Weaning Premature Babies

One of my NCT friends had her baby early and really struggled when it came to weaning. 

There is a lot of weaning guidance available for babies born on or around their due date (from week 37 of pregnancy onwards is considered term). However, not a lot for the 10% of all babies who decided to make an early appearance! 

At the time I offered my nutrition and feeding support to my friend but I also want to help many more mums just like her so I decided to write this blog.

Weaning Premature Babies by Sarah Almond Bushell - the Children’s Nutritionist

What do the guidelines say?

A lot of the guidance about weaning babies born at term isn’t relevant for premature babies, and there is lots of misinformation out there on the internet, so I wanted to set things straight with this blog. 

Before we dive in, you should know that not all premature babies need specialised weaning advice. If they were born after 34 weeks, are growing well and are healthy, they can follow the standard weaning advice for babies born at full term (1). 

Some premature babies however need a bit of help to catch up as they may be smaller than expected, so they will need their weaning diet carefully planned to ensure they are not gaining too much fat and not enough muscle. 

‘Corrected age’ 

You might have heard healthcare professionals use the term ‘corrected age’. This is counted from a baby’s due date, taking into account how early a baby was born. For example, a baby born at 30 weeks who is 14 weeks old, would be 4 weeks corrected. ‘Actual age’ is the baby’s age from the date they were born. 

Healthcare professionals use the corrected age to assess the baby’s development appropriately. In this example, the healthcare professionals would be for the baby to be reaching the developmental milestones of a 4-week old rather than a 14-week old baby. 

The impact of being born prematurely

Like term babies, every premature baby will be different, however, being premature can impact both:

  • Development

  • Nutrition Status

Some premature babies may have been born with a Low Birth Weight (LBW), which it defined as weighing less than 2.5kg at birth, other babies may have Inter Uterine Growth Retardation (IUGR) which can occur whenever they were born. A carefully planned weaning diet might be needed to help achieve ‘catch up growth’ if they haven’t yet managed it before starting solids. 

Premature babies who have other medical needs or have had a bumpy start to life may be at higher risk for nutrition and feeding problems. Sometimes this is linked to their medical condition and other times linked to developmental delay affecting their eating and drinking skills.

In addition, when you are born early, the nutritional stores that are usually laid down in the third trimester of pregnancy in readiness for birth, are missing.

This means that some babies are malnourished when they are born needing intensive nutrition support on the special care baby unit and can be at risk of under-nutrition or poor growth as they grow older.

Over the last 10 years or so the nutritional care that babies receive on the special care baby unit in the first few months of life has improved so much, it means that lots of premature babies manage to catch up before they start weaning. 

When should I start weaning my premature baby by Sarah Almond Bushell - the Children’s Nutritionist

When should I start weaning my premature baby?

The NHS guidelines advise that weaning should start at around 6 months of age, however these guidelines don’t apply to most preterm babies. 

Unfortunately, there is a lack of evidence based guidance on weaning premature babies because there is very little research available (2). 

How do I know when to start weaning my premature baby? 

Rather than looking at age, the key is understanding your baby’s developmental milestones and recognising when they are showing readiness cues. 

However, in comparison to a baby born on time, the development signs that indicate your baby is ready for weaning are different. 

Let’s look at this a bit more closely by comparing the 3 developmental readiness signs in a term baby: 

  1. The absence of the tongue-thrust reflex – This is when the tongue doesn’t stick out in response to something touching it. However, the tongue-thrust reflex stays for a long time in a lot of premature babies and eating food regularly actually helps it go away. So you don’t need to wait for the absence of the tongue-thrust reflex when thinking about weaning your premature baby.

  2. Being able to sit unaided – Sitting is a skill that many premature babies won’t be able to do independently for a while. Being able to sit without having to concentrate on doing it is essential to minimise the risk of choking. 

    However, providing a well-supported highchair (with a footrest, support behind the knees and around the waist), can provide the stability they need so your baby can concentrate on coordinating themselves for eating. 

  3. Good hand-eye coordination – From around 6 ½ months, general weaning guidance is to introduce finger foods regardless of whether you have started with spoon feeding or Baby Led Weaning (BLW). In order to do this, babies need to have developed good hand-eye coordination. However, many preterm babies won’t have yet developed this coordination at the start of weaning and that’s ok, it simply means that spoon feeding is a necessity.

Understandably, as the usual milestones for term babies don’t apply to pre-term babies, more often than not you may not be sure if your baby is ready. Personalised weaning advice from your Dietitian or Healthcare team can be really helpful.

When should I start weaning my premature baby by Sarah Almond Bushell - the Children’s Nutritionist

What are the readiness cues for weaning my premature baby?

As the ‘normal’ cues don’t apply, the following information (2) can be helpful to decide whether your premature baby is ready to start solids. It might be that your baby only has a few of these and that’s fine, they don’t need them all. I wholeheartedly believe that parents are the best judge of when their baby is ready for weaning. Look out for: 

  • Leaning forward with their mouth open ‘asking’ for food when a spoon is presented.

  • Holding their head steady when sitting upright in a supported position. This is usually around 4 months corrected age.

  • Exploring hand-eye coordination, for example picking up toys and moving them upwards towards their mouth to explore.

  • Showing an interest in the food that others are eating however, this should not be taken as a cue on its own as many babies do this anyway.

Signs that do not indicate your premature (or term) baby is ready for weaning:

  • When your baby is demanding more milk and is hungrier than usual 

  • When your baby is waking more often through the night to feed.

  • Achieving a certain weight.

  • Reaching a certain age.

Preterm baby’s nutritional needs by Sarah Almond Bushell - the Children’s Nutritionist

Preterm baby’s nutritional needs

For all babies, breastmilk alone can’t provide enough energy or nutrients to meet a baby’s nutritional requirements beyond a certain point, and so weaning becomes necessary to complement it. 

At the start of weaning, milk intake sometimes decreases as it becomes displaced by the solid foods eaten and unfortunately traditional starter foods like vegetables and fruit, are low in energy. 

This means that your baby won’t be meeting their nutritional requirements, so fairly rapid progression towards including meat, fish, eggs, dairy foods and starchy carbohydrates in your baby’s weaning diet is actually really important.

Premature babies may not have the skills to drive forward this quick progression on their own. Hunger is not the driver for food intake for little ones who are learning to eat,  it’s their developmental skill level that moves them along. Therefore you may need to help by making foods easier to each by cooking them till very soft, pureeing and mashing and offering them on a spoon.

After first tastes have been accepted, you can balance your baby’s meals following this 3 point method:

  1. Start with an iron-rich protein food (meat or plant based) like some slow-cooked lamb, a minced beef meatball, a lentil puree or ½ a boiled egg.

  2. Add a vitamin C rich food, for example, a broccoli floret or a couple of strawberries halved.

  3. Finish with an energy rich food like a soldier of buttered toast or sweet potato mashed with butter.

In addition, because the important nutrient stores usually made during the third trimester of pregnancy are missing, some premature babies also need more nutrition to build up these stores.  

Breastfed premature babies will normally be discharged from hospital on an iron supplement and formula-fed babies will receive additional iron as the special prem baby formula is supplemented. 

It is important that these iron supplements continue until babies are consuming adequate iron in their weaning diet. Iron from food sources is more readily absorbed than iron from supplements, so we prefer baies to get this important nutrient from food ideally. 

Nature & Nurture Baby & Child Vitamins

Will my prem baby need vitamin supplements?

All babies, regardless of when they were born, are recommended to have a daily supplement of Vitamin A, C and D (the only exception to this is babies having more than 500ml formula/day as they will be receiving these already from the formula). 

Not all supplements are equal, each containing different amounts of the three vitamins so look at the label and pick the one you think is best. If you have a dietitian, they will look at your baby’s weaning diet and advise which supplement best fits their needs.

The recommendations for Vitamin Supplements are

  • Vitamin D 8.5 – 10mcg

  • Vitamin A 200mcg

  • Vitamin C 20mg

Nature & Nurture Baby Vitamins are the only brand available that contain these exact doses. Here is my amazon affiliate link if you wish to buy them . (Note Amazon pay me a small commission for the sale but the cost to you remains the same)

Your baby may also be on an iron supplement too and you should continue this until the medical team advise you to stop.

Are there risks in delaying weaning in a preterm baby

It is really common for parents of premature babies to feel anxious about starting solids they report that this is because they fear that their baby is not developmentally ready and might not be able to eat. 

However, delaying weaning can result in:

  • Malnutrition as their nutritional requirements might not be met,

  • Poor growth as they aren’t getting enough nutrition,

  • Delayed development as eating food brings challenges which encourage skill development.  

Although more research is needed in this area, doctors suggest that babies who don’t have challenging solid foods at this time appear to be at greater risk of feeding difficulties [6] during childhood.

We also see premature babies who remain on pureed food for a long time for the very same reasons, parents are concerned that their baby may not cope with lumpy textures and choke. 

However, there is a time-critical developmental ‘window of opportunity’ (8, 9, 10), which closes at 9 months uncorrected age, when babies are more open to accepting new textures.  If this is missed there can be feeding difficulties and eating challenges later. 

Can my premature baby do baby led weaning by Sarah Almond Bushell - the Children’s Nutritionist

Can my premature baby do baby led weaning?

The two popular methods of weaning are baby led weaning and traditional or spoon weaning. How to choose between the two must be based on your babies abilities in terms of their development for safety reasons to minimise the risks of choking.

  • Traditional weaning involves making purees and spoon feeding your baby, gradually increasing to lumpier foods and introducing finger foods alongside. 

  • Baby-led weaning (BLW) involves babies self-feeding and exploring food by providing it in its whole form.

If you think back to the developmental cues we spoke about earlier, a lot of premature babies, will not yet be able to sit upright unsupported or have proficient hand-eye coordination.

For this reason, BLW may not be advisable.

They need core stability to minimise the risk of choking and without hand-eye coordination they simply can’t get the food to their mouths. 

It is also known that BLW consume less nutrition during the first few months of weaning in comparison to spoon fed babies(5). Therefore, if growth or nutrition is a concern then BLW might not be advisable. 

Is there a better way to wean my premature baby?

Another approach is a ‘combined approach’ where finger foods are offered alongside purees. This can be helpful as this will teach your baby how to master hand-eye coordination through regular practice, while still getting the nutrition they need via spoon fed balanced meals.

If babies have medical conditions or issues with swallowing as a result of being premature it’s likely that they will be under a Feeding Team or Speech & Language Therapist who may have an individualised plan for weaning (6). 

Tommee Tippee Essentials Cup

Cup introduction

As well as eating, weaning is an opportunity to learn how to drink from a cup rather than a bottle or the breast. It’s worth introducing a cup right at the start of weaning so that eating and drinking skills are learned at the same time. The amount of water actually swallowed at the start of weaning doesn’t contribute much to their fluid intake, it’s more about getting them practising and becoming familiar with a cup. 

Often the flow of water can be too fast from an open cup and so premature babies may find a spouted free-flow beaker easier. I like the Tommee Tippee First cup.

At first tip the cup up and pour out the water to show your baby what it does before offering it to them to drink from (7) . 

It may be a few weeks before your baby tries to pick up the cup themselves. When they do it can be helpful to fill the cup just to half full so that it isn’t too heavy for your baby to lift and so that the cup doesn’t need to be tipped too far for the water to flow out.

How should I offer the first meal?

When it comes to learning to eat, it must be fun. Focus your attention on the experience rather than the amount of food your baby eats. You might need to reassure your baby that eating solid food is a happy experience (7) so that they’ll want to do it again and again. It may take a while for premature babies to get used to taking food from a spoon, so this phase may last between 2-4 weeks. I have a step by step guide on how to offer the first meal that you can read here .

Is there anything else I should do to help my baby develop her skills?

As well as eating food, there are sensory experiences that need to be encouraged and explored in order for babies to learn about food and eating (11). There are 8 senses involved in weaning that need to be mastered (7), and they are: 

Tidy Tot Sensory Weaning

1. Visual (sight)

2. Tactile (touch, textures)

3. Auditory (sound)

4. Olfactory (smell)

5. Gustatory (taste)

6. Proprioception (Movement) 

7. Vestibular (Balance)

8. Interoception (Understanding internal feelings like hunger, sickness, fullness)

Babies who have lots of opportunities to use their senses have more highly developed brains which is linked to food acceptance, developmental skills, intellect and behaviour (12).

The best way to encourage sensory weaning is to offer lots of opportunities for exploration, for example, messy play with a variety of different textured foodstuffs, presenting food in colourful combinations and offering a variety of different textures, you can read more about sensory weaning in my blog I wrote for Tidy Tot during Weaning Week here.

Interacting with your baby at mealtimes

Arguably the most important part of feeding is being able to communicate with your baby and respond to their cues. We know that babies born at full term can communicate their needs to their parents around 4-6 months (13) and there is some evidence that premature babies are able to do this too in relation to feeding (6). 

For example, when your baby has had enough food they will turn their head away or if they would like more they may lean forward with an open mouth. It’s really important to take notice and learn what your baby’s signals are for ‘finished’ and ‘more please’ so you can respond to your baby’s requests accurately (14).

This is called responsive feeding and strengthens the bond of attachment between you which is actually very important for the future wellbeing.

To do responsive feeding well, it’s important to make sure that the mealtime is calm and enjoyable with no distractions so your baby get your undivided attention.

It’s also about getting their highchair seating right and positioned opposite you so you are facing each other and communicating to your baby about what they are having, whether its hot or cold, what colour it is and that it’s yummy. 

It’s also about your role as a parent in making sure the food you provide is nutritious and tasty but importantly developmentally appropriate for their stage and it’s also about having the predictability of a routine, so your baby learns what happens next.

Getting the ‘food parenting’ or feeding part right is just as important as the food your offer. If you would like to dive deeper into feeding you can pop your name on my waiting list for my Positive Food Parenting course coming soon.

Weaning Premature Babies by Sarah Almond Bushell - the Children’s Nutritionist

What should I do if my baby doesn’t like the food?

Try, try and try again.

Repeated exposure to rejected foods is important for premature babies just as it is for babies born at term in order to teach them about different tastes and flavours. It’s not something they are born knowing how to do and so sometimes it can take 10 to 100 times of trying a food before your baby accepts it.

This is fine. It doesn’t mean they don’t like it, it just means they haven’t learned to like it yet. (15).

The wider the variety of tastes and flavours offered before 9-10 months of age, the more likely it is that your child will eat a wider range and be willing to try new foods when they are older (16).

I feel like progress is really slow, what can I do to help my baby along?

Sit and eat with your baby at mealtimes. Because eating is a skill that babies have to learn, it’s helpful if they can see you doing it first. Babies watch and mimic others and learn how to eat this way.

For example, if you give your baby a green bean for the first time they won’t know how to eat it. But if they see you pick it up and put it to your mouth, open your mouth, bite down and take a piece off. They will then watch you move it around your mouth and swallow before going for a second bite.

It can be helpful if both parents are there at some mealtimes and any brothers or sisters too, as each one of us eats in a slightly different way.

Research suggests that children who join in at family mealtimes accept a wider range of foods when they are older than those who eat alone (17).

For the full reference list please contact me .

Sarah Almond Bushell MPhil, BSc (Hons) RD MBDA - Registered Dietitian & Children’s Nutritionist

Sarah Almond Bushell MPhil, BSc (Hons) RD MBDA – Registered Dietitian & Children’s Nutritionist

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