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What factors influence mothers in the UK and Ireland to wean their infants before six months of age?

This narrative literature review by Cathryne Edmunds and Sue Green, outlines key factors associated with early weaning before six months of age. 

What factors influence mothers in the UK and Ireland to wean their infants before six months of age?

Cathryne Edmunds Health Visitor, Dorset NHS Trust
Sue M Green Associate Professor, University of Southampton
 

Key points

  • Introduction of solid foods or ‘weaning’ in the UK often occurs before the DH (2003) recommended age of six months.
  • Weaning before four months of age was associated with infants no longer satisfied with milk feeds, waking at night and mothers less than 24 years of age.
  • Weaning between four and six months was associated with knowledge of weaning guidelines and advice from health visitors and the internet.
  • Health visitors need to be aware of the key factors associated with early weaning to plan health promotion interventions.
  • The ongoing debate as to the ideal age to wean can cause confusion and conflicting advice for parents and health visitors.
     

Abstract

Current advice from the Department of Health (DH) recommends introducing solid food to infants, a practice usually termed ‘weaning’, at six months old. However, as many health visitors will report, mothers often choose to wean their infant before the age of five months. This narrative review of published research, identified through a systematic literature search, outlines key factors associated with mothers weaning before six months. Maternal decision to do so is associated with a number of factors, such as: infants no longer being satisfied with milk feeds, infants waking more often during the night, and mothers aged 24 years or under.

Rather than one single causative factor, it is suggested that a complex interplay of different factors will influence the mother’s decision to wean early. Health visitors support mothers during the first few months of the infant’s life and part of their role is to educate mothers on the risks of early weaning. An awareness of the key factors associated with early weaning assists health visitors in assessing risk of early weaning and to plan appropriate health promotion interventions.

Key words: Weaning, infant, health visitors, education


Introduction

Working with mothers and carers to ensure good nutritional intake by infants to promote growth and development has been a long-standing role of the health visitor (Murphy, 2003). One aspect of this role is to provide information on the appropriate time to wean (Gildea and Stewart, 2009).


What is the problem?

Many mothers in the UK appear to introduce solid foods – weaning or complementary feeding (World Health Organisation, WHO, 2001) - before six months of age. One study (Bolling et al, 2007) showed that 51% of mothers had started weaning their infant by the time it was four months, though the most recent UK study (McAndrew et al, 2012) stated that 75% of mothers had weaned their infants by five months of age. These studies, and others, suggest that a large number of parents do not follow the 2003 DH guidelines on weaning (Moore et al, 2014).

Why does it matter?

This is an important issue because the start age of weaning appears to influence health outcomes, with those weaned before four months being most affected. Weaning before 17 weeks has been associated with a range of negative health outcomes (Arden, 2010). These include eczema (Tarini et al, 2006), childhood wheezy, respiratory illnesses (Wilson et al, 1998), higher body fat and body mass index (Wilson et al, 1998) and increased risk of childhood obesity (Sloan et al, 2007; Griffiths et al, 2008). Weaning before six months is associated with respiratory infections (DH, 2003) and exposure to pathogens present in food that may predispose the infant to gastrointestinal disease (Wilson et al, 1998). It has also been suggested that solid foods may overload the digestive and absorptive mechanisms of the immature gut, leading to increased potential for sensitisation to food antigens (Wilson et al, 1998). Weaning after six months may lead to eating problems such as difficulty with tolerating solid foods (Northstone et al, 2000). It can also result in under-nutrition such as iron and zinc deficiency (Hart, 2006).


Current guidelines

A number of guidelines inform health visitor practice concerning weaning. The DH guidelines (2003) advise that six months is the recommended age for the introduction of solid foods for infants, but also says that all infants should be managed individually. The Scientific Advisory Committee on Nutrition (SACN) says the same, though it added that, if infants were weaned early, it should not be before the end of 17 weeks (SACN, 2001). More recent guidelines from the British Dietetic Association (BDA) (2013) offer the same advice. The Healthy Child Programme (DH, 2009) provides a guidance framework for health visitors and this too recommends that weaning should be delayed until infants are around six months of age.

Globally, there has been some debate about the optimal age to start weaning (Agostoni et al, 2008, and European Food Safety Agency, 2009). The WHO recommendations arise from a systematic review of 16 studies, which aimed to establish the optimal age for discontinuation of exclusive breastfeeding (WHO, 2001). As it included seven studies from less developed countries, the relevance of the WHO (2001) recommendations to the UK setting has been questioned (Grimshaw et al, 2009). Others have outlined that the application of rigid guidelines relating to what is essentially a developmental process can be problematic (Arden, 2010). The debate about the best age to wean can result in conflicting advice and confusion for mothers, health visitors and other health professionals (Moore et al, 2014). The BDA has suggested that many healthcare professionals find it difficult to interpret and use current guidance.


Role of the health visitor

The health visitor leads and delivers the guidance framework The Healthy Child Programme (DH, 2009), which covers pregnancy and the first five years of life. It is during this period that the foundations of future health and well-being are laid down (DH, 2009). There is evidence that these early years are a time when mothers are particularly receptive to learning and making changes (DH, 2009). Health visitors play a crucial role in ensuring that mothers get good support at the start of their baby’s life. They are in an ideal position to inform mothers of the correct age to wean and identify those who need additional support. Therefore, an awareness of the key factors associated with early weaning will help health visitors to assess risk and plan health promotion interventions for mothers. This article aims to summarise recent research studies, which report factors that influence mothers in the UK and Ireland to wean their infants before six months of age.


Literature search

A systematic literature review was undertaken to locate and review recent published evidence, investigating factors that may influence mothers in the UK and Ireland to wean their infants before six months. CINAHL®, MEDLINE™ and AMED were searched using the EBSCO host on April 2014 for the period 2004 to 2014.


Results

Eight studies were located as a result of the search strategy (Table 1). The studies were appraised using a critique tool from the Centre for Evidence Based Management (CEBM) (2014) Critical Appraisal of a Survey. The CEBM is an organisation that is dedicated to the practice, teaching and dissemination of high-quality evidence-based medicine, to improve healthcare in everyday clinical practice.

Click here to view Table 1: Summary of data presented in the selected papers

The following studies employed a questionnaire design, which incorporated open and closed questions that were completed via the internet (Arden, 2010; Moore et al, 2012; Moore et al, 2014) or via the post (Wright et al, 2004; White, 2009; Tarrant et al, 2010; McAndrew et al, 2012; Spillman, 2012). Arden (2010), Moore et al (2012), and Moore et al (2014) used online questionnaires, recruiting parents via UK internet parenting discussion forums and support organisations. This method of recruitment is unlikely to result in a nationally representative group as only mothers who access the internet and participate in online forum groups are targeted. In addition, mothers who use the internet may be better informed about weaning from researching this subject on the internet (Cline and Haynes, 2001).

The response rate in the studies was generally good with an acceptable response rate above 35% (Jackson and Furnham, 2001). However, certain groups are less likely to respond. Mothers who are unable to read and write or understand the language will not have the opportunity to participate in the research (Andrews et al, 2003). Furthermore, a questionnaire is likely to be completed by those who have a particular interest in infant feeding (Cline and Haynes, 2001).

The validity of the responses given can also be questioned. Completion of a questionnaire requires time so mothers who are able to participate may provide an incomplete questionnaire or complete it without due consideration of the responses (Spillman, 2012). The structured nature of a questionnaire can limit the responses given. Researchers can partly overcome this problem by allowing space for comments, which can provide insightful information (Andrews et al, 2003). This method was employed by White (2009), Arden (2010), Tarrant et al (2010), McAndrew et al (2012), Moore et al (2012) and Spillman (2012). In addition, it is impossible to verify whether a respondent is an appropriate participant as the questionnaire can be completed by anyone who receives it (Wright, 2005).

Two studies used additional approaches, which included interviewing parents (Tarrant et al, 2010) and using weaning diaries (Wright et al, 2004). Tarrant et al undertook interviews with participants in addition to administering questionnaires. The use of interviews generally enhances the validity of the responses; however, drawbacks include limited responses to speed up the interview and changed responses as a result of face-to-face contact with an interviewer (Alder et al, 2004). Most of the studies asked parents to recall decisions made up to three years previously. Responses relied on memory of events and views. Knowledge of the outcome of decisions may affect the memory of the factors influencing that decision (Pieters et al, 2006). Furthermore, some parents may have given responses that they thought should be given, rather than reporting what actually happened (Spillman, 2012).

Many of the studies had small numbers of participants, ranging from 104 (Spillman, 2012) to 10,768 (McAndrew et al, 2012).

Six of the studies collected data from England (Wright et al, 2004; Arden, 2010; McAndrew et al, 2012; Moore et al, 2012; Spillman, 2012; Moore et al, 2014), one study collected data from Scotland (White, 2009) and one collected data from Ireland (Tarrant et al, 2010). The socio-economic background of the participants varied. The participants in the studies by Arden (2010) and Moore et al (2012, 2014) were mainly women educated to degree level or equivalent. This is likely to result in higher breastfeeding rates relative to UK norms (Bolling et al, 2007). Highly educated white women are more likely to adhere to breastfeeding recommendations to breastfeed for the first six months and, consequently, follow weaning recommendations (Wright et al, 2006). However, although knowledge of guidelines may be higher in this group, they are still exposed to controversies regarding age of weaning, and Arden (2010) identified that a large percentage of participants did not follow current guidelines.

White (2009) undertook a small study of 114 participants in North Ayrshire, where 24% of the population lives in some of the most deprived areas of Scotland. While the number of participants was low, the results were reported to be similar to the Scottish data obtained from the Infant Feeding Survey (Bolling et al, 2007).

The largest study by McAndrew et al (2012) reported the responses of women who participated in the Infant Feeding Survey. This survey is conducted every five years to establish information about infant feeding practices and reports information on the incidence, prevalence and duration of breastfeeding and other feeding practices by mothers in the UK. The findings from the smaller studies were similar to this study, suggesting some key factors at play, such as: infants no longer satisfied with milk feeds, infants waking more often during the night and mothers aged 24 years or less.

Whilst recognising the limitations of the studies reviewed, key findings can be outlined that are relevant to practice. The reported age of weaning ranged from six weeks (Tarrant et al, 2010) to six months and above (Arden 2010; McAndrew et al, 2012; Spillman, 2012; Moore et al, 2014). The research describes a range of factors, rather than one single factor influencing parental decision to wean their infant before six months of age.


Factors associated with weaning before four months of age

Figure 1 shows factors that were identified as being associated with weaning before four months with the most prevalent being parents’ perception that the infant was no longer satisfied with milk feeds (Wright et al, 2004; Arden, 2010; Tarrant et al, 2010 and McAndrew et al, 2012). This was associated with the infant waking more often during the night (Arden, 2010; Tarrant et al, 2010; McAndrew et al, 2012; Moore et al, 2014).

Other identified factors associated with early weaning included maternal age and socio-economic status. A clear relationship was found between maternal age and the age of weaning, with mothers aged 24 years or less more likely to wean before four months (Tarrant et al, 2010; McAndrew et al, 2012; Moore et al, 2012; Moore et al, 2014). Socio-economic status of the mother was linked to early weaning, with mothers working in manual occupations more likely to have weaned their infants by four months than those working in professional occupations (Wright et al, 2004; White, 2009; McAndrew et al, 2012). Three studies identified that mothers with lower educational attainment were more likely to wean earlier than those who had received a higher level of education (Tarrant et al, 2010; Moore et al, 2012; Spillman, 2012).

Finally, early weaning was associated with mothers receiving feeding advice from the family, with the maternal grandmother highlighted as one of the principle sources (Tarrant et al, 2010; Spillman, 2012).


Figure 1: Factors associated with weaning before four months of age.


Factors associated with weaning between four and six months

Figure 2 shows factors that were identified as being associated with weaning between four and six months of age in the research studies reviewed. The key factor was reported to be parental knowledge and understanding of the national guidelines (Arden, 2010; Moore et al, 2012; Moore et al, 2014). Other influencing factors were reported to include use of the internet to seek advice concerning weaning (Moore et al, 2012; Moore et al, 2014) and professional advice given by a health visitor (Tarrant et al, 2010; McAndrew et al, 2012).


Figure 2: Factors associated with weaning between four and six months of age.

Figure 2: Factors associated with weaning between four and six months of age.

As can be seen, key differences were identified in the factors that influenced those who weaned before four months and those who waited until four to six months.


Discussion

The findings of the selected research have identified potential factors, which can influence the decision to wean early, and these can be used to inform risk assessment and plan health promotion activities. Of particular importance is identification of risk factors for weaning before four months of age due to the morbidity associated with very early introduction. Weaning before six months of age is associated with respiratory infections (DH, 2003) and exposure to pathogens present in food that may predispose the infant to gastrointestinal disease (Naylor and Morrow, 2001).

Some papers suggest that the inconsistency of information and conflicting advice regarding the recommended age to wean an infant has resulted in confusion amongst mothers (Arden 2010; Moore et al, 2012; Spillman, 2012; Moore et al; 2014). Evidence suggests that advice from health visitors regarding the correct weaning age may be inconsistent (Moore et al, 2012). Health visitors are in an ideal position to give infant feeding advice to mothers so it is important that their knowledge and advice regarding the weaning guidelines is consistent (Moore et al, 2014).

However, Arden (2010) and Moore et al (2014) report that the current DH guidelines (2003) are confusing. The guidelines state that six months is the recommended age for weaning, but also that ‘all infants should be managed individually’. This is open to interpretation. Some health visitors may follow a rigid approach to weaning from six months while their colleagues may advise weaning around this time in response to signs from the baby. And others may suggest weaning much earlier (Moore et al, 2012).

Arden (2010) and Moore et al (2014) suggest that DH weaning guidelines should be worded to enable health visitors to promote them in a way that allows the mother to respond to the needs of their infant. Confusion can occur when the mother has observed signs from the infant that indicate a readiness for weaning earlier than the guidelines state or when it is apparent to a health visitor that an infant is ready to wean, but the mother wants to wait until the infant reaches the recommended weaning age. Moore et al (2012) report that mothers see multiple health visitors who often advised differently, leading to a lack of confidence in the information they receive. Mothers need accurate and practical information to help them make appropriate choices for their infant (Arden, 2010).

Despite the DH guidelines, it is apparent that mothers still perceive the infant waking at night and not being satisfied with milk feeds as an indication that they should start weaning. This is particularly clear in those weaning before four months (Wright et al, 2004; Arden, 2010; Tarrant et al, 2010; McAndrew et al, 2012). This suggests that it may be necessary for health visitors to provide further communication to mothers about the correct signs of readiness to wean.

The input of family members is important because mothers are so influenced by their advice when it comes to perceived readiness to wean (Alder et al, 2004; Tarrant et al, 2010; Spillman et al, 2012). Mothers and family members may believe that the guidelines are incorrect when they consider previous generations being weaned earlier without any apparent health consequences (Anderson et al, 2001). This highlights the need for health visitors to communicate with the influential family members of some mothers. This may be a challenge, particularly as those family members may have weaned before with no apparent negative consequences. The less well-educated mothers and younger mothers are another group in need of support as evidence suggests they are likely to wean early and to be less influenced by professional advice (Tarrant et al, 2010; Moore et al, 2012; Moore et al, 2014; McAndrew et al, 2014).

Later weaning - from four to six months - was shown to be influenced by advice from health visitors (Arden, 2010; Tarrant et al, 2010; McAndrew et al, 2014). Health visitors are reported to be a primary source of weaning advice (White, 2009), highlighting the importance that health visitors follow the DH weaning guidelines when advising mothers.

Mothers are given a sometimes bewildering range of information, often with conflicting information concerning the best way to care for their infant. The DH guidelines (2003) on weaning are just one of many sources of information that parents may access. Advice labels on solid foods, marketed specifically for young infants, may be more accessible to mothers than other forms of information. These labels may state that the food can be given to infants from four months. The European Union has indicated that they intend to review the labelling, but has not specified a time framework (DH, 2003).


Implications for practice

Health visitors need to identify mothers least likely to comply with the DH recommendations. Interventions by the health visitor should be targeted specifically to their reasons for non-compliance, if possible.

They should advise mothers on the risks associated with early weaning, and need to be aware of the numerous conflicting sources of information about weaning.

One aspect of the role of the health visitor is providing information on the appropriate time to wean infants. This should include educating parents on the risks of early weaning.

Health visitors should determine an interpretation of the DH guidelines that can be consistently delivered.


Conclusion

There is no doubt that some mothers choose to wean their infants before the age of six months and a proportion of these wean before four months of age. This review has identified some of the key factors associated with early weaning and has indicated that there does not appear to be one specific factor; instead, there are a number of factors. Having an understanding of these factors will allow health visitors to develop targeted interventions to improve adherence with weaning guidelines. Whilst most of the studies explored were small, utilising a questionnaire design that can lead to biased responses, they do provide some useful information for health visitors about potential risk factors for early weaning.

Mothers are not always aware of the possible harmful effects of early weaning, particularly when it is before four months. However, there is evidence that early weaning continues in the UK and Ireland and, therefore, health visitors have a role in educating mothers on the risks of early weaning.


Acknowledgements

The author would like to thank Solent Trust for their sponsorship, support and encouragement.


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