Baby-led weaning: Introducing complementary foods in infancy

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Table

Best practices for BLW

Baby-led weaning (BLW) is an alternative approach to the introduction of complementary foods in infancy, which is gaining in popularity. In BLW, infants are presented with table foods first, foregoing traditional pureéd foods and spoon-feeding. Proponents posit that BLW allows infants to develop better autonomy and self-regulate eating, thereby reducing the risk of obesity by developing a healthier relationship with foods. However, the risks associated with BLW can be severe (eg, choking, growth faltering, anemia) if proper education around implementation and supervision are not provided.

Pediatricians, therefore, need to be aware of the best practices for BLW. This article will discuss the phenomenon of BLW, including how it differs from traditional introduction of complementary foods; outline both the theoretical and evidence-based advantages of BLW, as well as the potential risks and strategies to minimize these risks; and provide guidance for how to best counsel families who choose BLW to do so in a safe and developmentally appropriate way.

Introduction

Over the last decade, the discussion around the introduction of complementary foods (solid foods) has centered around the timing of the introduction of solid foods. Recently, however, the practice of BLW has added the question of how to best introduce solid foods.

Baby-led weaning is an alternative approach to the introduction of complementary foods in infancy, in which infants are presented with table foods rather than puréed foods and spoon-feeding. Baby-led weaning is actually a misnomer, as the approach does not involve weaning from breast milk or formula feeding, but rather the addition of solid foods to an infant’s diet.¹ It is often perceived as a significant deviation from traditional methods of introducing complementary foods and is in contrast to American Academy of Pediatrics (AAP) recommendations of parent-initiated spoon-feeding of puréed foods.²

However, the practices of BLW, stemming from the central tenant of self-feeding by the infant from the first initiation of solid foods,³ have theoretical benefits that often are appealing to parents. Furthermore, this practice is likely what caregivers did for thousands of years prior to the introduction of commercially available, prepared “baby foods.”¹ Healthcare providers may be skeptical about BLW practices,⁴ but given that these practices have anecdotally been gaining popularity over the last decade in the United States, there is a need for providers to familiarize themselves with BLW practices in order to counsel their patients’ parents about best practices related to BLW.

History of BLW

The concept of BLW has been traced back to online parent forums from around 2001,⁵ with a large gain in momentum attributed to British author Gill Rapley, PhD, who wrote a book for parents in 2008 titled Baby-led Weaning: Helping Your Baby Love Good Food.⁶ Since that time, BLW has gained popularity in Australia and the United Kingdom, more recently catching on in the United States. Websites, social network groups, and numerous books for parents have grown out of this movement, championing BLW as a “more natural,” “healthier,” and “fuss-free” way to introduce complementary foods.^7-9

The central tenet of BLW is allowing an infant to self-feed from the first introduction of complementary food. This eliminates the parent’s role in spoon-feeding initial puréed foods.^1,3 Instead, BLW relies on the infant’s grasping and self-feeding whole-form foods starting around age 6 months (Figure). All food ingested is therefore controlled by the infant’s own actions and feeding, as opposed to a parent placing a spoon in the infant’s mouth. Parents are encouraged to provide infants with soft foods that they can easily grasp and place in their mouth, such as sticks of steamed vegetables. Babies first starting to be fed by BLW are encouraged to explore the foods presented to them, with a lesser emphasis on ingestion as the primary goal.⁶

A common saying in the BLW community is that “Food is for fun until age 1,” meaning that in the first few months of starting complementary foods infants should be allowed to explore the new concepts of touching, manipulating, smelling, and chewing solid foods, without a focus on consumption. This low-pressure approach is hypothesized to allow an infant to develop a “healthy” relationship with food, growing his/her autonomy, and allowing the infant to self-regulate eating.¹⁰ Infants are in full control of their eating and set the pace of their meal, deciding when they are “done.” This contrasts to traditional spoon-feeding of purees in which the caregiver sets the pace of spoonfuls offered, perhaps being motivated to have the infant “finish” a predetermined serving of food. Baby-led weaning highlights the importance of the infant joining the family table immediately through sharing whole-form foods and observing and learning from the family’s eating practices.^1,5,11 Infants are provided with finger-food portions of the family’s prepared meals rather than puréed foods or “baby foods,”^6,7 allowing for shared meal experiences,

These BLW practices deviate from currently recommended feeding protocols in the United States. Baby-led weaning suggests delaying the initiation of complementary foods until at least age 6 months or when an infant is able to sit unsupported with good head control, grasp objects, and bring objects to his/her mouth. For some infants, this may be as late as 8 months. Through delaying, proponents of BLW suggest that the child is more developmentally prepared to feed itself and consume solid foods.³

Current guidelines from the AAP recommend introducing iron-fortified cereals by spoon-feeding between ages 4 and 6 months.² Delaying the introduction of complementary foods in BLW extends the interval of exclusive milk feedings to 6 months or beyond with continuation of full breastfeeding or formula feeding with no additional supplemental nutrition. In addition, this delaying of complementary foods through BLW aligns with the AAP² and World Health Organization (WHO)¹² recommendations for exclusive breastfeeding for the first 6 months of life. Studies have found that mothers who initiate breastfeeding, and breastfeed for longer, are more likely to follow BLW practices.¹

The infant-directed nature of BLW has been noted to complement that of breastfeeding in which the infant decides how much and how quickly they eat, with proponents lauding it as a “more natural” approach.⁵ Despite BLW pairing well with breastfeeding, it should be noted that formula-fed infants also can follow the BLW approach.

Theoretical advantages of BLW

There are many theoretical advantages of BLW (Table). First, it is posited that as BLW allows an infant to have autonomy over feeding, the infant will learn to attend to his or her internal cues of satiety and hunger, rather than focus on external cues (ie, taking a mouthful because the infant is hungry rather than because a spoonful is being presented).^5,11,13 Decreasing “obesogenic” behaviors (ie, eating in the absence of hunger, lower satiety responsiveness, greater food responsivity) are thought to be especially important in light of the current pediatric obesity epidemic. The evidence around BLW in promoting these healthier eating behaviors has been limited, with one cross-sectional study¹³ finding that BLW infants (compared with non–BLW infants) have better appetite control (satiety responsiveness), and another randomized controlled study finding poorer appetite control and greater food enjoyment in BLW infants.¹⁴

Children’s later food preferences are thought to be influenced by early food exposures.¹⁵ Qualitative studies have found that parents perceive BLW to have a positive impact on their infant’s diet.^1,16 As BLW infants are exposed to “table foods” from the beginning, it is thought that they may have preferences for a wider variety of foods than traditionally fed infants. One cross-sectional study found no difference in picky eating among BLW and non-BLW infants,¹³ while another cross-sectional study,¹⁷ based on parent self-report, found BLW infants to have greater preferences for carbohydrates whereas non-BLW infants had a greater preference for sweet foods. With regard to nutrient intake, a randomized controlled trial¹⁸ found no difference in macronutrient intake between BLW and non-BLW groups. Also, BLW is thought to promote greater acceptance of food textures by skipping over puréed foods and introducing a greater variety of textures at an earlier point.

Originators and lay proponents of BLW cite that healthier eating habits and intake may have a positive influence on a child’s weight status and risk for obesity. Evidence around this has been mixed with some studies finding BLW infants to be at a greater risk of underweight and overweight¹⁷ than their traditionally fed peers. However other studies have found BLW to be protective against overweight,¹³ or found no difference in weight outcomes between groups.¹⁴

Finally, BLW is considered an easier method of introduction of solid foods for parents and families. Through sharing common whole foods, there is no additional preparation of foods for the infant, allowing for increased time together at the family table, rather than the baby being spoon-fed separately in a highchair. The benefits of family mealtimes are numerous,¹⁹ underlining the importance of starting the practice of eating together as early as possible. Baby-led weaning may allow earlier introduction of the family mealtime.

Theoretical disadvantages of BLW

The potential disadvantages or risks of BLW are perhaps more important to discuss than the advantages (Table). A common concern from healthcare providers about BLW is its safety,¹ specifically with regard to risks of choking, growth faltering, and anemia.

With regard to choking, it is posited that an infant may be at greater risk of choking on a firmer piece of solid food as opposed to a puréed version of the same food. Proponents of BLW suggest that by allowing an infant full control over the placement of the food in their mouth they will develop better skills in mastication and moving the food bolus safely through the oral cavity.⁶ It is also thought that spoon-feeding purées may encourage infants to “slurp” their food, creating a vacuum that propels the food rapidly into the pharynx, teaching the infant to swallow before learning to chew.

Estimating the frequency of choking in BLW is difficult as it relies on parental report of true choking events as opposed to gagging,¹ some amount of which is thought to be developmentally normal. A randomized control trial²⁰ using a modified BLW approach (versus traditional approach) found no differences in choking events or infants being offered high-choking-risk foods (eg, apple slices, sausages, whole grapes, and so on) between groups.

Growth faltering is another potential disadvantage of BLW. Because the infant is given the “responsibility” of feeding itself, there are concerns that he or she may not consume enough calories to sustain growth on a healthy trajectory. Inadequate caloric consumption from BLW may result from an infant not being developmentally ready to self-feed (fine motor, gross motor, or coordination skills), or from not having the physical stamina or attention to sustain intake.

The originators of BLW recommend continued volume and frequency of milk feedings “on-demand,” as well as offering a milk feeding prior to offering solid foods to ensure the infant gets adequate calories. Specifically, the originators of BLW recommend offering an infant solids when he/she is not hungry, so that milk will remain the main source of nutrition. This goes against advice from the AAP that suggests giving the infant the majority of the milk feeding after solids, so that the infant will consume more of the solid foods and not be full of milk. A randomized controlled trial¹⁴ of a modified version of BLW that encouraged offering high-energy foods at each meal found no cases of growth faltering in the BLW group, although some infants had nonclinical slowed growth.

Sufficient iron intake is a nutritional challenge for infants around the world. As BLW infants forego purees, including the iron-fortified cereals that are common and recommended first foods, it is thought that they could be at greater risk of anemia. Whereas a cross-sectional study²¹ found that BLW infants’ daily intake of iron was less than half that of traditionally fed infants, a randomized controlled trial²² investigating risk of low iron intake, markers of iron stores, and anemia found no differences between a control group and a BLW group provided with education around increased iron intake. These findings underline the important role that healthcare providers play in early nutritional counseling and the direct effect this can have on the outcomes of their patients.

The final, and least serious, potential disadvantage in a BLW approach is the mess created by allowing an infant autonomy over his/her own food and intake. Through the exploration of foods, BLW infants have free reign to mash their sweet potatoes into their hair, throw spaghetti on the floor, or cover themselves in yogurt, for example. For some families, this may represent a significant economic challenge.

Introducing potentially allergenic foods

The guidelines for introduction of potentially allergenic foods (peanut, cow’s milk, wheat, hen’s eggs) have undergone considerable changes in the past decade. Prior to 2008, avoidance of these foods until aged 2 to 3 years was the standard advice both for breastfeeding mothers and for infants starting complementary foods. This advice was removed in the 2008 AAP Committee on Nutrition’s clinical report on the relationship between atopic disease and early nutrition and the timing of introduction of allergenic foods was no longer specified.²³

In 2015, the Learning Early About Peanuts study was published.²⁴ This randomized controlled trial demonstrated decreased peanut allergy in high-risk children who had early peanut introduction compared with later introduction and has led to specific guidelines²⁵ recommending introduction of peanuts around age 4 months (after evaluation for allergy) for high-risk children with severe eczema or egg allergy.

Children with mild to moderate eczema should start consuming peanuts by age 6 months but do not require specialized testing. Children with no specific risk factors can start eating peanuts whenever their parents desire. The practice of BLW can incorporate this early introduction but this does require some planning. The consistency of peanut butter makes it difficult for infants to safely and effectively self-feed. Instead, peanut butter-containing snacks or baked goods incorporating peanut butter powder can be utilized.

How clinicians can support BLW

Although some pediatricians may have reservations about BLW, it is important for all pediatric practitioners to be familiar with BLW practices in or- der to effectively counsel around safest practices. Pediatricians should not entirely dismiss or “shut down” parents who express interest in BLW, as this may lead to alienation of the caregiver, preventing an open dialogue and the ability to counsel against high-risk behaviors. The pediatrician may even open the conversation about the introduction of solid foods at the 4-month well-child visit, discussing recommendations for exclusive milk feedings until 6 months, and asking about plans for introduction of solid foods including BLW approaches.

Summary

Baby-led weaning is an alternative approach to the introduction of complementary foods that is rooted in a strong theoretical framework around autonomy promotion in the realm of feeding. Current evidence is equivocal with regard to the potential health benefits in terms of eating behaviors, dietary intake, and weight outcomes. There is also little-to-no current evidence to support an increased risk of choking, anemia, or growth faltering associated with BLW, especially when BLW is done in a modified way. Pediatricians should familiarize themselves with modified BLW practices to counsel their patient’s caregivers to avoid choking risks and provide sufficient energy and nutrient intake.

ACKNOWLEDGEMENTS OF RESEARCH SUPPORT: Dr Pesch is supported by the American Heart Association (17F17FTF33630183). Dr Shubeck is supported by the National Clinician Scholars Program at the Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan.

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