Choking and Baby Led Weaning (BLW): What does the most recent research say?
Last week during one of my webinars about BLW, a registered dietitian harshly interrupted me to voice her concerns about choking. She told me that what I’m saying is very scary and I should take my videos down. She said that my babies are cute and all but I should temper my enthusiasm about BLW. I’m sure this dietitian isn’t the only one to be scared about choking. That’s why I wrote up this blog post that addresses why babies who do BLW safely are not more at risk of choking compared to babies who eat jarred baby food, using the most recent research. I would like to thank Gill Rapley and dietetics intern Natalie Quathamer for their support and assistance in addressing this.
Choking: the main concern
When it comes to Baby Led Weaning, both parents and healthcare professionals find the risk of choking as a major concern. This is a very fair concern, as a baby’s first bite is a brand new experience of mastering chewing, swallowing and breathing all together for the first time, putting them at an overall higher risk of choking. To help quantify the current state of the issue, more than 12,000 children from age 0-14 have a non-fatal choking incident attributable to food in the US each year, as found by Chapin et al. in 2013 (1). No parent wants their child to choke, and as a professional it is your duty to protect the wellbeing of your clients. Unsurprisingly, choking is reported again and again as the #1 fear with regards to BLW in studies such as that by D’Andrea et al. in 2016 (2). That’s why I will spend a considerable amount of time addressing this very warranted concern.
What’s my objective with this post?
The goal here today is to focus on making you feel more comfortable with the fact that BLW babies are not more at risk of choking than babies fed with traditional spoon-fed approaches, using the most recent science.
What about baby’s motor skills?
First, let’s take a look at the average feeding timeline for a baby, to better understand the physiology of feeding. As many seminal studies, such as that by Woolridge in 1986 (3) have seen, at birth babies are able to feed themselves on their own. Physiologically, they have the innate reflex to suckle at the breast. Babies know when to feed, how to feed, when to stop and at what pace. Once they hit 1 ½ or 2 years old, we can again assume that most babies can feed themselves without help. This leaves a gap, starting at around six months, where we assume we have to feed babies with a spoon. However, babies do not lose their ability to self-regulate on when to feed, when to stop and at what pace, but are simply developing new physiological traits that change how and what they eat. These motor skill changes that develop around 6 months, like coordinating the grabbing and bringing of big objects like toys to their mouth and being able to sit upright with minimal help, make self-feeding a reasonable endeavour for most healthy infants at this time, as indicated in a literature review done by Cameron, Heath and Taylor in 2012 (4).
Traditionally speaking, we don’t tend to respect these new developmental milestones which can be a problem. Babies are then subject to being fed, at someone else’s pace and on someone else’s schedule, which has the power to lead to unexpected bites, overconsumption and a more stressful feeding environment.
What about oral motor skills?
So babies can maintain the correct position and bring food to their mouth, but what about oral motor skills? Well in their 2017 study, Cameron, Heath and Taylor (4) continue by noting that infants are able to handle foods that are soft in texture at 6 months by “munching” which is using up and down jaw movements to mash the food and eventually form a bolus. With this linear practice of munching, biting and chewing with age, babies get to apply and tweak their oral motor skills as they come in, rather than waiting in a spoon-feeding approach. This may have the power to prevent possible feeding difficulties in the future as well as choking episodes, since they have already developed, tested and fine-tuned their skills.
The gag reflex
I want to touch briefly on gagging, the protective reflex that helps prevent choking. Babies at six months of age have a gag reflex that is triggered at a much more frontal place in their mouth, as indicated by Rapley in 2011 (5). A possible benefit of BLW is that since only large pieces of food are offered at a time when the gag reflex is at the front of the mouth, this may help keep only well-masticated food to the back. It is important to note that BLW babies may gag more than their spoon-fed counterparts, as seen in the BLISS study by Taylor et.al in 2017 (6). However, by 8 months of age when these babies had a better grasp on self-feeding, they began to gag less than the control group.
Safety of jarred foods
Another consideration is the question of whether purees themselves are easy to eat, particularly once the ability to chew has developed. As noted in the thesis by Delaney in 2010 (7), for babies who can chew, purees are actually not that easy to manage, as the puree spreads throughout the mouth with chewing action and is very difficult to gather in a bolus.
What does the most recent science say?
Let’s finally get down to the nitty-gritty: what exactly does the newest science have to say specifically about BLW and choking risk? The best evidence to refute the idea that BLW leads to a higher choking risk is again the ongoing BLISS study by Taylor et.al in 2017 (6). This was a 2 year long Randomized Control Trial (RCT), where a control group of spoon fed babies were compared with a group of babies fed using the BLISS method, which is a combination of regular BLW techniques with extra instruction (such as choking prevention and offering high iron foods). Overall, the study found that that there was no difference in the number of babies who choked between the groups. Not only that, but it found no evidence of growth faltering or risk of iron deficiency in BLISS babies.
Another RCT by Fangupo et.al in 2016 (8) also showed that infants are not more at risk of choking following a BLW approach than spoon-fed. Better though still, is an editorial in the journal JAMA pediatrics, by Lakshman, Clifton and Ong in 2017 (9). This study pronounces BLW as a safe and effective intervention; no difference in energy intake, growth faltering or iron deficiency were noted, and no more choking incidents than in traditional spoon feeding. They even go so far as to suggest it may be recommended. It is important as purveyors of accurate science to look at all sides of the research. Another study from New Zealand by Morison et.al in 2016 (10), did indicate a possibly higher choking risk with a BLW-style approach. However, this study did not adequately define BLW; parents simply chose if they thought themselves to belong in the BLW group or the traditional feeding group, making the results difficult to state in a conclusive manner. An important take-away from this study was that education regarding inappropriate foods for infants, whether doing BLW or spoon-feeding, continues to be low. This further promotes the role of the dietitian during the infant feeding process, regardless of the approach.
What is the takeaway?
In summary, we need to remember that choking is a multifactorial issue; posture, chewing abilities, and distractions all need to be accounted for. However, with a dietitian-led BLW approach, babies are focused on their food, able to eat at their own pace, are under no pressure and most importantly, are not at a higher risk of choking than with purees.
How can we make sure BLW is being done safely?
- Make sure the baby is sitting upright while eating (none of those lying back bouncy chairs or high chairs that aren’t at 90˚).
- Limit distractions: no TV, IPad, cell phone or big crowds for the first few weeks so baby is not overwhelmed and can focus
- Make sure the baby is ready to feed him/herself on their own. Don’t start too early
- Do not feed the baby by putting foods into their mouth. You can lodge the food further down and actually cause choking by doing this
- Offer appropriate foods that they can easily grab and are soft enough to handle.
- Sign up for my BLW Online Course today or sign up to an in-person BLW workshop given by a member of my International Baby Led Weaning Network of Registered Dietitians.
- Chapin, M. M., et al. (2013). “Nonfatal Choking on Food Among Children 14 Years or Younger in the United States, 2001–2009.” Pediatrics 132(2): 275-281.
- D’Andrea, E, KIELYN JENKINS, MARIA MATHEWS, BARBARA ROEBOTHAN (2016). Baby-led Weaning: A Preliminary Investigation. Canadian Journal of Dietetic Practice and Research
- Woolridge, M. W. (1986). “The ‘anatomy’ of infant sucking.” Midwifery 2(4): 164-171.
- Cameron, S. L., Heath, A-L. M., & Taylor, R. W. (2012). Healthcare professionals’ and mothers’ knowledge of, attitudes to and experiences with, Baby-Led Weaning: a content analysis study. BMJ Open, 2 (6), 1-9. doi:10.1136/bmjopen-2012001542
- Rapley, G. (2011). Transitioning to solid foods at the baby’s own pace. Community Practitioner, Jun;84(6):20-3.
- Taylor, R.W., Williams, S.M., Fangupo, L.J., Wheeler, B.J., Daniels, L., Fleming, E.A., McArthur, J., Morison, B., Erickson, L.W., Davies, R.S., Bacchus, S., Cameron, S.L. and Heath, A-L. M. (2017) ‘Effect of a baby-led approach to complementary feeding on infant growth and overweight: A randomised clinical trial’, JAMA Pediatrics, 171(9): 838-846.
- Delaney, A.L. (2010) Oral-motor Movement Patterns in Feeding Development. Ph.D. (Communicative Disorders). University of Wisconsin-Madison.
- Fangupo, L. J., Heath, A-L. M., Williams, S. M., Erickson, L. W., Morison, B. J., Fleming, E. A.,…Taylor, R. W. (2016). A Baby-Led Approach to Eating Solids and Risk of Choking. Pediatrics, 138 (4), 1-8. doi:10.1542/peds.2016-0772
- Lakshman, R.; Clifton, E.A. and Ong, K.K. (2017) ‘Baby-led weaning – safe and effective but not preventive of obesity’, JAMA Pediatrics, 171(9): 832-833
- Morison, B. J., Taylor, R. W., Haszard, J. J., Schramm, C. J., Erickson, L. W., Fangupo L. J.,…Heath, A-L. M. (2016). How different are baby-led weaning and conventional complementary feeding? A cross-sectional study of infants aged 6–8 months. BMJ Open, 6 (5), 1-11. doi:10.1136/bmjopen-2015010665