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Continuing Education - Child Health - What to do and how to do it when introducing solids

Weaning babies onto solids is an opportunity for health professionals and parents to make an impact on their current and long-term nutrition, writes Teresa Kelly

In the early months of life, infants are totally dependent on mother’s milk or infant formula for their nutritional needs. Solid foods from a spoon are introduced at around six months of age and by one year old, they account for two thirds of the infant’s energy intake. Breast or formula milk accounts for only one-third of energy. Complimentary or solid foods now provide the mainstay of nutrition needs.

The concept of infant programming for adult disease has gained widespread credence in the last 10 years. Research suggests that nutrition in the first 1000 days, from conception to two years old, has a positive lifelong effect on health. Well-timed nutritional interventions in the first year may be crucial to future health. It is a period of unprecedented growth. At birth an infant’s brain weighs 400 grams. At 12 months, the weight has increased three-fold proportional to body weight.

The process of moving from a liquid milk diet at birth to sharing in family meals at one year old occurs against a backdrop of well defined stages in attachment behaviour. Good weaning practices will support this attachment sensitive period and program food choices well into childhood.

Setting the scene
The choice of breast feeding or formula feeding has a huge impact on weaning onto solid foods. While breastfeeding is the preferred option for all infants, less than half of mothers in Ireland are breastfeeding on discharge from hospital. Whether a baby is breast or formula fed affects appetite regulation, body composition and the timing and choice of solids.

The publication ‘Best Practice for Infant Feeding in Ireland’ (FSAI, 2012) sets out clear guidance for health professionals on stages and milestones for infant feeding in the first year and beyond.

Weaning is the process of introducing solid foods to infants. The FSAI guidelines suggest that weaning takes place at about six months; infants should not be introduced to solid food before four months (17 weeks) of age and the start of weaning should not be delayed past six months (26 weeks) of age. (FSAI: 46)

In contrast, over 20 % of mothers in Ireland wean their infants onto solid food before 12 weeks of age. There is a window during which infants are ready for solids. The signs will differ between infants and may include:

  • Slowing of weight gain
  • Waking again at night, after having settled into a pattern
  • Infants start to put objects into their mouth and show an interest in food while others are eating
  • Sitting with support.

Home prepared or commercial
The greater the variety of tastes an infant is introduced to at around six months, the greater the food choices in later childhood. Breastfed infants receive food tastes through mother’s milk while formula fed infants receive these tastes through solids. Infants accept and learn to like strong-tasting foods within weeks if they are given often. Weaning onto a wide range of home-prepared foods helps infants to develop taste and predicts better acceptance in the future.

The first steps
Whatever the choice of feeding, create a relaxed attitude around food. Starting solids is the first major change in eating for infants. Pick a time when baby is alert and relaxed. Early afternoon is often a good time. Give before or during milk feed.

First foods should be soft, wet, smooth and lump free. Sieve the food through a plastic sieve, or blend it in a liquidiser. A liquidiser is essential for meat – slow-cooked casseroles and stews made with meat, vegetables and water are ideal because the meat softens and is easier to liquidise. Suitable first foods include:

  • Cooked and pureed vegetables such as potatoes, carrot, parsnip, turnip, onion, butternut squash, sweet potato
  • Cooked and pureed fruit such as apple, pear and ripe banana
  • Cereals such as rice, corn flour or oats, and wheat from around six months
  • Meat sources such as lamb, beef or chicken at around six months
  • White fish such as cod and haddock or oily fish such as mackerel, salmon and canned tuna
  • Sauce mixes or packet soups are not suitable for children under 12 months, because of the high salt content. Use vegetable water, breast milk or formula instead.
Meal plan for infants starting solids
  Breakfast Midmorning Lunch Midafternoon Tea Bedtime
Day 1
  • Breast/bottle
  • Baby rice
  • Stewed pear or apple
Breast/ formula Sweet potato, leek and pea puree Breast/
  • Potato,courgette and broccoli puree
  • Water or diluted juice
Breast/ formula
Day 2
  • Breast/bottle
  • Baby rice
  • Apple and raisin puree
Breast/ formula Potato and cauliflower puree Breast/
  • Tomato, leek and lentil puree
  • Water or diluted juice
Breast/ formula
Day 3
  • Breast/bottle
  • Baby rice
  • Stewed peaches, apples and pear
Breast/ formula Carrot and pea puree Breast/
  • Leek, sweet potato and pea puree
  • Water or diluted juice
Breast/ formula
Day 4
  • Breast/bottle
  • Baby rice
  • Poached apricot and pear
Breast/ formula Broccoli, potato and turnip puree Breast/
  • Potato, parsnip and car rot water or diluted juice puree
Breast/ formula
Note: Portion size: 5-10 teaspoons per meal

The first spoon feed
Choose a small, shallow plastic teaspoon. Offer one to two teaspoons of food or more if baby is keen. Mix to a thin smooth consistency with breast milk, formula milk or water. When the infant is taking five to six teaspoons at one time, include a second spoon feed. If a baby refuses a food, try again in a day or two.

When parents understand that the initial spitting back of solids is part of the process of handling the new texture, they are encouraged to continue.

What about gluten?
Gluten, and foods with gluten, such as porridge, Ready brek, or rusks can be started from around six months. Starting gluten before four months or delaying beyond seven months increases the risk of coeliac disease and type 1 diabetes later in childhood. The risk of coeliac disease is lower if mother gives foods with gluten while she is still breastfeeding

Seven to nine months
Infants need to experience more solid food to develop oral motor skill. A delay in introducing lumpy foods beyond 10 months is more likely to result in food refusal at 15 months. Equally, children should not be introduced to lumps too early as this may feel unsafe and cause them to reject the food. They often prefer soft lumps such as those found in porridge or wellmashed stew than hard lumps which can sometimes be found in minced meat. Breastfed infants may accept lumps faster because of greater oral control.

Use the following guidelines for this stage of weaning:

  • As a baby gets used to solids, make a thicker puree by using less liquid or adding potato or baby rice
  • Provide foods that have soft lumps such as porridge or finely mashed potato
  • Add the mashed food to pureed solids, adding a little more texture each time
  • Mash potatoes and vegetables and liquidise meat
  • Give 30-50g of oily fish such as salmon once or twice a week from seven months as a source of Omega-3 fats
  • Give soft finger foods such as soft fruit, cooked carrot, bread sticks, fingers of toast.

Key nutrients
Iron is a key nutrient in infancy and is strongly associated with neurodevelopment. Iron-rich foods such as lamb or beef, but not liver because of the vitamin A content, can be started in the early stages of weaning from six months.

Infant milk or breast milk supplies calcium. As the weaning process moves forward towards nine months, infants can be breastfed on demand or given three to four formula milk feeds per day. Vitamin D3 supports the absorption of calcium.

It is HSE policy that infants from birth to 12 months, whether breast fed or formula fed, receive a supplement of 5mg of vitamin D3 per day. Supplements are available in pharmacies without a prescription.

For young children, formula is a meal equivalent and if it is not reduced as the infant nears one year old, it will compete with iron for absorption. In general, water should be offered with dinner to optimise iron uptake. Be sure that the water is given from a beaker or cup, without a lid.

Getting the message across
Parents who are still finding equilibrium with their infant can be unsettled by inconsistent information from families and healthcare professionals. Young children learn by association; they will accept patterns and routine from about 10 or 12 weeks old. When these patterns are encouraged it lays down an excellent foundation for weaning onto solids.

For infants, food is about exposure to new tastes and texture, and must be age appropriate. For health professionals, weaning infants onto solid foods is an opportunity to make an impact on current and long-term nutrition.

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