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Transcript
Pediatric Nutrition Network
DC Pediatric Nutrition Volume 13
Fall November 2014
Baby-Led Weaning: A review of
the popular book, the literature,
and current Canadian
Recommendations
Written by: Jennifer Buccino MEd RD CDE,
The Hospital for Sick Children
Inside this issue:
Baby-Led
Weaning:
A review and
current Recommendations
1-6
Editor’s Notes
2
Chair’s Notes
7
Infant feeding recommendations and practices around the globe continue to evolve. Traditionally, new parents were advised to spoon feed
pureed foods between 4 and 6 months of age, and to start with infant iron
-fortified cereals (grains), followed by vegetables, fruit, dairy and finally
meat. Historical methods used to wean infants to solid complementary
foods have been challenged and have ultimately been modified to allow a
more flexible approach to feeding. Advancements in knowledge of allergy prevention have spurred the change to a more liberal transition to
complementary feeding. Current Health Canada recommendations align
with WHO recommendations and promote exclusive breastfeeding for
the first 6 months and for breastfeeding to continue up to 2 years of life.
They recommend introducing complementary foods at 6 months of age
and promote iron-rich foods such as meat and meat alternatives and iron
fortified infant cereals as first foods (1, 2). What comes next is essentially up to the caregiver, with honey being the only restriction in the first
year. Two key resources for dietetic practice: Nutrition for healthy Terms
infants from birth to 6 months (1), and 6-24 months (3) have been updated and revised to correspond to the new guidelines.
At the same time the concept of Baby-led weaning (BLW) is emerging. Anecdotally BLW has increased in popularity among new moms,
has a great following in social media and on the internet, and is starting
to materialize as a theme in the literature. This review aims to provide an
overview of BLW and the current state of research on BLW, relate it to
current feeding guidelines and provide some thoughts and considerations
for registered dietitians (RDs) working with infants and young families.
DC Pediatric Nutrition Volume 13
What is Baby-led Weaning
(BLW): A book review
In 2008 Rapley and Murkett published
the now popular book “Baby-Led Weaning:
The Essential Guide to Introducing Solids and
Helping your Baby to grow up a happy and
confident eater” (4). Since its publication the
BLW approach to feeding has gained popularity establishing itself as the trend in infant
feeding. BLW discourages spoon-feeding purees and instead encourages offering foods in
their whole form. Foods offered are hand-held
and easily graspable. Infants explore new
foods with their hands when interested, selffeed from the very beginning, and take control
over how much and how quickly they eat. Babies are included in family meals and eat family foods upon initiation of complementary
feeding right from 6 months of age.
According to Rapley and Murkett (4),
babies who follow a BLW approach get the
chance to experiment with foods and learn to
manage textures earlier than those fed purees.
They suggest that spoon-feeding purees triggers a gag-reflex and that parents often persuade a baby to eat more food and coax “one
more bite” which may lead to unhealthy eating habits such as overeating and potential
overweight/obesity later in life.
Benefits of BLW include that it is enjoyable and natural, that it encourages infants to
learn about, and to trust food, and how to eat
safely. BLW is said to help infants gain confidence in self-feeding and reach their optimal
feeding potential earlier because they practice
feeding skills often with textures. Rapley and
Murkett suggest that those who follow BLW
have better nutrition, appetite control, longterm health, and develop a positive attitude
towards food. The authors claim that it diminishes mealtime battles and pickiness in the
toddler years. Ideally BLW is preceded by
exclusive breastfeeding when babies have already learned to be in control of the amount
of food consumed (4).
Baby-Led Weaning advantages are said
November 2014 Page 2
Editor’s Note
Greetings! Hope everyone is enjoying
the changing of seasons. The feature article
for our fall newsletter is a hot topic that
you’ve likely been approached about by patient families, friends and even coworkers.
Baby-Led Weaning is a new trend in infant
feeding. Baby led weaning has a large following in mom groups and social media. A
big thank you goes out to Jennifer for reviewing the book and associated literature
surrounding this new approach to feeding.
Our reviewers also deserve a thank you as
well.
Remember, we are always looking for
new ideas and topics. If you have an idea or
would like to suggest a newsletter topic,
send me a message. Contact me if you
would like to review a book or be an author
for one of our newsletters.
Warm regards,
Andrea Young, RD
DCPNN editor
[email protected]
to be numerous and sound convincing. In order
to fully understand BLW and its benefits the
literature must also be considered.
A review of the literature
While the definition and expectations of
BLW may be clear in the book, there is inconsistency in the literature as no one study used
the same definition for their BLW adherent
groups. Most of the studies reviewed gauged the
degree of adherence to BLW techniques by asking survey questions relating to self-feeding
practices versus spoon-feeding by parent. The
studies all grouped patients into feeding categories based on how much the subjects self-fed.
For example, in one sample (5) only 9% of the
199 study participants were classified as following BLW as per Rapley’s criteria. Twenty-one
DC Pediatric Nutrition Volume 13
percent were self-identified as BLW however
this group did not fit into the adherent BLW
group because they were also spoon feeding
about half of the time. In contrast, Brown and
Lee (6) found that half of their sample (52%
based on spoon feeding use, and 57% based on
use of purees) were classified as BLW, and 52%
had provided first foods in solid form. Without a
consistent definition studies in the literature actual rates of those following a BLW approach is
difficult to measure.
Despite a lack of consistency in definition,
characteristics of mothers who are classified in
the studies to follow BLW are evident. These
mothers are more likely to breastfeed, and to
introduce complementary foods at the right time
(i.e. approx. 6 months) (5, 6, 7). In one group
18/20 mothers started BLW between 5.5 and 5
months and all had exclusively breastfed to this
age (8). Cameron and colleagues (5) found that
53% of participants in the adherent BLW group
exclusively breastfed to 6 months compared to
only 21% in the parent-led group. The BLW cohort is also likely to be highly educated, with
one study finding that 66% or moms had a University degree (5, 6, 7). These mothers are also
likely to have higher occupation levels, and to
be married (6).
Advantages & disadvantages of BLW
Including infants at the family meal table
tends to be a theme for those following BLW. A
New Zealand population-based online survey
(5) looking at feeding practices and healthrelated behaviours of families self-identified as
following BLW found those following BLW ate
more family meals together. This was a similar
finding to 2 other studies who revealed that infants following a BLW approach tended to be
included in family meals and eat from the family pot more so than spoon feeders (6, 8). Family
meals promote healthy eating habits and encourage optimal nutrition if the family eats a healthy
diet as well as social development (3).
By 6 months of age, most babies are developmentally ready to eat solids foods (1, 7). A 4
month old would not have the head or mouth
control for solids foods and may only have the
November 2014 Page 3
ability to suckle, suck and swallow, (1, 7).
However a 6 month old baby would conceivably have the necessary control to manage
textures and eat more solids as demonstrated
by improved head control, ability to sit up in
a high chair, and interest and ability to pick
up and try to put food in their mouth (1, 7).
Wright and colleagues (9) found that 56% of
their subjects reached out for food before 6
months. Half of the infants were reaching out
for and eating finger foods between 6-8
months. By 8 months most (90%) of the infants were eating.
With provision of hand-held whole
foods comes the concern of choking. Choking is a serious matter and foods posing a
choking hazard should be strictly avoided.
The distinction between choking and gagging is difficult to assess due to the selfreport nature of the studies. In one study,
33% reported a choking episode with the
likely cause being whole foods, however it
was difficult to assess whether there was an
actual airway obstruction (5). In contrast only 6% of subjects in another study reported a
choking episode (10). Regardless, choking is
certainly a concern to parents and healthcare
professionals alike. Cameron and colleagues
(5) found that 55% of their participants did
not want to try BLW because of the risk of
choking and in a later qualitative study, they
found that healthcare practitioners expressed
concern with the potential for choking with
this feeding approach (8).
In the newly revised Nutrition for
Healthy term infant guidelines for infants 624 months (3), parents are encouraged s to
provide a variety of different textures including fingers foods from 6 months onwards
making BLW a very appropriate approach in
terms of provision of textures. Textures can
still be introduced without using a strict
BLW method. Delaying textures may be associated with feeding difficulties and decreased intake of vegetables and fruits in
older children. Healthcare professionals
agree that BLW may encourage optimal oral
and chewing development as baby is offered
DC Pediatric Nutrition Volume 13
pieces of food earlier than traditional approaches (8).
Rapley and Murkett claim improved health
and nutrition, and less pickiness in toddlerhood
(4). Townsend & Pitchford (10) looked at influence of weaning style on food preference, BMI
and picky eating in childhood. In their sample
the BLW preferred carbohydrate foods (grains)
whereas the spoon fed group liked sweet foods.
The authors speculate that perhaps offering
CHO in whole form (i.e. toast) may highlight
perceptual features that is masked when food is
pureed which may impact the preference for it.
The spoon fed group had greater exposure to all
food groups compared to the BLW group however they concluded that weaning style was
more influential than exposure on preference
rating.
Responsive feeding may be another advantage of BLW (7). Health Canada recommendations highlight the importance of practicing
responsive feeding (ie. responding to hunger and
satiety cues and allowing the child to guide
feeding) to promote the development of healthy
eating skills (3). Within the responsive feeding
section it states “Promote offering finger foods
to encourage self-feeding”. Parents who respond
to their child’s hunger and satiety cues intuitively allow the child to determine the pace of feeding. In practice this is a similar philosophy to
the Feeding relationship concept that many pediatric dietitians use regularly. Ellyn Satter
stresses that for a positive or healthy feeding
relationship to exist the parent is responsible for
providing healthy nutritious foods and the child
is responsible for deciding what, how much and
how fast they eat (11).
Growth faltering is a concern raised by
healthcare practitioners (8). Only one study
looked at the influence of BLW on BMI and
found that the BLW group had a significantly
lower BMI than the spoon fed group with the
BLW BMI being close to the NHS and CDC
average and the spoon-fed group was above the
average. More children in the BLW group were
classified as underweight (n=3) and there were
no underweight children in the spoon fed group.
Further research is needed to fully understand
the impact of BLW on growth.
November 2014 Page 4
Poor iron status was a concern expressed
by healthcare practitioners (8) as BLW followers may be less likely to offer iron containing foods (eg. iron-fortified cereals) as
first foods (5). Overwhelmingly, BLW
groups tend to introduce fruit and vegetables
first (5, 6, 8, 9). In one study >75% of the
BLW were likely to start with fruit or vegetable (6). Infants born full term have adequate iron stores for the first 6 months of
life. At 6 month an increase in iron requirements and a depletion of iron stores necessitates supplementation with dietary iron.
Without adequate iron intake infants are at
risk for iron deficiency which may cause irreversible cognitive delay. For this reason
our recommendations in Canada are to start
with iron-containing foods (meat and meat
alternatives, or iron-fortified infant cereal)
(3). Of note, participants of one study reported spoon feeding iron-fortified cereal in order to increase their infants iron intake (8).
BLW babies may ingest more bioavailable
iron containing foods from a family meal
making this a mute point. However, to date
no one has looked at when BLW infants
were introduced to iron containing foods or
to their iron status.
Three studies (5, 6, 8) found parental
concerns about BLW including anxiety
about whether their baby was getting enough
nutrients, ability to eat enough food, and
about the mess created during meal times.
This anxiety may result in parents spoon
feeding and using more pureed (5,6,8). Some
parents also reported spoon feeding when the
child was sick to increase energy intake, and
avoid the mess (8). That said, many report
that BLW made sense, and perceived that it
was less time consuming, cheaper, had less
meal prep and less mealtime stress (8). Parents that used BLW would highly recommend it however 60% would recommend
using it in combo with spoon feeding (5).
One participant quoted “As someone who’s
done it both ways (BLW and spoon-feeding),
I think they’re both pretty messy and wasteful!” (8).
DC Pediatric Nutrition Volume 13
To date, no studies have looked at the effect
of BLW on the identification of allergies. Previous feeding recommendations have advised
starting one single ingredient food at a time and
waiting a few days in between making the concept of family meals inappropriate for an infant.
Current Health Canada recommendations do not
include this statement. Waiting a few days between new foods is only recommended when
introducing common food allergens (peanuts
and tree nuts, fish, wheat, soy and eggs) to allow
a parent to identify the food that caused a reaction (3). Presumable, infants at low risk of food
allergies could therefore partake in the family
meal.
Summary
The literature on Baby-Led Weaning is
small but growing. In theory, BLW offers many
advantages. In practice, the potential disadvantages need to be considered. Risk of choking, poor iron status and potential for growth
faltering are concerns that are only partially validated. Risk of choking may or may not be of
concern based on the literature and needs to be
distinguished from the natural reflex of gagging.
At present, it appears as though BLW does not
contribute to poor growth. It may in fact contribute to more optimal growth however one study
does not substantiate the healthy growth and development claim stated by Rapley and Murkett
in their book. Iron status of infants following
BLW remains unknown and essential to answer
prior to fully recommending that parents follow
a BLW approach 100% of the time.
From a parents perspective, BLW appears
to be beneficial. As a strategy, it offers flexibility by decreasing meal preparation time and
eliminates the need to feed family members at
separate times. Family meals offer more than
simply nutritional benefits as the child learns
about their family, their environment and how to
manage different foods. Nutritionally the caveat
being that the infant diets is only as healthy as
the family’s diet. If there is room for improvement in the nutritional content of family foods
consumed one would likely suggest that BLW is
not the ideal strategy for infants. More im-
November 2014 Page 5
portantly, BLW is advantageous as infants
self-regulate their intake by responding to
hunger and satiety cues thereby promoting
healthy eating habits and growth and development. The key here is that regardless of
feeding approach, parents need to adopt responsive feeding practices.
The final question to be considered is:
why does there need to be one feeding approach? As seen in a few of the studies, parents may be combining BLW and spoon
feeding for a multitude of reasons. Perhaps
some babies simply respond better to one
approach over another. Offering a baby solid
pieces of well cooked food when they refuse
to eat purees from a spoon would be a very
appropriate strategy. Alternatively offering
some pureed meat or an iron-containing food
would ensure optimal intake of essential nutrients while allowing a child to explore and
experiment with new whole foods and textures. Until there is more evidence to diminish or eliminate the concerns discussed a
combination of approaches may be the way
to go. This would ensure nutritional adequacy and still contribute to oral motor skills
development all while practicing responsive
feeding. Ultimately, a mixed approach with
regards to feeding may offer the best of both
worlds.
The November 2014 Fall Edition
of DCPNN Newsletter was published by Janet Schlenker.
The contents of this newsletter
article does not imply endorsement by the DC Pediatric Nutrition
Network.
© 2014 Dietitians of Canada Pediatric Nutrition Network. All
Rights Reserved
DC Pediatric Nutrition Volume 13
November 2014 Page 6
References:
1.
Nutrition for Healthy Term Infants: Recommendations from Birth to Six Months. A
joint statement of Health Canada, Canadian Paediatric Society, Dietitians of Canada,
and Breastfeeding Committee for Canada. (2014). Retrieved from:
http://www.hc-sc.gc.ca/fn-an/nutrition/infant-nourisson/recom/index-eng.php
2.
World Health Organization. Infant and young child feeding: Model Chapter for textbooks for medical students and allied health professionals. (2009). WHO Press, World
Health Organization. Retrieved from:
http://whqlibdoc.who.int/publications/2009/9789241597494_eng.pdf?ua=1
3.
Nutrition for Healthy Term Infants: Recommendations from Six to 24 Months. A joint
statement of Health Canada, Canadian Paediatric Society, Dietitians of Canada, and
Breastfeeding Committee for Canada. (2014). Retrieved from:
http://www.hc-sc.gc.ca/fn-an/nutrition/infant-nourisson/recom/recom-6-24-months-6-24-mois-eng.php
4.
Rapley G and Murkett T. (2010). Baby-Led Weaning, The essential guide to introducing
solids foods and helping your baby to grow up a happy and confident eater. New York,
NY. The Experiment.
5.
Cameron SL, Taylor RW, Heath AM. Parent-led or baby-led? Associations between
complementary feeding practices and health-related behaviours in a survey of New Zealand families. BMJ Open 2013; 3:e003946.doi:10.1136/bmjopen-2013-003946.
6.
Brown A, Lee M. A descriptive study investigating the use and nature of baby-led weaning in a UK sample of mothers. Maternal and Child Nutrition 2011; 7: 34-47.
7.
Cameron SL, Heath AM, Taylor RW. How Feasible is baby-led weaning as an approach
to infant feeding? A review of the evidence. Nutrients 2012; 4, 1575-1609.
8.
Cameron SL, Health AM, RW Taylor. 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.
9.
CM Wright, Cameron K, Tsiaka M, Parkinson KN. Is baby-led weaning feasible? When
do babies first reach out for and eat finger foods? Maternal and Child Nutrition 2011; 7:
27-33.
10. E Townsend, NJ Pitchford. 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.
11. Satter, E. (1999). Secrets of feeding a healthy family. Madison, WI. Kelcy Press.
DC Pediatric Nutrition Volume 13
November 2014 Page 7
Chair Notes
2014 Fall Newsletter
Though we are heading into the end of 2014, fall always seems like the
real New Year to me. Summer vacations are over, school and work routines
are back in full swing and projects get back on line.
We had our first teleconference Annual Business meeting. It was still a
small group, but members who wouldn’t necessarily be able to attend the
conference were able to join in. Look for the minutes as well as the 20132014 Activities Report, the 2013-2014 Financial Report and the 2014-2015
Executive list on the DCPNN website.
Also, look forward to changes to our website. Dietitians of Canada is
changing the platform for the Network websites and they will be called communities. They will look more like a social media sites and will be more user friendly and easier to navigate. Look for these changes to our website in
the first couple of months of 2015.
More tele-education sessions are being planned. Keep an eye on your
email for details to come. If you have suggestions for topics and speakers,
please let me know.
Have a great fall.
Karen Kristensen, RD
DCPNN Chair
[email protected]
at
http://www.dietitians.ca/members/login.aspx?ReturnUrl=%2fnetworks%2fpediatric.aspx