CRITICALLY APPRAISED TOPIC TITLE: AUTHOR Date CLINICAL...

CRITICALLY APPRAISED TOPIC

TITLE:

What are the effects of baby-led weaning on global childhood development in children less than 3 years of age?

AUTHOR

Prepared by: Olivia Meyers, Erin Oakley, Sara Brockman, Joe Brooks, Hannah Spencer, Hannah Rennolds, Taylor Schwab, Katherine Howe, Meg Milan

Date 10/22/18

Reviewed by: Carole Ivey, PhD, OTR/L

CLINICAL SCENARIO

Feeding is an essential activity of daily living (ADL) for everyone, especially children, as it is crucial for proper growth and development. Baby-led weaning (BLW) is a specific feeding method in which the traditional step of

spoon feeding is skipped when transitioning from breast milk or formula, and instead babies are encouraged to

self-feed solid foods. It is important for occupational therapists (OTs), especially those working in early intervention, to understand not only the process, but also the risks and benefits associated with various feeding methods. This baseline understanding should be used when discussing feeding options with questioning parents, who may have been exposed to the concepts through various outlets, some of which may lack reliability. Additionally, parents may not know how to search or have access to the most credible or up to date information so the occupational therapy practitioner can bridge this gap. In order to be evidence-based practitioners, research should be assessed to determine the effect that baby-led

weaning could pose on global development, which will inform best practice and help families make informed choices about what feeding approach(es) to implement.

FOCUSED CLINICAL QUESTION

What are the effects of baby-led weaning on global childhood development in children less than 3 years of age?

SUMMARY OF SEARCH

From the literature search, seven articles were identified that met the inclusion and exclusion criteria, including 3 RCTs (level I), 2 cross-sectional studies (level II), and 2 qualitative studies (level IV). From the initial search, three articles were identified as best evidence for the effects of baby-led weaning on global childhood development in children less than 3 years of age. The study conducted by Arden and Abbott (2015) was helpful in understanding the BLW experience from the point of view of this group of mothers and gave insight to benefits and challenges that would be important to

discuss with parents who may be considering BLW. There was not a significant difference in body mass index (BMI) between children who participated in spoon feeding versus baby-led weaning, and children who participated in baby-led weaning showed less food fussiness and greater food enjoyment (Taylor et al., 2017). Additionally, mothers that utilized a baby-led weaning approach to feeding indicated the importance of food enjoyment when introducing their children to solid foods (Arden & Abbott, 2015). Furthermore, children that participate in baby-led weaning show increased independence and family involvement during mealtime (Arden

& Abbott, 2015; Morison et al., 2016).

Key points for future research: ● Examining the effects and findings for infants who use baby-led weaning without modifications or

additional supports and with a more diverse group of participants. ● The nutritional outcomes for children following a baby-led weaning approach due to a delayed

introduction to solids, consisting on longitudinal data ● The impact of baby-led weaning on the rate of choking, nutrition, and growth using a larger, and more

representative, sample size. ● Oral-motor and fine-motor development for children that participate in baby-led weaning versus total

spoon feeding.

CLINICAL BOTTOM LINE

It is within OT’s scope of practice to educate parents on the development of feeding skills and offer advice on feeding strategies. Subsequently, it is important to be knowledgeable about the research on its effectiveness to

be evidence based practitioners and to offer caregivers the best available evidence. Evidence shows that BLW creates some nutritional differences when compared to traditional spoon-feeding, such as more saturated fat but less iron, vitamin B12, and zinc. Research also shows that BLW increases feeding independence and

decreases food fussiness, but there are no differences in energy intake, BMI, or risk of choking. Ultimately, more research needs to be done on the connection between BLW and development to answer this clinical question. Future research to benefit OT could include global child development, functional performance, and their relation to feeding method. As practitioners, we can support the families that we work with in the feeding choices they make, whether they choose spoon-feeding or BLW, or a combination of methods.

This critically appraised topic has been peer-reviewed by a course instructor as part of a university assignment.

SEARCH STRATEGY

Terms used to guide the search strategy

● Patient/Client Group: Children who have undergone the baby-led weaning (BLW) intervention by 3 years old

● Intervention (or Assessment):baby-led weaning, baby-led feeding, Baby-Led Introduction to SolidS (BLISS), complementary feeding, auto weaning, self-weaning

● Comparison: N/A

● Outcome(s):Global child development, including oral motor skills and fine motor skills

Databases and Sites Searched Search Terms Limits Used

CINAHL Complete

Baby-led weaning

________________________

Baby-weaning OR baby-led

feeding AND development

● English Language

● Full Text

● Published: September 2008-September 2018

____________________


● Full Text


PubMed Baby led weaning AND

development


● Full Text


Academic Search Complete Baby led weaning AND

development

Google Scholar Baby-led weaning ● Published within 10 years

Child Development and

Adolescent Studies

Baby led weaning AND

development

TRIP “Database” - website Baby led weaning

Web of Science Baby led weaning ● English Language

● Full Text


Ovid Baby led weaning ● Published 2008-2018

Cochrane - Baby led weaning

- Baby led weaning AND development

- Baby led weaning OR baby led feeding AND development

● Published prior to 2008

AJOT - Baby led weaning

- Baby led feeding

- Infant feeding

- Complementary feeding

● Published prior to September 2008

INCLUSION and EXCLUSION CRITERIA

Inclusion Criteria

● Included studies must have similar feeding culture to the United States

● Included studies must be published within the last 10 years

Exclusion Criteria

● Study was published more than 10 years ago

● Study was published in a language other than English

RESULTS OF SEARCH

A total of _7_ relevant studies were located and categorised as shown in Table 1 (based on Levels of Evidence, Centre for Evidence Based Medicine, 2011)

Table 1: Summary of Study Designs of Articles Retrieved

Study Design/Methodology of Articles Retrieved

Level Number Located Author (Year)

Randomized Controlled Trial I 3 Taylor, R., Williams, S., & Fangupo, L., 2017

Daniels, L., Williams, A., Cameron, S., Flemming, S., Taylor, E., & Taylor, B., 2015

Fangupo, et. al. 2016

Qualitative (phenomenology) N/A 2 Arden, M. & Abbott, R., 2015.

Brown, A. & Lee, M., 2011.

Cross Sectional Study II 2 Morison, B., Taylor, R., Haszard, J., Schramm, C., Williams Erickson, L., Fangupo, L., Fleming, E., Luciano, A., Heath, A-L., 2016. Cameron, S. L., Taylor, R. W., & Heath, A. M., 2015.

BEST EVIDENCE

The following study/paper(s) were identified as the ‘best’ evidence and selected for critical appraisal.

A) “Experiences of baby-led weaning: Trust, control and renegotiation.” by Arden, M. A., & Abbott, R. L.

B) “Effect of baby-led approach to complementary feeding on infant growth and overweight A randomized clinical trial” by Taylor, R.W., Williams, S.M., Fangupo, L.J., Wheeler, B.J., Taylor, B.J., Daniels, L., Fleming, E.A., McArthur, J., Morrison, B., Erickson, L.W., Davies, R.S., Bacchus, S., Cameron, S.L., Heath, A.-L.M.

C) “How different are baby-led weaning and conventional complementary feeding? A cross-sectional study of infants aged 6–8 months.” by Morison, B. J., Taylor, R. W., Haszard, J. J., Schramm, C. J., Williams

Erickson, L., Fangupo, L. J., Fleming, E. A., Luciano, A.,Heath, A.-L. M.

Reasons for selecting these studies were:

➢ Highest level of evidence (Level 1 RCT)

➢ Recent - within 10 years

➢ Qualitative research in order to provide additional perspectives to support higher levels of evidence

SUMMARY OF BEST EVIDENCE

Table 2A: Description and appraisal of “Experiences of baby-led weaning: Trust, control and renegotiation.” by Arden, M. A., & Abbott, R. L. (2015)

Aim/Objective of the Study/Systematic Review:

The study aimed to investigate the experiences of mothers in the United Kingdom (UK) that used a baby-led weaning (BLW) approach. Specifically, the researchers wanted to look at the relationship between mother and

infant to better understand the overall approach of BLW and the beliefs that drive parents to attempt it, and finally the overall benefits and challenges of the approach.

Study Design

Design: Qualitative, Phenomenological Design: the study sought to understand the lived experience of mothers who had attempted BLW.

Level IV Evidence

Methods: Semi-structured interviews were used, and took place over the course of 5 emails between each subject and the researcher. In the appendix of the article the researchers included the questions that were included in each of the emails. The questions in the first four emails were all the same for each of the participants, and the fifth email included questions that were based on the responses that the interviewers

received from the first four emails.

Data Collection: The semi-structured interviews were conducted via email. Each email contained a set of questions which were asked to be completed in the subjects’ own time. The first four emails were sent with

planned questions and the fifth and final email was sent with follow-up questions only that pertained to the answers of the first four. A reminder email was sent after a week of no reply, if no response was received after

another 2 weeks then the participant was labeled withdrawn. After the response to the final email the participant was sent a debriefing email and a voucher. At the end of the paper the researchers declared that they had no conflicts of interest that would have interfered with the study. As there was no intervention, there was no need to blind participants or researchers. Based on the review of the article there may have been selection bias due to the researchers’ sole recruitment

strategy being on a volunteer basis, which could have led the participants to be more positive and willing to participate. This similarly relates to the probability that some sampling bias could also be apparent because the population selected is very homogenous in both social class and level of education. Data Analysis: The data were organized using an inductive, data-driven process. All identifying features (names, DOB, etc.) were removed before the data was analyzed using NVivo8 software. After the initial reading of the email transcripts, the emails were re-read and annotated with initial ideas for codes. The data were

organized into 90 codes based on the research questions. Codes were then categorized into potential themes and organized into a “thematic map” and merged by the researchers based on repetitions. The researchers

listed four final main themes and each of these had several subthemes beneath it. The four main themes were: trusting the child, parental control and responsibility, precious milk, and renegotiating BLW.

Setting

The study took place via email correspondence between the researchers and the participating mothers.

Participants

The participants were recruited via advertisements on internet parenting sites and forums which had an emphasis on baby-led weaning as well as some without to include a wider range of participant knowledge. The participants were asked to email the researchers if interested and were promised a 10 pound voucher as a

thank you at the end of the study.

Inclusion Criteria: The inclusion criteria included that parents: (1) had tried BLW, (2) had an infant between

9-15 months, and (3) were currently living in the UK. 27 women emailed for information, 25 consented, and 15 completed the whole interview process.

Exclusion criteria: not explicitly stated in the article.

Main Themes

The researchers listed four final main themes and each of these had several subthemes beneath it. The four main themes were: trusting the child, parental control and responsibility, precious milk, and renegotiating BLW.

Original Authors’ Conclusions

The overall conclusions of the study pointed to two main reasons that BLW was attempted: traditional weaning attempts had failed or it was a part of their parenting philosophy. The experiences of these mothers that participated in the study also yielded two largely contrasting themes: trusting the child versus parental control. BLW required that parents both let their children explore foods but also offer them a healthy selection from

which to choose and monitor them closely while they explore and attempt to eat it. It was a common thread among mothers that they were nervous about whether or not their children would self-select nutritious foods and if they would get enough sustenance from solid foods if they weren’t actually ingesting very much. It was also a common theme among parents to adjust to the notion that “food before [age] one is just for fun” and that letting their children play with food was an important part of introduction to solids. Many of the children that underwent BLW showed high levels of independence, refusing to be spoon-fed.

BLW also did not mean that the infants were no longer receiving milk or formula from their mothers. This should continue until at least the first year to ensure that the children are receiving adequate nutrition.

Incorporating BLW and breast/bottle feeding provides double the chance for mother-infant bonding during mealtime which correlated with a parent report of strong attachment with their children in the study. Finally, and very importantly, there were several practical limitations that were discussed by parents regarding BLW. The approach can be very messy because children often play with the foods they are being introduced to. Food

selection, set up, and clean up are therefore important to mealtime as well. Some mothers also noted difficulties carrying over practices that they were implementing at home and what was being done at daycare. Lastly, some mothers had a different definition of BLW and how it should and can be combined with traditional weaning to be inclusive to all infants and meet them at their developmental levels.

Critical Appraisal

Rigor

Procedural Rigor: The researchers provided a very detailed description of how the data was both collected and analyzed as demonstrated by their thoroughly mapped out decision trail. No formal training was mentioned for the researchers, and as there was no specific site for the study (conducted via email); this was also not discussed. Because the interviews were conducted via email there was no need for the researchers to take copious amounts of field notes, but instead researchers annotated the email scripts. Data was not collected in more than one manner; emails were the sole form of communication between researchers and participants. There was reading and re-reading of scripts between researchers in order to ensure that initial codes had inter-

reader reliability.

Audibility: The initial themes were categorized in the broadest sense of the research question and not by the individual interview questions, in order to maintain the breadth of knowledge that the study sought to understand. The researchers also made sure that each email transcript was read and annotated and then re-

read and re-annotated to ensure that the initial information being drawn was free of reader bias. By using a software system the researchers ensured adequate organization of topics and the development of a thematic map from 90 initial codes was created. After the initial codes were organized, they were gleaned for repetitions

and merged. However, a second set of eyes was necessary to read through after the collation to ensure that the remaining codes completely covered the breadth of data collected. The codes were then categorized into smaller groups that were related, thus yielding 4 main themes with 5-6 subthemes beneath them in order to encompass any nuances in the data.

Overall Rigor:

Credibility: The study reviewed did have several components that lead to strong credibility. After the last email

of interview questions, the researchers sent a debriefing email to the subjects to ensure their understanding of the study and to be sure that their responses were reflective of their experiences. However, there was no triangulation of results. The researchers only collected data in one form, via email.

Transferability: The findings of the study only represent a rather small portion of the population (mothers in the UK that have attempted BLW) and therefore their experiences are not generalizable to the population of mothers and parents as a whole. These mothers were active on online forums and websites that described BLW

meaning that they probably have some level of education and resources (access to a computer and knowledge

of trending parenting techniques). However, the study does give us an initial idea of how BLW can fit into a household and what the potential parental triumphs and obstacles are.

Dependability: The results of the study were dependable. There is a clear audit trail from the research question to the formation of codes and the findings related with the initial question. The researchers also made sure to explain clearly and in great detail how their data was collected and analyzed.

Confirmability: Data was read by multiple researchers and software was used to limit the opportunity for bias during the coding process. The names and identifying features of the participants were also removed from the data prior to reading so there was no way for researchers to bring prior biases into the reading of emails and transcript annotations.

Reported Limitations: The researchers discussed several limitations that may have impacted the results of

their study. The first is that because the subjects were recruited from online forums it is assumed that they are most likely middle class and educated which may have slightly limited the sample. The researchers did discuss,

however, that most mothers who choose to attempt BLW fit within the demographic of middle class, educated women so this characteristic may not have been limiting. The sample was also self-selecting, so the subjects were motivated and willing to participate in the study which could have had an impact on their responses. In the future, the researchers would recruit participants from a wider range of areas. Finally, because the study required five sets of questions within the email chain it was deemed a “significant commitment” by the

researchers. The study experienced a fairly high dropout rate (10 of the original 27) before the interview was completed. Perhaps if the interviews were completed at a one time, in-person session this level of drop out could have been avoided.

Interpretation of Results

● While the sample size was relatively small, it was of appropriate size for this study. ● There was procedural rigor evidenced by an appropriate level of detail throughout the study and a clear

decision trail allowing for auditability ● Member checking was used to establish credibility; however, triangulation was not used. ● These results represent a small portion of the population in the UK and therefore are not transferable to

all populations. ● Limitations were reported and bias was acknowledged throughout the study.

Clinical Bottom Line Feeding and eating are important occupations addressed by occupational therapists. An understanding of baby-led weaning (BLW) is particularly relevant for an occupational therapy (OT) practitioner working in early intervention because of the population's age range (0-3 years). It is within OT’s scope of practice to educate

parents on the development of feeding skills and offer advice on feeding strategies. OTs working in that setting need to understand the principles of baby-led weaning, the potential benefits and hazards, and the possible long-term effects regarding overall development in order to accurately address parent’s questions and concerns. While this study offers a picture of the lived experience of BLW from a mother’s perspective, it is not intended to compare BLW to traditional feeding or make recommendations for which to use. If further research

does show there are significant short-term and long-term benefits compared to current UK Department of Health guidelines, it could inform new guidelines. This would need to be implemented by OTs in order to

continue being evidence based practitioners by offering families the most current, empirically supported approaches to feeding. Overall, this study illustrates the experience of using this approach to feeding and proves useful information for health professionals working to support parents during this stage.

Summary/Conclusion

The study conducted by Arden and Abbott was helpful in understanding the BLW experience from the point of view of this group of mothers and gave insight to benefits and challenges that would be important to discuss

with parents who may be considering BLW as a weaning approach. Overall, it was clear that the approach to weaning worked differently with each family and following the child’s needs (both nutritional and developmental) was essential.

Table 2B: Description and appraisal of “Effect of baby-led approach to complementary feeding on infant growth and overweight A randomized clinical trial” by Taylor, R.W., Williams, S.M., Fangupo, L.J., Wheeler, B.J.,

Taylor, B.J., Daniels, L., Fleming, E.A., McArthur, J., Morrison, B., Erickson, L.W., Davies, R.S., Bacchus, S., Cameron, S.L., Heath, A.-L.M. (2017)


The objective of this study was to determine if a baby-led approach to weaning, specifically Baby-Led Introduction to SolidS (BLISS), results in lower body mass index (BMI) in children as compared to traditional spoon feeding. The study secondarily examined potential differences in energy self-regulation, eating behaviors, and energy intake between the children.

Study Design

● Randomized control trial (Level I evidence)

● Participants were randomly assigned to either the intervention group or the control group

● Data was collected at various times throughout the study, and the final collection was done when the

child was 24 months old

● Researchers that collected outcomes were blinded to group allocation

Data Analysis:

The researchers first calculated Mean and Standard Deviation for all of the dependent variables being measured. Following this, linear mixed methods were used to estimate the difference (adjusted difference) in BMI and BMI z scores between the BLISS and the control group. Linear regression was used to analyze differences between the two groups for all of the secondary variables. These analysis methods were appropriate given the types of data that were examined in the study.

Setting

This study took place in Dunedin, New Zealand (NZ). Although specific locations for feeding were not reported, it is likely that the feedings took place in the families own homes and communities. The BLISS group had 8 supplemental meetings. Five meetings occurred with an International Board Certified Lactation Consultant (IBCLC); of these meetings 3 were face-to-face and 2 were over the phone. The additional three meetings were held with a specialist to provide information to support the BLW process such as paying attention to cues, providing high energy and iron right foods that are easy to pick up, and how to avoid choking. It is stated that

the 3 meetings with the trained researchers were face-to-face, but there are no other location specifics provided.

Participants

N=206 recruited, 166 were available for the final 24 month analysis

Intervention/BLISS Group=105, 88 participated in the final 24 month analysis

Control/Spoon-fed Group=101, 78 participated in the final 24 month analysis

Mean age of the 206 mothers was 31.3 years.

Women were recruited in late pregnancy from the only maternity hospital in Dunedin, NZ from December 19, 2012 to March 17, 2014.

Eligible women were those who lived locally, were older than 16 years, and were less than 34 weeks pregnant. Children were excluded if they were born prematurely or hand congenital abnormalities that may likely effect

feeding or growth.

The women were then randomized into one of the two groups after stratification of the mothers based on first

or subsequent child and maternal education.

Intervention Investigated

Control

Traditional Spoon-fed group

The intervention for this group was not described in any detail, but it can be gathered that children were fed pureed foods from a spoon by a caregiver. Location for the feedings was not directly stated, but it can be assumed that they took place in the families own homes. This group did not receive any extra services outside

of government funded standard midwife and well-child care, and there was no information on who provided these services or where they took place. Hours of treatment would vary based on length of feedings and wellness visits.

Experimental

Baby-led Introduction to SolidS (BLISS) group

For this intervention, the infant was to feed himself or herself safe solid foods that were typical of the family diet and were introduced at 6 months of age. Location was not specified but likely took place in the families own homes. In addition, parents in this group received 5 sessions from an International Board Certified Lactation Consultant (IBCLC), 3 sessions from a trained researcher providing individualized advice and support, and

additional resources (food ideas, recipe books, and safety information) to support the baby-led approach. Six of

the 8 session were face-to-face but there is no further detail on where these session were held, and two of the 8 session were done over the phone. The length of the meetings with the IBCLC were 10-60 minutes long and the meetings with the trained researchers were 30-60 minutes long. Total hours of treatment would be based on length of feedings and accumulated length of the 8 meetings.

Outcome Measures (Primary and Secondary)

Primary:

BMI and BMI z scores were calculated using weight and length gathered from an electronic scale and a 100-cm

board. The BMI z scores were created using the World Health Organization reference data. This data was

collected when the children were 12 and 24 months of age.

Secondary:

Weeks of exclusive breastfeeding, age when complementary foods were introduced, age when the baby was feeding him or herself regularly, and age when baby was feeding him or herself all of their food was collected from the Brief Feeding Questionnaire (1-5 ranking scale) filled out by parents when their child was 2, 4, 6, 7, 8, 9, 12 and 24 months old.

Whether mother or child made mealtime decisions, caregiver distress score, and whether child was a picky eater was collected from the Toddler-Parent Mealtime Behavior Questionnaire (1-5 ranking scale) filled out by parents when their child was 12 months old.

Satiety responsiveness, Food responsiveness, Food fussiness, and Enjoyment of food was measured with the Children’s Eating Behavior Questionnaire (1-5 ranking scale), which parents filled out when their child was 12 and 24 months of age.

Main Findings


A baby-led approach to weaning does not appear to affect BMI or energy self-regulation in children when compared to traditional spoon feeding. A baby-led approach may have some benefit in children’s attitudes toward food, such as reducing food fussiness. Additional research is needed to examine effects and findings for infants who use baby-led weaning without the modifications or additional supports provided in this study.

Critical Appraisal

Validity

Contamination: Adherence data that was collected found that the children were not strictly fed based on one

feeding practice which indicates some contamination.

Co-intervention: While there is no direct indication that either group received other forms of treatment, there is a likely chance that other guidance and/or services were utilized over the 24-month period. It should also be noted that the BLISS group received extra services from an International Board Certified Lactation Consultant (IBCLC) and from trained researchers. In this study the researchers include these services as part of the

intervention, however this may raise some concern when considering co-intervention as it relates to outcomes.

Timing of Intervention: Timing of the extra sessions was stated and seems appropriate. Likewise, 6-24 months

of age for the utilization of a weaning approach aligns developmentally for the children. The fact that the intervention took place over an 18 month period causes consideration of other reasons for change during that time.

Site of Intervention: With no detail on where the face-to-face meetings occurred, it is difficult to analyze that portion of the intervention. Additionally, actual feedings occurring in family homes introduces much variability in location, setting, and environmental factors.

Use of different therapists for Intervention: For the instructional sessions, parents received education from the

same IBCLC, but used two trained researchers and it was not specified if both were equally utilized with all

parents. Also, with parents as the providers to the children, there would be many natural differences in the specifics of how the feedings were rendered

Memory Bias: The questionnaires that were used to measure many of the secondary outcomes required parents

to recall details that revolved around the feedings including how the child responded and their own levels of stress. It may have been difficult for parents to reflect on some of these items over a period of time and therefor may have altered accuracy.

Interrater reliability may be affected because four different researchers collected data for BMI calculations thus some inconsistencies may be present.

Rater bias: Since parents were aware which group their own child was in there is some possibility that they

filled out the questionnaires based on results that they wanted.


● The researchers found no significant differences in BMI or BMI z scores between the BLISS group and the control group at 12 or 24 months of age.

● Based on parent questionnaires, babies in the BLISS group scored lower on satiety responsiveness at 24 months, but were found to be significantly less fussy and picky about food at 12 months. The BLISS babies were also found to be higher for enjoyment of food at 12 and 24 months old.

● Based on the adherence measures given at 6, 7, 8, 9, 12, and 24 months, the researchers found that babies in the BLISS group were more likely to feed themselves than the control group at every age.

Summary/Conclusion

This two year randomized control trial examined whether or not Baby-led Introduction to SolidS (BLISS), a

complementary feeding practice comparable to BLW, has significant influence on being overweight and secondary outcomes of self-regulation and food fussiness, additional concerns relevant to the field of occupational therapy. Although the article provides information about the meetings and support provided to the BLISS group, it is difficult to distinguish if the feeding practices itself or the educational sessions and guidance provided to the control group were the intervention being analyzed. In addition to the lack of clear interventions, this study does not provide clear rationale for analysis methods, strong evidence to support the

interventions, or ready to implement strategies for occupational therapists. These factors, paired with high levels of bias throughout the study, suggest many limitations exist making it difficult to generalize the findings to potential mothers and families OTs may work with. As one of the only studies discovered in a comprehensive literature search, it is clear more research is needed surrounding the topic of baby-led weaning and developmental outcomes for infants.

Table 2C: Description and appraisal of “How different are baby-led weaning and conventional complementary feeding? A cross-sectional study of infants aged 6–8 months” by Morison, et. al., 2016.


The objective of this study was to evaluate the differences between nutrient and food intake and compare differences in ‘family meals’ for infants following a BLW approach compared to infants following a TSF (traditional spoon-feeding) approach.

Study Design

Level II: three groups, nonrandomized (cross-sectional design)

Based on the mothers’ responses to the type of feeding approach used with their children, the participants were placed into three groups:

- Traditional spoon feeding (TSF) - Partial baby-led weaning (partial BLW) - Full baby-led weaning (full BLW)

No direct intervention was administered during the study. Caregivers followed the feeding method of their assigned group based upon their understanding of that feeding method, with no other intervention provided by the study. Caregivers used this feeding method whenever feeding their child, with the exception of

breastfeeding and bottle-feeding. Questionnaires were used to gain insight about the differences between the groups including: nutrient intake, types of foods eaten, when foods were introduced, and whom the child ate each meal with.

*Note: p-values were calculated to compare group differences using only the TSF and full BLW groups

Setting

The intervention of BLW, partial BLW, or TSF took place in each family’s natural environment in New Zealand. Questionnaires were also completed by caregivers in the natural environment.

Participants

The 51 participants in the study were assigned into one of three groups based upon parent report of feeding

method: TSF (26), partial BLW (7), and full BLW (18). ● Gender:

○ % male = 54% (TSF), 57% (partial BLW), 44% (full BLW)

○ % female = 46% (TSF), 43% (partial BLW), 56% (full BLW)

● Ethnicity:

○ % NZ European = 77% (TSF), 86% (partial BLW), 65% (full BLW)

○ % other = 23% (TSF), 14% (partial BLW), 35% (full BLW)

● Disease/disability diagnosis = ○ N/A (presence of congenital abnormality, physical condition, or intellectual disorder was an

exclusion criteria)

Inclusion criteria

● Infant 6–8 months of age when the Weighted Diet Record (WDR) was completed ● Mother able to communicate in English or Te Reo Maori (the language of the indigenous

people of New Zealand)

● Mother 16 years of age or older

Exclusion criteria

● Infant born before 37 weeks gestation ● Presence of a congenital abnormality, physical condition or intellectual disability likely to affect the

infant’s feeding or growth.

Recruitment

● A total of 51 participants were recruited from three studies – ‘Infant Feeding Study’, ‘How to Measure Infant Feeding’ study, and the control group of the ‘Baby-Led Introduction to SolidS’ study.

● ‘Infant Feeding Study’ Recruitment ○ Newspaper ads, social media, community posters, word of mouth in parent support networks

● ‘How to Measure Infant Feeding’ Study Recruitment ○ Ads on social media, community posters, word of mouth in parent support networks

● ‘Baby-Led Introduction to Solids’ Study Recruitment

○ All women in the Queen Mary Maternity Unit at Dunedin Hospital were invited to participate

Type of Sample

● Purposive

Intervention Investigated

Control

There was no control group in this study, a noted limitation by researchers of the study.

Experimental

There was no experimental group in this study.

Outcome Measures (Primary and Secondary)

Measure 1: The Feeding Questionnaire

- Duration of exclusive breast feeding, age when complementary foods were introduced, extent of infant self-feeding versus parent feeding on first complementary feeding occasion, ages when iron-fortified infant cereal and red meat were introduced, and whether breast milk or formula was currently being consumed

- Reliability and validity were not reported - Completed by caregiver in the natural environment

Measure 2: Weighted Diet Records (WDR)

- Record of foods eaten- time of day, type and brand of food and drink, preparation method, weight of food and drink, consistency of food and drink, who fed the child, total weight and estimated portions of any leftover food or drink

- Descriptions of recipes used- raw amounts of ingredients, cooking method and proportion of the total recipe fed to child

- ‘End of Day Questionnaire’- determined for each meal/snack whether child ate with at least one adult,

and whether the meal ingredients and preparation were the same as or different from the family meal - Reliability and validity were not reported - Completed by caregiver in the natural environment - Blinded registered dietician reviewed and corrected data, when required

Main Findings


Infants following a BLW approach had similar energy intakes compared to those following a TSF approach but appeared to have higher intakes of saturated fat and lower intakes of iron, zinc, and vitamin B12. A high proportion of both groups were offered foods considered to be a high choking risk. BLW infants were eating meals with family members more frequently than the TSF group. The cross-sectional design allowed researchers to get a glimpse into commonalities between the different groups; however, future research is needed that incorporates more clearly defined definitions and feeding guidelines so there can be a more

accurate comparison between groups. Additionally, future research to benefit occupational therapy should expand beyond nutrition and feeding patterns; the focus should include infant and child development and functional performance and their relation to feeding method.

Critical Appraisal

Validity

● Contamination: ○ Although there is no true control group, intervention was implemented by parents and based

upon personal understanding of the different complementary feeding techniques. Differences in interpretation about the approaches could have led to variations in implementation, leading to contamination across the three groups. Having clearer definitions about the approaches prior to

the study or designing a study in which there were standard guidelines to follow could help to limit this bias.

● Co-intervention: ○ Participants were recruited from other complementary feeding studies. It is unclear if

participants were involved in these studies simultaneously. It is also not clear which participants were associated with which study. The intervention from other studies could affect the outcomes of this study, resulting in co-intervention.

● Timing of intervention: ○ Data was collected on one day for some participants versus three days for other participants.

This variation in the timing of the collection methods can lead to variability in responses. Also, the timing of intervention was broken into three main feeding periods: breakfast, lunch, and evening meal. No specific time parameters were given to families nor were the times in which the feedings took place reported in the results, so it is unclear how much variability took place in regard to timing.

● Site of intervention:

○ The intervention took place in the natural setting, most likely the caregivers’ home. This leads to much variability across all participants and groups.

● Use of different therapists to provide intervention:

○ The intervention was provided by the caregiver. The intervention could have been delivered in very different ways depending upon factors such as understanding about the approach and parent personality. Also, it was not addressed who was assisting with the feeding for each child, i.e., just the mother, just the father, a combination, etc., or if this person(s) was consistent or changed over time.

● Baseline Equality:

○ The groups were evenly matched. The researchers were intentional in choosing participants from other studies that fit the needs of their study and the groups were matched according to age, sex, and demographic variables.


Feeding Behaviors

● Most infants in the BLW group fed themselves more than half of their food by 6-8 months compared to the TSF, where feeding was predominately shared between the adult and infant (p <0.001).

Foods

● 69% of participants offered foods to their child thought to pose a choking risk; this was consistent between groups.

● There was no statistical difference between groups in the consumption of fruits (p=0.791), vegetables (p=0.353), or the number receiving commercial baby foods (p=0.393).

Nutrients

● BLW infants had a higher intake of total fat (p=0.042), saturated fat (p<0.001) and percent energy

from fat (p<0.001) compared to the TSF group. ● BLW infants had a lower intake of iron (p<0.001), zinc (p=0.001), vitamin B12(p<0.001), vitamin C

(p=0.001), and dietary fiber (p=0.023) compared to the TSF group. ● There were no differences found between the mean intake of energy (p=0.50), sugar (p=0.067), or

sodium (p=0.911) between groups.

Family Meals

● Full BLW infants were more involved in family mealtime and were significantly more likely to eat with their family during lunch and evening meals (lunch p=0.001, dinner p=0.020)

Limitations of this study include the following: inadequately powered sample, absence of a control group, and limited bias control. The small sample size, consisting of only 51 participants, was a limitation noted by the researchers. This limits the generalizability of the results. The lack of variability amongst group members (i.e.,

majority NZ European) further limits the generalizability. Secondly, the study did not use a control group.

Without a control group, it is difficult to determine whether the intervention of BLW affected outcomes. The interventions were being administered by a variety of individuals (caregivers) with no standard protocol. Furthermore, participants were assigned to groups based upon caregivers’ understanding of the different complementary feeding approaches, rather than having a set definition. Differences in understanding about the approaches as well as personal factors likely led to variations in approaches among similar groups, leading to both intervention bias and timing bias. Lastly, the study was conducted in a different country (New Zealand) with different cultures, a different healthcare system from the United States, and variations in genetic

predispositions; these factors further limit the generalizability of the results.

Summary/Conclusion

The study found that BLW infants were more likely than TSF infants to feed themselves most or all their food and were more likely to eat with a family member at lunch or dinner compared to the TSF infants. There were no differences found between the groups in the energy intake; however, BLW did consume more total, including more saturated fat, and less iron, vitamin B12, and zinc.

While BLW infants in the study ate significantly more meals with an adult and self-fed more, this approach will not meet the needs of every child and family. The exclusion criteria of this study excluded many individuals who would receive occupational therapy services. Occupational therapists working in pediatric settings should not tell families which approach to take, but rather inform and support families while they make the best choice for their child and their family. Occupational therapists can teach family members how to incorporate their infant or child into mealtimes and teach self-feeding strategies, tailored to the child’s needs, no matter what approach the family is following. Future research is needed to better understand the developmental and functional

implications of following a BLW approach.

Table 3: Characteristics of included studies

Study 1

[Arden, M. A., & Abbott,

R. L., 2015]

Study 2

[Taylor et.al., 2017]

Study 3

[Morison et.al., 2016]

Intervention investigated

Design: qualitative phenomenological design

BLISS method of baby-led weaning

Baby-led weaning

Comparison intervention

Participants: 15 mothers who had tried BLW

Traditional spoon feeding Traditional spoon feeding

Outcomes used Methods: structured interview via email

-BMI and BMI z scores -Energy Self-regulation -Satiety Responsiveness -Food Responsiveness -Food Fussiness

-Enjoyment of Food -Mealtime Decisions -Caregiver Distress -Picky Eating

-Energy Intake

-Feeding questionnaire

-Weighted Diet Records (WDR)

Findings Themes: Trusting the Child, Parental Control and Responsibility, Precious Milk, and Renegotiating BLW

-No significant difference in BMI or BMI z scores

-Kids in BLISS group had less food fussiness and greater food enjoyment and

greater likelihood of feeding themselves

-No significant differences in rates of choking, iron deficiency, energy intake or

prevalence of being overweight

-No significant difference in energy intake between infants following BLW approach compared to TSF approach

-BLW infants were eating meals with family members more frequently than the TSF group

-A high proportion of both

groups offered foods considered to be a high

choking risk

IMPLICATIONS FOR PRACTICE, EDUCATION and FUTURE RESEARCH

Practice

- Educate clinicians about baby feeding/weaning approach options, including BLW, and the risks and possible benefits associated with each approach.

- BLW has grown in popularity. Occupational therapists can work with families to provide strategies for adapting the method in a way that works safely for their child in their environment, taking into account

the child’s and family’s unique needs.

- Occupational therapists will be able to answer questions regarding baby-led weaning methods and coach and support families when they choose a method for their child.

Education

- Provide direct education to parents on development of feeding skills, options for feeding practices, and any needed modifications for their child. It is important to consider the desires and individual needs of each family, follow the needs of the child, and to provide support based on these needs and choices.

(Arden & Abbott, 2015) - Provide direct education to parents about choking, hazardous foods, and how to handle choking events.

Further investigation into the BLISS study was done regarding choking and gagging, and no significant

difference was found between baby-led weaning and traditional spoon feeding methods. (Fangupo et. al., 2016) This indicates that fear of choking should not alone be a deterrent for baby-led weaning, however care should be taken to avoid choking hazards regardless of method.

- Provide direct education to parents on the proper nutritional requirements for a developing infants, and ensure that they are receiving a well balanced diet. What constitutes a balanced diet for adults or older children may not be nutritionally adequate for infants and toddlers. (Cameron, Taylor, and Heath, 2015)

- Development of education resources regarding the feeding approaches available, including BLW, risks and possible benefits, how to implement the approach, and modifications of the approach for various infants (More research is needed to provide specific evidence-based recommendations about who would

benefit from the approach, who would not benefit, and how to provide adaptations for individuals with disabilities).

Future Research

- Future research to benefit occupational therapy should include investigation into possible impacts of feeding method on child development and functional performance. Specific areas of research could focus on oral-motor development, fine motor development, engagement in self-feeding, and food

tolerance.

- Look at BLW practices in America, and implications of practice within our healthcare system. - Look at BLW in a more diverse sample of children, including various abilities/disabilities, cultures, and a

broader range of economic and social resources.

REFERENCES

Arden, M. A., & Abbott, R. L. (2015). Experiences of baby-led weaning: trust, control and renegotiation. Maternal &

Child Nutrition, 11(4), 829-844. doi:10.1111/mcn.12106

Brown, A. & Lee, M. (2013). An exploration of experiences of mothers following a baby-led weaning style:

developmental readiness for complementary foods. Maternal & Child Nutrition, 9(2), 233-243. doi:10.1111/j.1740-

8709.2011.00360.x

Cameron, S. L., Taylor, R. W., & Heath, A. M. (2015). 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, 15(1), 1-11. doi:10.1186/s12887-015-0422-8

Daniels, L., Heath, A. M., Williams, S. M., Cameron, S. L., Fleming, E. A., Taylor, B. J., & ... Taylor, R. W. (2015).

Baby-Led Introduction to SolidS (BLISS) study: a randomised controlled trial of a baby-led approach to complementary

feeding. BMC Pediatrics, 151-15. doi:10.1186/s12887-015-0491-8

Fangupo, L. J., Heath, A. M., WIlliams, S. M., WIlliams, L. W. E., Morison, B. J., Fleming, E. A., Taylor, B. J., Wheeler, B. J., & Taylor, R. W. (2016). A Baby-Led Approach to Eating Solids and Risk of Choking. Pediatrics 138(4), 1-10. doi:10.1542/peds.2016-0772

Morison, B. J., Taylor, R. W., Haszard, J. J., Schramm, C. J., Erickson, L. W., Fangupo, L. J., … Heath, A. L. M. (2016). How different are baby-led weaning and conventional complementary feeding? A cross-sectional study of infants aged 6-8 months. BMJ Open, 6(5), 1-11. https://doi.org/10.1136/bmjopen-2015-010665

Taylor, R. W., Williams, S. M., Fangupo, L. J., Wheeler, B. J., Taylor, B. J., Daniels, L., . . . Heath, A.-L., M. (2017). Effect of a baby-led approach to complementary feeding on infant growth and overweight a randomized clinical trial. JAMA Pediatrics, 171(9), 838-846. doi:10.1001/jamapediatrics.2017.1284.

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