast feeding was misleading. BMJ 2011; 342:d987
4. Department of Health (DH). Weaning and the weaning diet: Report of the Working Group on the Weaning diet of the Committee on Medical Aspects of Food Policy. Report on Health and Social Subjects. HMSO: London, 1994
5. World Health Organization (WHO.) Global strategy for infant and youngchild feeding. 2003 http://www.who.org/ http://www.who.int/nutrition/ topics/global_strategy/en/index.html [Accessed Sept 2011]

6. Scientific Advisory Committee on Nutrition (SACN). Optimal Duration of Exclusive Breastfeeding and Introduction of Weaning. 2001 http://www. sacn.gov.uk/ www.sacn.gov.uk [Accessed Sept 2011]
7. Department of Health (DH). Infant Feeding Recommendation. 2003 http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@ dh/@en/documents/digitalasset/dh_4096999.pdf [Accessed Sept 2011]
8. Department of Health (DH). Weaning: starting solid food. 2007 http:// www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/ digitalasset/dh_084164.pdf [Accessed Sept 2011]
9. NHS Choices. Birth to Five: Your NHS guide to parenting in the early years. 2011 http://www.nhs.uk/Planners/birthtofive/Pages/ Weaningfirststeps.aspx . [Accessed Sept 2011]
10. Paediatric Group of the British Dietetic Association. Position Statement: Weaning infants onto solid foods. 2010 http://www.bda.  uk.com/publications/statements/PositionStatementWeaning.pdf [Accessed Sept 2011]
11. Northstone K, Emmett P, Nethersole F. The effect of age of introduction to lumpy solids on foods eaten and reported feeding difficulties at 6 and 15 months. J Hum Nutr Diet 2001; 14(1): 43-54.

12. Coulthard H, Harris G, Emmett P. Delayed introduction of lumpy foods to children during the complementary feeding period affects child's food acceptance and feeding at 7 years of age. Matern Child Nutr 2009; 5(1): 75-85
13. Ward Platt MP. Demand weaning: infants' answer to professionals' dilemmas. Arch Dis Child 2009; 94(2): 79-80 14. Harris G, Grimshaw K. What you need to know about weaning. J Fam Health Care 2009; 19(1): s1-s4
15. Agostoni C, Decsi T, Fewtrell M et al. Complementary feeding: a commentary by the ESPGHAN Committee on Nutrition. J Pediatr Gastroenterol Nutr 2008; 46(1): 99-110
16. Scientific Advisory Committee on Nutrition (SACN). Paper for discussion: Draft scope and Terms of Reference for a review of complementary and young child feeding. 2011
17. Department of Health (DH). Introducing your baby to solid food in Birth to Five. 2009 http://www.dh.gov.uk/prod_consum_dh/groups/ dh_digitalassets/documents/digitalasset/dh_107668.pdf [Accessed Sept 2011]
18. Maier AS, Chabanet C, Schaal B et al. Breastfeeding and experience with variety early in weaning increase infants' acceptance of new foods for up to two months. Clin Nutr 2008; 27(6): 849-857
19. Harris G. Development of taste and food preferences in children. Curr Opin Clin Nutr Metab Care 2008; 11(3): 315-319
20. Wright CM, Cameron K, Tsiaka M, Parkinson KN. Is baby-led weaning feasible? When do babies first reach out for and eat finger foods? Matern Child Nutr 2011; 7(1): 27-33.
21. American Dietetic Association. Eat right with colour. 2011 http://www. eatright.org/nnm/ [Accessed Sept 2011]
22. Foods Standards Agency. Organic Foods. 2011 http://www.food.gov.uk/foodindustry/farmingfood/organicfood/ \l "h_10 http://www.food.  gov.uk/foodindustry/farmingfood/organicfood/#h_10 [Accessed Sept 2011]
23. Department of Health (DH). Guide to bottle feeding. 2011 http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/ digitalasset/dh_124526.pdf [Accessed Sept 2011]
24. NICE. National Institute for Health and Clinical Excellence guidelines: Improving the nutrition of pregnant and breastfeeding mothers and children in low-income households. National Institute for Health and Clinical Excellence, 1-105. London: NICE, 2008
25. British Dietetic Association (BDA): Food Allergy and Intolerance Specialist Group. Practical Dietary Prevention Strategies for Infants at risk of developing Allergic Diseases. BDA, 2010