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Best practice in weaning

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VOL: 97, ISSUE: 32, PAGE NO: 56

CHRISTINE NORGATE, RGN, RM, RHV, is a health visitor, Stopsley Clinic, Luton, Bedfordshire

Charlie was a very engaging, cheerful eight-month-old and clearly thriving when he attended the child health clinic. However, his anxious parents had a different picture to present. His weaning diet was causing them great concern. Having started out well on a variety of foods, his intake had gradually deteriorated to the point where he would now only tolerate a few commercial baby foods, and most of these were of the highly sweetened variety. His parents had read that at this age he should be learning to chew soft lumps, but Charlie spat them out. They were concerned and perplexed as they had started out with such good intentions that their son would eat a wholesome, varied diet. This is a situation encountered every day by health visitors working in child health clinics, and for this family, as for many others, it was important to go back to basics.

Charlie was a very engaging, cheerful eight-month-old and clearly thriving when he attended the child health clinic. However, his anxious parents had a different picture to present. His weaning diet was causing them great concern. Having started out well on a variety of foods, his intake had gradually deteriorated to the point where he would now only tolerate a few commercial baby foods, and most of these were of the highly sweetened variety. His parents had read that at this age he should be learning to chew soft lumps, but Charlie spat them out. They were concerned and perplexed as they had started out with such good intentions that their son would eat a wholesome, varied diet. This is a situation encountered every day by health visitors working in child health clinics, and for this family, as for many others, it was important to go back to basics.

Signs that the baby is ready for the introduction of solid foods include still seeming hungry after a good milk feed has been taken, demanding more frequent feeds, and a previously settled baby waking in the night again for a feed (Health Education Authority, 1999). A runny puree of baby rice mixed with breast or formula milk, vegetables or fruit may be offered. Initially, the baby will appear to drink from the spoon, and as much is spat out as is swallowed. Gradually the baby develops the neuromuscular skill of moving the bolus of food to the back of the mouth and swallowing. At this point the purees can be made thicker. The number of servings should be gradually built up to three meals a day, and the milk intake should stay roughly the same as before.

Salt should not be added to baby foods, as the immature kidneys cannot excrete it. It is also inadvisable to sweeten any but the most sour of foods - for example, rhubarb or stewed cooking apples - since this may encourage a sweet tooth, and babies often then start to refuse savoury foods (Department of Health, 1994). Honey should not be given to babies under the age of one year due to the risk of infant botulism (Health Education Authority, 1999). Wheat-based foods containing gluten - for example, pasta, bread and wheat cereals - should not be introduced until after the age of six months, since it is impossible to identify in advance those babies who may develop coeliac disease (Department of Health, 1994). Nuts and seeds, fish and shellfish, eggs and citrus fruits should be avoided before the age of six months, as these foods are common allergens. Families with a strong history of atopic conditions will need specific advice regarding weaning and the exclusion of nuts from the diet until at least the age of three. In any case whole nuts should never be given to any child under the age of five because of the risk of choking. Ground or flaked nuts should be given instead.

Rusks are popular first foods for parents to offer their babies, but caution should be exercised in their use, since not all are gluten-free and all contain some sugar, even those labelled low sugar. Having grown accustomed to the sweet taste and soft texture of rusk and milk as their breakfast, many babies then refuse to eat more grown-up breakfast cereals.

After the age of six months, the weaning process should become much simpler, with the baby taking more family foods. Citrus fruits, well cooked eggs, fish, wheat-based foods, groundnuts and peanut butter can all be gradually introduced at this age.

The texture of the food should be coarsened over a period of time to become more mashed or minced than pureed. This encourages a chewing action essential for later speech development. Many parents are reluctant to introduce lumps before the eruption of the first teeth, but the first teeth to appear are usually incisors, which do not assist with chewing, and babies become very adept at chewing with their hard gums. Recent research (Northstone et al, 2001) has suggested that the late introduction of soft lumpy foods increases the likelihood of a child becoming a fussy eater in later life.

Later, finger foods, such as strips of bread or breadsticks, peeled apple or banana, can be given. At this age the baby will probably not require a milk feed after a substantial two-course lunch, and a drink from a trainer beaker can be offered. Between the ages of nine to 12 months a baby should be eating three meals of family foods, plus healthy snacks such as fruit, and approximately 600ml of breast or formula milk. The diet should include three or four servings per day of starchy foods and fruit or vegetables, and one or two servings of protein foods - meat or meat alternatives. After the first birthday, full-fat cow's milk can be offered. Since infants have a small stomach capacity and large energy requirements the foods they are offered should be full fat and dense in calories. Low-fat, high-fibre diets considered healthy for adults are not suitable for infants. In particular, bran-based foods have been shown to block the absorption of iron and other minerals (Health Education Authority, 1999).

Biscuits and cakes should be given only occasionally, since they are of limited nutritional value and encourage a sweet tooth. They should never be given as a reward for eating savoury foods or withheld for poor behaviour, since this gives emotional connotations to foods. Babies do not know that sweets and chocolate exist unless adults give sweets to them, so it is wise to avoid them in early infancy. Children will become aware of their existence once they begin to socialise at playgroup or nursery, by which time they should not have developed a sweet tooth and are unlikely to ruin their diet or their teeth by eating too many. This is not an argument for never allowing sweets, but for caution and moderation for the sake of good nutritional habits for life.

Commercial versus home-cooked foods
Parents are confronted by a bewildering variety of packets, jars and cans of commercial baby foods and bombarded with advertising and free samples from the manufacturers. It is not surprising that many parents find that they have relied on these products and then have difficulty persuading their baby to accept any family foods. While commercial baby foods have their use as a convenience - for instance, when the family is travelling or eating a meal unsuitable for the baby - they were never intended to be breakfast, dinner and tea. If the eventual aim is a family diet, then it is preferable for family foods to be offered from the outset. In addition, the transition from purees to soft lumps is by necessity rather abrupt with commercial foods, and many babies baulk at the unfamiliar texture and flatly refuse to take lumpier foods. This transition can be made rather more gradually with home cooking.

Many commercial baby foods are high in sugars, not all are gluten-free, and some have some surprising ingredients - for example, thickeners, such as calcium carbonate and xantham and guar gums - so it would be wise for parents to read the ingredients when choosing products for their babies.

Iron
The body stores of iron, with which a full-term, healthy baby is born, have been largely used up by the age of four to six months (Ministry of Agriculture, Fisheries and Food, 1997). Iron deficiency anaemia has been identified as a common problem during early childhood, affecting cognitive and physical growth and development (Department of Health, 1994), so it is crucial that the weaning diet provides sufficient iron to prevent this. One or two servings of iron-containing foods a day, such as breakfast cereal in the morning and meat or fish with the main meal, would provide adequate iron.

Good sources of iron include red meat, poultry, oily fish, fortified breakfast cereals, dark green vegetables, bread, pulses and dried fruit, such as apricots, figs and prunes. If they are served with foods containing vitamin C, such as fruit or vegetables, then the absorption of iron is increased. Tea and coffee inhibit the absorption of iron and should not be given to young children.

Drinks
Breast- or formula milk should be given as the main milk feed for the first year of life. As weaning progresses, cooled boiled water or well diluted fruit juices can be offered in a trainer beaker. Fruit juice, squash, fizzy drinks and flavoured milks all contain significant amounts of sugar, so their use should not be encouraged. In particular, giving these drinks in a feeding bottle increases the contact with the teeth and therefore the risk of dental decay. In addition, large quantities of these drinks can suppress small appetites and so drinking times need to be kept short and unfinished portions disposed of. Diet drinks are not suitable for young children due to the large amount of artificial sweeteners in them.

Eating is a social activity as well as a biological necessity, so if meal times are relaxed, chatty affairs with the focus away from a child's eating behaviour then feeding problems can often be avoided. If meals are taken together at a table, rather than 'on the hoof' or in front of the television, then so much the better for the child's social development and meal time behaviour.

As Griffiths (2000) identified, health visitors are well placed to promote healthy weaning and to intervene where problems present. Opportunities present themselves in child health clinics, postnatal groups and during developmental surveillance sessions. In addition, there are a variety of initiatives around the country, tailored to meet the needs of local communities, such as cookery sessions, food cooperatives and 'taste-ins'. All new parents are issued with the Birth to Five book (Health Education Authority, 1994), which contains a comprehensive section on weaning. It is available in a variety of languages.

Conclusion
It is important to reflect on the high rates of obesity, diabetes, cancer and coronary heart disease in this country. The part played by nutrition is well recognised and documented. Therefore it is incumbent on all of us, wherever we work with parents and children, to promote healthy weaning practices from as early as possible in a child's life in the hope that we can have some impact on these rates in the future.

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