First Foods : Puree on Spoon or Finger Foods?

The baby-led weaning (BLW) approach to introducing solids to infants has become popular in recent years in UK, New Zealand and Australia. It has also been adopted by some parents in Hong Kong.

Baby-Led Weaning (BLW)

Adopting BLW, parents do not offer infants food by spoon. Infants are to feed themselves the solid foods right from the start of the complementary feeding period. Usually, infants are offered pieces of whole food in “stick-shaped” that they can pick up and feed themselves. A wide range of foods are suggested as the first foods, including fruit, vegetables, meat, fish, cheese, well-cooked eggs, bread and pasta.1

Advocates of the BLW approach to complementary feeding argue that it shares similarity with breastfeeding in that eating is under the control of infants. This may have implications for the development of appropriate energy self-regulation, healthy eating habits and prevention of obesity.1

Concern of Safety and Nutrient Uptake of BLW

Obviously, BLW approach for introducing solid foods is not suitable for all infants of 6 months old. Infants vary in the age when they are developmentally ready to feed themselves. Longitudinal study in UK showed that 56% of infants reaching out for foods before 6 months and yet 6% still did not demonstrate this sign at 8 months.2 The age infants self-feed crackers ranges from 4 to 14 months, with mean age at 7.7 months.3 Health care professionals have expressed concerns regarding the use of BLW approach to complementary feeding, namely, whether the infants will consume sufficient energy and iron, and whether they will be at increased risk of choking.4
This may be particularly relevant if the diet mainly consists of low energy finger foods such as fruit and vegetables. An observational study of complementary diet in New Zealand showed that full BLW infants were considerably less likely to consume iron-fortified infant cereal and red meat than infants who were traditionally spoon fed. BLW infants were found having a lower intake of iron, zinc and vitamin B12 than infants receiving traditional spoon feeding.5Infants aged 6 to12 months have a high demand of iron (recommended iron intake is 11 mg per day).6Prolonged inadequate iron intake may lead to iron deficiency and iron deficiency anaemia, which can impact on the central nervous system and development of the infants.

Researches on BLW

There are only few studies on BLW. The results of a few small scaled association studies supported the notion that Baby-Led approach conferred a favourable impact on healthy eating behaviour in children. Mothers who followed the approach perceived that it promoted positive eating behaviour for infants, in terms of reduced fussiness and more food enjoyment. 7, 8 However, the finding was based mainly on parental reports rather than objective assessment by the researchers. The Baby-Led Introduction to SolidS (BLISS) study was a randomized clinical trial designed to determine whether BLW prevents overweight. The results showed that infants following BLW approach did not result in a healthier BMI at 24 months than those commenced weaning by traditional spoon feeding.8

The BLISS study also analyzed the dietary and nutrient intake of the infants. It demonstrated that iron and zinc intake of the infants could be safeguarded by following a modified BLW approach which emphasized on food choices. The intervention using modified BLW approach included 3 face-to-face contacts at 5.5, 7 and 9 months of age to provide feeding advice focusing on responsive feeding14, 15, apart from standard Well Child Care in maternity centres. In addition, the mothers were given explicit information and resources on food choices to address the concerns of choking by foods, iron deficiency and growth faltering as a result of inadequate energy intake.9, 10 The modified approach advised parents to avoid foods at risk of choking and include an iron rich food, an energy-rich food and one fruit or vegetable in each meal (see table below).

Table 1: Examples of high choking- risk, iron- rich, high- energy food listed in the BLISS Study10

Examples of high-choking-risk foods :

Raw vegetables (e.g., carrot, celery, salad leaves); Raw apple; Rice crackers, Potato crisps, Corn chips, Whole nuts, Dried fruit (e.g., raisins, cranberries); Cherries, Grapes, Berries, Cherry tomatoes; Peas, Corn, Candy or Sweets; Meat sausages, Other hard food (i.e., foods that cannot be squashed against the roof of the mouth with the tongue)

Examples of Iron- containing foods :

Beef, Pork, Chicken, Fish, Lamb, Liver, Iron-fortified infant rice cereal (offered as spread on toast) , Baked beans, Lentils, Hummus, Chickpeas

Examples of high-energy foods :

Foods from the meat, fish, dairy, cereals and grains food groups; Fruits : Avocado and Banana; Vegetables: Pumpkin, Potato and Sweet potato

The control group received standard Well Child Care from the maternity centres only. The results showed that the intervention and control groups did not differ in energy, iron and zinc intake at 7 and 12 months. There were no significant differences in plasma ferritin and zinc or the prevalence of depleted iron stores, early functional iron deficiency or iron deficiency anaemia at 12 months between the two groups. 11, 12 Infants in the modified BLW group were not more likely to have choking incidents than the control group although they gagged more frequently at 6 months while not at 8 months.13 Growth faltering was not observed in both groups.8

These findings may indicate that following the modified BLW approach on food choices of BLISS study might have positive preventive effects on the risk of choking and nutrient deficiency.

A balanced approach

At present, there is insufficient evidence to draw conclusion about BLW approach. As long as the first foods are iron-rich and energy dense, parents can choose their preferred feeding approach taking into account their infants' developmental ability and acceptance of the feeding approach.

BLW may be safe if the infants can reach out and put food into their mouth before 6 months and foods offered do not carry risk of choking as described in the BLISS advice. The foods offered should be iron-rich and energy-rich. In addition to finger food, the food can be offered from a spoon in puree. The infants will either lean forward to accept the food on spoon with a wide open mouth, or they will take the spoon and suck the puree.

For infants who begin with puree foods, parents should gradually introduce mashed and minced textures. Offer finger foods (best if chosen from family dining table) alongside spoon feeding as soon as the infant indicates he is ready.

Parents and caregivers should allow infants to enjoy family meal and trust them in appetite control. Regardless of the approach used, offer foods to infants only when they are hungry. Never pressure them overtly or covertly to eat if they do not want to. Do not use foods to soothe infants. Last but not least, be flexible at feeding interactions with infants and explore a wide variety of foods and food texture provided they are safe.16, 17,18

Feeding children is challenging especially in the transitional feeding period. Child health workers should offer assistance to parents when they encounter problems in food choice or difficulty in feeding.

Family Health Service organizes public health talks (in Cantonese only) delivered by dietitians for parents and caregivers on feeding infants of 6-11 months regularly. Please click on the following link for details.

http://www.fhs.gov.hk/tc_chi/main_ser/healthtalk_timetable.html

Reference:

  1. Rapley G, Murkett T. Baby-led weaning: Helping your baby to love good food. Random House; 2008.
  2. Wright CM, Cameron K, Tsiaka M, Parkinson KN. Is baby-led weaning feasible? When do infants first reach out for and eat finger foods? Matern Child Nutr 2011;7(1)27-33. Retrieved from: https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1740-8709.2010.00274.x
  3. Carruth BR, Skinner JD. Feeding Behaviors and Other Motor Development in Children (2–24 Months). J Am Coll Nutr. 2002 Apr;21(2):88-96. Retrieved from: https://www.tandfonline.com/doi/abs/10.1080/07315724.2002.10719199
  4. Cameron SL, Heath A-LM, Taylor RW. Healthcare professionals' and mothers' knowledge of, attitudes to and experiences with, baby-led weaning: a content analysis study. BMJ Open 2012;2:e001542 Retrieved from: https://bmjopen.bmj.com/content/2/6/e001542.short
  5. Morison BJ, Taylor RW, Haszard JJ, Schramm CJ, Erickson LW, Fangupo LJ, Fleming EA, Luciano A, Heath AM. How different are baby-led weaning and conventional complementary feeding? A cross-sectional study of infants aged 6–8 months. BMJ Open 2016;6:e010665. Retrieved from: https://bmjopen.bmj.com/content/6/5/e010665?utm_source=trendmd&utm_medium=cpc&utm_campaign=aim&utm_content=Journalcontent&utm_term=TrendMDPhase4
  6. Office of Dietary Supplements, National Institutes of Health. US. Dietary Reference Intakes (DRIs): Recommended Dietary Allowances and Adequate Intakes, Elements. Retrieved from: https://ods.od.nih.gov/Health_Information/Dietary_Reference_Intakes.aspx
  7. Brown A, Jones SW, Rowan H. Baby-Led Weaning: The Evidence to Date. Curr Nutr Rep 2017; 6:148–156 DOI 10.1007/s13668-017-0201-2 Retrieved from: https://link.springer.com/article/10.1007/s13668-017-0201-2
  8. Taylor RW, William SM, Fangupo LJ, Wheeler BJ, Taylor BJ, Daniels L, Fleming EA, McArthur J, Erikson LW, Davies RS, Bacchus S, Cameron SL. Effect of a Baby-Led Approach to Complementary Feeding on Infant Growth and Overweight. A Randomized Clinical Trial. JAMA Pediatr 2017 Sep 1;171(9):838-846. doi: 10.1001/jamapediatrics.2017.1284. Retrieved from: https://jamanetwork.com/journals/jamapediatrics/article-abstract/2634362?redirect=true
  9. Daniels L, Heath ALM, Williams SM, Cameron SL, Fleming EA, Taylor BJ, Wheeler BJ, Gibson RS, Taylor RW. Baby-Led Introduction to SolidS (BLISS) study: a randomised controlled trial of a baby-led approach to complementary feeding. BMC Pediatrics 2015; 15:179 DOI 10.1186/s12887-015-0491-8 Retrieved from: https://bmcpediatr.biomedcentral.com/articles/10.1186/s12887-015-0491-8
  10. Cameron SL, Taylor RW, Heath AL. Development and pilot testing of Baby-Led Introduction to SolidS - a version of Baby-Led Weaning modified to address concerns about iron deficiency, growth faltering and choking. BMC Pediatrics 2015; 15:99 DOI 10.1186/s12887-015-0422-8 Retrieved form: https://bmcpediatr.biomedcentral.com/articles/10.1186/s12887-015-0422-8
  11. Daniels L, Taylor RW, Williams SM, Gibson RS, Fleming EA, Wheeler BJ, Taylor BJ, Haszard JJ, Heath AM. Impact of a modified version of baby led weaning on iron intake and status: a randomised controlled trial. BMJ Open 2018; 8:e019036. doi:10.1136/bmjopen-2017-019036 Retrieved from:

    https://bmjopen.bmj.com/content/8/6/e019036.long

  12. Daniels L, Taylor RW, Williams SM, Gibson RS, Samman S, Wheeler BJ, Taylor BJ, Fleming EA, Hartley NK, Heath AM. Modified Version of Baby-Led Weaning Does Not Result in Lower Zinc Intake or Status in Infants: A Randomized Controlled Trial. J Acad Nutr Diet. 2018 Jun;118(6):1006-1016.e1. doi: 10.1016/j.jand.2018.02.005. Retrieved from: https://www.sciencedirect.com/science/article/pii/S2212267218301606
  13. Fangupo LJ, Heath AM, William SM, Erickson Williams LW, Morison BJ, Fleming EA, Taylor BJ, Wheeler BJ,Taylor RW. A Baby-Led Approach to Eating Solids and Risk of Choking.Pediatrics. 2016 Oct;138(4). pii: e20160772. Epub 2016 Sep 19. Retrieved from: http://pediatrics.aappublications.org/content/138/4/e20160772
  14. Family Health Service, Department of Health. How can we make mealtime enjoyable? Healthy Eating for 6 to 24 month old children (1) Getting Started. 2017. Retrieved from: http://www.fhs.gov.hk/english/health_info/child/14727.html#09
  15. Family Health Service, Department of Health. Understand babies' signs of hunger and fullness. Healthy Eating for 6 to 24 month old children (1) Getting Started. 2017. Retrieved from: http://www.fhs.gov.hk/english/health_info/child/14727.html#10
  16. Family Health Service, Department of Health. Healthy Eating for 6 to 24 month old children (1) Getting Started. 2017.
  17. Family Health Service, Department of Health. Healthy Eating for 6 to 24 month old Children (2) Moving On (6 – 12 months). 2017.
  18. Family Health Service, Department of Health. Healthy Eating for 6 to 24 month old children (3) Ready to go (12- 24 months). 2017.