Introduction of Solid Foods

1. Introduction of Solid Foods Milk – whether breastmilk or formula milk - contains all the nutrients a baby needs until it is around 6 months old. At that point, the stores of iron the baby has will begin to be depleted and the baby has begun to develop the skills and abilities – sitting up unaided, chewing and swallowing for example - that will enable it to move onto combining milk feeds with solid foods. Learning to eat, like other developmental stages, is a process for a baby and takes time and patience.

2. NHS Message on Introduction of Solid Foods For some time, the NHS message was to introduce complimentary foods from 4-6 months of age and signs of readiness were mainly around behavioural signs – waking more frequently, seeming interested in food etc. In 2004 the guidance was changed to reflect research into the impact of weaning at 4 months and further information around readiness. It also reflects the Government’s recommendation of exclusive breastfeeding until 6 months. Current message: Introduction to solids should be done at around 6 months. If a mum is planning to do it earlier, they should consult a health professional and avoid a number of foods (covered later).

3. Not before 4 months • Solid foods should not be given to babies younger than 17 weeks as their bodies are not ready for foods other than milk. Key reasons are: • It reduces the absorption of nutrients from breast milk (COMA 1994) • Babies at this age have Insufficient development of neuro-muscular co-ordination to eat safely • Their gut and kidneys are not mature enough to process foods and waste products • It increases the risk of infections and allergies

4. Why at 6 months? One of the main reasons for the guidance changing was research into the developmental readiness of a baby to accept food. At 6 months the baby’s digestive system is more developed and has begun to produce the enzymes necessarily to break down more complex solid foods. The baby has also lost the tongue thrust reflex – this is the reflex that makes a baby poke its tongue out of the mouth – it is used to prevent a baby swallowing things that are ‘foreign to it’. At 4 months, this reflex is still present in most babies and for those weaning at this age, they will see the baby’s tongue forcing most of the food back out of the mouth.

5. Signs of readiness At 6 months of age, the baby is also better co-ordinated and able to: Reach and grabs accurately by coordinating eyes, hands and mouth – enabling them to be able to pick up and hold pieces of food or spoons Sit up unaided with good control of their heads Move food around their mouths and swallow Only when all three signs are demonstrated is a baby ready to be offered solid foods.

6. False Signs Often mums describe a range of different factors as suggesting a baby is ‘ready for solids’: Waking at night when previously slept through Baby requesting more milk feeds/drinking more at each feed and being hungry afterwards Chewing fists/blankets/toys Watching parent’s eat Trying to grab spoons/food

7. False Signs Many of these signs indicate that a baby is experiencing a ‘growth spurt’ – and can often be solved with giving additional feeds for a few days. It may be that the wakefulness or chewing are signs of the baby teething – which also occurs at around 4-6 months. Grabbing spoons/watching parents are ways a baby is demonstrating its interest in the world – not necessarily an interest in the food because they don’t actually understand what it is yet.

8. Sleeping • Common belief that giving solids will help babies to • sleep longer at night • No evidence for this • Henig MJ, Nommsen LA, Peerson JM et al Intake and growth of breast-fed and formula – fed infants in relation to the timing of introduction of complementary foods: the DARLING study (1993)

9. Other considerations Although the recommendation is to wait until around 6 months, baby food manufacturers are still able to label food as suitable from 4 months. This presents a message that 4 months is the ‘normal’ time to introduce solid foods. The ingredients within the baby foods can be labelled in this way because technically they are suitable although the recommendation is to wait until 6 months. There has been some research linking the early introduction of solid foods with increased risks of obesity – linked to the fact that early introduction of foods may result in babies being overfed – or fed inappropriate foods. Evidence in this area is limited.

10. Other considerations SACN (Scientific Advisory Committee on Nutrition) are currently looking at evidence for the recommendation for introducing solid foods at 6 months. They are also looking at whether specific foods such as wheat should be introduced before 6 months. They will also undertake an updated Infant Feeding Survey during 2010 which will report in 2011/12. This may result in a more broad statement around introducing foods between 4 and 6 months – but as the Committee has yet to report on this, the NHS recommendation will remain the same for the foreseeable future. Your role is to support current messages.

11. Pressure to wean earlier • There are many factors at play which will influence a family’s decision around when to introduce solid foods to their baby – and what sort of foods they will introduce. • Pressure from family members or friends • Baby waking at night • Confusion over messages • Wanting to move onto next phase • Cultural beliefs • Marketing practices e.g. “labels say it is ok from 4 months” • Influence from health professionals • Previous experience of feeding baby earlier

12. Why should I wait? • Complete the activity “Why should I wait” and share your thoughts with colleagues.

13. Foods to avoid If weaning before 6 months avoid: Wheat Eggs Shellfish Nuts Seeds Liver unpasteurised cheeses These are linked with increased risk of allergies and food safety – for example, choking and risk of listeria.

14. Foods to avoid during weaning SALT – when cooking, salt shouldn’t be added. Babies cannot process salt and high levels can damage baby’s kidneys. If you must add salt, do it after taking they baby’s’ portion out. SUGAR – babies don’t need the empty calories in sugar and adding sugar will encourage a sweet tooth later on HONEY – should be avoided until after the age of 1 year because there is a risk of botulism in honey WHOLE NUTS – linked with a risk of choking under 5s LOW FAT FOODS - Under 2s need fats for development PROCESSED FOODS – contain too much salt for under 1s BONES of fish pose a risk of choking RAW EGGS or LIGHTLY COOKED EGGS – risk of salmonella

15. Introduction of Solid Foods There are several ways in which to begin to introduce solid foods to the baby. The more ‘traditional’ approach is that using pureed foods and baby rice offered in small quantities on a spoon. Baby-led weaning is another approach which has gained more popularity in recent years – that approach builds on the principle of a baby learning skills by trial and error and is about how they eat. Both will be described in this session.

16. Introduction of Solid Foods At the beginning, the introduction of food is more about introducing new tastes and textures and learning new skills than the food providing the nutrients for the baby. They will still rely on their milk feeds for that for some time yet. Each baby will take it at their own pace, will learn and react differently. Patience and a relaxed approach is the key to success.

17. Introduction of Solid Foods Key tips for mums: Expect mess It takes time Be patient - let the baby touch the food if they want to. Be prepared – have cloths and wipes available, cover the floor – food can get everywhere! Make sure your baby is sitting up straight and is facing forward. A highchair may be helpful. Remember its about learning – not eating - at first

18. Getting Started Small amounts of simple foods should be offered at first. For example: mashed vegetable mashed fruit or puree fruit baby cereal eg rice or oats mixed with breast milk or infant formula Mums should pick a time of day when they are both relaxed and offer tastes of food after a normal milk feed or half way through a milk feed. A plastic spoon is gentle on gums.

19. First Foods Cereals eg baby rice or oats mixed with breast milk/infant formula Mashed cooked vegetables eg potato and carrot, sweet potato and parsnip, yam Mashed banana, cooked apple or pear, ripe peaches or tinned fruit in fruit juice – drain off the juice and mash Use a little of baby’s milk to mix food to consistency

20. Introducing more solids Once the baby is comfortable eating a few teaspoons at one meal a day, it can be gradually increased to a few teaspoons 2 and then 3 times a day – to time with family ‘mealtimes’. Mums should be encouraged to let the baby guide to how much he/she wants. New foods should be introduced one at a time to ensure the mum can identify is anything upsets the baby’s stomach They should also be encouraged to continue with their normal milk feeds.

21. More foods to try Once baby is used to eating vegetables and fruit add meat and alternatives group and bread and alternatives group eg Pureed or mashed up meat, fish and chicken Mashed rice, noodles or pasta Lentils (dhal) or pulses Full fat dairy foods eg yogurt, fromagefrais, custard Mashed family meals Vegetarian babies should eat a range of pulses and beans and sources of protein such a soya/quorn

22. Happy Weaning Other hints and tips: Mums should offer a range of different tastes and textures – even foods they don’t like – to encourage the baby to have a wide range of foods If baby doesn’t like the food the first time, try again over a few meal times. Be relaxed. Ensure that baby eats with family. Use spices and herbs

23. Finger Foods Encourage baby to chew Encourage as early as baby is ready: usually around 7 months Cooked carrots, cauliflower and broccoli Toast, breadsticks Chapatti Banana, slice of ripe pear, peaches Cooked pasta shapes Sticks of cheese, mini baby bel

24. 7 – 9 months Once the baby has become used to eating a range of different foods and become confident in eating, the baby should be encouraged to eat normal family meal. Some parts may need to be mashed or chopped into small pieces. Milk will become less important to the baby – they should breastfeed on demand or, if formula fed, be drinking around 500mls per day.

25. From about Nine Months Ideally baby is having 3 solid meals a day with the rest of family having – chopped or mashed family meals 3 - 4 servings of bread and alternatives 3 - 4 servings fruit and vegetables 2 servings meat and alternatives Breast milk on demand or 500mls infant formula milk Snacks – fruit, bread, toast

26. At one year 3 family meals and snacks – Eat with family No more than 500mls/1 pint cows milk a day Breast milk on demand

27. Baby-led Weaning The adult-led approach described before is the most common approach to introducing solids. Baby-led weaning is an approach advocated by Gill Rapley, whose background in Health Visiting and work with UNICEF led her to undertake research into the way babies learn to eat. As a result of the research, she published a book “Baby – Led Weaning”, and a complimentary DVD and has now launched a website – www.babyled.com to promote this approach to introducing solid foods. Clips from the DVD are available via youtube.

28. Baby-led Weaning The principles behind baby-led weaning – are exactly as they suggest – the process is led by the baby. Babies learn most of their key skills by watching and copying – moving, rolling, crawling, walking, talking – and learn with support from adults, rather than being taught directly. Eating is one of the few skills we feel that we have to teach them. For some babies, the adult-led approach seems to suit them. But on the flip side, you may have already experienced the sight of a mother frantically forcing a spoon into a reluctant baby’s mouth. It often results in a frustrated mother and frustrated baby.

29. Baby-led Weaning For some babies, the adult-led approach seems to suit them. But on the flip side, you may have already experienced the sight of a mother frantically forcing a spoon into a reluctant baby’s mouth. It often results in a frustrated mother and frustrated baby.

30. What is Baby Led Weaning? • Infant controls his/her own solid food by self feeding from the start of the weaning process. • Given a variety of finger food in a high chair ie soft fruit, baton shaped pieces of natural shapes that have a handle eg broccoli. • Not bite size bits

31. Baby Led Weaning • Advantages • Babies learn to cope with lumps better • Babies learn to chew earlier • Controls what, how and how much they want • It is more fun for the baby (and therefore, for the parent) • It is natural • Learn more about individual foods – rather than pureed tastes all mushed up together • No mealtime battles • Less fussy • Cheaper – baby eats what parents do

32. Baby Led Weaning • How is it ‘done’? • Make sure baby has already been ‘fed’ (a milk feed) • Allow baby to touch, feel and experiment with foods • Let baby join in normal mealtimes/snack times • Make sure baby is sitting upright and safely – in a highchair or on a lap • Offer finger foods that are easy to hold in their hand – sticks of finger food like broccoli, carrots, parsnips etc (soft but not soggy) • Offer food – don’t be tempted to put it in the baby’s mouth – and less is more.

33. Baby Led Weaning • Using the link below have a look at the information on BLW and watch the clips from Gill Rapley’s Baby Led Weaning DVD to understand the approach in more detail. • www.rapleyweaning.com • www.baby-led.com • Discuss what you see with your colleagues in the forum.

34. Premature Baby • Wean in same way as term baby • Start 5 – 7 months chronological age not • corrected age (Bliss - premature baby • charity)

35. Commercial Baby Foods • There is a huge commercial market for baby foods – with associated advertising campaigns and promotions. Indeed, a recent Celebrity diet craze promoted the “Baby Food diet” as a way to lose weight. • Commercial baby foods are prepared to nutritional standards but still contain added sweeteners and preservatives that home cooked foods do not. In addition, despite ranges offering a vast variety of meals and tastes, many are bland and tastes startlingly similar. • These are also much more expensive than home cooked foods and lull parents into a routine of thinking their babies are better with commercially prepared – rather than home cooked foods

36. Commercial Baby Foods • Commercially prepared baby foods are ok for convenience on odd occasions, but shouldn’t form the basis for a baby’s introduction to solid foods for several reasons: • Uniform texture, don’t offer challenge to babies • Ingredients heated to high temperatures possibly destroying key nutrients • Not exactly fresh if it can last on a shelf for up to 2 years • Doesn’t encourage wide range of tastes • Contain more water, sugar and starch than homemade foods • Costs much more than equivalent home cooked versions

37. Try it yourself • Complete the “Try it yourself” activity.

38. Home cooked meals • Mums should be encouraged to cook for their own babies – even if they don’t have great cooking skills. In the first few weeks, cooked vegetable sticks or mashed vegetables will be more than enough. • Think about some easy recipes to explore together – base around current family meals. • Use it as an opportunity for the whole family to eat healthily and share meals. • Babies will always eat the leftovers the rest of the family won’t.

39. Making baby food Cool food as quickly as possible (ideally within 1 or 2 hours) and place it in the fridge or freezer. Food placed in the fridge should be eaten within 2 days. Make sure frozen food is thoroughly defrosted before reheating. Safest: overnight in fridge or defrost in microwave. Always wash hands before food preparation and check baby’s hands are clean before feeding Keep surfaces and chopping boards clean. Prevent pets from coming near food or food preparation surfaces Cook all food thoroughly and cool it to a lukewarm temperature before giving to baby. Avoid raw eggs and raw shellfish

40. Different Cultures Key messages: Traditional home cooked foods are healthier than commercial foods or “western foods” The marketing of baby foods makes everyone want to buy them but home cooked foods are cheaper and more nourishing for baby

41. Cerelac • Nestle product marketed for babies older than 8 months. It is mixed with water and contains wheat, oats, rice, skimmed milk powder oils and some vitamins. • It is used by many families from Asian or African-Caribbean backgrounds. • It is a high calorie food (211 cals per 50g serving) and is marketed to fatten babies. • It is not necessary in the UK as a supply of protein foods and calories.

42. Drinks and Cups Cooled boiled water best for teeth Pure fruit juice only at mealtimes diluted one part juice to 10 parts water Squashes, fizzy drinks, undiluted pure fruit juice are not recommended because they are acidic and cause dental erosion Drinking tea interferes with iron absorption so should be avoided Drinks should be given in lidded cups or beakers – bottles should be replaced as soon as baby can use a cup

43. More Information • Many parents lack of confidence with introducing solid foods. Ensure you are aware of services available locally in Children’s centres, weaning parties or groups eg baby massage, breastfeeding groups, or via the family’s Health Visitor. • Other sources of information include: • www.nhs.uk/start4life and www.nhs.uk