The when, what and why of baby weaning

'Is this one of the worst wrong turns in the history of parenting advice?" was the rather dramatic introductory sentence in a New Scientist article last month about weaning babies.

It was referring to current public health advice to delay the introduction of solid foods until after six months, based on the World Health Organisation’s recommendation that babies should be exclusively breastfed until then. But now there are studies suggesting a shift towards later weaning may be a factor in the worldwide increase in food allergies (see panel).

However, the risk of allergies is only one consideration in trying to optimise the nutrition of infants during the first 12 months, when they triple their birth weight.

There is evidence that exposing them to a wide range of tastes at an early stage will lead to healthier eating later in life. And chronic illnesses of adulthood, such as heart disease and diabetes, may have their origins in this period of development.

No pressure then. But for parents desperate to do what’s best for their babies, seemingly contradictory advice can be unsettling.

Not much more than a decade ago, starting solids from four months was the general recommendation. Then many European countries, but not all, changed their health promotion policies to incorporate the WHO six-month milestone.

However, as the European Food Safety Authority pointed out in its 2009 scientific opinion on complementary feeding of infants, while member states differed in their recommendations, they all agreed babies should not be introduced to solids before four months or any later than six months.

Babies’ digestive systems are not ready to cope with anything other than breastmilk or formula before 17 weeks, and by 26 weeks their stores of iron from the womb have become depleted and need to be supplemented through food.

Cause of concern

So it was of some concern when the

Growing Up in Ireland

survey reported in 2012 that just under 10 per cent of Irish children were weaned onto solids by three months of age; 46 per cent by four months of age; and less than a third were weaned after six months, as per the WHO recommendation.

Other research highlighted the unsuitability of what was being given to some babies, such as chocolate, crisps and ice-cream, and the addition of salt, sugar, gravy and sauces to weaning food,

Clearly, the health message was either not getting through or being ignored in large numbers.

The policy now would be to recommend "around" six months, explains Dr Mary Flynn, chief specialist in Public Health Nutrition with the Food Safety Authority of Ireland (FSAI). But there is no point in saying it is not difficult to wait that long, "as the baby will have to be fed more often", she points out. "I would say hang on to as close as you can, making sure that the baby is still growing well."

However, if your baby is showing all the signs (see panel) of being ready by five months, “don’t be driving yourself demented” by waiting, she suggests. And if a health professional working with you says the baby needs it earlier, it’s important you go with that.

The FSAI published a Best Practice for Infant Feeding in Ireland guide for healthcare professionals in 2012. Noting that parents had indicated they wanted "more practical, food-based information to cover this important life stage", it set out to provide that in the 76-page booklet.

At stage one of weaning, gluten-free cereal, for example, baby rice, and pureed vegetables and fruit, followed by pureed meat and fish, are all recommended. If not started until six months, a baby is likely to move very quickly to the thicker purees and mashed food of stage two.

Stage three is usually between nine and 12 months and involves lumpy and chopped foods and harder finger food.

Throughout that first year, whether fed with breastmilk or formula, and then starting solids, the HSE recommends babies be given five micrograms of vitamin D3 daily. “We would suspect that babies could do with it longer than that,” says Flynn, adding that official current health policy will be reviewed but in the meantime parents can decide to continue after 12 months.

Dietitian Michelle Gray suggests that when starting solids, choose a time when both parent and baby are relaxed. Give a little of the breast or formula milk first, so they are not too hungry.

“If they are starving, they are likely to suck up the solid food really quickly and might start to gag, and that might put them off,” she says. “Start with one spoon and they may or may not take it – if they are looking distressed, just stop and give them the rest of the milk feed.”

Once they are taking five to six teaspoons at one feed, introduce a second feed in the day, building it up to three meals of five to 10 teaspoons a day in the first stage, says Gray, who works for the website first1000days.ie, launched in June 2013 byDanone Early Life Nutrition.

Food consistency

It’s very important that babies progress not only in the range but also in the consistency of food, says Gray.

“It’s a scary time for mums; there is that fear of the risk of choking,” she acknowledges. But gagging is normal and if you don’t introduce lumps by 10 months there is research to show that by aged seven, they are a lot fussier.

Equally don’t be put off by babies screwing up their faces when trying something – it doesn’t necessarily mean they hate it. Also, they may need to taste something more than a dozen times before liking it.

The first year of a baby's life throws up so many questions that parents often find conflicting information when they seek answers, agrees Alice Callahan, author of The Science of Mom: A research-based guide to your baby's first year, published in the US by Johns Hopkins University Press last August.

Based on studies she had read, Callahan was comfortable with letting both of her babies explore solids around four-and- a-half to five months of age.

"I knew that some data suggest that offering solids in that four to six-month window might decrease my kids' risk of food allergies. But this decision was also about following my babies' individual development," she tells The Irish Times.

“By this age, they were sitting up and showing an interest in food. However, neither of them actually wanted to eat more than little tastes until around five-and-a-half to six months.”

Evidence-based advice

She thinks the HSE and FSAI recommendations of starting solids around six months, but saying it is safe to do it between 17 and 26 weeks if there are individual signs of readiness, is “good, evidence-based advice”.

Callahan draws on her academic background, including a PhD in nutritional biology, to write a blog (scienceofmom.com) about how science informs parenthood, as she raises her two children, a daughter aged five and 10-month-old son, at home in Oregon.

“I encourage parents to start by looking for information from health professionals, government organisations and universities. They’ll usually do a great job of summarising the scientific consensus and steering you in the right direction.”

As new studies hit the headlines, Callahan cautions against putting too much stock in any one piece of research. It is important to recognise that science builds slowly, as studies accumulate and understanding improves.

But while you should be sceptical of new information and ensure that you’re looking at good sources, “remain open-minded”, she adds, and “always ready to learn more”.

When you understand why parenting advice changes, you’re in a better position to judge whether to take it or leave it.

swayman@irishtimes.com

Introduce common allergens into a baby's diet earlier rather than later Families without a history of allergies don't need to worry unduly when it comes to introducing the more common allergens such as eggs, fish, nuts (ground-up) and so on into a baby's diet. But it's sensible to start with one food at a time and watch for any adverse reaction over two to three days before introducing another.

Data from research is now indicating an early introduction of these foods rather than avoidance, explains Prof Jonathan Hourihane, paediatric allergy consultant and chairman of the Irish Food Allergy network.

In the wake of the Learning Early About Peanut (Leap) study, it is a matter of trying to change parents' mindset from "God I mustn't" to "Oh, I should," he says.

Consensus among allergy organisations on that study is that healthcare providers should recommend introducing peanut- containing products into the diet of "high-risk" infants early on in life (between four and 11 months), as delaying their introduction may be associated with an increased risk of developing peanut allergy.

If a baby has eczema, the risk of a food allergy is higher. Those with severe eczema – not just a baby rash, stresses Hourihane – may need to be tested before introducing the high-risk foods. Although, “that’s controversial and not universally agreed yet”, he adds.

Four per cent of Irish two-year-olds have food allergies and those for whom milk and eggs are allergens will mostly grow out of them by the age of five.

On the subject of introducing gluten (a protein found in wheat, rye barley and oats), Dr Mary Flynn of the Food Safety Authority of Ireland says this should be done between six and seven months to minimise hypersensitivity or intolerance. Start with a very small amount and gradually increase.

Research indicates that introducing gluten after seven months of age increases the risk of coeliac disease, type 1 diabetes mellitus and wheat allergy.

What they found in Scandinavia, Flynn explains, was that when the start of weaning was delayed until six months, babies were being given rice first, as usual, and not moving on to gluten until eight or nine months, and there was an increase in the numbers developing coeliac disease.

“If you breastfeed while you are weaning on to solid food,” Flynn adds, “that is the most protective thing against food allergy and intolerance.”

For more information see ifan.ie; fsai.ie and coeliac.ie