Childhood obesity has important consequences for morbidity and mortality throughout life.1 In 2010, an estimated 43 million children younger than 5 years were obese or overweight worldwide, and the prevalence is expected to increase from 6.7% to 9.1% by 2020.2 Antenatal to early postnatal life is a period of rapid growth and developmental plasticity and therefore considered to be particularly sensitive for obesity prevention.3 Weaning, or the introduction of solid foods, is an important developmental milestone during this window of opportunity for obesity prevention and is a well-reasoned target for interventions. Baby-led weaning encourages infant self-feeding of all solid foods, rather than adult-led spoonfeeding, and is hypothesized to promote self-regulation of energy intake, a trait linked to the development of obesity in observational studies,4 and thereby lower obesity risk.5 However, concerns have been raised that baby-led weaning may increase the risks for infant undernutrition and choking, with most health care professionals reluctant to recommend it.6 In this issue of JAMA Pediatrics, Taylor et al7 describe the first randomized clinical trial to test the efficacy and safety of baby-led weaning to prevent excess infancy weight gain. The authors recruited 206 pregnant women and randomly allocated 105 to receive the Baby-Led Introduction to Solids (BLISS) intervention and the other 101 to receive usual care. The BLISS intervention was delivered through 8 contacts (from antenatal to 9 months postpartum), during which mothers were supported to breastfeed exclusively until their infant was 6 months of age and to allow infants to feed themselves solid foods rather than be spoon-fed from 6 months onward. The primary outcome was body mass index (BMI) at ages 12 and 24 months. Energy self-regulation, eating behaviors, and energy intake were also measured using validated instruments. Despite good adherence to the intervention, no differences were found in BMI z score, prevalence of overweight, energy intake, or energy self-regulation between infants in the intervention and control groups at ages 12 or 24 months. These findings highlight the importance of rigorous randomized clinical testing of infant feeding approaches and other behavioral interventions, even though such approaches already have wide popularity among parents and experts based on intuition and previous weak observational evidence.8 The trial was well conducted. Recruited women were less likely to be from deprived households than nonparticipants but were similar in other measured aspects. As highlighted by the authors, outside of a trial setting, women who choose baby-led weaning are more likely to have higher socioeconomic status, which may explain the observed association with lower obesity prevalence in previous nonrandomized studies. The high retention rate (80.5% at 24 months), high adherence to the intervention, and use of validated instruments to measure the outcomes of the trial provide much needed robust evidence regarding this weaning approach, allowing definitive conclusions to be drawn. We learn much from this trial, despite the lack of efficacy on the primary outcome of obesity risk. Baby-led weaning promoted successful weaning, as indicated by greater enjoyment of food, less fussy or picky eating behaviors, ongoing selffeeding of most foods to age 12 months, and a substantial 4-week longer duration of exclusive breastfeeding. Of importance, the baby-led weaning intervention was safe. No group differences were noted in energy intake, growth faltering, or iron-deficient anemia. Intervention infants gagged more frequently at age 6 months but less frequently at age 8 months, and there were no differences in the numbers of self-limiting or more serious choking events.9 These findings help allay concerns regarding the safety of baby-led weaning. Parents may be allowed a free choice in the manner of infant weaning, or baby-led weaning might even be encouraged as an approach to address concerns regarding infant food neophobia, food refusal, and disruptive mealtime behaviors. The BLISS intervention provided individualized support and advice to promote high-iron, high-energy foods and fewer foods that posed a choking risk. Thus, the safety of baby-led weaning promotion in the community needs to be confirmed. What then for obesity prevention? The BLISS intervention had demonstrable effects on eating behaviors with potential relevance to later obesity risk. However, contrary to the hypothesized benefit of baby-led weaning, the directional effects on these eating behaviors correlate with increased rather than decreased obesity risk. BLISS resulted in greater enjoyment of food (ie, pleasure derived from food) at 12 and 24 months, lower satiety responsiveness (ie, eating appropriately in response to feelings of fullness) at 24 months, and insignificant increases in BMI and prevalence of overweight at 12 months (15.1% vs 6%) compared with control infants. As a proposed target for obesity prevention, energy self-regulation aims to promote greater cognitive control over internal emotions and thrill-seeking urges and a greater awareness of true intrinsic signals of appetite and satiety to avoid eating in the absence of hunger. Baby-led weaning gives the infant autonomy, which in turn might promote the development or expression of energy selfRelated article page 838 Opinion

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婴儿主导的断奶——安全有效，但不能预防肥胖

儿童肥胖对一生的发病率和死亡率具有重要影响。 1 2010 年，全世界估计有 4300 万 5 岁以下儿童肥胖或超重，预计到 2020 年，患病率将从 6.7% 增加到 9.1%。2 产前到产后早期生命是一个快速生长和发育可塑性的时期，因此被认为对预防肥胖特别敏感。 3 断奶或引入固体食物是在这个预防肥胖的机会之窗期间的一个重要发育里程碑，是一个有充分理由的干预的目标。以婴儿为主导的断奶鼓励婴儿自行喂食所有固体食物，而不是由成人主导的用勺子喂食，并假设促进能量摄入的自我调节，观察性研究中发现的一种与肥胖发展相关的特征，4 从而降低肥胖风险。 5 然而，人们担心以婴儿为主导的断奶可能会增加婴儿营养不良和窒息的风险，大多数医疗保健专业人员不愿推荐这种做法.6 在本期 JAMA Pediatrics 中，Taylor 等人 7 描述了第一个随机临床试验，以测试以婴儿为主导的断奶预防婴儿期体重过度增加的有效性和安全性。作者招募了 206 名孕妇，随机分配 105 名接受婴儿主导的固体引入 (BLISS) 干预，另外 101 名接受常规护理。BLISS 干预是通过 8 次接触（从产前到产后 9 个月）进行的，在此期间，母亲被支持纯母乳喂养，直到婴儿 6 个月大，并允许婴儿从 6 个月起喂自己固体食物而不是用勺子喂食。主要结果是 12 个月和 24 个月时的体重指数 (BMI)。还使用经过验证的仪器测量了能量自我调节、饮食行为和能量摄入。尽管对干预措施的依从性良好，但干预组和对照组在 12 或 24 个月大的婴儿之间的 BMI z 评分、超重患病率、能量摄入或能量自我调节没有差异。这些发现强调了对婴儿喂养方法和其他行为干预进行严格随机临床测试的重要性，尽管基于直觉和先前薄弱的观察证据，这种方法已经在父母和专家中广受欢迎。8 试验进行得很好。与非参与者相比，被招募的女性来自贫困家庭的可能性较小，但在其他衡量方面相似。正如作者所强调的，在试验环境之外，选择以婴儿为主导的断奶的女性更有可能拥有更高的社会经济地位，这可以解释在之前的非随机研究中观察到的与肥胖患病率较低的关联。高保留率（24 个月时为 80.5%）、对干预措施的高依从性以及使用经过验证的工具来衡量试验的结果为这种脱机方法提供了急需的有力证据，从而可以得出明确的结论。我们从这次试验中学到了很多，尽管对肥胖风险的主要结果缺乏疗效。以婴儿为主导的断奶促进了成功的断奶，这表现在更多地享受食物、更少挑剔或挑剔的饮食行为、大多数食物持续到 12 个月大时自行喂养，以及纯母乳喂养持续时间大幅延长 4 周。重要的是，以婴儿为主导的断奶干预是安全的。在能量摄入、生长迟缓或缺铁性贫血方面没有发现组间差异。干预婴儿在 6 个月大时更频繁地作呕，但在 8 个月大时较少发生，自限性或更严重窒息事件的数量没有差异。9 这些发现有助于减轻对婴儿主导断奶安全性的担忧。可以允许父母以婴儿断奶的方式自由选择，甚至可以鼓励以婴儿为主导的断奶作为解决婴儿食物新恐惧症、拒绝食物和破坏性进餐行为的担忧的一种方法。BLISS 干预措施提供了个性化的支持和建议，以促进高铁、高能量食品和减少有窒息风险的食品。因此，社区婴儿主导断奶推广的安全性有待确认。那么预防肥胖怎么办？BLISS 干预对饮食行为产生了明显的影响，并可能与后来的肥胖风险相关。然而，与婴儿主导断奶的假设益处相反，对这些饮食行为的定向影响与肥胖风险增加而非减少相关。BLISS 导致在 12 个月和 24 个月时更享受食物（即从食物中获得的快乐），降低饱腹感（即，24 个月时适当进食以应对饱腹感），与对照婴儿相比，12 个月时 BMI 和超重发生率没有显着增加（15.1% 对 6%）。作为预防肥胖的建议目标，能量自我调节旨在促进对内部情绪和寻求刺激的冲动的更大认知控制，以及对食欲和饱腹感的真实内在信号的更大认识，以避免在没有饥饿的情况下进食。婴儿主导的断奶给予婴儿自主权，这反过来可能促进能量自我的发展或表达 相关文章第 838 页 意见 能量自我调节旨在促进对内部情绪和寻求刺激的冲动的更大认知控制，以及对食欲和饱腹感的真实内在信号的更大意识，以避免在没有饥饿的情况下进食。婴儿主导的断奶给予婴儿自主权，这反过来可能促进能量自我的发展或表达 相关文章第 838 页 意见 能量自我调节旨在促进对内部情绪和寻求刺激的冲动的更大认知控制，以及对食欲和饱腹感的真实内在信号的更大意识，以避免在没有饥饿的情况下进食。婴儿主导的断奶给予婴儿自主权，这反过来可能促进能量自我的发展或表达 相关文章第 838 页 意见