This is a method that has been in the news a lot in recent years, especially on social networks! I am of course referring to EMR or child-led diversification. After briefly mentioning the principle and historicalevolution of the method, the prerequisites as well as the advantages and disadvantages, I would like to give you an overview of the results of 4 recent international studies on the subject. The aim is, as you will have understood, to inform you more and more so that you can choose the best method of food diversification for your child, according to your own convictions and feelings.
What is EMR?
DME consists of introducing solid foods directly, in addition to breast or infant milk, without going through a progressive diversification with a gradient evolution of the texture. I would like to take this opportunity to say that the blended texture can, and indeed should, also be offered to baby, even in DME. In this method of introduction, the child puts the food in his mouth himself: he eats alone, hence the notion of " autonomy ". The approach is based on the fact that the oral, motor and muscular capacities are mature enough to mash food with a suitable texture (melting so that the child can mash the food himself in his mouth by the simple force of mashing between his tongue and palate, even if he does not yet have teeth). This allows most babies to feed themselves from the age of 6 months onwards while protecting their airways, thanks to a firm and stable sitting position at 90° with a minimum of support and supported feet. It is preferable to start this method with sufficient time to awaken, as it requires a high level of demand for the textures and sizes of the pieces. Of course, there is no obligation, even if it seems tempting and trendy, because this method is not suitable for all babies, nor for all parents!
For the record, the method of this baby-led complementary feeding was first described and detailed by Gill Rapley (" BLW " or " Baby Led-Weaning" ) and evolved in 2015 into the BLISS method ("Baby Led Introduction to SolidS") in order to secure the approach concerning false routes and choking and to meet the consequent nutritional needs of this rapid growth phase of 0/3 years olds with the notion of an energetic and iron-rich diet at each meal.
The advantages of this method are obviously: mutual trust in oro-motor skills and alsoexperimentation, discovery andinteraction with food, especially with the hands, through the 5 senses. In addition, the child eats consciously, at his or her own pace, following his or her own needs and sensations of hunger and satiety (this is calledself-regulation). On the other hand, there are some practical disadvantages, as this is a messy method: the dog is welcome to pick up food scraps that have fallen on the floor! The childcare method does not always allow for continuity of what is undertaken at home and the preparation of these specific meals, in texture and size, can add constraints for some families as there are few adapted infant and industrial foods available to help parents at present.
After these few essential reminders, we now come to the heart of the matter with the review of international studies on EMR...
Study on self-reported choking in EMR
This study explored the frequency of choking in DME and non-DME babies. A total of 1151 mothers of infants aged 4-12 months reported how they introduced solid foods to their infants. Mothers recalled whether their baby had ever choked and, if so, how often and on what type of food and textures. In total, 13. 6% of the infants had choked before. No significant association was found between weaning style and choking. For infants who had previously choked, infants following a traditional weaning approach experienced significantly more choking episodes for chunky foods and lumpy purees than infants following a BLW or BLISS approach. Baby-led weaning was therefore not associated with an increased risk of choking, and the highest frequency of choking on lumpy foods occurred in those who received them least often. However, the limitations of the results, self-selection of the sample and reliability of recall should be noted. In addition, infants had a more frequent sensory gag reflex at 6 months but less frequent at 8 months than control infants because they trained earlier!
Study on the nutritional effect of DME on growth and weight gain
The aim of this New Zealand study was to determine whether the BLISS approach, with the support of a lactation consultant, results in a lower body mass index (BMI) than traditional spoon-feeding. The results showed that the BLISS approach did not result in a more appropriate BMI than conventional diversification, although the children were reported to have less food fussiness. As for the influence of DME on infant weight gain, a review of 8 studies was done in 2021 and the results were indecisive: some studies seem to show lower weight gain in DME infants, others show similar energy intakes to those following the progressive method. So we can wait forFrench studies!
Study on the impact of BLISS on iron intake
The aim of this study was to determine the iron intake and biochemical iron status of 206 pathology-free term infants, 101 of whom were controls and 105 of whom were diversified using the BLISS method. Each of the infants received midwifery care and only the BLISS infants had 8 additional visits for education and method support. The results show us that dietary iron intakes (heme and non-heme) are broadly (and surprisingly!) identical regardless of dietary diversification. In addition,haemoglobin, plasma ferritin, body iron and iron status, the frequency of early functional iron deficiency and the presence ofiron deficiency anaemia are also broadly identical in both groups. The most alarming finding is rather that in both methods the recommended dietary allowances are not met.
Study on the knowledge, attitudes and experiences of health professionals and mothers regarding EMR
In 2019, this study highlights that mothers prefer to listen to another mother who is already practising EMR rather than health professionals. Parents who want to practice EMR will do so and seek their information from (potentially) unreliable sources via the internet or social networks. It is therefore essential toinform and train the various health professionals involved in young children's feeding.
As you can see, many more precise studies are needed to find out more about the impact of this method on the child's nutritional status. If there were only 3 points to remember on this diversification: I would say that it is absolutely necessary to ensure thesafety aspect of the food intake and to provide caloric and iron-rich foods at each meal.
To conclude this article, I feel it is essential to remind you of theimportance of support from a paediatric dietician and of nutritional advice adapted to the child for families for food diversification: classic, led by the child or mixed. Paediatric dietetics is a specialisation that is still not well known by the general public, but as you will have understood, the dietician-nutritionist is not only to be consulted in the context of weight loss in adults. In my opinion, the earlier the information is given as a preventive measure, the better it is perceived, without the guilt of having done the wrong thing, and the more impact it has on the future health of the young child...
Dietician - Nutritionist specialising in paediatrics
Bibliographic sources
- Opinion of the Haut Conseil de la Santé Publique on the revision of the dietary guidelines for children aged 0-36 months and 3-17 years of 30 June 2020
- PUBMED: Cameron SL, Taylor RW, Heath AL. Development and pilot testing of Baby-Led Introduction to SolidS - a version of Baby-Led Weaning modified to address concerns about iron deficiency, faltering growth and choking. BMC Pediatr. 26 August 2015;15:99. doi: 10.1186/s12887-015-0422-8. PMID: 26306667; PMCID: PMC4549838
- PUBMED: Brown A. No difference in self-reported frequency of choking between infants introduced to solid foods using a baby-directed weaning or a traditional spoon-feeding approach. J Hum Nutr Diet. 2018 Aug;31(4):496-504. doi: 10.1111/jhn.12528. EPUB 2017 Dec 5. PMID: 29205569
- PUBMED: Taylor RW, Williams SM, Fangupo LJ, Wheeler BJ, Taylor BJ, Daniels L, Fleming EA, McArthur J, Morison B, Erickson LW, Davies RS, Bacchus S, Cameron SL, Heath AM. Effect of a baby-directed approach to complementary feeding on infant growth and overweight: a randomized clinical trial. JAMA Pediatr. 2017 Sep 1;171(9):838-846. doi: 10.1001/jamapediatrics.2017.1284. PMID: 28692728; PMCID: PMC5710413
- PUBMED: Daniels L, Taylor RW, Williams SM, Gibson RS, Fleming EA, Wheeler BJ, Taylor BJ, Haszard JJ, Heath AM. Impact of a modified version of baby-led weaning on iron intake and status: a randomised controlled trial. BMJ Open. 2018 Jun 27;8( 6):e019036. doi: 10.1136/bmjopen-2017-019036. PMID: 29950456; PMCID: PMC6020950
- PUBMED: Cameron SL, Heath AL, Taylor RW. Health professionals' and mothers' knowledge, attitudes and experiences of baby-led weaning: a content analysis study. BMJ Open. 2012 Nov 26;2(6):e001542. doi: 10.1136/bmjopen-2012-001542. PMID: 23183112; PMCID: PMC3532980