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Pediatric Obesity

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Brown, A. & Lee, M. (2015). Early influences on child satiety-responsiveness: the role of weaning style. Pediatric
Obesity, 10(1), 57-66.
http://dx.doi.org/10.1111/j.2047-6310.2013.00207.x

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PEDIATRICOBESITY
ORIGINALRESEARCH doi:10.1111/j.2047-6310.2013.00207.x

Early influences on child satiety-responsiveness:

ORIGINALRESEARCH
the role of weaning style
A. Brown1 and M. D. Lee2
1
Department of Public Health and Policy Studies, College of Human and Health Sciences, Swansea University, Swansea, UK;
2
Department of Psychology, College of Human and Health Sciences, Swansea University, Swansea, UK

Received 30 October 2012; revised 10 July 2013; accepted 15 October 2013

Summary
Background: Nutrition during infancy may have a long-term impact upon weight gain and eating style.
How infants are introduced to solid foods may be important. Traditionally, infants are introduced to solid
foods via spoon-feeding of purees. However, baby-led weaning advocates allowing infants to self-feed
foods in their whole form. Advocates suggest this may promote healthy eating styles, but evidence is
sparse. The aim of the current study was to compare child eating behaviour at 18–24 months between
infants weaned using a traditional weaning approach and those weaned using a baby-led weaning style.
Methods: Two hundred ninety-eight mothers with an infant aged 18–24 months completed a longitudinal,
self-report questionnaire. In Phase One, mothers with an infant aged 6–12 months reported breastfeeding
duration, timing of solid foods, weaning style (baby-led or standard) and maternal control, measured using
the Child Feeding Questionnaire. At 18–24 months, post-partum mothers completed a follow-up question-
naire examining child eating style (satiety-responsiveness, food-responsiveness, fussiness, enjoyment of
food) and reported child weight.
Results: Infants weaned using a baby-led approach were significantly more satiety-responsive and less
likely to be overweight compared with those weaned using a standard approach. This was independent of
breastfeeding duration, timing of introduction to complementary foods and maternal control.
Conclusions: A baby-led weaning approach may encourage greater satiety-responsiveness and healthy
weight-gain trajectories in infants. However, the limitations of a self-report correlational study are noted.
Further research using randomized controlled trial is needed.

Keywords: Baby-led, child weight, satiety-responsiveness, weaning.

Introduction responsiveness as a heritable component of appe-

tite comes from a subset of this cohort, who were
Childhood obesity remains a concern in the UK and homozygous for the high risk A allele variant of the
USA (1,2) with many negative health and social FTO gene. Those with two copies of the A allele
implications (3). While there are multiple determi- had higher BMI and were also lower in satiety-
nants of obesity (4), there is increasing recognition responsiveness as measured using the Child Eating
of the role of gene–environment interactions in Behaviour Questionnaire (CEBQ) (8).
the development of obesity (5). Recently, Wardle Given the strong evidence in support of an appetite
and colleagues have put forward the appetite– phenotype (6–8), which influences children’s risk of
environmental interaction model of obesity suggest- obesity, it is especially important to understand the
ing that weight gain is the product of the interaction role the early feeding environment and to establish
between genetically determined appetite traits the characteristics of an environment that amelio-
and the environment (6). In a large cohort study, rates the risk of obesity. For example, one key
children’s satiety-responsiveness was negatively environmental factor is a controlling parental child-
related to body mass index (BMI) standard deviation feeding style, which has been shown to lead to
(SD) scores (7). Evidence in support of satiety- poorer appetite regulation (9,10). Controlling feeding
Address for correspondence: Dr A Brown, College of Human and Health Sciences, Swansea University, Swansea SA2 8PP, UK. E-mail:
[email protected]
© 2013 The Authors
Pediatric Obesity published by John Wiley & Sons Ltd on behalf of International Association for the Study of Obesity. Pediatric Obesity
10, 57–66
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and
reproduction in any medium, provided the original work is properly cited.
AB was supported by an ESRC Postdoctoral Fellowship.
AB was responsible for data collection, data analysis and initial draft. Both AB and MD revised the manuscript.
 58 | A. Brown & M. D. Lee

practices such as by restricting diet and pressuring Both breastfeeding and BLW place the infant in
ORIGINALRESEARCH

children to eat are associated with a decreased control of intake (23,31,32). Given the positive
ability to regulate intake according to appetite. association between breastfeeding and satiety-
Restricting intake of food can lead to increased responsiveness, we hypothesize that BLW could
intake when allowed free access (11,12), whereas potentially maximize satiety-responsiveness and be a
pressure to eat can lead to increased fussiness positive environmental influence on the risk of obesity.
(13,14). As a consequence, high levels of maternal To date, evidence for this notion is mainly anecdotal
control can affect children’s BMI and weight-gain and based on small-scale studies (33,34). One study
trajectories. Typically, restrictive practices have been has suggested that children who followed a BLW
linked to increased weight gain (15), while pressure approach during weaning are less likely to prefer
to eat can lead to increased fussiness and subse- sweet foods and less likely to be overweight, although
quent underweight (16). However, it should be noted sample size was small and based on self-report (35).
that not all studies have found conclusive evidence Alternatively, we have previously suggested that low
or rely on predominantly white, middle-class, levels of maternal control encouraged by BLW and/or
US-based samples (17,18). associated tendency for breastfeeding in mothers
Another aspect of the early food environment is the using BLW account for any improved outcomes rather
choice of infant feeding method and the way in which than self-feeding and absence of purées per se
the transition to solids progresses. It is already (31,32). Furthermore, Sachs has questioned whether
known that longer breastfeeding duration (19) and BLW is quantifiably different from many parents who
later introduction to complementary foods (20) are introduce solid foods to their infant without consider-
protective against later risk of becoming overweight. ing themselves ‘baby-led’ (36).
Breastfeeding may promote satiety-responsiveness The aim of this current study was twofold. Firstly,
in childhood (21), as breastfed infants have greater we set out to examine whether infants weaned with
opportunity to self-regulate their own intake of milk a baby-led approach exhibited differences in eating
(22). This may be due to lower maternal control behaviour during the second year compared with
during milk feeding (23), as the quantity of milk those weaned using a standard approach. Secondly,
taken and duration of feeding is led by the infant. we further explored the role of maternal control,
Indeed, breastfed infants have a lower risk of breastfeeding duration and timing of introduction to
childhood obesity while infants who are bottle-fed solid foods in these relationships. Here we report the
with either formula or expressed milk are at greater results of the second phase of a two-part study. In
risk of over-consumption and increased weight gain Phase One, we showed that a BLW style was asso-
(24). ciated with significantly lower levels of control com-
It is also important to understand the potential pared with mothers who followed a standard
influence of weaning practices on the risk of obesity. weaning (SW) approach in babies between 6 and 12
Later introduction to complementary foods and months (32). In Phase Two, reported here, we col-
maternal child-feeding style during this period are lected follow-up data 12 months later in order to
associated with infant weight (16,25,26). Interest is investigate how appetite traits such as satiety-
also growing in how infants are introduced to com- responsiveness at 18–24 months of age are related
plementary foods. Traditionally, infants are weaned to both weaning approach and maternal child-
with puréed foods, which tend to be spoon-fed by a feeding style during the weaning period.
parent/carer along with a gradual introduction to
finger foods (27). However, a recent popular trend in Methods
weaning, baby-led weaning (BLW; Google search of
Participants
‘baby-led weaning’ produces over 1.1 million hits:
Accessed 24/06/12), emphasizes self-feeding rather Approval for this study was granted by the Depart-
than spoon-feeding by infants from 6 months old ment of Psychology Research Ethics Committee. All
(28). Foods in their whole form are presented to the participants gave informed consent prior to inclusion
baby, who self-selects, grasps, brings to the mouth in the study. All aspects of this study have been
and consumes of its own volition (29,30). A reported performed in accordance with the ethical standards
characteristic of BLW is that maternal control over- set out in the 1964 Declaration of Helsinki.
feeding is minimal such that the infant decides which In Phase One, 604 mothers with an infant aged
food item is selected, how much of it is consumed 6–12 months (mean age 8.34 months) whom had
and the speed of consumption throughout an eating started consuming complementary foods completed
episode (31,32). a questionnaire examining weaning style. Consent

© 2013 The Authors

Pediatric Obesity published by John Wiley & Sons Ltd on behalf of International Association for the Study of Obesity. Pediatric Obesity
10, 57–66
 Weaning satiety-responsiveness | 59

was sought from mothers to be contacted for poten- of the time or less. Alternatively, if mothers reported

ORIGINALRESEARCH
tial follow-up. Four hundred twenty-three mothers using both spoon-feeding and purées more than
(70.26%) consented to being contacted. Mothers 10% of the time they were classified as SW. This
were invited to take part in Phase Two when their categorization was made during Phase One based
children were between 18 and 24 months of age. on the lack of formal definition of BLW. BLW is
Three hundred twenty-five mothers responded to the defined by a lack of puree use and allowing the infant
request (76.8% of consented sample, 53.98% of to self-feed. Using a 10% cut-off for purée use and
original sample). After exclusion criteria (child health spoon-feeding reflected the main tenets of the
problems or severe issues with weight such as failure method while allowing those who very occasionally
to thrive, failure to give consent or incomplete survey used purees or spoon-feeding (for example when
entry), 298 mothers remained in the full analysis feeding a yoghurt or out in public) and identified as
(70.45% of consented sample, 49.5% of original being baby-led as to be included in the BLW group.
sample). Further details are available in the initial study (31,32).
In Phase One, mothers were recruited via local Based on this categorization, 351 (58.1%) partici-
mother-and-baby groups based in South West Wales pants in Phase One were classified as following a
(UK) and through online parenting forums based in the BLW feeding style and 253 (41.9%) as following a
UK. For the groups, contact wa s made with group SW approach. Mothers also completed a copy of the
leaders who distributed questionnaires to group Child Feeding Questionnaire (CFQ) (37), reported
members. Questionnaires were returned to the leader breastfeeding duration and timing of introduction to
in a sealed envelope or via post to the researcher. In complementary foods.
addition, posters were placed in centres around the In Phase Two, mothers completed a second copy
city asking participants to contact the researcher for of the CFQ (37) answering items targeting restriction,
further details via email, phone or post. Question- pressure to eat, monitoring, concern for child weight
naires had information letters attached with details of and perceived responsibility. Five scales of the CEBQ
how to contact the researcher if further information [food-responsiveness’, ‘enjoyment of food’, ‘satiety-
was required. Study adverts were also placed on responsiveness’, ‘slowness in eating’ and ‘food
specific research request boards on online message fussiness’] were also completed (38). The ‘food-
boards on parenting forums based in the UK (e.g. responsiveness’ scale measures desire of the child
http://www.mumsnet.com; http://www.bounty.com) to eat in response to food stimuli regardless of how
with an online link to complete the questionnaire via hungry they are. ‘Enjoyment of food’ reflects a posi-
survey monkey. All participants were, however, based tive eating style and enjoyment of eating. ‘Satiety-
in the UK. Details were given on how to contact the responsiveness’ examines ability to regulate intake of
researcher if needed. Participants completing the food in relation to satiety. Linked to this, ‘slowness in
questionnaire via paper or online copy were given a eating’ reflects the speed at which a child eats.
written debrief at the end of the questionnaire and Finally, ‘food fussiness’ is defined by picky and
given researcher contact details if they wanted further limited food choices. Participants also self-reported
information. All participants were given instruction to the current weight of their child.
contact their relevant health professional if completing
the questionnaire had raised any questions or issues
Data analysis
with regard to caring for their baby (32).
For Phase Two, data were collected predominantly Data analyses were carried out using Statistical
via an online questionnaire designed and hosted Package for the Social Sciences (SPSS) v16 (SPSS
using SurveyMonkey.com. Mothers who consented UK Ltd., IBM, Surrey, UK) Data were checked for
to follow-up at stage one were sent a link to com- normal distribution and found adequate. The CFQ
plete the second part of the study online or offered a (37) and CEBQ (38) are typically used for pre-school
paper copy. Overall, 94.96% of participants com- aged and older children. Therefore, principal
pleted the survey online. components analysis using varimax rotation was per-
formed on both the CFQ and CEBQ to ensure that
the original factor structures held within this new
Measures
sample and age range (39). Factors with eigenvalues
In Phase One, mothers reported their weaning style over 1 were retained. A threshold of 0.5 was used
in terms of degree of spoon and purée use. Mothers based on recommendations by Nunnally (40).
were classed as baby-led weaners (BLW) if they Factors produced mirrored those on the original
reported using both spoon feeding and purées 10% questionnaires. As a further test of reliability,

© 2013 The Authors

Pediatric Obesity published by John Wiley & Sons Ltd on behalf of International Association for the Study of Obesity. Pediatric Obesity
10, 57–66
 60 | A. Brown & M. D. Lee

Cronbach’s alpha was computed for items loading cantly later [t(287) = 3.018, P < 0.003]. Therefore,
ORIGINALRESEARCH

above the threshold onto each scale and found to be age of introduction to solid foods and finger foods
over 0.7 for each scale. Therefore both the CFQ and were also controlled for throughout.
CEBQ were scored as per original instructions. Mean duration of breastfeeding in the sample was
Infant birth and current weight were converted to z 26.11 weeks (SD: 23.27 weeks). No significant dif-
scores. Current infant weight was also classified as ference in breastfeeding duration was evident
normal weight (5th–85th percentile), underweight between the two weaning groups [t(296) = −0.710,
(<5th percentile) or overweight/obese (>85th percen- P = 0.478], although mothers in the BLW group
tile) for infant age and gender according to the World were significantly more likely to have initiated
Health Organization Child Growth Standard Charts breastfeeding at birth [t(296) = −3.211, P = 0.001].
(41). Breastfeeding initiation was therefore controlled for in
A multivariate analysis of covariance (MANCOVA) comparisons between groups.
was used to examine differences in child-eating
behaviour for infants weaned using a BLW or SW Maternal child-feeding style
approach while controlling for maternal education,
Significant differences in current maternal child-
breastfeeding duration and timing of introduction to
feeding style were seen between those who weaned
complementary foods. The MANCOVA was then
using a BLW or SW approach. Mothers who followed
repeated, controlling additionally for maternal control
a BLW approach reported significantly current lower
at Phase One and Two.
levels of concern for child weight [F(1, 278) = 6.714,
P < 0.01], pressure to eat [F(1, 278) = 5.273,
Results P < 0.05], restriction [F(1, 278) = 15.383, P < 0.001]
Weaning style and monitoring [F(1, 278) = 5.808, P < 0.05] com-
pared with mothers who weaned using a SW
One hundred sixty-three (54.7%) of the Phase Two
approach. No significant difference was seen
sample had been classified as following a BLW style,
between the two groups for perceived responsibility.
and 135 (45.3%) as following a SW style. This com-
pared with 58.1% of the original sample following a
Child eating behaviour
BLW style and 41.9% following a SW style, suggest-
ing similar uptake of the Phase Two questionnaire in A MANCOVA found significant differences between
the two weaning groups. those weaned following a BLW or SW style for the
As found in Phase One, the BLW group had a Child Eating Behaviour measures of food-
significantly higher level of education [F(287) = responsiveness, satiety-responsiveness and food
3.2189, P < 0.01] in comparison with those using a fussiness (Table 2). No significant difference was
SW approach, although no significant difference was found for enjoyment of food. Those infants who had
found for maternal age. Maternal education was followed BLW were reported to be significantly less
therefore controlled for throughout. There was no food-responsive and less fussy and significantly more
significant difference in the age or education of satiety-responsive than those following SW style (see
mothers who completed the Phase Two follow-up Table 1).
compared with the whole sample in Phase One. Breastfeeding duration was significantly associated
Mean current age of child was 21.46 months (SD: with satiety-responsiveness (Pearson’s r = 0.134,
3.05) ranging from 18 to 24 months. No significant P = 0.01) and inversely associated with fussiness
difference in child age was seen between the BLW (Pearson’s r = −0.145, P = 0.007). Infants who were
and SW groups. All children were considered fully breastfed for a longer duration were reported as
weaned in that they were reported to be eating a significantly more satiety-responsive and significantly
wide range of family foods at regular meal times. less fussy.
Infants who were weaned using a SW approach Timing of introduction to complementary foods
were introduced to solid foods significantly earlier was significantly inversely associated with fussiness
than those weaned following a BLW approach (Pearson’s r = −0.179, P = 0.001), but no other
[t(287) = 2.069, P < 0.01]. behaviour. Infants who were weaned at an earlier age
Participants also indicated the age of their infant were reported to be significantly more fussy at 18–24
when they were first introduced to foods in their months.
whole form [finger foods] (as opposed to purees, e.g. Age at which infants were introduced to finger
toast, cooked carrot stick). Children were introduced foods was significantly associated with food-
to finger foods (rather than first food per se) signifi- responsiveness (Pearson’s r = 0.182, P = 0.001).

© 2013 The Authors

Pediatric Obesity published by John Wiley & Sons Ltd on behalf of International Association for the Study of Obesity. Pediatric Obesity
10, 57–66
 Weaning satiety-responsiveness | 61

Table 1 Maternal sample distribution by demographic Infants who were introduced to whole foods at an

ORIGINALRESEARCH
factors earlier stage were significantly less food-responsive.
Indicator Group BLW SW
Child eating behaviour and maternal
n % n % child-feeding style
Age (years) ≤19 3 1.0 5 1.7 The association between maternal child-feeding
20–24 21 7.0 26 8.7
style at Phase One and Phase Two and current
25–29 60 20.1 41 13.8
eating behaviour was examined. Analyses were per-
30–34 53 17.8 46 15.4
formed separately for those in the BLW and SW
35 ≥ 26 8.7 17 5.7
Education School 34 11.4 30 10.0 groups (Table 3). Phase One control was placed as a
College 52 17.4 34 11.4 covariate when examining the relationship between
Higher 41 13.8 47 15.8 control and eating behaviour at Phase Two.
Post-graduate 36 12.1 24 8.1 Significant associations were found between
Marital status Married 110 36.9 91 30.5 maternal control at Phase One and current eating
Cohabiting 15.4 15.4 36 12.1 behaviour, but only for those in the SW group. High
Partner 1 0.3 4 1.3 levels of restriction were significantly associated with
Single 6 2.0 8 2.6 lower levels of satiety-responsiveness, whereas
Maternal Professional / 61 22.2 56 20.3 concern for infant weight was significantly associated
occupation managerial with higher levels of food fussiness. High levels of
Skilled 18 6.5 14 5.1 pressure to eat were also associated with signifi-
Unskilled 43 15.6 30 10.9 cantly lower levels of enjoyment of food.
Stay-at-home 29 10.6 24 8.7
For Phase Two control, pressure to eat was signifi-
mother
cantly positively associated with food-responsiveness
BLW, baby-led weaning group; SW, standard weaning group. for both weaning groups while restriction was

Table 2 Differences
Behaviour Mean (standard error) Significance
in child eating
BLW SW behaviour for infants
at 18–24 months
Food-responsiveness 2.85 (.50) 3.18 (.45) F(1, 268) = 16.143, P < 0.001
weaned following a
Satiety-responsiveness 2.61 (.43) 2.42 (.38) F(1, 268) = 5.492, P < 0.05
baby-led weaning
Food fussiness 3.26 (.37) 3.03 (.32) F(1, 268) = 5.535, P < 0.05
(BLW) or standard
Enjoyment of food 1.91 (.86) 1.84 (.73) F(1, 268) = .546, P > 0.05
weaning (SW) style

Table 3 Association between maternal control and later child eating behaviour at 18–24 months

Food- Satiety- Food Enjoyment

responsiveness responsiveness fussiness of food
BLW SW BLW SW BLW SW BLW SW
Maternal control Concern for 0.041 −0.118 −0.037 −0.017 −0.101 0.210** −0.011 −0.044
during Phase One infant weight
Restriction −0.077 −0.034 −0.120 −0.212** −0.167 0.091 0.069 0.009
Pressure to eat 0.071 −0.130 −0.025 0.022 −0.018 0.065 0.029 −0.327**
Monitoring −0.130 −0.017 −0.045 0.018 −0.100 0.046 0.019 −0.094
Maternal control Concern for −0.012 0.188 0.041 0.008 −0.022 0.071 0.086 −0.64
during Phase Two infant weight
Restriction 0.059 0.157* −0.171* −0.279** −0.012 0.135* 0.014 −0.113
Pressure to eat 0.212** 0.227** 0.112 0.017 0.071 0.035 −0.084 −0.044
Monitoring 0.052 −0.051 −0.106 −0.113 −0.005 −0.184* −0.061 0.103
*P < 0.05, **P < 0.01. BLW, baby-led weaning group; SW, standard weaning group.

© 2013 The Authors

Pediatric Obesity published by John Wiley & Sons Ltd on behalf of International Association for the Study of Obesity. Pediatric Obesity
10, 57–66
 62 | A. Brown & M. D. Lee

significantly associated with higher levels of food- A MANCOVA showed significant differences for food-
ORIGINALRESEARCH

responsiveness (for the SW group) and lower levels of responsiveness [F(1, 249) = 4.778, P < 0.01] and
satiety-responsiveness for both weaning groups. satiety-responsiveness [F(1, 249) = 4.500, P < 0.01]
Finally, among the SW group, both higher levels of remained between those following BLW or SW
monitoring and concern for infant weight were asso- approach. Infants weaned using a BLW approach
ciated with increased food fussiness. were rated as significantly less food-responsive and
significantly more satiety-responsive than those
Child weight weaned following a SW approach, independently of
maternal education, maternal control, breastfeeding
No significant difference in birth weight or weight at
duration, child weight and timing of introduction to
6 months was found between the two groups.
complementary foods.
Current child weight was examined and compared
No significant difference between the two groups
for the two weaning groups. Overall, 10.1% of the
remained for food fussiness once covariates were
sample (n = 30) did not provide a current weight for
accounted for.
their infant. Of the remaining, infants in the sample
were predominantly within normal weight expecta-
tions for their age (74.5%, n = 222). Of the sample, Discussion
11.7% were overweight (n = 35) and 3.7% were
These results demonstrate for the first time the
underweight (n = 11).
impact of weaning approach and maternal behaviour
Infants in the SW group were however significantly
during the weaning period (6–12 months) on later
currently heavier than those in the BLW group [F(1,
child eating behaviour at 18–24 months old. Mothers
225) = 7.931, P = 0.005]. This relationship was inde-
who used BLW (infant self-feeds foods in their solid
pendent of birth weight, breastfeeding duration, age
form) had children who were perceived at follow-up
of introduction to solid foods and maternal control at
as having better appetite control and had a lower
both Phase One and Phase Two. Mean weight in
BMI than children weaned using a SW style (spoon-
kilogram of infants in the SW group was 12.86 (SD:
feeding puréed foods). These findings indicate that
3.73) compared with 11.79 (SD: 3.53) in the BLW
the approach adopted at the time of weaning,
group.
coupled with maternal feeding style, affect child
Pearson’s chi-square also revealed a significant
eating behaviour 12 months later.
association between current weight category and
In this sample, use of the BLW approach predicted
weaning style [χ2 (2, 268) = 8.100, P < 0.017]. For
lower levels of food-responsiveness and higher
the BLW group, 86.5% were of normal weight, 8.1%
satiety-responsiveness compared with a SW
overweight and 5.4% underweight. In comparison,
approach. High levels of food-responsiveness (desire
78.3% of those in the SW group were normal weight,
to eat in response to food stimuli regardless of
19.2% overweight and 2.5% underweight. A greater
hunger) (42) and low levels of satiety-responsiveness
percentage of those infants who were overweight
(ability to regulate intake of food in relation to satiety)
followed a SW approach.
(43) have been associated with greater risk of child-
Infant birth weight, weight at 6 months and current
hood overweight. We suggest therefore that adop-
weight were unrelated to current child satiety or
tion of a BLW approach provides an environment
food-responsiveness. However, current child weight
during the development of eating patterns that pro-
was significantly inversely associated with perceived
motes eating according to appetite. Indeed, infants
fussy eating (Pearson’s r = −0.171, P = 0.003).
in the SW group were significantly heavier than those
in the BLW group, with a greater proportion of SW
Child eating behaviour, maternal
infants with a weight over the 85th percentile
child-feeding style and weaning style
(although it has to be recognized that the overall
As child eating behaviour was associated with number of infants above this centile was low).
weaning style, maternal child-feeding style, child There are a number of possible explanations why
weight and weaning behaviours, the analyses infants following a BLW approach are more satiety-
between weaning approach and later child eating responsive and less food-responsive. Firstly, it could
behaviour were performed for a second time, placing be argued that BLW is merely associated with other
maternal education, maternal child-feeding style, behaviours that have been linked to specific
breastfeeding duration, timing of introduction to appetitive traits. For example, mothers who follow a
complementary and finger foods, birth weight and BLW style are more likely to breastfeed, introduce
current weight as covariates in the analysis. complementary foods at a later date and use lower

© 2013 The Authors

Pediatric Obesity published by John Wiley & Sons Ltd on behalf of International Association for the Study of Obesity. Pediatric Obesity
10, 57–66
 Weaning satiety-responsiveness | 63

levels of control over their infants intake of food, It is also possible that one of the benefits of BLW is

ORIGINALRESEARCH
(29,31) all of which are all associated with a that it maximizes learning about the post-ingestive
decreased risk of obesity (19–21). Mothers who consequences of food. Numerous studies have
adopt BLW have consistently been shown to have a demonstrated that sensory properties of food can
high level of education, which is typically associated over a number of exposures become associated with
with healthier child diet and weight (44) and this post-ingestive effects, e.g. visual cues, flavours and
was also reflected in this sample. However, we textures become associated with how satiating that
found that use of BLW was associated with satiety- food is (47). In turn, learned food experience influ-
responsiveness at 18–24 months independently of ences food selection and portion-size choices appro-
maternal control, breastfeeding duration, timing of priately (50). With BLW, foods are presented in their
introduction to complementary foods and maternal whole form such as an apple or piece of chicken
demographic background. rather than in a less-recognizable puréed form. More-
Moreover, when exploring the association between over, infants are often given a selection of discrete
maternal control and eating style (where previous food pieces to choose from (e.g. a piece of toast,
literature has shown a link between high levels of slices of banana). This contrasts with purées which
maternal control and a breakdown in self-regulation often consist of different foods and flavours mixed
(9,10)), BLW appeared to protect the infant from high together (e.g. a sweet potato, parsnip and carrot
levels of maternal control. Whereas for those infants purée) (31). For commercially prepared purées, the
weaned using a SW approach, maternal control both main ingredient may not fit in with the main flavour of
during infancy and the current time period was asso- the purée (e.g. a potato-based purée having a pre-
ciated with poorer self-regulation, these relationships dominant broccoli flavour), setting up a relationship
did not exist, or were weaker, among the BLW group, between flavour and post-ingestive consequences
suggesting an intervening factor. that will later change again as the transition is made
Potentially therefore, there is something unique from purées to discrete food items. We postulate that
about BLW that sets it apart from SW methods. perhaps BLW enables early and more stable learning
Although speculative, it is plausible that by allowing about the satiating capacity of foods, thus promoting
infants to choose which food offering to grasp satiety-responsiveness. This of course needs to be
and bring to the mouth without much parental tested empirically and it will be important to establish
involvement the pace and duration of eating if enhanced satiety-responsiveness continues further
episodes are optimal for the development of satiety- into childhood.
responsiveness. Infants are given greater opportunity Infants who followed a BLW style were also rated
to determine the end point of a meal compared with as significantly less fussy than infants following a SW
spoon-feeding where the parent may consciously or style, supporting speculation that BLW fosters posi-
subconsciously wish the set portion-size to be con- tive appetitive traits (34). However, once maternal
sumed. Even when maternal desire for control is control was accounted for, this relationship disap-
higher, the ability of the infant to control the pace and peared and weaning style did not remain predictive
size of the meal may overcome this. Moreover, of fussiness in the regression analysis. This is not to
greater participation in family meal times (30,45) may say a BLW approach is not associated with a wider
extend meal duration and decrease overall eating acceptance of foods, but that it may be explained by
speed, which has been associated with increases in the low level of maternal control involved in the
physiological signs of satiety (46). Babies have no method. Indeed, lower levels of maternal control over
notion of portion sizes or habitual plate clearing, and child diet have been associated with lower levels of
when given the opportunity will likely determine when pickiness and fussiness in older children (51). This is
the meal finishes without regard to how much food an interesting finding as it not only highlights the
remains uneaten. Ability to eat to satiety rather than impact of weaning style, but suggests that for those
finishing the portion available may be an important who adopt a SW approach, doing so in a responsive
element in protection against overweight (47). Evi- way may be beneficial to later food preferences in
dence shows that pre-school children are less likely children.
to finish a larger-than-needed portion-size (48), but Finally, infants who followed a BLW approach were
that this ability reduces by later childhood and adult- significantly less likely to have a weight centile > 85th
hood (49). A BLW approach may thus prolong or than those who followed a SW approach, supporting
protect this ability, increasing the likelihood of con- previous findings (35). Placing the infant in control of
tinued satiety-responsiveness into older childhood food intake and greater acceptance of a wider variety
and adulthood. of tastes may promote a healthier weight trajectory.

© 2013 The Authors

Pediatric Obesity published by John Wiley & Sons Ltd on behalf of International Association for the Study of Obesity. Pediatric Obesity
10, 57–66
 64 | A. Brown & M. D. Lee

However, this association must be taken with caution progress (60). If an infant is perceived as a fussy
ORIGINALRESEARCH

as weight was self-reported by parents and numbers eater, mothers may not feel confident in adopting a
of infants in the overweight range were small. Further BLW approach or allowing the infant opportunity to
research clearly needs to examine impact of BLW on Cself-regulate appetite. Instead, they may choose to
longer term weight trajectories. use traditional methods of purées and spoon-
These findings do need to be considered in light of feeding to have greater control and measure of what
limitations. Firstly, the sample was self-selecting both their infant is consuming. Alternatively, they may
in terms of participation and decision to follow a start the weaning process using a BLW approach,
certain approach to weaning. It may be that parents but struggle and move to spoon-feeding. Child
who are especially concerned with infant weight and weight and eating style can drive maternal child-
eating style or their own health choose to adopt a feeding style for older children (9,10), thus it is likely
BLW approach as they have heard anecdotal stories for younger infants. Rather than BLW leading to an
about its benefits. Indeed, mothers in the BLW group infant who is more responsive and less fussy,
had a higher level of education, although this was perhaps infants who are less fussy and more
controlled for in the analyses. Another possibility is responsive are more likely to start or continue fol-
that parents who follow a BLW approach are more lowing a BLW approach.
aware of the importance of eating to appetite and the Linked to this, maternal personality may also play a
health benefits of and have a strong belief in the role. Previous work has shown that mothers who
ability of BLW to lead to positive eating styles and follow BLW are lower in anxiety and feel more relaxed
thus influencing the way they complete the question- specifically in relation to the weaning process than
naire. Further research should consider a population- mothers following a SW approach (30). Mothers who
based sample or indeed a randomized controlled are high in anxiety are more likely to use a restrictive
trial. and controlling feeding style (61) and mothers who
Criticisms could also be made on the methodology are controlling in their parenting style are more likely
used, although in light of the dearth of research in the to use a controlling maternal-feeding style (62) and
area the sample and methodology were considered have overweight children (63). Perhaps therefore,
appropriate for initial exploration. The current study mothers who are more anxious in general gravitate to
relied on self-report of child eating behaviour and a SW approach as it allows greater control and
weight which could have been open to responder measurement, which in turn impacts upon child
bias or error. Analyses were also correlational and weight and eating style.
cannot determine causality. Further research should Limitations aside, these findings raise important
seek to observe child eating behaviour and measure questions not only in regard to the timing when
intake of nutrients and weight rather than rely on infants are introduced to complementary foods, but
parental report. Again, a randomized controlled trial how this process takes place. Evidence is starting to
may be needed to ascertain impact of the approach build that a BLW approach may encourage a satiety-
among other wider factors. responsive eating style to develop; understanding
Additionally, measures to categorize BLW vs. SW how this works in greater detail may be an important
were devised for the study (see Methodology). In the step in developing early interventions to combat
absence of a clinical definition of BLW, these meas- rising childhood obesity. Data, however, now needs
ures were considered appropriate and felt to reflect to move away from relying on parental self-report
definitions in popular literature and discussion with (e.g. utilizing observations of child intake such as an
parents. Finally, the CFQ and CEBQ are also typically eating in the absence of hunger task) while subject
used for older children (although the CFQ is consid- selection issues also need to be reduced through
ered valid from two years (37)). However recent work randomization.
in the area has employed (and validated (51)) these In summary, babies who transition from a milk diet
measures in reference to children under the age of 2 to solid foods using the BLW method show greater
years both for the CEBQ (53–55) and CFQ satiety-responsiveness and decreased likelihood of
(16,25,56,57). Child eating behaviour (58) and mater- overweight at 18–24 months compared with those
nal child-feeding style (59) are also considered stable using the standard spoon-and-purée approach.
for older children. Influences on childhood weight gain are complex
It is also important to consider the role of infant and driven at least partly by genetics. However,
characteristics. Much emphasis is placed on intake potentially the BLW approach may provide a protec-
of food and infant weight gain during the weaning tive environment to ameliorate the overall risk of
period with mothers concerned about their infants obesity. Further research is needed.

© 2013 The Authors

Pediatric Obesity published by John Wiley & Sons Ltd on behalf of International Association for the Study of Obesity. Pediatric Obesity
10, 57–66
 Weaning satiety-responsiveness | 65

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Pediatric Obesity published by John Wiley & Sons Ltd on behalf of International Association for the Study of Obesity. Pediatric Obesity
10, 57–66