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Scientific Review: Is Baby-Led Weaning a Complementary Feeding Method that Prevents Childhood Obesity?

By: Paula Alonso Gálvez, School of Nutrition, Universidad Francisco Marroquín, Guatemala.

¿Es el baby-led weaning un método de alimentación complementaria que previene obesidad infantil?

RESUMEN

Baby-led weaning (BLW) es un método alternativo para la alimentación complementaria, reconocido por promover una alimentación regulada y autónoma en el infante. El objetivo de este artículo de revisión es establecer la evidencia con respecto al método BLW en la prevención de obesidad infantil. El método BLW se ha vinculado con la promoción de alimentación consciente, permitiendo al infante auto-regular la ingesta de alimentos. Esto se ha propuesto como un factor potencial que puede contribuir a reducir el riesgo de obesidad. Varios estudios han demostrado que aquellos infantes que siguieron el método BLW tenían menor índice de masa corporal e incidencia de obesidad; sin embargo, otros estudios no han encontrado diferencia estadísticamente significativa con respecto al índice de masa corporal. Información reciente sobre el método BLW y prevención de obesidad deriva de estudios transversales y un único ensayo clínico aleatorizado que modificó el método original de BLW. Se requiere de más investigación para verificar la influencia del método de BLW en la prevención de obesidad infantil.

Palabras clave: Baby-led weaning, introducción a alimentos sólidos, alimentación complementaria, alimentación intuitiva, obesidad infantil, prevención de obesidad

ABSTRACT

Baby-led weaning (BLW) is an alternative method of complementary feeding, known to promote infant self-feeding and responsive eating. The aim of this review was to establish the evidence with respect to the BLW method in the prevention of childhood obesity. BLW has been seen to promote responsive eating, allowing the infant to self-regulate food intake. This has been proposed as a potential factor that lowers the risk of obesity. Several studies have found that children who followed BLW had a lower body mass index and incidence of obesity; however, other studies have found no significant difference in regards to body mass index (BMI). Current information on BLW and obesity prevention is derived from cross-sectional studies and a randomized clinical trial that modified the original BLW method. Further research is warranted to verify the influence of BLW in the prevention of childhood obesity.

Keywords: Baby-led weaning, introduction to solids, complementary feeding, intuitive eating, childhood obesity, obesity prevention

Introduction

There are a lot of questions about when to begin complementary feeding. Complementary feeding, according to the World Health Organization (WHO), is the phase in which breast milk is insufficient to meet the nutritional demands of an infant and therefore requires the addition of other foods and liquids. This phase typically begins at 6 months of age and can last until 24 months of age (1). This is a critical phase in an infant´s life since it establishes the eating patterns, habits, likes, and dislikes, and can even predispose to undernutrition or overnutrition.

The introduction of food and liquids different from breastmilk or formula can be done through different methods. Currently, the baby-led weaning method (BLW) has gained popularity (2). This alternative method promotes infant self-feeding as it allows the infant to decide what, how, at what pace, and how much food to eat (2–4).

Childhood obesity is considered one of the most serious health problems in the 21st century. In 2016 it was estimated that over 41 million children worldwide under the age of 5 were overweight (5). The obesity epidemic is not only affecting developed countries, its incidence is also increasing alarmingly in developing countries.

The problem with childhood obesity is that it increases the risk of obesity in adolescence and adulthood, which in turn, increases the risk of developing chronic non-communicable diseases, like diabetes, hypertension, dyslipidemia, among others (5). The introduction of solid foods is an important developmental milestone that can aid obesity prevention (6).

The aim of this review was to establish evidence on the complementary feeding BLW method in childhood obesity prevention.

Baby-led weaning vs. traditional introduction to solids

The traditional method of complementary feeding has been based on the gradual exposure to foods and liquids with varying textures. This method starts with the introduction of puréed foods and continues with mash and chopped foods until reaching finger foods. By the time the infant is 12-24 months, he should be eating the family diet with no texture modification (4,7). This method is generally led by the caregiver, meaning he or she is the one that introduces the food into the infant´s mouth. Additionally, there is somewhat of a consensus on which foods groups are introduced in each month of the child’s development. Generally, fruits, vegetables, and cereals are the first foods to be introduced, followed by meat, poultry, and legumes around 9 to 11 months of age. This method has been associated with a higher intake of foods, leading to greater weight gain (8).

In contrast, BLW focuses on encouraging the infant to feed themselves. This method offers opportunities for the infant to choose when to start, what to eat, the pace, and the amount of food that will be eaten at each meal, allowing the infant to develop the ability to determine their own food intake (3,8,9). The commonly offered foods in BLW include chopped and finger foods since the infant has the motor skills to grasp them and bring them to their mouth. Puréed foods are generally not eaten in BLW, because they need to be spoon-fed by someone other than the infant. The method also recommends introducing a wider range of foods from the very beginning of food introduction. The options include fruit, vegetables, meat, cheese, eggs, grains, legumes, and fish. However, the consumption of cereals is limited in BLW, since they require a spoon or utensil to be eaten (7–9). In some cases, a utensil may be offered to the infant for thin consistency foods, like yogurt or custards, but it is generally done after the first few months of food introduction (9). Table 1 gives a comparison between the traditional method and BLW.

Table 1. Comparison of tradition method and BLW in complementary feeding

  Traditional method Baby-led weaning
Responsible for introducing oral feeding Caregiver Infant
Texture of foods introduced Puréed, mashed, chopped and finger foods Chopped and finger foods
Foods generally introduced in first months Fruits, vegetables and cereals Fruit, vegetables, meat, cheese, eggs, grains, legumes, and fish.

Potential advantages and disadvantages of baby-led weaning

There have been many proposed advantages and disadvantages to BLW. Table 2 summarizes the ones listed below.

The most recognized advantage in BLW is that it allows the infant to self-regulate their intake of foods (2,4). According to Daniels et al, self-regulation is defined as “the capacity to adjust the quantity eaten according to the physiological needs of the consumer” (9). It encourages a more responsive eating style, since the infant is more sensitive to his or her satiety cues.  This follows the same self-feeding characteristics of breastfeeding. A breastfed infant is better able to self-regulate their intake by sucking for as long and often as they need, following the WHO recommendation of breastfeeding at demand (7). The self-regulated intake has been proposed as a potential factor in lowering the risk of obesity. Also, it reduces the pressure exerted on the infant and allows for a more pleasant mealtime (8). 

It is suggested that BLW encourages a greater acceptance of foods with a variety of textures and flavors, leading to “healthier” eating habits as the child grows. Taylor et al found that BLW promoted a greater enjoyment of food and less fussy or picky eating behaviors (10). Infants following a BLW method are more likely to consume family foods with a variety of taste and texture (9). Rowan and Harris found that, after 3 months of introducing food solids through BLW, infants consumed, on average, 57% of the same foods as the mothers (11). This also contributes to more pleasant mealtimes.

Studies have shown that following a BLW approach to introducing solids has been identified as the strongest predictor of weaning off breastfeeding at the recommended age (7). This is beneficial due to the fact that nutritional reserves can no longer meet the nutritional demands around 6 months of age. If the age of weaning is postponed, the infant is at risk of developing nutritional deficiencies. However, some evidence suggests that following a baby-led approach can lead to a  later introduction of solid foods (4). The contradictory evidence may be due to the fact that the recommended introduction period may vary from institutions. Some have recommended introducing solids at 4 months of age, while others recommend until 6 months of age. The WHO recommendation for the introduction of solid foods is 6 months of age (1).

Another highly recognized advantage to BLW is the promotion of motor skills development, due to the fact that the infant utilizes many of these during feeding. Feeding time is associated with experiencing different colors, textures, temperatures with all the senses. This process allows for a continuing practice of different motor skills, including gross and fine, like hand grasp, thumb-finger grasp, and use of utensils (9). Also, the participation of the infant in the familiar context of mealtimes is of extreme importance, because imitation is one of the pillars of infant learning (3).

Some authors have suggested that the BLW is associated with less maternal anxiety, less restrictive feeding, and exerts less pressure in the infant. It has also been shown that mothers who practice BLW are more likely to have exclusively breastfed, have a higher level of education, and are fully incorporated in their work when the infant is 12 months of age (8).

The potential disadvantages of BLW include increased risk of choking, nutritional deficiencies, and inadequate energy intake (2,6).

The increased risk of choking is due to the child’s limited chewing ability around 6 months of age, which increases the chance of swallowing big chunks of foods that can get stuck (8). Also, infants are beginning to learn to eat and experiencing moving foods around the mouth, biting, and chewing (4). A study by Cameron et al found that 30% of a group of women using BLW as a complementary feeding method reported an episode of choking. However, the mothers that cited the occurrence of choking said that the child dealt with the problem on their own and got rid of the food through coughing (7). The choking hazard can be managed by giving food in form of sticks (elongated and narrow shape) and a soft texture, generally a texture that allows the food to be squished between the fingers. Foods with a circular or cylindrical form are generally avoided or have to be cut into smaller stick-like shape.

The most common nutritional deficiency associated with BLW is iron deficiency. Iron-fortified infant cereals are an important source of iron for infants; however, intake of cereals is generally omitted in BLW because it is a food that needs to be spoon-fed (2,7). There are other foods rich in iron that can be incorporated in the BLW method, like red meat, green leafy vegetables, and eggs. Informing the caregiver about sources for iron may be the best way to avoid iron deficiency in infants that do not receive fortified infant cereals. The BLISS study evaluated the prevalence of iron deficiency anemia between the BLISS and control group but found no significant differences (10).

The inadequate energy intake can lead to undernutrition in some infants, affecting weight and height gain, and leading to growth failure. This is due to the fact that the necessary skills needed to eat (bring food to the mouth, chew, swallow) aren’t completely developed until the infant reaches 8 months of age (4). Fortunately, in the first months of introducing solids, breast milk, or formula is still considered the main source of nutrients, therefore the nutritional demands are fulfilled (8,9). The BLISS study examined energy intake through food diaries to calculate infant intake. There was no significant difference in energy intake between the BLISS and the control group at 7 and 12 months (10).

Another concern regarding the BLW is that mealtime can sometimes be considered playtime because the infant is allowed to interact with foods as he pleases. This, in some cases, has confused mothers whether the child is actually eating or just playing with food (7,8).

Table 2. Potential advantages and disadvantages of BLW

Advantages Disadvantages
Self-regulation of intake
More pleasant mealtime
Healthier eating habits
Weaning at recommended age*
Less anxiety in caregiver
Less pressure to eat
Motor skill development
Risk of choking
Nutritional deficiencies (iron)
Inadequate energy intake
Growth failure
Confusion of mealtime with playtime

*There is contradictory evidence due to the different recommendations of age to initiate complementary feeding

Responsive eating

Self-regulated intake aims to promote greater cognitive control over internal emotions and impulses and a greater awareness of true intrinsic signals of appetite and satiety to avoid eating in the absence of hunger (6). BLW allows the infant to have the autonomy needed to recognize these signals, promoting a more developed self-regulated intake (4).

A review on the development of healthy eating habits early in life, found that responsive feeding was one of the most important practices for encouraging healthy eating habits early in life. It recommended that parents should promote responsive feeding to reduce the risk of obesity (7).

Multiple studies affirm the benefit of self-regulated intake in BLW, such as a lower risk of obesity, because the infant is in control of the amount of food eaten. This self-regulated intake occurs because there is a more accurate response to internal hunger and satiety cues (2,6,9). By listening to the body’s response to food, intake can be adequately modified, avoiding a higher caloric intake. A study by Brown and Lee found that infants who followed BLW were reported by their parents to be able to regulate the intake of food in relation to satiety, having a higher satiety-responsiveness than those who had followed a traditional method (p<0.01). However, the infants were less responsive to food, meaning they were more likely to eat in response to food stimuli regardless of hunger than those who had followed a traditional method (p<0.01) (12).

The traditional method, led by the caregiver, can lead to a higher intake of foods, by forcing the infant to finish the plate or just ignoring the satiety cues. According to Cameron et al, “nonresponsive feeding is thought to override the child’s internal hunger and satiety regulatory cues, causing the child to lose the ability to accurately respond to their own physical hunger signals” (7). A higher intake of foods leads to a higher weight gain during infancy and adolescence, increasing the risk of obesity and metabolic syndrome in adult age (8).

Childhood obesity and BLW

There is increasing evidence that environmental factors in early life predict later health. Nutritional and metabolic exposure during critical periods of early human development, the first 1,000 days of life, can have a long-term effect on health in childhood. Multiple studies have found that a high protein intake or low-fat intake during the first two years of life is associated with increased growth and higher subsequent BMI or overweight and high serum leptin levels. The association between high protein intake in early life and later obesity may occur because of increased levels of growth factors that stimulate growth and promote the proliferation of adipocytes. On the other hand, early low fat intake has been associated with being overweight and high serum levels of leptin in adulthood, which suggests programming of leptin resistance (13).

A study by Townsend and Pitchford reported a significant lower difference in body mass index (BMI) and incidence of obesity in children at 20-78 months who followed BLW than those who followed the traditional method (p=0.005). This study also found that the BLW group had a significant difference in food preference for carbohydrates compared to the spoon-fed group (p=0.003). However, there was also a significant difference in preference for sweet foods, fruits, protein, meals, vegetables (p<0.0001, p<0.0001, p=0.003, p<0.0001 and p=0.005, respectively) (14). The study by Brown and Lee mentioned above also found that toddlers who followed BLW had significantly lower mean body weight, than those who had followed a traditional method (p=0.005) (12).

Taylor et al described the first randomized clinical trial to test the efficacy and safety of BLW to prevent excess infancy weight gain (6). The aim of this study was to determine whether a baby-led approach to complementary feeding results in differences in BMI z scores. This study was named the BLISS study because BLISS stands for Baby-Led Introduction to Solids, adhering to the principles of BLW, but modified in response to concerns regarding potential growth faltering, iron deficiency, and choking. There was no significant difference between the BLISS and the control group for BMI z scores at 12 or 24 months (0.21; 95% CI, −0.07 to 0.48) or 24 (0.16; 95% CI, −0.13 to 0.45). At 24 months, 5 of 78 infants (6.4%) were overweight (BMI≥95th percentile) in the control group compared with 9 of 87 (10.3%) in the BLISS group (relative risk, 1.8; 95% CI, 0.6-5.7) (10). Therefore, the BLISS did not result in a benefit for bodyweight when compared to traditional feeding practices. This study is the only randomized controlled trial to date about BLW. Yet, it found no statistical difference between the BLISS method and the traditional method regarding BMI z scores at 12 and 24 months. Unfortunately, the BLISS study modified the BLW method to reduce concerns about potential growth faltering, iron deficiency and choking. Therefore, it was not a true evaluation of the BLW method. Additional research is required to determine the true extent of the current information, without any modifications to the BLW method.

The results from most studies presented above are derived from self-reported information from parents about child eating behavior and weight. This may not be accurate and may be open to responder bias or error. Also, most of the studies available are cross-sectional studies. Further research should rely mostly on randomized controlled trials to verify the influence of BLW on childhood obesity.

Additionally, Lakshman et al stated that the possible reason why autonomy in feeding or self-regulated intake might not be beneficial but instead may be harmful for obesity prevention in infants is that infants’ intrinsic appetitive and satiety cues may mediate a natural tendency toward overconsumption in the absence of external restraint. These eating behaviors are believed to be partly heritable and determined by the same genetic variants that predict adult BMI and obesity risk (6).

Conclusions

BLW is an alternative method to the introduction of solid foods that can provide different advantages on self-regulation of intake, pleasant mealtime, healthier eating habits, weaning at the recommended age, among others. However, there are still concerns about the method regarding the increased risk of choking, nutritional deficiencies, and inadequate energy intake.

The current information about BLW is mostly derived from cross-sectional studies. Further research is warranted to verify the influence of BLW in the prevention of childhood obesity.

References

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