Feeding premature babies solids

Introducing solid foods to preterm infants in developed countries

. 2012;60 Suppl 2:31-8.

doi: 10.1159/000335336. Epub 2012 Apr 30.

D J Palmer¹, M Makrides

Affiliations

Affiliation

¹ School of Paediatrics and Child Health, University of Western Australia, Perth, WA, Australia. [email protected]

PMID: 22555187
DOI: 10.1159/000335336

Free article

D J Palmer et al. Ann Nutr Metab. 2012.

Free article

. 2012;60 Suppl 2:31-8.

doi: 10.1159/000335336. Epub 2012 Apr 30.

Authors

D J Palmer¹, M Makrides

Affiliation

¹ School of Paediatrics and Child Health, University of Western Australia, Perth, WA, Australia. [email protected]

PMID: 22555187
DOI: 10.1159/000335336

Abstract

The addition of solid foods to an infant's diet is required to provide adequate nutrition, as eventually an infant will be unable to consume a sufficient volume of breast milk to meet their nutritional needs. The timing of this important dietary change for infants born preterm (<37 weeks of gestation) should take into consideration their delayed early gross motor developmental progress, increased nutritional requirements, organ immaturity, increased gut permeability and increased risk of hospitalization from infections. Good head control is important for safe eating of solid foods: this developmental milestone may be delayed in preterm infants up to 3 months of corrected age. One randomized controlled trial has demonstrated improved nutritional intakes with the introduction of nutrient-dense solid foods from 13 weeks of uncorrected age, resulting in improved nutritional iron status and greater rate of growth during infancy. There is neither current evidence for an increased infection rate with an early introduction of solid foods in developed countries, nor is there evidence that in preterm infants maturation of renal function is reduced. However, one observational study has determined that preterm infants who had 4 or more solid foods introduced prior to 17 weeks of corrected age, or who had any solid foods introduced prior to 10 weeks of corrected age, had an increased risk of eczema development. A compromise is needed to balance the nutritional benefits of commencing solid foods from 13 weeks of uncorrected age with the risks of increased eczema development, along with ensuring developmental readiness. Based on the current evidence, 3 months (13 weeks) of corrected age seems to be an appropriate age to commence nutrient-dense solid foods for most preterm infants. Further research, with an emphasis on immediate as well as longer-term consequences, would be valuable to provide more specific evidence-based guidelines regarding the introduction of solid food for preterm infants.

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Complementary feeding in preterm infants: a position paper by Italian neonatal, paediatric and paediatric gastroenterology joint societies.
Baldassarre ME, Panza R, Cresi F, Salvatori G, Corvaglia L, Aceti A, Giannì ML, Liotto N, Ilardi L, Laforgia N, Maggio L, Lionetti P, Agostoni C, Orfeo L, Di Mauro A, Staiano A, Mosca F; Italian Society of Paediatrics (SIP), Italian Society of Neonatology (SIN) and Italian Society of Paediatric Gastroenterology, Hepatology and Nutrition (SIGENP). Baldassarre ME, et al. Ital J Pediatr. 2022 Aug 5;48(1):143. doi: 10.1186/s13052-022-01275-w. Ital J Pediatr. 2022. PMID: 35932061 Free PMC article. Review.
Complementary Feeding: Recommendations for the Introduction of Allergenic Foods and Gluten in the Preterm Infant.
Chiale F, Maggiora E, Aceti A, Liotto N, Coscia A, Peila C, Baldassarre ME, Bertino E, Cresi F. Chiale F, et al. Nutrients. 2021 Jul 20;13(7):2477. doi: 10.3390/nu13072477. Nutrients. 2021. PMID: 34371985 Free PMC article.
Longitudinal Study Depicting Differences in Complementary Feeding and Anthropometric Parameters in Late Preterm Infants up to 2 Years of Age.
Gómez-Martín M, Herrero-Morín D, Solís G, Suarez M, Fernández N, Arboleya S, Gueimonde M, González S. Gómez-Martín M, et al. Nutrients. 2021 Mar 18;13(3):982. doi: 10.3390/nu13030982. Nutrients. 2021. PMID: 33803743 Free PMC article.
Introduction and feeding practices of solid food in preterm infants born in Salzburg!
Hofstätter E, Köttstorfer V, Stroicz P, Schütz S, Auer-Hackenberg L, Brandner J, Wald M. Hofstätter E, et al. BMC Pediatr. 2021 Jan 27;21(1):56. doi: 10.1186/s12887-021-02505-6. BMC Pediatr. 2021. PMID: 33499832 Free PMC article.
Complementary Feeding in the Preterm Infants: Summary of Available Macronutrient Intakes and Requirements.
Salvatori G, Martini L, The Study Group On Neonatal Nutrition And Gastroenterology-Italian Society Of Neonatology OBO. Salvatori G, et al. Nutrients. 2020 Nov 30;12(12):3696. doi: 10.3390/nu12123696. Nutrients. 2020. PMID: 33266017 Free PMC article.

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Starting Solids with your Preemie

I don’t know about you, but I couldn’t wait to start solids with my preemie. Anything that brought normalcy, and a sense of another milestone being hit felt victorious! Starting solids with your preemie or NICU grad is an exciting step.

I read up on conventional foods for preemies, as well as alternative and natural routes. It wasn’t until I began feeding my daughter solids that her needs became clear to me.

Our family tries to do everything as natural as possible, so food is a big topic in our house. I greatly wanted to do baby-led weaning with our preemie, but we quickly found out that her coordination just wasn’t there yet. Despite not wanting to do purees, we believed that it was the best decision for her health. Conventional advice suggests babies being on rice cereal, but with lots of research, and professional support we knew that rice cereal had no nutritional value, and that it would probably cause more harm to her already leaky gut. Through a lot of research, reading, and many talks with our doctors we found an incredible resource the Weston A Price Foundation. This became a great resource for healing our preemie’s gut and beginning to feed our preemie solids.

Here are my top 5 tips for starting solids with your preemie or NICU baby:

1. Wait

Seriously, wait as long as you can! Their little guts are underdeveloped and need extra time to heal. Breast milk is a great healer for getting digestion and immunity on track, but if that isn’t an option, an organic formula will do great. I know it’s hard to wait, but in the long run, it will benefit them. We received a lot of pressure from our pediatrician to start solids at four months (two months adjusted), and that is when we decided to find a more holistic doctor. I am so thankful that we made this switch because her gut has mostly healed, and she is on a great track with her weight gain. The problem arises when only one aspect – like weight gain – is addressed, rather than the whole picture. The dangers of leaky gut syndrome are far reaching and don’t resolve themselves.

2. Use real food

When starting on solid foods, start with real foods like banana, avocado, apples etc. that have more nutrition than packaged foods. Feeding my daughter only enhanced my real food journey, I began to understand that foods that came in a package, even those that were organic, were limited on nutrition. I began making my own baby food for her, and I loved knowing that she was getting a great start to life.

3. Good fats!

Healthy fat is so important for babies, especially preemies. Did you know the human brain is made of almost 60% fat? This means that in order for our little ones to develop well, extra fats go a long way. Good fats like avocado, coconut oil, butter are a good way for your baby to get full and be healthy. We literally put fat in every meal that our kids eat, and have seen great results from this. We love knowing that good fats help them digest their meats and vegetables and give their brain an extra boost.

4. Be patient

Watch your baby for signs of readiness. Can they sit up un assisted? Are they curious about what’s on your plate? Do they seem hungry after nursing or a bottle? If yes, then give it a go. If baby pushes the food away or doesn’t take much, don’t worry. In time they will. Just enjoy the moment and remember that each baby has their own process.

5. Have fun!

Starting solids with your preemie or NICU baby and making your own baby food can be a ton of fun. I always loved finding healthy real food recipes for my preemie and finding her favorite flavors. There are so many options for making and storing baby food now that it is actually really easy!

It won’t be long before your little one will be a big one, eating burgers and fries and going to the mall with their friends. Enjoy this tiny season by savoring the moments and having a gentle beginning. Please consult your doctor or pediatrician with any of these issues, and feel free to find a pediatrician that you can agree with and take their insight and make it a reality.

Happy eating!

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Complementary foods for premature babies - Articles about baby food from pediatricians and MAMAKO experts

Premature babies are babies born before the 37th week of gestation. Prematurity is not determined by birth weight, but by the date of preterm birth.

- Alla Anatolyevna, premature babies have special nutritional needs from the first days of life. What factors influence the initiation of complementary foods in preterm infants and when to introduce complementary foods to a premature infant?

— There are different degrees of prematurity, so the principles of feeding and nutrition of children will also be different.

Timing of the introduction of complementary foods in premature babies

— From birth, a premature baby receives only breast milk or powdered milk formula, but there comes a time when he can no longer satisfy his needs with them. The main task of complementary foods is to diversify the diet and increase the amount of nutrients - proteins, fats, carbohydrates - so that the baby can fully grow and develop.

When a baby is born on time, it is started on solid food at 5.5-6 months. Pediatricians determine when it is time to feed a premature baby as follows: the term of his prematurity is added to the age of the baby. For example, a child was born at 35 weeks, 5 weeks ahead of schedule: for these five weeks, the timing of the start of complementary foods is shifted for him.

The main signs of readiness for complementary foods:

the child looks healthy, feels good, smiles, cheerful;
children are active, have muscle tone, are physically well developed;
twofold weight gain since birth;
good sleep;
a chewing reflex appeared - the child begins to chew, bite;
good appetite - if the child wants to eat, he will be happy to receive vegetables;
the baby sits independently - the child should receive complementary foods while sitting at the table; it is desirable that he sees the product he eats;
active interest in what parents eat, desire to participate in family meals.

— Proper complementary feeding of premature babies increases the nutritional value of their diet and certainly helps to catch up. Then why not start feeding babies earlier?

— A premature baby has an immature system of the gastrointestinal tract, an immature enzyme system. He does not mature in the womb of his mother, but on his own. Therefore, in the tables of complementary foods for premature babies, the time for the introduction of complementary foods, as a rule, is postponed for the period that the child did not sit in the tummy. With age, the number of villi in the intestines increases, the pancreas begins to work better, more saliva is produced: this means that it is time to introduce complementary foods - gradually, consistently, under the supervision of a doctor.

- Complementary feeding of a breastfed premature baby and complementary feeding of a formula-fed premature baby will be different?

— There are many guidelines for the introduction of complementary foods for premature babies, and they are available in print and online. But before the introduction of complementary foods to a child who was born prematurely, especially a very premature one, it is necessary to visit a pediatrician. The doctor who leads and observes the baby prescribes complementary foods, taking into account his individual characteristics.

- Let's say a child cannot gain weight for a long time. Is the timing of the start of complementary foods even more shifted?

— Premature babies have a more pronounced weight curve and better weight gain than term babies. If a child has not gained proper weight by the age of introducing complementary foods, this means that his nutrition is chosen incorrectly or insufficiently, there are some problems with digestion. In this case, you first need to establish basic nutrition, select supplementary foods, double the weight and get in good physical shape - and only then start complementary foods.

Complementary foods are additional nutrition for healthy children who have no complaints. Therefore, digestion problems should not be solved with the help of complementary foods, and weight gain with the help of complementary foods will not work.

— What complementary foods should be given to a premature baby?

- The first complementary foods for premature babies are two main types of food:

Complementary foods for a premature baby will not differ much from complementary foods for a full-term baby, because by the time solid foods are introduced, a premature baby should get rid of problems with the gastrointestinal tract, become stronger , grow up. And the parents start complementary foods, almost forgetting that the baby was born prematurely.

— What is the right way to feed such a child?

— The basic rule for the introduction of complementary foods for all babies (premature babies are no exception) is gradualness.

How much complementary foods to give
- Complementary foods begin with a teaspoon. Each next portion can be doubled, so they come to full feeding only after two to three weeks (full-term babies receive a full portion after five to seven feedings).
When to give complementary foods
- It is more correct to give a new product in the morning. If something does not like it or the baby burps, there will be time to calm him down, observe and decide what to do next.

— Besides being underweight, when should we delay or stop giving the baby new foods?

- Pediatricians pay special attention to the following signs:

the child has not doubled its birth weight;
with a lack of weight, complementary foods were introduced and stomach problems began - regurgitation, bloating, anxiety when feeding, a different character of the stool - liquid, frothy, with a changed color and smell;
began to introduce complementary foods - skin problems appeared: dryness, redness, itching.

- Baby food based on goat milk is better absorbed by the body of children. Is it suitable for premature babies?

- The good digestibility of goat's milk helps premature babies gain weight better at the stage when the PRE formula is no longer used. And here mixtures on goat's milk for artificial and mixed feeding can be recommended. Gluten-free fortified cereals with goat milk MAMAKO ^® can be used for the first feeding of premature babies (they do not need to be boiled, formula milk or expressed milk as a supplement is not required). For further complementary foods, multi-cereal cereals, fruit curds and cream soups can be advised. The same milk base of mixtures and complementary foods helps the digestive organs adapt faster when switching from one product to another.

Premature babies are born before 37 weeks of gestation. And they take longer to mature for solid foods, so complementary foods are introduced a little later than healthy babies. New food is given gradually, taking into account those features that the doctor will reveal during the examination.

* Breast milk is the best food for babies. WHO recommends exclusive breastfeeding for the first 6 months of a child's life and continued breastfeeding after complementary foods are introduced until the age of 2 years. Before introducing new products into the baby's diet, you should consult with a specialist. The material is for informational purposes and cannot replace the advice of a healthcare professional. For nutrition of children from 6+ months. The product is certified.

Article | Complementary foods: start on time

The introduction of complementary foods is an important life stage for both the child and the mother. Ekaterina Kostennikova, a breastfeeding consultant, and Olga Novichkova, a child analytical psychotherapist, talk about how to properly introduce a baby to new foods and whether there is a difference in the introduction of complementary foods in premature babies.

The right time

With the start of complementary foods, the baby expands his experience of interacting with the outside world - he gets acquainted with new tastes, smells, sensations. The introduction of complementary foods contributes to the process of separation of the child, if it is correlated with this important developmental stage in time.

WHO recommends that children who are exclusively breastfed should begin complementary feeding no earlier than six months of age. From about this age, the child's needs for nutrients and energy can no longer be 100% satisfied with breast milk, and the introduction of other sources of nutrition becomes a necessity.

With any type of feeding, WHO recommends introducing complementary foods no earlier than 4 months of age. Until this age, the child's neuromuscular coordination is not sufficiently developed, which allows the formation of a food bolus and swallowing it, therefore, the gag reflex is triggered, as well as the reflex of pushing "foreign" objects out of the mouth with the tongue.

It was because of these reflexes that in the Soviet years the recommendation to start complementary foods with fruit juices was widespread. However, over time, it became clear that this approach has unreasonably high risks for the health of the child: fruit acids are too aggressive a product for the child's immature digestive system and therefore can harm the gastrointestinal tract. Other risks of starting complementary foods too early also include a high likelihood of food allergies.

As for premature babies, that is, babies born before the 37th week of gestational age, they need more careful attention. If the baby was born only 1-3 weeks ahead of schedule, then, most likely, the difference with children born on time will already level out by six months and prematurity will not affect the start of complementary feeding in any way.

At the same time, babies born before 34–35 weeks of gestation require an individual approach. The main thing is not to create an excessive load on the immature gastrointestinal tract of a child who is not yet ready to receive adult food. The mother of a premature baby should be guided by the developmental standards established by pediatricians and the general signs of the child's readiness for complementary foods:

food interest;
ability to hold the head and be in a semi-sitting position with support;
extinction of the ejection reflex of the tongue.

Complementary feeding guidelines for premature babies

Babies born prematurely, especially those with VLBW (very low birth weight) and ELBW (extremely low birth weight), often lag behind in development. For a more accurate assessment of development, one should rely not so much on the weight itself, but rather compare it with the height of the child and, by linking these two indicators, judge physical development.

Particular difficulties arise in children with severe damage to the central nervous system, bronchopulmonary dysplasia and other serious diseases. In such situations, correctly introduced complementary foods significantly help the child's body to return to normal.

However, according to WHO recommendations (hereinafter information is provided from the Guidelines for the WHO European Region with a special focus on the republics of the former Soviet Union "Feeding and nutrition of infants and young children"), small children grow and develop normally if they are exclusively on breastfeeding! At the same time, it is important for them not to introduce complementary foods too early (before 6 months), as this slows down physical development.

Complementary foods should not be introduced before the age of four months - until this time, neither the digestive system nor the metabolic processes have yet "ripened" to the full.

Exclusive breastfeeding for up to 6 months has health benefits for babies. Complementary feeding before 6 months is justified in case of obvious lack of weight during breastfeeding. Its later appointment (after 6 full months of passport age, which is equal to 26 weeks) is also not recommended due to the lack of a supply of micronutrients in the body and frequent lag in physical development.

In general, the principles of introducing complementary foods to preterm infants are the same as for full-term infants. Products are introduced slowly and gradually. Preference should be given to freshly prepared food with little use of water (for example, stewing instead of boiling or steaming), as well as industrial baby food products, since they are prepared using environmentally friendly raw materials, they have a guaranteed composition and an age-appropriate degree of grinding, enriched vitamins and minerals.

For premature babies, attention should be paid to the presence of proteins in their diet, which are necessary for accelerated growth. The following amino acids are important: cysteine, taurine, tyrosine. As for the lack of iodine (if detected), then premature babies need it in an increased amount. Also, the need for iron should be attributed to the characteristics of premature and underweight children: they need a good food source of iron earlier than full-term ones.

In small children, the motility and microflora of the gastrointestinal tract are often impaired, so the order of introduction of products is determined individually.

Throughout the introduction of complementary foods, it is essential to increase the nutritional value of the diet by adding foods to the diet, rather than displacing formula or breast milk. This product remains the main source of nutrients for the child of the first year of life, and possibly even longer.

Stages of introduction of complementary foods

Complementary foods can be divided into 4 stages, in which the relationship between the development of the physiology of the child and the need for trace elements is presented.

Stage 1

When introducing complementary foods, the first task for a child is to learn how to eat from a spoon. The suggested small amount of food at the tip of a teaspoon will allow the child to learn to remove food with their lips and move it around in their mouth for swallowing. As the first products, mashed one-component products are suitable: cereals (except wheat), boiled at home and mashed rice, mashed potatoes, soft, thick porridge from cereals or vegetables. Complementary foods should be given 1-2 times a day after breastfeeding or formula.

Stage 2

After getting used to spoon feeding, children are ready for new foods, and the indicator is the ability to sit without support and transfer objects from one hand to another. It is possible to introduce well-cooked and mashed meat into the diet (especially the liver, which is well suited in terms of consistency), vegetables, fruits, legumes, grain products. New tastes should be introduced along with previously familiar dishes. Food can be given lumpy, coarser in structure - mixed with mashed potatoes. Frequency - 2-3 times a day.

3rd stage

It is marked by the development of more precise motor skills, the appearance of teeth. It is important for parents to encourage motor skills by allowing them to take food with their fingers (eating with their hands). Dairy products can be included in the diet (liquids - in a cup), after 9 months, when breastfeeding is completed, cow's milk is acceptable. Features of food are as follows: softened, mashed into large particles. The diet can include fruits and vegetables, legumes and some fish, meat, liver, eggs, cheese, kefir. You can spread a little butter on the bread. Meal frequency - 2-3 main meals, with light snacks in between (yogurt, kefir, apples).

Stage 4

Focuses on developing independent eating skills. Products mashed or chopped, cubes of fruit, vegetables, cheese, bread. The restriction should be introduced on fatty foods and salt. In general, by the age of one year, children can eat food from the family table, which means the end of complementary foods and the transition to regular food with slight adjustments for age (fatty meat, mushrooms, sweet cakes, etc.).

Products

Cereal products are rich in carbohydrates, micronutrients (but also rich in phytates, which negatively affect the absorption of micronutrients), cysteine. Potatoes are rich in vitamin C and are a source of thiamine. Vegetables and fruits are important as sources of non-nutritional substances (antioxidants) and dietary fiber, vitamins C, A, group B. Dark green vegetables are rich in folate, potassium, and magnesium. Lean meats and fish are good sources of zinc, while liver is an excellent source of protein and essential micronutrients such as taurine and tyrosine. The liver is exceptionally rich in iron and is well absorbed.

Eggs are widely accepted as a versatile food with high biological value (they contain cysteine, taurine and tyrosine, which are important for premature babies), but it is not advisable to introduce proteins into the diet before 6 months - they are associated with allergic reactions.

Dairy products should not be given in large quantities until 9 months, and cow's milk should be given directly between 9 and 12 months. Fermented milk products - yogurt and kefir - are rich in calcium, protein, phosphorus and riboflavin, cheese is rich in calcium, sodium, vitamin A, and contains the amino acid cyrosine.

Fruit juices are safe and healthy in small amounts, but only juices without artificial sweeteners or simple carbohydrates. Honey, tea and herbal teas should not be given to infants due to the negative effect on the absorption of important vitamins and trace elements.

Infant formula is used when micronutrient fortification is required. Together with them, homemade food should be given for a greater variety of taste sensations and textures.

How to increase the energy density of complementary foods

1. Add less water in favor of a thicker product (viscosity should be appropriate for the child).

2. Replace most (or all) of the water with breast milk or infant formula.

3. Add milk powder, vegetable oil, fat to thick porridge no more than 1 teaspoon per 100 g of product.

4. Introduce fruits and vegetables, liver, meat, fish, kefir, eggs into the diet.

More than just food

For children, trying new tastes and textures opens up a new world of sensations that they have never experienced before. This expands the mental space of the child and contributes to its development. The insular lobe of the cerebral cortex is responsible for taste recognition, among the functions of which are the perception of body signals, emotions, empathy. Comparing the age recommended by WHO for the start of complementary feeding with the development of the psyche, mutual patterns are visible.

From about six months of life, the baby got used to the image of his mother, adapted to the world around him and began to "let" the world around him into his consciousness. The increase in external stimuli in accordance with the possibilities of their processing by the child's body helps to increase the idea of the world around and oneself more and more, thereby developing the little person.

Way of knowing yourself and the world around you

What is new food for a child? Something unknown, but helping to know your feelings through taste. Food, which is not directly related to mom, is thus a kind of bridge to independence. Now hunger begins to be satisfied not only with mother's milk, but also with the help of something else that can also nourish. Thus, the mother is still close and needed, but symbolically her vital significance is reduced. This moment is the very beginning of the relationship's transformation from dependent intimacy to trust and true love.

The child can eat new different foods on his own - with his hands, with a spoon, holding a bag of mashed potatoes. In addition to the further development of fine motor skills, this helps to form independence, the right to choose what and how to eat, smearing complementary foods as preparation for the next stage of child development. All these new sensations are large in scope, but the child is already able to assimilate this experience and use it for good.

Complementary foods symbolically turns the child to self-knowledge, contributing to the development of individuality.

Communication with mother

When introducing complementary foods, mothers need to remember that until the age of one, complementary foods are an additional, but not the main source of nutrition for the child. Breast milk or its substitutes are still the main ones. This is due to several factors.

1. The nutritional value of breast milk is not comparable to foods that are usually introduced as first complementary foods (for example, mashed squash has only 15 kcal per 100 g, while breast milk has calorie content of 70–80 kcal).

At the same time, the capacity of the stomach in infants is still small - about 30 ml per 1 kg of body weight, so the child is not yet able to consume large amounts of food. And if at the same time its nutritional value is low, the child's needs for energy and nutrients will not be satisfied.

2. The need of a six-, seven-, eight-, and even twelve-month-old (one-year-old) child in close contact with the mother is no less than that of a one-month-old baby. The gradual introduction of new food along with the presence of the mother will calm the child from the excitement of the new experience. For both the child and the mother, a gradual transition from dependent intimacy to not so dependent freedom and the right to choose is important.

When a mother finds a way to give closeness to her baby beyond breastfeeding, it supports the baby in the transition to separation, as the vital need for food no longer comes so directly from the mother.

It should also be noted that suckling (mother's breast, her substitute, but in mother's arms, with mother's smell, loving look) satisfies the most important need for basic security. The transition to biting from a purely sucking reflex has its origins in other senses, thereby developing the psyche.

Better not be late!

Delaying the start of complementary foods can also have adverse health effects on the baby. Among the risks of starting complementary foods too late (after 8-9 months) are the following:

growth retardation and lack of energy and nutrients;

development of micronutrient deficiencies, especially iron and zinc;

delayed development of chewing skills and loss of food interest;

delay in the skill of bringing objects to the mouth - will slow down the development of fine motor skills and the development of the child as a whole.
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