Premature Babies - When Weaning is Not Straightforward

Many premature babies will be introduced and take to solid food in much the same way as full term babies. But for some, weaning will be more difficult with special needs that must be accomodated. The purpose of the post is to raise awareness of these issues. It has been informed by my special mummies, but is not a clinical post or substitute for medical advice.

Today I want to talk to you about weaning when things are not straight forward. There are several issues that can be encountered when weaning a premature baby, but it has to be said that these issues can happen with term babies too.

Severe reflux - all babies are born with immature sphincters, the valve in the oesophagus that regulates the food and fluid travelling down into the stomach. A lot of babies are happy chuckers, some have pain, and in others reflux can be very serious indeed. Premature babies, qutie logically, are more prone to reflux due to their immature digestive systems having to do a lot of work.

Associated with the vomiting and pain is acid build up, like heart burn. The baby may find this is much worse once they are off milk and introduced to solids (although in many cases weaning can actually help babies with mild to moderate reflux)

Swallowing problems - Many premature babies have been on long term ventilation. Some babies can have temporary or even permanent damage that can make eating incredibly difficult. Sometimes this can sit alongside other problems like reflux. Very often parents will be advised to "go back to basics" and keep the baby on pureed foods for longer, and be a lot slower in introducing lumps and textures.

If you feel, during weaning, that your baby is struggling or not making progress, don't hesitate in contacting your consultant or health visitor. Babies sometimes need a referral to a speech and language therapist (SALT) These therapists do more than just help with speech, they can look at functional problems with the mouth and with the swallowing reflex, and sometimes work in partnership with a dietician.

Oral aversion - Some children have had complicated pathways through NICU and sometimes onto PICU (paediatric intensive care units) and have required long term tube feeding and procedures. These children may then be unwilling or unable to accept food or liquid into their mouths at all. Here Carole shares her experiences with her son Luke

Luke is under the care of GOSH London Specialist Feeding and Eating disorder team. Our ultimate aim is to tube wean. My portage worker has been the biggest source of help, the local SALT admits that Luke is an extreme case. We've had to start with the basics. No pressure to touch food, just be near it. Then dry food, handling dried pasta, dry porridge oats, hiding toys in it and getting the dust on his hands. We started off with big spoons (the kind you dish your dinner up with) scooping and pouring the dried food. Nothing went near his mouth. graduated to touching smooth wet food and now Luke will handle messy food, it took us 18 months to get to this stage. next step is asking him to put food to his mouth, lips not even in his mouth. We blow bubbles with straws in milkshake and if he accidently sucks or gets some liquid on his lips then thats a bonus. For Luke the issue isn't about tastes and finding a food he likes (if one more person suggests have you tried chocolate/custard/pear puree/ etc grrr) it about overcoming sensory issues and having to learn what food is because he missed all his developmental milestones (sucking, watching other people eat, spoons, touching and being around food) and had no relationship with food. It doesn't help that Luke has left sided vocal cord palsy so his swallow is never going to be great.

Sensory issues - For premature babies one of the paradoxes with weaning is that we start on actual age, around 6 months.  For a baby born very early, this can mean they are not sitting independently, not touching things much yet, and certainly not handling foods. Imagine everything being fed to you and not being able to touch it. For some premature babies, this is further complicated by underlying issues that cause them to have problems in processing the world around them, and can be symptom of autism (but not always)

Sharron shares her experiences with her son Callam.

Callam, was born at 29 weeks and was not expected to live. He did not breathe for the first 10 minutes of his life. He had total renal failure, a brain haemorrhage and anaemia to name but a few of his problems and was ventilated for the first 7 days of his life. At around 11 days old we were told that Callam had tested positive for CMV (Cyto Megalo Virus).

Callam has lived with a very restricted diet which started from birth with severe reflux up to 18 month of age. He only ate age 4 month puree baby food until the age of 2 years and after this he could not eat mixed textures. The only foods he eats now (age 12) are brown or yellow, coated and with no ‘bits’ in. His main diet is cheese sandwich for dinner and chicken nuggets and chips for tea daily.

Callam has come a long way over his 12 years and things are easier to deal with now as he is starting to try new things but things haven’t always been easy. We have been stared at and talked about and passed judgement on and made to feel like the worst parents in the world.

When he was 2-3 years we would try and ‘force feed’ him as we didn’t know what the issue was then. He could go days without eating and, as a parent, its heartbreaking to see your child not eating and getting thinner, especially when you go to the hospital and see ‘failure to thrive’ on the front of his case notes. We would get people saying “leave him with me, I’ll get him eating” and that would really annoy me as, if that would have actually worked, I would have gladly left him with them. Even his old Consultant said that he would start eating once he started school and saw the other children. Sadly, this wasn’t the case.

Luckily, we found a fantastic Eating Specialist at Birmingham Children’s Hospital, changed Consultants at our local hospital and managed to get a referral there. She suggested various different ways of getting him to try foods including relaxation at age 8 and things have started to improve, although we still have a long way to go.

He has also got a diagnosis of Autistic Spectrum Disorder now and his eating problems are probably because of the ASD but could also be linked to the CMV (Cyto Megalo Virus) he was born with.

My message - If you feel your journey with your baby or toddler and food is not normal and becoming difficult or complicated seek help, but you may need to search for it. A common experience seems to be that Health Visitors, unless you are lucky with a good one, and some are former neo natal nurses, are not aware of some of the complications with weaning premature babies and may not know, immediately, how best to help.

Also, what I want to say is, don't judge. If you see a two year old eating baby food out of a jar, there probably is a darn good reason. And whilst, to an outsider, the solution to overcoming these problems may seem simple "if they are hungry enough they will eat", it's rarely that simple.

HiPP Organic Baby Food

Coinciding with weaning week I was approached by HiPP Organic to review and give away some products. Like many mums I joined a lot of the baby clubs when pregnant, and the  HiPP Baby Club was one of my favourites. They even have a little section on weaning premature babies.

I feel the same way about commercially produced baby food as I do about disposable nappies. They most definitely have their place, but I wouldn't use it every day. I would use jars or pouches when out and about, and for travelling. I also found they were useful for husband duty!

Packaged foods are also useful if you want to offer something to your baby you wouldn't be inclined to make yourself. Also some premature babies are incredibly fussy about texture, and commercial foods can be really good for them, as they are consistent, without funny lumps and bumps for the first weaning stage.

I do think organic food is preferable for babies, when its seasonal and affordable, and commercially produced foods are a good way of providing that. I think for most families eating organic fruit and vegetables all the time is a big ask, I know our budget doesn't always stretch to it. 

So here is what I was sent

• Creamy Porridge - box
• Banana and Peach Breakfast - box
• My First Sunday Dinner - jar
• Apple and Pear Pudding - jar
• Baana Custard - jar
• 100% Fruit Mango Apple and Peach - pouch
• 100% Fruit Peach Apple Blueberry and Raspberry - pouch

I haven't reviewed them as such, because Joseph is a bit beyond them now however we did use the pouches for travelling recently, they are great for trips on the plane, and are ok through customs in Australia, who are notoriously fussy about food. I do love the traditional glass jars, but at times the pouches are handy as they are so light and take up little room.

I have chosen to give them away to my new premmie mum friend Sammantha who has a little boy born at a similar gestation to Joseph for the same reason, who is about to start on her weaning journey with him.

Modelled by the lovely Simone from The SFR Family Blog

Calories and Your Premature Baby

I've written this from a parent's perspective if you have specific concerns please address them with your baby/child's GP, Health Visitor or Consultant/Dietician.

For former low birth weight babies, weaning can be a difficult time. Many first foods are low in calories, like pureed vegetables and fruits. In the first weeks of weaning I found Joseph's already low weight dropped a little, as he dropped his milk feeds a bit to make way for food. I found it all evened out, however was advised to ensure I enriched his food.

I know I found the help of other mums of premature and low birthweight children invaluable and wanted to share some of that wisdom in a blog post. I asked for ideas on Facebook last night and was overwhelmed at the response!

I think ensuring our babies get adequate nutrition is important, but we also need to make sure we instill healthy eating habits for life. I do think, whilst there is a place for double cream etc, we need to be creative, so here are some great ideas for adding calories and variety to your small person's diet. I used to vary what I used, as I didn't want Joseph's diet too high in saturated fat.

• olive oil - add it into purees and mashed potato as well as using it in cooking
• other oils like rapeseed, almond, peanut and sunflower 
• avocado - either pureed, as slices or a spread
• banana - and you can mix it with cream or full fat yoghurt
• Greek yoghurt, a huge favourite here!
• marscapone cheese- I used to make a cheats baby cheesecake with a crumbled rusk, a tablespoon of marscapone and then a fruit puree.
• hoummous - commercial is fine but its very easy to make at home
• another suggestion from Hiba is tahini, it makes a lovely dip with lemon juice
• nut butters - there are lots of different varieties not just peanut
• pasta - and of course it carries calorie rich sauces well
• oily fish 
• aubergine cooked with olive oil until soft - can be pureed, used as a dip, or a sandwich filling, thanks Hiba!
• Kirsten has a great suggestion of offering several courses, another idea is monkey platters
• dips - sour cream, hoummous, chocolate philadelphia, nutella
• cheese is great and you can use different types 
• some babies and youngsters love olives (Joseph used to!)
• soya based yoghurts and puddings, alpro do some lovely ones
• there are ready made powders you can add to food, but I would only use those on medical advice
• sugar, golden syrup, maple syrup

I think if you need to boost calories its good to use a variety. I do get concerned that if you are always giving a baby say double cream, they will get used to the taste and find it hard to accept food without it. There is a body of evidence that premature babies can be prone to obesity in later life. I think one of the factors could be the eating habits they developed as infants carry on in to later life.

I do think its important to remember that not every child is going to be on the 50th centile, and naturally some children will be small. It's a good idea to get a range of advice, especially if you are unsure about what is being suggested.

The other important thing to remember is that growth does slow down naturally, and once children hit around 2, the gap does close, Joseph, although still slender, isn't that different from his peers, although still in small clothes!

What are some of the ways you help your child eat a good diet rich in calories? Any favourite recipes?


 

Baby Led Weaning and It's Limitations

As you may have read yesterday, I read Gillian Rapley's Baby Led Weaning whilst pregnant, and again when Joseph was in special care. A lot of what I read made sense, until I came across a few paragraphs where Gillian advised she did not recommend it for extremely premature infants. I wanted to write a little about the limitations of baby-led weaning today.

What are the basic principles of baby led weaning? The first thing is, the baby decides when they start, not the parent. The parent offers opportunities to explore with food, but the baby always makes the first move. Babies use their hands to eat. It's more than just "offering finger foods", the baby might dip a fist into porridge, or even eat like a puppy! The baby decides what and how much they eat. There is not parent led spoon feeding. The baby might go on to use a preloaded spoon, but they decide what the do with it.

What are the problems with this style of weaning and premature babies? As I explained yesterday with premature babies, the general consensus in the UK is that the baby is weaned on their actual age, somewhere between 5-8 months. So with a baby born before 34 weeks especially, their motor skills, both find and gross are not going to be in line with the ability of their stomachs to process the food.

Babies who were born prematurely have specific dietary needs. They need iron rich foods, and calorie dense foods.  The Baby Led Weaning motto "food is fun until they are one" does not apply to the premature baby. In addition teeth can be late developing in preemies, Joseph didn't have a single tooth until he was one, where many term one year olds have 4 or more, which increases the range of foods you can offer. Iron rich foods, which are often meat based, are difficult to offer to a child under the age of one with no teeth and difficulty in manipulating food with their hands.

Is Baby Led Weaning really superior? There haven't been a lot of studies into baby led weaning. One study implied that babies who were baby led weaned as opposed to spoon food develop less of a liking for sweet foods. However, extremely interestingly for me, there is no difference in terms of fussy eating in toddler hood! Often baby led weaning is sold as the antidote to fussiness and that's simply not the case. If your going to have a picky toddler you are going to have a picky toddler!

What is the answer then? I think it's really important not to limit our premature babies, and to give up just because it's difficult for them to manipulate food in their hands and get it to their mouths, and masticate and consume that food. I came across this research from Glasgow which is exactly what I did. The researchers were concerned that in a minority of children (like mine) their nutritional needs would not be met by baby led weaning and they suggested a combined approach, offering finger foods at parents meal times and supplementing with spoon feeding.

Collaborative weaning I like to think I coined the term collaborative weaning to describe this half way house. Whenever I spoon fed Joseph I offered an equivalent finger food. So pureed mango was accompanied by slices. If we had apple porridge I offered slices of apple with extremely close supervision. I encouraged finger dipping and licking. I always adapted our meals for Joseph, so he could have what we were having.

In summary, for the vast majority of sub 34 weekers I think a pure Baby Led approach will be difficult if not impossible. I do think the pure spoon feeding method has limitations too and a combined approach is a good one.

Food is more than just about getting nutrition. It's a social activitiy. Food sharing, eating together and exploring are great fun, and important for future social development.  Manipulation of food aids fine motor skill development, and it also helps develop speech.  We need to get the balance right between nutritional intake and the other benefits of eating, and be willing to experiment.

Tomorrow I'll talk more about nutrition and calories and tips for enriching the food our babies eat.

How I Weaned Joseph

I find weaning, particularly with premature babies, to be such a confusing topic and something I am asked about often, so this week I am concentrating on weaning, but especially with premature babies.

When Joseph was in NICU I recall reading that premature babies are weaned on their actual age, that is from when they are born, not when they should have been born. There are three key reasons for this. Firstly the gut is processing food in one way or another from the moment they are born, as the placenta is no longer doing its job. Therefore it makes sense that the system will be ready for food at around 6 months of age. Secondly the developing premature baby needs additional iron stores. Yes they take supplements, but there are downsides to these, so the sooner food is established, the sooner this iron supplementation can finish. And finally, there is some evidence that weaning helps with speech, and I certainly have found this to be the case.

Initally, when pregnant I had read Baby Led Weaning by Gill Rapley. Expecting a fat termie, that's how I wanted to wean my baby. However Gill advises against BLW with babies born before 37 weeks gestations. I will post tomorrow about the limitations of Baby Led Weaning and how these can be overcome.

I decided that I would try and use the principles but adapt them to suit us. I started Joseph at 24 weeks actual age, which is chronologically 6 months (6 x 4 weeks). He was ready and had been for a few weeks. He mouthed for food and tried to reach out as much as he could. Being 13 weeks early meant his motor skills were way behind. I do think in termie babies this is often just copying behaviour, but in premature babies is often an indicator of readiness.

Joseph had avocado for his first food. I decided that for me the most important principle of Baby Led Weaning was less the finger food aspect and more the fact that the child is eating what the family is eating. I would have avocado on toast, and he would have it in a bowl.

Joseph quickly learnt to like a wide variety of food. I would always offer some finger good as well, and when possible the same foodstuff, so pureed carrot was accompanied by softly cooked sticks of carrot.

I found weaning really enjoyable, and I tried wherever possible just to puree up a bit of what we were having rather than cook seperate meals, which I found really easy. I did use Annabel Karmel  quite a lot too, and adapted her food for us.

I would like to say my approach has produced a well rounded brilliant eater, but at nearly 3 he's as fussy as the next toddler!

Such is life!

Weaning Your Premature Baby

I've been meaning to do some posts on weaning for ages, so this week, I have decided, is weaning week. If you have any questions post them on the facebook page or here and we (me and the other mums) will help where we can. There is so much experience here to draw from!

I wanted to share this video as this was in our early weeks of weaning. Tomorrow I will talk more about what we did and our experiences and I really want to get across that weaning can be fun. I also felt it was at this point I was growing in confidence as a mum and really getting to know Joseph as a person.

So to start off with if you are going to be weaning soon, and for premature babies that is between 5 to 8 months from their actual date of birth, not corrected age, the Bliss booklet is invaluable, and free. 

Silent Sunday