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Weaning premature babies

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Sarah Almond Bushell, the Children’s Nutritionist, talks to us about important things to consider when weaning premature babies including signs your baby is ready for weaning, how to ensure your baby is getting the right nutrition and how to involve all their senses and explore food.

Weaning premature babies can sometimes be a struggle for parents. There is a lot of weaning guidance available for babies born on or around their due date (from week 37 of pregnancy onwards is considered term), but not a lot for the 10% of babies considered premature.

What is recommended by health professionals?

A lot of the guidance about weaning babies born at term doesn’t apply to premature babies, and there is lots of misinformation out there on the internet, so my aim is to set things straight with this blog.

Not all premature babies need specialised weaning advice. Those who were born after 34 weeks, are growing well and are healthy, can generally follow the standard weaning advice for babies born at full term.

Other babies however will need a bit of extra help to catch up as they may be smaller than expected. Smaller premature babies need their weaning diet carefully planned to ensure they are not gaining too much fat and not enough muscle.

Like term babies, every premature baby will be different, however, being premature can impact both a baby’s development and their nutrition status.

Premature babies who have additional medical needs, or have spent a lot of time in hospital, may be at higher risk for nutrition and feeding problems. This can be linked to their medical condition or a  developmental delay that affects their eating and drinking skills.

In addition, when you are born early, the nutritional stores that are usually laid down in the third trimester of pregnancy in readiness for birth, are missing. This means that some babies are malnourished when they are born and need intensive nutrition support on the special care baby unit. They may have been tube fed or intravenously fed and can be at risk of under-nutrition or poor growth as they grow older.

There is a lot of support for parents on the special care baby unit and over the last 10 years, the nutritional care that babies receive in the first few months of life has improved dramatically. This means that lots of premature babies manage to catch up before they start weaning.

When should I start weaning my premature baby?

The NHS guidelines advise that weaning should start at around 6 months of age. However, these guidelines don’t apply to most preemies. Unfortunately, there is a lack of evidence-based guidance on weaning premature babies because there is very little research available.

Rather than looking at age, the key is understanding your baby’s developmental milestones and recognising when they are showing readiness cues. These cues can be different to a baby born on time.

Let’s compare the 3 developmental readiness signs in a term baby with that of a premature baby:

1. The absence of the tongue-thrust reflex – This is when the tongue doesn’t stick out in response to something touching it. However, the tongue-thrust reflex stays for a long time in a lot of premature babies and eating food regularly actually helps it go away. You do not need to wait for the absence of the tongue-thrust reflex when thinking about weaning your premature baby.

2. Being able to sit unsupported – Sitting is a skill that many premature babies won’t be able to master independently for a while. Being able to sit without having to concentrate on doing it is essential to minimise the risk of choking. However, providing a well-supported highchair (with a footrest, support behind the knees and around the waist), can provide the stability they need to help your baby concentrate on coordinating themselves for eating.

3. Good hand-eye coordination – From around six and a half months, general weaning guidance is to introduce finger foods regardless of whether you are following spoon feeding or Baby Led Weaning (BLW). In order to do this, babies need to have developed good hand-eye coordination. However, many preterm babies won’t have yet developed this coordination at the start of weaning. It is ok to keep going with spoon feeding alone.

With these different milestones, it’s advisable to seek expert advice from a dietitian or healthcare professional when you are thinking about starting solids.

What readiness cues might my premature baby show?

As the ‘normal’ cues don’t apply, the following information may help you decide whether your premature baby is ready to start solids. They don’t need them all, but these are the signs to look out for:

  • Leaning forward with their mouth open ‘asking’ for food when a spoon is presented.
  • Holding their head steady when sitting upright in a supported position. From around four months corrected age.
  • Getting to grips with hand-eye coordination. This could be picking up toys and moving them upwards towards their mouth to explore.
  • Showing an interest in the food that others are eating however, this should not be taken as a cue on its own as many babies do this anyway.

Are there specific nutritional needs for premature babies?

For all babies, breastmilk alone (or formula for that matter) can’t provide enough energy or nutrients to meet a baby’s nutritional requirements beyond a certain point, and so weaning becomes necessary to complement it.

At the start of weaning, milk intake sometimes decreases as it becomes replaced by the solid foods eaten and unfortunately traditional starter foods like vegetables and fruit, are much lower in energy than milk.

This means that your baby won’t be meeting their nutritional requirements, and sometimes their weight gain becomes static. Therefore, fairly rapid progression towards including meat, fish, eggs, dairy foods and starchy carbohydrates in your baby’s weaning diet is actually really important.

Premature babies may not have the skills to drive forward this quick progression on their own. Hunger is not the driver for food intake for little ones who are learning to eat, it’s their developmental skill level that moves them along. Therefore, you may need to help by making foods easier to eat by cooking them until they are very soft, pureeing and mashing and offering them on a spoon.

After first tastes have been accepted, you can consider balancing your baby’s meals by following this three-point method:

  1. Start with an iron-rich protein food (meat or plant-based) like some slow-cooked lamb, a minced beef meatball, a lentil puree or ½ a boiled egg.
  2. Add a vitamin C rich food, for example, a broccoli floret or a couple of strawberries halved.
  3. Finish with an energy rich food like a soldier of buttered toast or sweet potato mashed with butter.

In addition, because the important nutrient stores usually made during the third trimester of pregnancy are missing, some premature babies also need more nutrition to build up these stores.

Breastfed premature babies will normally be discharged from hospital on an iron supplement and formula-fed babies will receive additional iron as the special prem baby formula is supplemented. It is important that these iron supplements continue until babies are consuming adequate iron in their weaning diet. Iron from food sources is more readily absorbed than iron from supplements, so we prefer babies to get this important nutrient from food ideally. If you are not sure whether your baby has reached this stage, ask to see a Registered Dietitian.

All babies, regardless of when they were born, are recommended to have a daily supplement of Vitamin A, C and D (the only exception to this is babies having more than 500ml formula/day as they will be receiving these already from the formula).

Can my premature baby do baby led weaning?

The two popular methods of weaning are baby led weaning (BLW) and traditional or spoon weaning. How to choose between the two must be based on your baby’s abilities taking into consideration their development, and safety reasons to minimise the risk of choking.

  • Traditional weaning involves making purees and spoon feeding your baby, gradually increasing to lumpier foods and introducing finger foods alongside.
  • Baby-led weaning (BLW) involves babies self-feeding and exploring food by providing it in its whole form.

If you think back to the developmental cues we spoke about earlier, a lot of premature babies, will not yet be able to sit upright unsupported or have proficient hand-eye coordination. For this reason, BLW may not be advisable as it simply isn’t safe.

They need core stability to minimise the risk of choking and without hand-eye coordination they simply can’t get the food to their mouths.

It is also known that BLW babies consume less nutrition during the first few months of weaning in comparison to spoon fed babies. Therefore, if growth or nutrition is a concern then BLW might not be advisable for a premature baby.

How else can I develop my baby’s eating skills?

As well as eating food, there are sensory experiences that need to be encouraged and explored in order for babies to learn about food and eating. There are 8 senses involved in weaning that need to be mastered, and they are:

  1. Visual (sight)
  2. Tactile (touch, textures)
  3. Auditory (sound)
  4. Olfactory (smell)
  5. Gustatory (taste)
  6. Proprioception (Movement)
  7. Vestibular (Balance)
  8. Interoception (Understanding internal feelings like hunger, sickness, fullness)

Babies who have lots of opportunities to use their senses have more highly developed brains which is linked to food acceptance, developmental skills, intellect and behaviour.

The best way to encourage sensory weaning is to offer lots of opportunities for exploration, for example, messy play with a variety of different textured foodstuffs, presenting food in colourful combinations and offering a variety of different textures, you can read more about sensory weaning in my blog I wrote for Tidy Tot during Weaning Week here.

 

Communication is important

Arguably the most important part of feeding is being able to communicate with your baby and respond to their cues. We know that babies born at full term can communicate their needs to their parents around 4-6 months and there is some evidence that premature babies are able to do this too in relation to feeding.

For example, when your baby has had enough food they will turn their head away or if they would like more they may lean forward with an open mouth. It’s really important to take notice and learn what your baby’s signals are for ‘finished’ and ‘more please’ so you can respond to your baby’s requests accurately.

This is called responsive feeding and strengthens the bond of attachment between you which is actually very important for their future wellbeing.

Another top tip for encouraging premature babies to eat is to keep trying different foods, even if they are at first rejected. Repeated exposure to rejected foods is as important for premature babies as it is for babies born at term in order to teach them about different tastes and flavours. It’s not something they are born knowing how to do and so sometimes it can take 10 to 100 times of trying a food before your baby accepts it.

It’s also important to sit and eat with your baby at mealtimes. Eating is a

skill that babies have to learn, it’s helpful if they can see you doing it first. Babies watch and mimic others and learn how to eat this way.

For more specialised support from Sarah on weaning, please visit her website at www.childrensnutrition.co.uk

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