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Infant feeding: weaning

The purpose of this guideline is to provide guidance about infant feeding and weaning at Great Ormond Street Hospital (GOSH).

Age of introduction of solid foods

The Department of Health (Department of Health 2003) recommends that healthy term infants need no nutrition other than breast milk or formula milk until six months (26 weeks) of age (Rationale 1).

Some babies may benefit from solids sooner and may be ready for solids from four months (17 weeks of age). Each baby should be assessed on its needs for solids individually. Discuss this with your ward dietitian (Rationale 2).

Some babies with certain clinical conditions may have solids introduced before 17 weeks as a means for them to take their prescribed supplements eg cystic fibrosis, metabolic disorders. Discuss with your ward dietitian (Rationale 3).

Premature babies must be assessed individually for their readiness for solids – discuss with your ward dietitian (Rationale 4).

How to give solids

The baby must be well supported and not slouching with its abdomen doubled over; use a reclining chair for younger babies, or a high chair once they can support themselves (Rationale 5).

Use age-appropriate bowls to put the food in.

Food should be given from a hard plastic weaning spoon that will not crack. Do not use a metal spoon (Rationale 6).

First weaning foods are for tastes only. A few teaspoons should be offered before one feed.

Foods should be of a smooth puree texture (Rationale 7). Once the baby is happy with this, offer puree foods before a second feed, and then a third feed, gradually increasing the quantity (Rationale 8).

The consistency can be made thicker as the baby learns to eat. Don’t move on to thicker textures too quickly (Rationale 9). By nine to 12 months of age, most healthy babies will be able to cope with minced and mashed textures.

Babies at GOSH may not progress so quickly and must be individually assessed (Rationale 10).

It is very important that babies in hospital are offered food at mealtimes and that eating becomes part of the daily routine (Rationale 11).

Allow messy play – give the baby their own spoon to feed themselves and let them use their hands (Rationale 12). Never leave a baby alone with food (Rationale 13).

Most babies will be fed in their cubicles and their parents and family should be encouraged to feed them (Rationale 14).

Older children should be encouraged to eat in the ward dining room/play area with other children or their family (Rationale 15). For older children make sure that furniture, cutlery and crockery is age appropriate and that the dining area is a cheery environment, without too many distractions (Rationale 16).

Which solids to give

Babies under one year of age must be fed commercial baby foods: tins, packets, jars, according to Trust policy. In exceptional circumstances some older infants (over nine months of age) may be fed from the ward trolley with the permission of the ward manager and parent (Rationale 17).

First foods should be baby rice, puree fruits and puree vegetables. Commercial baby foods are available via a top up system (Appendix 1) (Rationale 18).

Full feed volumes should be given whilst first weaning foods are given (Rationale 19).

Once established on baby rice, fruits and vegetables, weaning foods can include puree meat/fish/cheese dinners and milk-based baby desserts. It is important to offer savoury foods as well as sweet foods (Rationale 20).

Salt and sugar must not be added to solids for infants (Rationale 21).

The move on to commercial baby foods containing lumps will need to be assessed for the individual baby. Some babies do not cope well with the texture of these ‘second stage’ baby foods and will manage better if the lumps are mashed up (Rationale 22).

If a baby is finding difficulty swallowing solid foods, consider a referral to your ward speech and language therapist (Rationale 23).

A guide for weaning babies at home is given in Appendix 2 and may not be achievable for patients in GOSH (Rationale 24).

If a baby is having a special therapeutic feed from the Special Feeds Unit, they are likely to also need a special diet.

Discuss weaning diets with your ward dietitian. Meals may be sent from the Diet Kitchen if the commercial baby foods are not suitable (Rationale 25).

As more solids are taken the baby will naturally take less formula. From seven months a healthy baby taking solids has a fluid requirement of 120ml/kg. Fluid does not necessarily have to be taken as feed and will depend on how well the baby is eating.

If there are any doubts about the baby’s intake discuss with your ward dietitian (Rationale 26).

Babies can be given water from a cup from six months of age. Use Ready To Feed (RTF) water, order number: ABT 055. Juices should not be given (Rationale 27). Bottle-feeding is discouraged from one year of age in healthy children (Rationale 28).

Please note: Sick babies and children may need to drink from a bottle well into their toddlerhood (Rationale 29).

Feeding difficulties in tube fed infants and young children

Stimulate the mouth during a tube feed – seek the advice of your ward speech and language therapist for the right technique (Rationale 30). Give the baby a dummy to suck while they are being tube fed (Rationale 31).

Make sure that normal interactions take place while tube feeding eg hold and cuddle the baby within sight of your face, make eye contact and talk to them (Rationale 32).

Sit young children, where possible, with others of their own age at meal times (Rationale 33). Introduce fun activities related to food eg feeding dolls or teddies, making food shapes from play dough – seek the advice of your ward play specialist for further help (Rationale 34).

Provide food for tasting if the baby or child is allowed to eat – seek advice from your ward dietitian if they are on a special feed (Rationale 35).

Look at the timings of when feed is given (eg daytime boluses or overnight feeding) and offer foods at other times (Rationale 36). Liaise with your ward dietitian if feed volumes are reduced as intake of food increases (Rationale 37).

Appendix

Appendix 1: Baby foods NHS supply chain January 2012

Appendix 2: Suitable weaning foods at home

Rationale

Rationale 1: Breast milk and formula milk meet the nutritional requirements of most healthy babies for the first six months of life (World Health Organisation 2001; Department of Health (DH) 2003).

Rationale 2: Sick infants have different nutritional requirements to healthy babies. The dietician will ensure the diet is nutritionally adequate and that appropriate solids are offered. 

Rationale 3: To ensure nutritional adequacy and that appropriate solids are offered.

Rationale 4: The degree of prematurity will determine the appropriate age for introduction of solids.

Rationale 5: To ensure the baby is comfortable and the stomach is not compressed.

Rationale 6: The shallow bowl of a weaning spoon allows the baby to more easily take food from it. A metal spoon may harm the baby’s mouth.

Rationale 7: To allow the baby to practise how to move a bolus of food around and to experience flavours and textures (North 2004).

Rationale 8: To allow the baby to learn to eat solid food.

Rationale 9: The baby may choke on thicker textures and become food aversive.

Rationale 10: Sick babies are often developmentally delayed and may take longer to progress from puree foods to thicker textures.

Rationale 11: To encourage normal developmental milestones.

Rationale 12: To encourage normal developmental milestones.

Rationale 13: To prevent choking.

Rationale 14: To encourage normal family social interactions around feeding times.

Rationale 15: To encourage normal social interactions around meal times.

Rationale 16: To create an environment that is conducive to eating (NHS Estates 2003).

Rationale 17: For microbiological safety. To determine that it is safe to feed the individual baby this way.

Rationale 18: To comply with recommendations (DH 1994).

Rationale 19: To ensure nutritional adequacy.

Rationale 20: To introduce a wider range of nutrients and tastes to the diet (DH 1994).

Rationale 21: To comply with recommendations (DH

Rationale 22: Puree phase mixed with lump phase is not easy for babies to chew and swallow without choking.

Rationale 23: To assess whether there is any anatomical dysfunction that is interfering with feeding and accepting appropriate food textures.

Rationale 24: There is no provision for freshly cooked foods for weaning diets.

Rationale 25: To ensure that the correct foods are given.

Rationale 26: To ensure nutritional adequacy.

Rationale 27: The acidity and sugar content of juices can cause dental caries (DH 1994)

Rationale 28: To progress to feeding from a cup (DH 1994). 

Rationale 29: Developmental milestones may be delayed in sick children. They may gain comfort from sucking from a bottle.

Rationale 30: To help the baby learn to associate feeding with the sensation of touch in the mouth area.

Rationale 31: To associate mouth activity with feeling their hunger satisfied.

Rationale 32: To help the baby associate feeding times with social activity and comfort (Douglas 2002; Harris et al 2000; Southall and Schwartz 2000).

Rationale 33: To help the child associate feeding times with social activity and comfort (Douglas 2002; Harris et al 2000; Southall and Scwartz 2000).

Rationale 34: To reduce anxiety around feeding and mealtimes.

Rationale 35: To familiarise the child with flavours and textures and to ensure the correct foods are given.

Rationale 36: To introduce new food tastes when the child is likely to be most hungry and receptive to oral intake.

Rationale 37: To ensure nutritional adequacy is maintained.

References

Reference 1:
World Health Organisation (WHO) (2001)  Global Strategy for Infant and Young Child Feeding. http://www.who.int/nutrition/topics/global_strategy/en/index.html Viewed on: 9 January 2014. 

Reference 2:
Department of Health (2003) Infant Feeding Recommendation. www.greenwichbreastfeeding.com Viewed on: 9 January 2014.

Reference 3:
North J (Ed) (2004) Breastfeeding: A Practical Guide for Parents. London, Dorling Kingsley

Reference 4:
NHS Estates (2003) Better Hospital Food: Catering Services for Children and Young Adults. London, NHS Estates.

Reference 5:
Department of Health (1994) Report on Health and Social Subjects No 45. Weaning and the Weaning Diet. London, HMSO.

Reference 6:
Douglas J (2002) Psychological Treatment of Food Refusal in Young Children. Child and Adolescent Mental Health No 4 Vol 7: 340-348.

Reference 7:
Harris G et al (2000) Food Refusal Associated with Illness. Child Psychology & Psychiatry Review No 4 Vol 5: 148-156.

Reference 8:
Southall A, Schwartz A (Eds) (2000) Feeding Problems in Children a practical guide. Oxford, Radcliffe Medical Press.

Document control information

Lead author(s)
Vanessa Shaw, Head of Dietetics, Dietetics

Additional authors
Úna McCrann, CNS to Specialist Feeding Disorder Practicioner

Document owner
Vanessa Shaw, Head of Dietetics, Dietetics

Approved by
Guideline Approval Group

First introduced: 26 July 2007
Date approved:
28 April 2014
Review schedule: Three years
Next review:
28 April 2017
Document version: 1.2
Replaces version:
1.1