Conventional weaning vs baby-led weaning: Which one is suitable for my baby?

Weaning period is a crucial time in an infant's life, in which babies are first introduced to solid food (1). Weaning is defined as a “period during which other foods or liquids are provided along with breast milk” and “any nutrient-containing foods or liquids other than breastmilk given during that period of complementary feeding" are complementary food (2). According to World Health Organisation (WHO), the introduction of complementary feeding should start when exclusive breastfeeding is inadequate to provide enough nutrients and energy for the infant's growth and development (1). Conventionally, traditional spoon-feeding (TSF) is used by most parents/caregivers in which infants are initially offered smoothly blended foods, progressing in texture (i.e. mashed/chopped/diced) as the child grows, and then finally to family food when he/she reaches 12 months old (1). Finger foods are encouraged as this helps in their fine motor development (3). In Malaysia, the Ministry of Health advocates responsive feeding with emphasis on TSF and finger food as snacks (3). The same goes for the United Kingdom and New Zealand, in which finger foods are recommended from the start of complementary food introduction or from 7 months respectively (4, 5).

However, over the last 10-15 years, an alternative feeding style known as ‘baby led weaning’ (BLW), has become popular in some developed countries (6). Instead of giving infants ‘special food'; either blended or pureed form, they are given family foods in their whole form. BLW key features include (7,8):

(a) First foods for baby in a whole food form (i.e. finger food)

(b) Self-feed principle - baby feeds oneself by selecting and picking up their food of choice from what is offered, instead of being spoon-fed.

(c) To start only when the infant is ready for food (refer to my website section on ‘Infant Weaning’)

(d) Giving some ‘autonomy’ to the infant to choose what, how much they want to eat, and be part of the family mealtimes.

(e) Milk feeding (breastmilk/formula milk) continues on-demand, unconnected with mealtimes.

(f) Eating together with the family at all mealtimes.

If you were to ask those mothers/caregivers who are practising BLW on their reasons for this choice of feeding style, many of them would say ‘I want to try a natural way to feed my baby.’, ‘those commercial baby food is not healthy’, I love food and I want her to grow up appreciating food’ and ‘it is convenient, we all can eat together as a family’.

On a contrary, those who are not practising BLW would express their opinions such as ‘it is too messy’, ‘my take on it- he just plays with the food’, ‘my biggest fear is choking’ and ‘it is too time-consuming. I have to wait for my baby to play and then eat her food’.

Confusing, right? I am sure some of you (yes, you as parents!) are still undecided whether to use TSF or BLW approach for your child. To date, there is still not enough evidence to draw conclusions about BLW approach. Most evidence are from observational studies and low quality randomised controlled trials. Hence, it is not widely recommended by paediatricians, nutritionists and in international and local guidelines. However, there are plenty of websites, books and social network groups advocating BLW as “more natural”, “healthier” and “fuss-free”.

I will try to address the common questions on these two feeding approaches, key points, and differences of TSF vs BLW so that parents are well-informed about these two different approaches.

"Food is for fun until age one"

In BLW approach, infants explore the complementary food served to them. Concepts of touching, manipulating, smelling, and chewing solid foods, without pressuring the child to eat are emphasised in this approach. This low-pressure approach is believed to allow infant to develop ‘self-autonomy’ and ‘healthy’ relationship with food. Infants are in full control of their eating and set the pace of their meal, deciding when they are ‘done’.

Isn’t that similar with breastfeeding? If you have breastfed your baby before (I hope that you are doing so as breastmilk is STILL the best for your baby!), you will know that it is impossible to force a baby to breastfeed once the baby is ‘full’. So, breastfed babies are actually used to feeding themselves long before they start solids. On the other hand, a baby who is bottle-fed relies on his/her mother to take the lead, mimicking the concept of traditional spoon-feeding, in which the parents/caregivers set the pace of spoonful purees offered. Very often, the parents/caregivers are unsure if the child is ‘full’ or not.

Thus, theoretically, BLW allows an infant to recognise his/her internal cues of satiety and hunger rather than focusing on external cues (i.e taking a mouthful because the infant is hungry rather than because a spoonful is being presented).

Having said that, the evidence around BLW in promoting this healthier eating behaviour has been limited to observational studies (6,8).

If the parents/caregivers can recognise hunger and satiety cues, it doesn’t really matter if one practises conventional weaning or BLW. Do check out the section on 'feeding behaviours' in my website for further details. In the light of paediatric obesity epidemic occurring worldwide including in Malaysia, the main principle to decrease ‘obesogenic’ behaviours is to practice responsive feeding (which I will write in my next blog, tune in for it!).

“My child is less fussy”

Children’s later food preferences are thought to be influenced by early food exposures (9). Babies (aged 6 months and older) who self-feed are in fact, very keen to try new food. As BLW infants are exposed to ‘family food’ or also known as ‘table food’ from the beginning, it is thought that they may have preferences for a wider choice of foods than infants fed via conventional weaning methods (TSF). Some may say that parents/caregivers who use the conventional weaning approach tend to focus on increasing quantity of food, rather than expanding the diet. I am very sure your grandparents or even your great-grandparents do that! Mine did. Hahaha.

This aspect has been formally discussed in systematic reviews (6,8) and it has been found that there are no differences in food preferences between BLW and traditionally weaned groups. However, it was noted that BLW infants tend to prefer carbohydrates and saturated fats whereas those spoon-fed infants preferred sweet rich food. This could be due to family foods given to infants may not be cooked in a healthy manner, specifically the mode of cooking (rich in salt and sugar, processed food, food flavoured with stock cubes). Perhaps, BLW approach is a ‘window of opportunity’ for the whole family to adopt healthy eating behaviours with a variety of nutrient-dense food that BOTH the family and infant can enjoy.

As for traditional weaning, since most parents are working, buying commercially infant food or ready-made purees seem like the easier and convenient option. Bear in mind, commercially infant foods tend to be sweet in taste (marketing strategy to entice your child to like them) and thus, that explains the reason for spoon-fed infants having a preference for sweet food.

To avoid these risks, regardless of whether one chooses BLW or conventional weaning approach, parents/caregivers should try to make the diet served to their children as healthy, adequate, and enjoyable as possible.

“Isn’t pureed food easier to digest and will therefore have sufficient nutrients?”

It is true that food arriving in the stomach in pureed form is easier to digest than food in large pieces. Nonetheless, mouths are designed to mash and chew (a natural way to puree food!). By mixing saliva with food helps to kick-start the digestion process-especially the digestion of starchy foods. By allowing the child to develop chewing skills, the child tend to grow up liking different textures. Pureed foods on the other hand, are just swallowed without any chewing process. If the infant is still not exposed to different textures of food by 10 months of age, there is a risk of feeding difficulties later (10).

If one prefers to use the conventional weaning approach, as per advocated by most guidelines including Malaysian guidelines, introducing finger food at the beginning of weaning, and gradually moving from smooth blended texture to thicker lumpier texture from the 3rd week of weaning, may help to develop your child’s chewing abilities.

Those who have reservations about BLW often express concerns that the child may not consume enough calories to sustain growth and energy. Current evidence including from longitudinal studies have shown that no BLW child experienced growth faltering, although some infants had non-clinical slow growth (6,8). Most importantly, offer your child a wide variety of foods at every meal, including at least 1 high-energy food (e.g sandwich spread with avocado/cream cheese or meals cooked with margarine/butter/oil) and 1 high-iron food (meat/ fish/chicken/tofu).

Children who are traditionally spoon-feed with purees including iron-fortified cereals tend to have lower risk of anaemia (lack of iron) (6,8). Since most graspable food for BLW are fruits and steam vegetables, there is a slight risk of the infant having lower intakes of iron, zinc and vitamin B12. So, if you are planning to use BLW, I would suggest that you include foods that are rich with sources of iron, zinc and vitamin B12.

Almost all food that are offered to spoon-fed infants can be prepared in ways that are appropriate for BLW (9).

Table 1. Examples of spoon-fed foods and the equivalent BLW options (9)

"Won't my child choke?"

Choking can easily occur in infants who are learning to eat, regardless of whether being fed conventionally or via BLW approach (6,8). Main thing is to avoid high risk choking foods that are firm and round (e.g. coin shaped foods such as cherry tomatoes, grapes, popcorns, nuts, sausages, apple slices), not leaving the child alone, and ensuring that your child is fed in an upright supported position (e.g in a high chair) (11).

Very often the concerns of choking are based on observations by parents/caregivers of their babies gagging on food. Gagging and choking are related BUT THEY ARE NOT THE SAME THING. Gagging is a retching movement that pushes food away from the airway if it is too big to be swallowed. The baby opens his/her mouth and pushes the tongue forward; the baby may even vomit a little. In fact, gag reflex is a safety mechanism created for babies to manage food safely. Choking happens when the airway is completely or partially blocked. A baby who is truly choking is usually silent. Normal babies have an efficient coughing reflex. If they are sitting upright or leaning forward, it is best not to disturb them when they are clearing their airway. Of course, regardless of weaning style, I would suggest that every parent should learn how to do infant cardiopulmonary resuscitation (CPR) and take up a first-aid course to know what to do when a choking incident occurs.

“Is BLW for my baby?”

Not every baby is suitable for BLW. Babies who have delayed development, or conditions that interfere with their ability to get food to their mouth, or to chew and swallow may not be suited for BLW approach. (7) Such babies will probably do better with conventional feeding or combination of spoon-feeding and finger foods. BLW works well once a baby is ready for solid food and able to feed oneself with solids. So, do not compare your child with your friends’ or relatives’ child. Trust your child to know what he/she needs. If your child is not ready for self-feeding, be patient. An infant who is not able to self-feed by 8 months of age should be evaluated for developmental delays and traditional feeding approaches should be strongly considered (11).

If one is quite uptight on cleanliness and find it time consuming to prepare fresh and homemade family food, then BLW is also not for you. Starting BLW at the beginning can be super messy. At first, food is just another toy for infants. So they will find it a delight to squish and spread the food. Sometimes, the mess is just due to their immature skills.

Although some parents might find it time-consuming to prepare home-cooked food, it is actually cost-saving if one serves the same family food to their infants. Commercially infant foods can be expensive.

"NOT ONE SIZE FITS ALL"

Traditional feeding approaches are still generally favored by most parents/caregivers worldwide. If you are still thinking of trying BLW, do check out Gill Rapley’s book (Baby -led weaning. Helping your baby to love good food). There are plenty of practical tips for BLW. If you have decided to go for conventional weaning, do check out my website for practical tips. You can even modify your feeding style to partial BLW. My take on it is to incorporate responsive feeding in both BLW and TSF.

At the end of the day, what is more important is that your child is given a variety of food in terms of textures, colours and sizes; think of the nutrients that your child is taking.

Happy feeding your child!

References:

1. World Health Organization. UNICEF. Global strategy on infant and young child feeding. Geneva. World Health Organization.;2002. http://www.who.int/nutrition/publications/infant feeding/9241562218/en/

2. ESPGHAN. Complementary feeding: a commentary by ESPGHAN Committee on Nutrition. Journal of Pediatric Gastroenterology and Nutrition 2008; 46: 99-100

3. Garis panduan pemberian makanan bayi dan kanak-kanak kecil. Bahagian Pemakanan Kementerian Kesihatan Malaysia. 2009

4. https://www.nhs.uk/start4life/first-food

5.http://www.health.govt.nz/yourhealth/pregnancy-and-kids/first-year/6-12-months/feeding-your-baby

6. D'Auria E, Bergamini M, Staiano A, et al. Baby-led weaning: what a systematic review of the literature adds on. Italian Journal of Pediatrics 2018; 44(1): 49

7. Rapley G. Baby-led weaning: transitioning to solid foods at the baby’s own pace. Community practitioner 2011;84(6): 20-23

8. Brown A, Wyn Jones S, Rowan H. Baby-led weaning: The evidence to date. Curr Nutr Resp 2017; 6: 148-156

9. Cameron SL, Heath AL, Taylor RW. How feasible is baby-led weaning as an approach to infant feeding? A review of the evidence. Nutrients 2012;4: 1575-1609

10. Northstone K, Emmet P, Nethersole F. The effect of age of introduction to lumpy solids on foods eaten and reported feeding difficulties at 6 and 15 months. J. Hum Nutr Diet 2001;14:43-54

11. Megan H Pesch, Sarah P Shubeck, Heather Burrows. Baby-led weaning. Introducing complementary foods in infancy. Contemporary Pediatrics 2019;36(1):24-28