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

Complementary feeding approaches and risk of choking: A systematic review

There are two main complementary feeding (CF) approaches: traditional spoon-feeding (TSF) and baby-led weaning (BLW). Many parents and healthcare professionals have concerns about the risk of choking associated with BLW. Since asphyxia is one of infants' main causes of death, this study aims to understand the influence of the CF approach adopted by caregivers on infants' risk of choking. A systematic review was performed. The search was conducted through PubMed, Scopus, and Web of Science databases. We included randomized controlled trials or observational studies published between January 2010 and November 2023, with a clear definition of the intervention and directly assessing the risk of choking. After the selection procedure, 7 of the 165 studies initially identified were included. No study reported statistically significant differences in the risk of choking between babies following BLW, baby-led introduction to solids (BLISS), and TSF. In five studies, although not statistically significant, infants in the TSF group had more choking episodes than those in the BLW or BLISS groups. The risk of choking does not seem to be associated with the CF approach. Instead, it may be related to the familiarity of the baby with each texture and the parent's understanding of the information about how to minimize the risk of choking. Recall bias may be present in all included studies. Advice on how to modify foods to make them safer needs to be clearer and reinforced to all parents.

A Descriptive Study of Spanish and Ecuadorian Commercial Infant Cereals: Are They in Line with Current Recommendations?

Cereals are an important source of nutrients, especially used in complementary feeding. The objective of this study is to review the nutritional composition of cereal-based foods for infants from 4 months and toddlers that are offered in Spain and Ecuador, countries selected because of the opportunity to work in them, and due to their socio-economic differences (industrialized and developing countries, respectively). The number of these products was 105 cereals in Spain and 22 in Ecuador. The products were classified as gluten-free cereals, five cereals, eight cereals, multigrain cereals, and cookies. A 25 g serving was used to determine the percentage in which the samples analyzed can cover the Reference Nutrient Intake (RNI) for micronutrients in infants from 7 months and toddlers according to the European Food Safety Authority (EFSA). Nutritional information per 100 g of dry product was collected according to medium, minimum, and maximum units, and nutrient density was calculated. The age range in which these products are recommended is different in both countries. The nutritional composition presents some differences; Spanish cereals show a lower content of sodium, added sugars, hydrolyzed cereals, and maltodextrin than Ecuadorian cereals. Commercialized cereals could contribute to satisfying the nutritional needs of infants and toddlers; however, they can also be a source of non-recommended components.

Complementary Feeding: Tradition, Innovation and Pitfalls

According to WHO, "complementary feeding (CF) is the process starting when breast milk alone or infant formula alone is no longer sufficient to meet the nutritional requirements of infants, and therefore, other foods and liquids are needed, along with breast human milk or a breastmilk substitute". CF is one of the most important "critical and sensitive periods" in human life: indeed, timing and approaches to solid foods introduction in an infant's nutrition are of utmost importance as potential epigenetic factors from infancy to adulthood. CF is also deeply influenced by each country and single-family traditions, culture, and beliefs. The aim of our narrative review is to analyze traditional CF practices, including innovative and alternative ones that emerged in the last decades, such as baby-led weaning or plant-based weaning, and to evaluate their effects on the risk of developing non-communicable diseases. Moreover, we will discuss pitfalls and misunderstandings that pediatricians frequently have to face when dealing with complementary feeding. Health care professionals must not have prejudices against parents' wishes or traditions about CF; rather, they should support and educate them in case of any alternative CF choice, always pursuing the infant's adequate growth, neuro- and taste development, and the achievement of correct eating behavior as the primary goal.

Diet and Lipid-Lowering Nutraceuticals in Pediatric Patients with Familial Hypercholesterolemia

Familial hypercholesterolemia is a genetically determined disease characterized by elevated plasma total and LDL cholesterol levels from the very first years of life, leading to early atherosclerosis. Nutritional intervention is the first-line treatment, complemented with nutraceuticals and drug therapy when necessary. Nutraceuticals with a lipid-lowering effect have been extensively studied in the past few decades, and have been recently included in international guidelines as a complement to nutritional and pharmacological treatment in subjects with dyslipidemia. In this review, we explore current nutritional interventions for dyslipidemia in childhood, with a specific focus on the main nutraceuticals studied for treating severe dyslipidemia in pediatric patients. Additionally, we briefly describe their primary mechanisms of action and highlight the advantages and risks associated with the use of lipid-lowering nutraceuticals in childhood.

Estimated energy and nutrient intake in complementary feeding methods in Brazilian infants: randomized clinical trial

Inadequate nutrient intake during complementary feeding (CF) can affect healthy infant growth and development. A randomized clinical trial was conducted to examine the energy and nutrient intake in Brazilian children randomly assigned to three distinct CF methods. Mother-infant pairs participated in the study, with mothers receiving interventions in one of three CF approaches: (A) strict Parent-Led Weaning (PLW); (B) strict Baby-Led Introduction to Solids (BLISS); and (C) a mixed method. Assessments were made at 5.5 months, nine months, and 12 months of the child's age. Food consumption was measured through 24-h dietary recalls at nine and 12 months, with intake estimates calculated using the Brazilian Food Composition Table. Means or medians of energy and nutrients were compared between groups using ANOVA with Tukey's post hoc test or the Kruskal-Wallis test. A total of 115 infants were evaluated at nine months, and 102 at 12 months. Children in the PLW, BLISS, and mixed method groups exhibited comparable dietary intakes of energy, macronutrients, and micronutrients at both nine and 12 months. Infants following PLW, BLISS, and mixed methods demonstrated similar levels of energy and nutrient intake, underscoring the effectiveness of these strategies in ensuring comparable nutrient intake during the critical phase of CF.Trial registration The trial was registered in the Brazilian Registry of Clinical Trials (ReBEC) with identifier [RBR-229scm U1111-1226-9516], [ https://ensaiosclinicos.gov.br/rg/RBR-229scm ]. The full data of the first registration was on 24/09/2019.

Adherence to different complementary feeding methods in the first year of life: A randomized clinical trial

BACKGROUND

Infant-guided methods, such as Baby-Led Introduction to SolidS (BLISS), encourage children to feed themselves from the same food consumed by their family since the beginning of the introduction of complementary foods, in opposition to the Parent-Led Weaning (PLW) method, which proposes foods mashed with a fork and given by parents. Adherence to child-guided methods is low due to a lack of confidence in the children's ability to feed themselves. This study aimed to assess adherence to three methods of food introduction: PLW, BLISS, or mixed (PLW and BLISS) at seven, nine, and 12 months of age.

METHODS

A randomized clinical trial was conducted with mother-infant pairs undergoing intervention at 5.5 months of age. Data were presented in absolute numbers and percentages and analyzed using the Chi-Square test.

RESULTS

The sample was constituted of 139 mother-infant pairs: 45 (32%) used PLW, 48 (35%) used BLISS, and 46 (33%) used the mixed method. Adherence to the method at seven, nine, and 12 months of age children was 34.1% (n = 45), 28.5% (n = 37), and 34.1% (n = 46), respectively. The mixed method presented significantly higher adherence results: 69.0% (n = 29) at seven months, 55.8% (n = 24) at nine months, and 78.6% (n = 33) at 12 months (p<0.001). Among the sample that unfollowed the proposed method, those who used PLW and BLISS migrated mostly to the mixed method at 12 months, 60.0% (n = 27) and 72.9% (n = 35) of them, respectively, because of the feeding mode and 97.8% (n = 44) and 100.0% (n = 48) because of food consistency.

CONCLUSION

Complementary feeding in a mixed method presented higher adherence at seven, nine, and 12 months of age of children, which shows the feasibility of this approach to guide families in the introduction of complementary feeding.

Choking, gagging and complementary feeding methods in the first year of life: a randomized clinical trial

OBJECTIVE

Compare the occurrence of choking and gagging in infants subjected to three complementary feeding (CF) methods.

METHODS

Randomized clinical trial with mother-infant pairs, allocated according to the following methods of CF: a) Parent-Led Weaning (PLW) - group control, b) Baby-Led Introduction to SolidS (BLISS), and c) mixed (initially BLISS and if the infant presents a lack of interest or dissatisfaction, PLW), with the last two methods guided by the infant. Mothers received nutritional intervention on CF and prevention of choking and gagging according to the method at 5.5 months of age and remained in follow-up until 12 months. Frequencies of choking and gagging were collected by questionnaire at nine and 12 months. The comparison between groups was performed using the analysis of variance test (p < 0.05).

RESULTS

130 infants were followed, and 34 (26.2%) children presented choking between six and 12 months of age, 13 (30.2%) in PLW, 10 (22.2%) BLISS, and 11 (26.2%) mixed method, no significative difference between methods (p > 0.05). The choking was caused mainly by the semi-solid/solid consistency. Moreover, 100 (80%) infants aged from six to 12 months presented gagging and their characteristics were not statistically different among groups (p > 0.05).

CONCLUSION

Infants following a baby-led feeding method that includes advice on minimizing choking risk do not seem more likely to choke than infants following traditional feeding practice that includes advice on minimizing choking risk.

The effect of baby-led weaning and traditional complementary feeding trainings on baby development

PURPOSE

The aim of this study was to evaluate the risks of self-feeding, transition to early solid food and family meals, choking risk, anemia risk and obesity risk in 6-12-month-old infants who were introduced to complementary feeding using the traditional complementary feeding (TCF) and baby-led weaning (BLW) methods/training.

DESIGN AND METHODS

Mothers of infants who had not yet transitioned to complementary feeding were included in this randomized study. The mothers of 62 infants included in the study were randomized into the intervention groups as TCF and BLW, classified according to the number of children and education level. The research was carried out according to the CONSORT-2010 guidelines after randomization and was concluded with 52 infants and their mothers.

RESULTS

It was found in the study that self-feeding and transition to solid foods in infants fed with the BLW method was higher than the infants fed with the TCF method (p < 0.05). A significant increase was observed in the hemoglobin level of infants fed with the BLW method over time (p < 0.001).

CONCLUSIONS

It was concluded that the BLW method did not lead to risks of obesity, anemia and iron deficiency in transition to complementary feeding. Secondary results indicated that feeding with the BLW method promoted self-feeding and early transition to solid foods and did not lead to the risk of choking.

PRACTICE IMPLICATIONS

Complementary feeding with the BLW method can be safely used by both mothers, healthcare professionals and researchers.

TRIAL REGISTRATION

register.

CLINICALTRIALS

gov; Identifier: NCT05771324.

Nutritional Considerations for the First Year of Life

Feeding during the first year of life is a dynamic process with unique questions, concerns, and milestones emerging at every step. This article will review a small selection of specific questions and concerns related to feeding in the first 12 months of infancy. The aim of this article is to inform and support pediatric providers and parents during this crucial developmental period. [Pediatr Ann. 2023;52(9):e316-e321.].

Can the complementary feeding method be a strategy to reduce the offer of ultra-processed foods?

OBJECTIVE

To verify the prevalence of the offer of ultra-processed foods (UPFs), and to analyze their associated factors in the child's first year of life.

METHODS

Cross-sectional study with 119 mother-infant pairs. At 5.5 months of the child, the mothers received guidance on complementary feeding (CF) according to three methods: Parent-Led Weaning (PLW), Baby-Led Introduction to SolidS (BLISS), or mixed (a combination of PLW and BLISS). At nine and 12 months, the mothers answered a questionnaire about the offer of UPFs. The NOVA classification, which classifies foods according to the nature, extent, and purposes of the industrial processes to which they are subjected, was used to list the UPFs. Descriptive statistics and multivariate Poisson regression, following a multilevel hierarchical model according to the proximity to the outcome, were used to estimate the association between dependent and independent variables.

RESULTS

The prevalence of UPF consumption was 63% (n = 75) in the first year of life. Receiving guidance on healthy CF in the BLISS method showed to be a protective factor for offering UPFs (RR 0.72; CI95 0.52-0.99). Attending less than six prenatal consultations was a risk factor for the UPFs provision (RR 1.39; CI95 1.07-1.80).

CONCLUSION

The prevalence of UPFs offered in the first year of life in this study can be considered high, and future interventions aimed at avoiding UPFs offered in this population should consider the CF method.

Functional constipation symptoms and complementary feeding methods: A randomized clinical trial

INTRODUCTION

The aim of the study was to investigate the impact of different complementary feeding methods on the prevalence of functional constipation symptoms in infants at 12 months of age.

MATERIAL AND METHODS

Randomized clinical trial in mother-infant dyads that underwent the intervention at 5.5 months post birth, randomly allocated to one of three complementary food introduction methods: PLW (parent-led weaning), Baby-led Introduction to SolidS (BLISS) and a mixed approach. The symptoms of constipation were assessed at 12 months with an online questionnaire based on the Rome IV diagnostic criteria and adapted to our sample. The data were summarised as absolute frequencies and percentages and compared by means of the χ² test. The project was approved by the ethics committee of the Hospital de Clínicas de Porto Alegre under number 2019-0230.

RESULTS

We analysed data corresponding to 135 infants, 45 allocated to PLW, 48 to BLISS and 42 to the mixed approach. The prevalence of constipation symptoms was 49.6% in the overall sample (n = 67), 60% (n = 27) in the PLW group, 47.9% (n = 23) in the BLISS group and 40.5% (n = 17) in the mixed approach group. We found no association between functional constipation symptoms and the method used to introduce complementary foods (P = .183).

CONCLUSIONS

The prevalence of functional constipation symptoms was high in the study population. The presence of constipation symptoms was not associated with the complementary feeding approach.

What Has Changed over Years on Complementary Feeding in Italy: An Update

Current practice regarding complementary feeding (CF) is influenced by socio-cultural background. Our group already investigated the Italian approach to CF in the years 2015-2017. Our aim was to update those data by finding out: if the habits have changed nationwide, how the trends changed in each area, and if the differences between regions still exist. We devised and submitted to Italian primary care paediatricians (PCP) a questionnaire consisting of four items regarding the suggestions they gave to families about CF and compared the results to the ones from our previous survey. We collected 595 responses. Traditional weaning was the most recommended method, with a significant reduction compared to the period of 2015-2017 (41% vs. 60%); conversely, the proportion of PCP endorsing baby-led weaning (BLW) or traditional spoon-feeding with adult food tastings has increased, while the endorsement of commercial baby foods dropped. BLW is still more popular in the North and Centre compared to the South (24.9%, 22.3%, and 16.7%, respectively). The age to start CF and the habit of giving written information have not changed over time. Our results highlighted that Italian paediatricians encourage BLW and traditional CF with adult tastings more than in the past, at the expense of traditional spoon-feeding.

Consensus on complementary feeding from the Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition: COCO 2023

Complementary feeding (CF) is defined as the feeding of infants that complements breastfeeding, or alternatively, feeding with a breast milk substitute, and is a process that is more than simply a guide as to what and how to introduce foods. The information provided by healthcare professionals must be up-to-date and evidence-based. Most of the recommendations that appear in the different international guidelines and position papers are widely applicable, but some must be regionalized or adapted to fit the conditions and reality of each geographic zone. The Nutrition Working Group of the Latin American Society for Pediatric Gastroenterology, Hepatology and Nutrition (LASPGHAN) summoned a group of experts from each of the society's member countries, to develop a consensus on CF, incorporating, whenever possible, local information adapted to the reality of the region. The aim of the present document is to show the results of that endeavor. Utilizing the Delphi method, a total of 34 statements on relevant aspects of CF were evaluated, discussed, and voted upon.

Adherence to different methods for introducing complementary food to 7-month-old babies: a randomized clinical trial

Objective:

To assess the adherence to three methods of food introduction for 7-month-old babies.

Methods:

This is a randomized clinical trial conducted with mother-infant pairs, submitted to the intervention with five and a half months of age and three different methods for food introduction according to randomization: Parent-Led Weaning (PLW), Baby-Led Introduction to SolidS (BLISS), or mixed (specially developed for this study). Adherence to the method was assessed at the seventh month of age, via telephone call to the caregiver by a researcher blinded to the method. The analyses were performed using the Chi-Square test and data are presented in absolute numbers and percentages.

Results:

A total of 139 mother-infant pairs were evaluated; 46 of them were allocated to the PLW method; 47, to the BLISS; and 46, to the mixed. At seven months of age, 60 (43.2%) mothers reported that the infants were following the proposed feeding method. When analyzing each approach, the mixed method showed a higher likelihood of adherence (71.7%, n=33), followed by the PLW method (39.1%, n=18) and by the BLISS (19.2%, n=9) (p<0.001). Among the sample that did not follow the proposed method, those that had been randomized to the PLW and BLISS methods mostly migrated to the mixed method (92.9%; n=26 and 92.1%; n=35, respectively) (p<0.001).

Conclusions:

Complementary feeding in a mixed approach obtained greater adherence in 7-month-old babies.

Complementary feeding methods and introduction of ultra-processed foods: A randomized clinical trial

Introduction

Complementary feeding (CF) is defined as a period when foods, other than milk, are introduced to the infant's diet. Unfortunately, frequent consumption of ultra-processed foods (UPF) has become highly prevalent early in an infant's life. The aim was to verify the association of CF methods with the introduction of UPF in early childhood.

Methods

This randomized clinical trial involved pairs of mother-infants, allocated in groups receiving different CF interventions: strict Parent-Led Weaning (PLW); strict Baby-Led Introduction to SolidS (BLISS), or mixed-method. The intervention consisted of a counseling session on healthy eating at the child's 5.5 months of age. A structured questionnaire was created based on the NOVA classification for the definition of UPF and applied at 9 and 12 months. The effect of the CF method intervention was measured by a survival curve for UPF offered for the first time in early childhood between groups. Cox regression was used to estimate its magnitude. The primary analysis was done in three groups (PLW, BLISS, and Mixed) and the secondary analysis was done in two groups (PLW, and BLISS + Mixed).

Results

A total of 139 mother-infant pairs were eligible and 129 followed the study. The prevalence of infants who were exposed to UPF in early childhood was 58.9% (n = 76), being 71.4% in the PLW group, 53.3% in the BLISS group, and 52.4% in the Mixed group, without differences between them (p = 0.133). The PLW group intervention had a greater chance of exposure to ice cream or popsicles (p = 0.032) and sweet crackers (p = 0.009), compared with the other two CF groups. The Cox regression did not find significant differences between the three groups. However, the regression with two groups estimated a 38% reduction in the offer of UPF in the BLISS + Mixed group intervention (p = 0.049).

Discussion

The CF intervention promoting greater infant autonomy (BLISS and Mixed) was associated with a reduction in the offer of UPF in early childhood. This knowledge may contribute to supporting strategies aimed at reducing UPF consumption by the young infant.

Brazilian registry of clinical trials ReBEC

[https://ensaiosclinicos.gov.br/rg/RBR-229scm], identifier [RBR-229scm U1111-1226-9516].

"Baby-led weaning" - Progress in infant feeding or risky trend?

Baby-led weaning (BLW), proposed as a new form of complementary feeding, has emerged as a real trend phenomenon in the media. Infants are seated at the family table from the age of 6 months, facing the foods they grab and bring to their mouth: they decide which foods they want to eat and what amount. The consumption of mashed foods and the use of a spoon are totally discouraged. BLW is increasingly used in nurseries and centers of young children. A bibliographic search carried out between 2000 and 2021 found 423 articles, of which 38 were selected. The clinical studies selected are 11 cross-sectional observational studies and two randomized controlled studies. BLW promotes breastfeeding, the early introduction of morsels, the respect of the child's appetite, the use of unprocessed foods, and the choice of "homemade" and friendliness. These benefits can nonetheless be reached with usual complementary feeding (SCF), according to current recommendations. Other benefits are claimed without scientific evidence such as easier achievement of dietary complementary feeding and an optimal growth with prevention of excess weight gain. BLW has some obvious downsides. The infant may not get enough energy, iron, zinc, vitamins, and other nutrients, or too much protein, saturated fat, salt, or sugar. The risk of choking, which must be distinguished from the physiological gagging reflex, has not been ruled out by scientific studies. Currently, the Nutrition Committee of the French Pediatric Society considers that the data published to date in terms of benefits and risks of BLW do not lend themselves to advice for this practice in preference over SCF carried out according to current recommendations.

Baby-led weaning: A thematic analysis of comments made by parents using online parenting forums

BACKGROUND

Baby-led weaning (BLW) centres on making the baby an active partner, rather than a passive recipient of complementary feeding. Key features of BLW include self-feeding foods in their natural form, eating with the rest of the family and consuming family foods. This differs from traditional weaning (TW) where parents initially spoon feed purees, alongside finger foods, before graduating to more textured food. Previous research, however, has suggested parents may not fully adhere to one weaning style. This study aimed to explore how the meaning and interpretation of BLW may contribute to the weaning style used.

METHODS

Messages and responses posted on three UK parenting forums, and relating to complementary feeding, were analysed using an interpretive thematic approach.

RESULTS

The characterisation of BLW by parents was varied but they described BLW having an ethos which included trusting the baby, role modelling, developing confidence with food and sharing the social aspects of mealtimes. BLW also offered an alternative to those actively seeking something different or a default for those whose baby refused purees or spoon feeding. BLW felt like a natural progression, with low parental effort for some, and a source of anxiety, stress, choking risk and mess for others. Many parents struggled to find a process (what to eat and when) within BLW, that they could follow. Finger foods were used synonymously with BLW but many mixed/blurred aspects of both TW and BLW.

CONCLUSIONS

The interpretation of BLW varies considerably between parents and a broader definition of BLW may be required, along with guidance on the process and purpose of BLW. This article is protected by copyright. All rights reserved.

Selenium intakes and plasma selenium of New Zealand toddlers: secondary analysis of a randomised controlled trial

Little is known about Se intakes and status in very young New Zealand children. However, Se intakes below recommendations and lower Se status compared with international studies have been reported in New Zealand (particularly South Island) adults. The Baby-Led Introduction to SolidS (BLISS) randomised controlled trial compared a modified version of baby-led weaning (infants feed themselves rather than being spoon-fed), with traditional spoon-feeding (Control). Weighed 3-d diet records were collected and plasma Se concentration measured using inductively coupled plasma mass spectrometry (ICP-MS). In total, 101 (BLISS n 50, Control n 51) 12-month-old toddlers provided complete data. The OR of Se intakes below the estimated average requirement (EAR) was no different between BLISS and Control (OR: 0·89; 95 % CI 0·39, 2·03), and there was no difference in mean plasma Se concentration between groups (0·04 μmol/l; 95 % CI -0·03, 0·11). In an adjusted model, consuming breast milk was associated with lower plasma Se concentrations (-0·12 μmol/l; 95 % CI -0·19, -0·04). Of the food groups other than infant milk (breast milk or infant formula), 'breads and cereals' contributed the most to Se intakes (12 % of intake). In conclusion, Se intakes and plasma Se concentrations of 12-month-old New Zealand toddlers were no different between those who had followed a baby-led approach to complementary feeding and those who followed traditional spoon-feeding. However, more than half of toddlers had Se intakes below the EAR.

Complementary Feeding Caregivers’ Practices and Growth, Risk of Overweight/Obesity, and Other Non-Communicable Diseases: A Systematic Review and Meta-Analysis

Several institutions propose responsive feeding (RF) as the caregivers’ relational standard when nurturing a child, from breast/formula feeding onwards. Previous systematic reviews (SRs) on caregivers’ feeding practices (CFPs) have included studies on populations from countries with different cultures, rates of malnutrition, and incomes, whereas this SR compares different CFPs only in healthy children (4–24 months) from industrialized countries. Clinical questions were about the influence of different CFPs on several important outcomes, namely growth, overweight/obesity, risk of choking, dental caries, type 2 diabetes (DM2), and hypertension. The literature review does not support any Baby Led Weaning’s or Baby-Led Introduction to SolidS’ (BLISS) positive influence on children’s weight–length gain, nor their preventive effect on future overweight/obesity. RF-CFPs can result in adequate weight gain and a lower incidence of overweight/obesity during the first two years of life, whereas restrictive styles and coercive styles, two kinds of non-RF in CF, can have a negative effect, favoring excess weight and lower weight, respectively. Choking risk: failure to supervise a child’s meals by an adult represents the most important risk factor; no cause–effect relation between BLW/BLISS/RF/NRCF and choking could be found. Risks of DM2, hypertension, and caries: different CFPs cannot be considered as a risky or preventive factor for developing these conditions later in life.

Use of the Baby-Led Weaning (BLW) Method in Complementary Feeding of the Infant-A Cross-Sectional Study of Mothers Using and Not Using the BLW Method

Baby-led weaning (BLW) is an increasingly popular way of expanding a baby’s diet. It is based on the baby becoming physically ready to feed himself, effectively supplementing his diet, which until now has been based on breast milk or modified milk. The aim of the study was to assess mothers’ knowledge about the use of the BLW method to expand the diet of a young child. The essence of the study assumed the analysis of the advantages and disadvantages of using this method indicated by mothers. Materials and Methods: A total of 320 mothers participated in the study. Data for the study were collected anonymously using the CAWI method. The research tool was the original questionnaire relating to the knowledge about the BLW method and the application of the BLW method in practice. Results: The BLW method was used by 240 (75%) women. The reasons for not using the BLW method were: the child did not cooperate n = 30 (37.5%) and was not ready to use the BLW method n = 20 (25%). In total, 182 (75.8%) mothers using BLW and 63 (78.8%) mothers not using BLW started extending the diet before the child was 6 months old. According to 270 (84.4%) mothers, including 205 (85.4%) using BLW, stable sitting in a highchair/on the lap is a decisive factor for starting the dietary expansion with the BLW method. Conclusions: Mothers’ knowledge of the BLW method as a way of expanding a young child’s diet was insufficient. It seems important to implement appropriate educational activities on the methods of expanding children’s diets to broaden parents’ knowledge of the influence of nutrition on infant development.

Practical Implementation of the BLW Method During the Expansion of the Infant Diet—A Study Among Polish Children

The aim of the study was to verify the knowledge of mothers of children under 3 years of age about the Baby Led Weaning (BLW) feeding model and their practical implementation of this method. The study involved 761 mothers and their children. After analysis of the inclusion and exclusion criterion, the information provided by women 699 aged 21–48 years was included in the final data analysis. In the study group, most children were breastfed for 6 months to 1 year (n = 256, 36.7%), 1 year to 2 years (n = 179, 25.6%) and over 2 years (n = 71, 10.2%). Starting dietary expansion before 17 weeks of age was implemented in 47 (6.7%) children, between and 17–26 weeks of age in 328 (46.9%) children, and after 26 weeks of age in 324 (46.3%) children. Feeding food and dishes from the family table was practiced by 518 (74.1%) mothers. Spoon-feeding was practiced by 529 (75.6%) children, 157 (22.4%) children were fed this way sometimes. Taking into account the above data, feeding with the BLW method was used in 170 children (24.2%). In the examined group of mothers the use of the BLW method in feeding their children, especially during diet expansion, was declared by 408 women (74.8%). The child's independent decision concerning what the child will eat and what is according to the BLW method is accepted by 434 (62.1%) mothers. Among the positive aspects of using the BLW method, the women surveyed indicated the child's independence, while among the disadvantages, the omnipresent mess and chaos when eating meals.

Traditional complementary feeding or BLW (Baby Led Weaning) method? - A cross-sectional study of Polish infants during complementary feeding

Baby-led weaning (BLW) is an increasingly well-known method of complementary feeding for infants. The BLW method is based on the fact that the baby becomes physically ready to eat on its own and can henceforth effectively supplement its diet, which was previously based on breast milk or formula milk. The aim of the study was to compare complementary feeding among mothers using and not using the BLW method. The study took into account, among other things, the frequency of spoon feeding, eating from the family table, and eating meals with a pulpy consistency. The study also determined the frequency of the risk of choking/gagging, food regurgitation or the occurrence of vomiting during a meal in the study groups. Material and method: a cross-sectional survey was conducted among mothers of children from 6 months to 36 months of age residing throughout Poland.

RESULTS

The study group was divided into three subgroups: mothers using BLW (M-BLW), mothers not familiar with the BLW method (M-NoBLW)), mothers not using the BLW method - mothers using the spoon-feeding method) (M-TS). Among the mothers surveyed, 413 women (63.93%) used the BLW method, 222 mothers (34.36%) did not use the BLW method of which 50 (7.73%) of these were unfamiliar with the method, and 172 (26.62%) simply did not use it. Among M-TS mothers, the child was most often entirely or mostly spoon-fed by an adult (73.84%), and the same was true for the M-NoBLW group (70.0%). In the M-BLW group, 58.60% of children were half-fed by an adult with a spoon. half ate independently.

CONCLUSIONS

Infants fed by the BLW method were more likely to have their diets expanded after 6 months of age, they were also more likely to be given products from the family table than children fed traditionally with a spoon. Full BLW was implemented by only 29% of children in the BLW group. The vomiting reflex, spitting food out of the mouth, and gagging, were more common among children fed by the BLW method. In contrast, choking occurred comparably often in both groups - in 5.4% of spoon-fed children and 6.9% of BLW-fed children.

Estimated energy and nutrient intake for infants following baby-led and traditional weaning approaches

Baby-led weaning (BLW), where infants self-feedwithout the use of spoon-feeding by a caregiver, continues to be a popular approach to starting solids. However, concerns remain amongst health professionals that infants using this method may not consume sufficient energy or nutrients from solid foods. Little research has examined how different weaning approaches shape dietary intake. The aim of this study was to use a three-day weighed diet diary to measure estimated energy and nutrient intake in infants aged 6-12 months. Diet diaries were completed by 71 parents and analysed to compareestimated infant intake from milk and solid foods for those either following a BLW or traditional spoon-feeding approach (TW). Intake was analysed for each weaning group in two age groups: 26-39 and 40-52 weeks, to account for different eating patterns at the start and end of the weaning process. For the younger infants, significant differences in estimatedenergy intake were found, with TW infants consuming 285 kcal from solid foods compared with 120 kcal for BLW infants. Conversely, BLW infants consumed more calories and nutrients from breast or formula milk, consistent with a slower transition to solid foods. No differences were found in estimated intake amongst older infants suggesting BLW infants had 'caught up' with their spoon-fed peers. Overall, few infantsregardless of weaning group met recommended intake guidelines for energy (either over or under consuming) with many deficient in iron and zinc intake. The findings are important for those supporting parents through the transition to solid foods. This article is protected by copyright. All rights reserved.

Complementary feeding methods in the first year of life: a study protocol for a randomized clinical trial

Background

The traditional spoon-feeding approach to introduction of solid foods during the complementary feeding period is supported by consensus in the scientific literature. However, a method called Baby-Led Introduction to SolidS (BLISS) has been proposed as an alternative, allowing infants to self-feed with no adult interference. To date, there have been no trials in the Brazilian population to evaluate the effectiveness of BLISS in comparison to the traditional approach.

Methods/design

To evaluate and compare three different complementary feeding methods. Data on 144 mother-child pairs will be randomized into intervention groups by methods: (A) strict Parent-Led Weaning; (B) strict Baby-Led Introduction to SolidS; and (C) a mixed method. Prospective participants from Porto Alegre, Brazil, and nearby cities will be recruited through the Internet. The interventions will be performed by nutritionists and speech therapists, at 5.5 months of age of the child, at a private nutrition office equipped with a test kitchen where meals will be prepared according to the randomized method. The pairs will be followed up at 7, 9, and 12 months of age. Data will be collected through questionnaires designed especially for this study, which will include a 24h child food recall, questionnaires on the child’s and parents’ eating behavior, oral habits, eating difficulties, and choking prevalence. At 12 months of age, children will undergo blood collection to measure hemoglobin, ferritin, and C-reactive protein, saliva collection for analysis of genetic polymorphisms, and oral examination. Anthropometric parameters (child and maternal) will be measured at the baseline intervention, at a 9 month home visit, and at the end-of-study visit at the hospital. The primary outcome will be child growth and nutritional status z-scores at 12 months; secondary outcomes will include iron status, feeding behavior, acceptability of the methods, dietary variety, choking, eating behaviors, food preferences, acceptance of bitter and sweet flavors, suction, oral habits, oral hygiene behavior, dental caries, gingival health status, and functional constipation.

Discussion

The trial intends to ascertain whether there are potential advantages to the BLISS complementary feeding method in this specific population, generating data to support families and healthcare providers.

Trial registration

Brazilian Clinical Trials Registry (ReBEC): RBR- 229scm number U1111-1226-9516. Registered on September 24, 2019.

Brazilian health professionals' perception about the Baby-Led Weaning (BLW) method for complementary feeding: an exploratory study

Objective:

To describe Brazilian health professionals’ perception about the Baby-Led Weaning (BLW) method use for complementary feeding.

Methods:

Cross-sectional, descriptive study including 458 health professionals graduated in Nursing, Speech Therapy, Medicine, Nutrition or Dentistry and working in Pediatrics, being directly or indirectly involved with pediatric nutrition. We used a convenience non-probability sampling. The questionnaire applied to participants addressed demographic characteristics, academic degree, workplace, knowledge about clinical practice and perceptions about the possible advantages of the BLW method.

Results:

Participants had a mean age of 34.5±8.5 years, 64.6% of them working in Southeast Brazil and 65.3% being nutritionists. Most participants reported being acquainted with the BLW method (82.0%). Regarding clinical practice, 38.3% mentioned having recommended the BLW some times, 37.5% often and 20.5% always. Most participants fully agreed that the BLW method could have advantages for babies, for example, having them more likely to share family meals, facilitating adaptation to food flavors and consistencies, enhancing chewing and favoring the development of motor skills. On the other hand, important disagreements were also expressed regarding the BLW convenience and the possibility to create less concerns or anxiety in parents.

Conclusions:

The BLW method reported as advantageous, but disagreements were also raised, probably because scientific evidences on the suject are scarse. Further investigation is needed so we can better understand the risks and benefits and health care professionals can feel effectively assisted to offer support and advice to parents and caretakers.

Comparison of food and nutrient intake in infants aged 6-12 months, following baby-led or traditional weaning: A cross-sectional study

BACKGROUND

A baby-led approach to weaning (BLW) encompasses self-feeding and self-selecting graspable foods, offering an alternative to traditional weaning (TW). This cross-sectional study explored adherence to characteristics of BLW and differences in food group exposure and nutrient intake between babies following either TW or BLW.

METHODS

Nutritional data were collected via multiple-pass 24-h recall, following parental completion of an online survey.

RESULTS

Infants were grouped according to age (6-8 months; TW [n = 36] and BLW [n = 24]) and (9-12 months; TW [n = 24] and BLW [n = 12]). BLW babies were more likely to be breast fed (p = 0.002), consumed a higher percentage of foods also consumed by their mother (p = 0.008) and were fed less purees (p < 0.001) at 6-8 months. TW babies were spoon fed more (p ≤ 0.001) at all ages. Amongst babies aged 6-8 months, total intake (from complementary food plus milk) of iron (p = 0.021), zinc (p = 0.048), iodine (p = 0.031), vitamin B12 (p = 0.002) and vitamin D (p = 0.042) and both vitamin B12 (p = 0.027) and vitamin D (p = 0.035) from complementary food alone was higher in babies following TW. Compared to TW, BLW babies aged 6-8 months had a higher percentage energy intake from fat (p = 0.043) and saturated fat (p = 0.026) from their milk. No differences in nutrient intake were observed amongst infants aged 9-12 months. Few differences were observed between groups in their number of exposures to specific food groups.

CONCLUSIONS

TW infants had higher intakes of key micronutrients at 6-8 months, although there were few differences in nutritional intake at 9-12 months or food group exposure between babies following TW or BLW. BLW appears to be socially desirable. Guidance for parents is required, along with larger, longer-term studies, which explore the potential impact of BLW in later childhood.

Complementary Feeding in Italy: From Tradition to Innovation

Complementary feeding (CF) is a pivotal phase of the individual’s growth, during which children develops their future dietary habits. To date, only few studies investigated and compared weaning modalities between different geographical areas. The aim of this article is to describe the current Italian practice for CF in healthy term infants among different areas (North, Center, South) of Italy. Two different multiple-choice questionnaires were produced and sent to 665 Italian primary care pediatricians (PCP) and 2023 families with children under 1 year of age. As emerged from our investigation, in Italy CF is usually started between the 5th and 6th month of life. The preferred approach (chosen by 77% of families) involves the use of home-cooked liquid or semi-liquid ailments, or industrial baby foods. A new CF modality is emerging, consisting of traditional complementary foods with adult food tastings (10% of families). Approximately 91% of pediatricians give written dietary suggestions, and 83% of families follow their advice. We found significantly divergent weaning habits among different areas of Italy. PCP have a key role in guiding parents during the introduction of new foods in their infant’s diet and should take this as an opportunity to educate the whole family to healthy dietary habits.

Nutritional Approach to Prevention and Treatment of Cardiovascular Disease in Childhood

Coronary Heart Disease (CHD) is a major mortality and morbidity cause in adulthood worldwide. The atherosclerotic process starts even before birth, progresses through childhood and, if not stopped, eventually leads to CHD. Therefore, it is important to start prevention from the earliest stages of life. CHD prevention can be performed at different interventional stages: primordial prevention is aimed at preventing risk factors, primary prevention is aimed at early identification and treatment of risk factors, secondary prevention is aimed at reducing the risk of further events in those patients who have already experienced a CHD event. In this context, CHD risk stratification is of utmost importance, in order to tailor the preventive and therapeutic approach. Nutritional intervention is the milestone treatment in pediatric patients at increased CHD risk. According to the Developmental Origin of Health and Disease theory, the origins of lifestyle-related disease is formed in the so called “first thousand days” from conception, when an insult, either positive or negative, can cause life-lasting consequences. Nutrition is a positive epigenetic factor: an adequate nutritional intervention in a developmental critical period can change the outcome from childhood into adulthood.

Baby-Led Weaning: What Role Does It Play in Obesity Risk during the First Years? A Systematic Review

Childhood is a window of opportunity for the prevention of the obesity pandemic. Since “the first 1000 days of life” is a period in which healthy eating habits must be acquired, it should be the target for preventive strategies. Baby-led weaning (BLW) is an emergent way of weaning that could influence children’s health. The nutrition committees of the main pediatric societies affirm there is not enough evidence to support which is the best method of weaning. The aim was to determinate the influence of BLW on the infant’s weight gain compared to the traditional spoon-feeding, and to assess if it could decrease the risk of obesity in children. A systematic review was conducted, following the PRISMA method. Pubmed, Web of Science, Embase, and Cochrane Library were searched. Out of 747 articles, eight studies (2875 total infants) were included (two randomized control trials, 6 observational studies). Results were indecisive, while some studies seem to demonstrate lower weight gain in infants that apply BLW, others show inconclusive results. The risk of bias in all included studies was moderate or high. In conclusion, more clinical trials and prospective studies should be done prior to providing a general recommendation about the best method of weaning to reduce the risk of obesity.

The iron content of healthy diets for one day for breastfed babies and young children

AIMS

Early childhood anaemia due to iron deficiency is widespread in remote communities across northern Australia. Current recommendations for healthy food to complement breastfeeding at age 6 to 23 months include iron-rich and iron-enriched foods. An electronic nutrient analysis was undertaken to assess the iron content of hypothetical healthy diets for breastfed babies and young children aged 6 to 23 months in Australia, in comparison with their estimated requirements.

METHODS

Hypothetical diets for 1 day were developed that were consistent with the Foundation Diets for breastfed infants 6 to 12 months and for toddlers 13 to 23 months. Nutrient content was derived using the Australian Food Composition database in FoodWorks 10. The iron content of these two diets were compared with Estimated Average Requirements (EARs) and Recommended Dietary Intakes (RDIs) for iron for infants aged 7 to 12 months and children aged 1 to 3 years.

RESULTS

The iron content of the hypothetical diet for breastfed infants aged 6 to 12 months (5.8 mg) was less than the EAR (7 mg, 83%) and the RDI (11 mg, 53%). For young breastfed children aged 13 to 23 months, the iron content of the hypothetical diet was 4.4 mg; above the EAR (4 mg, 110%) but less than RDI (9 mg, 49%).

CONCLUSIONS

Breastfeeding has health and neurodevelopmental benefits for infants and young children that are particularly important in remote Australia where food insecurity and poor nutrition compromise health and wellbeing. Adequate iron intake is also important for neurodevelopment in early life but healthy diets for breastfed babies and young children may have insufficient iron content to meet requirements. The upcoming revision of the Australian Dietary Guidelines provides an opportunity to consider this issue.

Parents' Perception of the Complementary Baby-Led Weaning Feeding Method: A Validation Study

This study aims to construct and validate a questionnaire that allows Parents’ Perceptions of the complementary Baby-Led Weaning feeding method (PaPerc-BLW questionnaire) to be evaluated. An instrumental design was used. Five child nutrition experts took part in the development and content validity. The questionnaire was administered to a sample of 216 Spanish parents of infants aged 0–6 months to determine psychometric properties (construct validity and internal consistency). The factor analysis explained 65.12% of variance with three factors (Promoting infant autonomy and development; Infant’s health; Parents’ fear to apply BLW), and internal consistency was α = 0.67. The mean score of the PaPerc-BLW questionnaire for the total sample was 4.14 (DS = 0.64, 95% CI = 4.06–4.23). Significant differences were found in the parents’ perception of baby-led weaning feeding method based on variables as previous children (p ≤ 0.001). Otherwise, the sample included in the study could bias the results, since 98.6% indicated that they were familiar with the BLW method and 62% had previous experience Despite this limitation, the PaPerc-BLW questionnaire offers adequate validity for evaluating parents’ perception of the baby-led weaning method.

Fostering infant food texture acceptance: A pilot intervention promoting food texture introduction between 8 and 15 months

Healthy infant feeding practices form the basis of healthy eating behaviour later in life. The effect of providing parents with recommendations on textured food introduction between 8 and 15 months on children's experience with and acceptance of textured foods was studied. Sixty parent/child dyads were randomly assigned to a control group (CG) receiving current French recommendations and an intervention group (IG) receiving a brochure with supplementary advice, tips and monthly counselling on food texture introduction. After the intervention, parents completed self-report measures about the introduction of 188 food items, including purees, soft/small pieces, hard/large pieces and double textures. Children's acceptance of eight textured foods was assessed in a laboratory setting. Parents in the IG introduced more soft/small food pieces (P = 0.004) but not more complex textures (P = 0.15). There was no group difference in children acceptance for any of the textured foods offered in the laboratory. Independent of their study group, children's exposure to texture was associated with birth order, self-feeding with fingers, low gagging frequency and seldom use of commercial baby foods. Higher acceptance was associated with higher exposure to food pieces but not to pureed foods (either smooth or rough) and with children's eating behavioural traits (high food enjoyment, high food responsiveness and low food fussiness). This pilot intervention demonstrated that providing information can be effective in promoting the introduction of small and soft food pieces, but the most effective way to influence the introduction of more challenging textures (hard pieces and double texture) is uncertain. Further research should focus on the identification of barriers to complex texture introduction and on how building on this knowledge for a population-based public health intervention.

BABY-LED WEANING, AN OVERVIEW OF THE NEW APPROACH TO FOOD INTRODUCTION: INTEGRATIVE LITERATURE REVIEW

Objective:

To analyze the scientific literature on Baby-Led Weaning with an integrative literature review to identify risks and benefits.

Data source:

The databases used were: National Library of Medicine (MEDLINE), Latin American and Caribbean Literature in Health Sciences (LILACS – Literatura Latino-Americana e do Caribe em Ciências da Saúde), US National Library of Medicine (PubMed), and Virtual Health Library (BVS – Biblioteca Virtual em Saúde) in December 2017. The inclusion criteria established were publications in English with the descriptor “baby-led weaning” in the heading, abstract, or keywords, classified as original articles, of primary nature, and available online and in full. We excluded review articles, editorials, letters to the editor, critical commentaries, and books on the subject, as well as articles not available in full and duplicates.

Data summary:

We identified 106 articles, of which 17 met the selection criteria. The Baby-Led Weaning method was significantly associated with the baby’s satiety, the start of complementary feeding, and adequacy of weight gain. On the other hand, choking and the intake of micronutrients were negatively associated, however with no statistical differences.

Conclusions:

Despite the benefits found, the risks still deserve attention and should be investigated with longitudinal randomized controlled studies to ensure the safety of the method when practiced exclusively.

Complementary feeding: new styles versus old myths

Early life feeding habits may potentially alter future metabolic programming and body composition. Complementary feeding is the period of time when infants introduce food different from milk in their diet, together with a gradual reduction of the intake of milk (either breast milk or formula), to finally acquire the diet model of their family. This period is important in the transition of the infant from milk feeding to family foods, and is necessary for both nutritional and developmental reasons. The timing for introducing complementary foods and the method of feeding have changed over time. Available literature data show increasing interest and concerns about the impact of complementary feeding timing and modality on the onset of later non-communicable disorders, such as overweight and obesity, allergic diseases, celiac disease, or diabetes. While international scientific guidelines on complementary feeding have been published, many baby food companies' websites, blogs, and books, in most European countries exist. The aim of this manuscript is to look over current recommendations, and to revise "old myths." The adoption of an adequate weaning method is a cornerstone in the development of life-long health status. A correct strategy could reduce the risk of feeding disorders and other health problems later in life.

Sex differences in the application of WHO standards to Shanghai infants from birth to 18 months

BACKGROUND

The number of obese children in Shanghai has increased annually. Shanghai growth standards are higher than the World Health Organization's (WHO's) growth standards, which may influence caregiver feeding practices and enhance the risk of overweight in infants.

METHOD

A cluster-randomized controlled trial analysed 15,019 infants (healthy newborns, ≥3 clinical consultations in one year) from 19 community health service centers in two urban areas in Shanghai. Randomization was performed at the community level. A total of 8510 infants in the S-group were assessed with the Shanghai growth standards, and 6509 infants in the W-group were assessed by the WHO growth standards. Follow-up data were collected at 1, 2, 4, 6, 9, 12 and 18 months. Changes in the weight-for-age z score (WAZ), length-for-age z score (LAZ), and weight-for length z score (WLZ) were assessed using mixed regression models. Sex differences were compared between groups at all follow-up periods.

RESULTS

Compared to the S-group, the percent of overweight in boys in the W-group significantly decreased starting at 9 months (4.9% vs 3.3%, P = 0.011 at 9 months, 4.5% vs 2.5%, P < 0.001 at 12 months and 3.1% vs 0.8%, P < 0.001 at 18 months), and the percent of overweight in girls in the W-group significantly decreased starting at 12 months (3.0% vs 1.8%, P = 0.009 at 12 months and 1.7% vs 0.6%, P = 0.039 at 18 months). A decreased weight in boys (from 4 months to 18 months, P < 0.05) and an increased length in girls (from 6 months to 18 months, P < 0.05) were the key reasons for the decreased overweight percentage in the W-group.

CONCLUSION

The adoption of the WHO growth standards could result in markedly decreased weight gain in boys and increased length gain in girls beyond the age of 18 months among urban Shanghai infants.

TRIAL REGISTRATION NUMBER

ChiCTR1800015371.

Fecal Microbiotas of Indonesian and New Zealand Children Differ in Complexity and Bifidobacterial Taxa during the First Year of Life

The biological succession that occurs during the first year of life in the gut of infants in Western countries is broadly predictable in terms of the increasing complexity of the composition of microbiotas. Less information is available about microbiotas in Asian countries, where environmental, nutritional, and cultural influences may differentially affect the composition and development of the microbial community. We compared the fecal microbiotas of Indonesian (n = 204) and New Zealand (NZ) (n = 74) infants 6 to 7 months and 12 months of age. Comparisons were made by analysis of 16S rRNA gene sequences and derivation of community diversity metrics, relative abundances of bacterial families, enterotypes, and cooccurrence correlation networks. Abundances of Bifidobacterium longum subsp. infantis and B. longum subsp. longum were determined by quantitative PCR. All observations supported the view that the Indonesian and NZ infant microbiotas developed in complexity over time, but the changes were much greater for NZ infants. B. longum subsp. infantis dominated the microbiotas of Indonesian children, whereas B. longum subsp. longum was dominant in NZ children. Network analysis showed that the niche model (in which trophic adaptation results in preferential colonization) of the assemblage of microbiotas was supported in Indonesian infants, whereas the neutral (stochastic) model was supported by the development of the microbiotas of NZ infants. The results of the study show that the development of the fecal microbiota is not the same for infants in all countries, and they point to the necessity of obtaining a better understanding of the factors that control the colonization of the gut in early life.IMPORTANCE This study addresses the microbiology of a natural ecosystem (the infant bowel) for children in a rural setting in Indonesia and in an urban environment in New Zealand. Analysis of DNA sequences generated from the microbial community (microbiota) in the feces of the infants during the first year of life showed marked differences in the composition and complexity of the bacterial collections. The differences were most likely due to differences in the prevalence and duration of breastfeeding of infants in the two countries. These kinds of studies are essential for developing concepts of microbial ecology related to the influence of nutrition and environment on the development of the gut microbiota and for determining the long-term effects of microbiological events in early life on human health and well-being.

Interventions for preventing obesity in children

EDITORIAL NOTE

This Cochrane review is now out of date and should not be used for reference. It has been split into four age groups and updated. Please refer to the 5‐11 and 12‐18 age group Cochrane reviews which were published in May 2024: https://doi.org/10.1002/14651858.CD015328.pub2 https://doi.org/10.1002/14651858.CD015330.pub2 The 2‐4 age group Cochrane review is planned for publication in September 2024.

BACKGROUND

Prevention of childhood obesity is an international public health priority given the significant impact of obesity on acute and chronic diseases, general health, development and well-being. The international evidence base for strategies to prevent obesity is very large and is accumulating rapidly. This is an update of a previous review.

OBJECTIVES

To determine the effectiveness of a range of interventions that include diet or physical activity components, or both, designed to prevent obesity in children.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsychINFO and CINAHL in June 2015. We re-ran the search from June 2015 to January 2018 and included a search of trial registers.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of diet or physical activity interventions, or combined diet and physical activity interventions, for preventing overweight or obesity in children (0-17 years) that reported outcomes at a minimum of 12 weeks from baseline.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data, assessed risk-of-bias and evaluated overall certainty of the evidence using GRADE. We extracted data on adiposity outcomes, sociodemographic characteristics, adverse events, intervention process and costs. We meta-analysed data as guided by the Cochrane Handbook for Systematic Reviews of Interventions and presented separate meta-analyses by age group for child 0 to 5 years, 6 to 12 years, and 13 to 18 years for zBMI and BMI.

MAIN RESULTS

We included 153 RCTs, mostly from the USA or Europe. Thirteen studies were based in upper-middle-income countries (UMIC: Brazil, Ecuador, Lebanon, Mexico, Thailand, Turkey, US-Mexico border), and one was based in a lower middle-income country (LMIC: Egypt). The majority (85) targeted children aged 6 to 12 years.Children aged 0-5 years: There is moderate-certainty evidence from 16 RCTs (n = 6261) that diet combined with physical activity interventions, compared with control, reduced BMI (mean difference (MD) -0.07 kg/m2, 95% confidence interval (CI) -0.14 to -0.01), and had a similar effect (11 RCTs, n = 5536) on zBMI (MD -0.11, 95% CI -0.21 to 0.01). Neither diet (moderate-certainty evidence) nor physical activity interventions alone (high-certainty evidence) compared with control reduced BMI (physical activity alone: MD -0.22 kg/m2, 95% CI -0.44 to 0.01) or zBMI (diet alone: MD -0.14, 95% CI -0.32 to 0.04; physical activity alone: MD 0.01, 95% CI -0.10 to 0.13) in children aged 0-5 years.Children aged 6 to 12 years: There is moderate-certainty evidence from 14 RCTs (n = 16,410) that physical activity interventions, compared with control, reduced BMI (MD -0.10 kg/m2, 95% CI -0.14 to -0.05). However, there is moderate-certainty evidence that they had little or no effect on zBMI (MD -0.02, 95% CI -0.06 to 0.02). There is low-certainty evidence from 20 RCTs (n = 24,043) that diet combined with physical activity interventions, compared with control, reduced zBMI (MD -0.05 kg/m2, 95% CI -0.10 to -0.01). There is high-certainty evidence that diet interventions, compared with control, had little impact on zBMI (MD -0.03, 95% CI -0.06 to 0.01) or BMI (-0.02 kg/m2, 95% CI -0.11 to 0.06).Children aged 13 to 18 years: There is very low-certainty evidence that physical activity interventions, compared with control reduced BMI (MD -1.53 kg/m2, 95% CI -2.67 to -0.39; 4 RCTs; n = 720); and low-certainty evidence for a reduction in zBMI (MD -0.2, 95% CI -0.3 to -0.1; 1 RCT; n = 100). There is low-certainty evidence from eight RCTs (n = 16,583) that diet combined with physical activity interventions, compared with control, had no effect on BMI (MD -0.02 kg/m2, 95% CI -0.10 to 0.05); or zBMI (MD 0.01, 95% CI -0.05 to 0.07; 6 RCTs; n = 16,543). Evidence from two RCTs (low-certainty evidence; n = 294) found no effect of diet interventions on BMI.Direct comparisons of interventions: Two RCTs reported data directly comparing diet with either physical activity or diet combined with physical activity interventions for children aged 6 to 12 years and reported no differences.Heterogeneity was apparent in the results from all three age groups, which could not be entirely explained by setting or duration of the interventions. Where reported, interventions did not appear to result in adverse effects (16 RCTs) or increase health inequalities (gender: 30 RCTs; socioeconomic status: 18 RCTs), although relatively few studies examined these factors.Re-running the searches in January 2018 identified 315 records with potential relevance to this review, which will be synthesised in the next update.

AUTHORS' CONCLUSIONS

Interventions that include diet combined with physical activity interventions can reduce the risk of obesity (zBMI and BMI) in young children aged 0 to 5 years. There is weaker evidence from a single study that dietary interventions may be beneficial.However, interventions that focus only on physical activity do not appear to be effective in children of this age. In contrast, interventions that only focus on physical activity can reduce the risk of obesity (BMI) in children aged 6 to 12 years, and adolescents aged 13 to 18 years. In these age groups, there is no evidence that interventions that only focus on diet are effective, and some evidence that diet combined with physical activity interventions may be effective. Importantly, this updated review also suggests that interventions to prevent childhood obesity do not appear to result in adverse effects or health inequalities.The review will not be updated in its current form. To manage the growth in RCTs of child obesity prevention interventions, in future, this review will be split into three separate reviews based on child age.

Standard v. baby-led complementary feeding: a comparison of food and nutrient intakes in 6–12-month-old infants in the UK

Objective:

To compare food and nutrient intakes of infants aged 6–12 months following a baby-led complementary feeding (BLCF) approach and a standard weaning (SW) approach.

Design:

Participants completed an online questionnaire consisting of sociodemographic questions, a 28 d FFQ and a 24 h dietary recall.

Setting:

UK.

Participants:

Infants (n 134) aged 6–12 months (n 88, BLCF; n 46, SW).

Results:

There was no difference between weaning methods for the food groups ‘fruits’, ‘vegetables’, ‘all fish’, ‘meat and fish’, ‘sugary’ or ‘starchy’ foods. The SW group was offered ‘fortified infant cereals’ (P < 0·001), ‘salty snacks’ at 6–8 months (P = 0·03), ‘dairy and dairy-based desserts’ at 9–12 months (P = 0·04) and ‘pre-prepared baby foods’ at all ages (P < 0·001) more often than the BLCF group. The SW group was offered ‘oily fish’ at all ages (P < 0·001) and 6–8 months (P = 0·01) and ‘processed meats’ at all ages (P < 0·001), 6–8 months (P = 0·003) and 9–12 months (P < 0·001) less often than the BLCF group. The BLCF group had significantly greater intakes of Na (P = 0·028) and fat from food (P = 0·035), and significantly lower intakes of Fe from milk (P = 0·012) and free sugar in the 6–8 months subgroup (P = 0·03) v. the SW group. Fe intake was below the Reference Nutrient Intake (RNI) for both groups and Na was above the RNI in the BLCF group.

Conclusion:

Compared with the SW group, the BLCF group was offered foods higher in Na and lower in Fe; however, the foods offered contained less free sugar.

Screening and Referral for Childhood Obesity: Adherence to the U.S. Preventive Services Task Force Recommendation

INTRODUCTION

The U.S. Preventive Services Task Force recommends clinicians screen children aged 6 years or older for obesity and offer or refer children with obesity to intensive weight management programs. This study explores clinician awareness of weight management programs meeting the recommendation, adherence to the recommendation of screening and referral, and associations between provider and practice characteristics and weight management program referrals.

METHODS

This cross-sectional study used data from the DocStyles survey 2017, a web-based panel survey, analyzed in 2017. Among 1,023 clinicians who see pediatric patients, this study examined clinician awareness of weight management programs in their communities that met the recommendation, practice of screening for childhood obesity, and referral to weight management programs. Multivariable logistic regression estimated associations between the demographic and practice characteristics of clinicians and weight management program referrals.

RESULTS

Only 24.6% of surveyed clinicians were aware of a weight management program that met the U.S. Preventive Services Task Force recommendation in their community; of those aware, 88.9% referred patients to these weight management programs. Most (83.6%) clinicians screened children for obesity in ≥75% of visits. Overall, 53.5% of clinicians provided referrals to weight management programs. Referral was higher among female clinicians and clinicians serving mostly middle-income patients. Providers without teaching hospital privileges had lower odds of referral.

CONCLUSIONS

Adherence to clinical recommendations is essential to curbing the childhood obesity epidemic. Only one in four surveyed clinicians were aware of weight management programs in their community meeting U.S. Preventive Services Task Force criteria. Half of clinicians referred pediatric patients with obesity to a weight management program. Results suggest efforts are needed to increase awareness of, and referral to, weight management programs meeting the recommendation.

Baby-led complementary feeding: Randomized controlled study

BACKGROUND

Baby-led weaning (BLW) is an approach to introducing solid foods to infants that gives control of the feeding process to the infant. Anecdotal evidence suggests that BLW is becoming popular with parents, but scientific research is limited to a few publications. This study assessed growth, hematological parameters and iron intake in 6-12-month-old infants fed by traditional or baby-led complementary feeding.

METHODS

We recruited 280 healthy 5-6-month-old infants allocated to a control (traditional spoon feeding; TSF) group or an intervention (BLW) group in a randomized controlled trial. Infant growth, hematologic parameters and iron intake were evaluated at age 12 months.

RESULTS

Infants in the TSF were significantly heavier than those in the BLW group. Mean weight in the BLW group was 10.4 ± 0.9 kg compared with 11.1 ± 0.5 kg in the TSF group. There was no statistically significant difference in the iron intake from complementary foods between the BLW (7.97 ± 1.37 mg/day) and TSF (7.90 ± 1.68 mg/day) participants who completed the diet records. Hematologic parameters were similar at 12 months. The incidence of choking reported in the weekly interviews was not different between the groups.

CONCLUSIONS

To the best of our knowledge, this is the first randomized -controlled study to have examined the impact of weaning method on iron intake, hematological parameters and growth in breast-fed infants. BLW can be an alternative complementary feeding type without increasing the risk of iron deficiency, choking or growth impairment.

Mediation Analysis as a Means of Identifying Dietary Components That Differentially Affect the Fecal Microbiota of Infants Weaned by Modified Baby-Led and Traditional Approaches

The introduction of "solids" (i.e., complementary foods) to the milk-only diet in early infancy affects the development of the gut microbiota. The aim of this study was to determine whether a "baby-led" approach to complementary feeding that encourages the early introduction of an adult-type diet results in alterations of the gut microbiota composition compared to traditional spoon-feeding. The Baby-Led Introduction to SolidS (BLISS) study randomized 206 infants to BLISS (a modified version of baby-led weaning [BLW], the introduction of solids at 6 months of age, followed by self-feeding of family foods) or control (traditional spoon-feeding of purées) groups. Fecal microbiotas and 3-day weighed-diet records were analyzed for a subset of 74 infants at 7 and 12 months of age. The composition of the microbiota was determined by sequencing of 16S rRNA genes amplified by PCR from bulk DNA extracted from feces. Diet records were used to estimate food and dietary fiber intake. Alpha diversity (number of operational taxonomic units [OTUs]) was significantly lower in BLISS infants at 12 months of age (difference [95% confidence interval {CI}] of 31 OTUs [3.4 to 58.5]; P = 0.028), and while there were no significant differences between control and BLISS infants in relative abundances of Bifidobacteriaceae, Enterobacteriaceae, Veillonellaceae, Bacteroidaceae, Erysipelotrichaceae, Lachnospiraceae, or Ruminococcaceae at 7 or 12 months of age, OTUs representing the genus Roseburia were less prevalent in BLISS microbiotas at 12 months. Mediation models demonstrated that the intake of "fruit and vegetables" and "dietary fiber" explained 29% and 25%, respectively, of the relationship between group (BLISS versus control) and alpha diversity.IMPORTANCE The introduction of solid foods (complementary feeding or weaning) to infants leads to more-complex compositions of microbial communities (microbiota or microbiome) in the gut. In baby-led weaning (BLW), infants are given only finger foods that they can pick up and feed themselves-there is no parental spoon-feeding of puréed baby foods-and infants are encouraged to eat family meals. BLW is a new approach to infant feeding that is increasing in popularity in the United States, New Zealand, the United Kingdom, and Canada. We used mediation modeling, commonly used in health research but not in microbiota studies until now, to identify particular dietary components that affected the development of the infant gut microbiota.

Impact of a Modified Version of Baby-Led Weaning on Dietary Variety and Food Preferences in Infants

The aim of this study was to determine whether food variety and perceived food preferences differ in infants following baby-led instead of traditional spoon-feeding approaches to introducing solids. A total of 206 women (41.3% primiparous) were recruited in late pregnancy from a single maternity hospital (response rate 23.4%) and randomized to Control (n = 101) or BLISS (n = 105) groups. All participants received government-funded Well Child care. BLISS participants also received support to exclusively breastfeed to 6 months and three educational sessions on BLISS (Baby-Led Weaning, modified to reduce the risk of iron deficiency, growth faltering, and choking) at 5.5, 7, and 9 months. Food variety was calculated from three-day weighed diet records at 7, 12, and 24 months. Questionnaires assessed infant preference for different tastes and textures at 12 months, and for 'vegetables', 'fruit', 'meat and fish', or 'desserts' at 24 months. At 24 months, 50.5% of participants provided diet record data, and 78.2% provided food preference data. BLISS participants had greater variety in 'core' (difference in counts over three days, 95% CI: 1.3, 0.4 to 2.2), 'non-core' (0.6, 0.2 to 0.9), and 'meat and other protein' (1.3, 0.8 to 1.9) foods at 7 months, and in 'fruit and vegetable' foods at 24 months (2, 0.4 to 3.6). The only differences in perceived food preferences observed were very small (i.e., <5% difference in score, at 12 months only). Infants following the modified Baby-Led Weaning were exposed to more varied and textured foods from an early age, but only an increased variety in 'fruit and vegetable' intake was apparent by two years of age.