Thesis - Baby-led Weaning: an emerging trend in Denmark by DeCostaMorell

FACULTY O F S C I E N C E UNIVERSITY OF COPENHAGEN

Baby-led Weaning; an emerging trend in Denmark. How is baby-led weaning practised in Denmark? What is the evidence on health related outcomes associated with the practice of baby-led weaning?

MSc Thesis Patricia DeCosta Supervisors Kim F. Michaelsen and Annemette Nielsen 1

Title page University: University of Copenhagen, Faculty of Science Name of department: Department of Nutrition, Exercise and Sports Degree: MSc Human Nutrition Author: Patricia DeCosta Study ID: fkm734 Title: Baby-led Weaning; an emerging trend in Denmark. How is baby-led weaning practised in Denmark? What is the evidence on health related outcomes associated with the practice of babyled weaning? ECTS points: 45 Date submitted: 15.10.2014 Academic supervisors: Kim F. Michaelsen - Professor at the Department of Nutrition, Exercise and Sports (Paediatric and International Nutrition) Annemette Nielsen - Assistant Professor at the Department of Food and Resource Economics

Preface and Acknowledgements This Masterâ&#x20AC;&#x2122;s Thesis in Human Nutrition was written at the Department of Nutrition, Exercise and Sports (NEXS) at University of Copenhagen, faculty of SCIENCE, during the time period; December 2013 to October 2014 and was submitted on the 15th October 2014. I owe a special thank you to my two supervisors, Kim Fleischer Michaelsen and Annemette Nielsen, who have provided valuable guidance and insight from their diverse fields of expertise. Without their curiosity and open-mindedness the writing of this Thesis would not have been possible. Thank you to all the parents, children and Health Visitors taking part in this study. Thank you to all the people who have helped me during the writing of this Thesis with critical discussions and final proofreading.

Abstract Introduction and background: Baby-led weaning is a different approach to infant feeding, which promotes self-feeding opposed to parental spoon feeding and the introduction of complementary foods led by the infant. This feeding method, which was originally described by the British Health Visitor Gill Rapley, has gained popularity in the UK and New Zealand and is now also emerging in Denmark. Aim: The aim of this study was to conduct a review on the current evidence on baby-led weaning and to examine how baby-led weaning is practised in Denmark. Based on these findings this Thesis aimed to critically evaluate the evidence for the proposed health related risks and benefits of following this approach to weaning. Methods: For the literature review; studies on baby-led weaning were identified using relevant electronic databases. To gain an insight into the practice of baby-led weaning in Denmark, a qualitative study was conducted; 10 parents from Denmark and the United Kingdom and 3 Health Visitors from Copenhagen Municipality completed one of two semi-structured interviews examining different aspects related to the practice of baby-led weaning. The transcribed interviews were analysed using a combination of a deductive and an inductive approach. Results from a review of baby-led weaning studies: Eleven studies reporting original data, published in English were identified and included in the review. Thus far, evidence demonstrated that mothers practising baby-led weaning were more likely to be married, have a higher education, a higher occupation and to have breastfed their infant and breastfed for a longer duration of time compared to mothers using standard weaning. Practising baby-led weaning was associated with later introduction of complementary foods, greater participation in meal times and exposure to family foods. Levels of anxiety about weaning and feeding were reported to be lower in mothers who adopted a baby-led weaning approach. This included significantly lower levels of restriction, pressure to eat and monitoring compared to mothers following a standard weaning approach. One prospective study showed that baby-led weaned infants were reported to be less picky, having better appetite regulation and were less likely to be overweight compared to standard weaned infants. One study highlighted that infants who are relatively developmentally delayed, might be at greater risk of nutrient deficiency if weaned following a baby-led weaning 4

approach. The small number of studies and the lack of more objective outcome measures were the major limitations of the studies currently conducted in this field. Results from interviews with baby-led weaning parents and Health Visitors: Informants from Denmark practised baby-led weaning in a manner that closely followed the baby-led weaning method originally described by Rapley. The main emphasis from parents regarding their childÂ´s diet was that eating should be a positive experience and that their diet was varied and healthy. Children were exposed to, and repeatedly tasted a variety of foods, and parents hoped this would lead to adventurous eaters in the future. All the children received a wholesome and varied diet which included fish, meat, fruit, vegetables, fat and oils. Their intake of complementary food was likely to be less than the average spoon-fed infant in the first few months of weaning, but all infants continued to be breastfeed on demand. The practice of baby-led weaning was associated with other responsive parenting practices, such as co-sleeping, extended breastfeeding, babywearing and baby signing. In contrast to the United Kingdom, Health Visitors in Denmark played a much more important role. Their role as an authority figure was evident and their view on babyled weaning was important to the informants. The participantâ&#x20AC;&#x2122;s receptiveness to the Health Visitors advice was dependent on the Health Visitors attitude, or initial reaction to baby-led weaning. Despite the positive experiences that mothers consistently reported, going against official advice triggered some feelings of insecurity and self-doubt in parents from Denmark. Conclusions: Baby-led weaning may encourage an array of healthful behaviours, such as introduction of solids at the recommended age of 26 weeks and longer duration of breastfeeding, promote a responsive feeding environment and early exposure to a variety of foods. Baby-led weaning may encourage healthy appetite regulation and decrease the risk of overweight in toddlerhood. In the light of these indicators, further research into this approach to weaning is very relevant. Increasing Health Visitors knowledge of BLW could possibly enhance communication with parents practising BLW, ensuring a better outcome for the individual child without causing the parents unnecessary concerns. To this date no study has adequately examined the risk of iron or energy deficiency in baby-led weaned children. Likewise, no research has studied the relationship between the timing of introduction of whole food and the risk of choking. Given that the number of parents practising baby-led weaning is rising, more studies on these aspects of the practice are urgently needed.

Table of Contents

Abbreviations and terminology BLW

Baby-led weaning

BMI

Body Mass Index

Danish Health and Medicines Authority

Sundhedsstyrelsen

Denmark

SES

Socioeconomic status

Standard weaning

United Kingdom

Weaning

The introduction of solid foods also referred to as complementary food; comprising of all liquid or solid foods other than breast milk or infant formula.

WHO

World Health Organization

Introduction Weaning is the period where infants transition from a diet of exclusive milk feeding, onto gradually eating solid food and ends with the cessation of breast or formula feeding. With formula feeding, the weaning stage is recommended to last until the child is 1 year old (Department of Health 2013, Sundhedsstyrelsen 2011), whereas continued breastfeeding is recommended to the age of 2 years or beyond by the World Health Organization (WHO) (WHO 2001). In 2001, after a systematic review and expert consultation, WHO amended their official advice on exclusive breastfeeding, from 4 - 6 months, to the first 6 months of life (WHO 2001). The change in recommendation regarding exclusive breastfeeding, consequently affected the timing of introduction of complementary foods to around 6 months of age. Naturally, spoon feeding and the pureeing of food has been a prerequisite for feeding infants solids at 4 months or even younger. However, a 6 month old child is at a more advanced stage developmentally compared to a 4 month old child. On this basis, the necessity of parental spoon feeding and use of mashed and pureed food has therefore been questioned (Rapley, Murkett 2008). The concept of baby-led Weaning (BLW) was first described in 2008 by Health Visitor Gill Rapley in her book “Baby-led Weaning, Helping your baby to love good food”, which was first published in the United Kingdom (UK) (Rapley, Murkett 2008). Gill Rapley developed the theory of BLW while studying young children’s developmental readiness for solids as part of her (unpublished) Master’s degree (Rapley 2003). In summary, the starting point of BLW is the child’s developmental readiness. Weaning is initiated by the infant, when they are ready and start to feed themselves. This occurs around 6 months of age, when the infant can support its head and can sit with little or no support. The parent’s part of the weaning process is to provide suitable food and the opportunity to eat and explore. Breast (or formula) feeding on demand is continued and the child decides when he/she is ready to reduce milk feedings. The baby is actively engaging in family mealtimes from the onset of weaning. Food is offered in shapes and sizes that are easy to handle, rather than being mashed or pureed. The child is not spoon-fed by parents, but is in charge of feeding itself from the beginning. The weaning stage proceeds at the infants own pace and parents are reminded not to expect the 8

number and volume of milk feeding to decrease until approximately nine months of age, although this will vary depending on the individual child (Rapley, Murkett 2008). There is a great deal of emphasis in BLW that the transition to solid foods should be a positive experience for the child, where the child is allowed to explore a whole new world of smells, tastes, textures and sensations. It is an opportunity for the child to learn a multitude of new skills and gain confidence and independence (Rapley, Murkett 2008). Several benefits of BLW have been proposed. Specifically, it has been hypothesised that BLW may decrease pickiness in later childhood (Townsend, Pitchford 2012), prevent overweight by attuning children to their own cues of hunger and satiety (Brown, Lee 2013a) and encouraging a maternal feeding style low in control (Brown, Lee 2011b).

Background Since 2008, BLW has gained increasing popularity amongst parents, predominately in the UK and other English speaking countries. There is currently no estimation to the number of parents following BLW in the UK or around the world. However, it is clear that it is a growing trend: The book “Baby-led Weaning, Helping your baby to love good food” has now been translated into 12 different languages (Rapley 2014). Searches on ‘baby-led weaning’ on Google produce over 1.18 million results (26.05.14). A recent survey from New Zealand, found that out of 200 parents of children in the weaning stage, around 30% reported that they practised BLW, although only 9% were found to adhere to BLW in terms of using minimal parental spoon-feeding (Cameron, Taylor et al. 2013). The Danish Facebook-group; Baby-led weaning DK, provides evidence that the trend is also growing in Denmark (DK). During the writing of this Thesis (December 2013 – October 2014) the number of parents in this group has increased from approximately 800 members to more than 1700 members (Baby-led weaning DK 2014). Currently, there are a number of studies describing how BLW is practised and the characteristics of the parents choosing this weaning style. However, these studies are currently limited to samples of UK based mothers (Brown, Lee 2011a, Townsend, Pitchford 2012, Arden, Abbott 2014) and New Zealand based mothers (Cameron, Heath et al. 2012, Cameron, Taylor et al. 2013). There is currently no published literature describing BLW in DK. Many aspects, such as cultural and

structural differences between the UK and DK might affect how BLW is understood, interpreted and practised: Scientific evidence on optimal nutrition in the complementary feeding period remains very limited and most guidelines are not evidence based (Agostoni, Decsi et al. 2008). The WHO’s recommendations to introduce complementary foods is mainly based on the recommendation for optimal duration of exclusive breastfeeding, which is 26 weeks (WHO 2001). The lack of evidence related to the complementary feeding period is reflected in the lack of consistency in the official guidelines between countries, even within Europe (Michaelsen, Larnkjær et al. 2010). The official recommendations for introduction of solids vary considerably between DK and UK (Sundhedsstyrelsen 2011, Department of Health 2013). The discrepancies in the official guidelines, means that BLW is more controversial in DK compared to the UK, where several aspects of BLW, such as introducing finger-foods from 6 months, is also recommended by the Department of Health UK. The Department of Health UK, emphasise that babies should be allowed to feed themselves, using their fingers, as soon as they show an interest and that initially getting used to the idea of eating is more important than how much the baby eats, as they will still be getting most of their nutrition from breast milk or infant formula (Department of Health 2013). The Department of Health UK, also recommend that babies are ready to eat solids when they can stay in a sitting position and hold their head steady, can co-ordinate their eyes, hands and mouth so that they can look at the food, pick it up and put it in their mouth all by themselves and when they can swallow food (Department of Health 2013). These developmental signs of readiness mirror the philosophy of BLW. Apart from being able to hold their head, developmental milestones are not part of the recommendations for readiness from the Danish Health and Medicines Authority (Sundhedsstyrelsen 2011). The Danish Health and Medicines Authority state, that if the child starts waking at night and appears to be more hungry, it may be a sign of readiness. By comparison the Department of Health UK specifically claim that; “waking in the night when the child has previously slept through or requesting extra milk feeds are not signs of readiness” and that; “any increase in appetite should be met with more milk feeds until the child is developmentally ready to eat, or reaches 26 weeks”. The Department of Health UK does not discourage parental spoon feeding or advocate BLW, however, they do state that “If you are using a spoon, wait for your baby to open their mouth before you offer the food. Your baby may like to hold a spoon too” indicating that spoon-feeding is

optional. In an article examining the compatibility of BLW with the official UK feeding recommendations, Sachs (2011) concluded that there was relatively less of a difference between the BLW approach and current UK Department of Health recommendations, compared to the difference between the current recommendations and the traditional staged puree approach (Sachs 2011). Besides discrepancies in the official guidelines, structural and cultural differences between the countries may also affect how BLW is understood and practised: Primarily, large subsidises on childcare from the Danish government means that 86% of one year old children in DK are in childcare, rising to 94% for 2-year olds (Haagensen 2011). In the UK only 56% of mothers with a one year old are employed, rising only by 1% for mothers of 2-year olds (Ward 2012). The relatively shorter time spent exclusively rearing children and the quicker return to the labour market in DK may constitute a practical barrier for following BLW. In theory, this could lead to a smaller segment of parents choosing to follow this trend. It could also lead to parents modifying or adapting BLW to fit into a lifestyle where both parents work and the child is in nursery. Secondly, BLW is relatively unknown to the general population, parents and health workers in DK and there is currently no published literature in Danish describing BLW. This means that to some extent, access to information may dictate what specific group of parents will be introduced to BLW. The baby-led weaning book by Rapley and Murkutt (2008) is not translated into Danish so it may be a prerequisite for parents following BLW, that they have the ability and confidence to read a book in English. Another important factor that may influence which segment of the population this method has been introduced to is the type of media, including internet-sites and blogs, the parents are influenced by. Diverse media has written about, and either promoted or discouraged the use of BLW. Examples include a vegan food blog called ‘Månebarnet’ (Grønhøj-Krause 2014) and a parenting website promoting responsive parenting called ‘Harmoniske unger’ (Carendi 2013) which have both written about the benefits of using BLW. On the contrary, a very popular published writer and Health Visitor Helen Lyng Hansen, also known as ‘Net Sundhedsplejersken’, advises parents against using BLW in her book ‘Helens Bog om Børn og Mad’, as she state that BLW does not ensure adequate calorie intake (Hansen 2011). However, during the writing of this Thesis, an article in more mainstream media, the Danish Broadcasting Corporation (DR), wrote an article about BLW (Bøjesen, Kvist 2014). During the week following the publication of the article,

more than 500 new members joined the Danish Facebook group for BLW (Baby-led Weaning DK 2014). This fact indicates that parentâ&#x20AC;&#x2122;s interest for BLW is growing as more information becomes available and that the trend is likely to grow in the future. Currently evidence points to the fact that nutrition during the complementary feeding period can affect long term health and the risk of future non-communicable diseases. Consequently, emphasis in current research has shifted to focus on long term health as opposed to prevention of malnutrition (Agostoni, Decsi et al. 2008, Michaelsen, LarnkjĂŚr et al. 2010). Particularly the association between infant nutrition and growth, and the association with the later risk of overweight and obesity makes research in this life stage very relevant. However, to my knowledge there has been little or no emphasis on research examining the effect of how solids are being introduced, opposed to when and what foods are introduced.

Aim The aim of this study is twofold: to review the current literature on BLW in order to get an understanding of the current state of knowledge within this new approach to infant nutrition. Secondly, to gain an insight into how BLW is practised in DK comparatively to the UK using qualitative data. The results from the review of the existing literature on BLW together with the results from the qualitative study will lay the foundation for a discussion that aims to critically evaluate the evidence for the proposed health related benefits and risks of following BLW. In order to thoroughly discuss the scientific rationale for any suggested negative or positive outcome connected with this practice of weaning, knowledge and evidence from other areas of childhood nutrition is drawn upon.

Limitation It is exceedingly relevant for researchers in infant nutrition and health professionals to be aware of new trends in infant feeding that might have an effect on health, growth and nutrient status of infants and young children. As these trends gain popularity, it is important to conduct studies assessing the health status of infants following the method in question. However, assessing the

health status of infants who are weaned following BLW is beyond the scope of this study. Instead, the purpose of this study is to gain an insight into the practice of BLW in DK and the current state of evidence in the area, creating a foundation for further research.

Methods Method for a review of baby-led weaning studies Studies on BLW were identified using the electronic databases PubMed, Ovid, Web of Science and Google Scholar. The initial search took place in January 2014. Another search was carried out in September 2014 in order to identify any further studies being published during the timespan. Search terms used to identify relevant studies were; Baby-led weaning, Baby led weaning, BLW, finger foods and self-feeding. In addition, reference lists from the included articles were used to identify relevant studies. A search protocol was not produced and followed in order to perform a systematic literature search. However, considering the comprehensive search in all the relevant databases and the references from the identified literature, all relevant studies on BLW should be considered to be included in this review. All identified studies on Baby-led weaning, reporting original data and published in English were included in the review. This included 11 articles.

Method for interviews with baby-led weaning parents and Health Visitors Recruitment and participants Recruitment of families in DK practising BLW was done through an online Face Book-group called Baby-led weaning DK (Baby-led weaning DK 2014). In addition to this, 1 mother was contacted via the health visiting team in Copenhagen municipality. The first 5 mothers to respond to the advertisement, who fulfilled the criteria, were included in the study. In 2 out of these 5 families the father also participated in the interview, leading to a total of 7 informants taking part in the interviews in DK.

Recruitment of families in the UK was conducted through an online community called Baby-led Weaning, via a parenting website called BabyCenter. Because of limited resources, informants needed to be located within the local London area. However, the UK online BLW communities were not specific to any geographical area, therefore additional recruitment was done through a local South London baby group not specific to baby-led weaning. In total, 5 mothers from England were recruited, but due to practical implications 2 participants were prevented from completing the interview during the given time period. Health Visitors were recruited through the Health Visiting team at Copenhagen Municipality. Three Health Visitors reported back that they had experience with families in DK who practised BLW. These 3 Health Visitors were included in the study. The inclusion criteria were parents of healthy infants between the ages of 5-12 months, who identified themselves as practising BLW. The specific age range was chosen in order to obtain data from parents with babies from various stages in the weaning process. Parents of children with restrictive diets, due to allergies or medical issues, were excluded as this would interfere with normal eating practices. The inclusion criteria regarding the Health Visitors were; previous experience with one or more family practising BLW.

Ethics As no data defined as sensitive, according to the Danish Data Protection Agency, was retrieved from participants, an institutional review board approval was not needed for this study (Danish Health Research Ethics Committee 2013. 2013). All potential participants responding to the online advertisement were provided with a letter which included information about the research and contact details for the researcher and both supervisors (see appendix 1). The participants were informed, in writing, that participation was anonymous and names would not be connected to any data presented. It was also stated, that participation was on an entirely voluntary basis and that it was possible to withdraw from the study at any time prior to the submission date of the final thesis. This was repeated verbally to the informants on the day of the interview. The informants

were also informed that any further inquiry into the study or the practice of BLW could be done following the interview.

Data collection Ten interviews, including 7 DK based mothers and fathers and 3 Health Visitors from the Municipality of Copenhagen, were conducted in December 2013 and January 2014. Interviews with 3 UK based mothers were conducted in and around London between the 22 nd of January 2014 and the 30th of January 2014. In addition to the interviews, a mealtime with the child was observed; this was done with the exception of 1 family. The interviews were semi-structured and conducted in Danish and English respectively (appendix 2). The interviews were recorded for later transcription and lasted between 25 and 98 minutes. The interviews with the Health Visitors lasted between 10-24 minutes.

Data analysis The interviews were all transcribed (example in appendix 3). Initially, a template method was applied to the data, as central concepts or themes were defined beforehand (Christensen, Schmidt et al. 2008). During the analysis, textural passages referring to these concepts were then identified and grouped together. The themes defined prior to the interview were, among others; nutritional concerns regarding food intake as well as fat and iron intake. However, as very little empirical data existed on the practice of BLW and no descriptive studies had been carried out in a Danish context, an inductive approach to the analysis was also applied to the data. This approach enabled relevant themes to be developed on the basis of the interviews (Christensen, Schmidt et al. 2008). Emerging themes from each transcript were identified and grouped into topics. Comparison between data from DK and UK was done to identify similarity or variances within the themes. In order to answer the central research question: How is BLW practised in DK? The focus remained on data from the informants from DK when presenting the results. Transcription of the interviews and coding of themes was all done manually by the author. Additionally, the final quotations from informants in Danish were translated to English by the author.

Results from a review of baby-led weaning studies Eleven studies on BLW are summarised and presented in the following section and an overview is presented in table 1.

Table 1. Author

Participants

Definition of BLW

Study design

Key findings

Brown, Lee 2011a

UK based mothers with an infant aged 6-12 months (n = 655) following SW or BLW.

Using spoonfeeding and purees ≤10 % of the time.

Cross-sectional, online questionnaire.

Mothers practising BLW were more likely have higher education (P < 0.01), higher occupation (P < 0.05) and to be married ( < 0.01). Mothers practising BLW were les likely to have returned to work 12 month postpartum (P < 0.05). BLW was associat with a later introduction of complement foods (P < 0.001), greater participation in meal times (P < 0.001) and exposure to family foods (P < 0.01). Levels of anxiety about weaning and feeding were lower i mothers who adopted a BLW approach ( < 0.01). BLW infants were breastfed for a significantly longer duration than SW infants (127.36 days for BLW vs. 82.11 da for SW, P < 0.001) independently of maternal socioeconomic status (SES).

Brown, Lee 2011b

UK based mothers with an infant aged 6-12 months (n = 604) following SW or BLW.

Using spoonfeeding and purees ≤10 % of the time.

Cross-sectional, online questionnaire.

Mothers who followed BLW reported significantly lower levels of restriction, pressure to eat and monitoring compare to mothers who followed a standard weaning (SW) approach (P < 0.001). Mothers practising BLW reported lower levels of concern for child weight compa to mothers following SW (P < 0.001) independently of infant birth weight and current weight.

Wright, Cameron et al.

Existing UK

Data obtained

Questionnaires

It was reported that 56% of the infants h

2011

cohort (n = 602). Parents following SW.

prior to the concept of BLW being described.

regarding age of infants when first reaching out for finger foods and developmental status.

reached out for food before 6 months of age; however 6% had still not reached ou for food at age 8 months. Infants who ha not reached out for food by 6 months we also less likely to be walking unaided at a 1 year (P < 0.001).

Townsend, Pitchford 2012

UK based parents (n = 155) following SW or BLW.

Selfidentification of practising BLW.

Cross sectional and partly Casecontrolled. Questionnaires on infant feeding practices, child’s preferences and food exposure.

A significantly increased liking for carbohydrates was reported in the BLW group (P < 0.003). Carbohydrates were th most preferred foods by the BLW group compared to sweet foods for the SW group. No difference in picky eating was found between the two weaning groups. BLW infants were breastfed for a significantly longer duration than SW infants (23.7 months for BLW vs. 9.5 months for SW, P < 0.0001).

Moore, Milligan et al. 2012

UK based parents who had weaned a child since the introduction of the current UK guidelines (n =3607).

Selfidentification of practising BLW.

Cross-sectional, online questionnaire.

Following the BLW weaning approach wa the most reliable predictor for weaning a or later than 26 weeks.

Rowan, Harris 2012

US and UK based mothers (n = 10)

Selfidentification

3-day food diaries at 6 and 9

There was no significant change in paren dietary intake during the first three mon

following SW.

of practising BLW

months (at baseline and post-BLW implementation) .

of weaning. Infants were offered 57% of the same foods as the parents ate.

New Zealand based Healthcare professionals (n = 31) and mothers with infants aged 8-24 months (n = 20) following BLW.

Selfidentification of practising or having practised BLW during the weaning period.

Semi-structured interview, crosssectional.

Contrary to mothers practising BLW, Healthcare professionals had strong concerns about the risk of iron deficiency inadequate energy intake and choking.

Cameron, Taylor et al. 2013

New Zealand based mothers with infants age 6-12 months (n = 199) following SW or BLW.

Infant mostly or always selffed at 6–7 months, and also selfidentification of practising BLW.

Cross-sectional, online questionnaire.

Out of 30% of parents who reported practising BLW, only 9% practised it consistently. The extent to which BLW w followed was associated with potential benefits (e.g. sharing family meals) and risks (e.g. low iron first foods as infants were not given iron enrich baby-cereals)

Brown, Lee 2013a

UK based mothers with infants aged 6-12 months, followed up at 18-24 months (n = 298). Mothers following SW or BLW.

Using spoonfeeding and purees ≤10 % of the time.

Questionnaires paper or online, Cohort.

Baby-led weaned infants were significan more satiety responsive (P < 0.001) and l likely to be overweight at 18-24 (P < 0.01 months of age, compared to infants weaned using a SW approach. This was independent of breastfeeding duration, initiation of weaning and maternal contr

Cameron, Heath et al. 2012

Some parents offered their children raw apple, which is considered to be a chokin hazard at this age.

Brown, Lee 2013b

UK based mothers with infants aged 1218 months (n = 36) following BLW.

Using spoonfeeding and purees â&#x2030;¤10 % of the time.

Semi-structured Interview, descriptive analysis.

BLW may encourage mothers to follow th recommended principles of delayed and gradual introduction to solids based on developmental readiness and offering family foods emphasising tastes, texture and a variety of foods.

Arden, Abbott 2014

UK based mothers with infants aged 9-15 months (n = 15) following BLW.

Selfidentification of practising BLW or having practised it in the past.

Semi-structured interview over the course of 5 emails, descriptive analysis.

Mothers practising BLW could be divided two groups; as part of a parenting philosophy, or when initial attempt to follow a traditional weaning approach ha failed. Late consumption of food was a possible concern.

Larger studies; cross-sectional, case controlled and cohort design The following 3 studies examined the relationship between BLW and maternal control, food fussiness, satiety responsiveness and body mass index (BMI). Maternal control of child feeding during the weaning period: differences between mothers following a baby-led or standard weaning approach (Brown, Lee 2011b). In this cross-sectional study 604 mothers with an infant aged 6-12 months following standard weaning (SW) or BLW, completed an online copy of the Child Feeding Questionnaire (Birch, Fisher et al. 2001). The results showed that mothers who practised BLW reported significantly lower levels of restriction (P < 0.001), pressure to eat (P < 0.001), and monitoring (P < 0.001) compared to mothers who followed a SW approach. Mothers practising BLW also reported lower levels of concern for child weight compared to mothers following SW (P < 0.001), independently of infant birth weight and current weight. Mothers practising BLW had significantly higher levels of education (P < 0.001), had a professional or managerial job (P < 0.001) and were less likely to have returned to work 12 months postpartum (P < 0.05) compared to those using a SW approach. These factors were therefore controlled for throughout the analysis. However, based on the cross-sectional design of this study it cannot determined whether it was the practice of BLW that caused mothers to be less controlling, or simply less controlling mothers who chose to follow the BLW approach. Early influences on child satiety-responsiveness: the role of weaning style (Brown, Lee 2013a). In this cohort, the authors followed up on their study from 2011 (Brown, Lee 2011b) in order to examine the effect of BLW on later eating behaviour in the second year of life. Further, they wanted to explore the role in which maternal control, breastfeeding duration and timing of weaning played in the relationship between BLW and eating behaviour. Mothers, originally surveyed when their child was 6-12 months, were invited to take part in the study when their child was 18-24 months old. Out of the original sample, 298 mothers remained in the full analyses. In this study, mothers completed a copy of the Child Feeding Questionnaire (Birch, Fisher et al. 2001) as they did in the previous study. Additionally, they completed five dimensions of the Children's Eating Behaviour Questionnaire (Wardle, Guthrie et al. 2001), namely; food-responsiveness,

enjoyment of food, satiety-responsiveness, slowness in eating and food fussiness. Additionally, they reported the current weight of their child. Their results were as follows: SW infants were introduced to solid foods earlier than the BLW infants (P < 0.01), but were introduced to whole foods or finger foods significantly later (P < 0.003). Breastfeeding initiation at birth was higher in the BLW group (P < 0.001). Additionally, mothers in the BLW group had a higher level of education compared to mothers in the SW group (P < 0.01). Therefore, timing of introduction of solids and finger foods was controlled for throughout the analysis, as was breastfeeding initiation and level of education. In terms of maternal child-feeding style, significant differences were seen between the two groups: Mothers who followed a BLW approach reported lower levels of concern for child weight (P < 0.01), pressure to eat (P < 0.05), restriction (P < 0.001) and monitoring (P < 0.05) compared with mothers who used a SW style. Significant differences were also observed in reported eating behaviour: BLW infants were reported to be less fussy (P < 0.005), less food-responsive (desire to eat in response to food stimuli regardless of hunger) (P < 0.001) and more satiety-responsive (ability to regulate intake of food in relation to satiety) (P < 0.001) than SW infants at 18-24 months. The differences in food-responsiveness and satiety-responsiveness were evident independently of maternal education, maternal control, breastfeeding duration, child weight and timing of weaning. However, no significant difference between the two groups remained for food fussiness once these covariates were accounted for. Fussiness was associated with timing of weaning and duration of breastfeeding. Infants who were weaned at an earlier age were reported to be more fussy at 18–24 months (P = 0.001). Infants who were breastfed for a longer duration were reported as more satiety-responsive (P = 0.01) and less fussy (P = 0.007). Interestingly, this study found that maternal control at the weaning phase (6-12 months) was associated with the childrens eating behaviour at 18-24 months, but only for the SW group. They found that in this group, a high level of restriction was associated with lower levels of satietyresponsiveness (P < 0.01). Concern for infant weight was significantly associated with higher levels of food fussiness (P < 0.01) and high levels of pressure to eat were associated with significantly lower levels of enjoyment of food (P < 0.01). Based on these results, the authors suggested that

practising BLW protected against the effect of high maternal control on later eating behaviour outcomes. Maternal control at 18-24 months was also significantly associated with eating behaviour at that age (18-24 months): Again, some of these effects were only evident in SW children. Pressure to eat was positively associated with food-responsiveness (P < 0.001) and restriction was associated with lower levels of satiety-responsiveness (P < 0.05) for both weaning groups. For the SW children, restriction was also associated with higher levels of food-responsiveness (P < 0.001), while higher levels of monitoring and concern for infant weight were associated with increased food fussiness (P < 0.05). Based on the WHO’s Child Growth Standard Charts, the study found a significant association between current weight category and weaning style (P < 0.017): Of the children in the SW group 78.3% were normal weight, 19.2% overweight and 2.5% underweight. In the BLW group 86.5% of the children were normal weight, 8.1% were overweight and were 5.4% underweight. It was evident that the children in the SW group were significantly heavier than those in the BLW group (P = 0.005) independent of birth weight, breastfeeding duration, age of weaning and maternal control at both 6-12 months and 18-24 months. The greatest limitation to this study was that outcome measures were self-reported, therefore, the possibility of reporting bias in the BLW group cannot be completely eliminated. Ideally an objective measure of BMI should be applied (height and weight measured by researchers). Additionally, the proportion of over/underweight children in the sample was very small; this could explain why no significant difference regarding underweight was found between the two groups. A power calculation for detecting underweight could have been useful. Baby knows best? The impact of weaning style on food preferences and body mass index in early childhood in a case-controlled sample (Townsend, Pitchford 2012). This study also explored the relationship between food fussiness, BMI and the practice of BLW. A total of 155 mothers practising either BLW or SW completed questionnaires on infant feeding practices, child’s preferences and food exposure. The study was cross sectional (when comparing BMI, they included the whole sample) and partly case-controlled (when comparing food preferences they included 74 age-matched children). They found an increased liking for carbohydrates, such as

bread and pasta reported by the BLW group, compared to the SW group (P < 0.003). Furthermore, carbohydrates were reported to be the most preferred foods by the BLW group, compared to sweet foods for the SW group. No significant differences in picky eating or BMI were found between the two weaning groups. BLW infants were breastfed for a significantly longer duration than those who used an SW (23.7 months for BLW vs. 9.5 months for SW, P < 0.0001). However, this study had several important limitations; subjects were divided into groups based on self-identification of BLW, this classification is likely to include a range of parental spoon-feeding and use of purees (Cameron, Taylor et al. 2013). Significant associations could possibly have been obtained on variables such as picky eating and BMI, if a more objective classification of BLW had been used (i.e. using spoon-feeding and purees ≤10 % of the time). The small sample size and the small number of overweight/underweight children were too small to allow statistical comparisons on measures of BMI.

Large cross-sectional descriptive studies A descriptive study investigating the use and nature of baby-led weaning in a UK sample of mothers (Brown, Lee 2011a). In this cross-sectional descriptive study; 655 UK based mothers with an infant aged 6-12 months completed an online questionnaire. The mothers were divided into two groups, based on practising either BLW or SW. Mothers practising BLW were more likely to have higher education (P < 0.01), higher occupation (P < 0.05), be married (P < 0.01) and have breastfed their infant (P < 0.001). Mothers practising BLW were also less likely to have returned to work 12 months postpartum (P < 0.05). BLW was associated with a later introduction of complementary foods (P < 0.001), greater participation in meal times (P < 0.001) and exposure to family foods (P < 0.01). Mothers practising BLW gave significantly more milk feeds (breast or formula) during the day than mothers following a SW approach (P < 0.001). Likewise, at 6 months, BLW infants were offered fewer meals per day than SW infants (P < 0.001). Levels of anxiety about weaning and feeding were lower in mothers who adopted a BLW approach (P < 0.01). BLW infants were breastfed for a significantly longer duration than SW infants (127.36 days for BLW vs. 82.11 days for SW, P < 0.001) independently of maternal socioeconomic status (SES).

An online survey of knowledge of the weaning guidelines, advice from health visitors and other factors that influence weaning timing in UK mothers (Moore, Milligan et al. 2012). In this large cross-sectional study of 3607 UK based parents, who had weaned a child since the introduction of the current UK guidelines, following a BLW approach was the strongest predictor for weaning at, or later than 26 weeks.

Descriptive analyses based on qualitative interviews and small sample sizes An exploration of experiences of mothers following a baby-led weaning style: developmental readiness for complementary foods (Brown, Lee 2013b). In the study a sample of 36 UK based mothers following BLW were interviewed using a semi-structured interview method. The findings were considered in relation to the Department of Health UK weaning guidelines, concerning the development of eating styles and weight gain in young children. The study aimed to offer an insight into BLW for health care practitioners. Some of their key messages were as follows: BLW may encourage mothers to follow the recommended principles of delayed and gradual introduction to solids based on developmental readiness and offering family foods emphasising tastes, textures and variety of foods. Mothers in the survey displayed both healthful and positive behaviours towards their infant. The authors suggest that the positive behaviours and characteristics could be explained by maternal background and attitudes, but also that the mothers explicitly stated that the BLW method had improved their family diet and encouraged them to hand over control to the infants. The mothers also emphasised that their infants willingly accepted strong flavours and spices, eating meals such as curries from an early age. They reported that the mothers believed that this approach would lead to less fussiness and greater variety of food eaten in the future. As recognised by the authors, this study sample of self-selecting mothers who successfully practised BLW might not have been representative of a wider population practising BLW. The aim of the study was not to be representative but rather offering a helpful insight for healthcare practitioner. Experiences of baby-led weaning: trust, control and renegotiation (Arden, Abbott 2014). This study was based on a series of semi-structured interviews. The aim was to investigate the reported experiences and feelings of mothers practising BLW and to gain an understanding of the 24

benefits and the challenges of using the BLW weaning approach, together with the beliefs that underpin these experiences. Fifteen women completed a series of interviews conducted over a series of five emails. The authors found that the approach to BLW, evident in their study, provided a feeding method that might lower maternal control and promote better self-regulation in later life. They highlighted that the timing of which some infants ingested complementary food was an issue of potential concern. Some participants cited the phrase â&#x20AC;&#x153;food until one is just for funâ&#x20AC;? and believed that breast milk provided adequate nutrition well beyond 9 months of age. Of particular concern were the participants who had changed from a traditional weaning approach to BLW due to their infants refusing to be fed, but where the change to BLW had not resulted in improved eating. On this background, the authors argued that the practice of BLW could inadvertently act to mask potential eating problems. They identified the division of mothers practising BLW in two groups; as part of a parenting philosophy (a number of participants mentioned extended breastfeeding, co-sleeping, baby-wearing and attachment parenting alongside breastfeeding and BLW), or when initial attempt to follow a traditional weaning approach had failed. One limitation to this study was the self-reporting definition of BLW; in fact all participants reported use of parental spoon-feeding on a regular basis. Healthcare professionals' and mothers' knowledge of, attitudes to and experiences with, BabyLed Weaning: a content analysis study (Cameron, Heath et al. 2012). This study included 31 healthcare professionals including; dietitians, paediatricians, general practitioners and midwives, and 20 mothers who had used BLW when introducing solids to their infant. Data was based on two semi-structured interviews; one for healthcare professionals and one for parents. Healthcare professionals had limited direct experience with BLW and the main concerns raised were the potential for increased risk of choking, iron deficiency and inadequate energy intake. The healthcare professionals also suggested a number of potential benefits associated with BLW; such as greater opportunity for shared family meal times, fewer mealtime battles, healthier eating behaviours, greater convenience and possible developmental advantages. However, most felt reluctant to recommend BLW because of their concern about the potential increased risk of choking. In contrast, mothers who had used this style of feeding reported no major concerns with BLW. They considered BLW to be a healthier, more convenient and less stressful way to introduce complementary foods to their infant and recommended this feeding approach to other mothers.

The authors reported that some parents described offering raw apple to their infant. They noted that this practice should be discouraged, as raw apple is a choking hazard at this age. The limitation to this study was the notion that the majority of the interviewed healthcare practitioners had no personal experience with BLW and in many cases (18/31) had never heard about the concept.

Other studies Parent-led or baby-led? Associations between complementary feeding practices and healthrelated behaviours in a survey of New Zealand families (Cameron, Taylor et al. 2013). The aim of this study was to identify feeding practices and selected health-related behaviours in families practising either BLW or SW. A total of 199 participants, all mothers, completed an online survey regarding feeding practices during the weaning period. Unique to this study was that the BLW cases and SW controls came from a jointly recruited population. Recruitment was done via advertisements in four healthcare centres and BLW was not mentioned in the material. Out of the sample, 30 % self-identified as practising BLW, however only 9% (n=17) were classed as adherent BLW based to their feeding practice (defined as the baby feeding themselves all or most of the time at 6â&#x20AC;&#x201C;7 months of age, with little or no parental spoon-feeding). On the basis of this participants were divided in three groups; adherent BLW (9%), self-identified BLW (21%) and parent-led feeding (70%). A greater proportion in the adherent BLW group (53%) met the WHO recommendation to exclusively breastfeed for 6 months compared to the self-identified BLW (28%) and parent-led feeding (21%) groups (P = 0.026). The adherent BLW group was more likely to be having the same foods that the family ate, compared to the other two groups (P = 0.018). Additionally, the adherent BLW children were not offered infant iron-fortified cereal as their first food and were less likely to be offered commercially prepared baby food (P = 0.002). No difference was found between the groups in the proportion reporting at least one gagging or choking episode (P > 0.05). However, more than 30% of the total sample reported at least one choking episode. The authors suggested that this was due to parents inability to distinguish between choking and gagging and emphasised that due to the rarity of serious choking episodes,

their small study was not powered to identify differences in the rates between the three feeding groups. This study also offers some indication as to how common the practice of BLW is in New Zealand. As the study sample was not entirely representative of the general population, the numbers have to be interpreted with reservation. Nonetheless, this study recruited parents of young children in general and BLW was not mentioned in the recruitment material. Although 9% were classified as practising BLW in its adherent form, another 21% self-identified with practising BLW. More than one third of the sample had not heard of BLW previously. However, upon a brief introduction to BLW included in the survey, 46% of these participants reported that they would consider using the method with another child. These numbers indicate that the practice of BLW is not only being practised by a significant proportion of the population, but also that greater knowledge of the practice would further increase the number of parents following this method. It also highlights the apparent discrepancy between the practices of adherent BLW and self-reported BLW. The main limitation to this study was that the recruitment for participants were done in urban health centres of New Zealand, the results may therefore not be representative of the larger population. Is baby-led weaning feasible? When do babies first reach out for and eat finger foods? (Wright, Cameron et al. 2011). With this study the authors aimed to establish whether infants would be developmentally ready to self-feed by 6 months of age, when complementary feeding should commence. They used data from the UK cohort; Gateshead Millennium Study (Parkinson, Pearce et al. 2011) to define the range of ages at which infants reached out for and consumed finger foods. Additionally, they related this to developmental status. Infants in the study were recruited shortly after birth and followed prospectively using postal questionnaires. Out of 923 eligible children, 602 had data on when they first reached out for food. They found that 340 (56%) had done so before age 6 months, but 36 (6%) had still not reached out for food at age 8 months. Infants who had not reached out for food by 6 months were also less likely to be walking unaided at age 1 year (P < 0.001). The authors concluded that BLW is most likely feasible for a majority of infants, but could lead to nutritional problems for infants who are relatively developmentally delayed. However, it is possible that the number of infants not reaching out for food at 8 months could have been overestimated due to the use of a SW feeding style, where infants were not expected or encouraged to independently handle food. 27

Baby-led weaning and the family diet. A pilot study (Rowan, Harris 2012). The aim of this study was to assess the impact of BLW on the family diet. Dietary intake was recorded using a 3-day diet diary to determine the dietary intake of the participants before, and three months after, initiating weaning using a BLW approach. Complete data from 10 participants were obtained and subsequently used for analysis. The results showed that there was no significant change in parent’s dietary intake during the first three months of weaning. Infants were offered 57% of the same foods as the parents ate. This study was limited by the very small sample size.

Results from interviews with baby-led weaning parents and Health Visitors The analysis of the data highlighted central themes regarding the practice of BLW. These themes were divided into three topics, specifically: The practice of baby-led weaning in Denmark and the children’s nutritional intake; Parental norms and values and; Deviating from authoritative advice. Finally, results from the interviews with the Health Visitors from DK are presented in; The Health Visitors perspective. The results below describe the practice of BLW in DK which were generally comparable to the practice in the UK. Results from the UK participants are discussed only when the practices or values differed between the two countries. The informants has been given fictive names, the age of their child is shown in brackets following statements. When quotations have been shortened it has been marked (…).

The informants Five mothers and 2 fathers, representing 5 families, were interviewed in Denmark. Three families were living in Copenhagen and 2 families were living in smaller towns outside the capital. All the families from DK who took part in the interviews were cohabiting, as opposed to to married and had just 1 child. Three mothers and 1 father had a high education level (Master’s or higher), 1 mother and 1 father were, at the time of the interview, studying degrees which would put them in the category of high educational level once their education was completed. The remaining mother was a teacher, which corresponds to medium education level according to Statistics Denmark

(Jacobsen 2004). The informant’s ages ranged from 25 to 38 years. The children’s ages were 6, 7, 7, 11 and 11 months at the time of the interview. Three mothers were interviewed in the UK. One mother had low education level, 1 had medium and 1 had high education level. They were all married, and had more than 1 child. They had all practised BLW with an older child and 1 informant had followed a SW approach with her two older children. The informant’s ages ranged from 29 to 34 years of age. The children’s ages were 5, 11 and 12 months at the time of the interview.

The practice of baby-led weaning in Denmark and the children’s nutritional intake The results showed that families from DK practised BLW in a way that closely followed the method described by Rapley and Murkutt (2008), regarding the time of weaning being based on developmental readiness and child’s initiative to eat, offering whole foods opposed to mashed or pureed foods, and letting the child self-feed (Rapley, Murkett 2008). Participants were introduced to the practice of BLW either via word-of-mouth or through various internet sites/blogs or other books about babies and food. However, they had all purchased and read the BLW book by Rapley and Murkutt (2008) and were or had been a member of the Danish Facebook-group Baby-led Weaning DK.

Description of family diet It was evident that the informants were very similar in terms of the diets they were eating and offering to their children. The informants described their diet as healthy, varied, fresh and mostly organic and preferably seasonal. Dinners were home cooked every evening. The three families living in Copenhagen received organic meal boxes from the company ‘Årstiderne’, which provided them with a variety of evening meals on five days of the week. No foods or food-groups were restricted. The families indicated that they followed the guidelines on limiting salt and sugar but if they referred to it, it was like it was common sense. Generally, there was a lot of emphasis on offering a wide variety of food, but not a lot of emphasis on restricting foods. One informant explained it like this:

Anders: “He is not given candy. We are not fanatical but we do not offer it. If we are out for a walk and there is a lady who thinks he is a really cute baby and thinks he should have a cookie, then he will be allowed to taste a cookie” (Eleven-month-old child).

The definition of healthy foods seemed to be concerned with wholesome home cooked food, fresh fruit, vegetables and produce rather than low-fat products.

Breastfeeding introducing solids and cutting down on milk feeds The informants based the decision to initiate weaning on two considerations, namely: the wish to follow official recommendations of exclusively breastfeeding until 26 weeks; and responding to their child’s cues of readiness. For all but one infant, who was weaned at 20 weeks, weaning was initiated between 24 and 26 weeks of age. Ida: “We started when she was five and a half months or so, just to offer her, you know put a little fruit in front of her. For her it was mostly play, it was very little she actually put in her mouth. Then it just came little by little. She tasted more and more, and now she has actually started to eat” (7month old child).

It was clear that the informants initially had a clear goal of following the recommendations of exclusive breastfeeding for 26 weeks, as this recommendation was viewed as important for the child’s health. However, the informants reported starting a week or two earlier. Reasons for this were the parents own excitement to start weaning and an impression of self-feeding skills being sufficiently developed. All the mothers were breastfeeding their children on demand and it was clear that this practice offered reassurance to the participants regarding the nutritional needs of their child in the early months of weaning. The parents reported that it was difficult to estimate how much food was actually ingested in the early weaning phase, but continued breastfeeding would ensure that the nutritional need of the child would be meet. The common experience for the participants was that their child continuously progressed in terms of their feeding skills and actual food intake. To begin with, this was evident by the content of their nappy and later when the child started to drop the number of milk feedings. Participants with older children reported that this happened between 8-10 months. Lina: “He used to, a month ago, a month and a half ago, to ask for something (breastfeed) at ten, ten thirty. He does not do that anymore. And then there was also in the afternoon, he does not do that any longer either” (11-month-old child).

The informant’s reference for assessing the quantity of food their children were initially consuming was the food intake of other infants of similar age. When compared with infants being fed porridge and purees, the participants clearly felt that their child did not consume the same volume of solids as their peers. In addition to continued breastfeeding on demand, mothers were reassured by the fact that they perceived their child as happy, thriving and gaining weight.

Meeting and acceptance of family foods It was evident from the results that weaning had been an overwhelmingly positive experience for the parents, and that this was primarily based on the perceived enjoyment of the child. The informants all described how their child met food with interest and curiosity. They talked about how their child would taste everything that was offered to them and even repeatedly tasting food which had initially caused a grimace, perceived by parents as dislike. Mille: “Yes I think he likes most things. Sometimes he looks like, at first when he puts it to his mouth, urgh what was that? Then he puts it back in his mouth anyway” (11-month-old child).

Introducing the child to the family food and integrating them into family mealtimes was not perceived as being difficult. The informants mentioned making a few adjustments, such as not using salt when cooking, including appropriate finger foods in the early weaning phase, or making alternatives to breakfast which may have been cereals for the adults. An example of this could be ‘baby pancakes’ and porridge sticks baked in the oven. Otherwise, the parents found that they could eat the food they usually ate and even found that their children enjoyed strong flavours and even spicy foods. Lotte: “That is what I have discovered now that we have changed over to her eating our food, is that it is the right thing because the things she thought was most interesting was something that was very spicy like curry or whatever it may have been, she thinks that is really, really, really exciting” (7month-old child).

The informants felt that integrating the child into family meals from the onset of weaning made the whole process of weaning much simpler. They explained that they, in a way, could skip a whole phase of the weaning process, namely the spoon feeding and pureeing phase, which they did not feel was even necessary when the child could very well feed themselves. Signe: “It is not that I do not want to spend time and energy making food especially for him, I just do not see any reason to do it, because he can eat what we are having. So I am thinking that you just end up with an extra transition if you first get him used to porridge and purees and then have to get

him used to normal food. So I kind of just feel like it is a waste. It is a natural transition because he can easily feed himself (6-month-old child). Lina: "Generally it has just suited us really well. We cook food every day anyway, so the only thing we have changed is not putting salt in the food "(11-month-old child).

In this way, practising BLW was viewed as easier over time. The informants expressed a similar view when they talked about BLW being messy. They argued that all parents eventually had to hand over more control to the child and allow self-feeding, so that traditional spoon feeding only served to delay the messy part of weaning.

Encouragement to eat and use of parental spoon-feeding The informants from DK did not spoon-feed their children, although this was not mentioned as an important principle for the informants. The consensus was that spoon feeding had never been necessary. The informants mention that their children refused to be fed by them, and speculated that this was due to never having been used to it. Signe: â&#x20AC;&#x153;No, well I am not, we have said from the beginning that we will not be fanatical about it. So now we see if it can work for us and if it does then that is fine and if it does not then we will go for Plan B (...) I do not think it would be easy to feed him, because he can do it himself and he wants to do it himself. Whether it is because he has learned it through the way we started like this, or if he has been like that from the beginning, I do not knowâ&#x20AC;? (6-month-old child).

Due to reasons discussed below, some parental spoon-feeding was employed by the UK based mothers. UK based mothers also reported using some kind of verbal encouragements for their child to eat. One UK based mother described how they had a family rule about trying foods once before being allowed to refuse it. This was in contrast to the parents from DK who did not report using such encouragement. One father from DK explains how he trusts the child to decide on his own food selection. Anders: "I think that one; it is good for the parents if they can figure out how to let go of control, and then to say; it is good for you and your child, because it is an amazing experience and the child also has this intuition to eat what it needs, both in terms of quantity but also in terms of what things it selects out of what we put on the table. Whether it is completely magical that it just knows that it needs iron or whether it needs vitamin C or something, or whether it is more intuitive, and that it obviously will work out if you have a child who is just a little bit interested in what it is doing with this food, then it will taste it all "(11-month-old child).

However, this contrast in encouragement to eat could simply be due to the fact that the UK mothers are referring to practices used with their older children, not during the weaning phase. Whether this was the case was not completely clear from the basis of the interviews.

Practicality: Time taking to eat; the mess and; attending nursery. It was clear from the results that meal times normally lasted at least half an hour and this was consistently reported, and observed, regardless of the childâ&#x20AC;&#x2122;s age. All children touched, tasted, squished, sucked, chewed and explored their food, and this activity kept them happily engaged and entertained without any encouragement from the parents. Signe: â&#x20AC;&#x153;He can sit and eat for a long time. At first it was only for ten minutes max. But that was because it was me who said stop (...) now he can easily sit up then it is up to him to say when he is done. He can easily sit for half an hour. I think sometimes he can even sit for three quarters of an hourâ&#x20AC;? (6-month-old child).

None of the informants from DK viewed the time it took the child to eat a meal as an obstacle or barrier to BLW. On the contrary, informants expressed relief that they could just eat their own food without having to spoon feed their child first. In fact, the majority of the interviews were conducted during a lunch or morning meal where the child was so engrossed in their meal that the parent/parents could start the interview. Being able to eat together as a family was clearly stated as an advantage, rather than disadvantage, by the informants. These results somehow contrasted when compared with the UK mothers who did explained that the long mealtimes and subsequent clean-up could be a drawback to BLW, due to the fact that they had other children to consider. This was evident at the morning meal where they would spoon-feed breakfast to their youngest child in order to get everyone ready to leave for school. When asked specifically about any drawbacks to practising BLW, the mess was mentioned. However, the informants did not put much emphasis on this fact. Few measures such as using apron type bibs and covering the floor under the highchair helped to make clean-ups easier. Parents would also bring food that they saw as being less messy when eating outside the home, or parents of the younger children reported that they could just offer a breastfed until they got home.

None or the children from DK attended a nursery; two families used a private child-minder. The decision to use a private child-minder was not related to practising BLW, but it was mentioned as an advantage as the child could continue to self-feed when the informants had to return to work.

Risk of choking There was a clear consensus amongst the informants about the belief that practising BLW did not pose a greater risk of choking compared to traditional spoon-feeding. Although informants reported that the risk of choking briefly caused anxiety when watching their child eat at the onset of weaning, the informants reported that they were quickly reassured about their child’s ability to safely handle food. Lotte: "No, she has coughed a little after we started it (BLW), but, so of course in the moment you become a little, but erm, but it has convinced me much more to see how she handles it, compared to reading it in the book for example” (7-month-old child).

The informants reported that it was their strong belief that BLW was as safe as, or even safer than traditional weaning, this was based on their own observation of their children. The informants talked about how they were initially reassured by observing the effective gag reflex in their children and later, how competent their children became at moving food around in their mouths.

Meat/iron The informants reported offering meat and fish from the beginning of weaning. The informants considered meat and fish to be ideal weaning foods. They also reported that meat or fish had been preferred by their children at the start of weaning. Mille: “Yes, that was actually something that he preferred, meat. Or at least it was something that worked best from the beginning, if he got a piece of meat” (11-month-old child).

One Informant, who had initially used purees for the first few weeks of weaning, had started to offer meat after changing over to BLW. In this way, changing to BLW had prompted this mother to introduce family food such as meat and fish, which she had not done earlier. Some parents from DK gave iron supplements as recommended by Sundhedsstyrelsen. They were aware that the BLW book by Rapley and Merkutt did not specifically recommend the use of iron supplements, as this is not recommended in the UK, where the importance of iron rich food is emphasised in its place. However, as will be discussed later, it was evident that following these Danish recommendations, on for example iron, acted to reassure the informants that their children received what they 34

needed. In relation to the concern about adequate iron intake, the informants reported not offering cow’s milk as a drink to their children.

Fat and calorie density During the interview informants were specifically asked if they employed any strategies to ensure a high energy/fat content of the diet. It was clear that the informants viewed the practice of continued breastfeeding as ensuring high fat/energy density of the diet. As they did not replace breastfeeding with low calorie fruit/vegetable puree and porridges, they did not need to substitute this fat back into the diet. Signe: “No, not really, and I am thinking that while I am breastfeeding as much as I do now I believe that he will probably get enough through that. But of course, when he starts eating more, well, I will have to find out what I need to do” (6-month-old child).

However, the informants reported that their own diet naturally contained an array of calorie rich foods. At the meals observed, all children were offered high calorie foods mainly as spreads. Examples of this were butter, almond and peanut butter, pesto, cheese, mayonnaise and remoulade (a tartar sauce like dipping). The informants also reported that they did not use low fat products and naturally used different fats and oils in their cooking. Mille "No, well he always gets offered full fat products. We eat quite a bit of fat and so does he. In the beginning where he preferred fruit porridge I put some almond butter in sometimes. I actually think that it tasted better, but also to have some fat in and something that would fill him up a little bit" (11-month-old child).

In this way, a calorie and fat rich diet was ensured by naturally incorporating fat into meals, together with continued breastfeeding on demand.

Parental norms and values Using an inductive approach, several themes which concerned parental norms and values emerged. Four key themes were identified, namely: Baby-led weaning is natural; mealtimes as a joint positive experience; trusting the child and letting go of control and; baby-led weaning as part of a parenting philosophy.

Baby-led weaning is natural A strong theme and rationale given for following BLW was that it is “how nature intended it to be” or “nature knows what it is doing”. The informants talked about how babies know how to seek the 35

breast and feed from the moment they are born, and believed that this innate ability and strong drive to self-feed continued throughout the weaning phase. Signe: “It is just a natural transition, because he can easily feed himself. They can do that from the moment they are born; they know how to drink milk. That is the core (of BLW) for me” (6-month-old child).

In this way, feeding was viewed as a continued process from birth to the end of weaning. Progressing to eating solid foods was viewed as a natural continuation of breastfeeding, where it made sense that the child remained in control of their own food intake. For the parent to take control of the infant’s food intake, when introducing solids, was seen as unnecessary and making weaning more complicated. In addition to being natural, the informants describe BLW as being logical and just making sense. The informants described how BLW followed the child’s development, but some also talked about how the practice of BLW would naturally challenge and improve the child’s motor and oral motor stills. Mille: ”I think that it is important that he gets to train his oral-motor skills, fine motor skills and coordination (...) Generally, it is important to us that the things he can do himself, he should do himself. I also let him climb up the stairs when we get home. Not all the way up, but the last bit of the way or the last few steps” (11-month-old child).

In this way, parents described their role in their child’s development as offering the opportunity for development as soon as the child is ready, mirroring their approach to weaning.

Mealtimes as a joint positive experience It was clear from the data that having a joint mealtime was very important to the informants. Sitting down and enjoying good food was valued by the families and the informants clearly wished to make the introduction to food and mealtime a positive one. Sharing meals and mealtimes gave the informants a sense of including their child in an important family activity, rather than having to feed the child separately, which was not viewed as the same integration in mealtimes. Signe “So I think about the fact that he is a natural part of the table when he is here. He also thinks that it is really cosy when we eat dinner together, for example, when my boyfriend is also home. Then he just sits looking at us when we are talking. So that is really what I am thinking, that there is space for everyone” (6-month-old child).

At the same time it was emphasised that parents allowed the child time and space to eat and explore at their own pace. In this way, practising BLW allowed parents to include the child in mealtimes, while giving the necessary space at the same time. The child’s enjoyment was viewed as central to the weaning process, and also acted to facilitate a connection between food and something enjoyable. Ida: “I am thinking that she also experiences meals as something nice, and the thing about discovering new foods, that it is exciting and all that” (7-month-old child).

Often parents would describe how gratifying they found the whole experience of observing their child’s enjoyment when eating. Ensuring a positive association to an array of family foods from the beginning of weaning, also acted to lay the foundations for the child to accept a healthy varied diet in the future. The reoccurring theme was that food should be varied, healthy and enjoyed in a common social setting. Ida: ”That it is varied, she should taste a lot different things, that is kind of what I think is most important. And yes, that it is healthy and that she eats the same as us, I also think that is quite important” (7-month-old child).

Similar to the enjoyment being central, the value of being able to eat a variety of food and being an adventurous eater was evident from the data. The informants described how they loved seeing their child tasting and eating everything they were offered. Eating together was clearly a common priority for the families and integrating the child into this family value was important. In this way, introducing a variety of flavours from family food was a priority, not only in terms of the child’s health, but also to socialise the child into a family where food variety and joint family meals are treasured. However, being able to eat a variety of food was not discussed in relation to wider social norms or expectations outside the home. That mealtimes should be an enjoyable experience was a key element of BLW for all the informants. Generally, the informants believed that practising BLW was an important tool in achieving this goal, however one informant pointed out that reality did not always live up to this expectation. Mille: “It is also important that it should be a pleasure, but it is still not always the case. When he gets upset quickly, we can get a little tired of it, but yes, I do not know if would be different if, but it is certainly annoying when we have made it all ready, then five minutes later (pause)”

Interviewer: “Then he just does not want to anymore?" Mille "No, and then there is food all over the place” (11-month-old child).

As highlighted above, it was evident that practising BLW came with some expectations about certain outcomes. As illustrated later, informants also expressed hope that BLW would facilitate appetite control and a healthy relationship with food in their children.

Trusting the child and letting go of control Aspects of trusting the child and parental release of control were recurring topics throughout the interviews. The data illustrated that parents stayed in control of the selection of food offered to the children throughout the day, in that way the informants expressed that they were in control of what their children were eating. Within this frame the informants mainly talked about how they had to trust the child with regard to the volume and specific selection of food consumed. Ida: “And I feel that I have just decided to let go and say; she will stop eating when she has had enough and she will ask to eat when she is hungry. I can see that she is doing well and that is the main thing for me” (7-month-old child).

This act of releasing control, and allowing the child to be in control over his or her own food intake was not referred to as being difficult; the informants talked about how it felt good to trust the child through the process. The informants made a connection with this release of control as being similar to their experiences with breastfeeding. Signe: “perhaps it is a little harder, from the bottle, to let go and trust the child. I have never known how much (child's name) ate, but he is full and content” (6-month-old child).

The low levels of control reported by the informants were reflected in themes throughout the interviews. Letting go of control regarding certain aspects of their child’s food intake could be facilitated by several factors. Firstly, the informants all continued to breastfeed on demand and felt confident that this, in conjunction with increasing amounts of solid foods, would cover the nutritional need of their child. In the first few months of weaning the informants were aware that the large majority of nutrients should be met by continued breastfeeding. Consequently, actual food intake was not viewed as being very important at the initial state of weaning. Lotte: ”Eating is somewhat free now, now she is still eating for the fun of it, when she works up a hunger then it is much more important that she, and she starts to breastfeed less, that she actually gets some food in her” (7-month-old child).

Secondly, the informants with older children were reassured by the fact that they had already experienced a big drop in breast-feeding and by the end of the first year their children’s feeding skills were highly developed. Finally, the informants reported that their children showed a great interest in eating, happily spending half an hour or more at mealtimes and tasted everything that was offered. The main rationale for letting the child be in control of the volume and selection of food consumed was a strong belief that they were capable of self-feeding and regulating their own energy intake. However, this practice was also connected to possible future benefits such as less pickiness and appetite control in the future. Signe: “Erm, that he will not be pressured to eat. I do hope that it will give him a more natural relationship to food. Both in term of what he likes, not being picky but liking lots of different things and also in terms of knowing when he is full. At least that is what I hope, but that is difficult to predict” (6-month-old child).

Specifically, it was low parental control and interference during mealtimes that was viewed as central to teaching the child to respond to internal cues of hunger and satiety. The values of listening to these cues were referred to during the interviews. However, no direct reference to lower risk of future obesity was made. More prominent was the idea and hope that, low pressure combined with exposure to food variety and a positive atmosphere, would prevent their child from becoming a picky eater. As discussed in the previous section, fostering a child who was able to eat a variety of healthy foods was significant goal for the families. Arguably, the family’s diets would be described as being very healthy and this is mentioned as being a priority for the informants. In relation to this, the lack of focus and attention to the child’s food intake and the concept of releasing control can be viewed somewhat as a paradox. The reason for this paradox is likely that a controlling parenting style, in itself was viewed as being unhealthy for the child. Anders: “Food should not be a project and it should not be an erm, we just do not have any focus on it at all (...) we do not have any eating disorder on our child's behalf” (11-month-old child).

Letting go of control was also viewed as important in order to let their children experience the sensory aspect of eating, emphasising that food is much more than its nutritional value.

Lotte: “So for me it is about giving them some control back and letting them discover food in a completely different way, both regarding sensory aspects, because of course they get the taste if they get porridge, but here they experience it in their hand. And it smells different than if you get some kind of porridge and it is different textures and so on. So in that way, yes, let them discover the food” (7-month-old baby).

It was clear to the parents that handing over control to the child, gave their child an experience of independence that they were not willing to let go of again. This was evident when the informants talked about how their child insisted on feeding themselves and refused to be spoon-fed. Frederik “The times I have done it I have thought; if he could just taste it then hopefully he would begin to eat it. However I have never had any success with that (laughing) he does not open his mouth, you cannot feed him. He has never learned how to” (11-month-old child).

During the interview, informants were asked if anything would make them consider stopping with BLW. As illustrated above, the informants did not feel that it would be possible to prevent their child from feeding themselves after being introduced to food in this way.

Baby-led weaning as part of a broader parenting philosophy It was clear from the data that parents practising BLW often used other parenting methods generally viewed as being more responsive or gentle, such as co-sleeping, baby-wearing and extended breastfeeding. A number of families mentioned using baby sign language with their child to enhance early communication. The above practises are often associated with a parenting philosophy called Attachment Parenting. However, no parents mentioned adhering to any parenting philosophy in particular, although one talked about being introduced to BLW through a parenting site with similar ideology as Attachment Parenting. Chiefly though, there was a general agreement that being open-minded was a prerequisite for practising BLW in DK, but that the practice otherwise would appeal to a range of people. Signe: “No, there is almost no one who knows about baby-led weaning, if it was more widely known, there would probably be more people who used it (...) So no, I will not describe us as hippies or anything else like that” (6-month-old child).

Although these parents did not identify themselves with following any specific parenting style, it was clear that practising BLW was associated with other gentle/responsive parenting methods. In terms of parenting philosophy, it was also clear that the fathers in DK played a visible role in terms of being an active part of the decision to follow BLW and also taking actively part in the

interview. This was in contrast to the UK informants, where only the mother was represented, and previous descriptive studies on BLW.

Deviating from authoritative advice That practising BLW deviated from official guideline and a cultural norm in DK was apparent throughout the informant’s accounts of their experiences. This was in sharp contrast to the accounts given by UK based mothers and it clearly impacted on the experience of weaning.

Official guidelines and relationship with the Health Visitor It was evident that the informants felt that the practice of BLW went against the official weaning guidelines and was incompatible with the Health Visitor’s advice concerning the introduction of solid foods. Despite the positive experiences that mothers consistently reported, going against official advice triggered feelings of insecurity and self-doubt. Signe: “First of all, they (Health Visitors) do not know anything about it (BLW), and I think that is where I become a little unsure and feel that I lack some knowledge about how it (BLW) could be done here in Denmark. Because they think that he has to have porridge, and in the porridge you have to put in some infant formula, so that he gets enough nutrients. And one of them was almost offended when I said that he is allowed to feed himself and said; I simply do not understand that you dare. It is the thing about the risk of him getting something stuck in his throat” (6-month-old child).

This account was in clear contrast to the UK based informants, who did not report feelings of insecurity regarding the official guidelines in the UK. Heather (UK based mother): ”I think they (Health Visitors) are generally very supportive of it in this country, I think it is a recommended strategy on the NHS (National Health Service) website for weaning. I think it is one of the things they recommend now as an alternative to pureed weaning. It is not seen as a mainstream choice but not a controversial choice, it is very common now” (12-monthold child).

It was also clear from the data, that the Health Visitor in DK played a much greater role compared to the UK. This was evident as, unlike the UK based informants, reference to the Health Visitor was made continuously by the informants from DK. Discussing health related issues with a health visitor was still valued and offered reassurance to these first time parents. Anders: “It was not like we said; she is the only right person to ask (...) but there are just times where it is good to be able to get hold of someone who has some experience. It is quite nice to turn to someone who has been a Health Visitor for some years, or decades even, which then have some experience to base it on” (11-month-old child).

The informants reported receiving very different responses from their Health Visitor regarding the fact that they practised BLW. Some felt they were met with interest and some with a warning that it could be dangerous. The latter response clearly halted any further communication as informants felt that without any common ground, discussing food and feeding was not possible. The informants explained that this left them with a feeling of “standing on their own”. Informants who felt that their Health Visitor remained open minded or interested, reported that communication remained possible but not optimal. They explained that without the Health Visitor having any knowledge about BLW it was hard to have a discussion about the introduction to solids. The importance of the Health Visitor’s attitude, when it came to successful communication, was highlighted in the following statement: Lotte: “So I think that I will be going to use her selectively in the sense that if she does not back me up then I do not think that I will use her. So it very much depends on what her reaction is going be, but I have asked her about things previously yes” (7-month-old child).

Lotte had not discussed practising BLW with her Health Visitor, as she had only recently switched over from using traditional spoon-feeding. She was clear that the extent of which she would use her Health Visitor depended on how supportive her Health Visitor would be. Parents practising BLW in DK also had to deal with conflicting recommendations regarding, for example, iron supplementation which is recommended in DK but not in the UK. This fact highlighted how difficult it could be for parents to go against the official recommendations. Ida: “Regarding iron, I have chosen not give her iron supplements, but then I offer her meat every day. And I keep thinking; will she get enough of it? What if I forget to do enough variation?” (7month-old child).

This was contrasted with informants who had chosen to follow the recommendation for iron supplementation from six months of age. Signe: “Of course we give him D-drops and he is also just starting to get iron drops. And I know that according to the theory he does not need to have any because he should get it from the diet, but then I would rather be a sure that he gets everything that he needs” (6-month-old child).

It was clear, as illustrated in the above statements, that following the recommendations from The Danish Health and Medicines Authority, acted to reassure the parents that their child would have

their nutritional needs meet, in the same way as going against official recommendations was a cause of concern and self-doubt. The self-doubt expressed when discussing BLW in relation to official weaning recommendations was in clear contrast, not only to the informants from the UK, but also to their own view of BLW and how they perceive the health of their own child.

The Health Visitor’s perspective Interviews with Health Visitors in DK were conducted in order to gain an insight into how the growing trend of BLW was perceived among health professionals in DK, their knowledge on the subject, and how communications with these families was effected. A simple deductive method was applied in order to identify any relevant themes regarding; Knowledge, possibly benefits and concerns, and Communication.

Knowledge All Health Visitors expressed that they had very limited knowledge about the concept of BLW. None had any knowledge about BLW prior to meeting families practising it and the knowledge was generally limited to the information given to them by the families they had been in contact with. Contrasting interpretation of BLW was evident amongst the Health Visitors, likewise the views on the method varied considerably between the informants.

Benefits Some of the beneficial aspects of BLW according to the Health Visitors were the increased exposure to the variety of family foods. This was based on the Health Visitors experience that many families found that their child’s preferences became very narrow and specific to certain types of food, or their acceptance of food was limited to only a few versions of familiar meals of commercially produced baby foods. Another aspect of BLW that was viewed as positive, was specifically the responsive style of feeding that BLW promoted. Being gentle and responsive to the child’s cues when it came to introduction of solids was viewed as important. Additionally, giving the child a chance to actively be part of the meal and encouraging the parents to relax was believed to be very beneficial. This was based on experiences that the child’s motivation to eat and enjoyment of food often was helped by letting 43

them actively join in mealtimes and not pressing on with any food until the child clearly showed signs that he or she was ready to be fed the food in question. Low Parental pressure in particular was believed to be a very important component when encouraging children to eat.

Concerns One concern was that if children were not introduced to solid foods around 6 months or shortly after, the experience was that it could be very difficult getting them interested in food thereafter. One Health Visitor also expressed concern about the caloric adequacy of the diet; in particular whether children had the motoric ability to self-feed from the onset of weaning. It was also a concern whether BLW was a way to waiver the parental responsibility regarding the child’s food intake. This was based on experience with one BLW child who had dropped from being just above the 50th percentile to being just below it, following the start of eating solid foods. On the other hand, it was mentioned that the families practising BLW was not generally the ‘type’ of parents that they had great concerns about.

Communication The Health Visitors were all clear that the practice of BLW was not in line with the recommendations given by the Danish Health and Medicines Authority. However, the data clearly illustrated that ensuring successful communication with the families practising BLW was dependent on the response the families received from their Health Visitor. When met with a warning and reasoning why BLW was not an appropriate style of feeding, the Health Visitor found that the family was not taking her advice on aboard. Anne: “I am actually a little unsure about how much they actually took in, or whether they felt like, because I had just told them that it is not something we recommend doing here in Denmark, so my experience was that she did not want me to interfere too much. My feeling was that she probably did not listen to a lot of what I had to say” (Health Visitor).

This was in contrast to the experience of communication when the Health Visitor had responded with curiosity and mentioned that they respected the decision that the family had taken about following the method. In this scenario the experience was that communication was good and that they could still advise the family on aspects of nutrition and weaning.

Discussion As evident from the above review of studies conducted in the field, several desirable health outcomes have been associated with the practice of BLW. Based on existing literature and on indicators from the present study, some of these outcomes will be discussed in more detail. Throughout the discussion, evidence from other areas of childhood nutrition are used to critically evaluate whether specific aspects of BLW could have adverse or beneficial effects on immediate growth and development as well as future health outcomes. Specifically, the relationship between BLW and decreased risk of overweight will be discussed: Healthier weight ranges in BLW children might be mediated through encouraging a feeding style low in control and promoting better appetite regulation. Additionally, the relationship between BLW and decreased pickiness will be addressed. On the other hand, the practice of BLW has raised concerns amongst health professionals, whether BLW is associated with insufficient energy and iron intake or increased risk of choking will also be discussed. Finally, parental norms and values and the implications of going against official weaning recommendations in DK will be debated.

Evidence and rationale for possible benefits of baby-led weaning Characteristics of parents practising baby-led weaning

So far, the reviewed evidence demonstrates that parents/mothers practising BLW differ from the general population on several aspects: Mothers practising BLW are more likely to be married, have higher education, higher occupation and to have breastfed their infant (Brown, Lee 2011a, Townsend, Pitchford 2012). Practising BLW is associated with a later introduction of complementary foods, greater participation in meal times and exposure to family foods (Brown, Lee 2011a, Cameron, Taylor et al. 2013, Brown, Lee 2013a). Levels of anxiety about weaning and feeding were reported to be lower in mothers who adopted a BLW approach (Brown, Lee 2011a, Brown, Lee 2013). Mothers practising BLW reported significantly lower levels of restriction, pressure to eat and monitoring compared to mothers following SW (Brown, Lee 2011a, Brown, Lee 2013a). Mothers of BLW infants breastfed their child for a significantly longer duration of time than mothers of SW infants, independently of maternal SES (Townsend, Pitchford 2012, Brown, Lee 2011a). Indications of such parental characteristics were also evident in the current study of

families practising BLW in DK. As discussed throughout the following sections, many of these characteristics and behaviours are associated with more desirable long term health behaviours or outcomes. These factors must therefore be taken into consideration when examining the relationship between BLW and various health related outcomes. Decreased risk of overweight

A fairly consistent body of evidence now demonstrates that overweight and obesity in childhood and adolescence have adverse consequences on premature mortality and physical morbidity in adulthood (Reilly, Kelly 2010). Increasing evidence support the notion that nutrition in infancy and during the complementary feeding period have long-term effects on future health related outcomes and development of non-communicable diseases (Michaelsen, LarnkjĂŚr et al. 2010). One cohort study indicates that BLW may decrease the risk of becoming overweight in later childhood. Two mechanisms in which BLW may facilitate healthier weight gain in childhood is through the role of low maternal control and enhanced satiety responsiveness (Brown, Lee 2013a)

- Encouraging a feeding style low in control In the present study of parents in DK, participants all talked about letting go of control and handing it back to the child as being a central concept of BLW. During the observed mealtime it was evident that the children were allowed to eat without any interference from the parents. Furthermore, it was clear that the children did not need encouragement in order to actively engage in the shared meal. The reviewed evidence on BLW demonstrated that the practice of BLW is characterised by a feeding style low in control (Brown, Lee 2011b, Brown, Lee 2013a). Mothers practising BLW reported significantly lower levels of restriction, pressure to eat and monitoring compared to mothers who followed a SW approach. Restriction involves limiting access to particular foods, including favourite foods, as well as restricting the total amount of food. Pressure involves pressuring children to eat certain foods and pressure to eat more in general. Restriction and pressure are two primary aspects of control that have been linked to overweight and aspects of disordered eating (Scaglioni, Salvioni et al. 2008). Specifically, restrictive feeding strategies have been associated with increased food consumption and weight status (Birch, Fisher et al. 2003). Pressure to eat has been associated with fussiness, low nutrient intake and underweight (Faith, Scanlon et al. 2004). There is some evidence showing that the associations described above are not merely a case of reversed causality with mothers responding to their infantâ&#x20AC;&#x2122;s weight; data 46

from one study found that maternal control significantly moderated the influence of early infant weight gain on subsequent infant weight gain (Farrow, Blissett 2006). Specifically, when maternal control was moderate or low, infants seemed to regulate their own weight gain across the first year of life; with those infants who had rapid early weight gain slowing down and those with slow early weight gain accelerating in their subsequent growth. However, when maternal control at 6 months was high, child weight gain followed the opposite pattern and infants maintained consistency in their weight gain (Farrow, Blissett 2006). Based on the current evidence, adopting a responsive feeding style, characterised by low levels of parental control, is believed to be an important factor when it comes to the development of healthy eating habits (Schwartz, Scholtens et al. 2011). Due to the cross-sectional design of the two studies by Brown and Lee (Brown, Lee 2011b, Brown, Lee 2013a), the cause and effect relationship between low maternal control and BLW remains unclear. It could be argued that any causal relationship between BLW and a feeding style low in control is bidirectional; it is unlikely that parents who feel they need to control or monitor their childrenâ&#x20AC;&#x2122;s food intake would choose to practice BLW. On the other hand, BLW clearly forces parents to take a step back, accepting the childâ&#x20AC;&#x2122;s choice of food and their ability to respond to their own cues of hunger and satiety. Regardless of the cause-effect direction between low maternal control and BLW, Brown and Lee (2013a) provided evidence that the practice of BLW had a shielding effect of high measures of maternal control, during the weaning phase on later undesirable eating behaviours. They found that high levels of maternal control at the weaning phase (6-12 months) was only significantly associated with childrenâ&#x20AC;&#x2122;s eating behaviour at 18-24 months, for the SW children. Here, high levels of restriction were associated with lower levels of satiety-responsiveness. Concern for infant weight was associated with higher levels of food fussiness and high levels of pressure to eat were associated with lower levels of enjoyment of food. These associations were not evident in the BLW group, suggesting that the practice of BLW was actually protective against the negative effects of a controlling maternal feeding style.

- Appetite regulation

Brown and Lee (2013a) demonstrated that BLW children displayed better appetite regulation during the toddler years and this was reflected in a lower BMI and occurrences of overweight in the BLW group. This indicates that encouraging a feeding style that is sensitive to internal cues of hunger and satiety maybe an important strategy in childhood obesity prevention. BLW may encourage a number of practices associated with better satiety control and lower risk of overweight: BLW infants are more likely to be breastfed rather than fed formula milk (Brown, Lee 2011a) which has been associated with better satiety responsiveness (Faith, Scanlon et al. 2004). BLW encourages longer duration of breastfeeding (Brown, Lee 2011a, Townsend, Pitchford 2012) and longer duration of breastfeeding has been associated with increased satiety responsiveness (Brown, Lee 2013a, Harder, Bergmann et al. 2005). BLW also encourages later introduction of complementary foods (Moore, Milligan et al. 2012). Delayed introduction of complementary food, within the age range of 2 to 6 months, has been demonstrated to be protective against overweight in adulthood (Schack-Nielsen, Sorensen et al. 2010). It could be argued that the longer duration of breastfeeding and later introduction of solids, associated with BLW, are a consequence of practising BLW and not the other way around: breastfeeding duration was on average almost twice as long in the BLW group, compared to the SW group and it was independent of maternal SES (Brown, Lee 2011a, Townsend, Pitchford 2012). Additionally, the BLW theory encourages continual breastfeeding on demand, and milk feeds are not replaced relatively early in the weaning phase with energy-dense porridges and purees (Brown, Lee 2011a). In regard to the later introduction of solid foods, the practice of BLW is inherently connected to the developmental ability of the infant, which is seldom capable of handling and swallowing whole foods before reaching the age of 5-6 months (Stevenson, Allaire 1991). However, Brown and Lee (2013a) found that the association between BLW and better satietyresponsiveness and healthier BMI were independent of maternal control, breastfeeding duration, weight at birth and timing of weaning. This indicates that further aspects of BLW, other than low maternal control, duration of breastfeeding and timing of weaning, encourages efficient appetite control and healthier weight in BLW infants. In the following section evidence from further areas of infant nutrition are drawn upon in order to discuss how BLW may cause better appetite regulation and weight gain trajectories: The inborn ability of infants to self-regulate their calorie intake, according to their physiologic needs, has been demonstrated in various different studies: 48

Evidence of energy self-regulation has been shown in the early weaning phase (4-6 months), where it was demonstrated that the introduction of solids at 4 months caused a decrease in nursing frequency and duration, resulting in similar total energy intakes and growth rates, between infants exclusively breastfed and infants receiving complementary foods after 4 months (Cohen, Brown 1994). Similar findings have been reported in the later stage of weaning (4–11 months), where a significant negative association was found between energy density of the meal, and average portion size consumed by infants in this age group (Fox, Devaney et al. 2006). The ability of infants to efficiently align their energy intake to their need, makes their own cues the best guideline when initiation and terminating feeding. Thus, being responsive and attentive to infants cues of hunger and satiety is now being viewed as an essential part of responsive feeding, leading to better self-regulation in the context of ensuring healthy growth and preventing overweight and underweight in young children (Black, Aboud 2011, Schwartz, Scholtens et al. 2011). Letting the child initiate and terminate eating at every mealtime is an essential part of BLW. This practice was also observed in the current study of parents from DK, where the children were allowed to eat as much or little as they wished. Essentially, this means that parents practising BLW do not need to read the child’s cue of hunger and satiety, as the child is in control of their own food intake, thus effectively eliminating the bias interpretation of the child’s state of hunger by its parents. The fact that BLW infants rely on their own internal cues of satiety, opposed to their parent’s interpretations of their fullness, may be why BLW infants were reported to be better at regulating their appetite. Another important factor of BLW which may enhance satiety responsiveness in these infants is that they are offered food in more solid textures; duration of eating and thereby oral sensory exposure time is therefore greatly increased. Studies have demonstrated that a considerable duration of oral exposure time is needed before sensory signals leads to a substantial physiological or subjective satiety response (de Graaf 2012). SW infants are feed semi-liquid meals which are rapidly swallowed with a very short duration of time in the mouth. In adults, oral exposure time has been demonstrated to significantly affect the subsequent satiety response; two studies demonstrated that doubling the oro-sensory exposure time led to a 30-35% decrease in ad libitum intake (Weijzen, Smeets et al. 2009, Bolhuis, Lakemond et al. 2011). Based on studies in this field it 49

could be argued that infants fed pureed food will continuously experience a delayed satiety response compared to BLW infants and this may hamper their ability to accurately respond to signals of satiety during the weaning stage and beyond. Preventing pickiness and encourage variety

Data from the current study illustrated that raising a child who will eat a variety of foods was important to the informants, and that they hoped this could be achieved through the practice of BLW and exposure to a range of family foods. Preventing pickiness in children is also an important public health aim as picky eating/neophobia has been consistently associated with a higher intake of saturated fat and less food variety, including fruit and vegetables (Falciglia, Couch et al. 2000, Galloway, Lee et al. 2003). In recent years the process in which food preferences are formed, through infancy and childhood, has gained increased attention and evidence from this field of research will be discussed in the following sections.

- The effect of exposure on food preferences Childrenâ&#x20AC;&#x2122;s food preferences can seem so innate and hard to change, but evidence has demonstrated that preferences are shaped through experience and that the effect of this learning is through exposure (Capaldi, E.D. 1992). Taste preferences appear to be genetically mediated, with infants preferring sweet over sour and bitter tastes (Desor, Maller et al. 1977). However, flavour perception is experienced through a combination of taste, smell and chemosensory irritation. The innate taste preferences together with experience with flavours shape childrenâ&#x20AC;&#x2122;s individual food preferences (Cooke and Fildes, 2011). Although the focus in infant nutrition research may have shifted from prevention of malnutrition to promotion of long term health, and the formation of healthy eating habits, this is not well reflected in the current weaning guidelines (Schwartz, Scholtens et al. 2011). Food intake, and thereby nutrient intake, is greatly determined by preference and the importance of palatability is even more pronounced in children (Birch, Fisher 1998). Two studies in school age children found that preference for fruit and vegetables was the only variable significantly correlated to the intake of these foods (Domel, Thompson et al. 1996, Birch, Reynolds, Hinton et al. 1999). As childrenâ&#x20AC;&#x2122;s food preferences are so important determinants of intake, looking at how preferences are shaped 50

in early childhood is vital in order to understand how the formation of healthy eating habits may be facilitated. Repeated exposure to novel foods, also called mere exposure, has consistently been demonstrated to positively change children’s preferences (Birch, Marlin 1982). It is believed that mere exposure plays an essential role in the acceptance of new food and that parents have to expose their children repeatedly to novel foods in order to see a positive change in liking (Schwartz, Scholtens et al. 2011).

- Overcoming neophobia The effect of mere exposure may be explained in evolutionary terms through the mechanism of ‘learned safety’; the increased acceptance of a given food consumed without any aversive postingestive consequence (Kalat, Rozin 1973). In this way, children will gradually ‘learn’ to accept and like foods as a consequence of repeated encounters without any negative consequences. The effect of mere exposure is particularly interesting in relation to BLW, as the baby-led weaned infant is effectively exposed to family food repeatedly from the start of weaning. This means that acceptance of family food is facilitated from the start of weaning, opposed to a later time where the influence of neophobia is also likely to be greater. Food neophobia is the fear or reluctance to eat novel or unknown foods and is thought to be an adaptive mechanism protecting young animals from ingesting potentially harmful substances (Rosin 1976). Neophobia becomes particular pronounced during the toddler years, the onset of neophobia may vary between infants but generally, neophobia tends to be minimal in infancy, followed by a rapid increase during the second year of life and then gradually tailing off after four years of age (Harper, Sanders 1975, Cashdan 1994).

- Mere exposure in practice Although mere exposure has been demonstrated to be an effective strategy in reversing the innate neophobic response in young children, children must actually taste novel foods repeatedly in order to positively shift their preferences (Birch, McPhee et al. 1987). The number of exposures needed before an increase in liking and intake is observed, has been estimated to be approximately 8-10 times (Birch, Marlin 1982). However, literature shows that parents find it very difficult to implement these tasting opportunities in the home environment. Research suggests that parents of preschool-aged children are only prepared to offer a new food to their child on average three to five times before deciding the child dislikes it (Carruth, Ziegler et al. 2004). Even

during the weaning period, where infants are less prone to neophobia, parents fail to offer their infant foods that they perceive to be disliked more than 3â&#x20AC;&#x201C;5 times, and in another sample in the same study mothers gave up after only 1 or 2 attempts (Maier, Chabanet et al. 2007). The difficulties of parents to successfully implement mere exposure as a strategy to create healthy food preferences and eating habits are illustrated in a review by Heath et al. (2011), who concluded that parents tended to avoid the stress associated with repeatedly offering their children foods that were likely to be rejected (Heath, Houston-Price et al. 2011). Additionally, getting children to repeatedly taste foods which they do not like may be very difficult without leading parents to pressure their child and creating a negative association concerning mealtimes. Although based on a small sample (n = 72) one study found a correlation between reluctance to try a food and subsequent hedonic experience, and the authors warn that urging a child to try an unfamiliar food when he or she is not positively prepared to do so, may constitute a barrier to further familiarisation with this food (Tuorila, Mustonen 2010). This is in line with research showing that parental pressure to consume foods is consistently associated with higher expression of food neophobia (Dovey, Staples et al. 2008).

- Baby-led weaning naturally encourage the effect of mere exposure In this light, practising BLW may be particular conducive for the process of mere exposure to take place naturally, without the need for coercion or the risk of increased anxiety around meal times. To my knowledge no study has examined the effect of self-feeding versus parental feeding and the willingness of young children to taste unfamiliar food. However, it is likely that the willingness to try novel foods is greatly increased when the child is in control of what to taste, in what quantities and has the freedom to spit out any food when the taste is not liked or merely not expected. Indication for such an effect of self-feeding is based on observations and parental accounts from the current study; parents of BLW infants reported that their child repeatedly tasted everything that was introduced to them. Even food that was not liked was repeatedly tasted, after initially being spat out. As discussed above, mere exposure or â&#x20AC;&#x2DC;learned safetyâ&#x20AC;&#x2122; are closely related to the neophobic tendencies and the reluctance to ingest novel foods which may or may not be safe. Ingesting limited quantities of a novel food is likely to be an evolutionary safety mechanism, which may therefore not be easily overwritten. Studies on food acceptance, observe that the intake of novel food gradually increases with the number of exposures, but that initial intake is very low or

limited to only tasting the food. The practice of BLW allows this process to take place repeatedly while the infant is still relying on breast milk to fulfil the majority of his or her nutritional requirement. During traditional weaning however, infants are expected to increasingly fill their caloric needs from solid foods comparatively early in the weaning phase. Therefore, parents will have to serve palatable food, already accepted by the infants, as the amount consumed of novel foods introduced may not fulfil the energy need of the child. Parents priority of meeting their childâ&#x20AC;&#x2122;s caloric requirement may be an important factor in why foods are only presented a limited amount of times before parents conclude that the child does not like it. Another barrier may also be the practicality of how to spoon-feed an infant food that is new or disliked, while maintaining a feeding style low in control. Babies being introduced to solids using the BLW method do not rely on solids to fulfil a great amount of their calorie needs in the first few months of weaning (Rapley, Murkett 2008), so can explore new foods without the emphasis being on the quantity ingested. According to Rapley and Murkett (2008), BLW infants do not generally cut down on their breastfeeds for the first few months of weaning, or until around 9 month of age (Rapley, Murkett 2008). Instead they supplement continued breastfeeding with increasing amount of solid foods. This is in contrast to SW practises, where the addition of calorie dense porridges and purees replace breast milk comparatively early in the weaning phase. This means that SW infants must be provided with a palatable diet high in energy and nutrients to sustain their growth and development.

- Baby-led weaning encourages exposure to variety and family food In a recent study of Danish mothers of 7 and 13 months old children, it was evident that food in the early phase of weaning was viewed as separate from the rest of the family, with no or little focus on variety in the diet (Nielsen, Michaelsen et al. 2014). This practice will fail to utilize the very important time of the weaning phase, where the low levels of neophobia make introduction to the variety of tastes and textures of family foods ideal. This is in contrast to findings of the current study and other studies on BLW, which find that children are repeatedly exposed to a variety of foods with different textures, tastes and flavours (Brown, Lee 2011a, Cameron, Taylor et al. 2013). Parents of BLW infants, from this and other studies, also talk about how their children enjoy foods with strong flavours such as curries, adding weight to the notion that the early

weaning phase is a time where infants are particularly curious and interested in a variety of flavours (Brown, Lee 2011a). The risk of weaning on a very monotonous diet was also something the Health Visitors talked about in the current study. They found that some infants eating ready-made baby food would become so used to particular flavours that they refused any other foods. Although parents may not regard ready-made baby food as optimal, they are often used due to practical concerns (Nielsen, Michaelsen et al. 2014). Ready-made baby foods are blended or mashed and are thereby inherently connected to spoon-feeding, therefore BLW naturally discourage the use of commercially produced baby food (Cameron, Taylor et al. 2013). Encouraging a weaning practice associated with lower pickiness is not only a public health aim, but an important parental concern: In the study by Nielsen et al. (2014) informants discussed how raising a picky eater was embarrassing and reflected negatively on parental success of bringing up their child. Likewise, the value of having an adventurous eater was also a strong theme in the current study. However, the strategies employed to minimising the chance of having a picky child, were quite different between the groups of parents: Informants practising BLW emphasised exposure to variety and no parental pressure as the most effective strategy. Whereas the informants from the study by Nielsen et al. (2014) emphasised the need to set limits and have rules in place such as insisting the child taste new foods before replacements were allowed. On this basis, the apparent cultural stigma attached to having a fussy eater may cause unintended and unhelpful pressure to be put upon children who are not very adventurous eaters by nature, whereas practising BLW may encourage a more low pressure approach.

- Baby-led weaning is associated with decreased food fussiness As showed in the review of studies on BLW, two studies have examined the associations between BLW and decreased fussiness in children (Townsend, Pitchford 2012, Brown, Lee 2013a). Brown and Lee (2013a) found that BLW infants were significantly less picky than the SW infants. However, the association between BLW and low fussiness was no longer significant after adjustment for maternal control, breastfeeding duration and timing of weaning. The reduced prevalence of picky eating was therefore likely mediated by these characteristics of BLW.

Based on the above discussion on mere exposure and ‘learned safety’, it is not surprising that factors such as low maternal control acted as a mediating factor in the relationship between BLW and lower levels of food fussiness. If children are being pressured, manipulated, or even forced to eat a food, this food will be associated with a negative consequence and the opposite of ‘learned safety’ will be the result. Interestingly, fussiness was associated with timing of weaning and duration of breastfeeding. Infants who were weaned at an earlier age were reported to be significantly more fussy at 18–24 months and infants who were breastfed for a longer duration were reported to be significantly less fussy (Brown, Lee 2013b). Other studies have also found an inverse association between duration of breastfeeding and picky eating (Galloway, Lee et al. 2003). One study demonstrated that BLW infants tended to prefer carbohydrates in contrast to SW infants who preferred sweets over other food groups (Townsend, Pitchford 2012). However, the study did not find a significant difference in the report of picky eaters between the groups. This could be explained by the fact that classification of BLW was based on self-identification of practising BLW. Self-classification is likely to include parents using various amounts of both spoon and puree feeding. One study found that only a third of surveyed parents, who classified themselves as practising BLW, actually practised it based on a more objective categorisation (Cameron, Taylor et al. 2013). Significant results on variables such as pickiness may have been obtained if a more strict classification of BLW had been applied. Due to the large discrepancy between self-identification of practising BLW and actually letting the child self-feed most of the time, future studies should use a predefined definition of BLW, such as ‘Spoon-feeding and puree use ≤10% of time’ which has been used in some studies (Brown, Lee 2011a, Brown, Lee 2011b, Brown, Lee 2013a). It should also be noted that exposure to a variety of foods from 6 months in itself is associated with healthier diets and nutrient intake throughout childhood and adulthood (Cooke 2007). Exposure to variety is therefore also likely to play a mediating factor in any relationship between BLW and healthy eating patterns, as the practice of BLW is associated with greater participation in meal times and exposure to family foods (Brown, Lee 2011, Cameron, Taylor et al. 2013).

In summary, children weaned by BLW have been shown to be less picky than children weaned by SW. Lower levels of maternal control in the BLW group may account for the association between BLW and lower levels of pickiness. Whether BLW forces parents to be less controlling, or less controlling parents choose to practice BLW, cannot be concluded. Furthermore, time of weaning, breastfeeding duration and early exposure to variety and family foods may also mediate the relationship between BLW and decreased pickiness. Self-feeding skills, motoric development

One of the core principles of BLW is that children should be offered whole foods from the onset of weaning (Rapley, Murkett 2008). Opposed to infants spoon-fed by parents, BLW infants practise and develop an array of skills during each mealtime; gross and fine motor skills, hand-eye coordination and oral-motor skills. They explore and problem solve, when they work out the amount of pressure needed to grasp different food item and develop techniques in order to prevent food from falling out while chewing. The official guidelines in DK put little emphasis on the developmental value of self-feeding during the early stage of weaning (Sundhedsstyrelsen 2011). Likewise, in a recent comprehensive review of the current literature regarding development of healthy eating habits in early life, the authors noted that apart from in the UK, guidelines encouraging the development of self-feeding skills are not adequately addressed (Schwartz, Scholtens et al. 2011). Encouraging self-feeding skills from the beginning of weaning may give BLW infants some advantages over SW infant, as early introduction of lumpy food and textures is associated with better long-term outcomes: Readiness for chewing has been identified to occur at around 6 months for most normal children, or on average, when the child is 6 to 7 months of age (Illingworth, Lister 1964). Development of infantsâ&#x20AC;&#x2122; oral motor skills is dependent on previous exposures to textures; movement patterns, such as lateral tongue movement, are texture-dependent and therefore emerge when the child is given the particular textures requiring the use of these skills (Mason, Harris et al. 2005). There is evidence to suggest that children need to be exposed to whole foods of varying textures early in the weaning phase when these chewing skills are emerging: Introduction of lumpy foods after 10 months has been significantly associated with feeding difficulties and more definite likes and dislikes at 15 months (Northstone, Emmett et al. 2001). Similarly, introduction of lumpy foods

after the age of 9 months has been associated with a reduced consumption of important food groups such as fruit and vegetables, and increased occurrence of feeding problems at 7 years of age (Coulthard, Harris et al. 2009). Additionally, experience with difficult-to-chew textures in infancy has been shown to facilitate preference for a more complex texture during later toddlerhood (Lundy, Field et al. 1998). As evident from the present study, BLW children would happily spend half an hour, or even longer, at mealtimes practising these developing skills. It could be argued, that offering only blended and mashed food beyond 6 months of age is preventing children from practising important self-feeding and oral-motor skills. Delaying the introduction of whole foods or lumpy foods beyond 9-10 months of age may carry future adverse implications. However, studies on oral skill development, as textures are being introduced throughout the weaning period, is unfortunately an under studied phenomenon (Delaney, Arvedson 2008). The lack of scientific studies on oral motor development may be the reason why little emphasis is placed on encouraging these emerging skills in the official weaning recommendations in general (Schwartz, Scholtens et al. 2011) and in DK (Sundhedsstyrelsen 2011). Introducing finger-foods and allowing infants to experiment with family foods from 6 months, could be encouraged alongside parental spoon-feeding. However, contrary to the UK, this practice is not advocated in DK. This means that BLW infants are much more likely to be exposed to family food, with a variety of textures early in the weaning period, compared to SW infants.

Evidence and rationale for proposed risk of baby-led weaning Sufficient iron intake?

Following the first 26 weeks of life, it is estimated that 90% of infants iron requirement must come from solid foods (Agostoni, Decsi et al. 2008). In many countries, baby cereals are fortified with iron to ensure adequate iron intake during the weaning phase. A study from New Zealand found that, unlike parents following SW, parents practising BLW did not offer iron fortified foods to their infants and identified this as a risk factor for low iron intake (Cameron, Taylor et al. 2013). Likewise, health professionals have expressed concerns about the risk of inadequate iron intake in BLW infants as these are not spoon-fed fortified cereals (Cameron, Heath et al. 2012). Whether

BLW infants are at higher risk of low iron status is difficult to predict, as factors other than iron fortified cereal may be important. The infants in the study by Cameron el al (2013), who identified the lack of fortified cereal as a possible risk factor, all consumed family meals and thereby presumably ate other foods high in iron. In the present study, all infants were introduced to both fish and meat from the start of weaning and these foods were reported to be very popular with the children. Specifically, one informant noted that it was the change to BLW from SW that had prompted her to serve meat and fish, which she had not done earlier. In this way, early introduction of iron rich food may be specifically encouraged when practising BLW. As the bioavailability of iron from meat and fish is estimated to be 5 times greater than iron fortified cereal (Rios, Hunter et al. 1975, Monsen 1988), this is likely to positively affect these children’s iron status. Additionally, contrary to the UK and New Zealand, iron supplementation is recommended for infants between 6-12 months of age by the Danish Food and Medicine Authority and intake is therefore not dependent on fortified baby food in DK (Sundhedsstyrelsen 2011). However, not all parents in the present study decided to follow this recommendation, instead they emphasised the use of iron rich food, as advised in the BLW book (Rapley, Murkett 2008), the Department of Health UK (Department of Health 2013) and internationally (Agostoni, Decsi et al. 2008). On one hand, BLW infants may be more vulnerable to low iron status due to other practices associated to BLW. Specifically, BLW infants are more likely to be breastfed and to be exclusively breastfeed for 26 weeks (Brown, Lee 2011a, Moore, Milligan et al. 2012). Both these practices may be overall beneficial, but they have also been associated with an increased risk of iron deficiency (Dube, Schwartz et al. 2010, Chantry, Howard et al. 2007). On the other hand, in addition to being offered a diet high in bioavailable iron, parents practising BLW, in this and other studies, had high education and high socio-economic status. Iron deficiency anaemia has been found to be significantly more frequent with low rather than high socio-economic status (Male, Persson et al. 2001). Additionally, parents in the current study did not offer cow’s milk as a main drink. Early introduction of cows' milk has been found to be a strong negative determinant of iron status (Male, Persson et al. 2001). Introduction of cow’s milk before 12 months of age is not internationally recommended (Agostoni, Decsi et al. 2008). Likewise, early introduction of cow’s milk is not recommended as part of BLW (Rapley, Murkett 2008). However, the discussion about

iron status in BLW infants will remain speculative until measures of iron status are carried out in a sample of BLW children compared to SW children. Increased risk of choking?

The BLW method stresses that several safety measures must be observed; namely, that the child should be able to sit up unaided or with little support and be able to support their head before being ready to safely self-feed. Additionally, parents are advised never to leave the child while eating and restrain from putting food into the baby’s mouth, as the child itself should be in charge (Rapley, Murkett 2008). Parents practising BLW are introducing whole foods from approximately 6 months of age, which has caused health professionals to speculate that the practice may increase the risk of choking (Cameron, Heath et al. 2012). In the UK, this reasoning may not seem logical as finger foods are also recommended by the Department of Health from 6 month of age and parents are encouraged to let their child feed themselves as soon as they show willingness (Department of Health 2013). However, whole pieces of food, or finger foods, are not recommended by the Danish Food and Medicine Authority, from 6 months of age, setting the practice of BLW apart from SW in this aspect. The risk of choking was also clearly a concern to one participant’s Health Visitor in the current study, who cited it as being the reason she would discourage the practice of BLW. One study found no difference between BLW and SW in the proportion of parents reporting at least one gagging or choking episode. However, more than 30% of the total sample reported at least one choking episode. The authors suggest that this was due to parent’s inability to distinguish between choking and gagging and emphasise that due to the rarity of serious choking episodes, their small study (n = 199) was not powered to identify differences in the rates between the feeding groups (Cameron, Taylor et al. 2013). However, practising BLW may cause parents to become over confident in their child’s ability to safely handle food. Another study has shown that hard foods such as whole apples were offered to the children (Cameron, Heath et al. 2012a). In the present study, parents reported that all hard fruit and vegetables were cooked and offered soft at the start of weaning, but not when the child was older (end of the first year). Whether this practice differs from normal SW practices is not known. Hard fruits and vegetables, such as apples and carrots, are not recommended for young children (Sundhedsstyrelsen 2011). Offering it early could potentially pose an increased risk of choking.

On the other hand, introducing whole foods from six months of age could also prove to minimise the risk of choking, by encouraging oral motor development for safe handling of lumps of food. At the beginning of weaning infants have a very effective and active gag-reflex, which acts to expel any foods that are being pressed to far back into the mouth (Rapley 2003). When observing BLW children eat during early weaning, it is clear that foods are effectively expelled by this gag-reflex and that the child happily continues to eat afterwards. Introducing whole foods at a later stage of weaning means that the child will have to learn how to handle lumpy foods at a time when the safety mechanism of the gag-reflex is much less prominent. Although speculative, this could suggest that early introduction of whole food might be an advantage when it comes to the risk of choking. This was clearly the views held by the informants from the present study. They reported that any food accidently pressed too far back in the mouth was efficiently expelled by an effective gag-reflex and they reported that their children quickly became competent eaters. Early introduction of age appropriate whole foods could possibly be more important in Denmark, as the majority of children above a year will be exposed to an array of whole foods including raw fruit and vegetables during time spent at nursery (Haagensen 2011). Children who have no experience and practice with whole foods may not have learned to handle this safely and may subsequently have a much greater risk of choking upon starting nursery or day-care. Interestingly, one study found that mothers of 7-month-old children in DK viewed the weaning guidelines mainly as safety rules regarding issues such as avoiding acute choking accidents, but that for mothers of 13-month-old children the nutritional guidelines were losing their relevance (Nielsen, Michaelsen et al. 2013). However, the idea that older children are more capable of handling whole food, even with no previous experience with such food, could be a risky assumption especially when combined with starting nursery. Sufficient energy intake?

Whether the practice of BLW will ensure a sufficient energy intake during the weaning phase has been questioned by a range of health professionals (Cameron, Heath et al. 2012a). This concern was also expressed by a Health Visitor from the current study. Two concerns in particular have been voiced, namely; whether self-feeding skills are sufficiently developed from 6 months to fulfil the energy requirements of the infant (Wright, Cameron et al. 2011) and; whether it is possible to 60

ensure sufficient energy density in the BLW infants diet (Cameron, Heath et al. 2012).These concerns will be discussed in turn.

- Developmentally delayed infants and self-feeding skills It has been suggested that following BLW could lead to nutritional problems for infants who are relatively developmentally delayed. Wright, Cameron et al. (2011) found that, although the majority of infants started reaching out for finger foods between 4-7 months, 6% had not done so by the time they were 8 months. The age of the child when first reaching out for finger foods was also associated with developmental stage at 12 months, suggesting that infants who were relatively developmentally delayed, would be at an increased risk of inadequate nutritional intake if they were weaned using BLW. As late introduction of solids increases the risk of nutritional deficiencies such as iron, a cautious and realistic approach is probably needed with children who are developmentally delayed. This is also stated in the BLW guidelines, which advises against using this method with children who are either premature or developmentally delayed and emphasise that BLW is only suitable for healthy, thriving infants (Rapley, Murkett 2008). However, it might be difficult for parents, especially first time parents, to detect slight developmental delays. Wright, Cameron et al. (2011) therefore suggest that parents should be advised that BLW is only a realistic option if the child is reaching out for and mouthing objects by the age of six months. It has to be mentioned that this study was based on retrospective data obtained from mothers following SW, not BLW, and hence infants largely unfamiliar with self-feeding. Therefore the number of infants not reaching out for food at 8 months may have, at least partly, been a reflection of SW feeding style where they were not expected or encouraged to independently handle food.

- Energy density of baby-led weaned infants diet Traditional weaning foods in DK are often fruit and vegetable purees and different types of porridges (Trolle, Holmboe et al. 2013). Due to the high energy requirements and small stomachs, infants require a diet with a high calorie density. Therefore, fat must be added to porridge and purees during the weaning phase when these foods replace breast milk. As BLW infants are not consuming these semisolid foods with added fat, but rather different whole foods, the calorie density of their diet has been questioned by a number of health professionals (Cameron, Heath et al. 2012). 61

During initial self-feeding, BLW infants are not capable of ingesting very large quantities of solid foods; therefore, breast milk is replaced at a slower rate compared to that of SW infants (Brown, Lee 2011a). In this way, BLW infants are likely to obtain more of their calorie and fat intake from breast milk compared to SW infants who will receive it from purees containing added fat. However, due to the ability of infants to self-regulate their calorie intake according to their physiologic need, total energy intake is likely to be similar (Fox, Devaney et al. 2006, Cohen, Brown 1994). The transition from breast milk to solid food is very gradual in BLW infants. Their intake of solid foods is slowly increased as their motor and oral skills are continually improving. No data exist on the actual intake of solid foods in BLW infants during early weaning, so the question remains whether the intake of solid food adequately meets the demands of the growing infant? WHO estimate that infants aged 6-8 months in industrialized countries, will need to consume approximately 196 kcal from complementary food if their intake of breast milk is average at 486 kcal. However, if energy consumed from breast milk is high at 698 kcal, no additional calories from complementary foods are needed at the age of 6-8 months, in order to meet the energy demand of the infant (WHO 1998). These findings suggest that the amount of solid food expected to cover the nutritional need of the infants during the early weaning phase (age 6-8 months) is largely dependent on calorie supply from breastfeeding. Indeed, based on self-reported data, mothers practising BLW gave significantly more milk feeds (breast or formula) during the day than mothers following a SW approach (Brown, Lee 2011a). This suggests that BLW infants can supplement their calorie need with breast milk during initial weaning, despite the fact that mothers have no way of accurately assessing the amount of food actually swallowed. At the age of 9-11 months, a greater amount of solid foods are needed in order to meet the calorie requirement of the infants. Even when intake of breast milk is high, additional calories are needed to adequately cover the energy requirement of the growing infant (WHO 1998). However, at this stage, infants have developed the pincer grip and BLW children are generally quite competent eaters. No association between infant weights and feeding style, BLW or SW, was found in a sample size of 702 infants between 6-12 months (Brown, Lee 2011b), indicating that BLW infants regulate or supplement their intake of solid food with breast milk according to their needs during the weaning phase. Amy and Lee (2013) found no significant differences between occurrences of underweight between SW children and BLW children at the age of 18-24 months. However, due to the very

small number of children (3.7%, n = 11) classed as underweight a bigger sample size might be needed in order to draw any conclusions. Although the above studies indicate that BLW is not associated with low calorie intake and underweight, the studies were based on parental report of infant’s weight. To assess whether there is an increased risk of underweight in BLW children, objective measures of height and weight on a sufficiently sized sample of infants should be conducted. Given the number of parents following this weaning style, such a study is urgently needed.

- Baby-led weaning and feeding problems Based on the finding from a recent qualitative study, it became apparent that BLW could potentially act to mask or legitimise genuine feeding problems (Arden, Abbott 2014). Arden and Abbott reported that a proportion of BLW children in their study had been weaned using this method following repeated and failed attempts by the parents to spoon-feed the traditional way. However, in some instances the change in weaning approach did not result in an improvement in food intake, at least not initially (Arden, Abbott 2014). The term used in the BLW book by Rapley and Murket; “food is for fun until they are one” was interpreted by these parents to mean that breast milk alone was adequate nutrition during the first year of life (Arden, Abbott 2014). One informant from the current study had also found BLW after several weeks of her daughter refusing to be spoon-fed, yet for her, the change resulted in a child who started to eat. If the cause of the problem is the child’s need for autonomy and control over his or her own food intake, changing to BLW may work very well and ensure that the introduction of solids is not delayed and remains a positive experience. However if food refusal is based on separate eating problems, not helped by giving the child more self-control, these unaddressed feeding problems may be overlooked and lead to problems including underweight. Children are very sensitive to the effect of inadequate nutrient intake during the early years and it is clearly a concern if parents practising BLW are at greater risk of overlooking feeding problems which could be physical in origin. The above finding may also have implications when comparing the weight of BLW infants with a control sample, without adjusting for the effect of some infants being in the BLW group due to feeding problems or food refusal. Statistically, this may put more underweight infants in the BLW group with the causal relationship being that their parents found BLW as a result of their Child’s food refusal or eating difficulties, not the other way around, effectively placing more of these 63

vulnerable infants in the BLW group. Studies examining the relationship between BLW and infants weight, should therefore gain information on whether BLW is practised due to feeding problems in the weaning stage in order to adjust for any possible effects of this during analysis.

Parental norms and values Parenting style

Parenting style is defined as the way parents and caregivers interact with a child in terms of attitudes and behaviours across domains of parenting (Darling, Steinberg 1993). The role of parenting style has been investigated and associated with various outcomes concerning the child. Parenting style regarding feeding behaviour has also been examined and associated with eating behaviours of the child (Schwartz, Scholtens et al. 2011). Parenting style has been conceptualised based on two main dimensions; demandingness and responsiveness (Baumrind 1971, Baumrind 1989). Demandingness refers to the degree of behavioural demand or control over the child, where responsiveness refers to the extent to which parents show warmth and supportiveness for the child. Based on these two dimensions, four patterns of parenting styles or behaviour has been described: 1 - authoritative/democratic (demandingness +, responsiveness +) characterised by parental involvement, nurturance, reasoning, and structure; 2 - authoritarian (demandingness +, responsiveness −) which is characterized by restrictive, punitive and power-assertive behaviour; 3 permissive/indulgent (demandingness −, responsiveness +) characterised by warmth and acceptance in combination with a lack of monitoring of the child's behaviour; and lastly; 4 neglectful/uninvolved (demandingness −, responsiveness −) characterised by little control and involvement with the child (Maccoby, Martin 1983). In terms of general parenting, an authoritative/democratic style has been associated with the most positive child outcomes. Likewise, when it comes to feeding practices this parenting style, providing structure in a positive context, has been associated with the development of the healthiest child eating habits (Ventura, Birch 2008). BLW can arguably be characterised as fitting into an authoritative/democratic feeding style: Parents remain in control over the child’s overall diet as they are in charge of the selection of food offered and made available to the child. Within this frame, the child is allowed to decide what to eat and how much to eat (Rapley, Murkett 2008). It was evident that this approach to feeding was 64

followed by the parents in the present study. Parents described how they were in control of what their children were offered and how they had to trust the child in regard to the volume and selection of food consumed.

BLW as part of a parenting philosophy

In the current study, one Health Visitor expressed concern as to whether BLW was a way to waiver the parental responsibility regarding the child’s food intake. This however, is not in line with current available literature on BLW, or findings from the present study. On the contrary, there is evidence that BLW is associated with more responsive parenting practices such as breastfeeding and longer duration of breastfeeding (Brown, Lee 2011a, Townsend, Pitchford 2012), co-sleeping, baby-wearing and attachment parenting (Arden, Abbott 2014). Based on the above associations and indicators from the current study, where such practices were also evident, it is unlikely that parents are practising BLW as a way of not taking responsibility regarding their child’s food intake. Additionally, the current study also stood apart from other studies on weaning, by the notion that fathers were actively involved in the weaning process and that two informants taking part in the study were fathers. Child centred feeding

Currently, the discussion about BLW is focussed on the possible future benefits or possible risks associated with the practice. However, for the parents practising BLW, the emphasis was mainly on following the child’s lead and the focus was quite firmly on the enjoyment of the child. The way the children in this study were introduced to solid foods was based on the child’s own initiative and curiosity. They were given time and patience to experiment with a new world of sensory impressions and they could trust their parents not to put any pressure on them to consume any specific items or quantities. Additionally, they were actively included in the family’s mealtimes and happily spent up to half an hour or more eating their meals. It could be speculated, that from the child’s perspective, these parameters may be very important; both in terms of future associations with healthy foods, but also in terms of building a trusting parent-child relationship. In many ways, BLW place the experience of the child central in the weaning process. However such an approach may not always be attainably. In the present study, the UK based mothers acknowledged that BLW

without any parental spoon feeding was just not practical, when they had to consider the needs of older sibling as well. The small sample of parents from DK may have been quite unique in terms of resources and devotion to the practice of BLW. Another study has criticised the current Danish guideline as being too narrowly focused on the childâ&#x20AC;&#x2122;s nutritional need, causing mothers to only follow the recommendations for a short period of time and to a limited degree (Nielsen, Michaelsen et al. 2014). It could be argued, that as BLW becomes more widely used it could act to further widen the gap between what is viewed as ideal for the child and what the parents are able to provide. In this way, the concept of BLW may further alienate parents without the surplus of various resources; not only to allow the time for the child to self-feed, but also to provide home cooked meals and continue to breastfeed on demand. Feeding problems and eating disorder

In the present study, as specified in the results, one informant had changed to BLW from SW when her daughter had refused to be spoon-fed and this change had successfully reversed her reluctance to eat solids. Other informants viewed BLW as a way to avoid eating disorders and ensure that the child grows up with a natural or non-problematic relationship with food. Generally, feeding problems in the weaning stage is not uncommon; in the 2010 Infant Feeding Survey, 11% of UK based mothers reported difficulties such as refusal to ingest, or disinterest in solid foods. Out of the 11% reporting difficulties, 19% reported refusal to eat from a spoon to be the problem (McAndrew, Thompson et al. 2012). When children were introduced to solids between 5-6 months, or after 6 months, the proportion of reported feeding problems was even higher at 17% (McAndrew, Thompson et al. 2012). These findings suggest that feeding problems are common and are likely to increase as more mothers aim to exclusively breastfeed, or bottle feed for the first 6 months. It also indicates that older children (above 5 months) are much more resistant or reluctant to make a passive transition to solid foods than younger babies. Allowing older children more autonomy and involvement could possibly be a very important factor that needs more consideration, now that the recommended time of weaning is around 6 months. The apparent greater resistance, particularly of older children, when it comes to transitioning to complementary foods needs to be addressed, both in terms of current practice and in terms of future research on the matter.

Additionally, there is increased concern that the growing public focus on health, nutrition and bodyweight, may have a negative effect on children´s perception of themselves and their food intake. In a recent survey, 41% of 13 year old girls in Denmark reported thinking often, or all the time, about their weight and whether they were overweight (Sørensen, Schultz 2014). Many other factors including culture and media influences are, of course, likely to a play a large role in this trend. However, in the light of such worrying findings, insight into how best to prevent early feeding problems and promote healthy body images and feeding patterns among children are greatly needed. The role of BLW in decreasing the risk of present and future feeding problems and eating disorders has not been experimentally tested. However, the nature of the practice, especially the low parental control and eating behaviour guided by hunger and satiety, together with the little focus and attention food issues are given, provide indicators for such benefits. Specifically, the combination of healthy food served, without any ‘rules’ or ideas about ‘good and bad’ foods, may be a valuable approach to avoiding disordered eating. However, any such associations remain speculative; prospective longitudinal studies are needed to tell whether such benefits of BLW exist.

Deviating from authoritative advice Departing from official weaning guidelines

Based on the reviewed evidence on BLW, it can be argued that the practice of BLW encourages, or is associated with, an array of healthful behaviours as previously discussed. The self-selecting sample of families surveyed for the presents study, arguably provided wholesome nutrition, and an eating environment ideal for the development of healthy eating habits for their children. Despite this, the fact that they deviated from the official recommendations on one aspect, namely letting the child self-feed without mashing or blending food, caused worry and self-doubt in these participants. This was most evident in the participants who had a Health Visitor who discouraged the practice. In the current study, informants from DK did not feel that the practice of BLW was compatibly with the official guidelines. Although parents felt BLW offered an array of health benefits, it was clear that when the practice was contrasted with the official guidelines, parents felt insecure and questioned their own choice. This acted to introduce an aspect of anxiety to an otherwise very 67

positive experience that weaning had been for these families. In contrast, informants from the UK did not feel that BLW deviated majorly from the official recommendations. This could possibly explain why these mothers were more relaxed about their choice of weaning and expressed less concerns regarding official guidelines. However it should be noted that the informants from the UK, had more than one child, whereas informants from DK were all first time parents. This difference is likely to at least partly explain any differences in concerns and anxieties. Nonetheless, the issue of weaning guidelines and the Health Visitors was a recurrent theme during the interviews with the informants from DK, whereas it was not mentioned by the UK based informants unless specifically questioned. The Health Visitor is bound to convey the advice set out by the Danish Health and Medicine Authority and can therefore not endorse a practice, like BLW, which deviate from these guidelines. However, if the aim of the health visiting team is to ensure the best possible outcome for the individual child, they must encourage and engage in a mutual communication and meet the families without prejudice. Results from the current study illustrated that without this approach from the Health Visitor, successful communication was not established. Arguably, this does not serve the childâ&#x20AC;&#x2122;s best interests. As discussed above, there may be a risk that the practice of BLW can act to mask possible eating problems not related to the childâ&#x20AC;&#x2122;s need for autonomy (Arden, Abbott 2014). In such an instance, it may be vital that the Health Visitor has encouraged a relationship with the family, where they would seek professional advice for such an issue. Additionally, BLW is not recommended for infants who are developmentally delayed, Health Visitors could inform parents who wish to practise BLW about the signs and indicators of developmental delays so parents have a better chance of recognising such indicators in their own child. Interestingly, Nielsen, et al. (2014) found that the current Danish weaning guidelines was not harmonious with the ordinary daily concerns and practices of mothers in DK. Suggesting that deviating from nutritional recommendations is not unique to parents practising BLW. They found that reasons, such as practical considerations for the whole family with a busy everyday life, socialising the child into the family and society at large, and creating personal relief from the strain small children put on time and energy, all served as socially acceptable reasons for knowingly departing from nutritional recommendations (Nielsen, Michaelsen et al. 2014). 68

In the current study, participants also used BLW to socialise the child into a family where food variety and joint family meals were seen as important values. However, being able to eat a variety of food was not discussed in relation to wider social norms or expectations outside the home, but rather in terms of securing a healthy diet. In this way, the focus of the informants practising BLW remained in line with the official nutritional recommendations. Lastly, deviating from the official guidelines by practising BLW may in fact be an advantage, rather than a concern: The international weaning guidelines has been criticised for focusing too narrowly on the childâ&#x20AC;&#x2122;s specific nutritional needs with focus on immediate and long-term health outcomes (Agostoni, Decsi et al. 2008). This approach is also evident in the Danish guidelines (Sundhedsstyrelsen 2011). However this narrow approach may fail to recognise and encourage practises which are believed to encourage long term healthy eating patterns (Schwartz, Scholtens et al. 2011). This was evident among mothers of 7-month-old children in DK, who did not view the official guidelines as tools for establishing long-term healthy eating patterns (Nielsen, Michaelsen et al. 2013). In the present study, practices believed to be associated with long-term healthy eating habits, were naturally encouraged and integrated into the weaning process.

Limitations Based on the current published literature, it is clear that research into this weaning practice is limited. Further, the current studies are either descriptive, based on qualitative research method, or based on self-reporting. The small number of studies and the lack of more objective outcome measures are the major limitation of the studies currently conducted in this field. Only one longitudinal study following a sample of BLW and SW infants has been performed to date. The limitation to the current qualitative study, is that data from this small, self-selecting sample of parents, who successfully practised BLW, cannot be generalised to a wider population of parents practising BLW in DK. Additionally, in order to maximise reliability, coding and analysis of the whole set of data should be done by more than one analyst/coder.

Conclusion Based on this small sample of self-selecting group of families practising BLW in DK, the following conclusions can be made: parents from DK practised BLW in a manner that closely followed the method initially described by Rapley and Merkutt, where no parental spoon-feeding of pureed or blended food was used. There were no aspects of the way these children were introduced to solid food that caused concern. On the contrary, these children were receiving a healthy varied diet and they were all breastfeed on demand. They were allowed time and space to explore and eat food and they were clearly enjoying mealtimes. They were presented with iron rich meat and fish from 6 months and the selection of family food included high fat options. Additionally, practising BLW was associated with other responsive parenting practices and increased paternal involvement in the weaning process. The question remain whether this sample is representative of families following BLW in DK. Based on this small study sample of self-selecting families practising BLW, no such conclusion can be made. Increasing Health Visitors knowledge about the practice of BLW could possibly aid communication with parents and thereby their receptiveness to guidance or advice. This would ensure the best possible outcome for the individual child without causing parents unnecessary worries. Currently, there is evidence from one cohort study suggesting that BLW may lead to better appetite regulation and healthier weight in toddlerhood. Evidence suggests that BLW may positively affect levels of pickiness in toddlers and that this effect is mediated by low levels of maternal control, duration of breastfeeding and timing of introduction to complementary foods. Further, the practice of BLW may protect the infant from the negative effect of high levels of maternal control. The practice of BLW may be particularly conducive for the effect of mere exposure to take place while maintaining a feeding style low in control. Additionally, later introduction of complementary foods, longer breastfeeding duration and early exposure to variety and family foods may also mediate the relationship between BLW and decreased pickiness, satiety responsiveness and healthier weight. As the practice of BLW encourages, or is associated with, an array of behaviours associated with healthier long term eating habits, the effect of BLW, or aspects thereof, in respect to public health should therefore not be ignored. Future studies based on

objective outcome measures are needed in order to further elucidate the relationship between BLW and various outcomes, such as healthful eating behaviours, satiety responsiveness and BMI.

Future research To this date, no study has adequately examined the risk of iron or energy deficiency in BLW children. Given the amount of parents practising BLW to various extents in the UK and other English speaking countries, and the notion that it is now spreading to other European countries, more studies on the subject are urgently needed. Although there is one study and a number of indications that suggest that BLW infants will successfully self-regulate their energy intake to correspond to their needs, these cannot be regarded as conclusive. Likewise, this study provides some indications that the practice of BLW is associated with early introduction of fish and meat rich in iron and the exclusion of cowâ&#x20AC;&#x2122;s milk before the age of one. Therefore, data from this study does not suggest that BLW infants should have a greater risk of low iron intake. However, no conclusions can be made on such a small sample size. Objective measures on growth and iron status are needed in order to assess whether BLW is associated with any greater risk of iron or energy insufficiency. Without such studies neither health professionals, nor parents, can feel assured that BLW is safe and Health Visitors will not be able to offer suitable and appropriate advice for the families wishing to practise BLW. There is some evidence indicating that the practice of BLW could potentially mask or legitimise genuine eating problems and thereby delaying appropriate referral and/or treatment for some children. Whether the parents are practising BLW due to initial problems and whether the child is actively taking an interest in food would be helpful questions for the Health Visitor to ask families following this practice. This also highlights the need for Health Visitors to have a better understanding of BLW and establish a respectful relationship with the families. On the other hand, evidence also demonstrates that BLW can actually benefit children with strong dislikes of being spoon-fed and thereby prevent delayed introduction of solid food and feeding problems. It would be interesting and relevant to explore both these aspects in future studies. As serious choking incidents are very rare, studies assessing whether there is an increased risk of choking associated with BLW may not be possible, as a very large sample size would be needed in

order to detect such a difference. However, there is persuasive reasoning for the hypothesis that introducing appropriate soft foods from 6 months could encourage the ability of infants to safely handle whole food and thereby decreasing the risk of choking. Studies examining childrenâ&#x20AC;&#x2122;s ability to handle whole foods at different ages, and the role of the gag-reflex should be conducted in the future, instead of relying on weaning traditions which are not evidence based, when advising parents not to introduce whole foods from 6 months of age. Future studies should be based on objective measurements of outcomes such as weight and height rather than self-reporting. Prospective longitudinal studies may provide satisfactory evidence, as the personal nature of the weaning process does not make randomised controlled trials a realistic option. Additionally, with the prevailing concern of an increased risk of choking and insufficient energy intake, a randomised controlled trial may be deemed unethical. A predefined classification of BLW should be used in future studies. Additionally, information on whether BLW was practised due to feeding problems when initially spoon-feeding should also be obtained.

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ROWAN, H. and HARRIS, C., 2012. Baby-led weaning and the family diet. A pilot study. Appetite, 58(3), pp. 1046-1049. SACHS, M., 2011. Baby-led weaning and current UK recommendations-are they compatible? Maternal & child nutrition, 7(1), pp. 1-2. SCAGLIONI, S., SALVIONI, M. and GALIMBERTI, C., 2008. Influence of parental attitudes in the development of children eating behaviour. British Journal of Nutrition, 99(S1), pp. S22-S25. SCHACK-NIELSEN, L., SORENSEN, T.I., MORTENSEN, E.L. and MICHAELSEN, K.F., 2010. Late introduction of complementary feeding, rather than duration of breastfeeding, may protect against adult overweight. The American Journal of Clinical Nutrition, 91(3), pp. 619-627. SCHWARTZ, C., SCHOLTENS, P.A., LALANNE, A., WEENEN, H. and NICKLAUS, S., 2011. Development of healthy eating habits early in life. Review of recent evidence and selected guidelines. Appetite, 57(3), pp. 796-807. SØRENSEN, H. and SCHULTZ, F., 2014. Analyse: 13-åriges tanker om krop og vægt.Mnage er utilfredse med deres krop 2. København: Børnerådet. STEVENSON, R.D. and ALLAIRE, J.H., 1991. The development of normal feeding and swallowing. Pediatric clinics of North America, 38(6), pp. 1439-1453. SUNDHEDSSTYRELSEN, DK., 2011-last update, Mad til spædbørn og småbørn – fra skemad til familiemad. Available: http://sundhedsstyrelsen.dk/publ/Publ2011/CFF/Boern/MadSpaedboernSmaaboern2011.pdf [05/8, 2014]. TOWNSEND, E. and PITCHFORD, N.J., 2012. Baby knows best? The impact of weaning style on food preferences and body mass index in early childhood in a case-controlled sample. BMJ open, 2(1), pp. e000298-2011-000298. TROLLE, E., HOLMBOE, U., MAJKEN, G., KARSTEN, K., YGILL, K. and CHRISTENSEN, T., 2013. Danskernes kostvaner. Spæd- og småbørn 2006-2007. DTU Fødevareinstituttet. TUORILA, H. and MUSTONEN, S., 2010. Reluctant trying of an unfamiliar food induces negative affection for the food. Appetite, 54(2), pp. 418-421. VENTURA, A.K. and BIRCH, L.L., 2008. Does parenting affect children's eating and weight status? International Journal of Behavioral Nutrition and Physical Activity, 5(1), pp. 15. WARD, R., 2012. Maternal and paternal employment rates by age of youngest dependent child in the family unit. Department for Work and Pensions. WEIJZEN, P.L., SMEETS, P.A. and DE GRAAF, C., 2009. Sip size of orangeade: effects on intake and sensory-specific satiation. British journal of nutrition, 102(07), pp. 1091-1097. WHO, 2001. The optimal duration of of exclusive breastfeeding: Report of an expert consultation; World Health Organization: Geneva, Switzerland. WHO, 1998. Complementary feeding of young children in developing countries: a review of current knowledge. World Health Organization: Geneva, Switzerland. WRIGHT, C.M., CAMERON, K., TSIAKA, M. and PARKINSON, K.N., 2011. Is baby-led weaning feasible? When do babies first reach out for and eat finger foods? Maternal & child nutrition, 7(1), pp. 27-33.

Appendix 1 â&#x20AC;&#x201C; informed consent Participants from the United Kingdom Baby-led weaning in practice Information sheet for participants Dear participant. Thank you for your interest in this study examining the practice of baby-led Weaning (BLW) in Denmark and England. In Denmark, BLW is largely unknown to researchers and health professionals, although the practice is now gaining followers amongst Danish parents. We are interested in how the BLW movement, which originated in the UK, is interpreted and practised in Denmark and how the challenges facing parents using BLW might differ between the countries. The study is based on a series of interviews with parents and health visitors who have had personal experience with BLW. The interview will take place in your home, but can be arranged elsewhere if you would prefer that, at a time that is convenient for you. If possible, I would also like to observe your child in a mealtime situation prior to the interview. The interview will take approximately one hour, but due to the nature of interviewing it may take longer. The study is part of my Masterâ&#x20AC;&#x2122;s Thesis in Human Nutrition at The Faculty of Science at the University of Copenhagen. The thesis is supervised by; Annemette Nielsen, Assistant Professor at the Department of Food and Resource Economics and Kim F. Michaelsen, Professor at the Department of Nutrition, Exercise and Sports (child- and international nutrition). All participants will remain anonymous and names will not be connected to any data presented. Participation is entirely voluntary and participants can withdraw at any time during the study. Further inquiry into the study or the practice of baby-led Weaning can be done following the interview. If you have any questions please feel free to contact me. Patricia DeCosta fkm734@alumni.ku.dk +45 XXXXXXXX

Participants from Denmark Baby-led Weaning i praksis Information til deltagere: Tak fordi, du vil deltage i dette studie, der har til formål at undersøge hvorledes Baby – led Weaning praktiseres i henholdsvis Danmark og England. Undersøgelsen er baseret på en række interviews med forældre og sundhedsplejersker, der har haft personlige erfaringer med Baby – led Weaning. Studiet er en del af mit kandidatspeciale i Human Nutrition på det Naturvidenskabelige Fakultet på Københavns Universitet. Studiet gennemføres under supervision af: Annemette Nielsen, adjunkt ved Institut for Fødevare og ressource økonomi., og Kim F. Michaelsen, Professor ved Det Natur- og Biovidenskabelige Fakultet (Børne- og international ernæring). Interviewet kan finde sted i dit eget hjem, men kan også arrangeres et andet sted, hvis du foretrækker dette. Interviewet vil foregå på et tidspunkt, der passer dig. Hvis det er muligt, vil jeg også gerne observere dit barn i en måltids-situationen umiddelbart før interviewet. Interviewet vil tage en til to timer. Enhver fremstilling af data vil være anonym, og specialet vil ikke indeholde navne på deltagere. Deltagelse i undersøgelsen er på frivillig basis, og deltagerne kan på ethvert tidspunkt trække sig fra studiet. Yderligere information eller spørgsmål omkring studiet eller Baby–led Weaning kan stilles efter interviewet. Hvis du har spørgsmål, er du velkommen til at kontakte mig. Patricia DeCosta fkm734@alumni.ku.dk +45 XXXXXXXX

Health Visitor’s from Denmark Baby-led Weaning i praksis Information til deltagere: Tak fordi, du vil deltage i dette studie, der har til formål at undersøge hvorledes Baby – led Weaning praktiseres i henholdsvis Danmark og England. Undersøgelsen er baseret på en række interviews med forældre og sundhedsplejersker, der har haft personlige erfaringer med Baby – led Weaning. Studiet er en del af mit kandidatspeciale i Human Nutrition på det Naturvidenskabelige Fakultet på Københavns Universitet. Studiet gennemføres under supervision af: Annemette Nielsen, adjunkt ved Institut for Fødevare og ressource økonomi, og Kim F. Michaelsen, Professor ved Det Natur- og Biovidenskabelige Fakultet (Børne- og international ernæring). Enhver fremstilling af data vil være anonym, og specialet vil ikke indeholde navne på deltagere. Deltagelse i undersøgelsen er på frivillig basis, og deltagere kan på ethvert tidspunkt trække sig fra studiet. Yderligere information eller spørgsmål omkring studiet eller Baby–led Weaning kan stilles efter interviewet. Hvis du har spørgsmål, er du velkommen til at kontakte mig. Patricia DeCosta fkm734@alumni.ku.dk +45 XXXXXXXX

Appendix 2 â&#x20AC;&#x201C; interview guide Interview questions - Parents 1.

Presentation of myself and the study.

Information about anonymity, right to withdraw and not to answer certain questions.

Can you tell me about you and your family? a) Number of children and their ages. b) Age c) Education d) Marital status

Breastfeeding a) Are you breastfeeding? b) How much does your baby feed? c) Do you use of formula milk? How much? d) Do you offer cowâ&#x20AC;&#x2122;s milk?

Can you explain to me in general terms, what BLW is? And what does it mean to you? a) Use of spoon feeding? (Why, why not. Is this a principle to you?) b) Can you tell me the reasons why you have chosen to follow BLW? c) If this is not your first child, did you use BLW with the older child? Why the change? What is the difference? d) Whose decision was it to use BLW? Do you and your partner agree on how you feed your child? If not, what are the conflicts? Can you give an example?

Can you tell me about your day yesterday, including your childâ&#x20AC;&#x2122;s meals? What food items were consumed? And drinks? Is this a fairly normal food intake for your infant?

Can you tell me about childâ&#x20AC;&#x2122;s meal times in general? a) What does he/she normally eat during the day? b) What happens? c) What is a good or a bad meal according to you? How do you respond to (good and bad mealtimes)? d) Do you always practice BLW, or are there exceptions? e) Do you adjust the type of food offered or the degree of self-feeding to match different situations? E.g. when visiting friends or eating out? Or are there places/situations that you avoid in order to follow BLW. f) Do you know of other ways of practising BLW? What are the core principles of BLW according to you?

Do you or your family follow any other diets?

When did your child have solid foods for the first time? a) Can you tell me about how it went? b) What was the reason for initiating weaning? c) Any specific challenges then, compared to now? d) Would you have done anything differently with the knowledge you have now?

10.

Are parents following BLW different from other parents? a) In what way? b) Any other aspect they might differ?

11. 83

What do you believe to be the benefits of BLW?

12.

Who decides what is eaten and how much? What happens if your baby does not want to eat/ eat what is served? Can you describe a situation where this has happened?

13.

Do you have any concerns related to your infantâ&#x20AC;&#x2122;s health regarding following BLW? a) Have you in the past considered stopping BLW? If yes, why? What happened? b) Do you have you baby weighed regularly? How many times? Why/why not?

14.

Do you have any strategies to ensure high energy density in your babyâ&#x20AC;&#x2122;s food? a) Addition of fat? b) Other strategies?

15.

Does your baby consume food high in iron? a) At what age was your baby offered meat and/or fish (other iron rich foods)? b) Are you giving iron supplements or using food fortified with iron?

16.

What are your views on the risk of choking? Do you believe that there is there an increased risk when following BLW? a) Have these (views on risk of choking) changed during the weaning phase? b) Have you experienced any choking incidences? If yes; what was the offending food? And how old was your baby?

17.

Are they any drawbacks to BLW? And what are they according to you?

18.

Have you discussed your choice of weaning style with your health visitor? a) If so, could you tell me about how you told her and her response to you? b) What were her views on BLW? c) Did she adjust her advice to suit your feeding approach? d) Do you seek/value her advice?

19.

Who do you go to to discuss any worries about your childâ&#x20AC;&#x2122;s health and eating with? Or to share your own experiences with?

20.

What does your family and friends think about BLW? 1) Can you give an example? 2) How do their views affect you? 3) Do you share your opinions about infant feeding with others? For example other mothers? 4) Or give advice? Can you tell me about a situation and that happened?

Interview guide - Parents

Præsentation 1. Præsentation af studiet og mig selv. 2. Information omkring anonymitet og retten til at trække sig.

Indledende spørgsmål 1. Kan du fortælle lidt om dig selv og din familie? a) Hvor mange børn har du, og hvor gamle er de? b) Og din egen alder? c) Hvad er din uddannelse? d) Er du gift, eller bor sammen med din partner? 2. Følger du/I andre diæter? 3. Ammer du dit barn? a) Hvor meget ammer han/hun nu? b) For han/hun modermælk erstatning eller komælk? Hvor meget ca.? 3. (Hvis der er ældre søskende) Er dette det første barn du har brugt BLW med? a) (hvis ja) Hvad er grunden til at du valgte BLW denne gang? b) Hvilken forskel syntes du at de to metoder har gjort?

Baggrund for valg af BLW 1. Kan du fortælle mig lidt om hvad BLW er? Både generelt og hvad det betyder for dig? 2. Bruger I ske og i hvilket omfang? a) Hvorfor? Hvorfor ikke? b) Har du et princip omkring brug af ske? 3. Hvad er grunden til at du valgte at følge BLW metoden?

a) Hvor kender du til BLW fra? b) Hvad er det ved BLW der tiltalte dig? 4. Hvornår fik dit barn mad for første gang? Kan du fortælle lidt om hvordan det foregik? a) Hvilke overvejelser gjorde du dig omkring starttidspunktet? b) Var der nogle specielle udfordringer i begyndelsen i forhold til nu? c) Med den viden du har nu, ville du have gjort noget anderledes dengang?

Hverdagspraksis omkring børnemad og BLW 1. Det måltid som dit I/dit barn lige har spist, var det et normalt måltid for dit barn? 2. Hvor lang tid tager et måltid normalt? 3. Spiser i sammen og spiser i det samme? 4. Hvad er vigtig for dig i forhold til både dit barns kost og måltider? 5. Hvem var det der besluttede at jeres barn skulle introduceres til mad med BLW metoden? a) Er du og din partner enige omkring brug af metoden? b) (Hvis nej) Hvad var grunden til jeres uenighed? c) Har du et eksempel på en situation hvor I er uenige, og hvordan I løser det? 6. Følger du altid BLW metoden, eller er det undtagelser? a) Justerer du måltider eller metoden i forskellige situationer? For eksempel når I besøger venner og familie eller spiser ude?

b) Eller er der situationer som du undgår fordi at I bruger BLW? 7. Hvem bestemmer hvad dit barn spiser og hvor meget han/hun spiser? 8. Hvad sker der hvis dit barn ikke vil spise noget eller ikke vil spise det I serverer? Kan du beskrive en situation hvor det er sket?

Holdninger og værdiger 1. Hvad syntes du kernen i BLW er? Eller hvad er kernen for dig? (hvad er de vigtige punkter?)

2. Er forældre der bruger BLW anderledes end andre forældre? På hvilke områder? Er der andre forskelle?

3. Hvilke fordele tror du BLW giver? Både for dig selv, din familie og dit barn? (nu og i fremtiden?) 4. Har du nogen bekymringer omkring dit barns sundhed i forbindelse med at bruge BLW? a) Har du nogen sinde overvejet at stoppe BLW. Hvis ja, hvorfor? b) Får du dit barn vejet regelmæssigt (Hvor ofte?) Hvorfor er det/ er det ikke vigtigt? 5. Kender du til andre måder at praktiserer BLW på? Måske andre der har andre fortolkninger af metoden?

Ulemper/bekymringer 1. Er der nogle ulemper ved at følge BLW? Hvad er ulemperne ifølge dig? a) Er der noget der kunne få dig til, eller have fået dig til at stoppe med BLW? 2. Tror du der er en større risiko for kvælning forbundet med BLW? a) Har din holdning til kvælningsrisiko ændret sig siden starten of overgangsperioden? b) Har du selv oplevet en kvælningsepisode med dit barn? Hvis ja, hvad skete der? Hvilken madvare var der tale om? Hvor gammel var dit barn?

Kilder til information og støtte 1. Har du fortalt din sundhedsplejerske om jeres valg af BLW metoden? a) Hvad var hendes respons? Kan du fortælle lidt om hvordan den samtale forløb? b) Hvad tror du hendes holdning til BLW var? c) Ændrede hun samtalen eller sine råd så de passede bedre til jeres fremgangsmåde? d) Bruger du hende til at rådføre dig omkring kostspørgsmål? Tager du hendes råd til dig? 2. Hos hvem eller hvor opsøger du råd og information omkring dit barns kost og sundhed? 3. Hvem deler du dine egne erfaringer med? 4. Hvad syntes din familie og venner om dit/jeres valg af BLW? a) Har du nogle eksempler på negativ/positiv respons fra din omgangskreds? b) Hvordan påvirker deres holdning dig?

5. Deler du selv ud af dine erfaringer eller gode råd til kost i overgangsperioden? For eksempel til andre mødre?

a) Kan du give et eksempel på en situation hvor du gjorde? Eller måske havde lyst til det? 6. Er det noget omkring BLW metoden du syntes er vigtig, som vi ikke har fået talt om?

Til slut – specifikke spørgsmål til kostindtag 1) Kan du fortælle mig hvad dit barn fik at spise og drikke i går? b) Morgenmad/frokost/aftenmad + mellemmåltider formiddags/eftermiddags mad 2) Bruger du nogen metode til at gøre dit barns måltider mere fedt/ kalorieholdigt? Kan du give nogle eksempler?

3) Hvor gammel var dit barn, da I begyndte at introducere kød og fisk? Hvis ikke introduceret; tilbyder i andre jernholdige madvarer? Hvilke? Giver I jerntilskud.

4) Ved du hvor omkring på vækstkurven dit barn ligger? (Vægt)

Prompting og opklarende spørgsmål: a) Kan du fortælle mig mere om det? b) Hvad synes du om det? c) Hvad mener du med det? d) Gentag (hvad du siger, er ...) e) Det er interessant ... kan du fortælle mig mere om det? f) Hvorfor tror du det er?

Interview guide – Health visitors

Præsentation 1. Præsentation af studiet og mig selv. 2. Information omkring anonymitet og retten til at trække sig.

Spørgsmål 1. 2.

Hvordan hørte du første gang om BLW? Hvor meget kendskab har du til BLW? a) Er det gennem familien?

b) Eller har du selv søgt information omkring emnet? 3. Hvor meget mener du at BLW afviger fra de officielle råd til overgangskosten fra Sundhedsstyrelsen? 4.

Er der aspekter af BLW, som du finder bekymrende? a) Hvilke?

b) Hvad baserer du det på? 5.

Er der aspekter af BLW, som du ser som positive? c) Hvilke?

d) Hvad baserer du det på? 6.

Hvordan får/fik du formidlet råd om kost i overgangsperioden til familien? a) Kunne du tilpasse dine råd?

b) Hvordan oplevede du kommunikationen?

Appendix 3 Extract from a meal observation and an interview Informant 1. Notes from the interview and observation of the morning meal: 9:15 - 01.12.2013. Observation Informant 1 is a 29 year old mother of a girl who is seven months and eleven days on the day of the interview. The daughter has two teeth on the bottom gums which appeared around six months of age. On the growth chat from the Health Visitor her weight is approximately around, or just below average. I observe the morning meal which starts around 9.15 until 9.40. This is a normal meal that both parents share with their daughter on weekends and weekdays, normally this meal last about thirty minutes. They tell me that the morning meal is the “boring meal” of the day, where they often eat the same things. The parents are eating some dark grained bread with spread and toppings; (maybe butter, jam, cheese?) In the beginning the daughter is a little bit upset and clingy (most likely due to my presence) and is therefore sat on her mother’s lap. Two thick small pancakes and half a banana is put on the table before her and she immediately grab the banana and puts it to her mouth and starts biting into it. She is happy now and is therefore put back into her chair. She is normally happy to sit in her own chair to eat. She smiles and looks at her parents in-between eating. The atmosphere is relaxed. She alternates between pancakes and banana, she looks like she is chewing quite confidently. Seemingly quite a bit gets swallowed and a bit falls out of her mouth. The parents tell me that it is quite new that so much is actually being eaten (Father: “sometimes we think; wow she is eating a lot, but then the food she is chewing on comes back out again”). A few times food ends up on the floor; the parents pick it up and give it back to their daughter without any comments. She is offered water in a normal glass throughout the meal by her father and drinks a few times. She then gets some of her parent’s bread and starts eating making some content baby sounds. She works on the bread by sucking and chewing, holding her fingers to her mouth to prevent food falling out. (Mother: “a lot more is being eaten within these last few days, before there was a lot of chewing going on but a lot also came back out”). After twenty minutes she starts to just play with the food, mushing it between her fingers 91

but not eating any more. Five minutes later the parents conclude that she is probably done now, as she is staring in to the air not paying any attention to the food. She is cleaned up in her chair and food from the floor and table is swept up. While her hands are being cleaned she just grabs one more mouthful of the mushed food from the table. Then the meal is over and the father takes their daughter and leaves us to do the interview. Extract from transcribed interview (Pause er mærkeret med … Og afbrydelse med -) I: Først vil jeg egentligt bare gerne høre om dig og din familie. Inf1: Ja, øh, jeg er 29, min kæreste er 36, og det er vores første barn, som så er syv en halv måned. Øh ja, vil du have mere af vide? I: Ja, hvornår er hun født? Inf1: Tyvende april i år. I: Ok. (Kort afbrydelse af informantens kæreste, der kommer ind i rummet). I: Hvad er din uddannelse? Inf1: Jeg er sociolog. I: Og, øh, har I andre diæter, i følger? Inf1: Nej nej altså overhoved ikke. Vi har, øh, altså vi spiser.. man kan sige, måske lidt mere nu, men i lang tid har vi egentlig spist ret meget økologisk og sådan, men det er ikke sådan, at vi spiser bare sådan almindeligt varieret. Det er ikke sådan, at vi, øh.. Int: Ja ok. Og ammer du? Inf1: Ja. Int: Og hvor meget ammer du?

Inf1: Øh, mellem de der, vil jeg tro, seks og otte gange om dagen, ja eller... Int: I døgnet? Inf1: Ja, nogle gange lidt mere om natten. Int. Hvor mange gange kan du...? Inf1: Ja, det er lidt, altså nu sover hun også i samme seng som os og det, øh, har øh.. Ja, lidt for mange gange lige for tiden vil jeg sige. Det er måske omkring fire- fem gange... Ja, det sådan.. Int: Hun ligger tæt og tager fat? Inf1 ja, lige præcis. Int. Og det er hende, der styrer, hvor meget hun ammer? Inf1: Ja. Int. Både dag og nat stadigvæk? Inf1. Ja. Int: Ja. Ok, får hun noget komælk eller erstatning? Inf1: Nej, det gør hun ikke. Altså forstået på den måde, at altså komælk får hun, hvis hun får... (kun 3 prikker)nu kan jeg ikke engang lige se, hvad det skulle være, fordi hun spiser jo noget af vores mad. Int. Ja. Inf1: Ja, så på den måde, men hun får det ikke isoleret. Altså, hun får ikke noget erstatning, og hun får heller ikke mælk på andre, altså komælk, på andre måder. Int. Øh, kan du øh, forklare mig lidt om, hvad BLW er? Eller i hvert fald hvad det betyder for dig? Inf1: Ja, for mig betyder det, at man eh, flere ting, men for det første at det er dem der selv, tager styringen, om man så må sige. Forstået på den måde at de har, altså de har, det er helt instinktivt, det gør de også med legetøj, de har den der med, at du gerne vil have tingene i munden, og det

har de jo af mange årsager, for at undersøge hvad det er og så videre. Men, øh, men nu er det også bare med mad, og det giver rigtig god mening, syntes jeg, fordi de altså, det er egentligt det samme, som når man ligger... Jeg syntes, det er sådan en bemærkelsesværdig ting det der med en baby, der kommer ud godt ved, hvad den skal for at overleve, det er at søge brystet. Og man kan sige, hvorfor skulle det være så meget anderledes, når det kan begynde at spise fast føde. Det kan jeg jo se, hun kan jo godt selv finde ud af det. Så for mig er det at give dem lidt kontrollen tilbage og lade dem opdage mad på en helt, helt anden måde, både altså sådan sansemæssigt, for smag får de selvfølgelig også, hvis de får grød, men her oplever de det også i hånden. Og det dufter meget mere forskelligt, end hvis man får et eller andet grød og forskellig struktur og så noget. Så på den måde er det, ja, lad dem selv opdage maden. Int: Ja. Hvordan fandt du selv ud af… Inf1: ja, altså hvordan vi startede.. Int: Hvordan fandt du ud af baby-led weaning? Inf1:Øh… Int: Og hvordan besluttede du dig for og.. og følge det? Inf1: Ehm, vi har sådan en bog, der hedder ”hundred procent naturlig baby”, tror jeg den hedder. Int: Ja… Inf1: Af Rebecca Pearson. Og der står noget deri om metoden. Og, eh, det havde jeg egentligt læst for lang tid siden, der jeg havde læst om, den er sådan bygget op, at der er baby- spisekammer, når der er... jeg tror det starter, når de er fem til seks måneder til dem der starter med at give dem mad? før, seks til syv måneder eller et eller andet, hvor den ligesom er bygget op baby spisekammer og der læste jeg om, i den bog, med udgangspunkt i, at jeg skulle give hende mos eller grød eller den slags. Og så læste jeg om metoden og så, øh, lagde jeg den lidt på hylden igen, og så gik jeg i gang med grød og mos til den store guldmedalje. Og så, øh, og det. Altså, vi havde en ret lang opstart, altså det tog os cirka tre uger, før hun overhoved ligesom begyndte at knække koden med, hvad det var hun skulle med det, altså synke det.

Int: Ja. Inf1: Og da hun så havde gjort det så gik det egentligt meget godt i en uge, hvor hun spiste løs, og så fungerede det slet ikke mere. Så nægtede hun at tage skeen, og hun ville meget hellere lege med den. Øh, så det var sådan noget med at prøve at snyde det i hende ved at lege lidt, og så fik hun alligevel lidt og så noget altså… Int: Og hvor gammel var hun der? Inf1: Jamen, det er så tre uger siden. Så der har hun været lidt før syv måneder. Int. Ja. Inf1. Så det gik slet ikke og så, øh, kan jeg ikke rigtig huske, om jeg googlede det over alt det der skemad, eller om jeg fandt tilbage til den der bog, som der så stod lidt i. En af delene. Hvor jeg så læste om den her metode og så tænkte jeg; det giver rigtig god mening også fordi hun før har fået lov til, som jeg også sagde før, fra fem måneder allerede har fået lov til at side og sutte, på det tidspunkt var det jo på nogle frugtstykker eller sådan noget. Og det kunne hun, altså for det første kunne jeg se, at hun syntes det var rigtig, rigtig sjovt. Og for det andet kunne jeg se, at hun godt kunne finde ud af det. Hun havde faktisk, hvor jeg var ved at gå lidt i panik, hvor jeg havde en appelsinbåd, tror jeg det var, som jeg, på det tidspunkt holdt jeg den så i hånden da hun var de der fem måneder eller holdt jeg den selv i fingrene. Men hun fik den suttet den ind, og så var jeg lidt åh nej åh nej bare hun ikke får den galt i halsen, og der spyttede hun den ud. (Afbrydelse af kæresten i et par sekunder). Inf1: Men, øh, så på den måde var det sådan, vi havde bevæget os lidt ud af det spor før uden at vide det. Altså hvor det bare havde været på forsøgsbasis, hvor hun fik lov at smage på lidt frugt og sådan noget. Og så da jeg læste det som der stod i den der bog, altså det er bare sådan en introduktion til det, så der står ikke så specielt meget. Der stod bare, at det kan man gøre. Og så læste jeg lidt om det på nettet, og så tænkte jeg, jeg ville læse bogen og så downloadede jeg bogen, og så læste jeg bogen. Så læste jeg egentligt den, og så gik vi i gang. Int: Og det er den baby-led weaning bog-

Inf1: ja, lige præcist. Int: Så eh, det har du været lidt inde på, med kontrol, hvad der tiltalte dig vedInf1: Ja, det var ligesom at babyen fik kontrollen tilbage. Men egentlig også sådan noget med, at det tænkte jeg ikke så meget over før, men det kan jeg se nu, lysten. Hun syntes jo selv, det er helt vildt fedt. Int: Er det nogen... fordi nu har du jo egentligt prøvet begge ting. Inf1: Ja. Int: Kan du forklare lidt om forskellen mellem de to måder? Inf1: Altså, forskellen er helt sikkert, at hun syntes det andet er sjovere. Det er den primære forskel. Altså, hun har en fest med at sidde og gøre det selv, og det var en kamp med den ske. Det var sjovt nok at lege med den, men det var ikke sjovt at få den i munden. Int: Nej. Inf1: Og så kan man selvfølgelig sige, jeg var sådan ret... da vi kørte på grød og mos var jeg sådan meget; hun skal ikke være vant til kun at spise søde ting. Så hun fik faktisk mest grøntsagsmos. Ehm, og hun fik også noget, jeg havde også købt noget hirsegrød og noget quinoagrød og sådan noget. Men var var sådan, det hele skal ikke smage sødt, ligesom nogen måske i min mødregruppe syntes jeg har været lidt for tilbøjelige til at klaske et eller andet frugtmos på eller et eller andet sødt på, fordi de troede de ikke kunne lide det. Så der var jeg sådan meget, øh, men det jeg så har fundet ud af, nu vi er gået over til at hun spiser vores mad, det er at det er det helt rigtige fordi hun, noget af det hun syntes har været mest interessant har været noget, der har været meget krydret. Int: Ok. Inf1: Med karry eller hvad det nu kan være, det syntes hun er virkelig, virkelig, virkelig spændende. Det kan også godt være, det har været det har været strukturen eller hvad, det kan jo være mange ting.

Int: Men hun har ikke noget imod at spise det I spiser, som er krydret. Inf1. Nej. Int: Også sådan noget krydderier som stærke ting? Inf1: Ja, lige præcist. Altså, vi har ikke, vi har måske ikke lavet det lige så stærk, som vi ellers ville have gjort, det ved jeg ikke... Det er ikke sådan at jeg kan huske, at vi har holdt tilbage. Int: Nej. Nu har du talt lidt om starttidspunktet, men hvornår startede i så første gang med at give hende mad? Inf1: Det er så… altså på dagen? Int: Altså i det hele taget, hvor gammel hun, var da i begyndte? Inf1: Der var hun så en uge før syv måneder. Int: Men, med at give mad da du startedeInf1: Nåh ja, undskyld, så er jeg med. Det gjorde vi en uge før hun fyldte seks måneder. Int: Ok. Inf1: Det var lidt tilfældigt, men det var det der med, du skal helst begynde lidt før seks måneder med det, får man af vide af sundhedsplejerskerne. Så det var sådan: ok, så starter vi en uges tid før. Int. Var det de overvejelser, var der nogle andre overvejelser? Inf1: Nej. Int: Det var derfor, du startede? Inf1: Det gjorde jeg faktisk udelukkende på bagrund af sundhedsstyrelsens eller min sundhedsplejeskes anbefalinger. Int: Ja, at det var start tidspunktet.

Inf1: Altså, der er nogle i min mødregruppe, der har startet før, men, øh, jeg så ikke rigtig nogen grund til det. Int: Nej, har din sundhedsplejeske anbefalet noget specielt? Inf1: Nej, ikke andet end, hun sagde; hun trives rigtig fint med at blive ammet, så i behøver ikke starte før lidt før seks måneder. Int: Øh, så ville du gøre det anderledes næste gang?... Hvis du skal, næste gang du skal til at giveInf1: Altså, det er faktisk et rigtigt svært spørgsmål fordi jeg kan se i min mødregruppe og nu går vi også til sådan noget baby tumling, at dem der får grød, altså på mange måder er det jo lettere, fordi de ikke sviner særlig meget. Int: Ja. Inf1: Øh, men på mange andre måder er baby-led weaning også sjovere og jeg tror, at babyen får meget mere ud at det. Men jeg tror, at jeg har brug for at se slutresultatet, før jeg egentligt tager stilling til det. Int: Ja. Inf1: Fordi der er selvfølgelig mange bekymringer omkring, får hun netop nok at spise. Eh.. altså.. Ja, og bliver hun dygtigere til at spise? Som jeg også selv siger, bliver de dygtigere til at spise selv tideligere? Så jeg tror egentlig… Int. Så det kunne være anderledes, hvis dit næste barn godt kunne lide at få ske? Inf1: Måske, jeg vil ikke udelukke det. Int: Ja ok, øh, jamen det går faktisk også lidt over i det praktiske, men, øh, jeg kan jo lige starte med at spørge ind til det måltid, som i lige har haft… Inf1: Ja. Int: Er det, er det et normalt måltid? Inf1: Ja, altså.

Int: Morgenmåltid. Inf1: Ja, altså normalt gør vi det lidt tidligere, øh, nu sov hun også lidt længe i dag, men normalt spiser vi der kvart over otte. Int: Og I siger, at I begge to altid sidder og spiser om morgenen sammen? Inf1: Ja, til morgenmad sidder vi sammen, frokostmåltidet er det så kun mig og aftenmåltidet er for det meste begge to, men nogle gange kun mig. Int: Ok, og til måltiderne, spiser I så det samme? Eller – Inf1: Det gør vi ikke til morgenmåltidet, det varierer lidt, det er fordi, at i hverdagene så spiser vi sådan noget rugfras, det er simpelthen for småt til, at hun kan få det op. Så der får hun typisk en banan, og så har jeg lavet sådan nogle små pandekager, som jeg også lavede i dag af, faktisk det mel som jeg havde købt til at lave grød til hende. Hirsemel, så hvor jeg blandede nogle æbler i. Int: Ja. Inf1: Øh, til frokost får hun rigtig meget det samme som os eller som mig, om aftenen der øh.. vi får sådan nogle måltidskasser fra årstiderne, så vi bestemmer ikke selv hundrede procent hvad vi selv spiser, så der får hun, hvad vi får, hvis det giver mening? Int: Ja, og hvad kunne du ellers finde på at lave til hende, hvis det ikke passer til.. Inf1: Øh... nu skal jeg se, altså... Int: Altså nu lavede I babypandekager, som hun kan tage fat i til morgenmad. Inf1: Ja, lige præcist, ja og typisk egentlig hvis, eh, får hun også, hvis vi har et eller andet tilovers fra aftensmaden, altså nu for eksempel havde vi nogle kartofler tilovers forleden dag, så fik hun sådan en kartoffelbåd til frokost også. Int: Ja. Inf1: Eller nogle både af et eller andet vi lige har, øh, noget tilovers, sådan noget typisk... Hvis hun ikke spiser det samme som os.

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