Weaning babies born prematurely

This leaflet is a guide to weaning your baby onto solids if they were born prematurely.

Weaning is the term used to describe how babies move away from milk and onto solid foods, this can also be referred to as 'complementary feeding' or 'introducing complementary foods'. Babies born prematurely may develop differently, making it harder to know when and how to wean your baby. The information below can support you with weaning your baby and aims to simplify the process.

Please read through this information to familiarise yourself with the different stages before you start to wean your baby. If you have questions, please contact your health visitor or dietitian.

When to start weaning

It is important to introduce solids once your baby is developmentally ready and showing appropriate weaning cues. This is usually around four to six months corrected age ('corrected age' refers to how old your baby would be if they were born on their due date). At this age, milk alone will not meet the nutritional requirements that your baby needs to grow and stay healthy. Extreme and very premature babies may need to start later. If unsure when to start, you can ask your dietitian for support.

Your baby may be ready to be offered weaning foods when they are showing three to four of the following cues:

• can sit up with little or no support
• can hold their head up easily and keep it upright while sitting
• placing their fingers, hands or objects in their mouth
• showing increased interest when other people are eating or when they are offered food
• can reach and hold food or open their mouth to accept food when it is offered
• biting and mouthing on toys

If your baby is not showing most of these signs by around six months corrected age, contact your health visitor, dietitian or speech and language therapist for advice and support.

Babies are more willing to accept new foods from around six to 10 months corrected age. This period is also critical for developing their oral feeding skills. Delaying the introduction of solids, unless clinically advised, can make it much harder for your child to accept new foods and textures going forward.

How to start weaning

Choose a time of day when your baby is alert, happy and not too hungry. It is important to allow plenty of time so you and your baby do not feel rushed. Either mid-morning or mid-afternoon after a nap is often a good time to start.

When you start weaning, it is important to avoid distractions such as television and electronic screens. This will help you and your baby focus on learning about foods and eating.

Exploring food is an important part of weaning. Babies learn through touch, taste and smell. As weaning progresses it is helpful for your baby to use their hands to explore and play with different foods. This can be messy, so you may want to place a plastic sheet, shower curtain or old towel on the floor under your baby’s highchair or supported seating. If the weather is warm enough, you could do this outside.

It is important to wait until the end of the mealtime before wiping your baby’s hands and face, to avoid disruptions to the meal.

Babies also learn by watching, so we advise eating foods and meals together where possible.

Always supervise your baby while they eat to ensure they are safe and happy.

Seating

Preterm babies require additional seating support when they start to wean. This is because they are often smaller in size, and it can take slightly longer to develop enough core strength to maintain an upright seated position when compared to term babies.

You may want to start weaning in a bouncer chair. It is important that your baby is kept upright and that they are not leaning too far back or to one side. It can be helpful to use a rolled-up towel and position this around their head to keep their head in a supported upright position. More specialist seats such as a Tumble Form chair can provide good support for early weaning. If babies lack stable support, they may struggle to develop oral skills and effective chewing. Keeping your baby upright also makes eating safer and reduces the risks of choking.

Once your baby grows bigger, they can move to a supportive, comfortable and adjustable highchair. They may still need a rolled up towel for additional support when they first progress into a highchair. Highchairs that have an adjustable footrest offer the best support as your baby grows.

First foods

Preterm babies are typically better suited to traditional spoon-led weaning with smooth purees to begin with. More recently, Bliss has recommended that once developmentally ready (for example, your baby can sit upright and bring objects to their mouth), soft finger foods can be introduced to encourage baby-led weaning. This will allow your baby to learn how different textures feel before putting them in their mouth and encourage self-feeding going forward.

Try offering home-cooked foods (with no added salt or sugar) where possible as this will help your baby transition onto family meals when they are older. Home cooked meals can also be easier to modify, therefore supporting the gradual transition from smooth purees to more textured and lumpy foods.

To encourage diet variety and food acceptance, it is important to offer your baby foods with different flavours and colours regularly. Babies sometimes grimace in response to a new flavour. This is probably a sensory response as it is a new experience rather than your baby not liking the food.

Commercial baby foods are convenient and appropriate to use if you prefer. However commercial baby foods are often poorly graded between stages and babies can find the texture transition with the lumpier consistencies more difficult to manage, resulting in gagging.

Examples of first foods to offer your baby

• Mashed or puréed soft-cooked starchy vegetables such as potato, sweet potato, yam or parsnip.
• Other soft-cooked vegetables such as carrot, butternut squash, cauliflower, broccoli.
• Mashed banana or avocado (mash with baby’s milk if a thinner consistency is required).
• Smooth baby rice or porridge mixed with baby’s milk, with or without the addition of fruit purée.
• Well-cooked smooth or pureed meat and fish.
• Well-cooked egg mashed with baby’s milk.
• Soft cooked mashed beans and lentils such as chickpeas, kidney beans, butter beans (avoid tinned baked beans as these can contain added salt and sugar).
• Mashed or puréed soft-cooked fruit such as apple, pear and peach (remove all skins and pips).

Introducing textures and lumps

Once your baby is comfortably swallowing and regularly eating two meals per day (around six to eight baby spoons of food per meal), it is important to start introducing more texture and lumps.

You can start by making homemade purées thicker by adding less liquid, or by adding in extra baby rice to purées. Once your baby can manage thicker purées you can introduce foods that can be well-mashed with a fork such as banana, avocado, soft-cooked sweet potato (remove skins), egg, stewed apple with soft lumps.

If using commercial baby foods, and your baby is finding it difficult to transition from stage 1 (four to six months) to stage 2 (seven months) jars or pouches, you can make the transition easier by mashing down the bigger lumps with a fork. Commercial stage 2 baby foods are a mixture of thin purées and thicker lumps which require good oral skills to be able to control. This can initially be harder to manage for babies who are born premature.

Finger foods

These foods support self-feeding, hand-to-mouth co-ordination, encourage the development of chewing skills. It will also allow your baby to explore how much or how little they would like to eat.

Finger foods can be offered once your baby is developmentally ready. You can offer these foods once your baby is progressing with their sitting and regularly mouthing on their hands and hand-held toys. If you are unsure if your baby is ready to start eating finger foods, you can ask your dietitian or health visitor for support.

Examples of finger foods to offer your baby

• It can be beneficial to offer bite and dissolve finger foods to start with, such as melty puffs and veg straws. These soften with saliva as your baby develops their early chewing. Once your baby is managing these early finger foods, then gradually progress to soft chewable foods.
• Ripe and peeled soft fruit such as banana, peach, raspberries, avocado.
• Soft-cooked vegetables including carrot, courgette, parsnip, sweet potato, butternut squash (hint – if you use a crinkle cutter it can be easier for them to grip and pick up).
• Well-cooked shredded meat, flaked fish, slices of omelette, eggy bread or scrambled egg.
• Thinly sliced or grated cheese.
• Toast fingers with butter, nut butter, hummus, cream cheese or smashed avocado.
• Well-cooked pasta shapes.

Foods to avoid

• Honey: may contain bacteria which can lead to a serious illness called infant botulism. Can be offered from 12 months of age.
• Whole nuts: are a choking hazard, so avoid offering to children under five years of age. Nut butters and ground nuts can be given to babies from six months of age.
• Mould ripened cheese: can increase the risk of food poisoning from Listeria bacteria. Heat destroys Listeria, so these types of cheeses can be given if well-cooked. Full-fat pasteurised cheeses can be given to all babies from six months of age.
• Low-fat foods: should not be given to children under two years of age. Fat is an excellent fuel source and is essential to meet the high requirements of growing babies and toddlers.
• Tea: should not be given to babies or toddlers as it contains tannins which interfere with iron absorption.

It is important to introduce all major allergens into your baby’s diet from six months. Major allergens include cow’s milk, eggs, gluten-containing foods (wheat, rye and barley), nuts and peanuts (offer ground or as nut butter), seeds (offer ground or smoothed ie tahini), soya and cooked fish and shellfish. Research has shown that delaying the introduction of allergens beyond six to 12 months of age can increase the risk of developing an allergy to these foods.

If your baby has a suspected or confirmed allergy, please consult your dietitian for further advice on what needs to be avoided within their diet.

Gagging and choking

Babies often gag and spit out their food when they are learning to eat unfamiliar textures. This is because their chewing is still developing and partially chewed food may tip to the back of their tongue causing them to gag. Don’t panic, gagging is normal and is a protective mechanism to reduce food going down the wrong way.

If your baby gags, remain calm and reassure them while they learn how to manage lumpier textures. If they continue to gag repeatedly on certain textures and become upset, leave it a few days before trying again.

If your baby continues to gag or you are concerned about their swallow, you can discuss this with your health visitor or speech and language therapist.

Choking is rare but can happen when food gets stuck in your baby’s airway making it hard for them to breath. If this happens, try to remain calm and remember the strategies you were taught during basic life support training. If they continue to choke, call 999 for immediate help.

To reduce the risks of choking, avoid offering hard foods and ensure that small round foods are well squashed (such as peas, sweetcorn, blueberries).

Food refusal

At some stage, most babies and toddlers will refuse food. This can be due to being too tired, unwell, teething, new food, taste or texture, or wanting to be more independent with self-feeding.

Strategies to improve food-acceptance:

• Introduce strong flavours such as garlic, onion, herbs and spices during the early stages of weaning as this will make an easier transition onto family foods.
• Offer new foods when they are well-rested and happy, and start by offering only a small amount to begin with.
• If food is refused, take it away and avoid offering an alternative until their next meal or snack time. Try not to worry if they have not eaten much as they will likely eat more at their next meal or the following day.
• Once weaning is established, offer two courses per meal as this gives another opportunity for different tastes.
• Expose them to the same food several times over a few weeks. Repeated exposure will improve familiarity and food-acceptance.
• Eating together or eating the same foods can help encourage your baby to try these.
• Although it can be frustrating, offer lots of smiles and reassurance along the way.

Introducing a cup

A beaker or cup can be introduced from six months corrected age, once they are sitting or in a supported highchair. To make it easier for your baby to learn how to drink from a cup, try using a ‘free flowing’ beaker or cup. These allow water or milk to pour out freely if you turn them upside down. Cups and beakers with valves still require your baby to suck in a similar way to bottle feeding.

It is best to only offer your baby milk or water to drink. Avoid offering fruit juice, fizzy drinks or sugar-sweetened beverages as these are not nutritious and can affect your baby’s appetite for foods. Sugar is also cariogenic meaning that it can cause tooth decay.

Supplements: vitamins and iron

Babies who are breastfeeding should be given a daily vitamin D supplement containing 8.5 to 10μg of vitamin D from birth, even if mum is already taking a supplement herself.

Preterm babies born less than 37 weeks gestation should be given 0.6ml Abidec daily until six months corrected age. This is prescribed and issued by your GP.

Preterm babies born less than 37 weeks gestation should be given iron supplements until six months actual age. This is prescribed and issued by your GP. It is best to discuss dosage with your doctor or dietitian as this will vary depending on your baby’s birthweight and type of milk.

The Department of Health recommends that all children aged six months to five years are given a daily multivitamin supplement containing vitamins A, C and D. Make sure to choose a multivitamin containing at least 10μg of vitamin D. If you are not sure, just ask your pharmacist or dietitian. If you qualify for ‘Healthy Start’, you are entitled to free vitamins; this can be discussed with your health visitor.

Who can I contact for further information?

Your dietitian: …..…………………………………………………………………………………

Contact number: 01223 216655

MyChart

We would encourage you to sign up for MyChart. This is the electronic patient portal at Cambridge University Hospitals that enables patients to securely access parts of their health record held within the hospital’s electronic patient record system (Epic). It is available via your home computer or mobile device.