Download guidelines for promoting age appropriate introduction to solid food

GUIDELINES FOR PROMOTING AGE APPROPRIATE
INTRODUCTION TO SOLID FOOD FOR BABIES
UP TO 12 MONTHS
Version:
Final
Ratified by (name of Committee):
Provider
Quality
Committee
Date ratified:
Date issued:
Expiry date:
(Document is not valid after this date)
Review date:
Lead Executive/Director:
Name of originator/author:
Target audience:
and
Safety
31 May 2011
June 2011
June 2014
September 2013
Vicky Preece, Associate Director of
Nursing and Therapies and Lead
Executive Nurse
Tina McKenzie, Health Improvement
Coordinator, Children & Young People
Julia Greer, Health Visitor
Health Visitors, Nursery Nurses &
Children’s Centre Staff.
All staff must ensure that no one in the organisation discriminates (directly or indirectly) or
victimises another person or patients on the grounds of sex, age, disability (including
reasons of a person’s association with disabled people), race or ethnicity, religion or
belief, gender, including transgender men and women, sexual orientation, marital status
or any other unjustifiable condition or requirement
If you would like this information in other languages or formats (i.e. large
print) please contact the Communications Team on 01905 760020 or email
communications@worcestershire.nhs.uk
CONTRIBUTION LIST
Key individuals involved in developing the document
Name
Sally Grainger
Isobel McDougall
Anthea Griffiths & Penny Turton
Worcestershire Infant Feeding Group
Emma Raine
Designation
Health Visitor
Health Visitor
Breast Feeding Coordinators
NCT & service user
Circulated to the following individuals for comments
Name
Helena Wood
Dr Andrew Short
Cath Ellicott
Liz Altay
Worcestershire Infant Feeding Group
Lesley Way
Sue Lunec
Helena Wood
Su Cuerden
Marie McCurry
Designation
Clinical Lead Health Visiting
Paediatrician
Children’s Centre Operational Manager
Consultant Public Health
Patient Safety Manager, Provider Services
Head of Medicines Management, Provider
Services
Professional Practice Facilitator, Health Visiting
Clinical Manager, Childrens Services
Associate Director, Childrens Services
These guidelines were approved by the Clinical Policies and Guidelines Group on
11 May 2011.
Introduction to Solids in Babies
Page 2 of 14
CONTENTS
1.
Introduction
Page 4
2.
Introducing Solids to a Premature Baby
Page 5
3.
When to Introduce Solids
Page 5
4.
How to Start
Page 6
5.
Vitamins
Page 8
6.
Solid Foods and Milk
Page 8
7.
Water and Other Drinks
Page 9
8.
5 A Day and Portion Size
Page 9
9.
Suitable Cups
Page 10
10.
Special Considerations
Page 10
11.
Food Additives
Page 12
12.
Constipation
Page 12
13.
Monitoring of Implementation of this Guideline
Page 13
14.
Dissemination and Archiving of the Guideline
Page 13
References
Page 14
Equality Impact Assessment
Page 15
Introduction to Solids in Babies
Page 3 of 14
(Taken from Worcestershire Maternal & Infant Feeding Strategy)
This guidance is intended for use by Health Care Professionals and Children’s
Centre Staff.
1. Introduction
Promoting Age Appropriate Introduction to Solids
The introduction of solid food, or weaning, means moving a baby gradually on
to healthy family foods. It is recommended that the optimum age for this is
around six months (DH 2007 & Food Standards Agency 2008). At this age
babies are developmentally ready to eat solids as they can now sit up, reach
and grab, put food to mouth, move food around their mouths and chew.
Government policy in the UK has consistently supported breastfeeding as
important in the promotion of maternal and infant health. Early in 2000, the
World Health Organisation (WHO) commissioned a systematic review of the
published scientific literature on the optimal duration of exclusive
breastfeeding and, as a result, revised its guidance in 2001 to recommend
exclusive breastfeeding for the first six months of an infant’s life. In 2001, the
UK Scientific Advisory Committee on Nutrition (SACN) considered this revised
recommendation and concluded that there was sufficient evidence at the
population level to advise that exclusive breastfeeding for six months is
nutritionally adequate. From 2003 onwards, UK Health Departments adopted
this revised guidance and therefore now recommend introduction of foods at
around six months of age. The WHO review assessed the effects of exclusive
breastfeeding for six months on child health, growth and development, and
maternal health, compared with exclusive breastfeeding for three/four months.
The conclusions were that there were no benefits of introducing solid food
between four and six months, and no deficits in growth in infants who were
exclusively breastfed for six months. Further details about the change in
recommendation can be found at the following link:
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPol
icyAndGuidance/DH_4097197 (DH 2010)
Introducing solids can begin with finger foods (for babies who are
developmentally ready), thus promoting baby to have control of their own
feeding. Breastfeeding would have been the ideal preparation for baby to
self-feed solids as they are able to feed at their own pace/regulate their own
appetite and balance their own intake of food and fluid by choosing how long
the feed should last (Rapley, 2008).
Solids should not be given before the baby is 17 weeks old (FSA 2010).
Giving solids to very young babies can increase the risk of allergy and
infections. This is because a baby’s immune system is too immature to cope
with foods that cause allergies or foods that contain harmful bacteria (FSA
2010). If solids are introduced before six months – gluten containing foods,
Introduction to Solids in Babies
Page 4 of 14
eggs, fish and shellfish, citrus fruit juices, nuts and seeds need to be
AVOIDED.
There is also increasing evidence that introducing solids earlier than the
current recommendations of six months can lead to rapid weight gain in
infancy which may in turn increase the risk of childhood obesity (Nat Obesity
Forum 2009, Child Growth Foundation 2010).
Start 4 Life resources available for staff, parents and carers can be accessed
on www.start4life.co.uk . Key messages are based on the most recent infant
health research.
2. Introducing Solids to a Premature Baby
It is recommended that this would be between five and seven months from
birth date, not the baby’s ‘corrected age’. Very occasionally a premature baby
may benefit from early introduction to solids but this would be under the
guidance of a Paediatrician. Signs that they are ready to wean would be the
same as below (Bliss 2009).
3. When to Introduce Solids
At around six months, babies are ready to move onto a mixed diet.
could be offered to babies when:
1.
2.
3.
4.
5.
Foods
Baby is developmentally ready (as below).
When baby can chew and digest solid foods (as below).
When there are no health disadvantages from introducing solid foods.
When there are no nutritional disadvantages.
When breast milk (&/or formula) alone are no longer nutritionally sufficient.
(Williams 2010)
1. Developmental readiness - Oral anatomy is developed:
• sucking pads and fatty tissue in cheeks are reduced for easier movement
and swallowing of food
• Lower jaw forward and larger
• Gag reflex moves to back of tongue around six months
• Teeth may be emerging
Oral ability:
•
•
up and down tongue movement - nine months
lip closure during swallowing – 12 months
Fine & Gross motor skills:
•
•
Can sit unsupported and no evidence of head lag
Co-ordinate eyes, hands and mouth and grasp food.
Introduction to Solids in Babies
Page 5 of 14
2. Ability to digest and tolerate solid foods:
Young babies have immature immune and digestive systems and immature
capacity for excreting solutes. There is a need to avoid putting unnecessary
stress on baby’s kidney (renal solute load). They are particularly vulnerable if
ill or weak. Breastfeeding will help digestion of solids (lipase – fat digesting
enzyme in breast milk).
3. Health cost of introducing other foods/drinks to breastfed baby too
soon:
• Unnecessary exposure to potential pathogens and allergens through
foods.
• Increased risk of severity of respiratory, ear and other infections.
• Increased risk of atopy in atopic families
• Increased risk of becoming obese
(Williams 2010)
4.
•
•
•
•
Nutritional disadvantages from giving other foods/drinks too soon:
Foods may reduce the bio-availability of nutrients from breast milk.
Displacement of breast milk/infant formula
Small stomachs full of food, so take less milk
Overall nutrient intake is lowered because the foods usually given are less
nutritious than breast milk/infant formula.
(Williams 2010)
Some babies around three to five months may begin to wake at night. It does
not necessarily mean that they are hungry and starting solids will not make a
baby more likely to sleep through the night again.
4. How to Start
All babies are different and some are not in a rush to start solids. Babies will
be finding out about different tastes and textures so patience is needed to let
babies explore by touching the food.
To start, babies should be encouraged to feed themselves with finger foods
such as a cooked piece of carrot or soft banana, alternatively, a small amount
of food could be offered from a spoon.
Babies should be given a wide range of textures and tastes. Some babies
need up to 10 exposures to a food before they will accept it. (DH 2007).
Babies do not have to progress through purees but if this is the preferred
option then, a little of baby’s usual milk (breast or formula) can be used to mix
the food to a desired consistency if required. Cow’s milk can also be added
to food after six months of age.
First foods to try:
•
Piece of soft fruit or vegetables small enough for baby to pick
up
Introduction to Solids in Babies
Page 6 of 14
•
Vegetables such as parsnip, potato, yam, sweet potato or
carrot
•
Banana, avocado, cooked apple or pear
•
Cereals such as baby rice mixed with milk
Family foods should be promoted as soon as possible, without the addition of
any salt or sugar. It is best to give babies home cooked food, as this develops
good eating behaviours.
Babies can choke on foods, so care should be taken with hard foods
such as raw carrot sticks, pieces of apple or small round foods like
grapes and cherry tomatoes. Also, care should be taken with foods
with skin on and bones.
Food should be cut into small pieces, skin and bones removed, hard
foods such as carrot and apple should be part boiled before giving to
young babies.
4.1 How to start solids and protect continued breastfeeding.
The prime aim is to give “nutrient-dense” foods NOT “calorie dense” foods.
Use solids to complement not displace breast milk. On-demand breastfeeding
should continue.
4.2 More foods to try
Once babies are used to eating fruit and vegetables, other foods can be
added, such as:
Meat, fish and chicken
Rice, noodles or pasta
Lentils (dhal) or pulses
Full fat dairy products, such as yoghurt, fromage frais or custard choose lower sugar varieties
Finger foods such as pieces of fruit, vegetables such as cooled green
beans, carrot sticks, cubes of cheese, pitta bread, chapatti or toast
Sweet biscuits and rusks should be avoided as these types of food
encourage a sweet tooth.
Encourage good eating habits straight away by recommending
having mealtimes together as a family.
Introduction to Solids in Babies
Page 7 of 14
4.3 Eating more – Eating Regularly
From about nine months babies should be offered:
• 3-4 servings of starchy food each day, such as potato, bread and rice.
• 3-4 servings of fruit and vegetables. Vitamin C in fruit and vegetables helps
to absorb iron, so fruit and vegetables should be given at mealtimes.
• 2 servings of meat, fish, eggs, dhal or other pulses.
Babies should experience many different tastes and textures before they are
12 months to promote a varied diet as they move into their second year.
5. Vitamins
It is recommended that all children are given vitamin drops with vitamins A, C,
D from the age of one year to five years old. Breastfed babies and babies
drinking less than 500ml of infant formula milk per day should begin vitamin
drops at six months of age or earlier if indicated. All pregnant and
breastfeeding women should also be encouraged to take C, D and Folic Acid
supplements.
For
further
information
regarding
vitamins
visit
www.healthystart.nhs.uk
6. Solid foods and milk
Once baby is eating more solid foods the amount of milk he/she wants will
start to reduce. A breastfed baby may drop a feed but breastfeeding will
continue to benefit both mother and baby for as long as they carry on (DH
2007). If the baby is being formula fed, they should continue to have around a
pint (500-600ml) of infant formula until they are 12 months old.
Foods to avoid up to one year old
SALT - babies under one year should have less than 1g of salt per
day, which is less than 0.4g sodium (look out for “hidden salts”)
SUGAR - sugary foods and drinks can lead to tooth decay. 23%of
Worcestershire children have evidence of tooth decay at age five (NHS
Dental Epidemiology programme for England” 2007/2008 data).
HONEY - Very occasionally honey can contain harmful bacteria that
can cause botulism. Botulism is caused by a bacteria that normally lives
in a dormant form in soil and dust and occasionally gets into honey. (FSA
2010).
NUTS – Whole nuts should be avoided, including peanuts, to children
under five as they could cause choking. There are also concerns
around nut allergy in families where there is a history of atopic
disease. Finely ground nuts can be given from 6 months if there are no
concerns around nut allergy (BDA 2007, FSA, 2009). For further guidance
www. Food.gov.uk/safereating/allergyintol/peanuts/pregnancy
LOW FAT, LOW CALORIE AND HIGH FIBRE FOODS are not advisable
foods for babies.
Introduction to Solids in Babies
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FISH – parents should avoid giving shark, swordfish or marlin as they
may contain unsuitable levels of mercury for babies which may affect
a developing nervous system. Raw shellfish should also be avoided
as there is an increased risk of food poisoning. For information on
recommended portions for age of child visit www.eatwell.gov.uk
EGGS - raw or lightly cooked eggs should not be given to babies.
Eggs can be given to babies over six months as long as they are cooked
until the white and the yolks are solid.
7. Water and other drinks
There is no need to give formula fed babies anything other than milk or water
to drink.
Breastfed babies do not need any other drinks even on the hottest of days.
Bottle fed babies may need some extra water, especially if the weather is hot.
Offer small sips of water in a cup with meals. For babies under six months
this needs to be cooled previously boiled water. For babies over six months
the water does not need to be boiled.
Breast milk is the best drink for babies up to one year and beyond.
Alternatively babies that are on formula milk can be introduced to full fat cow’s
milk as a drink once they are 12 months old and can be used in food from 6
months. It should not be given as a main drink before this age as it is not
nutritionally suitable (it does not contain enough iron and other nutrients
needed for growth and development).
Bottled water is not a healthier choice than tap water. Many natural mineral
waters are not suitable for babies as they are too high in minerals. The
sodium content should not be higher than 200 milligrams per litre.
Again, if the baby is under six months, the water will need to be boiled and
then cooled. If formula feeds are made up with bottled water then the water
will also need to be boiled.
Fruit juices are a good source of vitamin C but they also contain natural
sugars and are acidic which means they can cause tooth decay. There is no
need to give a baby fruit juice, but if parents do decide to give juices then it
needs to be diluted to one part juice, ten parts water and only offered at
mealtimes (FSA 2008) www.eatwell.gov.uk
8. 5 a day and portion size
For guidance around 5 a day and portion size, see www.5aday.nhs.uk
Introduction to Solids in Babies
Page 9 of 14
9. Suitable Cups
For babies that are bottle feeding, comfort sucking on bottles can become a
habit. Therefore, introduction of a cup/spouted cup at six months is
recommended with an aim to discontinue using a bottle by the baby’s first
birthday.
An open cup or a free flowing cup without a valve is recommended as
this will allow the baby to sip rather than suck which is better for their teeth.
10. Special Considerations
Vegetarian Diet
Children can grow and develop normally on a vegetarian diet or vegan diet,
although careful consideration needs to be given to ensure that nutritional
needs are met. Vegetarian and vegan diets can be high in fibre, and this can
lead to lower energy (calorie) intake, and reduced absorption of some
important minerals, such as iron and zinc (British Dietetic Association 2010).
All children between six months and five years old could benefit from taking
vitamin drops containing A, C and D (or earlier if indicated) but vegan children
additionally need vitamin B12. Vegan babies also need to eat good sources of
calcium, iron, vitamin D and protein (Vegetarian Society, 2010). Further
advice can be given by a Paediatric Dietician.
Nutrient
Vegan Sources
Additional non-vegan
sources
Calcium
* Soya products. Vegetable
sources e.g. tofu, bread, green
vegetables and beans
Breast milk. Dairy
products. Fish with
small bones that can be
mashed – e.g. tinned
salmon or sardines, if
fish is eaten
Protein
* Soya products, pulses,
hummus, tahini, textured
vegetable protein, e.g. tofu
Breast milk. Cows milk
and infant formula,
dairy products including
vegetarian cheese
**Quorn
Energy
(babies between
6 and 12 months
require 700 to
1000 kcals a
day
Vegetable oils and vegetable
ghee. *Soya margarines and
other milk free margarines.
Soya milk and products, seeds,
beans and pulses
Breast milk. Dairy
products.
Introduction to Solids in Babies
Food in general.
Page 10 of 14
Iron
Beans, pulses, dried fruit,
green vegetables, wholemeal
bread, wholegrain cereals,
fortified breakfast cereal
Eggs
Vitamin B12
Fortified foods, e.g. fortified
yeast extracts, LOW SALT
(Marmite).
Additional B12 supplements
may be required
Dairy products
Vitamin D
Exposure to sunlight is the
most important source
Fortified *soya milk and
products
Fortified cereals
Vitamin drops
Other fortified
margarines
Eggs
Oily fish
Riboflavin
Fortified cereals, ground
almonds (after 12 months)
green leafy vegetables, yeast
extracts, LOW SALT
Dairy products
(main source)
(Infant Feeding Guidelines, Dudley NHS Trust)
*Soya/gluten based products and ** Quorn – Textured vegetable protein and
similar products may be difficult for young babies to digest, and some
products can be relatively high in salt, but small amounts can be introduced
from nine months. Quorn products should not be relied on as the sole or
major source of protein since they are relatively low in calories and high in
fibre so may satisfy the child’s appetite before they have taken in enough
energy. (Vegetarian Society 2010, British Dietetic Society 2010).
*Soya formula is made from soya beans not cow’s milk. Soya–based infant
formulas have a high phytoestrogen content and it has been known for some
time that this may pose a long–term reproductive health risk (Committee on
Toxicity 2003). The Chief Medical Officer has advised (since 2004) that
soya–based infant formulas should not be used as the first choice for the
management of infants with proven cow’s milk sensitivity, lactose
intolerance, galactokinase deficiency and galactosaemia (BNF 2009). As
well as the risks to reproductive health, there have also been concerns that
exposure to soya proteins can adversely affect babies with hypothyroidism
and provoke allergy. (Sampson 1988; Businco et al 1992). In addition, up to
60 per cent of infants with cows milk protein–induced enterocolitis will be
Introduction to Solids in Babies
Page 11 of 14
equally sensitive to soy protein (Eastham 1989; Burks et al 1994; Whitington
and Gibson 1997). Much of this information is reflected in the advice
available to the general public on the Food Standards Agency website
(www.food.gov.uk). Taken from The Health Professional’s Guide to: “A
guide to infant formula for parents who are bottle feeding” Unicef UK 2010
www.babyfriendly.org.uk
Cow’s milk Intolerance.
Guidance currently being produced by Worcestershire Infant Feeding
group.
11. Food additives
Research funded by the Foods Standard Agency suggested that consumption
of mixes of certain artificial food colours and the preservative sodium
benzoate could be linked to increased hyperactivity in some children. It is
important to remember, however, that hyperactivity may have other causes.
For children experiencing signs of hyperactivity it may help to avoid the
following artificial colours:
Sunset yellow FCF (E110)
Quinoline yellow (E104)
Carmoisine (E122)
Allura Red (E129)
Tartrazine (E102)
Ponceau 4R (E124)
(For more information www.food.gov.uk)
12. Constipation
Constipation is defined in a number of ways:
Opening the bowels less than three times a week
Needing to strain to open your bowels on more than a quarter of occasions or
passing a hard or pellet-like stool on more than a quarter of occasions.
(NHS Choices 2010)
Constipation in babies and children is quite common, with about one in three
British parents reporting constipation at some time in their child’s life. Poor
diet, fear about using the toilet and poor toilet training can all be responsible.
Poor diet - children who are over-fed are more likely to have constipation, as
are those who do not get enough fluids. Babies who have too much milk are
also more likely to get constipation. As with adults, it is very important to
include enough fibre in their diet, ideally from fruit and vegetables.
Introduction to Solids in Babies
Page 12 of 14
12.1 Constipated babies who have not yet started solid food
Breast fed babies are unlikely to suffer with constipation. If using formula
feeds, make sure formula is made up to the manufacturer’s instructions (extra
scoops of powder or extra water should not be added). The feed should not
be diluted. It may help to change the brand of formula milk. There is no
physiological or research basis for offering water to an already well-hydrated
baby in order to produce softer or more frequent stools (Young, 1998).
Offering water to a neonate may affect their nutritional intake. Gently
massaging the abdomen in a clock-wise direction or cycling the legs in a
cycling motion may help stimulate the bowel.
12.2 Constipated babies who are eating solids
Should be offered plenty of water or diluted fruit juice or extra feeds if
breastfeeding. Encourage fruit, chopped, pureed, finger foods, depending on
their ability to chew. Offer fruits or juices that are high in sorbitol as these
can decrease constipation (prune, pear or apple) once babies have
started solids only.
The best fruits for babies to eat to treat constipation are:
Apples, Apricots, Grapes, Peaches, Pears, Plums, Prunes, Raspberries &
Strawberries.
If, after a change of diet, the baby or child is still constipated then they the
parents/carers will need to consult their GP.
(NHS Choices 2010)
13. Monitoring of Implementation of this Guideline
As these guidelines are meant as an information guide for Health Visitors and
others they will not be subject to clinical audit. Health Visitors will however be
expected to demonstrate a good working knowledge of the content of these
guidelines through supervision and annual appraisal.
14. Dissemination and Archiving of the Guidelines
The dissemination of this guideline is primarily via the internet and through
Team Brief. Once this guideline is reviewed and replaced the archiving
arrangements for it will follow the process set out in the WPCT Archiving
Policy.
Staff are strongly discouraged from printing off or photocopying this policy and
should understand that the internet version of the policy is the definitive
version.
Introduction to Solids in Babies
Page 13 of 14
References
Bliss (2009) www.bliss.org.uk
BDA (2007) British Dietetic Association Weaning Your Child .www.bda.uk.com
Child Growth Foundation (2010) An approach to Primary Prevention of Obesity in
children and adolescents.www.childgrowthhfoundation.org./accessed 11.1.11.
DH (2007/08) NHS Dental Epidemiology programme for England” 2007/2008
data. http://www.bascd.org/annual_survey_results.php
DH (2010) Start 4 Life. www.nhs.uk/start4life/documents
DH (2007) Weaning: Starting Solid Food . www.dh.gov.uk
Dudley Priority Health NHS Trust. Infant Feeding Guidelines
Food Standards Agency (2009) Weaning Your Baby. www.eatwell.gov.uk/
Food Standards Agency (2009)
www. Food.gov.uk/safereating/allergyintol/peanuts/pregnancy
National Obesity Forum (2009) www.National Obesity Forum.org.uk
NHS Choices (2010) Constipation. www.nhs.uk/cpnditions/constipation. accessed
11.1.11.
Rapley G.,(2009) Guidelines for Implementing a Baby-Led Approach to the
Introduction of Solid Food.
Scientific Advisory Committee on Nutrition (2001) www.sacn.gov.uk/
Start 4 Life (2010) www.nhs.uk/start4life
Southwark & Lambert PCT (2007) Nutrition in the Under 5’s Guidelines
Unicef UK (2010) The Health Professionals Guide to: ”A guide to infant formula for
parents who are bottle feeding” www.babyfriendly.org.uk
Vegetarian Society of the United Kingdom (2009) www.vegsoc.org.
WHO(2001) cited in DH (2010)
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicy
AndGuidance/DH_4097197
Williams C., (2010) Starting Solids: Where are we at? Where do we need to be?
Abstract. West Midlands Regional Start4Life Training. Feb 2010.
Young (1998) as cited in Unicef UK (2010) The Health Professional’s Guide to “A
Guide to Infant Formula For Parents who are Bottle Feeding.
Introduction to Solids in Babies
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