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Traditional Spoon Feeding vs. Baby Led Weaning

Ok so here we go, my next article on starting solids. In my first article I attempted to answer the when part of the starting solids debate. In a nutshell these are the conclusions I came to:

When should a baby start solids?

How old should a baby be when they start solids | What does the research say?

• It is not recommended to introduce solids/complementary foods to your baby before 17 weeks (4 months)
• It is not recommended to delay the introduction of solids/complementary foods to your baby past 6 months (26 weeks)
• If you choose to start solids/complementary foods when your child is physically ready somewhere between 4 and 6 months or at 6 months, as a parent you can probably relax as it is highly likely you have made an ok decision, backed up by current research and evidence based guidelines.

Now that the when to start solids component is somewhat resolved, I will now move onto answer the how to start solids question.

Or if not answer it, at least provide you with  information to either make your own decision, or spark enough interest for you to complete your own reading on the topic.

At the moment there are two quite distinct methods of introducing complementary foods/solids to your baby.

The traditional spoon feeding approach and Baby Led Weaning (BLW). Below I have quickly summarised the two methods.

What is Traditional Spoon Feeding?

• Babies are offered their first tastes of complementary foods via a spoon
• The texture of the food gradually increases as the baby is able to manage them
  • Smooth thin puree
  • Mashed/minced
  • Chopped
  • Finger food

• Infants should progress to eating a variety of foods and textures and be eating more family foods by one year of age
• Dieitians NZ published a concise fact sheet on starting solids (using the traditional method) in 2011 (Find it here)
• The Plunket NZ website has practical information on how to introduce solids to your baby using the traditional approach (Find it here)

 

What is Baby Led Weaning? (BLW)

• Babies are provided their first foods in a whole food form as finger foods
• Babies self feed by selecting and picking up the finger foods provided instead of being fed by someone else.
• The term BLW was coined by Gill Rapley a former midwife and health visitor based in the UK
• Gill Rapley the founder of BLW has a website rapleyweaning.com
• Gill Rapley published guidelines on implementing solids using the BLW approach in June 2008
• The Gill Rapley website has a leaflet on BLW available to download
• Supporters of BLW believe it could provide the following benefits 
  • Less fuss in terms of preparation from the parents perspective
  • More natural, babies start eating when they are ready
  • May prevent obesity as it focusses on babies natural hunger cues i.e. eat when hungry, stop when full
  • Less picky/fussy eating problems
  • Developmental and coordination benefits as the act of eating helps baby practice these skills.

So which is better: Spoon Feeding or Baby Led Weaning?

On one hand we have what we assume is the tried and true method of starting solids, spoon feeding.

On the other we have a newer approach which could have the potential to offer some benefits. Which is the better way to go?

With my science background, to answer this question I would like to see the results of a large RCT (Randomised Controlled Trial).

This would mean that there has been a study (or an ideally a number of studies)  conducted where babies were randomly assigned to either BLW or the traditional approach. Outcomes would then be measured to determine which was the best weaning method.  

I have been on the hunt to find just this. Unfortunately after quite a few searches of the literature, I have been unable to find this type of study.

Because of this lack of research it is pretty difficult to therefore say which method is conclusively the best for babies.It would seem that I am writing this article a touch too soon, as I've heard on the grapevine that there may have been one trial conducted recently by Otago University (my old haunt), but to date the results have not been published.

So watch this space, when, and if the data becomes available I will update this article.

To tell the truth, I am some what disappointed. The BLW approach fits well with my personal low fuss food philosophy, so I was  hoping I would be able to write this article and show you some strong evidence that BLW is a great way or the best way to go.  

Unfortunately that has not been the case. But all is not lost. The article does summarise what I was able to find, and is still hopefully interesting reading.

How common is BLW?

Based on my reading in various forums and online communities it would seem BLW is very common practice.

 But to truly follow BLW principles it is an all or nothing approach. i.e. all finger food and no spoon feeding until such time that the baby can self feed with a spoon. So how common is exclusive BLW?. I found one New Zealand study which quantified the numbers somewhat.

In this online survey of babies at 6-7months:

• 8% were following exclusive BLW, i.e. had not been offered any spoon feeds
• 21% were offering both spoon and finger foods
• Which leaves 71% were solely spoon feeding

So in essence at the moment, despite a lot of noise, not that many people (New Zealanders) are actually following an exclusive BLW approach.

What do the current guidelines and professional bodies say about BLW?

• The Food and Nutrition Guidelines for Healthy Infants and Toddlers Australia and New Zealand currently recommend the traditional method (Find it here, section 4.4 pg 24)
• The New Zealand Ministry of Health (MoH) do not currently recommend BLW due to a lack of research.  In 2012 the MoH acknowledged there may be benefits in terms of reducing obesity. But cannot recommend BLW until they are confident of its safety.

They identified 3 potential risks of Baby Led Weaning

• Babies may not get enough iron
• Babies may be more likely to choke on food
• Babies may not get enough food to grow well

Iron status and Baby Led Weaning

The iron status of infants and toddlers is actually something that is a legitimate concern from a public health perspective.

From around six months of age our breast milk no longer provides sufficient iron to meet our infants full iron requirements.

Iron deficiency has been found to be relatively common amongst children aged 6-24 months. Countries like Australia and New Zealand are not exempt from this issue.

Some ANZ statistics

• 14% of Auckland children 6-23 months found to be Iron deficient (7-27% depending on ethnicity)  (find it here)
• 29% of South Island New Zealand children 6-24 months found to have suboptimal iron status (find it here)
• 38-41% of Adelaide children 6-24 months found to have sub optimal iron status (find it here)

I was unable to find any large studies on BLW and Iron status in infants.  

From the above statistics, it would seem iron status is in issue even when traditional methods of starting complementary foods are used. The concern would be if following BLW could worsen iron status.

 3 reasons why BLW might lead to poorer iron status.

1.  If you are following BLW principles then iron fortified baby cereals would not be part of your babies diet. Iron fortified baby cereals are known to improve iron status in infants.
2. Babies may not be offered iron rich foods following BLW principles (see table below for iron rich foods)
3. Babies may not be developmentally ready to pick up and eat the iron rich foods that are provided

3 reasons why BLW may not be any worse than traditional practices for iron status

1. Despite evidence that iron fortified baby cereals can improve iron status, and despite their relatively wide use in both Australia and New Zealand, the statistics show that iron status is still low.
2. Parents can be educated to ensure appropriate iron rich foods (Particularly those containing haem iron) are made available early on.  A small pilot study out of the University of Otago has shown that parents following a BLW approach who received education on high iron foods were more likely to offer these more regularly than parents who followed BLW with no additional education on iron containing foods
3. A UK study  found that for the majority of babies it is feasible that they will begin reaching out for foods at an appropriate age for BLW to be successful in maintaining iron status. They found:

• 56% of babies had reached out for food before 6 months of age
• 85% of babies had reached out for food between 4 and 7 months of age
• 6% were still not reaching out for food by 8 months of age

The same study did however conclude that BLW could lead to nutritional implications for babies that were relatively developmentally delayed.

Whether you choose the BLW or traditional spoon feeding route to start your baby on complementary foods.

I think it is prudent for all parents feeding kids to be aware of foods which provide iron and ensure they are offered sooner rather than later.

I hear the saying "food under one is just for fun" used by many people, particularly those following BLW principals.

And whilst I somewhat agree, from an Iron perspective if your baby has been exclusively breastfed, then at around 6 months of age they are going to need some iron rich foods to ensure their iron status is maintained.

Well-nourished babies born at full term typically have sufficient iron stores for the first 6 months of life.

Infants aged 7-12 month, due to their rapid growth and development have very high iron requirements of 11mg per day. Breast milk is actually very low in iron, containing approximately 0.76mg per litre. Meaning if a baby is not taking any other complementary foods after 6 months they may need to be drinking 14 litres of breast milk a day to meet these needs.

So although breast milk provides fantastic nutrition for our babies under 6 months of age, after this time other foods are needed to keep our babies healthy and thriving.

A very quick lesson on iron

There are essentially two types of dietary iron. Haem iron and non-haem iron. Haem iron has a greater bioavailability than non-haem iron (i.e. our body absorbs it better).

Haem iron takes its name from the fact that it is the iron which is bound to haemoglobin proteins. Animal products contain both haem and non-haem iron. Plant and iron fortified food sources of iron only contain non-haem iron.

Whilst haem iron absorption is not typically affected by the other things we eat and drink, non-haem iron absorption can either be improved or diminished by other dietary factors.

• Tea decreases our body's absorption of non-haem iron due to its tannin content. Coffee and caffeinated beverages do as well but not to the same degree as tea. (hopefully none of our young ones are indulging in tea or caffeinated beverages though!)
• Vitamin C increases the absorption of non-haem iron. So including vitamin C rich foods at a meal can improve absorption. In some instances good sources of non-haem iron and vitamin C are combined in one food, broccoli is an example.
• Combining haem iron containing foods with non-haem iron containing foods boosts absorption. This is known as the MFP (Meat, Fish Poultry) factor. For example a lamb and chickpea curry, or a chicken and vegetable salad.

That being said, plant based foods do provide great sources of iron, we just need to be slightly more mindful about how and when we are eating them to ensure we get their full benefit.

 

Choking and Baby Led Weaning

To date I have been unable to find any good quality scientific investigations that looked at the choking risks associated with BLW vs. traditional spoon feeding.

Although I believe there are two  studies which may be under way investigating this, one based in Scotland and one in New Zealand, so again watch this space.

As mentioned above a UK study found that the majority of babies had the developmental skill to reach out and grasp food from around 6 months of age.

The next question is when do babies develop the skills required to: Bite food, chew food, move food  it the back of their mouths and then swallow lumps of food?  Babies need to be able to do all of these things safely before they could be expected to manage a BLW approach.  

A literature review from the University of Otago Human Nutrition Department suggests that from around 6 months most babies have the oral motor skills necessary to do all these things. There is even some thought that it might help babies to consolidate and practice these skills if they are given opportunities to try at the time they develop them, i.e. offering appropriate finger foods from around six months of age.

I was unable to locate any choking data on traditional spoon feeding.  I discovered one small study that interviewed parents who had used BLW principles to introduce complementary foods to their baby. In this study 30% of parents reported babies had experienced a choking episode.

In all reported instances the baby was able to clear their throats themselves with coughing/gagging and did not require any first aid.

The most common food to be reported as a problem was raw apple. Due to a scarcity of data I am unsure if 30% is higher or lower than the number of choking episodes experienced when using traditional spoon feeding.

Based on my reading to date I have come to the following conclusions regarding choking:

• Before around 6 months of age babies will not necessarily have the skills required to successfully bite, chew, and move lumps of food safely. Therefore if you are gong to follow a BLW approach it would be sensible to begin offering appropriate finger foods closer to 6 months than earlier.
• From around 6 months of age most babies should be able to manage appropriate/soft finger foods, and there could be some developmental benefits of doing so.  Whether you are going exclusively down the BLW route or not, I think it is still sensible to consider offering some safe finger foods at this age.
• Whether you are following BLW or traditional spoon feeding principles be sensible when you introduce finger foods. Hard foods such as carrot sticks or raw apple present choking risks. As do small hard foods like nuts and small round/oval foods that could block airways such as whole grapes, these types of foods should be avoided until you are confident of your babies eating abilities. i.e. they are not appropriate first foods.  Here is a comprehensive list of foods that pose a choking risk
• Never leave your young child unsupervised when eating solids
• It is a good idea for parents to know what to do if their child experiences a choking episode.  All parents should seriously consider completing a first aid/CPR course at about the time their baby is due to start solids.
• Below is The St John's Ambulance UK video demonstrating how to treat a choking a baby. I strongly urge you to view it if is something you are not familiar with, or even just as a refresher

 

 

Growth and Baby Led Weaning

I located one relatively small observational case control study out of the UK which looked at the impact of weaning method (BLW or spoon feeding) on food preferences, and BMI (Body Mass Index). Study numbers were small but these are  some of the results of the 'baby know's best' study

• BLW babies showed a preference towards carbohydrate based foods
• Spoon fed babies preferred sweet foods
• Increased incidence of underweight babies amongst the BLW group
• Increase incidence of obesity amongst the spoon fed group
• There was no difference in fussy/picky eating between the two groups

From a growth perspective, neither being overweight or underweight are great outcomes.

So based on this small study I think it is difficult to draw much/any conclusions related to which method is best from a growth perspective.

BLW is based on the premise that babies are offered family foods right from the start. If your family follows a healthy balanced diet then this seems appropriate.

However there would be some concern and potential risks if parents decided to adopt a BLW approach, but continued to maintain unhealthy eating practices themselves. I doubt any baby would benefit if their first/only exposures to food and drinks were unhealthy options high in fat salt and sugar. McDonalds fries and ice-cream or KFC and Coke spring to mind as a bad idea.  

If you are going to adopt a BLW take an honest look at how your family currently eats and drinks.

Is your diet what you would consider healthy and nutritious or could it be improved? On the flip side, I also feel people need to ensure they are not just giving their baby's solely low energy options as complementary foods.  Anecdotally many first foods (BLW or traditional spoon feeding) can be quite low in energy.

Green vegetables such as broccoli, zucchini and spinach although packed full of vitamins, minerals and fibre are lacking in protein, carbohydrate and fat.

Babies don't need to be on calorie-restrictive diets when it comes to their solids/complementary foods.

So have a think about what you are offering, does it cover all the nutritional bases, or have you inadvertently restricted your baby's diet to just fruit and low energy vegetables.

Food allergy and introducing solids/complementary foods

In my previous article on when to introduce solids. I looked at the guidelines and current  recommendations related to food allergy. From a timing perspective it is now generally recognised that:

• There is no benefit in delaying potential allergy foods past 6 months of age, even in high risk children (i.e. those with a family history of food allergy)
• The guidelines from Australasia, Europe and America allergy bodies all suggest solids can commence from 4-6 months of age.
• There is some evidence that there may be a protective window of opportunity for the introduction of solids between 4 an 6 months of age, although to date the mechanism is uncertain.

So whether you choose to follow BLW or a traditional spoon-feeding we should be confident to start our baby's on the potentially allergenic foods earlier in their introduction to complementary foods rather than later (Cows milk, Soy, Wheat, Egg, Peanut, Fish).

It is sensible to introduce these foods one at a time, spaced by a few days so that if your child does develop a reaction it is easier to identify which food was the potential culprit.

So where does this leave me?

I have 3 children. My first 2 children had a combo approach when it comes to starting solids. A mix of traditional spoon-feeding with a good dose of finger foods.

My youngest baby is currently 4 months of age. She is exclusively breastfed at the moment. To be honest before I completed all this reading I was pretty confident that I was going to stick with an exclusive BLW approach for her.

Over the past years I have had more and more exposure to the principles of BLW and as I have changed as a mum its philosophies seemed to fit more and more with my parenting style.

But to be honest, because of my background there are actually a few unanswered questions when it comes to BLW for me to take the leap and go exclusively down the BLW route.

My plans are therefore to:

1. Introduce solids somewhere between 4 and 6 months of age. Based on my experience with my other kids it is probably going to be around the 5 month mark.
2. I will ensure the foods I offer are high in iron
3. I intend to expose my baby to the allergy foods earlier in her solids journey than later.
4. My baby will be offered family foods, and dependent on what they are will depend whether they are offered via a spoon or as finger foods.

• Items like porridge, risotto, soup, casseroles etc will be offered via a spoon
• Items like scrambled eggs, toast, vegetables, pasta will be offered as finger foods

How and when to offer solids/complementary foods to our baby's can be a contentious topic. Many people have very strong views either way. In fact based on my experiences in online forums it can turn into quite a heated, somewhat militant debate.

In my previous article I concluded that as long as your baby was older than four months but no later than 6 months then based on the current evidence and guidelines you will have made an ok decision.

When it comes to which method to use, BLW or a traditional approach my advice is the same. Choose the method that suits you, your baby, your family and your parenting style the best.

Whichever you decide as long as it is done sensibly you have probably made an OK decision. So be confident and enjoy the experience.

I will keep my eye's peeled and my ear's to the ground in relation to new evidence on BLW. If and when new evidence comes to hand I will endeavour to update this article.

Thank you for reading, if you have made it to the end you have done very well ( I know it was fairly hefty).

 

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