Transcript Weaning - Southern Health NHS Foundation Trust

Weaning
Sally-Ann Denton
Chief Community and Paediatric Dietitian
Portsmouth Hospitals NHS Trust
September 2010
Definition:
“
the process of expanding the diet to
include foods and drinks other than breast
milk or infant formula” (DOH 1994)
3
fundamental considerations:
the age of weaning onset
 the nutritional composition of weaning foods at
each transitional stage
 the influence of the infant diet on adult disease
outcomes

 To
meet energy and nutrient
requirements especially iron
 To
aid development of oro-motor
skills e.g. chewing
When to Wean?
 The
current national recommendation is to
introduce solid foods at around six months
of age (26 weeks). This is based on
recommendations from the Scientific
Advisory Committee on Nutrition (SACN),
which is in line with the guidance from the
World Health Organisation (WHO) on
exclusive breastfeeding.
DOH :National Infant Feeding Team June 2010
Rational Behind Guidance
 Breast
milk provides all the nutrients an infant needs for
healthy growth and development for the first 6 months
 Immune
system, maturation of gastrointestinal tract, oral
development all ready to cope with solids by 6 months
 Prior
to this gut more vulnerable to infection and allergy
 Active
spoon feeding with the upper lip moving down to
clear the spoon occurs at 6 months
 No
benefits from introducing solids between 4-6 months
have been shown( DOH 2004)
Readiness to wean:

Look for three signs that show a baby is ready
for solids. The baby should be able to:
 Stay in a sitting position and hold their head
steady;
 Co-ordinate their eyes, hands and mouth and
look at food. They can pick up food and put it
in their mouth all by themselves
 Swallow food. Babies who are not ready will
push their food back out, so they get more
around their face than they do in their mouth.
Factors to consider:
A narrow window lies between early and
late weaning
 variation between needs of individual
infants

Problems with poor timing
Early weaning
Late weaning
• coughs and chestiness
• growth faltering
(short term)
• ? obesity (long term)
• ↓ nutritional sufficiencydisplacement of breast milk
with low energy/low
nutrient foods
• Fe deficiency anaemia
•  risk of some allergies
(especially poor weight
gain) due to inadequate
energy and nutrient intake
(Fe)
• delayed psychomotor
development (speech,
feeding and chewing skills)
Current Practice
Infant
Feeding Survey 2005:
51% introduced solids at 4 months in 2005
(cf 85% in 2000)
large study in NE of England found 94%
children weaned before 4 months (Wright et
al., 2004)
Reasons cited by parents for early weaning:
 56% hoped that their infant would settle more
easily after the introduction of solids
 52 % hoped that the infant would sleep through
the night.
Reasons for continuing with solids once
introduced:
 infant seemed to enjoy them (83 %)
 infant was happier and more content (60 %)
Most women (75 %) were unconcerned about
introducing solids at the time that they did.
Nutrient Profile Of First Weaning Foods
Mature
Baby rice
breast milk (reconstituted)
Carrots
Energy
(kcal/100g)
Fat (%energy)
69
66
22
53
23
<1
Protein (%energy)
8
12
10
CHO (%energy)
39
65
80
Fe (mg/100g)
0.07
1
0
Vit D (µ/100g)
0.04
1
0
Practicalities
Stage 1
 Smooth
~ 6 months ( 26 wks) (17 weeks earliest)
consistency but may be lumpier if weaned at 6
months
 Some will be ready for soft finger foods
 Examples baby rice, pureed home cooked rice, pureed
vegetables & fruit
 Solids from spoon NEVER in bottle
 Introduce variety of tastes
 No added salt* or sugar
 Encourage self feeding from start
*immature kidneys < 6months can’t concentrate urine –
What Can’t We Give Under
6months?
Stage 1 – more foods
Soft
cooked meat/pulses
Cow’s
milk products e.g. whole milk
yoghurt/custard/cheese sauce – from 6
months
Stage 2: 6-9 months
•
Introduction of different textures and tastes
•
Mashed/soft lumps/ soft finger foods
•
Gluten containing foods can be introduced
•
Meat, fish, well cooked eggs, all cereals and pulses
•
Milk feeds reduced (From 6 months whole milk can be
used to mix solids e.g. on cereal)
•
At 6 months introduce a cup
Stage 3 9-12 months
Aim
for 3 meals with snacks
Food
minced/finely chopped
Finger
Full
foods and self feeding
family diet
Stage 4 12 months
 Minimum
350 ml milk daily or 2 -3 servings dairy
products
 Whole
milk can be used as drink
 Starchy
 Fruit
foods:
& veg:
 Meat/alternatives:
minimum 4 servings daily
1 serving at each meal
minimum 4 servings daily
minimum 1 serving daily or 2
from veg sources
Other Considerations
– discourage
large volumes >
600ml/day
Milk
Limit
Discourage
Don’t
bottle
feeding from 1 year
Encourage
low fat
meat and oily fish
fatty and
sugary snacks
add sugar to
drinks
Vitamins
 Breast
fed infants are at risk of vitamin D deficiency
 Vitamin
A status can be a cause for concern if small
amounts of milk taken
 Vitamin
C important to aid Fe absorption
 From 6 months of age
 and D supplements*
 Infants
breast fed infants should have Vit A
consuming >500ml/day formula milk don’t need
 Between 1 and 5 years Vitamin A and D supplements
 should be given unless adequate intake can be assured
 from diverse diet (DOH 1994)
 Especially important for those of
 Middle Eastern origin and fussy

Asian, African and
eaters
* Healthy Start drops : Vit A 200µg Vit C 20mg Vit D 7µg
Responsive
feeding
Avoid early weaning
Appropriate portion sizes and food types
Upwards weight centile crossing can be
early warning
Avoid excessive milk – formula or breast
milk
Avoid sugary drinks in bottles
Weaning and Allergies

For high risk infants exclusive breastfeeding for
6 months may be protective

Avoid introduction of major allergens until 6
months BUT

No proven benefits in delaying the introduction
of allergens beyond 6 months

Delay may have nutritional and eating –
behaviour consequences
Weaning The Allergic Child
 Exclude
allergens proven to react to whilst
ensuring the diet is nutritionally adequate
 Referral to paediatric dietitian essential –
preferably before weaning starts
 Ensure appropriate type and quantity of
specialised formula given
 NB Goats milk / goats formula unsuitable
 Rice milk must not be given to <5’s
inorganic arsenic levels potentially harmful
Revision of COT Recommendations on
Peanut Avoidance
 “previous
precautionary advice to avoid peanut
consumption during pregnancy, breast feeding
and infancy, where there is atopy or atopic
disease in family members, is no longer
appropriate”
 www.eatwell.gov.uk
for current weaning
advice
 Current
UK RCT www.leapstudy.co.uk
Baby Led Weaning
Developed
by a health visitor (Gill Rapley)
Babies
encouraged to pick up solid bits of
food rather than spoon feeding
purees/mashed foods
Minimal
evidence base but gaining
popularity with some parents
Baby led Weaning: The issues





Previous UK & USA studies show widely
different norms for age when finger feeding skills
acquired
UK study 2010 most started reaching out for
food 4-7mths but for many self –feeding still not
a routine part of meals at 8 months
Potential nutritional issues
Window of opportunity re mixed textures may be
missed
Potential choking hazard
of promoting self –feeding in
parallel with family meals would be more
appropriate
 Policy
 Need
to consider each baby as an
individual and wean when they are ready
and according to their developmental
stage/needs (true baby-led weaning)
Useful Resources
 For
further information visit
www.nhs.uk/start4life
 www.bda.uk.com
 Birth
to five Book
– food facts
Healthy Eating For
Toddlers
 Nutritional
needs
 Vitamins and minerals
 Fussy Eaters
Healthy Eating: A Question of
Balance
Eat 4 portions
daily (5 by school
age)Use to fill up
at meals
and in between
Include at every
meal and for
some snacks
3 servings
daily
Eat 1-2
servings daily
(2-3 if
vegetarian)
Limit to small
quantities a
few times a
week
Adapting Healthy Eating For
Young Children
Milk and dairy foods:

Babies – breast milk or formula until 1 year

Full fat milk needed until 2 years

Semi skimmed milk acceptable after 2 years if
eating a well balanced diet and growing well

Skimmed milk after 5 years if meeting above
criteria
Age
0-12 mths
1-3 years
4-6 years
7-10 years
11-18 yrs (m)
19-50+ yrs (m)
11-18 yrs (f)
19 - 50+ yrs (f)
Calcium RNI (mg/d)
525
350
450
500
1000
700
800
700
Fats and Sugars
Some fats necessary – moderate amounts of
butter/ margarine
 Limit high fat, high sugar snacks

Fibre

High fibre bulky diets not appropriate for under
2yrs
- But some fibre important

By 5 yrs moving towards adult low fat higher
fibre diet
How much and how often?
▶ Meal
patterns change as child ages
▶ Portion
sizes change with age and vary
according to child’s size/ appetite
▶ No
nationally agreed set portion sizes
▶ Use
Eatwell plate as guide
▶ Child’s
hand for fruit and veg
FOOD
1 year
2 -3years
3-5 years
Meat, fish, egg, beans and
pulses
½ - 1 tbsp
(15-25g) Minced/chopped
with gravy/sauce
½ - 1 hard cooked egg
½-1 tablespoon (15-25g)
beans or pulses
20g(1 tablespoon) grated/
2-3 dice sized cubes
1-1 ½ tablespoons(20-30g)
chopped/ 1 fish
finger/sausage 1 egg
1-2 tablespoons (20-40g)
beans or pulses
2-3 tablespoons (40-80g);
1-2 fish fingers/sausages 1
egg
1-2 tablespoons (20-40g)
beans or pulses
Cheese
Custard, rice pudding and
yoghurt
Potato, rice, couscous and
pasta
Bread
Chapatti/pitta bread
Breakfast cereal
Vegetables (fresh, frozen or
canned)
Fruit
Drinks (milk or water)
2 tablespoons / 1 small pot
(60g)
1 tablespoon (30g) mashed
potato, rice /pasta
½ -1 slice
¼ - ½ large
1 tablespoon (15g) porridge
or cereal
½ weetabix
1 tablespoon (30g) soft or
mashed
¼ -½ (40-80g) banana,
pear, apple
½- 1 small plum/ satsuma
½ - 1 small slice melon
2-3 strawberries
or grapes
1– 2 teaspoons dried fruit
1 heaped tablespoon(30g)
frozen/ canned fruit
¾ cup (100ml)
25-30g cubed(approx 4 dice 30-40g( approx 2
sized )
tablespoons grated) or 4-6
dice sized cubes
2-3 tablespoons (60-80g)
4 tablespoons / 1 x 120g 150g pot yoghurt
1-2 tablespoons (30-60g) 5- 2-3 tablespoons (60-80g)
6 small chips/wedges
6-8 chips/wedges
1 slice(40g)
1-2 slices (40-80g)
½-1 large
½-1 large
1 -1½ tablespoons (152-3 tablespoons (20-30g)
20g) porridge or cereal
porridge or cereal
½-1 weetabix
1 weetabix
1-2 tablespoons (30-60g)
2-3 tablespoons (60-80g)
¼ cereal bowlful chopped
½ cereal bowlful salad
salad
½- 1 (80-100g) apple pear
1 (100g) apple, banana,
or banana
pear
1 small plum / satsuma
1 plum / satsuma
1 slice melon
1 slice melon
4-5 strawberries or grapes
6-10 strawberries or grapes
½ tablespoon dried fruit
½ tablespoon dried fruit
1-2 heaped tablespoons
1-2 heaped tablespoons
(30-60 g)frozen/ canned
(30-60 g)frozen/ canned
fruit
fruit
1 cup ( 120-150ml)
1 cup ( 120-150ml)
Eatwell Minimum Servings
Food Group
Minimum Servings per day
Milk and dairy foods
3
Meat, fish and alternatives
2
3 (vegetarians)
Bread, other cereals and potatoes
4 or more depending on appetite
Some with every meal
Fruit and Vegetables
Fruit
Vegetables
Fatty and sugary foods
2 } moving to 5 a day for
2 } school children
Moderate amts spreading fats
Limit fatty/sugary snacks and drinks
Meal Patterns
Age
Meal Pattern
1 year
3 small meals +
3 snacks + milk
2-3 years
3 meals + 3 snacks
+ milk
3 years+
3 meals + 1-2 snacks
or milky drinks
Healthy Snacks
 Snacks
offered between meals should be
nutritious and varied
 Encourage
lower fat and lower sugar
alternatives to biscuits and crisps.
Healthy Snacks
▶ Bread,
crumpets, teacakes, muffins, fruit buns, malt
loaf, bagels, pita bread, raisin toast, scones, toast,
sandwiches, toasted sandwiches.
▶ fruit : fresh/dried/tinned in juice, raw vegetables or
salad
▶ Plain biscuits e.g. oatcakes, breadsticks, crackers,
rice cakes, crisp bread with marg/butter/cheese/dips
▶ Home-made plain popcorn
▶ Yoghurts / fromage frais , cheese cubes, frozen
yoghurt
▶ Low sugar breakfast cereals
Drinks
 Milk
or water are best choices
 Milk shakes & smoothies increase milk &
fruit intake
 Unsweetened fruit juice at meals helps
increase iron absorption
 Avoid tea or coffee for under 5’s
 Avoid sugary drinks between meals
Recommended Maximum Salt
Intakes
 0-6
mths <1g per day
 7-12 mths 1 g per day
 1-3 years 2g per day
 4-6 yrs 3g per day
 7-10 yrs 5g per day
 11+ 6g per day
 Adults 6g per day
Fussy Eating

Affects >20 % toddlers & is normal at a particular
developmental stage

Persists in a small number especially boys

Narrow range of foods eaten with an extreme
resistance /unwillingness to try new foods

Commonly found in children with neurodevelopmental difficulties e.g. autism

Some show phobic anxiety about new things in
general
Helpful Strategies
▶
Eating in social groups e.g. families eating
together; pre-school snack time, friends
▶
Praise when they eat well – ignore
undesirable behaviour
▶
Keep trying :some may need to be exposed
to a food > 10 times before it is accepted as a
liked food
▶
Start with accepted foods before introducing
new ones

Offer one choice – no backups

No bribery or distractions e.g. TV, DVDs

If meal refused wait until next planned meal/
snack time

Consistency from all carers

Start with accepted foods before introducing
new ones

Some will only accept new foods on separate
plate

Offer regular balanced meals and snacks –
based on 4 main food groups

Offer 2 courses at each meal. Ensures wider
variety of foods & nutrients are offered

Offer it as routine not as reward for finishing
main course

Don’t fill up on crisps, chocolate or drinks
between meals

Avoid conflict at meal times

Children experiencing faltering growth as a
result of food refusal need referral

Refer if concerns regarding nutritional
adequacy

Children's multivitamins can help relieve
anxiety and are helpful if diet very restricted
Useful Websites
www.nhs.uk/start4life
www.bda.uk.com
Birth
– food facts
to five Book
www.infantandtoddlerforum.org
 www.littlepeoplesplates.co.uk
 www.eatwell.gov.uk
Any Questions?