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Re: Weaning of infants; timing should be individualized

Dear Editor

I read with interest the review by Foote and Marriott about weaning practices.[1] I agree with some of the general sentiments and do suggest that more research is needed to fully understand the reasons for advocating a stance.

Weaning as a process, enables the nutritional needs of a rapidly growing child to be met. The growth in infants double by 5 months and expected on average to treble by 1 year. Adequate dietary provision to meet this demand is therefore essential. There should be a balance between energy, protein and vitamin provisions. The process of weaning, enables solids to be gradually introduced and the dependence on milk decreased as the main source of nutrition.

The process of weaning is applied in various ways by different cultures and this area would need to be understood and researched if we are to be consistent with the advise we give. Should the weaning practise be same for all cultures? Do we have enough information to give an affirmative answer? The WHO, has recommended that babies should be exclusively breast fed for 4-6 months. While this may be ideal in the developing world, difficulty implementing this in the industrial world may make this impractical.

The practice of weaning is not in doubt but the timing needs individualizing as a concept for it to work. The first COMA report recommends that weaning should start from 4–6 months and the 2nd and 3rd reports on present day practice, acknowledge the wide range of growth rates after birth and suggests that weaning may start from as early as 3 months.[2] This is a view I share. Infants utilize breast milk efficiently and by age of 6 months this will be inadequate. There are suggestions that the poor development of head control at 3 months may have a bearing on the lack of adequate suck and swallow at his age but by 4 months the improved neck control enables feeding in an upright position in a chair. By 5 months pureed foods can be taken and these babies can form a bolus before swallowing. I believe that early initiation of solids may facilitate acquisition of these skills. Another reason for discouraging early weaning, is the belief that renal and gut immaturity may not be efficient at handling the materials in weaning diets. The evidence for this assertion is weak. A review of the age at which 1st solids were introduced in the UK [3] showed that 19% were offered by 8weeks, 68% by 3 months, and 94% at 4 months. Solids may be offered earlier than parents acknowledge, since they are aware that it is contrary to professional advise. This diversity should encourage professionals to recognise the need to build on this practise in order to improve it.[4] There are issues of antigenic load on the gut, but the science and understanding of food allergies still needs further studies. Weaning should be an enjoyable and supportive process for child and parents and the specific needs of the infant, parent and culture must be considered at all times. Weaning as a process should be individualized and supported with good evidence to facilitate successful outcome. The place for research into cultural weaning practices, the components of weaning feeds, and effect of early ‘antigen attack’ are essential. Weaning should be considered from the ages of 4–6 months and this may be offered early if the infant’s need cannot be met wholly by milk. If an infant at 6 months is not weaned, the nutritional intake is likely to be inadequate.

References

(1) Foote KD, Marriott ID. Weaning of Infants. Arch Dis Child 2003;88;488-92.

(2) Department of health & social security Present day practice in Infant feeding; 3rd Report. London: HMSO, 1988.

(3) White A, Freath S, O’Brien M. Infant feedingLondon: HMSO, 1992.

(4) Sullivan SA , Birch LL. Infant dietary experience and acceptance of solid foods. Pediatr 1994;93: 271-7.

Send letter to journal:
Re: Weaning infants, encouraging breast feeding.

Dear Editor

The review by Foote and Marriott on infant weaning [1] was of interest especially in the light of the recent adoption by the UK Department of Health of 6 months as the age for the introduction of complementary foods.

The authors make a number of comparisons between artificial feeding and breast milk that deserve comment. They make the point that the nutrient density of cows milk based formula is less than that of breast milk, highlighting particularly the lower iron content of breast milk. There are inherent difficulties in analysing the composition of breast milk and making comparisons with formula feeding. Breast milk differs in its composition throughout lactation, depending on factors such as the infant’s age, frequency of feeding, time of day, etc. It is indeed the case that the iron content is lower in breast milk, but the presence of the transfer protein lactoferrin makes iron in breast milk more easily absorbed. Hence the iron concentration in artificial formulae is higher to compensate for less efficient absorption.

The authors cite anecdotal evidence from their Winchester clinic that mothers who breast-feed would rather discontinue than maintain exclusivity. It would be interesting to assess the understanding of those mothers about the nutrient composition of breast milk. Anecdotal experience from my own practice (Salford, Greater Manchester) is that many mothers believe that, apart from the colostrum produced in the first few days of lactation, formula feeding and breast-feeding are nutritionally pretty much the same. They are unaware of issues such as the bioavailability and better absorption of nutrients from breast milk. This belief that there is no great advantage to breast-feeding beyond a few weeks underpins decisions on how long to breast-feed their infants.

I strongly agree with the authors that encouraging more mothers to breast-feed is an imperative in the UK. There is also a need to give parents more specific information on the nutritional and immunological benefits of breast-feeding, not just in the antenatal period but also once lactation is established, when mothers are pondering decisions on the duration of breast-feeding and the timing of introduction of solids.

The authors point to social and cultural factors in the UK, which would make a major change in weaning policy difficult. They suggest that the best interests of infant health would be better served by encouraging more mothers to breast feed, rather than promoting exclusivity for 6 months.

I would add the observation that social and cultural factors in the UK are not conducive to breastfeeding beyond a few weeks of age. I would suggest that the short duration of breast-feeding in the UK, and the early introduction of solids, both stem from ignorance of the advantages of breast milk. Promoting a greater knowledge of the nutritional advantages of breast-feeding would address both problems, and permit the public to challenge the prevailing social climate, which leads to short periods of breast-feeding and premature weaning.

Reference

(1) Foote KD, Marriott LD. Weaning of infants. Arch Dis Child 2003;88:488-492.

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Re: Authors Response

Dear Editor

We are glad Dr Redfern[1] found our article[2] of interest.

We agree on most points. For clarity, the fact that there are difficulties inherent in comparing the nutritional adequacy of human milk with that of infant formula does not detract from our main point, namely that more research is required regarding the possible differing nutritional needs of formula versus breast fed infants at the onset of weaning. Regarding the anecdotal evidence, in Winchester mothers not wishing to continue exclusive breast-feeding beyond 4 months cite practical rather nutritional concerns. These are based on a belief that a little solid food given to breast fed babies between 4 and 6 months of age leads to increased contentment and longer gaps between night breast feeds-important considerations at a time when many mothers are returning to work.

We thank Drs Odeka and Wong[3] for their interest in our article.

Keith Foote
Lynne Marriott

References

(1) Redfern L. Weaning infants, encouraging breast feeding [electronic response to KD Foote and LD Marriott, Weaning of infants] archdischild.com http://adc.bmjjournals.com/cgi/eletters/archdischild;88/6/488#531

(2) KD Foote and LD Marriott. Weaning of infants. Arch Dis Child 2003;88:488-492.