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Weaning premature babies

There is a lot of weaning guidance available for babies born on or around their due date (from week 37 of pregnancy onwards), however, not a lot for those whose baby decides to make an early appearance which is actually around 10% of all babies!

What is premature?

A baby is called premature (or preterm) if they were born before 37 weeks. Just because they are born early, does not mean they will need specialist weaning advice, because babies born after 34 weeks who are healthy and growing well can follow standard weaning advice for babies born at full term.

Corrected age and actual age

You might have heard the term ‘corrected age’. This takes into account how early a baby was born and is counted from their due date. For example, a baby born at 32 weeks who is 14 weeks old, would be 6 weeks corrected. ‘Actual age’ is the baby’s age from the date they were born. The corrected age allows healthcare professionals to assess your baby’s development appropriately. In this example, the expectation would be for your baby to be reaching the usual milestones of a 6-week old rather than a 14-week old baby.

Why does being born prematurely affect nutrition?

It is likely your baby will have missed some or all of the third trimester of pregnancy, which is when most of their important nutritional stores, such as iron, are laid down. It’s also when protein and energy is used for a large growth spurt. Over the last decade the nutritional care that babies receive on the special care baby unit has improved dramatically, so lots of preterm babies manage to catch up with their nutritional status in the first few weeks. However, because all babies are different, some may still be at risk of under-nutrition or poor growth needing individualised weaning guidance. Your healthcare team will advise.

What is the current guidance on premature weaning?

The general weaning NHS guidelines that advise that weaning should start at around 6 months of age, don’t apply to most premature babies. Currently, there is a lack of government guidance on when and how parents should start weaning their preterm baby and that’s because there is very little research available specifically on preterm babies. The key is understanding your baby’s developmental milestones and looking out for their readiness cues. Consider the three signs for being ‘ready for weaning’ for term babies and see how the preterm baby might differ: 1) The tongue-thrust reflex - This is nearly always present in preterm babies and actually eating food regularly helps it go. 2) Being able to sit unaided - A lot of preterm babies don’t have the motor skills to be able to sit up unaided, but as long as they are appropriately supported in their highchair/seating, you can start weaning. 3) Good hand-eye coordination - Many preterm babies won't have mastered hand-eye coordination at the start of weaning and will need to practice this as they learn to eat.

What are the readiness cues for weaning a premature baby

As you can see, the usual developmental readiness cues do not apply to a preterm baby, however, the following cues can be helpful to decide whether a baby is ready to start solids. Babies don't need to have all of these in place, and I’m a great believer that parents are often the best judge of when their baby is ready: • Holding their head steady when sitting upright in a supported position - Many babies achieve this at around 4 months corrected age. • Picking up toys and putting them to their mouth to explore. • Leaning forward, mouth open ‘asking’ for food. • Some feel that showing an interest in the food that others are eating could be a sign for being ready for weaning, but many babies do this anyway and so should not be taken as a cue in isolation. They are not: • When your baby appears hungry and is demanding more milk. • When your baby is waking more frequently through 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, as there comes a point when a baby’s energy and nutrient requirements can’t be met by milk alone (breast or formula) and so starting solids is necessary. However, fruits and vegetables, which are traditional first weaning foods, are low in energy. At the same time, starting solids may lead to their milk intake decreasing as it becomes displaced by food. Therefore, a steady progression towards a balanced diet including meat, fish, dairy foods and starchy carbohydrates is important to provide the additional nutrients required.

Are there risks in delaying weaning in a preterm baby

Yes, aside from the risk of poor nutritional status and growth, many babies benefit from the challenges that weaning brings and it may actually enhance the progression of their eating and drinking skills. However, 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 and so getting regular support from your healthcare team if you are feeling unsure is important. In addition, we often see premature babies remaining on pureed food for longer than necessary due to concerns that they may not cope with lumpy textures and choke. Because challenging textures are necessary to develop the muscles in the mouth at the right time, research suggests that a delay beyond 9 months uncorrected age for the introduction of lumpy textures could lead to feeding problems later on. There is a developmental ‘window of opportunity’ when babies are open to accepting new flavours and textures and it is important that premature babies don’t miss this.

Can premature baby do baby-led weaning?

There are two approaches to weaning: • Traditional weaning - this involves feeding the baby smooth purees from a spoon, gradually increasing the texture and finger foods alongside. • Baby-led weaning (BLW) - this involves providing food in its whole form and allowing the baby to explore the food and self-feed. Safety is the most important factor to consider. If you are considering BLW your baby must have adequate stability in an upright seated position to minimise the risk of choking. Effective hand-eye coordination is also needed for successful BLW, without this, babies simply aren’t capable of bringing the food up to their mouths. Nevertheless, hand-eye coordination is a skill babies need to learn through regular practice, so a combined approach by offering finger foods alongside purees can be helpful. It is known too that BLW babies consume less nutrition at the start of weaning while 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.

Cup introduction

At the start of weaning it’s also important to introduce a cup to teach your baby drinking skills. At the very start the cup is more about practice and familiarity rather than a way of getting fluid in to your little one. Use a free-flow, two handled spouted beaker, which is filled no more than half full, so it doesn’t need to be tipped too far for the water to flow, and so it isn’t too heavy for the baby to lift. An open cup is good too but the water may flow too fast for premature babies and so starting with a free flow spouted beaker which controls the flow is often helpful.

Can I prevent fussy eating?

Repeated exposure to rejected foods is important for preterm babies just as it is for term babies in order to help them like new tastes and flavours. The wider the variety of flavours offered in the early stages of weaning before 9 months corrected age, the more likely a child will be to eat a wide range of foods when they are older. Including your baby at family mealtimes whenever you can, bring the highchair up to the table and let your baby have some of what you are having. This is known to be very beneficial in terms of learning how 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.

Do premature babies need supplements?

All babies, regardless of when they were born, are recommended to have a daily supplement of Vitamin A, C and D (the exception to this is babies having more than 500ml formula/day as they will be receiving these already from the formula): Vitamin D 8.5 - 10mcg Vitamin A 200mcg Vitamin C 20mg Many premature babies will also be on iron supplements until they are eating well enough, when their dietitian will advise them to stop.

Responsive feeding

It’s important to take notice of and respond to your baby’s cues when it comes to feeding. For example, when your baby has had enough food, they will turn their head away or if they want more they will lean forward with an open mouth. We know that from around 4 months both premature babies and babies born at term can communicate their needs to their parents. If you would like to learn more about nutrition and feeding for babies and toddlers head over to my blog www.childrensutrition.co.uk

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