Weaning a premature baby
Weaning a preterm baby doesn’t need to look very different to weaning a term infant. However, there are a few things you will need to consider when working with families.
Firstly, feeding has often been medicalised on the neonatal unit; growth is often a concern, milk is talked about in very strict parameters and feeds happen at regular timepoints rather than responsively. It can therefore be challenging for parents to let go of those conversations and to relax around feeding. Helping a family to relax into the weaning journey and to enjoy feeding is often our responsibility. Reassure where appropriate and support families to move away from a medicalised view of feeding, while continuing to monitor growth and nutritional adequacy.
Babies born prematurely may be more at risk of feeding difficulties because many of the reflexes that support the development of feeding skills emerge during the last trimester. When birth happens early, this development must continue outside the womb, which can make feeding more challenging for some babies.
These early feeding differences may become more apparent during weaning. If solids are introduced before a baby is developmentally ready, or there is a delay with progressing through textures, some babies may be more vulnerable to faltering growth, low iron intakes, delayed oral motor skill development and feeding aversions.
This article focuses on the specific considerations for infants born prematurely. General weaning guidance, including first foods, meal progression and feeding approaches, should be followed as for term infants unless otherwise indicated. For a full explanation of general weaning please refer to our HCP weaning guide.
Actual vs Corrected Age
Understanding actual vs corrected age is important in order to consider readiness for weaning and potential issues that may arise.
Actual or chronological age refers to a child’s age calculated from their date of birth.
Corrected age adjusts for prematurity and is calculated from the expected due date; this age gives a more accurate reflection of developmental readiness in preterm infants.
For example, an infant born at 28 weeks’ gestation is born 12 weeks early. When they are 6 months actual age, their corrected age is approximately 3 months.
Possible feeding challenges in babies born prematurely
Before considering weaning, it is helpful to think about the wider feeding journey and the challenges it can bring. While many babies born prematurely will feed without significant difficulty, some may need more support early on, and these early feeding experiences can influence how families approach weaning later.
Some of the more general feeding issues that may arise at the start of life include:
Reduced feeding efficiency
Some babies born prematurely have less mature sucking patterns, as well as smaller fat pads in their cheeks, which can make it harder to maintain a good latch, particularly during breastfeeding. Many breastfed babies rely on expressed breast milk.
Breastfeeding or expressing difficulties
Establishing breastfeeding can be challenging. Immature sucking patterns, early separation and the need for expressing may all affect bonding, latch and milk supply.
Slower development of feeding skills
Some babies take longer to develop the coordination needed for feeding, including the suck swallow breathe pattern.
Feeding aversion or sensory sensitivity
Babies who have had prolonged tube feeding or invasive procedures around the mouth may be more sensitive to touch, taste or texture, or may be more hesitant around feeding.
Reduced feeding stamina
Some babies may tire more easily, especially those with respiratory or cardiac issues.
Feeding instability in early infancy
Some babies may have episodes of desaturation, bradycardia or increased work of breathing during feeds, particularly in the early stages of feeding development. This may improve with maturity, but can also indicate that more support or assessment is needed.
Gastrointestinal symptoms
Reflux, vomiting, constipation and tolerance to feeds are all common in premature babies and can all make feeding more unsettled and affect overall intake.
The impact of underlying medical or developmental needs
Neurodevelopmental differences, a history of tube feeding, an increased risk of respiratory or cardiac conditions, and other medical issues can all impact feeding safety, skill development and nutritional intake.
Most of these challenges can be supported with the right advice and a responsive feeding approach, but significant concerns should be referred for specialist input.
When to start solids in preterm infants
As with a term baby, parents should be looking at developmental readiness within a corrected age window rather than age alone.
Premature babies are not usually ready for weaning until around 5 months corrected age, as prior to this, infants are unlikely to have the gastrointestinal and oral-motor maturity for safe feeding. Depending on gestation at birth, some babies will not be ready to begin solids until later in actual age than might be expected for a term infant. Introducing foods earlier than this point may increase the risk of choking or aspiration, which may lead to respiratory infections. Early feeding may also displace milk feeds, leading to nutritional inadequacy.
Instead of focusing too much on age, it is better to look at developmental signs of readiness which are:
- Good postural control: the ability to sit in a high chair with good trunk and head control
- Hand-to-mouth coordination: the ability to bring food or objects from the hand to the mouth (regardless of whether finger foods are being offered)
- Oral readiness: loss of the tongue-thrust reflex, allowing for food to be swallowed rather than pushed out of the mouth
In practice, many preterm infants will not demonstrate these signs until approximately 6 months corrected age. Assessment should always be individual, particularly for any infants with developmental concerns.
If babies are not showing readiness by around 7 months corrected age, parents should be advised to speak to a suitable healthcare provider such as their GP or paediatrician.
Potential challenges during weaning
Many preterm babies will move on to solid foods without significant difficulty, but some may experience feeding challenges during weaning. These issues might include:
- Delayed readiness for solids
- Some babies may take longer to develop the head control, coordination and oral skills needed for safe feeding.
- Slower progression through textures
- Moving on from smooth purées to lumpier textures may take longer for some babies. In some cases, parents may also feel anxious about progression, particularly if they have had a traumatic start to their baby’s life or are worried about choking.
- Gagging, coughing or choking more easily
- There may be immature oral-motor skills or difficulties with safe swallowing.
- Feeding aversion or distress around feeding
- Some babies may be more sensitive to tastes, textures or touch in and around the mouth. This can be the result of prolonged tube feeding or other oral procedures that may hold negative associations.
- Reduced feeding stamina
- Babies with ongoing respiratory or cardiac issues may tire more easily during feeding.
- Slower or more variable intake
- Intake may be less predictable during weaning, particularly where growth, energy requirements or feeding skills are still being established.
These challenges are not unique to preterm infants, but may be seen more often in this group. Supporting families with a calm, responsive approach to feeding, and allowing time for skills to develop, can help babies to progress at their own pace. Encouraging families not to compare their baby with others, especially term babies can be helpful. Any ongoing concerns should be explored further to ensure appropriate support is in place.
Nutritional considerations for preterm babies
Catch up growth
Some preterm infants require a period of catch-up growth after the early weeks of life, because of issues such as intrauterine growth restriction, early feeding challenges, reflux and increased requirements. However, nutritional management during weaning should aim to support proportionate growth, rather than simply adding additional calories and increasing growth on the weight centiles.
Healthy, balanced catch-up growth is characterised by gradual alignment of weight, length and head circumference centiles. Disproportionate increases in weight relative to length or head circumference may indicate excess energy intake without appropriate lean tissue or skeletal growth.
While adequate energy and protein are essential to support neurodevelopment and tissue growth, rapid or excessive catch-up growth, particularly when driven by excessive energy intakes, has been associated with an increased risk of adverse metabolic outcomes later in life. Observational studies have linked rapid early weight gain to a higher risk of insulin resistance, obesity, hypertension and cardiovascular disease.
During the early stages of weaning, solid foods should complement, rather than replace breastmilk or formula, which continue to be the primary source of energy, protein and micronutrients. Energy-dense solids should be introduced cautiously and within a developmentally appropriate feeding framework to ensure nutritional adequacy without promoting excess weight gain.
If there are issues with faltering growth, or rapid growth, referral to a dietitian is recommended.
Micronutrients & supplements
Iron rich foods should be a focus for all babies during weaning as breastmilk and infant formula are unlikely to meet the increased iron requirements of babies past 6 months of age. This is especially important for preterm babies as most iron stores are laid down in the third trimester, which some preterm babies miss.
Please check your local supplementation policy; but in many neonatal units it is standard practice for babies born <34 weeks’ gestation or with a birth weight of <1800g to require iron supplementation. It is usual for any supplementation to continue alongside the introduction of iron-rich solid foods.
Texture progression and oral-motor development
Complementary feeding is a period of learning, and can be a particularly steep learning curve for premature babies. Introducing solid food supports the development of oral-motor skills as well as providing important nutrients for growth and development.
UK guidance emphasises that safely moving through textures, whilst taking into account corrected age and readiness cues, can help infants to confidently develop chewing and swallowing skills. There are no set timelines for progressing through textures; parents should look at skill levels and progress as they feel appropriate.
Feeding behaviour and sensory considerations
Babies born prematurely may approach feeding in a different way to infants born at term because of changes to their sensory profile. Early interventions such as intubation, prolonged tube feeding and suctioning all of which can impact how an infant responds to sensory stimulation in the mouth during weaning. They may have heightened responses to sensory input or demonstrate learnt stress responses to oral stimulation; both of which can lead to difficulties with changes in taste and texture during weaning.
The aim is to approach feeding in a responsive, cue based way. A supportive positive environment, alongside pressure free feeding interactions will allow infants to gradually build confidence with new textures and flavours and will reduce the risk of long term feeding aversions.
Safety considerations
Healthcare professionals play a key role in supporting families to reduce risk while promoting positive feeding experiences.
Choking:
Risk can be minimised through appropriate preparation and supervision during feeding:
- First aid course: all parents and caregivers should be advised to carry out a first aid course to understand the difference between gagging and choking and to know what to do if their baby chokes.
- Ensure stable, upright positioning with good head and trunk support: babies should not be fed lying back, slumped or reclined.
- Close supervision at all times is essential: babies should never be left alone while eating.
- Offer developmentally appropriate textures: progression should be gradual and in line with skill development rather than age.
- Prepare foods safely: ensure they are soft, well cooked and appropriately sized, as you would with a baby born at term. High-risk foods should be avoided, including whole nuts, hard raw vegetables, small round foods, and foods that squish and spring back to shape (e.g. popcorn, marshmallows).
Food Hygiene
Good food hygiene during weaning is especially important for babies born preterm. They may be more vulnerable to infection due to immature immune and gastrointestinal systems, Healthcare professionals should support families with clear, practical advice on safe food preparation and storage, including:
- Washing hands thoroughly before preparing food or feeding
- Ensuring foods are freshly prepared, well cooked and cooled appropriately
- Check storage recommendations for storing leftover foods
- Always ensure feeding equipment and surfaces are clean feeding before cooking
When to refer to other professionals
Early identification of feeding difficulties and timely referral can support safe feeding progression and help prevent longer-term feeding and nutritional problems. It may be appropriate to consider a referral for further assessment in any of the following situations:
Readiness and progression
If a baby is not showing the signs of being ready to start weaning by around seven months corrected age, or there is significant parental concern about feeding development.
Growth and nutrition
Referral should be considered where there are concerns about growth or nutritional intake. This includes faltering growth, disproportionate or rapid catch-up growth, particularly where weight gain is increasing beyond length or head circumference, or concerns that reduced milk feeds during weaning are affecting overall nutritional adequacy.
Feeding safety
Feeding safety should always be considered carefully. Concerns about dysphagia or aspiration may present as persistent coughing or choking with feeds, a wet or gurgly vocal quality during or after feeding, or recurrent chest infections associated with feeding. These symptoms should not be overlooked and may require further assessment.
Feeding behaviour and tolerance
Feeding behaviour and tolerance can also indicate when additional support is needed. Severe feeding aversion or refusal, prolonged or highly distressing mealtimes, or marked anxiety, stress or other negative responses around feeding that limit intake or progression should prompt further review.
Key takeaways for healthcare professionals
- Use corrected age alongside developmental readiness cues when advising on the introduction of solid foods in infants born preterm. Avoid giving solid foods too early, but also avoid unnecessary delays where readiness is evident to prevent nutritional deficiencies.
- Be aware that there is a developmental window for food acceptance and skill acquisition. Once weaning has started, gradual exposure to a range of textures supports oral-motor development and may reduce later feeding difficulties.
- Prioritise balanced nutrition during weaning. Breastmilk or formula should remain the primary source of nutrition early in the weaning journey.
- Focus on environment and encouraging variety over volume. If a child is tracking appropriate growth, opening bowels regularly and satisfied after feeds, a variable intake is expected.
- Support proportionate catch-up growth. Growth should be assessed using weight, length and head circumference together, aiming for balanced progression rather than rapid weight gain alone.
- Identify feeding concerns early. Faltering growth, persistent coughing, choking, feeding distress, or limited progression through textures should prompt further assessment.
- Where appropriate, ensure advice is consistent with the infant’s neonatal discharge plan and follow-up pathway.
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Written by Lucy Wood
Lucy has a BSc honours degree from King’s College London with additional postgraduate learning through the British Dietetic Association and has been working as a registered dietitian for 12 years both within the NHS and the private sector.
