32 - Baby-led weaning prevalence and associated factors in Spain

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European Journal of Pediatrics https://doi.org/10.1007/s00431-020-03579-7

ORIGINAL ARTICLE

Baby-led weaning: prevalence and associated factors in Spain Mónica Pérez-Ríos 1,2 & Maria Isolina Santiago-Pérez 1 & Haylie Butler 2 & Nerea Mourino 2 & Alberto Malvar 1 & Xurxo Hervada 1 Received: 22 October 2019 / Revised: 4 December 2019 / Accepted: 10 January 2020 # Springer-Verlag GmbH Germany, part of Springer Nature 2020

Abstract The main goals of this study are to estimate the percentage of mothers who declared feeding their children with baby-led weaning (BLW) and to characterize them. A cross-sectional survey was carried out in 2016 targeting women who had given birth in 2016 (sample size 6777) in Galicia (Spain). The questionnaire included questions regarding the mother’s characteristics and behaviors, attitudes, and practices related to BLW. Prevalence of exclusive and non-exclusive BLW was estimated. Different maternal characteristics were evaluated for their possible association with BLW using a logistic regression model. The percentages and ORs were presented with a 95% confidence interval. The study included 6355 women, of which 38.6% (37.4–39.9) had heard of BLW and the overall prevalence of BLW was estimated at 14.0% (13.1–14.9). Prevalence of exclusive BLW was estimated at 2.1% (2.4–3.3). No differences were observed when age was taken into consideration. Children fed with BLW were more likely among mothers who continue with exclusive breastfeeding (OR, 4.1 (95% CI, 3.3–5.0)); live in an urban setting (OR, 1.6 (1.22.2)); or have a higher level of education (OR, 1.3 (1.1-1.5)). Conclusion: Full adherence to BLW seems low among mothers who claimed to have fed their children following this method. What is Known: • Baby-led weaning (BLW) has been present in our society for almost two decades, but it remains unclear how many mothers choose BLW for their children. What is New: • BLW is not a common choice for weaning in Spain, and more than half of the mothers had not heard about it. • Full adherence to BLW seems low among mothers who claimed to have fed their children following this method.

Keywords Feeding behavior . Feeding methods . Baby-led weaning . Cross-sectional study . Infants . Prevalence Abbreviations BLW Baby-led weaning CI Confidence interval OR Odds ratio

Introduction Complementary feeding should be introduced when milk, maternal or formula, cannot provide the nutrients and energy

Communicated by Mario Bianchetti This paper is part of the PhD work of Nerea Mourino * Mónica Pérez-Ríos [email protected]

Alberto Malvar [email protected] Xurxo Hervada [email protected]

Maria Isolina Santiago-Pérez [email protected] Haylie Butler [email protected]

1

Epidemiology Unit, Galician Directorate for Public Health. Consellería de Sanidade, Santiago de Compostela, Spain

Nerea Mourino [email protected]

2

Department of Preventive Medicine and Public Health, University of Santiago de Compostela, Santiago de Compostela, Spain

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necessary for the growth and optimal development of the child. Until now, there has not been consensus about when complementary feeding should be implemented. While the World Health Organization (WHO) places this age at 6 months, the European Society for Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) recommends complementary feeding between 17 and 24 weeks of life [11, 18]. However, there is consensus that complementary feeding should be safe and should satisfy the nutritional requirements of the child. The onset of complementary feeding typically occurs by spoon-feeding baby cereals and puréed foods to the child along with maternal or formula milk. These purées are composed of foods such as fruit, vegetables, meat, poultry or fish, all of which are progressively processed from a thin to thicker texture until the child is offered family foods. This is currently the recommendation followed by most pediatric societies and by the WHO. The latter also stipulates that at 12 months children should eat the same food as their families and, more precisely, that they should not be given finger foods until 8 months and that these should not be a substitute for baby cereals or purées [19]. At the beginning of the twenty-first century, baby-led weaning (BLW), auto-weaning, or regulated self-nutrition emerged as an alternative method of infant feeding. In 2008, a book [14] was published and the popularity of BLW increased. BLW in its purest form is based on the fact that children from 6 months on join the family at mealtimes, choose what they want to eat, and feed themselves. The food offered to the child is prepared and cut into fist-sized pieces and ideally should be family food. Initially, children use their hands to eat and as they grow, they use cutlery. The adult decides what to offer and must be a facilitator or passive subject in the process of feeding while the active subject is the child, who chooses what, how much, and how fast to eat. The adult does not feed the child and never forces or rushes the process [12]. There is some evidence from observational studies that BLW decreases the mothers´ pressure on children in relation to food, decreases restrictions or concerns about weight [1], and also encourages children to choose healthier foods such as carbohydrates [17]. Despite the popularity that BLW has achieved, different professionals have concerns about this method [3, 6, 7, 15, 16]. Although BLW has been present as such in society for almost two decades, it is not known how many mothers choose regulated self-weaning with their children. In countries where BLW is most popular, for example, New Zealand, prevalence was estimated at 30% [4]. In Spain, as in the majority of countries, prevalence remains unknown. The goals of this work are to estimate the percentage of mothers who declared feeding their children with BLW and to identify their characteristics.

Methods Study area and population The study was performed in Galicia, Spain, an autonomous northwestern region with an estimated population of 2.7 million in 2016. The boundaries of Galicia to the north and west are marked by the Atlantic Ocean, to the south by Portugal, and to the east by mainland Spain. Around half of the population lives in the countryside, with the remaining population living in medium-sized cities or small towns. The crude annual birth rate in 2016 was 7.02, and the mean maternal age was 32.6. Data source Within the framework of the Surveillance Information System on Risk Behaviors (SICRI), a crosssectional survey was carried out in 2016 targeting Galician women residents who were at least 18 years of age and had given birth to a live child between September 1, 2015, and August 31, 2016 (N = 19,213). The sample was selected from the Early Detection Program Registry of Endocrine and Metabolic Diseases during the Neonatal Period, using random sampling stratified by age group (18–24, 25–29, 30–34, 35– 39, 40 and older). The sample size (6777 in total) was calculated independently for each age stratum, with an expected prevalence of 50% and an error of less than or equal to 2%. The information was collected through a computer-assisted telephone interview (CATI) system, and the questionnaire included questions regarding the mother’s behaviors, attitudes, and practices 6 months prior to pregnancy, during pregnancy, at delivery, and at the time of the survey (between 3 and 16 months after delivery). Prevalence of baby-led weaning During the interview, mothers were asked if they had heard about baby-led weaning or selfregulated weaning; in the case of an affirmative, they were asked if their child was being fed by this method. In another section of the questionnaire, mothers were asked if their child was being fed with purées or baby cereals. Mothers who declared having fed their child only with BLW were classified as strict BLW, meaning an infant who is strictly fed by himself, without any use of spoon-feeding. On the other hand, if they responded affirmatively when asked if their child was being fed with purées or baby cereals and also had an affirmative to BLW, they were classified as non-strict. With this information, BLW prevalence was calculated, by child age, as the percentage of mothers who were feeding their children with BLW at the time of the interview. These percentages were accompanied by 95% confidence intervals (95% CI). The following maternal characteristics were evaluated for their possible association with BLW: a) at the time of delivery: age group, level of education (basic: illiterate, had no schooling, or did not complete primary education; medium: high school-educated; high: university educated), residential environment (urban, semi-urban, and rural), country of birth,

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employment status (workers, students, pensioners, others), marital status (single vs. not), primiparous (yes vs. no); b)lifestyle 6 months prior or during pregnancy: compliance with dietary recommendations of eating 3 portions of vegetables or fruits a day and fish 3 times a week (yes vs. no), performance of regular physical activity (yes vs. no), tobacco consumption (smoker, former smoker, and never smoker); c) lifestyle during pregnancy: attendance at childbirth preparation classes (yes vs. no); d) at the time of the survey: breastfeeding (never, before but not now, strict, or mixed). For each of these maternal characteristics (which a priori could be related to BLW), the odds ratio (OR) of BLW was estimated using a logistic regression model. The global model was adjusted taking into account all variables associated with the outcome at a p value < 0.2. The ORs were presented with a 95% CI. The analysis was performed with the weighted sample using the Stata program v14.2. Ethical approval by the Galician Ethics Committee was not necessary because this study was voluntary and anonymous, ensuring full confidentiality. The study was conducted by telephone, and accordingly, agreement to participate implies consent.

Results The study analyzed information provided from 6355 women aged between 18 and 50 years of which 44.2% were university educated, 57.1% were primiparous, 71.8% were working when the baby was born, 89.1% of the women were born in Spain, and 71.0% resided in urban environments. Among Galician mothers, 38.6% (37.4–39.9) had heard of BLW. The lowest prevalence was observed among younger (18–29 years) and older mothers (40 years and over) where prevalence was estimated at 32.4% (30.2–34.6) and 35.9% (33.0–38.8), respectively. Among mothers between the ages of 30 and 39, the prevalence was close to 40%. The overall prevalence of BLW in Galicia was estimated at 14.0% (13.1–14.9), varying according to the age of the child at the time of the interview (Fig. 1). Thus, among the mothers of children aged 4–5 months, the prevalence of BLW was 5.5% and at 6–7 months it was 10.8%. Among children aged 14–15 months, prevalence was estimated at 21.1%. Prevalence of strict BLW was estimated at 2.1% (2.4–3.3). No differences were observed when age was taken into consideration (Fig. 1). At the time of interview, 79.6% (76.8–82.5) and 57.0% (53.5–60.5) of mothers who declared as following BLW stated that the child was consuming purées or baby cereals, respectively; 2.9% (1.7–4.1) and 14.2% (11.7–16.7) had consumed purées and baby cereals, respectively, but no longer ate them;17.4% (14.7–20.2) of children fed following BLW had

never been fed purées, and 28.8% (25.6–32.0) had never had baby cereals. As shown in Fig. 2, mothers who fed their children by BLW were more likely to continue with breastfeeding, either strictly (OR, 4.1 (95% CI, 3.3–5.0)) or mixed (OR, 1.9 (1.5– 2.4)); live in an urban setting (OR, 1.6 (1.2–2.2)); be under 40 years old (OR, 1.5 (1.2–1.9)); have a higher level of education (OR, 1.3 (1.1–1.5)), or comply with dietary recommendations (OR, 1.3 (1.1–1.5)), among other variables.

Patient and public involvement No patient or public involvement.

Discussion Despite the popularity of BLW in countries like the UK or New Zealand, in Spain, BLW is not a common choice for weaning, and more than half of the mothers were not aware of it and the prevalence of use was low. Since no formal definition of BLW exists, it is unclear how to estimate the prevalence of use. Allowing families to selfidentify as following BLW does not seem to be a valid approach. As in other studies, it is noted that mothers, despite declaring that they have fed their children with BLW, complement with spoon-feeding [3, 4, 8]. Also, it is unclear whether BLW can include the limited use (less than 10%) of purées and spoon-feeding, or if it is ruled by a strict definition where only finger foods are provided. When prevalence of BLW use was estimated taking into account the use of purées or spoon-feeding, full adherence to BLW seems low and the prevalence of infants not ever spoon-fed decreased dramatically. At this point, it is important to highlight the fact that frequency of use of purées or spoon-food was not ascertained. The WHO recommendation regarding the age of introduction of complementary foods has provided BLW supporters with justification that a 6-month-old child has the necessary motor skills to safely face whole foods and does not need to be spoon-fed by adults [12]. However, even by proponents, it is not recommended below this age [13]. Nevertheless, the timing of introduction of solid food depends mainly, on baby growth pattern, skill, and feeding modality (breastfeeding or formula feeding); for these reasons, ESPGHAN suggests introducing complementary feeding between 17 and 24 weeks of life. Thus, the percentage of mothers who declare using BLW in children aged 4 or 5 months becomes important. The characteristics of Spanish mothers who fed their children with BLW are similar to those found in other studies. These studies have already indicated that breastfeeding [1, 17] or having higher education [1] was more frequent among BLW mothers. With respect to education level, the findings between studies are inconsistent [2].

Eur J Pediatr Fig. 1 Percentage of women who declared using baby-led weaning and strict baby-led weaning (BLW), by baby age groups in months

This study presents various limitations. The most important has to do with the study’s design which can be associated with memory bias. Also, due to the design of the questionnaire, it is impossible to know precisely key aspects related to BLW as at what week of life started, since information was obtained in months of life. In addition, a limitation of this study is that we relied on mothers to identify themselves as using or having used BLW. For some authors, this is an important limitation [7] and some suggest that it would be better to ask about the frequency at which children are spoon-fed and even point to a cut-off of 10% or less in the frequency of spoon-feeding to

Fig. 2 Characteristics associated with baby-led weaning among women. Odds ratio (OR) and 95% confidence intervals (95% CI)

classify it as BLW [1]. It should be noted that different studies [2, 7], including the present study, define BLW as it is stated by the mothers themselves, regardless of whether children are spoon-fed. But according to the strict, original definition [14], giving children baby cereals or purées is not BLW. In addition, the prevalence of strict BLW could be overestimated, since mothers might have forgotten or avoided mentioning specific situations in which they spoon-fed their children. This study has several strengths, mainly the sample size (it accounts for more than 1 in 3 of the 19,000 mothers who gave birth in Galicia in the studied period) and population representativeness. Moreover, the study did not solely focus on feeding practices, so mothers were not aware of its aim. It is not the objective of this work to assess the nutritional adequacy of BLW. However, it should be noted that a recent systematic review concludes that the available evidence is of low quality and insufficient to assess BLW in terms of energy or nutritional adequacy [7]. The studies conducted with the aim of evaluating the nutritional aspects of BLW are scarce. Sample sizes in most were small and were carried out on selected populations which results in low validity and the presence of bias, especially social desirability. Two studies, one observational [5] and the other a randomized study, [9] aimed to evaluate the BLISS study, a modified version of BLW where parents were given advice to offer “high-iron” foods with each meal, reported no difference in iron intake between groups. Overall, the results of the present study reflect that prevalence of strict BLW is low and characteristics of the mothers who fed their children with BLW are similar to those found in other studies, but a question related to the BLW definition remains. A clear definition of BLW is imperative in order to permit a precise estimation of prevalence. Health professionals working with parents who feed or are considering feeding their children by BLW should emphasize the importance of foods rich in minerals such as iron as part of

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the complementary feeding and should highlight the risk of choking on foods like raw apples [3, 10]. They should also emphasize the importance of adapting family meals to the nutritional and energy needs of the child, for example, by cooking without salt or sugar. Both professionals and parents who choose BLW should have adapted food guides in order to properly implement the method efficiently. Authors’ contributions MPR planned the study and supervised the work, performed the analisis, wrote the first draft and succesive versions. MIS planned the study and supervised the work, performed the analysis and contributed to the drafts of the succesive versions of the manuscript. HB contributed to the drafts of the succesive versions of the manuscript and provided critical comments. NM contributed to the drafts of the succesive versions of the manuscript and provided critical comments. AM planned the study and contributed to the drafts of the succesive versions of the manuscript and provided critical comments. XH planned the study and contributed to the drafts of the succesive versions of the manuscript and provided critical comments All the authors approved the final version of the paper. MPR is the guarantor.

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Compliance with ethical standards Conflict of interest The authors declare that they have no conflict of interest. Ethical approval This article does not contain any studies with human participants or animals performed by any of the authors.

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