A child's first meal
Parents often consult on feeding problems and guidelines have changed in recent years – Dr Dimple Devadas gives an up-to-date overview
Weaning or the introduction of solids can be an extremely pleasurable experience for parents but can also be an immensely stressful and anxious time.
Weaning methods have significant implications for infant health, notably in relation to normal development, mineral balance and the development of obesity1. Nutrition in the early years of life is a major determinant of growth and development and it also influences adult health2.
Changes to guidelines
The UK and Irish Department of Health guidelines3 now recommend breast feeding exclusively for the first six months, as this should meet all nutritional needs. This is in line with current World Health Organisation recommendations4.
The guidelines also state that solids are not to be introduced before 20 weeks. The decision to wean must balance the risk that weaning too early will stress the immature gut, kidneys and immune system5 as well as decreasing exposure to the protective effects of breast milk. Weaning too late may result in under nutrition and feeding problems.Observational studies support the finding that early introduction of solid foods may result in a 'heavier child', but these results have not been duplicated by other researchers6. Previous studies illustrate that health professionals and parental definitions of 'weaning' clearly vary. The addition of solid food to bottles for example may be perceived by some parents as 'milk feeds'8.
A matter of timing?
Previous studies in the literature7 indicate that an infant's behaviour appears to be the main stimuli for changing feeding practices and weaning. The use of food to 'comfort' or 'reward' a baby rather than to relieve hunger illustrates one of the non-nutritional uses of food and influences the timing of weaning. The recommended cues for weaning are:
• taking an interest in food (such as looking and playing)• waking during the night for a feed • persistently hungry after an adequate milk feed• demanding feeds more often than before.
The box top right outlines the ideal first foods.
When introducing solids make sure infants are well supported, preferably in a high chair. If not able to sit unsupported independently make sure they are well supported with cushions. Use suitable bowls and cutlery, such as soft unbreakable plastic spoons (rather than metal or disposable). Ensure a calm environment.
Be prepared for a messy few meals, so expect spillages on the mouth, clothes and floor. If food remains around the mouth and face, do not wipe so infants will be encouraged to lick the food.Remember it is important that they appreciate the taste of the food and get to enjoy it. Do not force feed but continue with milk (formula or breast supplementation for nutrition). Allow plenty of time, but babies will tend to get tired after 20 to 30 minutes.The box below right shows the weaning stages. Babies will graduate from initial liquid food such as baby powdered rice to more textured (not lumpy, as this may cause choking and food aversion) yet tasty food such as pureed carrot or suede as the process of mastication and chewing is gradually mastered.They are then ready to go to the next stage of 'bite dissolve' (foods that dissolve quickly once in the mouth) foods such as rusks. The final stage is 'family food' when the infant is ready to try the food the other family members eat. If during the weaning period infants either refuse food, lose weight or experience gastrointestinal symptoms, consider the following:
• Food intolerances (symptoms include vomiting, diarrhoea, tearing, back arching, weight loss that is precipitated by weaning)• Gastroesophageal reflux (colicky baby that becomes worse on weaning, vomiting, diarrhoea, but maybe silent with weight loss)• Behavioural (identified on accurate history)
Refer the child:
• If not gaining weight • Gastrointestinal symptoms such as diarrhoea, vomiting• Tearing, arching (signs of reflux)• Food refusalDr Dimple Devadas is a paediatric trust fellow at Great Ormond Street Hospital London –Dr Devada would like to thank Dr Susan Hill, consultant in paediatric gastroenterology, and Una McCrann, clinical nurse specialist in feeding at Great Ormond Street, for their specialist advice with this article