This article was first published in NHD Magazine in May 2018 under the title: “When and How to Start Complementary Feeding”.
Weaning, which is also referred to as complementary feeding, is “the process starting when breast milk alone is no longer sufficient to meet the nutritional requirements of infants, and therefore other foods and liquids are needed, along with breast milk”1. This occurs at a time of rapid growth and development, and is a learning process which involves exposure to new foods, tastes and feeding experiences. There is relatively limited evidence related to this, and a variety in complementary feeding practices between different countries2.
This article will examine the available evidence in relation to when and how to introduce complementary food in the context of UK guidelines.
When to Introduce First Foods:
Introducing complementary food too early poses the risk that the infant’s digestive system, immune system, kidneys and swallowing skills may not have developed enough to cope with solids3. But delaying weaning for too long may hinder the development of eating skills4, as well as potentially missing the ‘window of opportunity’ for introducing a variety of foods by 9 – 10 months5.
Encouraging a good variety of food within this ‘window of opportunity’ is thought to reduce the risk of fussy eating in later life5.
There can be confusion about when exactly to introduce complementary food; table one summarises the main points from guidelines related to this. The current UK guidelines promote waiting until six months to begin weaning, because “a succession of randomised trials have shown that giving complementary foods to breastfed infants before six months compromises breastmilk intake without increasing total energy intake or increasing weight gain and is associated with other negative health outcomes [including a higher incidence of gastrointestinal and respiratory infections]”6.
|UK Department of Health (1994)||No solids to be introduced before 4 months and to offer a mixed diet by 6 months.|
|WHO (2001)||Exclusive breastfeeding until six months of age, introduce complementary foods at six months while continuing to breastfeed.|
|UK Department of Health (2003)||Exclusive breastfeeding for the first six months of an infant’s life, introduce solids at six months (while continuing to breastfeed).|
|ESPGHAN (2017)||Complementary foods should not be introduced before 4
months, but should not be delayed beyond 6 months.
|SACN Draft Guideline (2017)||First complementary foods should be encouraged from around six months of age, no infant should begin complementary feeding prior to four months of age.|
Although it is agreed that it is important to wait until 6 months if using the baby-led weaning approach, there is some disagreement about waiting until 6 months if starting with introducing purees. For example, this doesn’t take into account individual circumstances and some babies may be ready for complementary food between 4-6 months (see table two below). Also, these guidelines are based on the benefits of exclusive breastfeeding, which may not apply to formula fed babies. ESPGHAN’s position paper on complementary feeding in 2017 also highlighted that “data suggests there may be some beneficial effect on iron stores of introducing complementary food alongside breast-feeding from 4 months, even in populations at low risk for iron deficiency”2.
In addition, there is research in relation to potential allergenic foods to consider. There appears to be an increased risk of allergy if solids are introduced before 3-4 months7, ESPGHAN (2017) highlight that “allergenic foods may be introduced when complementary feeding is commenced any time after 4 months. Infants at high risk of peanut allergy (those with severe eczema, egg allergy, or both) should have peanut introduced between 4 and 11 months” (ESPGHAN 2017)2. For example, a recent meta-analysis concluded that there was moderate-certainty evidence that introducing egg and peanut at 4 to 6 months was associated with reduced egg and peanut allergy respectively8. It is important to note that infants at high risk of egg or peanut allergy are advised to “seek medical advice before introducing these foods”2,7,9.
One of the most important things to consider about the timing of introducing complementary food is whether the individual infant seems ready for this.
Therefore, it is important to monitor for signs of readiness (as outlined in the table below).
|Signs of readiness:||Mistaken signs of readiness:|
How to Introduce First Foods:
The two main approaches to introducing complementary food are referred to as: ‘traditional weaning’ and ‘baby-led weaning’.
Traditional weaning involves introducing foods appropriate to baby’s age and development, starting with spoon feeding purees which can begin from 4-6 months if an infant is showing sufficient signs of readiness (although 6 months is the recommended age of introducing complementary foods in the UK)6.
6 months (or not before 4 months if parents choose to start earlier)
6 – 9 months
9 – 12+ months
**Adapted from Manual of Dietetic Practice 4th ed. “Section 3: Infants 0 – 1 Years”)10
Baby-led weaning is when the infant feeds themselves hand-held foods at family mealtimes instead of being spoon-fed by an adult; therefore it avoids the step of introducing puree foods. Advantages of this approach include that the infant has more control over what they are eating and it lends itself to a more responsive feeding style2. There are some suggestions that baby-led weaning may promote better eating patterns and reduced obesity risk later in life; but there currently isn’t enough evidence to support whether this is the case2. It has been highlighted that there isn’t enough evidence whether infants can consume a nutritionally adequate diet using this method (especially in terms of energy and iron)11. However, an approach called ‘Baby Led Introduction to SolidS’ has been developed which provides guidance on avoiding choking hazards as well as encouraging iron and energy-rich complementary foods12-13.
There isn’t currently enough evidence to make a judgment on whether baby-led or traditional weaning is more beneficial as only one randomised controlled trial (RCT) has compared both methods6. This RCT showed that by 1 year of age there was no difference in the iron intake or overall nutritional quality of the diets of babies who had received traditional weaning, compared to those who were weaned using a modified BLW approach (which involved educating parents about including iron rich foods and high energy foods at each meal)13. However this study didn’t look at the impact of a non-modified BLW approach.
In practice, it is best for families to weigh up the pros and cons of each method individually.
Regardless of whether traditional or baby-led weaning is used, there appears to be benefits of a ‘responsive’ feeding style which is a warm and supportive approach which avoids being too controlling or restrictive of intake2,14.
Tips for Responsive Feeding (adapted from: Feeding Guidelines for Infants and Young Toddlers: A Responsive Parenting Approach15):
- Respond promptly and predictably to signs of hunger and fullness
- Warm and nurturing feeding environment
- ‘Parent provide, child decide’ approach
- Avoid feeding to comfort or as a reward
- Never force the infant to eat
- Allow enough time to feed at the infant’s pace
- Establish good feeding routines
- Encourage self-feeding and messy play
- Model good eating habits and eat together
There is ongoing research in relation to when and how to introduce complementary feeding. Current UK guidelines recommend starting at around 6 months, and not before 4 months of age. In terms of how to start, there is not enough evidence to suggest that traditional or baby-led weaning is more beneficial; however a responsive feeding style seems to be positive in both contexts. It will be interesting to see the finalised version of the SACN report “Feeding in the First Year of Life” when it is released.
- WHO “Appropriate complementary feeding” [accessed February 2018 via: http://www.who.int/elena/titles/complementary_feeding/en/]
- ESPGHAN (2017) “Complementary Feeding: A Position Paper by ESPGHAN Committee on Nutrition”
- HSE (2006) “Training Programme for Public Health Nurses and Doctors in Child Health Screening, Surveillance and Health Promotion – Unit 7: Food & Nutrition”
- Northstone et al. (2001) “The effect of age of introduction to lumpy solids on foods eaten and reported feeding difficulties at 6 and 15 months”
- Coulthard et al. (2009) “Delayed introduction of lumpy foods to children during the complementary feeding period affects child’s food acceptance and feeding at 7 years of age”
- SACN (2017) “Draft Feeding in the First Year of Life Report”
- Muraro et al. (2014) “Food Allergy and Anaphylaxis Guidelines Group. EAACI food allergy and anaphylaxis guidelines. Primary prevention of food allergy”
- Lerodiakonou (2016) “Timing of allergenic food introduction to the infant diet and risk of allergenic or auto-immune disease. A systematic review and meta-analysis”
- NIAID (2017) “Addendum Guidelines for the Prevention of Peanut Allergy in the US”
- Manual of Dietetic Practice 4th ed. “Section 3: Infants 0 – 1 Years”
- Cameron et al. (2012) “How feasible is baby-led weaning as an approach to infant feeding? A review of the evidence”
- Cameron et al. (2015) “Development and pilot testing of baby-led introduction to SolidS—a version of baby-led weaning modified to address concerns about iron deficiency, growth faltering and choking”
- Erickson et al. (2018) “Impact of a Modified Version of Baby-Led Weaning on Infant Food and Nutrient Intakes: The BLISS Randomized Controlled Trial”
- Blissett (2011) “Relationships between parenting style, feeding style and feeding practices and fruit and vegetable consumption in early childhood”
- Pérez-Escamilla et al. (2017) “Feeding Guidelines for Infants and Young Toddlers: A Responsive Parenting Approach”