According to the Department of Health (2008) weaning is the gradual introduction of solid food into the diet of a baby at a time when breast or formulae milk alone is no longer enough for healthy growth and nutrition. The goal of weaning is that the child will eat the same solid foods as rest of the family.
This case study will explore the experiences witnessed by a student nurse on practice placement of a family within the community setting, as they begin weaning their six months old child. The assessment process will be explained, a childhood health need continuum selected and the health care interventions used will be analysed.
The family selected for this case study moved to this country from Pakistan two years ago and are of Hindu culture. Family members’ names have been changed in accordance with NMC Professional Code of Conduct (2004) to ensure confidentiality.
Mother is a home maker who shall hereafter be named Sarah, father named David is a Senior Housing Officer who worked nights at a local hospital therefore Sarah carries out most of the childcare. Their first child Emma was six months old upon time of visit and had been exclusively breastfed up until then.
The family live in rented accommodation with all basic amenities for example water, heating, sanitation and cooking facilities.
Within their local community there were many resources available for example, GP surgeries, shops, leisure centre, library, children’s centre housing sure start programme (Every Child Matters 2005) offering integrated education, health care, family support and health services. The wider extended family still lived in Pakistan
The rationale for selecting this family is that the author had visited Sarah and Emma on numerous occasions with the health visitor, and therefore formed a relationship of mutual trust and respect with them. This enabled the author to offer the family advice, help and support during the weaning process and also to offer social support. According to the Department of Health (2008) Mothers are delaying the introduction of solids into their baby’s diets. Only 2% of mothers were following the advice given by Health Visitors to delay weaning until 6 months of age.
This case study prompted an interested in learning more about cultural diversity and the effect on lifestyle and parenting style of different cultures in the areas of, for example, food, religious practices, language and family background.
When Emma was born a holistic assessment was undertaken by a health visitor to safeguard and promote Emma’s welfare. This consisted of an assessment of Emma’s developmental needs and strengths, taking into account the role of her parents, family and environmental factors. For this the Common Assessment Framework was used. (DOH 2000) (Appendix 1):
“The Common Assessment Framework is a standardized approach to conducting an assessment of a child’s additional needs and deciding how those needs should be met”.
This assessment continued when Sarah contacted her designated health visitor via telephone to arrange a home visit to discuss weaning. Upon arrival through chatting to health visitor Sarah explained that Emma is six months old and still solely breastfeeding, she knows that weaning is recommended around this age but feels she does not have enough of a knowledge base and therefore feels very anxious she has not began and also feels unsupported as her husband works antisocial hours. (Department of Health 2003) Recommend that babies should be exclusively breastfed for the first six month of life as it provided the best form of nutrition.
The Food Standards Agency (2008) states that weaning should commence at six months old as breast milk alone does not provide babies with enough nutrients, in particular iron for health grown and development. Iron deficiency anaemia is the most common haematological disorder in childhood between the ages of 6 months and 2 years. (Glasper, McEwing, Richardson 2007)
The health visitor Sarah by asking questions about how Emma is sleeping, if there has been any chance in her pattern, how she is developing physically i.e. can Emma hold her head up or can sit unsupported yet, and does she feel Emma is requiring more breastfeeds and if Sarah has offered her any food yet. Sarah stated that yes she feels Emma is hungrier and unsatisfied at times and she can sit up right by herself now.
The Department of Health (2008) states that although it is recommended that babies commence weaning at six months old every child is different and therefore should be assessed individually as to whether they are ready to begin weaning. Signs to look for are being able to sit up unsupported, being able to hold head up, wanting to chew or teething, change in sleeping pattern and curiosity with food.
Sarah stated that she had previously offered Emma finger foods and small amounts of pureed vegetables and chicken whilst still being breastfed but Emma refused. Therefore Sarah felt she was not doing it right and had not tried since therefore exclusively breastfeeding still. Sarah was also unsure of what other foods could be used to wean.
It was decided that this visit they would just discuss Sarah’s worries and anxieties related to her care for Emma and in particular her need for nutrition and therefore weaning. Health Visitor would also assess and weigh Emma and they would arrange another visit the following day to attempt feeding.
The health visitor then looked at Emma’s centile chart (Tanner et al 1966) at the back of her parent held record book to see if she was putting on weight at an appropriate rate. Centile charts show the position of a measured parameter within a statistical distribution. They do not show if that parameter is normal or abnormal. They merely show how it compares with that measurement in other individual’s. (www.patient.co.uk)
Sachs et al (2005) state that while monitoring babies’ weight gain by regular weighting and charting is very important and provides professionals with the opportunity to observe the child’s growth and detect and problems early, it also offers focus for interactions between mothers and health care providers. This opportunity arises at a baby clinic in the local Children’s Centre where Sarah has previously attended. Sarah stated that she would like to attend baby clinic more regularly as she feels isolated as a member of an ethnic minority living in the community and has no support from family or friends.
The health visitor then weighed Emma and plotted her weight on the centile chart. Emma’s weight that day was 7.1kg which was just under the 25th centile on the chart. Sarah had been worried that Emma was not putting on weight and stated that her husband thought she was not caring for Emma properly as she was not on the 50th centile. According to The Chid Growth Foundation the average child should be on the 50th centile. The health visitor explained that since birth Emma has gradually put on weight at an appropriate steady rate and reassured her she is caring for Emma very well.
Another visit was arranged for the next day at lunch time so that the health visitor could observe Sarah attempt to feed Emma. Upon arrival Sarah had prepared a pureed meal of chicken and vegetables. Sarah stated that this was a typical family meal but she was unsure of what other foods would be suitable to begin with. Health Visitor advised at this stage the aim is to get Emma used to taking food off a spoon and swallowing. (NHS Direct 2008). Therefore a small amount of fruit or vegetables pureed are ideal to begin with then can progress to meat, fish, poultry, diary products, cereals, grains, potatoes and rice. According to Rudolf and Levene (2006) the earlier a new tasting food is introduced, the more likely is it to be accepted.
The health visitor also advised that Sarah should commence feeding when Emma is happy and has the opportunity to play and make a mess therefore to allow time for this (Hockenberry M 2003).
It was noted that Sarah added salt to the meal but was strongly advised by the health visitor that salt is bad for babies kidneys’. According to Thompson (1998) salt intake increases renal solute load. A baby’s rental function takes several months to reach normal efficiency and a high renal solute load increases water loss in the urine therefore causing dehydration. Sarah stated that in Pakistan all foods have strong seasoning’s and spices and she had presumed this was appropriate for Emma.
The health visitor went on to discuss other foods that were not advised for weaning such as soft mould ripened cheeses (brie, camembert, liver pate, and soft-boiled or raw eggs, honey and artificial sweetener’s and advised that these foods carry the risk of containing bacteria. And advised it is best to use full dairy products as these are calorie rich. (http://www.babycentre.co.uk/baby/startingsolids/firstfoods)
The health visitor offered support and encouragement as she observed Sarah spoon feed Emma and advised that she should attempt to feed Emma a small amount of pureed vegetables and a mashed up banana for lunch and an evening meal of the same for the next two days then they would schedule an appointment again to see how they have progressed.
These visits also served as social support visits. Sarah postulated her feelings of isolation within the community, lack of support from family or friends, and being home alone everyday caring Emma and at night time while her husband works. The health visitor suggested visiting the well baby clinic again as it is a good opportunity to meet other mothers potentially in the same situation or stages of weaning. As well getting Emma weighed regularly. The health visitor also suggested attending a weaning party at the local children’s centre and offered information about various groups and courses offered. In particular, in response to demand, a multi-cultural weaning party had been arranged. Research by Walker et al (2006) suggests that mothers are likely to use family and friends as support and a source of information about childcare, in particular weaning and that peer support can help alleviate anxieties and worries that many parents have.
The last visit was again an observational and support visit. The Health Visitor provided weaning leaflets, baby recipes and a video in Urdu which were well received Appendix 2). Again Sarah fed Emma while Health Visitor overlooked, praise and encouragement was given and Sarah stated she felt she had progressed well over the previous two days, she now feels more confident in her technique of feeding and with the booklets and video provided she will begin making healthy recepies for Emma and in the mean time still top her up with breastfeeds. With the information supplied she was going to attend a number of social groups to gain significant friends/support so she could fully enjoy her time as a new mother.
At the end of the visit the health visitor offered another visit or suggested she can be contacted via telephone if Sarah requires anymore guidance.
This case study considered a childhood health need in relation to a family within the community.
The circumstances were outlined and following the assessment process the problem of weaning identified. It became apparent that the main issues were Sarah’s isolation in terms of lack of support from family or friends particularly as this was her first child and cultural differences in relation to food for example adding salt to Emma’s meal. Sarah did not have the knowledge base, experience, parenting skills or influence of peers/family. Through visits with Health Visitor and student nurse Mrs X gained confidence through knowledge and encouragement and therefore her parenting skills were improved. A trusting relationship developed, especially as the health visitor supplied leaflets, baby recipe books and a video in Urdu. The implications for a student nurses’ practice is understanding the importance and the roles and responsibilities of support offered within the community and how to access them.