A Baby-Led Approach to the Introduction of Solids and Risk of Choking


May 22, 2018 by: Louise Fangupo, MSc
Rachael Taylor, PhD
Article Tags:

In Western countries, parents typically introduce their infant to complementary foods by spoon-feeding them small amounts of pureed food. As the baby gets used to eating purees, a wider range of textures (mashed, diced, then whole) and tastes can be introduced.  In ‘baby-led’ approaches to the introduction of solids, the use of purees is generally bypassed and the infant feeds himself whole foods from the beginning of the complementary feeding period at around six months of age. Many people believe there are several advantages to a baby-led approach:
 
i) infants remain in control of their food intake, which might make it easier for them to recognize when they are full;
ii) infants are involved with family mealtimes rather than being fed separately, which is good for family interactions;
iii) they are offered a wider range of foods, which might make them less fussy about food. 

However, baby-led approaches also have potential downfalls, one of these being a possible increase in the risk of choking, especially in the early days. Are six-month-old infants really able to coordinate the complex processes of breathing, chewing, and swallowing when the food involved is served as whole pieces?

Our New Zealand-based study, the Baby-Led Introduction to SolidS (BLISS) study, involved 206 families, half of whom were given support and advice to safely implement a baby-led approach to solids with their infant (the ‘BLISS’ group). The advice included specific information about how to reduce the risk of choking, as outlined in Figure 1. Half of the study’s families did not receive any of our specific guidance about how to feed their babies (the ‘Control’ group). Instead, they would have received standard government recommendations in New Zealand that suggest that the first solids are given in pureed form, and that over time there is a gradual progression to mashed, then to chopped and finger foods. Information about reducing the risk of choking is also included in these recommendations.

Reassuringly, the infants in our baby-led group did not prove to be any more likely to choke than the babies who were fed more conventionally. In fact, we saw very few differences between the two groups. The most important findings really related to what foods parents were offering their baby – regardless of feeding style – and the observation that infants can choke on a wide variety of foods, not necessarily just the ones you might consider more ‘risky’. Our findings were:

•    35% of the babies from both groups choked at least once between 6 and 8 months of age.
•    By 12 months of age, nearly all babies had been offered at least one food which could be considered to have presented a choking hazard (such as a piece of raw apple or small diced meat).
•    The foods which babies actually choked on were many and varied, ranging from liquids, such as milk, to solid food items, such as banana.
•    Parents did not always closely supervise their babies while they ate; this is a problem because it is very important that there is someone there to notice if baby is choking and to help him recover quickly, or to get medical help if needed.

Based on these findings, it seems that there are several things which all parents and caregivers need to remember when introducing solids to babies. First, it is important to serve safe foods (such as those outlined in Figure 1 if using a baby-led approach). Second, each and every eating occasion should be supervised. Parents should also understand the difference between choking (where the baby’s airway is completely or partially blocked, so that breathing is compromised) and its benign counterpart, gagging (which may look alarming, but does not affect the airway or ability to breathe). Finally, because choking is sometimes unavoidable, parents should have knowledge of first aid measures for choking, and of how to perform CPR on babies. 

Figure 1: General principles for reducing the risk of food-related choking in baby-led approaches
1. Test foods before they are offered to ensure they are soft enough to mash with the tongue on the roof of the mouth (or are large and fibrous enough that small pieces do not break off when sucked and chewed, e.g., strips of meat) especially in the early months.
2. Avoid offering foods that form a crumb in the mouth.
3. Make sure that the foods offered are at least as long as the child’s fist, on at least one side of the food.
4. Make sure infants are always sitting upright when they are eating – never leaning backwards.
5. Never leave your baby alone with food; always have an adult with the child when he is eating.
6. Never let anyone except your baby put food into her mouth; the infant must eat at her own pace and under her own control.

Louise Fangupo

Louise Fangupo, MSc

Louise Fangupo MSc is a New Zealand Registered Dietitian with an interest in infant feeding. Her MSc project investigated whether a baby-led approach to complementary feeding altered the risk of choking and growth faltering in infants aged 0-12 months.

Rachael Taylor

Rachael Taylor, PhD

Rachael Taylor, PhD, is a Research Professor and Director of the Edgar Diabetes and Obesity Research Centre, based at the University of Otago in Dunedin, New Zealand. She leads or co-leads several large, randomised controlled trials investigating different approaches to effective weight management in children, adolescents, and families.