For the current study, the same team of New Zealand researchers returned to the original BLISS data but analyzed them a different way. Knowing that the American Academy of Pediatrics finds that solid food accounts for more than 50% of choking episodes, the researchers wondered whether baby-led or traditional weaning resulted in more choking.
The participating mothers were predominantly European (82%) and well-educated. For the study, the researchers randomly assigned participants to either the BLISS group or the traditional feeding group.
Participants assigned to the BLISS group followed specific guidelines for baby-led weaning. They were encouraged to avoid certain foods, including anything that couldn’t be mashed on the roof of the mouth with the tongue; very small foods such as nuts, grapes, sweets and food with pits; raw veggies; under-ripe or hard fruit, including raw apple; citrus fruits, unless each segment had been peeled; whole nuts and popcorn; and foods cut into coins, such as sausages or carrots.
The researchers also suggested that BLISS caregivers test foods before offering them to an infant to ensure they’re soft enough to mash with the tongue; avoid foods that form a crumb in the mouth; make sure any offered foods are at least as long as the child’s fist on at least one side; ensure that the infant is sitting upright while eating; monitor infants while eating and never leave them alone; and allow only the infant to put food into her or his mouth; all eating must be done at the infant’s own pace and under the infant’s control.
During the study, all the families received the standard child health care, which is available for free to all New Zealand children from birth to 5 years of age. Meanwhile, parents completed two four-week calendars when their infant was 6 and 8 months of age, indicating each day whether the infant had gagged or choked.
Gagging was common, the researchers found, with more than 8,000 reports across both groups. As the authors explained, choking is more serious and occurs when the airways are blocked, whereas gagging involves spitting up food or making retching movements. To new parents, these may be difficult to distinguish and so may not be accurately reported.
About one-third of the infants gagged at least once between ages 6 and 8 months old; however, the timing was different for each group. Though the BLISS infants gagged more frequently at 6 months, they gagged less frequently at 8 months than the spoon-fed babies.
Understanding how babies learn to eat
“The premise behind baby-led weaning is that when children start in life [breastfed or formula-fed], they are in control of their energy intake, deciding when to feed and when to stop,” said Rachael Taylor, senior author of the study and a research associate professor at the University of Otago.
The technique is attributed to Gill Rapley, who worked as an English health visitor — a mother’s home helper — and practiced baby-led weaning on her own children and then advocated it in her practice.
“Baby-led weaning has probably always existed. I stumbled upon the approach through experience, both as a parent and as a health professional, but it didn’t have a name. I later researched it, called it baby-led weaning and began to write about it,” said Rapley, who continued her research of child development and wrote several books about weaning.
She was not involved in the current study. Rapley noted that it was only when the World Health Organization officially changed its recommendation to introduce solid foods to babies at 6 months of age (instead of 4 months) that child development specialists could begin to question feeding babies purees. After all, though only slightly older, 6-month-olds could handle food on their own.
Rapley’s co-author, journalist Tracey Murkett, noted that previous research has showed children who are introduced to solid foods in this way are more likely to choose healthy foods and less likely to be overweight.
“It also seems to be a way to avoid mealtime battles and stress around food in toddlers and older children,” said Murkett, who also did not contribute to the current research. “Babies instinctively want to explore food cautiously, control what goes into their mouths and learn to feed themselves gradually.”
Babies are still eating hazardous foods
Though advocates for baby-led weaning might feel more confident based on the current study results, researchers uncovered a major problem: Most parents in the study offered their babies hazardous foods.
Across both groups, 52% of the babies had been offered high-choking-risk foods by the time they were 7 months old, and 94% had been offered them by 12 months of age.
Among the serious choking incidents, only a quarter involved foods highest on the choking risk list. Mostly, infants choked when feeding themselves whole foods — and this happened in both groups.
Dr. Sarah Murphy, an assistant professor at WWAMI School of Medicine at the University of Alaska, found some of the results to be “shocking.” Though the study authors took care to educate participants about high-risk foods, Murphy noted, “parents weren’t following this advice, and over half of the children were offered ‘high-risk’ foods at least once per day by 7 months.”
There was another lesson to be learned from the study.
“Most surprising was only 23% of the choking episodes were from foods deemed a ‘high choking hazard,’ ” said Murphy, who was not involved in the study. “This makes me think that we humans are actually pretty good about protecting our airways.”
True choking, in which the airway is blocked and emergency action is required, is extremely rare, observed Rapley and Murkett, while “the occasional brief bout of coughing while eating is a normal and unremarkable event, occurring frequently in individuals of all ages.” That means adults, too.
“The fact that the authors found that, in half the cases, the infant resolved the ‘choking’ issue himself suggests that a large proportion of these were not true choking episodes,” Rapley said.
Despite this criticism, she still believes the study is a “great contribution” to the existing scientific investigations of weaning, though “more research is vital so that parents can be given accurate safety information.”