To expect weaning guidelines to be evidence-based?

[xtinak]

Well, perhaps they are evidence based but I'm having a hard time locating the evidence! Please help. My daughter is now 4 months and I am still so confused.

I know the NHS guideline is based on the WHO guidance, which is to wait until 6 months, or rather to exclusively bf for 6 months before introducing complementary foods.I get that it's a guideline. It seems unlikely that there wouldn't be differences between what exactly is best across, for example, countries, breast/bottle/mixed fed babies and of course for individual babies, but still the WHO guidance has to offer an answer that will do the whole world.

Thing is, I still cannot see a strong argument for the difference between 4 and 6 months when it comes to the UK. For example, the fact that ebf longer might possibly delay the return of my period seems beyond irrelevant!When it comes to increased infection risk, the increased risk seems quite marginal, the types of infection non-serious, and the whole thing is complicated by the fact that formula is defined as a complementary food, so sometimes such infection may be associated with introducing formula rather than solids. And we know that formula introduces this small extra risk and most people accept this small risk quite happily!There doesn't seem to be an adverse effect on weight gain of solids at 4 months, despite the logic of milk being more nutritious than solids.

Often on MN I see an argument is presented that the gut may still be 'open' at 4 months. I had assumed this was true as it is so often cited, but it doesn't seem to be!? I've been searching for a relevant study to no avail and the Science of Mom blog discusses it here:

scienceofmom.com/2016/05/03/whats-up-with-the-virgin-gut-do-babies-really-have-an-open-gut-until-6-months-of-age/

The NHS also gives a mysterious list of foods not to introduce before 6 months if you do start solids early. Fair dos on honey - no one wants botulism. But this list also includes for example, dairy. But why? A majority of babies will have already encountered dairy in formula. Or gluten. Why? Where is the evidence that gluten at 4 months is bad but at 6 months is ok? I can't find it.I'm actually going mad trying to get to the bottom of it all. And if you can show me with science that some of what I've asserted above is false I will be all to happy to learn. Please someone rescue my sanity.

Mine started solids at around 3 months, seemed very ready and keen. No problems then or after. Otherwise breastfed.

NewAccount270219, my 17w when weaning was sat independently, grabbing the spoon and making attempts to feed herself and could very much express a preference and certainly only accepted what she wanted. By 5m, she was able to feed herself some easy finger foods under supervision.

Her language skills were poor for quite a while, but motor development varies so much that you cant make assumptions about what feeding a 4 month old actually looks like. I know a 4m old who was crawling at that age...

I totally agree with you in general though - your approach sounded very sensible.
I weaned early to minimise the risk of allergies btw, not because I had an early sitter. If she hadn't acted enthusiastically to weaning, or blatantly wasn't ready I would have obviously held off.

It was just the idea that 4m weaning meaning semi reclined almost force feeding purees that I was challenging, though for some babies that probably wouldn't be that far off, but it varies so much.

Introducing solids is very much a parental choice and says nothing about development.

They are not evidence-based. In continental Europe the advice is quite different. The 6-month idea came from WHO to protect babies in developing countries where the risk from contaminated food/water is high.

NewAccount270219 I remember this too from baby groups with DC1.

Type 1: "I'm baby led weaning don't you know, food before 1 is just for fun. She nibbles occasionally on the end of a broccoli stalk but my breast milk is more than enough for her!!!"

Type 2: "My boy is SO HUNGRY he's grabbing from our plates already at 3 months old! He will be a rugby player like daddy!"

Reminds me why I hated baby groups! Where are the normal mums in the middle.

I found weaning incredibly stressful due to the lack of evidence and everyone having very strong opinions.

The espghan complementary feeding guidance was a long read but presented all options.
Great ormond street also had some more user friendly guidance from dietitians

I weaned both mine at 6 months or thereabouts. I didn't see the point in starting early. They were happy on milk until then, it's tedious and messy and I'd rather wait until there's a higher chance of them actually eating something.

The weaning age changed to 6 months (from 4 months) in 2003 just before I had my first. Health visitors at the time were therefore still operating in a bit of s grey area where somewhere between those two points was good. All the papers I looked at at the time seemed very clear pre 16 weeks was bad but I couldn’t see anything saying before 6 months was bad. So I weaned mine from 19-24 weeks. I also thought they were starting to rue the 6 month warning guidelines as allergy rates had continued to go up so much? And we’re now thinking some exposure when the gut was still leaky was important?

Where babies are concerned there’s is often a lack of evidence based information.

However, for practical reasons I would not have wanted to start weaning earlier than 6 months. It’s a total faff! All that extra cooking, washing, cleaning. Going back to work isn’t a reason to start early. Whatever childcare you chose will be experienced with weaning and a 4 month old will eat so little that by the time they’re 6 months old they will still be almost totally reliant on milk.

Thank you for this thread!
I have always thought it totally defies logic that there is such a wide range of ages for every other type of development - rolling, sitting, walking, talking etc, yet we are supposed to believe that EVERY SINGLE BABY is suddenly ready for food on their 6 month 'birthday' and not a day sooner or later.
We have recently introduced food to our 5 month old. For weeks now he has been desperate to eat - I'm talking launching himself towards food, arms outstretched, mouth open, screeching! Again, it seems illogical to me to suggest that human babies would evolve in such a way that they show every outward sign of being ready for eating, months before their gut is developed?!

I read the primary research on weaning when having DD. To summarise:

1. Solids younger than 3 months- bad. Risk of digestive problems in later life.

1. Solids later than 6 months- bad. Various risk factors, mostly allergies.

1. Stopping breast feeding earlier than 6 months- bad.

1. Solids 3-6 months- variable. Risk of bowel problems declines from 3 months and some benefits to allergy risks starting early.

Many, many countries advise weaning slowly from around 4.5 months. The reason the NHS don't is to encourage breast feeding and to make the advice simple.

All of these outcomes are averages, they don't necessarily mean much dealing with an individual child.

Having kids is hard. You make the judgement based on the situation you are actually dealing with.

They are evidence based. Well, sort of.

Not before 17 weeks is sound, backed up by research, can cause gastro issues potentially lifelong if you start before this point.

Wait until around 6 months - is more clever wording than a strict instruction. I believe this is a compromise in UK. Previous trends show parents tend to wean a bit before guidelines anyway and almost never after, so sticking to the very end of the recommended window means more parents wait until after 4 months, even if very few wait until exactly 6 (about 1%). And actually they don't especially advise weaning any later due to concerns about iron levels in breastfed babies (which may be unfounded, but the best evidence we currently have shows a concern here). Sometimes guidance needs to be based on what people actually do, rather than 100% best practice. There is no harm to a ready-at-4-months baby waiting an extra 2 months, but there could be harm to a 2-3 month old baby being weaned because they are "almost 4 months anyway".

UK advice about avoiding wheat, meat, dairy, egg etc until 6 months - potentially outdated - based on older theories that early introduction causes allergies. Possibly due to be revoked in next few years, but it takes a while for new research to enter UK guidance since it has to be checked and approved and of sufficient quality. I believe babies at high risk of allergy e.g. eczema, severe family history etc sometimes get to see a paediatric dietition or allergy specialist who can advise on whether earlier introduction of specific foods is appropriate.

"Three signs of readiness" based on baby led weaning - these seem to be consistent across many countries and I don't think they are purely cultural, but I can't find any hard evidence to base them on either, just practical considerations (sitting up with support - reduced choking risk, loss of tongue thrust reflex - that one probably is evidenced as it's been in guidance for decades, baby can bring food to mouth by self, taste and swallow - not sure on this but is a developmental milestone reached between 17 and 26 weeks, thought to be associated with readiness.)

There's no evidence it's anything to do with breastfeeding rates. Introduction of solids does not tend to correlate with stopping breastfeeding looking at infant feeding survey data. Introduction of formula does, which could be causal or could simply be that if you're planning to cut down on breastfeeding of course you're going to introduce formula if your baby still needs one or the other.

Other cultural point - UK culture tends to be that once you start on solids you ramp up very quickly (various weaning guides I've got suggest 3-5 weeks from first tastes to three full meals - whereas other countries' guidance indicates a much slower start building up to three meals over three months or so) - may be another reason for later guideline, so as not to push breastfeeding out too soon. (OK maybe that part is to do with breastfeeding).

Sitting is to do with choking risk so it's irrelevant whether they are sitting alone or with support. I reckon also in order to differentiate from the older image of a weaning-ready baby being reclined and having very runny foods from a spoon - this is not appropriate given the evidence that we have, but it's a strongly familiar image to anyone who had contact with babies in the 90s or earlier, which may well be today's parents as children, often the last time people have had regular exposure to babies before having their own.

There's no evidence it's anything to do with breastfeeding rates.

To be clear, I was not linking the two medically, but my understanding is that part of the thinking in the NHS advice is to try to give a really simple message which supports the breast feeding message.

FWIW I live in Germany and they recommend starting between 4-6 months here. In the first two weeks offering vegetables and potatoes, then meat and fish, after a month you add grains and dairy, after two months fruit (though fruit jars are also sold from 4 months). Eggs only from 9 months and are supposedly terribly dangerous so only one a week - and they have all kinds of terror over various acidic fruits like kiwi and citrus, (the US does as well) whereas the NHS is like "meh".

So I surmised from that that honey, excess salt and choking risks are the things to worry about and the timing of other things is largely cultural. Have done baby led weaning essentially from 4 months with both of my DC (one born 2008, one last year) - obviously they did not actually eat anything at first, I think DS1 was 22 weeks and DS2 was about 18 weeks when each managed a first taste. I am partial to the theory in said popular book that their outer development probably does reflect the safety of food (not nutritional needs), and I actively prevented them from having food before 17 weeks. Then DS1 was very enthusiastic at trying food but didn't eat very much at all until he was almost 2, and DS2 demanded to be spoon fed from about 5 months and is averaging 2.5 meals a day at 7 months. I gave him chunky/lumpy roughly mashed stuff and some 8m+ jars from the start, and he's done fine with that.

If you're interested in looking at evidence in a world context, though not especially useful for weaning advice, Gabrielle Palmer's book Complementary Feeding is interesting. I did get a couple of things from that - mainly that culture will always be the starting point that official guidelines start from with evidence layered over the top - so it's useful to tease the two out and see which are actually based in fact and which are simply the default based on "what we have always done". And also that young children may be unable to digest grains until around 2 years, so it's a good idea not to have them featuring too heavily in their diet.

I also found this post interesting/useful, though note the date - she doesn't take into account the newer allergy info:
www.analyticalarmadillo.co.uk/2010/12/introducing-solids-schedules-outdated.html

Oh and why not, have this one as well - it's a bit more ranty and less well sourced though: www.analyticalarmadillo.co.uk/2013/09/13-baby-led-weaning-myths.html

Ah OK. That's what I wasn't sure about - having looked at NICE guidelines it seems to still be based on allergy fears. I can't see anything about simplifying the message around breastfeeding.

Hmm never mind - you probably are right: "Current UK policy is to promote exclusive breastfeeding (feeding only breast milk) for the first 6 months. Thereafter, it recommends that breastfeeding should continue for as long as the mother and baby wish, while gradually introducing a more varied diet (DH 2003)."

NHS guidelines are outdated, they aren't taking into account newer research into allergies but I expect they will be changed eventually. Here is a good summary of what the evidence tells us (with references) www.uptodate.com/contents/starting-solid-foods-during-infancy-beyond-the-basics

Here in Finland they advise starting between 4 and 6 months (6 months at the very latest, the advice is clear that you should start before their half birthday) with vegetables until 5 months and then introduce grains and meat and fish. Weirdly they say no dairy until 10 months but I ignored that. I followed NHS guidelines with my first and she had multiple allergies. My youngest was high risk for allergies as his dad is allergic to nuts so I was advised to introduce nuts (ground up) straight away and he has zero allergies (remains to be seen if he will develop Coeliac disease like me and his big sister but I made sure to introduce gluten early this time rather than wait until later like I did with his sister)

Also here if there are weight gain issues with an exclusively breastfed baby after 4 months they advise introducing solids instead of topping up with formula to help keep the breastfeeding going.

I waited until six months at sheer laziness. Much easier for me to EBF and as a FTM I overreacted at every little gagging sound. I actually really dislike weaning. Oh, and the whole baby-led vs purée thing.

There’s solid evidence to start early if severe food allergies run in the family, so consult your pediatrician if that’s the case. Food allergies can be really difficult to manage so definitely worth doing everything you can to
minimise risk

I read up the guidelines from different countries and looked up the scant research around them, then decided to wean my baby around 5 months. I then noticed just before I was going to start weaning that her stools changed and when she started weaning was immediately a spoon grabber.

Not evidence but personal experience once they get to 6 months they can handle normal food (ie can sit up and have developed a gag reflex) this means you can do baby led weaning and no need for purees. My 1st I did purees and mashes my older 2 I did baby led and i found it much easier and less of a faff and no need to wean them onto lumps then real food. My oldest is also the fussest eater of the three which I often wonder if it's related.

Sorry I haven’t RTFT but why do you want to start weaning early? What benefits will it bring?

We have DS his first taste of solids (potato mixed with breastmilk) at 5 and a half months and in hindsight, I would have waited. The reason is, even though he was ‘displaying signs of being ready and was interested in food’ I honestly don’t think he was really ready until about 7 months old or so, when he started to handle solids much better.

In the past, before the invention of jars of baby food, people would give their baby milk until 7/8 months before giving them ‘normal food’ I.e. no mush from a jar.
Then baby food was invented and the manufacturers convinced parents to start on solids earlier and earlier until 3 months was the norm - obviously the earlier you start the more baby food you’ll buy.

I know this isn’t what you asked. You want scientific evidence which is far enough, but this is my opinion.

I have a 4 and a half month old and have been trying to look into this too. Baby Facebook groups most people are quite militant not before 6 months or it increases risks of ibs and coeliac etc. I've tried to research and can only find evidence suggesting increased risk before 4 months/17 weeks or after 7 months. Also yes bus advice says avoid allergens before 6 months but other advice says to try gluten by 6 months. It's hard to know what to do for the best! I have only just bought a high chair so will see if she can sit in it and if she can I might try starting purees only. I have seen things saying no solids until 6 months whuch implies liquids (like purees) are actually ok 4-6months. Most people my age were weaned at 3 months and survived. My husband does have ibs so would like to reduce risk of that but I can't find any evidence that weaning older than 4 months but before 6 increases that risk other than internet warriors saying so