Is Baby-led Weaning Safe?

Fangupo LJ, Heath AM, Williams SM, et al. A baby-led approach to eating solids and risk of choking. Pediatrics. 2016;138(4):e20160772;doi:10.1542/peds.2016-0772.

The practice of baby-led weaning as a means of introducing complementary foods has grown in popularity. In baby-led weaning, infants feed themselves graspable pieces from the start of the introduction of solids to the diet. Supporters cite the advantages of a broader palate, better self-regulation, and a greater ease with varied textures. However, there remains concern about the safety of this approach, particularly regarding the risk of choking. Interestingly, despite growing interest from parents and health professionals, there has been little research regarding these fears.
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The Baby-Led Introduction to SolidS (BLISS) was a New Zealand study that was designed primarily to determine whether a modified version of baby-led weaning would assist with obesity prevention. The modifications made specifically addressed the risk of choking, which makes it possible for the current study to examine the potential differences between choking and gagging in baby-led weaning compared with traditional spoon-feeding practices.

BLISS was a 2-year randomized controlled trial. Enrolled infants could not be premature or have a congenital abnormality or disability likely to affect feeding or growth. Those assigned to the BLISS group received additional education and support above the standard, free, early-child health care provided in New Zealand. This education included specific instructions on how to recognize and minimize potential choking episodes, as well as information on differentiating choking from gagging.

Demographics were collected at baseline. Choking and gagging episodes were assessed via questionnaire several times between 6 and 12 months of age and included questions about symptoms, the particular food, and which caregiver was present. Parental supervision was also assessed, along with weighed diet records.

At the 12-month mark, 184 families remained in the study. Results showed that 35% of the infants involved in this study choked at least once between 6-8 months of age, and there were no significant differences between the BLISS infants and the traditionally fed infants. BLISS infants gagged more frequently at 6 months but less than control infants at 8 months. Significantly more BLISS (65%) than control (18%) infants waited until 6 months of age before starting solids (P < .01).

It was also noted that at 7 and 12 months, 54% and 94% of infants were offered food posing a choking risk during the weighed diet record period. There was no significant difference between the 2 feeding groups. These choking episodes were likely a result of self-feeding (84%), often with foods of “whole” consistency (58%). Infants resolved the choking episode without assistance about half the time (51%).

There were a few limitations to this study. There was insufficient power to determine whether the rates of the most clinically significant choking events differed by group. Also, the sample study demographics were disproportionally socioeconomically advantaged, which may limit applicability.

The BLISS approach to complementary feeding did not appear to result in more choking events in the first year of life than observed in the control group. This form of baby-led weaning does explicitly involve education to minimize choking episodes. While the BLISS infants did appear to gag more initially, this seemed to even out by 8 months of age, perhaps with feeding experience. The other interesting result to surface from this study was that half of the infants were offered at food that posed a choking risk at 7 months, which increased to almost every single participant by 12 months.

It seems that at the end of the day, regardless of the approach to feeding, health care providers must increase their educational efforts toward safe feeding practices. Advice on modifying foods that pose a choking risk needs to be added to the already lengthy list of early education given to families of infants. Armed with the right tools, caregivers can consider different methods such as baby-led weaning to introduce complementary foods safely.

Jessica Tomaszewski, MD, is an assistant clinical professor of pediatrics at the Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia, Pennsylvania, and a hospitalist pediatrician at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Delaware.

Charles A. Pohl, MD—Series Editor, is a professor of pediatrics, senior associate dean of student affairs and career counseling, and associate provost for student affairs at the Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia, Pennsylvania.