COVER STORY
WEANING PRETERM BABIES Around 10% of babies are born prematurely; this means that they have missed some or all of the third trimester of pregnancy when nutritional stores are laid down. This article provides advice on weaning a preterm infant, including ready-for-weaning cues and steps for ensuring that it is a positive experience for all involved. Nutritional care on the special care baby unit has improved over the last decade and many baby’s will have achieved catch-up nutritional status. Some, however, may still be at risk of malnutrition and poor growth and will require individualised weaning guidance. There is a lack of government guidance on how and when parents should wean their preterm baby, which means that personalised weaning advice is often needed due to parental anxiety and uncertainty about whether their baby has adequate motor skills.
Sarah Almond Bushell MPhil, BSc, RD, MBDA
Preterm babies who have other medical needs, or who have had a complex neonatal period, may be at higher risk of nutrition and feeding problems linked to the developmental delay of eating and drinking skills. CORRECTED AGE AND ACTUAL AGE
WHAT IS CONSIDERED PRETERM?
A preterm baby is one who is born before 37 weeks gestation. However, if they were born after 34 weeks, are growing well and are otherwise healthy, they may be able to follow general weaning guidance rather than the specialist information given here.1
Actual age is the baby’s age from the date they were born, whilst corrected age takes into account how preterm they were and is counted from their due date. For example, a baby born at 32 weeks who is 14 weeks old, would be six weeks corrected. The corrected age allows healthcare professionals to assess the baby’s development appropriately. In this example, the expectation would be for the baby to be reaching the usual milestones of a six-week old rather than a 14-week old baby. Both actual and corrected are used by healthcare professionals.
WHY ARE PRETERM BABIES MORE COMPLEX?
WHAT AGE SHOULD YOU START WEANING A PRETERM BABY?
Some babies may be smaller than expected, weighing less than 2.5kg at birth, referred to as low birth weight (LBW). Other babies may have Inter uterine growth retardation (IUGR) which can occur at any gestation. These babies will need their weaning diet carefully planned to achieve catch-up growth without altering body composition.
Sarah is a children’s nutritionist and baby weaning expert with 20 years’ experience in nutrition and dietetics. She is a trained SOS feeding therapist and is passionate about helping families improve their nutrition to optimise health. www.childrensnutrition.co.uk
@thechildrensnutritionist @feedingbabies
REFERENCES Please visit: https://www. nhdmag.com/ references.html
NHS guidelines advising that weaning should start at around six months of age don’t apply to most preterm babies. There is very little research specifically for preterm babies and a recommended age is not suggested.2 The key is to understand the baby’s developmental milestones and to look out for their readiness cues. Consider the following www.NHDmag.com December 2019 / January 2020 - Issue 150
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COVER STORY three signs for being ‘ready for weaning’ for term babies3 and see how the preterm baby might differ: The tongue-thrust reflex One of the signs of being ready to wean a term baby is the absence of the tongue-thrust reflex. This is tongue protrusion in response to something touching it. In many preterm babies the tongue-thrust reflex is present and regular practise by eating food helps it abate. In summary: you don’t need to wait for the absence of the tongue-thrust reflex when thinking about weaning a preterm baby. Being able to sit unaided Many preterm babies will not have the motor skills to be able to sit up unaided. However, postural stability is essential for optimal oral-motor range of motion, hand-eye coordination and fine motor and tactile manipulation of food. This can be provided with appropriate seating in a well-supported highchair. Support is required at the feet, behind the knees and around the waist and trunk. This is necessary so that the baby can concentrate on coordinating the skills needed for eating rather than prioritising vestibular and proprioceptive senses. In summary: Premature babies don’t need to be able to sit up unsupported to commence weaning, but supportive seating must be provided. Good hand-eye coordination In babies born at term, hand-eye coordination is needed so that they can start self-feeding irrespective of whether they are baby-led weaning (BLW) or traditionally weaning (see below for more on these weaning methods), because finger foods are important from 6.5 months. Many preterm babies won’t have good hand-eye coordination at the start of weaning and will need to be spoon-fed. In summary: Premature babies do not need to have hand-eye coordination before they can start weaning. WHAT ARE THE READINESS CUES?
The following cues2 can be helpful to decide whether a baby is ready to start solids. Babies don’t need to have all the following in place and often parents are the best judge of when their
baby is ready. Individual assessment of each baby is important. • Holding their head steady. When sitting upright in a supported position, preterm babies need to be able to hold their head steady in the midline for successful weaning. If babies also have other ongoing medical problems, their gross motor, fine motor and oral motor skills may be impacted. Therefore, waiting until a minimal level of motor ability is present (such as holding their head steady) is important prior to starting solids. Many babies achieve this at around four months corrected age. • Picking up toys and putting them in their mouth to explore. • Leaning forward, mouth open ‘asking’ for food. • Showing an interest in the food that others are eating. Some feel that this could be a sign for being ready for weaning, but many babies do this anyway and so this should not be taken as a cue in isolation. They are not ready: • when the baby appears hungry and is demanding more milk; • when the baby is waking more frequently though the night to feed; • when they reach a certain weight; • when they reach a certain age. IS NUTRITION A REASON TO START SOLIDS?
Yes, it can be. Meeting energy requirements is a reason to consider starting solids. Beyond a certain point, breast milk alone can’t provide enough energy to meet a baby’s nutritional requirements and, so, starting solids is necessary to complement it and meet their energy needs. Traditional first weaning foods, such as vegetables and fruit, are low in energy and don’t contribute much towards meeting energy requirements. At the same time, milk intake may decrease as it becomes displaced by food. Progression towards including meat, fish, dairy foods and starchy carbohydrates is important to provide the additional nutrients required.
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COVER STORY Table 1: Recommendations for vitamin supplements Vitamin A
200mcg
Vitamin C
20mg
Vitamin D
8.5 to 10mcg
Babies born at term have around six months’ supply of iron before it runs out and they need to obtain it from solid food. As iron is laid down in the third trimester of pregnancy, preterm babies often don’t have this luxury. Breastfed babies will be discharged from hospital on an iron supplement and formula-fed babies will receive supplemental iron via their formula. Iron supplements should continue until babies are consuming adequate iron in their weaning diet. Iron from food sources is more readily absorbed than iron from supplements. All babies, irrespective of their gestation, will need to progress through the stages of weaning and onto a balanced weaning diet in order to meet their nutritional requirements. The rate of progress is driven by skill rather than hunger in the early months, and parents should be encouraged to observe and respond to their baby’s cues. Vitamin A, C and D supplements are also recommended for all babies,4 and those having more than 500ml formula/day will receive these already, but breastfed babies will need supplementary drops. Not all supplements are equal, each containing different amounts of the three vitamins, so dietitians should consider the nutritional quality of the weaning diet when considering which supplement is best. WHICH METHOD OF WEANING IS BEST FOR A PRETERM BABY?
There are two approaches to weaning: • Traditional weaning, which involves feeding the baby smooth purees from a spoon, gradually increasing the texture and providing finger foods alongside. • Baby-led weaning (BLW), which involves providing food in its whole form and allowing the baby to explore the food and self-feed. The decision on which method is best for a preterm baby must be based upon their development to ensure safety. 12
For many preterm babies, BLW may not be advisable as it requires them to have adequate stability in an upright seated position and proficient hand-eye coordination. Without a stable base, they are at increased risk of choking and without hand-eye coordination, they simply can’t bring the food up to their mouths. Nevertheless, hand-eye coordination is a skill they need to learn through regular practice, so offering finger foods alongside purees can be helpful. Sometimes, parents refer to this as ‘a combined approach.’ It is known that BLW babies consume less nutrition at the start of weaning while their skills are being learned.5 Therefore, if growth is an issue and a carefully planned weaning diet is important, BLW may not be possible in order to achieve the required catch-up growth. If babies have medical conditions or issues with swallowing as a result of being preterm, it’s likely that they will be under a feeding team or speech and language therapist who may have an individualised plan for weaning.6 HOW TO OFFER THE FIRST MEAL
The initial focus of starting solids is about enjoyment, not the volume of food. The aim is to establish positive feeding interactions between the parents and the child. Parents may need to be taught how to use a highly expressive happy face and how to manage their own facial expressions to hide their own feeding anxieties. They must reassure their baby that eating solid food is a positive experience.7 Here are some steps for positive feeding interactions (this phase may last two to four weeks in some premature babies before they get used to taking food from a spoon). 1 Parents must begin with a highly expressive happy face to provide reassurance. 2 A small amount of puree should be placed directly on the highchair tray. 3 Show the baby the spoon and tell them what they are having to eat.
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COVER STORY 4 Take up a scant trace of the puree on the tip of the spoon. 5 Bring the spoon straight up to the baby’s mouth and leave a scant trace of puree on their bottom lip, then withdraw the spoon. 6 The parent should model lip smacking movements to encourage their baby to copy and take a taste of the puree. 7 The next step involves the scant trace of puree being placed inside the baby’s mouth on the inside of the lips. 8 Parent should say “aaaahh” as the spoon approaches to help encourage opening the mouth, and “mmmm” to encourage closing. 9 The next step involves placing the trace of puree on the tip of the tongue with parents using the “aaahhhs” and “mmmms” to encourage opening and closing. Steps can be repeated with increasing volumes of puree while the baby is content. Let the baby touch and play with the puree and have their own spoon if they show interest. It’s important that parents observe their baby’s cues and stop before the baby loses interest or becomes upset. Cleaning up, face wiping and spoon scraping are unpleasant for babies and should be avoided during the mealtime. It can be helpful if cleaning up happens away from the highchair to avoid negative associations with weaning. CUP INTRODUCTION
Cup drinking is another skill to learn and the volumes of water taken at the start of weaning don’t contribute much to their fluid intake. Introduction of the cup is for practice initially. A free-flow, two-handled spouted beaker can be helpful to start with, as water flows too fast from open cups. The cup should be filled to half full, so it doesn’t need to be tipped too far for the water to flow. The parent should introduce the cup at the end of the meal and demonstrate how it works by tipping water onto the highchair tray first7 before offering it to their baby. THE RISKS OF DELAYED WEANING
It is not uncommon for parents to want to delay the introduction of solids, as they feel that their
baby is not yet developmentally ready. Aside from the risk of poor nutritional status and growth, many babies benefit from the challenges that weaning brings and it may enhance the progression of their eating and drinking skills. There is little evidence to detail how much oral motor abilities are learned through practice. However, those babies who don’t have challenging solid foods at this time appear to be at greater risk of feeding difficulties.6 It is not uncommon for preterm babies to remain on pureed food for longer than necessary due to parental concern that they may not cope with lumpy textures and choke. Because challenging textures can be helpful to aid skill development, coupled with the developmental ‘window of opportunity’8,9,10 when babies are open to accepting new flavours and textures, it has been suggested that a delay beyond nine months uncorrected age for the introduction of lumpy textures could lead to feeding problems so must be avoided. SENSORY WEANING
Exposure to food is not enough for it to be accepted in the long term.11 There are eight senses involved in weaning, which must be encouraged and explored as part of learning how to eat and drink.7 The eight senses are as follows: 1 Visual (sight) 2 Tactile (touch, textures) 3 Auditory (sound) 4 Olfactory (smell) 5 Gustatory (taste) 6 Proprioception (location/orientation of self in space, eg, movement) 7 Vestibular (balance and orientation of self in relation to gravity) 8 Interoception (the ability to read and interpret internal bodily signal, eg, feeling hunger) Studies have shown that babies who have lots of opportunities to use their senses have a more complex map of neural connections in the brain linked to food acceptance, developmental skills, intellect and behaviour12 The best way to encourage sensory weaning is to offer many opportunities for exploration, for example, messy play with a variety of
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COVER STORY different textured foodstuffs, presenting food in colourful combinations and offering a variety of different textures. INTERACTION WITH PARENTS: RESPONSIVE FEEDING
Term babies around four to six months of age can communicate their needs to their parents and caregivers. 13 There is some evidence that preterm babies are able to do this too in relation to feeding. 6 A baby will turn their head away when they’ve had enough or lean forward with an open mouth when they want more. Parents should be encouraged to take notice and respond to these subtle cues and develop an appropriate food parenting style. 14 Responsive feeding ensures that: • the mealtime environment is calm and enjoyable with no distractions; • the child is seated in a well-supported highchair; • the child and parent are seated facing each other;
• the parent tells the child what they are having and what the expectation is; • the meal is nutritious, flavoursome and the texture is developmentally appropriate; • there is a predictable routine for mealtimes, so the child knows what to expect; • parents are attending to the child’s signals of hunger and fullness; • parents are responding quickly and supportively to help the child when they signal their needs. Repeated exposure to rejected foods is important for preterm babies, just as it is for term babies, in order to increase acceptance.15 The wider the variety of flavours offered in the early stages of weaning, the more likely a child will accept a new food when they are older.16 Including the baby at family mealtimes is known to be beneficial for learning to eat and drink. Babies watch and mimic others and learn how to eat this way. Evidence suggests that children who join in at family mealtimes accept a wider range of foods than those who eat alone.17
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Click here to read the Dec/Jan issue Articles include: • Weaning preterm babies
• Nasogastric tube feeding • Fussy eating in toddlers • Constipation and treatment • Popular liquid diets
• Plant-based diets • Care caterers in social care • Follow-on formula new regulations