Issue 124 supplement complementary feeding by NH Publishing Ltd

PAEDIATRIC SUPPLEMENT

COMPLEMENTARY FEEDING: THE EVIDENCEBASED GUIDE TO WHAT, WHEN AND HOW Kate Roberts Freelance Dietitian, Kate Roberts Nutrition

Kate is a Freelance Dietitian with a wide range of clinical experience of working with adults and children having previously working in the NHS. Her specialities are Diabetes and Allergies.

In 2002, the World Health Organisation (WHO)1 recommended that mothers should breastfeed exclusively until six months and then begin complementary feeding. This is what the majority of mothers in the UK are being advised.2 But is this the correct message? Are people following the advice? What can and should dietitians be recommending? Complementary feeding is the period when infants no longer get all the nutrients they need via breast milk or infant formula, therefore, other foods and liquids need to be introduced.1 It can also be called weaning, but this term can be confused with weaning off breastmilk onto infant formula. The overall aim of complementary feeding is for children to be getting the right nutrients at the right time and eventually eating more or less the same as the rest of their family by the age of one.1 New guidelines from the Scientific Advisory Committee on Nutrition (SACN) have recommended that Vitamin D should be supplemented in breastfed babies from birth.7 Nutrients which are needed in addition to breast milk and formula from four months are iron and zinc.11 There have been some excellent studies recently which have changed our outlook on complementary feeding. Here, I summarise the main points of each. Learning early about peanuts (LEAP) study 20153 This landmark study found that the introduction of peanuts to high risk infants reduced the incidence of peanut allergy. The LEAP study found that only 3% of the children who consumed peanuts between the ages of four to 11 months developed a peanut allergy by the age of five, compared to 17% in the group that avoided them. This trial was a game-changer in the advice that should be given to new parents, as, for decades, healthcare professionals

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had been recommending that allergens should be avoided. Enquiring about tolerance (EAT) 20164 In this study, six allergenic foods were introduced to breastfed infants from three months of age. The allergens included: peanut, cooked egg, cows’ milk, sesame, whitefish, and wheat. Although they were unable to statistically prove that introducing these foods reduced the incidence of allergy, they did prove that introducing them was safe; there were no cases of anaphylaxis and doing so did not adversely affect growth. The study did indicate that reducing the risk of allergy was dose-dependent. When it was strictly adhered to, there was a significant reduction in the development of allergies. Canadian Healthy Infant Longitudinal Development (CHILD) Study, 20165 This Canadian study included prospective questionnaires and skin prick testing, specifically looking at cows’ milk, egg and peanut. It found that exclusive breastfeeding up to six months did not affect the sensitisation of foods apart from cows’ milk. It did find that there was benefit to introducing the three allergens before the age of one. Following these studies, the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) Committee on Nutrition released a position paper in early 2017 on Complementary Feeding.6

I have based the following recommendations on the evidence above, as well as recommendations from ESPGHAN. DO PEOPLE FOLLOW THE CURRENT GUIDANCE?

Well, the short answer is no. Not all mothers can or want to exclusively breastfeed until six months for a variety of reasons. In the UK in 2010, 75% of parents had already introduced food by five months and only one in 100 mothers exclusively breastfed until six months.8 ESPGHAN suggests promoting exclusive breastfeeding until 17 weeks and having six months as a goal.6 WHEN CAN COMPLEMENTARY FOODS START TO BE INTRODUCED?

By 17 weeks infants possess the gastrointestinal and renal function to cope with complementary food.6 The necessary motor skills are developed between four to six months. It is actually more beneficial for acceptance of flavours and textures and avoidance of allergy to start complementary feeding early, somewhere between four to six months (but not before 17 weeks).6 It is good to start introducing solids as soon as the infant is ready. Parents should not delay the introduction of complementary foods past six months (26 weeks). There is, however, some confusion, as many healthcare professionals recommend that parents wait until six months unless there is a particular need. It is important to try and communicate with healthcare professionals in your wider multidisciplinary team to advise them of what you are advising and why. Signs that an infant is ready for complementary food:2 • Can hold their head up • Can bring their fingers to their mouth • Showing interest in food

HOW SHOULD COMPLEMENTARY FEEDING BEGIN?

Methods 1. Traditional: spoon feeding Benefits: • It’s an easy way to provide the infant with lots of new flavours. • Parents feel confident that the infant is eating. Potential risks: • Parents could give the infant the amount they think is right and not give the child the chance to stop when they are full. This can lead to children losing their satiety signals and may even be linked to obesity.12 • Purees can often be a mixture of different foods and infants will, therefore, not identify different flavours and what they are eating. 2. Baby-led weaning Benefits: • Infants see what food they are eating • Infants only eat what they want • Convenient • Eating the same as the whole family Potential risks: • Choking • Not getting enough to eat • Not getting enough iron Things to remember with baby-led weaning: • Avoid foods that are easy to choke on coin shaped foods (like slices of carrot and chopped sausage), grapes and raw apple which breaks off easily. • Encourage an iron-rich source at every meal time. • Ensure that baby is getting a high-energy component to every meal.9

Table 1: Traditional complementary feeding stages10 1

Around six months

Thicker consistency with some lumps; soft finger foods can also be introduced at this stage

Nine to 12 months

Mashed, chopped, minced consistency; more finger foods

12 months and older

Mashed, chopped family foods and a variety of finger foods

• Fruit and vegetables • Rice, pasta, potatoes, yam, bread and cereals • Meat, fish, pulses and eggs • Yoghurt, custard and cheese

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PAEDIATRIC SUPPLEMENT Table 2: Introducing allergenic foods and other nutrients Food/Nutrient Added sugar and salt Iron Gluten

Peanuts

Other allergens (such as cows’ milk, soy, egg etc) Honey

When they should be introduced Avoid in any complementary foods and drinks There is a high demand for iron in infants over six months, especially in breastfed babies; therefore, iron-rich foods should be encouraged. It is safe to introduce gluten after four months, it is not linked to an increase of incidence of coeliac disease or Type 1 diabetes. Large quantities, however, should be avoided. Infants who have severe eczema and/or egg allergy) should check with an ‘appropriately trained healthcare professional’ before having nuts. This may mean that they need to undergo skin prick testing and supervised introduction of peanuts. If the child has mild to moderate eczema, currently it is suggested that peanuts are introduced from six months of age. For those who do not have eczema, peanuts can be introduced as soon as some basic complementary foods have been introduced. They all may be introduced as soon as complementary feeding commences, unless diagnosed as having an allergy. Avoid until after 12 months.

A mixture of both would ensure the benefits of both methods. It is important that health professionals manage expectations of complementary feeding; it can be messy and frustrating when infants pull faces and refuse the food that has taken hours to prepare. Parents need to be aware that it may not be easy; as with every other part of parenting, you can never plan for how babies are going to react! THE CONTENT OF COMPLEMENTARY FOOD

A healthy diet should be encouraged from the start, with a focus on introducing a wide range of foods, especially bitter ones such as green vegetables. Infants may pull a face when trying a lot of foods for the first time; this is a natural reaction to a new flavour and does not necessarily indicate disgust. The key should always be to offer new foods multiple times which will help children to accept different flavours.

CONCLUSION

Dietitians can now recommend introducing complementary foods as soon as the infant is ready after 17 weeks, including allergenic foods. If a baby is at high risk of peanut allergy, it is essential to refer to an allergy team before commencing peanut-based foods. It is up to parents what method of complementary feeding style they use. A mixture of both traditional and baby-led weaning can be encouraged; in this way, parents are able to introduce flavours and allergens in a timely manner. However, they do need to watch for signs that their infants are full so they do not overfeed when using a spoon. From six months they can start letting their baby take control with finger foods and enjoy the benefits of baby-led weaning whilst continuing to introduce wider flavours and textures.

References 1 World Health Organisation (WHO) (2002). Complementary Feeding. Report of the Global Consultation. Geneva. 10-13 December 2001. Summary of Guiding Principles. http://apps.who.int/iris/bitstream/10665/42739/1/924154614X.pdf?ua=1 Accessed March 10, 2017 2 www.nhs.uk/Conditions/pregnancy-and-baby/Pages/solid-foods-weaning.aspx 3 Du Toit, G et al (2015). Randomised Trial of Peanut Consumption in Infants at Risk for Peanut Allergy. N Engl J Med 2015; 372:803-813 February 26, 2015 DOI: 10.1056/NEJMoa1414850 4 Perkin MR et al (2016). Randomised Trial of Introduction of Allergenic Foods in Breastfed Infants. N Engl J Med 2016; 374:1733-1743 May 5, 2016 DOI: 10.1056/NEJMoa1514210 5 Tran MM et al (2016) The Effects of Infant Feeding Practices on Food Sensitisation in a Canadian Birth Cohort. Am J Respir Crit Care Med 193; 2016: A6694 www.atsjournals.org/doi/abs/10.1164/ajrccm-conference.2016.193.1_MeetingAbstracts.A6694 6 Fewtrell M et al. Complementary Feeding: A Position Paper by the European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) Committee on Nutrition. JPGN, Vol 64, Number 1, January 2017 7 Scientific Advisory Committee on Nutrition (2016). Vitamin D and Health. www.gov.uk/government/groups/scientific-advisory-committee-on-nutrition 8 McAndrew F et al (2012). Infant Feeding Survey 2010. London, ONS: The Information Centre for Health and Social Care. 9 Daniels L et al. Baby-Led Introduction to SolidS (BLISS) study: a randomised control trial of a baby-led approach to complementary feeding. http:// bmcpediatr.biomedcentral.com/articles/10.1186/s12887-015-0491-8 10 Table from: www.bda.uk.com/foodfacts/WeaningYourChild.pdf 11 Thomas B and Bishop J (2007). Manual of Dietetic Practice. Blackwell Publishing Ltd, Oxford 12 Townsend E, Pitchford NJ. Baby knows best? The impact of weaning style on food preferences and body mass index in early childhood in a casecontrolled sample. BMJ Open 2012; 2: e000298. doi:10.1136/bmjopen-2011-000298