ARTICLE IN PRESS

Current Paediatrics (2004) 14, 8396

www.elsevierhealth.com/journals/cuoe

CURRENT PAEDIATRICS

Weaning: a worry as old as time

D.P. Daviesa,b,*, B. OHarea,b
a

University of Wales College of Medicine, Wales, UK

University Hospital of Wales, Heath Park, Cardiff CF14 4XN, UK

KEYWORDS
Nutrition;
Infant;
Weaning;
Breast-feeding;
Developing countries;
Health

Summary Against a background of an historical appreciation that sets the scene for
our current understanding, this article highlights present day practices in weaning,
the process of gradually replacing breast or bottle milk with solid foods as the main
source of nutrition for the young infant. Gastrointestinal, renal and nervous system
preparation provides the biological determinants for when weaning should begin.
The major nutrients of the weaning diet that best provide for optimum growth,
development and health are outlined. This understanding serves to help appreciate
the ideal programme of weaning and how its adequacies are best monitored,
traditionally by the correct interpretation of serial weight measurement. Modern
controversies are touched upon, especially the definition of weaning and the
particular problems of certain vulnerable infant groups. Finally, the worry and
concern still expressed by mothers, carers and health professionals alike about
weaning, is highlighted. This largely reflects the lack of a strong evidence-base for
the weaning process: further research in this area is needed.
& 2003 Published by Elsevier Ltd.

Practice points
*

Weaning, the process of gradually replacing breast milk or formula milk with solid
foods, continues to cause anxiety to
mothers, nurses and doctors alike
Biological determinants of weaning require
preparation of the young infant especially
in relation to maturity of the nervous
system and its neuro-muscular coodination; a functionally mature gastrointestinal
tract that can digest and absorb nutrients
and have sufficient motility; renal function
that must allow the young weanling to
cope with an increased solute load

*Corresponding author. Tel.: 44-1443-238-190.

E-mail address: daviesdp@cardiff.ac.uk (D.P. Davies).
0957-5839/$ - see front matter & 2003 Published by Elsevier Ltd.
doi:10.1016/j.cupe.2003.11.006

Current UK recommendations are, for the

majority of infants, whether breast milk or
formula fed, to be introduced to solid
foods between 4 and 6 months. This
contrasts with recent World Health Organisation (WHO) recommendations, heavily
influenced by the situation in resourcepoor countries, which recommend exclusive breast-feeding for 6 months
The scientific basis of weaning is the
requirement for food energy, protein, fats,
major minerals, iron, vitamins and other
micronutrients to satisfy normal growth
development and optimise health
The weaning period, which lasts between 6
and 9 months, has at its broad expectation
the basis of a healthy adult type diet given
in 3 meals a day interspersed with small
snacks, with milk still an important food

ARTICLE IN PRESS
84

D.P. Davies, B. OHare

Special considerations need to be given to

weaning in vulnerable infants, including:
those at risk of atopic disease; pre-term
and other low birth weight infants; those in
minority cultures, especially where the
mother might be of vegetarian/vegan
tradition; and infants in economically poor
countries especially those where there is a
high risk of HIV
Adequacy of the weaning process is still
best conventionally monitored by measurement and correct interpretation of weight
gain
Many mothers do have difficulty adhering
to conventional advice and introduce solids
before 4 months of age. Evidence is
emerging that this may often be related
more to social tradition rather than by
biological necessity. It remains to be seen
whether early weaning is associated with
either short or long term significant impairment of health.

Introduction
Many errors are daily committed in the method of
weaning children.
Treatise on the management of female complaints,
Alexander Hamilton, 1792
She shall feed the child only on (mothers) milk, but
when he has cut his front teeth it is well to accustom
him to more solid food, as women do of their own
accord, having learnt by this experience.
Galen of Pergamun, 170 A.D

The Jelliffes, those powerful advocates of breastfeeding throughout the 1970s and 1980s, reminded
us many years ago of the notion of the human newborn as an extero-gestate fetus for the first 9
months or so after birth. Over this period of
specially rapid growth and development the young
infant is, in biological terms, completely dependent on the mother for warmth, protection and
food, with the breast serving as an external
placenta. Nature then dictates that mothers milk,
in both its quantity and nutritional qualities,
becomes gradually nutritionally insufficient for
her babys growth and special nutritional needs,
necessitating the extero-gestate fetus to become a
transitional being, getting accustomed to new
foods of ever varying textures, tastes and nutrient
densities, until a full mini adult diet is reached.
It is the process of gradually replacing breast
milk, or in the modern world, formula milk, by solid

food as the main source of macro and micronutrients and energy that is embraced by the term
weaning, a word derived from the Anglo-Saxon
wenianFto accustom. But some variation in
definition does exist. Thus a recent (2002) World
Health Organisation (WHO) definition uses the term
weaning to indicate a complete cessation of breastfeeding.1 Interestingly, this concept is embraced in
some Romance cultures where, for example, in
French weaning is referred to as servage and in
Spanish, destetar, both words referring to separation from the breast. More conventionally weaning
is used to describe a period, not a single event,
where there is a gradual replacement of milk
(whether breast or formula), with its high fat, low
carbohydrate content, by non-milk foods of low fat
and high carbohydrate makeup. This latter definition is preferred in this article, being more realistic
in contemporary western societies.
The matter of weaning continues to cause more
anxiety to mothers, nurses and doctors than almost
any other issue in paediatric nutrition. But, perhaps
this should not come as too much of a surprise since
in this aspect of infant nutrition comparatively
little research has been undertaken, especially in
terms of the best age to wean, what constitutes the
most appropriate weaning foods and also what
effects weaning has on long term health. This
article offers a working synopsis of prevailing
views. Hopefully this will go some way to remove
some of the widely held trepidation!

HistoryFa necessary prelude to

contemporary understanding
Throughout history, frequent reference is made to
the weaning of the baby from the breast. From
biblical times written references to weaning have
often appeared in scrolls, diaries, journals, papers,
books, many written, perhaps surprisingly, by men!
The likely reason for such preoccupation is that
weaning was (and in many economically poor
countries is even now) the most dangerous period
in early childhood, through its associations with
particular diseases often leading to high mortality.
Thus in 18th century London up to 70% of infants
failed to survive their second birthday, a major
contribution to this appalling death toll being some
of the more common weaning diseases, especially
gastrointestinal infections.
Weaning from the breast was also a period of
change not only of diet but also of station. A
suckling was an infant with all that this implied,
but once the breast was left for good, the baby was

ARTICLE IN PRESS
Weaning: a worry as old as time

then generally regarded as a true child and as such

became a real member of the family. The upper
class child left the wet nurse and returned home to
the biological mother, while among the poorer
classes they were no longer fed at different times
but ate out of the family pot.
Until the dawning of the modern industrial era in
western countries early in the 19th century, advice
about weaning was dominated by the writings of
the Greek/Roman school of thought, led especially
by Soranus of Ephesus (90117 AD) and Galen of
Pergamun (130200 AD). For well over a thousand
years of literature on weaning, there is constant
reference made to these medical authors and their
pupils. Indeed even the widely respected writings
of the Byzantine and Arab schools, so dominant in
the middle ages, seem simply to have adapted this
ancient teaching to their more contemporary ways.
The discovery of the printing press in medieval
Europe towards the end of the 15th century further
cascaded these ancient teachings. There is much
common sense in all of these writings, some are
even evidence-based, and their understanding is
fundamental to the appreciation of current concerns about weaning in the modern world.

When to start?

85

does seem to be a difference between introducing

foods (the paps and the panadas) as a complementary food to breast milk, and the weaning process
itself which not uncommonly proceeded well into
the second year of life when children would be in
possession of several teeth and be capable of
sitting at the table and possessing some ability to
feed themselves. A theme condemned by many
medical writers was the custom of giving foods prechewed by the nurse or mother.
Down the ages it has also been a common
practice to give the infant alcoholic drinks,
especially gin, grape wines and brandy in the
wealthy families and beer in the poor, a custom
that achieved great popularity during the late 17th
and 18th centuries (Fig. 1).
Although it is now unthinkable that a child as
young as 612 months of age should be given
alcoholic drinks it has to be recognised that until
the development of clean water supplies, water
was rarely drunk by the general population because
of its widespread contamination. The most common
drink with a fairly high alcohol content for people
in Britain was ale, beer, or small beer, although
small beer was much weaker. It was therefore not
surprising that once a child was weaned and ate
similar food to the rest of the family, it was also

Surprisingly, when the baby should be initially

taken off the breast is not an aspect which receives
much consideration, since medical authorities
seem to have assumed that women would give
additional foods either when the child appeared to
be ready for them, or according to custom among
family and friends. (How little things have changed!) Sometimes it seems to have been the
eruption of teeth that offered guidance, but the
age at which foods other than breast milk were
actually first given was probably much earlier than
the time recommended by physicians and midwives
(again nothing new here!). Throughout history
there has also been an important thread that it is
the child rather than the mother who should decide
when weaning should take place.

What to give?
Initial foods commonly given to infants up to the
modern era included paps and panadas. Paps were
foods made of flour and bread cooked in milk with
additives for flavouring or added nutrition; panadas
were stews of bread, broth, milk and eggs. Many
recipes used to be made up from these foods;
indeed, in many parts of the developing world paps
and panadas are still widely used. However, there

Figure 1 yythroughout history it has also been not

uncommon practice to give the infant alcoholic drinks.
Taken from Hogarth, Gin Lane 1751. Note the infant
being fed gin. (Taken from Fildes, V.)

ARTICLE IN PRESS
86

natural for them to have the same drink. The

following quotation by the Edinburgh doctor,
William Buchan (1769) in his book Domestic
Medicine; or The Family Physician says it all: All
strong liquors are harmful to children. Some
parents teach their children to guzzle ale and
other strong liquors at every meal, but such a
practice cannot fail to do mischief: milk water,
butter milk or whey make the most proper drink
for children. If they have anything stronger, it may
be fine small beer, or a little wine mixed with
water.
But some interesting pointers to the beginning of
the weaning process do emerge. Soranus advised
that babies should be breast-fed completely for 6
months, although this was far from the actual
practice at that time. He also recognised that it
was bad to withhold solid foods until the child was
too old since this would lead to digestive problems
and difficulties in adapting to new foods. The Koran
advised the beginning of weaning at 2 years, but
this is not in any way a strict ruling, allowing the
child to be weaned earlier if necessary. In the 16th
century the ideal age for introducing mixed feeding
seems to have been between 79 months, but
apparently during the late 17th and 18th centuries
much earlier weaning from the breast was favoured, as early as 24 months. If there is a general
overall message that comes down the ages it is
that the process of weaning was recommended over
the wide age range, from 624 months. Late
weaning seems to have been advised for weak
or treasured children, but from the late 17th
century, a long suckling period did attract the
disapproval of many medical writers. Other factors
also considered when weaning a child early
included the help of a nurse and the state of the
mothers milk.

How to wean?
Most medical writers agreed that gradual weaning
is preferable to sudden weaning, a very cruel
practice sadly still all too prevalent in some
developing countries. Ways in which weaning from
the breast was achieved included giving food prior
to breast-feeding and encouraging suckling only at
night. But sometimes it was so very difficult to
wean the child from the breast belonging to the
mother or wet nurse that it was necessary to anoint
their breast with mustard, or by rubbing the top of
the nipple with aloe and other bitter substances.
Recall the words of the nurse in Romeo and Juliet
(c. 1594), who tells of the traumatic day of Juliets
weaning when 3 years old y

D.P. Davies, B. OHare

And she was weaned, I shall never forget it,

Of all the days of the year, upon that day;
For I had then laid wormwood to my dugy.
When it did taste the wormwood on the nipple
Of my dug and felt it bitter, pretty fool.
To see it tetchy, and fall out with the dug.

These methods were, perhaps not surprisingly, very

traumatic for the child and probably even more so
for the mother. Indeed, perhaps this was causally
related to the high prevalence of melancholia in
the mother that was written about so much during
the 16th and 17th centuries. Any obvious distress to
the baby accompanying weaning was soothed by
administering laxatives, alcohol and even opiates.
In the western world in industrial times, there
does appear to be a gradual decrease in the age of
weaning which probably relates to the growing
availability and the social acceptability of artificial
feeding, the fall in the number of wet nurses for
the middle classes and the movement of the
population from the countryside into towns. The
beginning of industrialisation also began to see
children weaned progressively in a way similar to
today, beginning with pureed or minced food
containing milk or broth, and progressing to foods
eaten by the rest of the family, mashed and cut into
small pieces as the child becomes older.

Importance of milk: the diseases of weaning

An important aspect was the recommendation for
foods containing milk being an important part of
the weaning diet, with the increasing awareness of
specific diseases resulting from deficient weaning
practices, especially scurvy, rickets (Fig. 2), bladder stones, night blindness and a very low
resistance to infection. Indeed it appears that the
18th century saw a definite decline in the nutritional value of foods when compared to the 16th
century. Surprisingly the diet, especially that of the
wealthy, did not include many milk or milk
products. This diet of mainly cereal and meat,
excluded vitamins A, D and C, also the amount of
calcium it contained was insufficient for a growing
child. Hence the laying down of the seeds of some
specific diseases of weaning. Poorer families,
however, seemed paradoxically to have a different
type of diet consisting mainly of bread, cheese, mill
salt, meat and pulses, so the poorer child was
probably much better fed in nutritional terms,
providing that enough food was given. White meats
and dairy foods, including eggs were eaten by the
poor and many cottages in the countryside kept a
cow, so milk was far more likely to be drunk by
these families than by the wealthy. But for as long

ARTICLE IN PRESS
Weaning: a worry as old as time

87

The Present
When to begin?
The timing of introducing non-milk foods is conditional on some important physiological determinants that are needed to prepare the young infant
for the nutritional transition that constitutes the
weaning process:
*

Figure 2 Rickets was noted a prevalent disease in the

18th century, a condition particularly associated with
weaning. The skeleton of Bowed Joseph, an 18th
century Edinburgh character whose skeleton is in the
Anatomy Museum of Edinburgh University. (Taken from
Fildes, V.)

as milk was in the diet, irrespective of the type of

milk, bone disease was less common.
The gastrointestinal disorders of weaning were
well described by the Scottish surgeon, John Aitken
in 1876 This is a violent purging frequently
attended with vomiting, wasting, etc. Causes: 1)
early 2) weaning improper food Cure: removal of
causes. This is a good description of weanling
diarrhoea so prevalent in areas of India, Africa and
Central America today, where stunted growth,
leanness and wasting are still associated with early
weaning.

The nervous system needs to have acquired a

level of maturity of neuromuscular coordination
that permits the safe taking of solid food from a
spoon and its movement as a bolus though the
mouth into the upper gastrointestinal tract to be
swallowed. Head control also has to be sufficiently mature to maintain a suitable posture for
the safe movement of this food.
The gastrointestinal tract must be functionally
prepared to digest and absorb dietary nutrients.
It must be sufficiently motile to transport the
food the length of the gut. The baby also has to
be protected by the process of gut closure from
the ingress into its body of large foreign protein
molecules that can lead to an abnormal immune
response and with it, physical illness. Secretory
IgA and other protective substances produced
within the gut wall play a vital role in this
function and they also reduce significant bacterial colonisation of the gut, which is a risk factor
for serious infection. Once again, the umbrella
of protection conferred by human milk, especially cells, IgA, numerous chemical substances
and enzymes play an important and insufficiently
appreciated role in preparation for weaning. The
gut also prepares itself for the diverse demands
of obtaining nutrients from a mixed diet, by
enhancing growth of its epithelium. For example, the large amount of sphingomyelin in human
milk, 35% of its total phospholipid, and many
other locally produced growth factors and
hormones have a major role promoting epithelial
growth. They act via their relevant receptors in
the small intestine to mediate this function and
are superimposed on genetic pre-programming;
The kidney must also be physiologically prepared
to allow the young weanling to cope with an
increasing solute load. It does this by improving
its concentration ability to preserve intact the
milieu interieu. If this physiological determinant fails, the danger of hyperosmolar states
that were so prevalent in the 1970s with the
widespread use of high solute formula milks and
the very early introduction of non-milk foods,
both contributing to hypernatraemia with its
serious short and long term complications.

ARTICLE IN PRESS
88

What does this state of multi-organ physiological

preparation tell us about the age to move from the
exterogestate fetus to the transitional human
beingthe weanling? This is often a difficult tightrope to negotiate, especially for infants in poor
developing countries. The too early introduction of
non-milk foods and (in HIV endemic parts of the
world) early cessation of breast-feeding will risk
foreign protein-mediated food intolerances, including coeliac disease. It can also expose the young to
infection, particularly of the gastrointestinal tract,
whilst also sewing the seeds of malnutrition and
abnormal internal body milieu states, especially
in the presence of diarrhoea and perhaps even
increasing the risk of childhood asthma. Beginning
weaning too late will risk undernutrition, as the
needs of the young increasingly outstrip the
capacity of the mothers milk (or indeed milk
formula) to satisfy these requirements for growth
and development and for certain micro-nutrients,
especially iron and zinc.
Delay in introducing solid foods of varying
textures, tastes and consistencies will also inhibit
the development of neuro-muscular mechanisms
needed to mechanically prepare and deliver nonmilk foods to the gastrointestinal tract, such as
chewing and moving the bolus of food in the mouth.
Missing out on this critical period may make for
feeding difficulties later. It is important to recognise that the eruption of teeth has no effect on the
weaning process, although in history (as mentioned
above), it has often been considered a useful
marker for the timing of weaning.

Current recommendations
For the majority of infants, solid foods for breast or
milk formula fed babies should be introduced
between 4 and 6 months of age, following the
1994 Department of Healths (DoH) recommendation2. There is no magic test to determine when
weaning should begin. It is essential that the health
professionals who purvey advice are sensitive to
the mother or other carers perception that the
baby, through its physical size and changed behaviour, might no longer be satisfied by milk alone,
whatever the official recommendations may be.
As a determinant for the starting of weaning, this
dictation by the baby and its pick-up by a sensitive
mother is critical and all too often denied by those
who set guidelines. In the western world this leads
to the reality that the majority of babies are being
introduced to solid foods by about 4 months of age.
Some (very few) seem to need solids before 3

D.P. Davies, B. OHare

months of age and as long as this is in response to a

babys perceived needs, there should be no
problem even though this is a very early introduction to solids. Throughout history, some babies are
given solid foods as a complementary food, simply
as a taster and not as part of a planned weaning
process. However, in most instances the giving of
non-milk foods does signal the beginning of the
weaning process itself.
Against this background it might come as a
surprise to read the 2002 WHO revised recommendation for weaning from the breast, which is that
mothers should exclusively breast feed for at least
6 months and continue breast-feeding up to, or
even beyond, 2 years1. The background to this is
the situation that applies to breast-feeding in poor
countries, with special reference to the current HIV
pandemic and the hazards of replacement feeding.
These are two critical factors that influence the
timing of weaning that can sometimes be seen to be
in opposition to each other. These issues are worth
exploring in a more detail.
In 2002 there were 800,000 children newly
infected with HIV, 90% of these by mother to child
transmission (MTCT) and 75% of this number were in
sub Saharan Africa. Where there are no interventions such as antenatal anti-retroviral therapy and
Caesarean section, the risk of transmission during
pregnancy is 510%, and during labour 1020%.
Added to this, the additional risks from breastfeeding must be considered. In the first 2 months
breast-feeding adds an extra 210% risk of transmission. Breast-feeding after 2 months but stopping
at 6 months adds another 15% chance of transmission, which increases a further 510% if the baby is
breast-fed until 1824 months of age. A recent
UNICEF factsheet on breast-feeding and HIV summarises these figures, warning that a baby breastfed for 6 months has one-third the risk of
transmission during breast-feeding than that of a
baby breast-fed for 2 years, although both groups
still having the 1530% risk of transmission during
pregnancy and delivery. The risks of breast-feeding
for continuing MTCT are therefore considerable.
And what does HIV infection mean to a child
living in, for example, sub-Saharan Africa? The vast
majority (90% in some studies) of children infected
with HIV at birth will die by the time they are 3
years of age. The remainder will die in their first
decade, generally when they are 6 or 7 years of age
having suffered multiple episodes of gastroenteritis, respiratory tract infections often including
tuberculosis and frequent episodes of oral candidiasis. Even if the child is seronegative, if its
mother is infected with HIV the risk of mortality is
greatly increased.

ARTICLE IN PRESS
Weaning: a worry as old as time

The reverse argument also has to be considered,

namely the risks in this setting of not breastfeeding. Eleven million children under the age of 5
die every year worldwide from malnutrition, and
two-thirds of these can be attributed to poor
feeding practices in the first year of life. UNICEF
warns that a baby who is receiving replacement
feeding in the first 2 months of life has a six-fold
increased mortality due to diarrhoea and other
infectious diseases. It is common in many resourcepoor countries to complement breast milk with
drinks such as water and tea. Yet it has been shown
that despite the climate, exclusively breast-fed
babies are no more likely to become dehydrated
and there is no nutritional benefit to these feeds.
Fewer than 35% of babies are exclusively breast-fed
for the first 4 months of life worldwide.
In summary, how are these issues resolved in
resource-poor developing countries (compared with
the developed industrial world) where additional
determinants for the timing of weaning include:
lack of appropriate available breast milk substitutes; high risk of microbiological contamination of
foods; few opportunities to administer antiretrovirals to HIV positive mothers; and an earlier return
to potential fertility with early cessation of lactation amenorhoea that inevitably follows stopping
breast-feeding. In these countries, delaying the
introduction of non-milk foods to 6 months is
seen as a factor that may help reduce mortality
and immediate and later morbidity, recognising at
the same time the continuing risks of HIV transmission. In rich countries where there are readily
affordable non-milk foods, where general hygiene
minimises contamination of food and where effective contraception is readily available, there is
really no need to change the 1994 WHO recommendation. Indeed, in this and other industrial
countries the (unrealistic) advice of exclusive
breast-feeding for 6 months (without extending
statutory maternity leave!) might even lead some
to not bother with breast-feeding in the first place.
A recent large study of weaning in normal term
babies in Britain showed that only 2% of breast-fed
infants did not receive any other foods for their
first 6 months.
What little scientific data there is available
supports the view that exclusive breast-feeding
for 6 months is probably safe for most babies in
terms of nutritional adequacy, providing that the
mother is well nourished. But, for the less well
nourished mother, babies exclusively breast-fed for
the first 6 months may be at risk of poor weight
gain. More robust evidence must be sought on this
recommendation before it can be universally
implemented. Indeed, it is also salutary to recall

89

that consideration has never been given to possible

differences in the weaning requirements for breast
or formula fed babies. Without this evidence it is
probably fair to say that reality and pragmatism
dictate, at least in the developed world, that
weaning best takes place between 4 and 6 months
of age, although the recent WHO recommendations
may, on balance, be seen as a necessary population
strategy for developing countries and for certain
individual babies in the developed world.

The process of weaning

There are many influences on the process of
weaning to which culture, taboos, religious belief,
ethnicity, tradition, medical opinion and dietary
fads all contribute in their individual ways. Also the
variation in rates at which young infants acquire
those special motor feeding skills that are a
prerequisite for safe weaning must be considered.
This article focuses on weaning in Britain where
the broad aim is to achieve, by about 12 months of
age the basis of a healthy adult type diet given in
3 meals a day, interspersed with small snacks and
with milk still considered as an important food.
Over the weaning period a wide range of foods
with different tastes and textures need to be
offered to enrich the palatal experiences of the
young infant. The process of introducing new foods
must be gradual and babies are likely to adapt best
if solid foods are offered initially from the spoon, or
given as finger foods, and not as solids made into
drinks, or given dissolved in milk or other fluids in a
bottle. It is also sensible not to introduce too early
those foods that are associated with nutritional
intolerances, atopic disease and allergies (see
later).
How these prerequisites are translated into the
actual weaning diet make up the process of
weaning and this can be best understood by
considering the particular vulnerabilities and requirements of the young human infant at this
developmental stage. At the core of these requirements is the need for the infant to satisfy normal
physical growth and the accompanying development that proceeds so rapidly at this time. This is
all made possible by providing protein building
blocks in the diet, complemented by key micro- and
macro-nutrients. Specific dietary reference values
provide the range of individual nutrient requirements to satisfy these needs. These are not
referred to further in this article but the interested
reader can consult relevant texts to learn more. In
what follows the emphasis is more on qualitative
aspects of the weaning diet.

ARTICLE IN PRESS
90

Food Energy
Fat is a major contributor to the energy content of
the weaning diet although as a steadily diminishing
percentage falling from over 50% in breast milk at
46 months to around 35% in the diet at about 18
months. Most of the weanlings fat comes in milk
complemented by a variety of other weaning foods.
Strongly contraindicated in the weaning diet are
low fat foods that can only slow down growth and
development. Semi-skimmed milk, provided the
diet is sufficiently varied, should await at least the
third year for its introduction. A recent survey
conducted through Mother and Baby magazine
found that, worryingly, many mothers were introducing their babies to low fat, low calorie meals in
order to lessen the risks of their children becoming
overweight. It needs to be impressed on mothers
that a healthy weaning diet is not the same as a
healthy adult diet.
Other energy rich foods are those that contain
the intrinsic cellular soluble sugars fructose,
glucose and sucrose, along with efficiently absorbed starches in cooked cereal products and rice.
Extrinsic sugars, as added sugars in fruit juices,
honey and table sugars for example, are also
needed although they should be used sparingly to
prevent young infants developing the habit of
too sweet a tooth and its links with poor dental
health later.

Structural fats and neural development

The continuing rapidity of the growth of the brain
and other neural tissues requires large amounts of
phospholipids that are rich in long chain polyunsaturated fatty acids (LCPFAs), especially docosahexanoic and arachidonic acids. It is likely also that
LCPFAs are needed for vascular endothelial growth
and the cell membranes of other tissues. Their
synthesis during weaning requires an adequate
amount in the diet of the essential linolelic and
alpha-linolenic fatty acids.

Non-absorbable carbohydrates
The weaning diet also has to accommodate those
elements that contribute to normal gastrointestinal
motility, especially of the large bowel, to prevent
sluggish bowel movement that ultimately leads to
constipation, which is a scourge of contemporary
western type societies. The main contributors to
this function are non-starch polysaccharides (NSP)
and complex polymers (previously called dietary
fibre and derived mostly from plant cell walls). But

D.P. Davies, B. OHare

it must be remembered that these are low energy

dense foods and giving too much NSP during
weaning is to be discouraged, as they may displace
more energy rich foods, and cause diarrhoea. Many
foods rich in NSP, such as cereal products and
legumes, also happen to be a rich source of
phytates that reduce bioavailability and hence
the absorption of micronutrients, especially iron
and zinc. In the indigenous British culture there is
little danger of the weaning diet having an overabundance of NSP, although the same perhaps
might not always be said of those cultures and
individuals who embrace vegetarian and (especially) vegan practices. With constipation such a
current concern the weaning period must be seen
as a good opportunity to lay down good future
dietary practices, as well as to satisfy current
nutritional needs. Encouraging young infants
to take and enjoy plant foods and fruit can do
much to help.

Protein
The essential determinants of lean body mass and
linear growth are provided mostly in the protein of
meat, fish, eggs and milk that contribute a proper
balance of essential amino acids. In western
countries protein deficiency is rare in otherwise
healthy children. But it is important to remember
that non-animal products and many plant foods are
much lower in protein and essential amino acids
than equivalent animal sources. This is why soya
protein-based formulas and other foods (such as
tofu) are such valuable elements to the weaning
diets in vegetarian and vegan families.

Major minerals
The fact that the skeleton, not forgetting the
teeth, contains most of the calcium, magnesium
and phosphate in the body shows how important it
is to ensure an adequate intake of these minerals in
the weaning diet. These are best provided in milk,
milk products and foods derived from calcium
fortified white flour. Phosphorous is also needed
for basic cellular metabolic processes including
energy release, as well as being an integral
component of phospholipids in cell membranes.
Sodium is the most important extracellular mineral
and this is well provided for in nearly all weaning
foods. Indeed, if anything there is now a concern
that many proprietary foods are overly rich in
sodium. The young kidney has only a limited ability
to excrete a sodium load and although risks of
hypernatraemia have virtually disappeared with

ARTICLE IN PRESS
Weaning: a worry as old as time

weaning practices that now contribute much less of

a solute load than a couple of decades ago, the
links that are now emerging between early sodium
intake and the tracking of high blood pressure into
adulthood makes sodium intake a very important
issue. The palate must be conditioned not to need
more salt. It goes without saying, therefore, that
salt should never be added to the weanlings diet.
Other minerals, particularly potassium, zinc and
copper are essential for cell and tissue growth as
well as on a general basis for enzyme synthesis. In
the average western weaning diet these should be
all well provided for.

Iron
Nutritional iron deficiency continues to be the most
commonly diagnosed nutritional disorder of early
childhood worldwide, and Britain is no exception.
With iron a vital component of haemoglobin,
myoglobin and many enzyme systems, psychomotor
apathy, poor weight gain and increased vulnerability to infections are all important and worryingly
common clinical consequences. The seeds are often
sown in bad weaning practices especially in certain
high-risk communities, notably Asian families that
have recently arrived in this country and other
socially disadvantaged inner city families. Red
meat and other meat products from which iron is
readily available, are an important part of the
weaning diet and their intake must be encouraged
along with other iron fortified foods. The non-haem
iron that is present in vegetables and other plants
has a much reduced bioavailability. Fibre, especially from cereals, legumes and other vegetables,
can also inhibit iron absorption through their high
phytate content. The vulnerability of those on
vegetarian and especially vegan diets is obvious.
(See also later). Another major risk factor for iron
deficiency is the giving of cows milk too early.
Cows milk is low in iron, causing intestinal blood
loss and also filling up the infant, therefore
discouraging other foods. It is for this reason that
breast milk or a fortified infant formula and not
cows milk should be an essential part of the
weaning diet until the second year of life. Iron
absorption is enhanced by vitamin C in the diet,
hence the value in vulnerable groups of this
particular supplement and also the inclusion of
fruits and lightly cooked or raw vegetables.

Vitamins
Most vitamins have specific functions. Vitamin A is
obtained from animal products and fish oils as pre-

91

formed retinol and as carotenes in vegetables and

fruit. It is essential for growth and neural development, immune function and as an anti-oxidant. The
B group vitamins found in a wide range of all foods
are integral to cell processes and tissue regeneration. Vitamin C, found especially in vegetables and
fruits (prolonged cooking can destroy vitamins), are
important as anti-oxidants and also assist the
absorption of iron from vegetable and other nonhaem iron sources. Vitamin D is vital for calcium
absorption and the deposition of calcium in bone. It
is naturally present in very few foods, with the
obvious exception of fatty fish, although research is
now showing that more Vitamin D might occur
naturally in eggs and meat than was previously
thought. Fortunately it is readily synthesised in the
skin by the action of ultra-violet B radiation on the
steroid precursor 7-dehydrocholesterol, the process being completed in the liver and kidney to the
active vitamin D metabolite. Vitamin E is made up
of tocopherols, the most active being alphatocopherol, found in fortified foods and especially
in fatty fish. It is needed to preserve the structural
integrity of phospholipid cell membranes and also
to help protect vascular endothelium and neural
cells from free radical damage.
This basic understanding of the major nutrients
of the weaning diet can now be translated into the
following general weaning programme that should
apply to most young infants in this country.
46 months
At this early stage the important learning skill for
the baby is to become accustomed to taking food
from a spoon. Patience is essential throughout the
weaning process. An initial first food could include;
a cereal; baby rice mixed with the babys usual
milk; mashed potatoes; yoghurt; and custard. It is
important to recognise that food intake at this very
early stage serves largely as a taster given by
spoon 2 to 3 times a day. Milk continues to be
essential for all nutrient needs. Other suitable
early foods once the baby accepts these bland
foods and is able to take food from the spoon
include pureed meats, pulses, fruit and a wide
variety of cereals.
69 months
This phase now sees solid foods as an increasingly
more important provider of energy and general
nutrition, with milk gradually becoming less important. Vegetables, lean meat, cheese, yoghurts
and bread are then gradually added in a mashed or
pureed form. These provide more varied tastes and
textures. Babies themselves may now be able to

ARTICLE IN PRESS
92

put foods into their own mouths, experimenting

with finger foods, for example toast.
912 months
This stage is now beginning to reflect a more
mature diet with 2 or 3 meals interspersed with
healthy snacks. The texture of food is now less
pureed. At this stage eggs and fish can be added,
although nut products are best delayed until the
second year.
In summary, providing the young infant with a
mixture of available foods, maintaining an intake of
fortified formula or breast milk (if the mother is of
adequate nutritional state) along with moderate
exposure to summer sunlight should provide an
adequately balanced weaning diet in this country.
The change from breast or infant formula to cows
milk should ideally be delayed until after the first
birthday, cows milk being a major risk factor for
iron deficiency. Water and fruit juices are important. Adding salt or sugar is also strongly discouraged because of respective links with later
hypertension and the general development of too
sweet a tooth, which sows the seeds for later
obesity and dental caries. The too early use of a
cup from the bottle is also to be discouraged since
the coordination needed to feed from a cup is often
difficult. There is the general recommendation that
after 12 months bottle feeds should be discouraged, with cup feeding being preferred. But if the
cup skill is overemphasised, fluid intake will be
insufficient. Babies themselves will determine
through their own individual skills, the timing when
fluids can satisfactorily be taken from the cup.
Maintaining a high fluid intake is also necessary to
keep a good urinary flow, therefore lessening the
risks of urinary-tract infection.
An example of weaning in a young child living in
Britain is shown in Table 1.

Practical Aspects
Weaning foods can be home prepared, commercial
or mixtures of the two types of baby foods. This
choice largely depends on the shopping and cooking
capabilities of the mother and father, and other
family choices. Financial considerations and confidence also play a part early on when only small
amounts of food are used with the potential for
huge wastage. Data on the nutritional composition
of many home prepared foods show great variability with, if anything, a tendency to be rather low
in protein, fat and iron and even of lower energy
density. Hence the potential value early on of

D.P. Davies, B. OHare

feeding commercial foods, either alone or as a

supplement. It would seem, however, that after
about 18 eighteen months the use of commercially
available baby foods in this country has declined
considerably. When the family pot is used it is
important once again to emphasise that salt and
sugar should not be added.
Irrespective of the type of food fed to the baby,
great care must always be taken regarding food
hygiene, including cooking and storage, to prevent
food borne microbial illness. Increasing use of
microwave cooking also means the risk of burning
the young infants mouth. These practical details
must always be emphasised as essential components of the weaning process along with the
perhaps more interesting, nutritional aspects. Not
to be forgotten is the need for patience. During
weaning, infant behaviour is often frustrating with
food refusal, spitting and smearing food on cloths
and utensils, etc. Parents and other carers have to
be assured that this is all part of the normal
exploratory weaning process.

Vulnerable groups
In some infants special consideration may need to
be given to the general process of weaning that has
just been described because of their particular
vulnerability. (Excluded from this section are
infants with diseases already diagnosed and who
may require special nutrition for illnesses such as
coeliac disease or milk intolerance).

Infants with, or at risk from, atopic disease,

recurrent wheezing and other allergies
It is tempting to believe that for infants with, or at
risk of asthma, hayfever, atopic dermatitis and
other allergies, a delay beyond the usual recommendations of introducing weaning foods is advisable especially in view of the physiological fall in
the levels of secretory IgA in the gut over the first 6
months of life. (This of course is naturally compensated for by the high quantity of IgA in breast milk
during this period). There is, however, no good
clinical or epidemiological evidence to support
delaying the introduction of potential food allergens commonly linked with these disorders, notably
milk protein, eggs and nuts, or even to prolong
breast feeding beyond 4 to 6 months to lessen the
risks of future illness by sensitisation. It is sensible
for a breast-feeding mother to avoid eating these
common food antigens in the early months after
birth since this could lessen the risk of illness in
her baby.

ARTICLE IN PRESS
Weaning: a worry as old as time

93

Table 1 One example of a typical pattern of weaning in a young child living in Britain.
d From about 4 months
Early morning: breast or bottle feed
Breakfast: baby cereal mixed with milk from feed. Breast or bottle feed
Dinner: finely sieved broth. Breast or bottle feed
Tea: breast or bottle feed
Late evening: breast or bottle feed
d From about 7 months
When cows milk is commenced, the opportunity should be taken to introduce a vitamin
supplement, such as the A, D and C drops available at Child Health Clinics
Early morning: breast or bottle feed
Breakfast: baby cereal mixed with milk from feed. Scrambled, poached or boiled egg. Breast
or bottle feed
Dinner: minced meat and vegetables or mashed white fish and vegetables. Fruit puree, custard
or milk pudding. Cup of milk
Tea: savoury ready-prepared food or sandwiches with savoury filling, for example soft cheese.
(Fine-textured wholemeal bread can be used at this stage.) Breast or bottle feed
Late evening: breast or bottle feed
d From about 9 months
Early morning: milk or fruit juice.
Breakfast: breakfast cereal with milk. Scrambled, poached or boiled egg. Fingers of toast with
butter. Cup of milk
Dinner: junior savoury ready-prepared food or well chopped meat and vegetables. Peeled
apple, banana or milk pudding. Cup of milk if required
Tea: cheese or fish dish or sandwiches with savoury filling. Cup of milk
Late evening: breast or bottle feed
d From about 12 months
Breakfast: breakfast cereal with milk. Crisply grilled bacon or egg. Toast with butter. Bottle/
cup of milk/breast feed
Mid-morning: drink of fruit juice
Dinner: chopped meat, chicken or steamed fish. Chopped vegetables and mashed potatoes.
Milk pudding, blancmange or yoghurt
Tea: scrambled, poached or boiled egg. Bread and butter. Orange, apple, banana or soft fruit
in season
Evening: bottle/cup of milk/breast feed

Pre-term and other low birth weight infants

Although some of these babies may go home from
the neonatal unit with poor weight gain and feeding
problems, including sucking and swallowing difficulties, the general rules of weaning still apply. It
may be thought that for infants who have suffered
intra-uterine growth retardation, introducing solid
foods before 4 months might be demanded by the
babies themselves. The reality seems to be the
opposite. In a recent national study of 2000 babies,
small for date babies, whether breast or formula
fed were less likely to have been started on solids
before 12 weeks. It may be that their size led to
greater parental concern and, therefore, a greater
likelihood to stick with the guidelines. Maybe even
their babies perceived small size downplayed the

6 am
10 am
2 pm
6 pm
10 pm

6 am
10 am
2 pm
6 pm
10 pm

On Awakening
9 am
1 pm
5 pm
8 pm

8 am
10.30 am
1 pm
5 pm
8 pm

need for solids, just as higher weights at around 6

weeks often leads to very early weaning. For preterm babies, some studies have even linked
improved growth rates and improved iron status if
solids, especially those of higher energy density and
protein content, are introduced to the diet at
about 3 months of age. More research is needed to
improve the evidence and to provide guidelines for
these two special categories of low birth weight
infants. This must also include the long term
influences on growth and health.

Infants in minority cultures

There is no doubt that culture, tradition and
religious beliefs have a profound effect on dietary

ARTICLE IN PRESS
94

D.P. Davies, B. OHare

practices. Ethnic minority communities in this

country are likely to vary in their weaning
behaviours. However, we need to be reminded that
there is no single ethnic minority culture and, as
with other instances of weaning, variations need
to be tolerated, indeed often encouraged, providing of course that the basic nutritional requirements are met. The following points need to be
considered.
Iron, vitamin D and other micronutrient deficiencies have been identified as major problems in
some Asian populations where whole cows (doorstep) milk is introduced at a very early age and
continued in large volumes. Not only does this risk
primary nutrient deficiencies, especially anaemia
and biochemical rickets, but by filling the stomach
the infant is less eager to take solid foods. Mothers,
especially those from Muslim backgrounds, are
more likely to introduce solid foods later, thus
compounding iron and vitamin D deficiencies. They
also have a tendency to use more convenience baby
foods, which are high in carbohydrates. It is
important to recognise that these patterns are also
to be found across other minority ethnic groups as
well as in the ethnic majority in inner cities and
other equivalent areas. As with all instances of
prolonged bottle feeding, babies miss out on
critical periods of the taste and texture variations
of solid weaning foods, which can lead to the
rejection of mixed tastes later on.
Awareness of these potential problems should
help in the primary care management and prevention of these weaning difficulties. But it is also
essential to involve the wider network of family
and friends to help the often vulnerable mother,
confused by unfamiliarity with food, a low income
and isolation.

This is another reason why the weaning diet of

vegetarian families should be rich in vitamin C.
Those on vegan diets are in theory more
vulnerable, although in day to day practice there
seem to be few problems. It is, important that the
food proteins given contain a good balance of
essential amino acids. Also, since vegetables and
fruit tend to be more bulky than cereals, too
much can reduce the amount of energy in the
diet. Similar problems to vegetarians apply to
high levels of phytate in the diet. A strictly
adhered to vegan diet cannot provide sufficient
vitamin B12 and advice how best to make up for
this potential vitamin deficiency should be
sought. Limited though these diets might seem to
be, vegan diets can promote normal infant
growth, providing that sensible guidelines are
offered. This especially applies to appropriate
breast milk substitutes; supplements, the type
and amount of dietary fat and also the nature of
solid foods.
Attention also has to be given to vegan mothers
since the composition of their breast milk may vary
considerably in its fat content. Infants may need
vitamin supplements if the maternal diet is in any
way inadequate and the same applies to infants
during weaning. Tofu, dried beans and meat
analogues should be introduced as part of the
weaning process. Another concern is the longterm
outcome in terms of the calcification of bone. Soy
based formulas should continue to be given well
into the childhood years to prevent these various
potential deficiencies. The involvement of a
paediatric dietician is essential when confronted
with these specials often difficult and sensitive
problems.

Vegetarian/Vegan traditions

Monitoring the weaning process

Hindu parents are more than likely to give a

vegetarian diet, but increasingly more of the
population from all cultures in this country are
adopting vegetarian practices. Less restrictive
lacto vegetarian or lacto ovo-vegetarian diets can
provide perfectly adequate nutrition during weaning, although some parents may need to be
educated in how best to provide for their babys
needs. It is especially important that these diets,
which can be bulky and often low in energy, might
make it difficult for the baby to take in enough
energy for growth and developmental needs. Many
legumes are also high in phytates which, through
their inhibitory activities, diminish the bioavailability of certain dietary minerals, especially iron.

Whether weaning is proceeding normally is best

judged overall by serial and accurate recordings of
weight gain on up to date charts. It is very
important to be able to correctly interpret profiles
of weight gain, which is not always an easy matter
since there continues to be insufficient recognition
of the fact that between about 6 and 12 months
considerable variation still exists in the profile of
weight gain in individual infants. Movement down
(and up) centile channels are still often the norm,
so it is difficult to give a precise definition of failure
to thrive that is a possible pointer to inadequate
weaning. A declining rate of weight gain is the basis
for this diagnosis and any baby who crosses a
centile line in a downward direction could be

ARTICLE IN PRESS
Weaning: a worry as old as time

potentially considered as one who is not being fed

sufficiently well, but this is only part of the
argument. Weight must be viewed in a holistic
way in the context of a careful history taken of food
intake, general health and also ethnicity, where
subtle variations in profiles of weight gain may not
be allowed for on a weight chart that relates more
to a total population. Thus, for example, downward
centile crossing in Chinese babies on charts derived
from the ethnic majority in this country is a well
recognised phenomenon that does sometimes lead
to an incorrect diagnosis of sub-optimal weight
gain. The same applies also to head growth and (if
measured) to growth in length. If inadequate
weight gain is diagnosed there needs to be an
examination of the nutritional adequacy of the
weaning diet, but not only its content. Non-organic
failure to thrive associated with behavioural
problems through sub-optimum maternal/child
interaction, must always be considered, especially
where there might be a history in the mother of
eating difficulties, for example anorexia nervosa.
The very real difficulties babies with cerebral palsy
and other neuro-developmental problems have
with mechanical aspects of weaning, especially
those concerned with swallowing, chewing and
transporting the food through the mouth, frequently lead to poor weight gain.
Another worry that frequently emerges during
the monitoring of weaning is abnormal fatness.
Understanding the background to this is also
necessary to interpret the seemingly accelerated
weight gain. At 6 months babies are naturally
chubby with fat contributing 25% of body weight: it
is almost as though nature is having to provide a
food reserve, anticipating the special vulnerability
of later weaning! As with failure to thrive, it is not
the absolute pattern of weight gain that is
important, but the context in which this takes
place, which includes family size and the nature of
foods that are given.
A qualitative measure of the adequacy of the
weaning diet is the stool pattern. Western countries are seeing an explosion in problems of
constipation that so often have their origins in
poor weaning practices, where the intake of NSPs
are minimal. As mentioned above, it is very
important for the weaning diet to contain sufficient
vegetables and fruit, along with cereals to sow the
seeds for satisfactory bowel motility.
Finally the iron status of the infant is a very
specific measure of the adequacy of the weaning
diet. Iron deficiency and anaemia is an important
and a particular problem in young children, where
the special difficulty in establishing a good pattern
of solids in the diets and without over-reliance on

95

cows milk renders many infants vulnerable to this

complication.

Conclusion
After the secure transition to immediate extrauterine life and the establishment of milk feeding,
weaning is the next major hurdle the young infant
has to clear in its journey through infancy and early
childhood. Weaning still causes a lot of worry to
parents and also to their professional advisors (who
all too often give inconsistent advice that serves
only to confuse) as it has done throughout history.
As we have shown in this article, many problems
can emerge as a consequence of poor weaning
practices, some immediate as well as some in the
longer term. Yet in 1994 the Department of Health
produced an extremely well referenced booklet on
weaning which, though perhaps lacking a sound
evidence-base in certain areas, nonetheless provides for sound and safe practices that do not
expose the young weanling to risk.2 Unfortunately,
knowledge of the nations guidelines on weaning on
the part of health professionals is limited, suggesting lack of awareness of the guidelines. It is
important for health professionals to offer consistent and accurate guidelines, speaking with one
voice in a language easily understood. The situation
is sometimes made more challenging by the multicultural nature and makeup of our society.
The problems facing the weanling in the developing world are enormous and of a totally different
calibre and nature to those in rich countries.
Culture, taboos, food choices, practices of food
preparation, abject poverty often dominated by illinformed elders and peer-groups often lead to poor
quality of food intake with its well known consequences. To these are added the problems caused
by AIDS in the developing world. We have barely
touched on these issues in this article but hopefully
we have given sufficient pointers to stimulate the
reader to read more about them elsewhere.
All parents (to be) should have received education about nutrition in their infants and this ideally
should have begun during the school years. Antenatal classes provide later opportunities. In these
classes, considerable time is spent on breastfeeding but all too often too little time is spent
on the transitional human beingFthe weanling.
Paediatricians need to be more involved with this
aspect than they are. The various child health
record booklets now widely used should also
include key points to help the mother wean her
baby. It has also to be appreciated that, and

ARTICLE IN PRESS
96

especially for young parents, reliance on their

home networks within their own communities also
provide critical support. Parents of children who
have special medical needs, and where there are
strong cultural and religious beliefs that might
introduce risk into the weaning process, need to be
dealt with sympathetically and with understanding
if their infants are to thrive at this time. Expert
dietetic advice must also be available to help
where difficulties might arise.
There is evidence to suggest that many mothers
do find it difficult to comply with national guidelines on when to introduce solid foods and are
introducing their babies to solids at 3 months or
earlier. Maybe this is simply a reflection of the
weakness in the evidence-base that underpins
these guidelines. But there is another possible
explanation. Formula feeding is a strong predictor
of early weaning, along with young maternal age,
cigarette smokings social class and the babys
weight during the first couple of months. Is weaning
driven by biological needs in the baby, or is it
socially driven by peer group pressure to conform?
When this takes place early, does it reflect less
good health behaviour, maybe leading to increased
fatness and a higher incidence of chest disorders?
History points more to the latter. It is easy is for the
young infant to form habits to caretaker practices. Very early weaning is not usually driven
by the biological imperative but more by the
social one.
Weaning times and weaning diets in many ways
constitute uncontrolled experimental interven-

D.P. Davies, B. OHare

tions. Difficult though outcome studies will be to

assess these interventions in terms of physical
growth and health, in both short and long terms,
only if this research (often necessarily opportunistic), is undertaken will we be more able to best
provide for the needs of the weanling. Out of
course, this necessity pales alongside the disastrous
consequences of inapropriate weaning for so many
children in the developing world, where major
mortalities and significant morbidity, have their
origins in this most hazardous of times.

References
1. World Health Organisation (WHO). Infant and young child
nutrition. Global strategy on infant and young child feeding.
WHO 55th World Health Assembly, 16 April 2002. A55/15.
http//www.who.int/gb/EBWHA/PDF/WHA55/ea5515.pdf
2. Department of Health. Weaning and the weaning diet. Report
on health and social subjects, no. 46. HMSO, London, 1994.

Further reading
1. Fewtrell MS, Lucas A, Morgan JB. Factors associated with
weaning in full term and pre-term infants. Arch Dis Child
Fetal Neonatal Ed 2003; 88:F296F301.
2.Fildes V. Breasts, bottles and babies: a history of infant
feeding. Edinburgh: Edinburgh University Press; 1986.