Some Healthy Discussion About Baby-Led Weaning

Hi Dr Flanders
I note you recommend purée weaning infants and wondered what your take was on Baby Led Weaning please?
AA

Thanks, AA, for bringing up Baby Led Weaning (BLW). For those readers who aren’t familiar with this approach, it was conceived and developed by Gill Rapley in the late 1990′s. At the time (and to a large extent, still today) the general approach to introducing solid foods to babies had a marked overemphasis on progressing a baby’s feeding skills based on parents’ agenda rather than baby’s … i.e. pediatrician gives parents a schedule to follow and parents then impose said schedule on baby. There was little consideration (if any) given to baby’s readiness (psychological and neurodevelopmental), preference, comfort levels, etc… Ms. Rapley appropriately took issue with this and developed an approach of introducing solids in a way that was far more respectful of, considerate to, and empowering for baby.

In my opinion, the principles behind BLW are solid. On a societal level, it presents a much more appropriate approach that puts the baby’s agenda front and center (where, in my opinion, it should be).

If you were to ask me if I had any concerns about BLW, the one minor issue I would bring up is that there appears to be an ‘anti-puree’ and ‘anti-spoon-feeding’ sentiment in the literature that I don’t quite understand. In my opinion, babies can eat pureed foods in a baby-led fashion. My favorite approach is to dump a pile of apple sauce in front of a baby and then sit back and enjoy watching her explore. Although 99% of the food will end up in and on places other than in her tummy, she will have had an enjoyable, authentic, baby-led feeding experience. As for spoons, I also believe that babies can eat from a spoon in a baby-led fashion. The key is to ensure that baby is actively eating off the spoon as opposed to passively receiving the spoon being pushed by parent into baby’s mouth. The former represents a child who is 100% empowered to decide for herself whether or not to eat what’s being offered. The latter, in my opinion, is force feeding (never advisable).

For more information about BLW, Check out Gill Rapley’s Site. Her Useful linkspage refers to a number of additional BLW resources on the web.

Hi
Thanks for such a speedy reply.

I would agree to some degree that babies can be spoon fed in a baby led fashion, and I think if offering a range of foods and textures some of those are bound to require a spoon eg yoghurt, rice pudding or suchlike? (ie Gill Rapley doesn’t support the notion of one food per few days, but offering a wide selection presented individually on the plate so the child can refuse a specific food if desired)

For the most part eg meals, I guess the question is why mush, rather than why not? why not just let the child feed themselves entirely? There doesn’t appear to be any research supporting the notion food “should” be mushed?

What BLW also theories (and something I’ve observed in practice) is that eating skills develop in tandem with the ability to pick up and “manage” different foods. As I’m sure you know well, eating isn’t just a case of swallowing; it’s getting the food to the mouth, chewing or processing, moving to the back of the mouth ready to swallow (by which point it needs to be safe to do so ie small enough)

As the gag reflex sits further forward in an infant’s mouth, conferring extra protection whilst developing skills, and moves back as they mature – if a baby has been limited to mostly mush, is there more of a risk the skills get out of sync? ie when a baby is 6 months, they can’t pick up say peas or sweetcorn as they haven’t developed a pincer grip; by the time they can they have generally had a couple of months working on learning to eat with the bigger items they can pick up?

Observing those BLW – in the first instance baby often holds on to the food as they move it around the gums to gnaw and suck, their eating skills can be visibly seen to be developing as they progress, which occurs in tandem with the physical skills to pick up and transfer to the mouth (which ultimately is a significant part of the rationale for waiting until around 6 months? ie the ability to put food to the mouth themselves occurring alongside internal gut closure)

The other question is that of volume. We note purée fed infants often consume more than those feeding themselves – if the spoon feeding is parent led, they can often spoon far faster than a baby could, which potentially makes it easier for the infant to over eat.

In the same way multiple milk ejections at the breast, slow the feed down – the child keeping control of their food and ultimately intake, makes for a much slower eating experience. Most recognise now the benefits of chewing food well and more slowly; that it gives the brain and body more chance to recognise it is full.

Many also recognise that a person being able to recognise they are full and stop eating, is far more likely to maintain a healthy weight as an adult. How and when do people lose that ability?

Even if the parent is holding out the spoon for the infant to come on to, if something tastes nice, is there the potential for the child to keep opening and leaning forward, because again they can swallow the purée faster than they could hope to feed themselves? If someone was holding chocolate mousse out for me, I may well be tempted to open a few more times than if I was feeding myself (but perhaps I’m just a chocolate addict  LOL)

You will also know yourself if you take a punnet of say berries and mush them, you often end up with a surprisingly small amount of purée as a result – allowing a higher calorie intake from a smaller volume, what would our weight do if we puréed every meal?

Another aspect is chewing for appropriate jaw development – whereas this is likely to be less significant for the breastfed infant, a baby who has sucked primarily from a bottle/dummy (which could hinder appropriate development of jaw muscles as highlighted by Brian Palmer DDS) could potentially benefit from chewing, not only for the jaw but also for the eustachian tubes?

In BLW infants we also note constipation is virtually unheard of – something many parents note following the introduction of “solids” (ironic given it often means anything but solid lol).

Kind regards
AA

Hi again AA. Thanks for such insightful and informative comments. You covered quite a swath of interesting topics and I will do my best to respond with the time and consideration that these topics deserve. I’ll apologize in advance if the responses below are too brief and superficial, but I intend to use many of your insights as fodder for future posts on this blog.

Re: your comment: “why not just let the child feed themselves entirely?”
I guess the concern here is what about the kids who aren’t yet able to do so? My approach to progressing feeding skills is ‘first walk, then run, then fly’. Some kids can ‘fly’ right off the bat in which case they would spend only days (or skip altogether) the puree stage. Others need to take small steps and progress slowly. For those kids, I’m of the opinion (though I am open to having my mind changed by compelling data) that the puree texture is a logical next step in the transition from liquid calories towards more complex solid food textures. You are correct that there is a paucity of good scientific data out there supporting the use of purees as a transitional food. That said, there is a paucity of data, in general, to support making recommendations for any first solid foods for babies. So we do the best we can with the (limited) information we currently have.

Re: progressing feeding in a developmentally appropriate fashion.
This ties in nicely with your other very valid point that there is more to feeding than just swallowing. I.e. feeding is a complex behavior involving the exquisitely complex coordination of (in addition to the gastrointestinal tract) multiple components of the central nervous system: fine motor, oromotor, gross motor, perception (smell, touch, taste, temperature, vision), cognition, emotion, motivation etc… All components must be 1) at an appropriate developmental stage and 2) able to intercommunicate in order for healthy feeding to ensue. Development of these systems is already occurring before birth as baby drinks amniotic fluid. There is further progression through pregnancy and then after birth with the onset of breastfeeding. The introduction of solid foods marks the next major ‘developmental milestone’ in the evolution of feeding skills. Some babies handle this challenge with ease. Other babies are less precocious. For them, any or all of these nervous system components may be lagging in development or capacities to intercommunicate. In these cases, baby needs practice and slower progression. As such, I feel that a gradual and slow progression from liquids to purees to soft solids etc. is the most logical way to challenge, develop, and promote coordination of these various CNS systems. As you point out, keeping a baby on purees when she is neurodevelopmentally beyond that level does not make any sense. On the other hand, presenting a baby with food consistencies that are beyond a baby’s neurodevelopmental capabilities is equally nonsensical (I’m picturing a hungry 8 month-old sitting at the table, nutcracker in hand, reaching for a bowl of unshelled walnuts). I don’t mean to say that BLW is not sensitive to this argument. In fact, the BLW approach embodies this notion of allowing development to occur, led by baby, in the appropriate manner and tempo. I just see purees as a sensible next step in the transition from liquid to solid calories. How long a baby chooses to stay at the puree stage is entirely up to her.

Re: BLW preventing constipation
How interesting! I was not aware of this. I would love to read more about this connection. Can you direct me to some related literature?

Re: Infant/child feeding development and their response to hunger and satiety.
Your points are well taken. In fact, there are a number of amazing studies that have emerged over the past 5-10 years linking abnormal development of feeding skills with childhood-onset obesity and other feeding disorders. These papers hypothesize that healthy development of hunger and satiety signals (from brain to gut and gut to brain) is crucial for maintaining long-term healthy body composition. In other words, babies need to feel hungry, understand the meaning of that feeling, communicate the need for food, feed themselves until comfortably satiated, understand the meaning of feeling full, and then stop feeding as a result. There are opportunities for this sequence to go awry and most of the time, problems are introduced when a parent presume to know better than his baby when she (the baby) is hungry/full, how hungry/full she is, and how much food she should eat at any given meal. Whenever a parent thinks he knows his baby’s hunger/satiety signals better than his baby does, there is a significant risk that baby will be fed when not hungry and deprived of food when hungry. Furthermore, baby is likely to be over or underfed during any given meal. Imagine how difficult it must be for baby’s hunger/satiety signals to develop faithfully when the hunger/fullness sensations are constantly mismatched with the timing and quantity of the feeds. The quality of the food can also adversely impact the development of baby’s hunger/satiety systems. Liquid calories (and to a lesser extent pureed calories), if fed in relative excess, do not necessarily promote appropriate hunger/satiety signaling. In other words, when calories are densely concentrated into a juice or mush, the body tends to under or overestimate the number of calories consumed. As such, children who take in the majority of their calories in the form of liquids have a much higher likelihood of being over or underweight. Furthermore, deranged hunger/satiety feedback/development increases the risk of obesity, failure to thrive, behavioral feeding disorders, eating disorders, micro and/or macronutrient deficiencies, etc. So I agree with you that babies and children should eat a wide and balanced range of foods and textures. Getting stuck on a single food type or consistency potentially leads to significant long term risk.

Thanks again for your valuable contribution to this post. If I’m ever in the UK, or you are anywhere near Toronto, perhaps we can meet over a large bowl of chocolate mousse, over-feed, and further discuss the finer points of infant and childhood nutrition 

DF

LOL @ 8mth old with a nutcracker! I absolutely agree there has to be both instinct and logic applied – I have seen young babies presented with a plate of salad with raw carrots. Whilst a great texture/sensory experience, if baby is hungry they’re unlikely to get enough down to hit the spot. Including some softer finger foods that can be more easily consumed makes more sense I think.

What I’ve also observed and identified in a survey was that when presented with a range of foods, meat was often a very popular first choice. Even more so in cases where there was increased risk for reduced haemoglobin levels; given what we also know about which nutrients an infant requires during the early weaning period – it would be interesting for someone to study self selection of foods further.

The section of your reply outlining infant/child feeding development and their response to hunger and satiety is absolutely fascinating! I am going to have to dig out more on that subject now.

WRT solid consumption before readiness, I think an interesting questions is whether there is evidence an infant needs solids prior to them being able to self feed themselves? (or indeed demonstrating a desire to do so) I am of course talking with regard to a typical breastfed infant (ie the biological norm) and there will always be exceptions to this (eg my premature son made it very clear he wanted solids prior to being able to put them in himself) – This is I think a central belief to baby led weaning.

This makes the most logical sense for me – no other mammal requires someone to look at and establish signs of readiness (and what did parents do before the magic lists of what to look for?) before starting to offer a different food every x days. Sure meat would likely have been pre chewed, but if I had no books/guidelines/societal norms influencing – I think the most obvious sign of solids readiness is an infant reaching for and eating food. We know this happens for most around the middle of the first year, and we know this also ties in with gut maturation in terms of closing and hindering direct access to the bloodstream?

However I waffle about my opinions on that here http://www.analyticalarmadillo.co.uk/2011/02/starting-solids-can-babies-be-ready.html

On a totally different note – our recent focus has been on ankyloglossia and solids, we are noting a high proportion of infants who are not progressing as we typically see with baby led weaning (and in severe cases even purées) have a type 3-4 tie (either undiagnosed or dismissed as insignificant). This makes the information you provided WRT response to hunger and satiety even more interesting!

Thanks for taking the time to reply, chocolate mousse is on me lol

AA