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A baby-led approach to introducing solids – a good idea?

Rachael Taylor Research Associate Professor

Current MoH complementary feeding guidelines

•  Wait until around 6 months •  Give milk feed first until baby is 8-9 months •  Start with pureed food, then progress

to mashed -> chopped -> whole •  Introduce one food at a time - try a new food

every 2-4 days •  Can introduce finger foods from 8-9

months •  Baby should be eating family food

by 12 months or so

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Baby-led weaning What about baby-led

weaning?

•  self-feed right from the start of complementary feeding

•  uses whole foods

•  families eat together

•  share family foods

Basic principles How BLW differs from conventional feeding

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(http://www.health.govt.nz/your-health/healthy-living/food-and-physical-activity/nutrition/baby-led-weaning: version current 11 May 2015 )

Proposed benefits

•  Improved appetite control -> obesity prevention?

•  More varied food intake •  Less food fussy •  Family interaction during meal times •  Better fine motor skills

Cameron  et  al  BMJ  Open  2012;2:e001542  

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Proposed disadvantages

•  Infants will be at increased risk of – choking –  iron deficiency – growth faltering

•  Dependent on food choice – not all handheld foods are healthy

•  Mess

Cameron  et  al  BMJ  Open  2012;2:e001542  

“The best thing is that an adult can eat their meal while the child is having theirs. There's no juggling trying to feed the baby while shoving a spoonful for yourself” (GP)

“I think it's healthier that the baby is in control of what they eat… and you aren't forcing them to eat...there's far too many of us who just finish our plates instead of stopping when we are full” (dietitian)

“The BLW method could have real advantages for coping with food and learning to eat i.e. for oral development. If babies are fed purées for too long they miss important windows for introducing different food textures” (speech-language therapist)

“Young children arrive here and they're under-two eating twisties, chocolate biscuits—would BLW be that for some mothers?” (practice nurse)

Cameron  et  al  BMJ  Open  2012;2:e001542  

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What do we know about BLW?

Matern  Child  Health  2011;7:34  

•  Mothers tend to be more educated and in higher paid jobs, but also less likely to return to work before 12m

•  breastfeed for longer (129 vs 85 days, P<0.001) and introduce complementary foods later (22.6 vs 19.9 weeks, P<0.001)

•  Infants fed by a spoon or with purees –  less likely to sit with family –  less likely to eat same foods –  offered more meals (3.3 vs 2.2, P<0.001) –  and less milk feeds (4.3 vs 5.9, P<0.001) –  consume more food (estimated by mother)

Almost 1/3 of NZ children are overweight or obese by the time they are only 2-4y

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10  

15  

20  

25  

30  

35  

40  

2-­‐4   5-­‐9   10-­‐14  

%  

Girls  

Boys  

NZ  Health  Survey  2011/12  Age  (years)  

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What is energy self-regulation?

•  Eating to your appetite

•  Young infants do this very well – if change density of formula (kJ/ml) -> infants change volume consumed -> similar overall energy

•  By 2-4 years of age children seem to lose or ignore this ability

Babies are eating more than they need from the start of weaning

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200  

400  

600  

800  

1000  

1200  

1400  

4-­‐6   7-­‐11   12-­‐24  

kcal  

Age  (months)  

Intake  

Requirement  

JADA  2004;104:S14  

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Eating behaviour at 18-24 months according to weaning style

ConvenDonal   BLW   P  

Food  responsiveness   3.18  (0.45)   2.85  (0.50)   <  0.001  

SaQety  responsiveness   2.42  (0.38)   2.61  (0.43)   <  0.05  

Food  fussiness   3.03  (0.32)   3.26  (0.37)   <  0.05  

Enjoyment  of  food   1.84  (0.73)   1.91  (0.86)   NS  

Data  from  298  parQcipants  Recruited  when  infants  were  6-­‐12  months  of  age  Self-­‐defined  as  BLW  or  convenQonal  

Pediatr  Obes  2015;10:57  

Does weight differ between conventionally and baby-led fed infants?

•  Brown et al (18-24m) – n = 135 conventional, 163 BLW – 12.86 (3.73) kg vs 11.89 (3.53) kg, P < 0.05

•  Townsend et al (20-78m) – n = 63 conventional, 92 BLW – UK BMI percentile 65th vs 54th, P = 0.05 – CDC BMI percentile 61st vs 49th, P = 0.009

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What don’t we know about BLW?

•  Whether they regulate their energy intake better •  What their growth is like •  Much about what they are eating – are family meals

always the right choice? •  Is choking is a real concern? •  How easy is it for families

to follow? •  Do they get enough iron?

BLISS study

•  Baby-Led Introduction to SolidS

•  Form of BLW modified to address concerns with choking, growth faltering, iron deficiency

•  RCT to determine whether a baby-led approach to complementary feeding improves energy self-regulation and prevents overweight without having a detrimental effect on iron status

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Pilot - iron intakes can be improved and risk of choking decreased with

Bliss compared with BLW

Mean  (SD)  serves/day   BLW   Bliss   P  n   4   4  High  iron  foods   0.7  (0.05)   2.4  (0.05)   0.001  High  energy  foods   5.9  (1.7)   6.3  (3.3)   0.836  Low-­‐energy  foods   3.8  (1.7)   5.8  (1.0)   0.229  High  choking  risk  foods   3.2  (1.6)   0.2  (0.2)   0.027  

Cameron  et  al.  BMC  Pediatric  2015  (in  press)  

Data  from  3  day  weighed  diet  records  

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BLISS   Usual care  

Ante-natal 1 week

1, 3.5 m

5.5, 7, 9 m

12 months

24 months

Group education Lactation consultant visit Lactation consultant visit

BLISS consultant visit

Main outcomes

Follow-up

Standard Well Child Care Main outcomes

Follow-up

206 women recruited from Queen Mary Maternity Hospital  

Principal  InvesDgators:  Assoc  Prof  Rachael  Taylor  and  Dr  Anne-­‐Louise  Heath  

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Image credits: 1) Yoshihide Nomura, https://www.flickr.com/photos/yoshimov/68668544, 2) Simon Wheatley, https://www.flickr.com/photos/simonwheatley/10765673446, 3) Gail_thepinkpeppercorn, https://www.flickr.com/photos/gail_thepinkpeppercorn/5446409558, 4) Simon Wheatley, https://www.flickr.com/photos/simonwheatley/10837405016, used under CC BY 2.0

BLISS in a nutshell

1. Start by offering foods that are adult finger-shaped. Your baby will find food easier to grasp if it is a stick or finger size and shape. Pieces of food should be long enough so that your baby can hold it and there is still some of the food sticking out the top of their closed fist. Check the food is cooked enough by trying a piece yourself – you should be able to squash it on the roof of your mouth with your tongue – if you can’t then cook it a bit longer and test again.

2. Always include your baby at meal times just as you would other family members. Talk to them as they explore and eat their food and have some eye contact. Don’t feel you must talk to your baby about everything they eat or make eye contact all the time.

3. Offer a variety of foods from the resources including one energy rich food and one high iron food at each meal. Wherever possible, offer your baby the same foods that the rest of the family is eating, so that he feels part of what is going on. Offer three or four different foods at a meal (e.g carrot, beef strip, cheese stick) and start with one piece of each food. You can always offer your baby “seconds”. Loading up your baby’s highchair with all sorts of foods will overwhelm him and there may be a lot of waste.

Offer your baby food when she‘s happy and content – following a milk feed for babies until 8-9 months. In the early days it can be tricky coordinating a suitable time for the family meal and when your baby is awake and content. Don’t expect this to fall into place immediately but as you progress you’ll find a routine that suits all of you.

Babies enjoy variety. Offer different foods or you can serve the same foods in different shapes or forms.

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blissbliss

Department of Human Nutrition, Department of Medicine and Department of Women’s and Children’s HealthUniversity of OtagoP. O. Box 56, DunedinEmail: bliss@otago.ac.nz Phone: (03) 471 6063

version 23.7.2015Image credit: 5) Gail_thepinkpeppercorn, https://www.flickr.com/photos/gail_thepinkpeppercorn/5553282848, 6) Rachel Coleman, https://www.flickr.com/photos/rmc28/3435379497, used under CC BY 2.0

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4. Avoid hurrying your baby. Allow her to decide the pace. In particular, don’t be tempted to ‘help’ her by putting things in her mouth for her.

5. Avoid offering ‘fast’ foods or foods that have added salt or sugar.

6. Always follow the basic safety rules

• Ensure that your baby is supported in an upright position – never leaning back – while he is eating. In the early days you can sit him on your lap, facing the table.

• Don’t leave your baby alone with food. Ever!

• DON’T offer foods such as peanuts, popcorn, whole grapes or any food in a coin shape – she may choke.

DON’T Expect:• Your baby to eat any food on the first few occasions. Once he has discovered

that these new toys taste nice, he will begin to suck, chew, and later, to swallow.

• A young baby to eat a whole piece of food at first as she won’t yet have developed the ability to get at food inside her fist.

• A young baby to have a perfectly “balanced” diet. There may be times when you think she is being a fussy or picky eater. Try to relax and allow your baby to explore foods, as they become more familiar with food and eating their acceptance of new tastes and texture will increase.

Do try rejected foods again later. Sometimes it can take up to ten attempts (at different meals) before your baby accepts a new food.

You may find yourself thinking “eat more” or “please eat some veges”. It’s normal for a parent to want the best for their child but resist putting food in your baby’s mouth. Babies are very good at regulating their own appetite so will eat as much as they need. As long as you continue to offer healthy nutritious foods your baby, in time, will learn healthy eating patterns.

Savoury vege loaf Cereal is the surprise ingredient which gives this meatloaf-style dish great texture and taste.

360g box Special K cereal, crushed500g low-fat cottage cheese1 medium onion, fi nely chopped6 mushrooms, thinly sliced1 capsicum, diced1 courgette, grated1 carrot, grated3 teaspoons dried sage1 teaspoon dried rosemary1 teaspoon salt3 Tablespoons peanut butter5 eggs6 Tablespoons baby rice

MethodPreheat oven to 180º Celsius. Mix all ingredients together in a large mixing bowl until moist.Press mixture into two greased 21 x 11cm loaf tins or a square 21cm cake tin. Bake for 45 minutes to 1 hour, until the centre feels fi rm when pressed.Cut in slices and serve with brown gravy or mushroom sauce, steamed vegetables and a large green salad. Garnish with chopped parsley.Serves 8.

Making this meal baby friendlyCut savoury vege loaf into pieces such as squares that are manageable for your baby to pick up.Serve with some avocado, and any other cooked vegetables that you have in the fridge.

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Beef stir fry2 carrots, peeled and sliced into small sticks1 capsicum, cut into sticks1 cup of green beans1 head of broccoli2 Tablespoons of oil1 large red onion chopped2 cloves of garlic, peeled, crushed or chopped500g beef sliced thinly1 teaspoon of soy sauce1 heaped teaspoon of ground ginger1 Tablespoon cornfl our1 cup (approx) water that is drained off the vegetables

MethodLightly boil carrots until just crisp. Add capsicum and green beans and take off heat. Place lid on pot and put aside.Chop broccoli into pieces that your baby will be able to pick up. Lightly steam broccoli and put aside.In a large wok or fry pan over a hot element stir-fry onion and garlic in oil.Add meat and continue cooking, stirring until meat is tender.Add soy, ginger and cornfl our and stir into the meat. Drain water from the boiled vegetables into a bowl.Add about 1 cup of this vegetable cooking water to the meat. Continue stirring until it makes a runny sauce.Add carrots, beans and broccoli. Mix all ingredients and serve with pasta or rice. Serves 4.

Making this meal baby friendlyThis meal can be served as is because your baby will be able to pick up pieces of vegetable and meat.Until your baby has got the hang of picking up small pieces of food with her thumb and fi rst fi nger, or is using cutlery, serve the stir fry with pasta spirals instead of rice.

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“Stir-fry is a great meal for our family, we have always loved stir-fry and it’s a meal that lends itself nicely to BLISS. We love watching Jane as she eats the rice, her pincer grip is so delicate!” (Grace, mother of Jane 10 months)

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Month  

Antenatal                    2                                      4                                    6              7              8              9                                          12                                                                            24  

Demographics  Feeding  intenQons  

Breas_eeding,  complementary  feeding,  mess,  convenience,  adherence  

BMI   BMI   BMI  

Weight  

Choking  

Energy  self-­‐regulaQon  

Weighed  diet  records,  food  preferences,  behaviours  

Iron  and  Zinc  status  

Fine  motor  skills  

Stool  samples  -­‐  microbiota  

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A) How to fill out your Food Diary

Answer step 1 to step 6 for everything your child eats and drinks, when s/he eats and drinks it. Please don’t rely on your memory at the end of the day.

Record the amount and description of ALL foods and drinks consumed — all meals and all snacks.

Begin each new day on its labelled page, (for example, Day 1). Remember each day starts at midnight and ends the following midnight. So please remember to record feeds that occur at night.

Use a new line for each food or drink. (You can use more than one line for a food or drink, but please start each new food or drink on a separate line).

Also please remember to include any additions to foods (for example, tomato sauce, salad dressing, gravy).

Step 1 Step 2 Step 3 Step 4 Step 5 Step 6

Time of day

Name of food or drink

Brand of food or drink Cooking method Weight of plate/mug

Weight of food/drink + plate/mug

Consistency of food/drink item

Food/drink was put in child’s mouth by: Weight of leftover

+ plate or mug

Estimation of what is left on

platePuréed Mashed Diced Whole Parent Child

Please write down the time your child had something to eat, or drink, including am or pm.

Describe the food or drink.

Name the brand. If the food was cooked write down how it was cooked (roasted, steamed, fried).

If the food was coated in something or you added things like sauce or butter please record this.

If a recipe was used to make a dish please write “see recipe” and write out the recipe on the page labelled “Recipes”.

1) Weigh an empty plate or mug using the scales provided.

2) Write down the weight.

1) Place the first food or drink on the plate/mug on the scales.

2) Write down the weight.

3) If you add several foods to the same plate you will need to write down the weight after each food is added.

Please tick the option that best describes the consistency of the food/drink item.

Please tick the option that best describes who put each food/drink in child’s mouth.

After your child has eaten their meal place the same plate or mug with all the leftovers on the scales and write down the total weight of the food or drink and the plate or mug.

Estimate how much of each food was left over (for example, 1 tablespoon mince, half the potato).

“Leftovers” are everything your child doesn’t eat so please try and scrape everything your child didn’t eat back on to the plate and weigh.

Adherence will be measured using WDR

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Assessed for eligibility (n = 1900)

Potentially eligible (n = 1061)

Excluded (n = 839) Lived out of town (n = 582) Mother < 16 years of age (n = 7) No longer pregnant or midwife advised not to ask (n = 50) > 34 weeks (n = 200)

Excluded (n = 96) Not staying in Dunedin for 2 years (n = 29) Born before 37 weeks (n = 18) Excluded for other health reasons (n = 40) Other (n = 9)

Gave consent and randomised (n = 214)

Declined (n = 673) Non-contactable (n = 78)

Allocation

Had missing data (n = 11) Lost to follow-up (n = 8) Did not attend (n = 3)

Analysed (n = 94) Received intervention (n = 90) Discontinued intervention (n = 4)

Analysis

Allocated to Bliss - initial (n = 108) Excluded post-birth (n = 3) Allocated to Bliss – final (n = 105)

Had missing data (n = 17) Lost to follow-up (n = 11) Did not attend (n = 6)

Analysed (n = 84) Received intervention (n = 83) Discontinued intervention (n = 1)

Allocated to Control - initial (n = 106) Excluded post-birth (n = 5) Allocated to Control – final (n = 101)

Gave consent and randomised

(n = 214) 24% response rate

Analysed (n = 94) Retention 90%

Analysed (n = 84) Retention 83%

Results from the BLISS study

•  We are currently analysing the 12 month outcomes

•  We expect these to be published later this year/early next year

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Acknowledgments

•  Dr Anne-Louise Heath (co-PI) •  AP Sheila Williams, Prof Barry Taylor, Dr Ben

Wheeler (co-investigators) •  Sonya Cameron, Lisa Daniels, Louise Fangupo,

Brit Morison, Liz Erickson, Sabina Bacchus (postgraduate students)

•  Jen McArthur, Liz Fleming, Rhondda Davies, Eloise Williams, Sara Boucher (staff)

•  Funding – MLA, KPS, Perpetual Trustees, Lotteries Health, University of Otago, NZ Federation of Women’s Institutes