Knowledge

Nearly half (n=13/31) of the healthcare professionals had heard about BLW. Most of these had been introduced to the concept by their colleagues or friends and family (rather than patients). The healthcare professionals who knew about BLW described it as the child feeding themself whole foods, instead of being spoon-fed purées. There was little discussion on the other aspects of BLW.

Attitudes

All healthcare professionals considered that BLW could be beneficial for the family and the child.

Healthcare professionals considered that shared family mealtimes would be the main advantage of BLW. They were aware of the nutritional and psychological benefits of family meals and they envisaged family mealtimes would be easier and more pleasant with BLW: The best thing is that an adult can eat their meal while the child is having theirs. There's no juggling trying to feed the baby while shoving a spoonful for yourself. (General Practitioner 3)

Some healthcare professionals thought mealtime battles would be less likely with BLW for two reasons: mothers would have an alternative approach to try if their child refused to be spoon-fed; and because BLW allows the child to eat at their own pace and stop when they have had enough, they would not be "bribed" (Dietitian 2) or "forced" (Lactation Consultant 1) to eat food: I think it's healthier that the baby is in control of what they eat… and you aren't forcing them to eat...there's far too many of us who just finish our plates instead of stopping when we are full. (Dietitian 2)

Overall, healthcare professionals thought BLW would encourage healthier dietary behaviours by promoting a wider variety of foods and allowing the child to explore and learn about food at their own pace: Being able to look at it, hold it and see it as food, instead of slop must have advantages? (Paediatrician 2)

They also considered BLW would encourage better appetite and self-regulation skills, as mothers would be less able to control the child's food intake. They saw similarities between BLW and breastfeeding on demand and thought the two would complement each other well.

A number of healthcare professionals who had children of their own thought BLW would be more convenient than the conventional method of spoon-feeding purées: It sounds so much easier. Making purées is time consuming, and then they hardly eat anything and you have to throw it all out or you buy those jars of food, which are really expensive. (Dietitian 4)

Healthcare professionals suggested two developmental advantages: BLW might encourage better oral and chewing skills because the child is offered pieces of food to eat so they may have more opportunity to develop their mouth and jaw movements instead of sucking food from a spoon as they do with purées; and enhanced fine motor skills as the child has greater opportunities to manipulate food with their fingers and practice their fine motor movements: The BLW method could have real advantages for coping with food and learning to eat i.e. for oral development. If babies are fed purées for too long they miss important windows for introducing different food textures. (Speech-Language Therapist 1) There must be some sort of fine motor benefits for baby being able to play, essentially, with its food. (General Practitioner 5)

However, in addition to these potential benefits, strong concerns about BLW were also expressed.

Choking was a major concern expressed by many of the healthcare professionals, particularly those who had not observed BLW. The potential risk of choking meant most healthcare professionals felt reluctant to recommend BLW: The potential for choking would make me feel very hesitant about giving my child whole food at 6 months. As a health professional I'd need to see some sound evidence before I could endorse this method [BLW]. (Dietitian 2)

The specific concerns voiced regarding choking were that a 6-month-old infant would not be developmentally ready to chew whole pieces of food and that mothers may leave the infant alone in their highchair with their food. In addition, healthcare professionals considered that mothers may become competitive about their infant's BLW progress, considering that their child is more advanced if they have certain foods or a greater variety of foods earlier than other children, and therefore might be motivated to offer unsafe foods that would increase the child's risk of choking: Just give the baby that food, she'll be fine. Sometimes it's almost like a challenge to see how they cope, another one of those competitive parenting things…oh look she's eating raw carrot at age 6 months. (Dietitian 1)

However, one healthcare professional considered that BLW may work well for parents whose infant experiences feeding problems when spoon-feeding is used: I know of similar feeding methods which are often used with children whose parents are having feeding difficulties with spoon-feeding and these can work very well. (Speech-Language Therapist 1)

Healthcare professionals considered that there were two possible dietary disadvantages with BLW: the potential for growth faltering, and for poor iron status. There was concern that adopting BLW would mean forgoing any iron-fortified infant cereal, and that a BLW diet would comprise low-energy low-iron fruits and vegetables and include very few iron-rich foods. In addition to low-energy foods, clumsy self-feeding (particularly at the beginning of BLW) might lead to growth faltering: The two parents I know who have chosen BLW are offering only fruits and vegetables. Although fruits and vegetables are great foods, babies need more nutrients… So I wonder how they would get these [nutrients] if they were only having fruits and vege…nutrients could be limited. (General Practitioner 1)

Contrasting this, a few healthcare professionals thought BLW infants could consume energy beyond their needs as a result of poor food choices: Young children arrive here and they're under-two eating twisties [an extruded cereal snack], chocolate biscuits—would BLW be that for some mothers? (Practice Nurse 2)

At the other extreme, some healthcare professionals commented that mothers (especially first-time mothers) are often apprehensive about their infant's growth and compare it with that of other infants and that a ‘chubby’ or ‘bonny’ baby is viewed as healthy even when it reflects overweight or obesity. Some healthcare professionals suggested that BLW may increase parental anxiety. They thought mothers would struggle watching their infant learn to eat, especially at the start when they might eat very little: Parents expect to see their child growing consistently—linear growth—and if they do not this evokes anxiety. How would you know if the child was eating enough? Parents would not cope with the child playing with food and not eating it. (Practice Nurse 7)

Finally, some healthcare professionals thought BLW would be messy for the mothers and suggested that there would be a lot of food wasted, which many mothers would not tolerate: I could imagine in the first couple of weeks that the infant wouldn't eat much and that there would be an awful lot of playing and squashing. Some mothers may not be able to cope with this. (Practice Nurse 11) I would be concerned about the mess and wastage of food. Some of our families live on a very tight food budget and I've seen the mess when doing BLW and I think a lot of food gets wasted. (Well-Child Provider 1)

Knowledge

The majority of mothers defined BLW as having three main components: offering finger-sized pieces of food, allowing the child to be in control of how much they ate, and not spoon-feeding purées: Letting your baby lead in terms of the pace and amount of solids eaten … offering them whole, safe foods when they are physically ready to feed themselves ... keeping milk [breast/formula] as their main food source until they naturally increase the amount they eat and drop milk feeds on their own. (Mother 2)

Nearly half the mothers first heard about BLW through a parenting group while others had discovered it online or were told about it by their Well-Child provider. One mother had not heard of the term ‘Baby-Led Weaning’ but said "it was instinctive" (Mother 1) to offer her child pieces of food and allow them to feed themself. The majority of mothers obtained their BLW information from online sources, drawing on other mothers’ experiences through blogs, threads and forums.

Attitudes

The main reason mothers chose to follow BLW was because it "made sense" (Mother 7) and "seemed logical" (Mother 13). Lifestyle reasons also motivated mothers to follow BLW. They considered that BLW was less time consuming and less expensive than making puréed food: With three other children, I was way too busy to prepare special foods i.e. purées and also I didn't want to buy them—they're expensive. (Mother 15)

Mothers considered that there were advantages of BLW during the complementary feeding period, and also in the future. During the complementary feeding period, mothers reported less meal preparation (the baby ate what the family was eating, there was no purée preparation) and reduced mealtime stress because they were not spoon-feeding the baby and eating their own meal simultaneously. Some mothers (n=6/20) reported it was liberating that BLW does not include a detailed step-by-step weaning protocol and instead promotes responding to the infant and thought that fewer ‘rules’ made the transition to food less frightening and complicated: With my first child I became so worried about getting the food [purées] to exactly the right consistency. It [BLW] made sense to me, because she was demand fed so it seemed like the natural progression. (Mother 8)

In addition, mothers believed that BLW had encouraged their child to develop healthier eating behaviours, for example, being able to respond appropriately to hunger and satiety cues, sharing family meals and eating a wider variety of foods: I felt it would give my daughter the opportunity to experience, from the outset, everything that is pleasurable about food, the textures, colours, individual tastes … a lovely way to have them be a real participant in the meal—eating what we eat, copying us, and really joining in … not being fed separately. (Mother 2)

Most mothers had no concerns with BLW (n=15/20). Those mothers who did have concerns were worried about the appropriateness of certain foods, for example, raw apple. Current guidelines on types of BLW foods to offer are incomplete and some mothers reported not knowing what foods to offer at what age: I wasn't worried but a bit concerned that some of the advice was conflicting e.g. the book says apple is fine and people I've spoken to who have used BLW have said no apples. (Mother 7)

One mother was concerned about her infant's iron intake, so she spoon-fed her infant iron-fortified rice cereal daily while following BLW. Other mothers felt that the iron from breast milk would be adequate until the infant started eating high iron meat or meat alternatives: Solids are just a taste and texture thing, breast milk or formula being their main nutrition until 9 months, so don't worry if your baby takes their time adjusting to solids. (Mother 6)

Nearly all mothers (n=19/20) reported that their infant gagged on food. Some mothers had completed a first aid course prior to their infant starting BLW to equip themselves for dealing with gagging or choking. Gagging was not a concern to mothers, instead they considered it was a natural part of a child learning to eat and adapting to new textures that are quite different to milk. Mothers were aware that an infant's gag reflex is much further forward on their tongue when they first start eating and because of this, they understood gagging was highly likely: I felt like I was really prepared, I had read the book4 so knew about gagging and choking and that mostly it is gagging because the baby's gag reflex is much further forward than an adult's…gagging is a very important learning process. (Mother 12)

Mothers viewed gagging as an innate safety mechanism that is activated when food has not been sufficiently chewed for swallowing. One parent explained that gagging returned the food to the front of the mouth for further chewing and that if the infant did not gag then the food could cause obstruction and possibly choking.

Mothers were aware choking was a common criticism of BLW, and although most reported that choking did not occur, 30% (n=6/20) reported one or more episodes. Although choking can be very serious, all mothers who reported choking (n=6/20) reported that the infant independently dealt with the choking by expelling the food from their mouth through coughing and mothers did not have to intervene with first aid. All mothers who could recall the food that was responsible (n=4/6) reported that raw apple was the food their infant had choked on. Mothers expressed feeling more relaxed around 4 weeks after introducing complementary foods; they saw that their infant could manage different textures, and was developing more coordinated eating skills. Mothers also felt that by this time the difference between gagging and choking was more obvious and that they realised it was mostly gagging.

Many of the mothers reported that mealtime mess was the main disadvantage of BLW. Infants were able to pick up their food and "squash, smear and throw it" (Mother 19). Some mothers were apprehensive about their infant eating in public or at other people's homes because of the mess. Mess was more of a problem in the early phases of BLW when the infant had not mastered the coordination skills needed to get food to their mouth, and mothers said as the level of skill improved the mess declined. Mothers who also had experience with the conventional method of starting solids thought finger foods and self-feeding were messy whatever the age: As someone who's done it both ways [BLW and spoon-feeding], I think they're both pretty messy and wasteful! (Mother 5)

Some mothers recalled feeling impatient during the first month of BLW as their infant, while learning to eat, could spend long periods of time at the table and appear to be "playing with food" (Mother 3).. Additionally, mothers reported that some family meals were not appropriate for their baby and that at these times knowing what to offer the infant was a challenge: I struggled with the “baby eats what the family eats” concept .... Most of what we really eat has a lot of salt, sugar, sauces, etc in it, and it takes work to think of how to adjust it or intervene in the cooking process to fit baby. (Mother 5)

Mothers recalled encountering both positive and negative experiences during the BLW period; however, all the mothers concluded that they would recommend BLW to other mothers: I couldn't imagine any other way of introducing solids and will certainly do BLW with any future children. I think the fact that our son has control over eating means that he doesn't have to fight for control…food is not a battleground here. (Mother 19)

Two mothers added that they would recommend supplementing BLW with some spoon-feeding for reassurance about nutrients: I say to people to use a combination. I felt good about this because she was able to explore food and learn about it but at the same time get the nutrients that she needed. (Mother 15)