Scottish maternal and infant nutrition survey 2017

7. Infant Nutrition: Complementary Foods

The gradual introduction of a variety of complementary foods ^[35] to an infant's diet, alongside usual milk feeds (breast or formula), is commonly referred to as "weaning". However, SACN's recent draft report on "Feeding in the First Year of Life" indicates that the purpose of introducing complementary foods is to "diversify the diet whilst breastfeeding continues during the early year of life, not to "wean" the infant from the breast". ^{( R5)}

Scottish Government policy recommends that complementary foods should be introduced to infants around six months of age. This is based on WHO guidance that has been in place since 2003. ^{( R32)}

For the first six months of life, an infant's nutritional needs can be met by breast milk or infant formula; from six month onwards an infant gradually needs more nutrients than milk alone can provide. ^{( R1, R24)} Around the age of six months, parents are advised to look for signs that their infant is developmentally ready to begin eating complementary foods. ^{( R24)}

It is recognised that some infants may be introduced to complementary foods earlier than six months for a variety of reasons. However, current advice states that this should never happen before an infant is four months old (17 weeks). ^{( R5, R24, R32, R33)}

It is recommended that the quantity and variety of complementary foods are gradually increased, so that by the time an infant is a year old, food rather than milk forms the main part of his/her diet. ^{( R1, R24)}

It is also recommended that an assortment of tastes and textures should be introduced to help promote the acceptance of a wide range of foods and ensure a balanced diet. Infants should progress from soft finger and mashed foods to lumpy and then minced foods. ^{( R1, R5, R24, R34)}

Creating the right environment to encourage good nutritional habits, together with the social aspects of feeding, are important when introducing complementary foods, ^{( R24)} however these topics were not covered in this survey.

This section of the report provides information on the introduction of complementary foods, as reported by mothers who responded to the 8-12 month postnatal survey. The vast majority of respondents to this survey (95%) had infants aged between eight and ten months. Please note that the terms "complementary foods" and "solid foods" are used interchangeably throughout this report.

7.1 Introducing complementary foods

Almost all mothers who responded to the 8-12 month survey indicated that their baby had been given foods other than milk (99.9%). The vast majority of these respondents (96%) waited until their infant was at least four months old before introducing complementary foods, with 46% waiting until six months or later. Only 3% of respondents reported introducing solid foods before their baby was four months old.

[Figure7.1; Table 7.1 & 7.2]

The vast majority of infants were at least four months old when complementary foods were first introduced.

Figure 7.1: How old was your baby when he/she first had any food apart from milk? (Percentage of respondents who recorded each age. Respondents who had introduced complementary foods).

Source: Q5, 8-12 Month Survey

The 2010 UK-wide Infant Feeding Survey ( IFS) showed a shift towards the later introduction of complementary foods. ^{( R7)} Due to small differences in the way this question was asked and reported on in the IFS and in this survey, it is not possible to present a direct comparison of results for the two surveys. However, it is clear that the trend highlighted in the IFS has continued since 2010.

In the 2010 survey, 32% of mothers in Scotland had already introduced solid foods by the time their baby was four months old (17 weeks), rising to 74% by the time babies were five months old (22 weeks).

Breastfeeding / expressing status

In general, infants who had never been given breast milk were introduced to complementary foods earlier than infants who had received breast milk. Seven percent (7%) of respondents who had never given their baby breast milk introduced solid foods before four months. The equivalent figure for mothers who had given their baby breast milk was 2%.

Almost half of respondents (49%) who had given breast milk waited until their baby was at least six months old before introducing complementary foods. By comparison, only 37% of mothers who did not give breast milk waited until this time.

[Table 7.3]

However, the timing of the introduction of complementary foods varied amongst infants who had been given breast milk. Overall, infants who had been given breast milk for less than six months were introduced to solid foods earlier than those who had been given breast milk for six months or more. Only 39% of infants who had been given breast milk for less than six months were introduced to complementary foods after they were six months old. The equivalent figure for babies who had been given breast milk for six months or more was 56%.

[Figure 7.2; Table 7.4]

Infants who were last given breast milk when they were six months or older were introduced to complementary foods later than other infants.

Figure 7.2: How old was your baby when he/she first had any food apart from milk? (Percentage of respondents who recorded each age, by age of baby when last given breast milk. Respondents who had introduced complementary foods).

Source: Q5, Q28, 8-12 Month Survey

Age of respondent

Overall, infants with younger mothers were introduced to complementary foods earlier than those with older mothers:

• While 8% of respondents aged 20-24 introduced solid foods before four months, only 1% of those aged 35 or over did so.
• 38% of mothers aged 20-24 waited until their baby was at least six months old before introducing solid foods, compared to 53% of respondents aged 35 or over.
• No results are presented for respondents aged 19 or under; there were too few respondents in this age group to produce meaningful results.

[Table C1: 8-12 Months – Results by Age of Respondent]

Deprivation

There was also an association between deprivation and the age at which complementary foods were introduced to infants. However, the differences between respondents who lived in the least / most deprived areas were less pronounced than those that were observed between younger / older mothers:

• Respondents who lived in the most deprived areas were more likely to introduce solid foods before four months ( SIMD1: 5%) than those who lived in the least deprived areas ( SIMD 5: 2%).
• 44% of respondents who lived in the most deprived areas ( SIMD 1) waited until their baby was at least six months old, compared to 50% in the least deprived areas ( SIMD 5).

[Table C2: 8-12 Months – Results by SIMD]

NHS board of Residence

There was some variation in the timing of the introduction of complementary foods depending on the respondent's NHS board of residence.

In NHS Greater Glasgow and Clyde, 52% of respondents waited until at least six months before introducing solid foods to their baby and very few reported giving solids before four months (1%). However, in NHS Ayrshire and Arran, only 39% waited until at least six months and 9% of mothers indicated that their baby had been given solid foods before four months.

There may be a variety of reasons for differences amongst geographical areas and care should be taken when comparing board results. For example, some areas have higher numbers of young mothers and some boards contain fewer areas of deprivation than others. There may also be differences in local practices within Health Visitor and Primary Care teams regarding support for infant feeding, and varying local initiatives.

[Figure 7.3; Table C3: 8-12 Months – Results by Board]

Infants who live in some NHS boards are given complementary foods earlier than those who live in others.

Figure 7.3: How old was your baby when he/she first had any food apart from milk? (Percentage of respondents who recorded six months or more / less than four months, by NHS board of residence. Respondents who had introduced complementary foods).

Source: Q5, 8-12 Month Survey

7.2 Reasons for introducing complementary foods

Mothers chose to introduce complementary foods to their infants, at the time that they did, for a variety of reasons. The most common reason given by survey respondents was that they "thought that it was the right time" for their baby (66%). Other frequently given reasons included: their "baby was able to sit up and hold food" (49%); "a health care professional advised" them to (39%); "previous experience with another baby" (33%).

[Figure 7.4; Table 7.5]

Most respondents introduced complementary foods when they thought that it was the "right time" to do so.

Figure 7.4: Why did you decide to start giving your baby foods other than milk at this age? (Percentage of respondents who selected each reason. Respondents who had introduced complementary foods).

Source: Q6, 8-12 Month Survey

In the 2010 UK-wide IFS, the most common reason given by mothers across the UK for introducing solid foods was that their baby was "not satisfied with milk" (52%). This reason was only selected by 30% of respondents in the current survey. ^{( R7)} However, it should be noted that respondents to both surveys were asked to select from a pre-determined list of reasons, and the lists presented in each survey varied slightly. This may have affected the way mothers responded to this question in the two surveys.

The reasons given for introducing complementary foods in the current survey varied widely depending on when complementary foods were first introduced:

• Respondents who introduced complementary foods before four months frequently indicated that they did so because their baby was "not satisfied with milk" (70%) or because their baby was "waking up during the night" (26%). These reasons were mentioned progressively less frequently by those who introduced solid foods later.
• Respondents who introduced solid foods earlier were also more likely to indicate that they had been influenced by an "other" reason, not explicitly listed in the questionnaire. Six percent (6%) of mothers who introduced solid foods before five months specifically mentioned "reflux" as a reason.
• Where solid foods were introduced at six months or later, mothers were more likely to indicate that they had been influenced by formal information sources such as a health care professional (59%) or NHS Health Scotland's Fun First Foods booklet (29%). ^{( R24)} They were also more likely to mention other leaflets and information, including information found on the Internet (41%).

[Figure 7.5; Table 7.5]

Reasons for starting to give complementary foods varied depending on when these foods were first introduced.

Figure 7.5: Why did you decide to start giving your baby foods other than milk at this age? (Percentage of respondents who selected each reason, by age of baby when foods first given. Respondents who had introduced complementary foods. Most common reasons highlighted).

Source: Q6, Q5, 8-12 Month Survey

7.3 Types of food given

The majority of respondents indicated that they gave breakfast cereal / porridge (70%), whole or pureed fruit (69%), and vegetables, other than potatoes and green leafy vegetables (52%), to their infants every day. These foods along with starchy foods, such as potatoes, rice and pasta, and dairy produce were the key features of the infants' diets in this survey.

[Figure 7.6; Table 7.6]

Breakfast cereal, fruit and vegetables are the foods given to infants most often.

Figure 7.6: How often does your baby have each of the following foods? (Percentage of respondents who selected each frequency. Respondents who had introduced complementary foods).

Source: Q7, Q8, 8-12 Month Survey

• Foods such as meat and fish, green leafy vegetables, and bread were given less frequently, but were still provided several times a week in the majority of cases.
• However, more than one in ten respondents reported never giving any type of bread (13%) or green leafy vegetables (11%) to their babies. Ten percent (10%) reported never giving any dairy produce, such as yogurt or cheese, and 7% never give meat or fish.
• Of the foods specifically listed in the survey, eggs were given least frequently; 47% of respondents indicated that eggs were given less than once a week or never.
• Respondents were also asked to indicate how frequently they gave commercial baby foods to their infants (for example, pouches, snacks, jars, tubs, bars). Forty-one percent (41%) of respondents reported using commercial baby foods five days or more per week. Twenty-seven percent (27%) give commercial baby foods less than once a week or never.

Results from the UK-wide 2010 IFS, were similar to the current survey in that breakfast cereals, fruit and vegetables were the foods given most frequently to infants. Eggs were also reported as being given infrequently in the 2010 survey. ^{( R7)} However, differences in the way that questions were asked in the two surveys mean that it is difficult to directly compare specific percentages across food groups.

[ Figure 7.6; Table 7.6]

Age of respondent

There was some variation in the diets of infants depending on the age of the mother:

• Respondents aged 20-24 were more likely to use commercial baby foods on a daily basis (42%) than those aged 30-34 (29%) or mothers aged 35 or over (31%).
• 57% of respondents aged 20-24 gave fruit on a daily basis, compared to 73% of those aged 30-34 and 35 and over.
• 5% of respondents aged 20-24 reported never giving vegetables, excluding potatoes or green leafy vegetables. Mothers in all other age groups (25+) only reported this in 1% of cases.
• 31% of respondents aged 20-24 gave dairy foods on a daily basis, compared to 41% of those aged 30-34 and 35 and over.
• No results are presented for respondents aged 19 or under; there were too few respondents in this age group to produce meaningful results.

[Table C1: 8-12 Months – Results by Age of Respondent]

Deprivation

There were also some differences in diet depending on whether respondents lived in the most / least deprived areas:

• Respondents who lived in the most deprived areas were more likely to use commercial baby foods on a daily basis ( SIMD 1: 38%) than those in the least deprived areas ( SIMD 5: 25%).
• Respondents who lived in the most deprived areas were less likely to give fruit on a daily basis ( SIMD 1: 61%) than mothers in less deprived areas ( SIMD 5: 76%).
• Respondents who lived in the most deprived area were less likely to give vegetables, excluding potatoes or green leafy vegetables, on daily basis ( SIMD 1: 44%) than those in the least deprived areas ( SIMD 5: 61%).
• Respondents who lived in the most deprived area were less likely to give dairy produce on daily basis ( SIMD 1: 33%) than mothers in the least deprived area ( SIMD 5: 44%).

[Table C2: 8-12 Months – Results by SIMD]

Food texture

In general, respondents reported feeding mashed, lumpy or pureed food to their babies, rather than allowing infants to feed these types of foods to themselves. On the other hand, infants were reported to frequently eat finger foods by themselves.

[Figure 7.7; Table 7.7]

Infants frequently feed finger foods to themselves, but tend to be fed mashed, lumpy or pureed food.

Figure 7.7: On average how often do you feed the following types of food to your baby and how often does he/she eat these foods by him/herself? (Percentage of respondents who selected each frequency. Respondents who had introduced complementary foods).

Source: Q9, Q10, 8-12 Month Survey

7.4 Meals, snacks and treats

NHS Health Scotland advice is that the number of meals containing solid foods should be gradually increased from one to two, and then to three meals per day as an infant seems ready. By the time a baby is a year old, food rather than milk should form the main part of his/her diet. ^{( R24)}

Meals per day

The majority of respondents (85%) indicated that their infants were already being given three or more meals per day. However, respondents were not asked to provide any information about the quantity of food served at each meal.

Of those infants who were receiving three or more meals per day, most (59%) did not start this until they were at least seven months old. However, 40% of these infants began three meals per day before seven months, with 7% starting before six months.

[Figure 7.8; Table 7.8 & 7.9]

Forty percent of infants, who regularly have three or more meals per day, started doing so before they were seven months old.

Figure 7.8: How many meals does your baby have per day? / How old was your baby when he/she regularly started having three or more meals of foods other than milk a day? (Percentage of respondents who indicated that their infant was having three or more meals per day / percentage of respondents who selected each age (respondents whose infant was having three or more meals per day only)).

Source: Q11, Q12, 8-12 Month Survey

In the 2010 UK-wide IFS, mothers with infants aged four to six months were asked how many meals they gave to their babies. At a UK level, 28% reported giving three or more meals of solid foods per day. ^{( R7)}

Due to differences in the age bracket of the infants in the 2010 IFS and the current survey it is not possible to present a direct comparison of results. However, the 2010 survey also showed a clear trend to towards giving an increased number of daily meals as infants got older.

Snacks and "treats"

Respondents were also asked to provide information on the number of snacks and "treats" given to their babies on a daily basis. The majority of infants (74%) received one or more snacks throughout the day. The term snack was not tightly defined within the questionnaire, but respondents were asked not to count foods such as "chocolate buttons, ice cream, crisps or cheese puffs" as a snack.

Twenty-nine percent (29%) of respondents indicated that they gave "treats" to their infant one or more times per day. For the purposes of the survey, treats were defined as items such as "chocolate buttons, ice cream, crisps or cheese puffs". A small number of survey respondents commented on their completed questionnaires that they had concerns about these types of foods being referred to as "treats".

[Figure 7.9; Table 7.8]

On average, more than a quarter of infants are given "treats" at least once a day.

Figure 7.9: On average how many meals, snacks and treats does your baby have per day? (Percentage of respondents who selected each frequency. Respondents who had introduced complementary foods).

Source: Q11, Q13, Q14, 8-12 Month Survey

Age of respondent

• Younger respondents were more likely to give their baby a snack than older mothers. On average, 78% of mothers aged 20-24 gave at least one snack per day, compared to 69% of those aged 35 and over.
• Younger respondents were also more likely to give their babies "treats". Nearly half of all mothers aged 20-24 gave one or more treats per day (49%), whereas less than a quarter of those aged 35 and over offered treats (22%).

[Table C1: 8-12 Months – Results by Age of Respondent]

Deprivation

• 78% of respondents from the most deprived areas ( SIMD 1) offered three or more meals per day, compared to 91% of mothers in the least deprived areas ( SIMD 5).
• However, mothers who lived in the most deprived areas were more likely to offer one or more snacks per day (79%) than those who lived in the least deprived areas (70%).
• Respondents who lived in the most deprived areas were also more likely to give their babies "treats". Thirty-nine percent (39%) of mothers in the most deprived areas gave one or more treats per day, whereas only 18% of those in the least deprived areas did so.

[Table C2: 8-12 Months – Results by SIMD]

7.5 Sources of information

Types of food

Almost all respondents (99.6%) indicated that they had access to information relating to the types of food they should give to their infants. A high proportion of all mothers reported that they had received information from web based resources (55%), a health care professional (55%), NHS Health Scotland's Fun First Foods booklet (47%), or other written materials such as books and leaflets (49%).

However, the source of information varied depending on whether this was the respondent's first baby or not. The vast majority of mothers who already had children reported using previous experience (92%). First time mothers were more likely to report receiving information from friends and family (46%) than mothers who already had children (17%).

[Figure 7.10; Table 7.10]

First time mothers are more likely to obtain information about what types of food to give from other people, including friends and family.

Figure 7.10: Still thinking about foods other than milk, where did you get information about what types of food to give to your baby? (Percentage of respondents who selected each source, by whether this is respondent's first baby. Most common sources highlighted in pink).

Source: Q15, Q1, 8-12 Month Survey

How much food

Overall, respondents were less likely to report having access to information about how much food to give to their babies. First time mothers in particular were more likely to report that they had not received any information on this topic (15%). Four percent (4%) of mothers who already had children indicated that they had not received any information about how much food to give their baby.

Again, respondents who already had children reported using previous experience (83%) as a source of information. First time mothers were more likely to obtain information from friends and family (31%) than previous mothers (10%).

[Figure 7.11; Table 7.11]

One in ten mothers did not have any information about how much food to give their infant.

Figure 7.11: Still thinking about foods other than milk, where did you get information about how much food to give to your baby? (Percentage of respondents who selected each source, by whether this is respondent's first baby. Most common sources highlighted in pink).

Source: Q16, Q1, 8-12 Month Survey

7.6 Drinks other than breast and formula milk

From around six months of age, breast milk or first milk infant formula can continue to be given alongside appropriate complementary foods. Other types of milk, such as cows' milk, are not recommended as a main drink until after an infant is 12 months old. ^{( R24)}

Generally speaking, tap water is the only alternative drink recommended for infants aged six to twelve months that can be given between meals. However, NHS Health Scotland's Fun First Foods advises that water or small amounts of unsweetened and diluted fresh fruit juice can be given alongside meals in a free-flow cup. ^{( R24)}

Only 4% of respondents reported giving no drinks apart from breast or formula milk, with the vast majority (92%) indicating that they offered water to their babies. More than one in ten respondents reported giving diluted fresh fruit juice (14%).

Some respondents did report giving drinks that are not recommended for infants, such as sugar free / no added sugar diluting juice (12%), cows' milk (4%), tea (3%), undiluted fresh fruit juice (2%), or diluting juice with added sugar (1%).

[Figure 7.12; Table 7.12]

Water is frequently offered to infants in addition to breast and/or formula milk.

Figure 7.12: Do you give your baby any drinks apart from breast milk or formula milk? (Percentage of respondents who selected each type of drink. Most common types of drink highlighted in pink).

Source: Q17, 8-12 Month Survey

In the 2010 UK-wide IFS, 78% of infants in Scotland were reported as receiving drinks other than milk by the time they were six months old. This had risen to 97% by the time infants were nine months. No information was captured regarding the specific types of drinks that were given. ^{( R7)}

7.7 Use of vitamin drops

It is currently recommended that infants should be given Vitamin D drops from birth, ^[36] unless receiving 500mls or more of formula milk a day. ^{( R5)}

Overall, 33% of mothers who responded to the 8-12 month survey reported giving their baby vitamin drops. Of those who were giving vitamin drops, the majority (85%) gave them every day or on most days.

[Figure 7.13; Table 7.13 & 7.14]

One third of infants are given vitamin drops at least some of the time.

Figure 7.13: Do you give your baby any vitamin drops? / How often do you give your baby vitamin drops? (Percentage of respondents who indicated that they give vitamin drops / percentage of respondents who selected each frequency (respondents who give vitamin drops only)).

Source: Q18, Q20, 8-12 Month Survey

In the 2010 UK-wide IFS, only 13% of mothers in Scotland reported giving vitamin drops to infants aged between eight and ten months. ^{( R7)}

Breastfeeding / expressing status

Vitamin drop usage varied amongst mothers depending on whether they had ever given their infant breast milk and by whether they were still giving breast milk to their baby at the time of completing the survey. Seventeen percent (17%) of respondents who had never given their baby breast milk reported giving vitamin drops. Mothers who had been giving breast milk, but who had now stopped, were less likely to be giving vitamin drops (28%) than those who were still breastfeeding / expressing milk (51%).

[Figure 7.14; Table 7.13]

Mothers who were still breastfeeding / expressing milk were more likely to be giving their baby vitamin drops.

Figure 7.14: Do you give your baby any vitamin drops? (Percentage of respondents who indicated that they were giving vitamin drops, by whether respondent was still breastfeeding / expressing milk for her baby).

Source: Q18 , Q26, Q27, 8-12 Month Survey

Age of respondent

• Younger respondents reported giving vitamin drops to their baby less frequently than older mothers. Twenty-three percent (23%) of respondents aged 20-24 indicated that they gave vitamin drops; the equivalent figure for respondents aged 35 and over was 35%.

[Table C1: 8-12 Months – Results by Age of Respondent]

Deprivation

• Nearly a third of respondents (31%) who lived in the most deprived areas ( SIMD 1) reported that they gave vitamin drops to their baby; the equivalent figure for respondents who lived in the least deprived areas ( SIMD 5) was 41%.

[Table C2: 8-12 Months – Results by SIMD]

Source of vitamin drops

Twenty-nine percent (29%) of respondents who indicated that they gave vitamin drops to their infants said that they received free Healthy Start vitamin drops. Sixty-three percent (63%) of respondents indicated that they bought vitamin drops (Healthy Start 23%, other type 40%), while 5% said that they got them on prescription.

[Figure 7.15; Table 7.15]

Most mothers who give vitamin drops to their infant buy them.

Figure 7.15: How do you usually get the vitamin drops for your baby? (Percentage of respondents who selected each source. Respondents who give vitamin drops).

Source: Q19, 8-12 Month Survey

In the 2010 UK-wide IFS, when infants were 8-10 months old, a similar proportion of mothers across the UK reported getting free Healthy Start vitamin drops (28%). However, only 10% of respondents reported buying Healthy Start vitamin drops, while 46% bought a different brand. Fifteen percent (15%) got vitamins on prescription. ^{( R7)}

7.8 Postnatal dietary supplements

In line with general health advice, women should aim to eat a healthy and varied diet following the birth of a baby. In addition, there is a specific recommendation that women who are breastfeeding should take a Vitamin D supplement. ^{( R1)}

Respondents to the 8-12 month postnatal survey were asked about their vitamin / iron intake. Thirty-five percent (35%) indicated that they were taking a supplement at the time of survey completion.

Dietary supplement use varied between mothers who were still giving breast milk compared with those who had stopped giving breast milk to their baby and those who had never breast fed /expressed milk:

• Over half of mothers (55%).who were still giving breast milk reported taking a supplement at the time of survey completion
• Less than a third (29%) of those who had been giving breast milk, but who had now stopped, were now taking a supplement.
• 17% of mothers who had never given their baby breast milk reported taking a supplement at the time they completed the survey.

[Figure 7.16; Table 7.16]

Mothers who were still breastfeeding / expressing milk at 8-12 months were more likely to be taking a vitamin / iron supplement.

Figure 7.16: Are you currently taking any vitamin or iron supplements yourself? (Percentage of respondents who indicated that they were taking a supplement, by whether mother was still breastfeeding / expressing milk for her baby).

Source: Q21, Q26, Q27, 8-12 Month Survey

The supplements most frequently taken by respondents to the 8-12 month survey were Vitamin D (26%), multi-vitamin (23%), multi-vitamin + iron combined (21%) or iron and/or folic acid (19%). Only 14% of these respondents reported taking Healthy Start vitamins.

[Figure 7.17; Table 7.17]

Vitamin D, multi-vitamin and iron were the supplements most often taken by postnatal respondents.

Figure 7.17: What types of supplements are you taking? (Percentage of respondents who selected each type of supplement. Respondents who were taking a supplement).

Source: Q22, 8-12 Month Survey

Other types of supplements, suitable for postnatal women, were frequently mentioned by respondents (8%); this included various branded multi-vitamin supplements for new / breastfeeding mothers. A further 11% of respondents mentioned other types of supplements (for example, Vitamin B12, calcium, Omega 3 and cod liver oil).

[Table 7.17]