Dr Annie FOK
FHKAM(Paed)

When discussing the introduction of complementary feeding with parents, it is prudent to stress that solid foods should be introduced by 6 months to ensure adequate nutrients and energy intake for appropriate growth and development.¹

As Baby-led Weaning (BLW) has grown in popularity in the last decade or so as a way to introduce complementary feeding, it is likely that health professionals will encounter parents who contemplate practicing BLW.

Traditionlly, complementary foods are introduced through graduated exposure to different textures. Infants are being fed with puréed foods by audits, before progressing to mashed and chopped food.^1,5-10 'Finger' foods and self-feeding do not contribute to a large part of the feeding until later in infancy.

In practice, many parents following a “baby-led” weaning approach are probably somewhere along the continuum of some spoon-feeding to total self-feeding, albeit much more at the latter end.

Development readiness of infants to feed themselves using their hands, as well as their innate ability to respond appropriately to both appetite and satiety are the underpinning principles of BLW, according to its proponents.²

By 6 months of age, most infants are able to sit unsupported, bring finger foods to their mouth, chew and swallow them,¹¹ it is therefore suggested that the feeding of puréed foods may not be necessary.^2,4 Since the infant decides on the amount of solid food intake, it has been proposed that BLW may lead to better energy self-regulation and a lower risk of obesity.^12,13 The other implied advantages include favourable effects on parental feeding practices,14 better diet quality with a variety of family food, 15 and more advanced motor and chewing skills.^2,4

Health professionals have raised several concerns with BLW, including an increased risk of nutritional deficiency, growth faltering and choking.^15,16 In BLW, although complementary food are made available to the infants from 6 months of age, there are concerns that the foods may not be ingested until much later and the first foods being offered may be low in energy, iron and zinc.Moreover, the mastication and coordination skills of a 6-month-old to safely manage whole pieces of food are in doubt.

What is the evidence?

To date, there has only been one randomised controlled trial, the 2-year Boby-Led Introduction to SolidS (BLISS) Study, conducted in New Zealand to assess the efficacy and acceptability of a modified version of BLW. The BLISS approach aims to address the three key concerns of health professionals about BLW, namely insufficient iron intake, choking and growth faltering.^16-19 Most of the others are cross-sectional studies, mainly using self-report questionnaires or interview data to examine the effects of BLW.^12-15,19

Is there an impact upon body weight?

Children’s Eating Behaviour Questionnaire (CEBQ), a psychometric instrument to measure satiety responsiveness (eating appropriately in response to appetite) and food responsiveness (eating in response to environmental food cues rather than hunger), among other parameters, has been used in the following studies. It has been postulated that high levels of food-responsiveness and low levels of satiety-responsiveness are associated with greater risk of childhood overweight.^13,17 

Infants in the BLISS intervention group were reported to be less satiety responsive at 24 months, less fussy / picky about food at 12 but not 24 months, and having more enjoyment of food at both 12 and 24 months.¹⁷ In another observational study, infants weaned using a baby-led approach were rated as significantly less food-responsive and more satiety-responsive than those using the conventional approach.¹³

Mothers who followed a baby-led approach reported significantly lower levels of unfavourable parental feeding practices such as food restriction, pressure to eat, concern for child weight and monitoring in a study using a parent-completed Child Feeding Questionnaire.¹⁴ However, a conclusion about causality cannot be drawn due to its cross-sectional design.

Is there a risk of nutritional deficiency?
In the BLISS study, parents in the intervention group were given advice to offer energy-dense and high-iron foods at every meal. There was no significant difference in intake of energy, macronutrients, iron and zinc between the intervention and control groups.^17,18 However, a high prevalence of inadequate iron intakes in both BLISS and conventional weaning groups were observed. Since BLISS is a modified version of BLW, no conclusions can be made about the risk of iron and zinc deficiency in infants following unmodified BLW.¹⁸

Is there a choking risk?
A total of 35% of infants choked at least once between 6 and 8 months of age, with no significant group differences in the BLISS study. Foods with a choking risk had been offered to 52% of infants at 7 months, and 95% at 12 months for both groups. The culprit included apple slices, crackers and sausages.¹⁹ Besides, in a semi-structured interview, 30% of a group of mothers who practised BLW reported an episode of choking.¹²

References:

1. World Health Organization, UNICEF. Global strategy for infant and young child feeding. World Health Organization; 2003.
   
2. Rapley G. Baby-led weaning: the theory and evidence behind the approach. Journal of Health Visiting. 2015;3(3): 144–151.
   
3. Rapley G, Murkett T. Baby-led weaning: Helping your baby to love good food. London: Vermillion; 2008. 256 p.
   
4.  Rapley G. Baby-led weaning: transitioning to solid foods at the baby’s own pace. Community Pract. 2011;84(6): 20–3.
   
5. Department of Health, United Kingdom. Complementary feeding. https://www.nhs.uk/start4life/baby/first-foods (accessed 27 March 2018)
   
6. Health Canada. Nutrition for healthy term infants: recommendations from six to 24 months. Health Canada; 2014. http://www.hc-sc.gc.ca/fn-an/nutrition/infant-nourisson/recom/recom-6-24-months-6-24-mois-eng.php (accessed 27 March 2018)
   
7. Ministry of Health, New Zealand. Feeding your baby. http://www.health.govt.nz/your-health/pregnancy-and-kids/first-year/6-12-months/feeding-your-baby (accessed 27 March 2018)
   
8. US Department of Agriculture. 2009. Infant Nutrition and Feeding: Chapter 5: Complementary Foods. 101–128.
   https://wicworks.fns.usda.gov/wicworks//Topics/FG/Chapter5_ComplementaryFoods.pdf (accessed 27 March 2018)
   
9. Family Health Service, Department of Health, Hong Kong. Healthy Eating for 6 to 24 month old children (1) Getting Started.
   http://www.fhs.gov.hk/english/health_info/child/14727.pdf (accessed 27 March 2018)
   
10. Family Health Service, Department of Health, Hong Kong. Healthy Eating for 6 to 24 month old children (2) Moving On.
    http://www.fhs.gov.hk/english/health_info/child/14722.pdf (accessed 27 March 2018)
    
11. Wright CM, Cameron K, Tsiaka M. Is baby-led weaning feasible? When do babies first reach out for and eat finger foods? Matern Child Nutr. 2011;7(1): 27–33
    
12. Townsend E, Pitchford N. Baby knows best? The impact of weaning style on food preferences and body mass index in early childhood in a case–controlled sample. BMJ Open. 2012;2:e000298. doi: 10.1136/bmjopen-2011-000298
    
13. Brown A, Lee MD. Early influences on child satiety-responsiveness: the role of weaning style. Pediatr Obes. 2013;10: 57–66.
    
14. Brown A, Lee M. Maternal control of child feeding during the weaning period: differences between mothers following a baby-led or standard weaning approach. Matern Child Health J. 2011;15: 1265–71
    
15. Cameron SL, Heath AL, Taylor RW. Healthcare professionals' and mothers' knowledge of, attitudes to and experiences with, Baby-Led Weaning: a content analysis study. BMJ Open. 2012;2:e001542. doi: 10.1136/bmjopen-2012-001542
    
16. Daniels L, Heath AL, Williams SM, Cameron SL, Fleming EA, Taylor BJ, et al. Baby-Led Introduction to SolidS (BLISS) study: a randomised controlled trial of a baby-led approach to complementary feeding. BMC Pediatr. 2015;15: 179.
    
17. Taylor RW, Williams SM, Fangupo LJ, Wheeler BJ, Taylor BJ, Daniels L, et al. Effect of a Baby-Led Approach to Complementary Feeding on Infant Growth and Overweight: A Randomized Clinical Trial. JAMA Pediatr. 2017;171(9): 838–846.
    
18. Daniels, L. (2017). Impact of a baby-led approach to complementary feeding on iron and zinc intake and status: A randomised controlled trial (Thesis, Doctor of Philosophy). University of Otago. Retrieved from https://ourarchive.otago.ac.nz/handle/10523/7709 (accessed 27 March 2018)Fangupo LJ, Heath AM, Williams SM, Erickson Williams LW, Morison BJ, Fleming EA, et al. A Baby-Led Approach to Eating Solids and Risk of Choking. Pediatrics. 2016;138(4). pii: e20160772.
19. Sachs M. Baby-led weaning and current UK recommendations—are they compatible? Matern Child Nutr. 2011;7: 1–2