Baby-led weaning

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Baby-led weaning (often also referred to as BLW) is an approach to adding complementary foods to a baby's diet of breast milk or formula. BLW facilitates oral motor development and strongly focuses on the family meal, while maintaining eating as a positive, interactive experience. [1] Baby-led weaning allows babies to control their solid food consumption by "self-feeding" from the start of their experience with food. The term weaning does not imply giving up breast milk or formula, but simply indicates the introduction of foods other than breast milk or formula.

Contents

Background

Current infant feeding recommendations by the American Academy of Pediatrics are that infants should be breast fed for the first 6 months, then be gradually introduced to solid food between the age of 6 months and 1 year. [2] However, for much of the twentieth century, mothers were told to maintain a strict schedule for breast feeding, limiting the time at breast and the frequency of feeds. [3] As a result, many mothers had low milk supply (as breast milk is a supply-demand phenomenon), and therefore their babies “failed to thrive.” [3] Infant formula became increasingly accepted as a way to supplement or replace breastmilk but there was also a move to introduce strained or mashed “baby foods” [3] from a younger age than is now known to be desirable. By the 1930s, a variety of commercial purees were available for purchase, with Gerber leading the way.

Overview

Baby-led weaning (term self-attributed to Michael Barrientos [4] ) places the emphasis on exploring taste, texture, color and smell as the baby sets their own pace for the meal, choosing which foods to concentrate on. Instead of the traditional method of spooning pureed food into the baby's mouth, the baby takes part in family mealtimes and is presented with a variety of foods in easy-to-grasp pieces, which he or she can freely choose and explore. Infants are offered a range of foods to provide a balanced diet from around 6 months. [4] Ideally, these will be the same foods that the rest of the family is eating, provided these foods are suitable for the infant.

Infants often begin by picking up and licking or sucking on the piece food, before progressing to eating. Babies are typically able to begin self-feeding at around 6 months old, [5] although some are ready and will reach for food as early as 5 months and some will wait until 7 or 8 months. The intention of this process is that it is tailored to suit the individual baby and their personal development, and that the infant’s appetite is respected with regard to which foods are chosen, the pace of eating, and how much is eaten.

Initial self-feeding attempts often result in very little food ingested as the baby explores textures and tastes through play, but the baby will soon start to swallow and digest what is offered. Although breastfeeding is the ideal nutritional precursor to baby led weaning (as the baby has been exposed to different flavors [6] via its mother's breast milk), it is also entirely possible to introduce a formula-fed baby to solids using the BLW approach. Formula-fed babies can successfully wean using BLW. [7]

Providing an infant with table foods initiates the development of strong oral motor control for chewing and swallowing, including tongue lateralization and eventual bolus formation. When an infant mouths a food texture, the tongue lateralization reflex forces them to move their tongue to the side to lick and taste the food, and engages the phasic bite reflex. Through continued practice, infants learn to volitionally lateralize their tongue and bite—the first step in the development of a munching/chewing pattern. [8]

Basic principles

The basic principles of baby-led weaning are:

Relation to child development

BLW is closely linked to the way in which babies develop in their first year, particularly in how their nutritional needs dovetail with their motor development.

Nutritional Requirements

As recommended by the World Health Organization and several other health authorities across the world, there is no need to introduce solid food to a baby's diet until after 6 months. This guidance is based on research indicating that it is from this age that infants begin to need additional nutrients that cannot be supplied by breastmilk or formula alone. The time period from 6 to 18–24 months of age is when the risk of malnutrition is high in infants and the role of breastmilk or infant formula remains important throughout this period. It is important that parents do not decrease the volume of milk feeds until the baby is taking in enough solid foods to support growth (AAP, 2013). Formula or breastfeeding is continued in conjunction with complementary foods and is always offered before solids in the first 12 months.

By the time most typically developing babies reach six months, their digestive system and their fine motor skills have developed enough to allow them to self-feed. Baby-led weaning takes advantage of the natural developmental progression of the child, both in relation to the age of beginning the transition to solid foods and to the gradual pace of this transition that happens when the infant is in control of the process.

Motor Development

From infancy, the only oral motor pattern a baby knows is suck-swallow-breathe. This reflexive way of eating allows infants to feed from birth (from a breast or bottle) while protecting their airway and meeting their nutritional needs. [8] The oral motor patterns required for eating and swallowing solids include tongue lateralization, tongue elevation, and munching/chewing, and unlike the suck-swallow-breathe sequence, coordination of these oral motor patterns is learned, not reflexive, although reflexes are present to allow a baby to begin to develop these patterns. [10] When an infant is offered a spoon of puree, the practiced or familiar oral motor pattern is sucking. Purees are thicker than formula or breast milk, but do not require chewing. They are therefore sucked off of a presented spoon and moved in the mouth in a similar fashion to liquid. This is generally seen as an integral part of the process of introducing solid foods and an important step in the acquisition of chewing skills. Conversely, professionals experienced in BLW note that effective chewing tends to appear sooner in infants who are not exposed to purees. The skills required for chewing are vastly different than those required for spoon feeding, and most babies do not need to be taught how to swallow. Swallowing is a deep brainstem reflex present by 15 weeks gestation [11] and well established by full term birth. Babies already know how to swallow, and thicker textures such as purees are considered both easier and safer for babies to swallow. For instance, young babies who have swallowing difficulty are often prescribed a diet of thickened milk (rather than drinking regular milk). [12] Purees, however, do teach baby a motor pattern: bring food in, move it back, swallow. Learning to ingest purees does not prepare a baby for chewing, which is problematic as most solid foods must be chewed after entering the mouth but before being moved back.

Indeed, current research supports that delayed experience with eating lumpy foods leads to poor food acceptance in later years. [13]

Through playful exploration and handling food, babies learn about texture and are able to practice new oral motor skills without any pressure to eat. BLW also allows them to be in charge of what goes in their mouth, how it goes in, and when. [8] Thus, they gradually develop the oral motor patterns required for mature bolus manipulation, chewing, and swallowing. The baby learns most effectively by watching and imitating others, while allowing her to eat the same food at the same time as the rest of the family contributes to a positive weaning experience.

Self-feeding supports the child's motor development on many vital areas, such as their hand-eye coordination and dexterity, as well as chewing. It encourages the child towards independence and often provides a stress-free alternative for meal times, for both the child and the parents. Some babies refuse to eat solids when offered with a spoon, but happily help themselves to finger food. [14] [15]

The originators of BLW assert other strategies which are in line with traditional feeding safety guidelines. For example, it is recommended that infants are seated upright, either on the parent's lap, or in a supportive high chair, for all feeding experiences. This allows for easy expulsion of the bolus by gagging, and decreases accidental movement of the food into the pharynx. Additionally, a child who has the trunk and head control to sit independently though a meal (proximal stability) will more likely demonstrate coordinated ability to move the tongue and jaw for chewing. [8]

Gag Reflex

When infants bring solid foods to their own mouth, they are the ones guiding the sensory experience, starting and stopping when they are comfortable and ready. When food does move too posteriorly in the mouth triggering a gag reflex, the entire bolus is expelled from the mouth– something that is not possible with a puree. Also, solid food moves slowly in comparison to liquid, and is not often sucked into the pharynx, which would allow for laryngeal penetration or aspiration of the bolus. The food bolus will trigger a gag response first and be expelled before it hits the laryngeal vestibule. Infants therefore utilize the gag reflex for learning three important concepts: the borders of their mouth, desensitizing their gag reflex, and how to protect their airway when volitionally swallowing solid foods. [4] As infants get closer to one year old, the gag reflex moves posteriorly, closer to the laryngeal vestibule. This allows food to move closer to the laryngeal vestibule before triggering a gag. Parents following BLW are advised to avoid classic “choking hazards” or airway shaped foods: whole grapes, coin-shaped slices of hotdogs, cherry tomatoes, etc. [4]

Scientific research

Very little scientific research has been done regarding baby-led weaning. [16] However, another 2020 study headed by child health specialist Charlotte M. Wright from the University of Glasgow, Scotland found that while BLW works for most babies, it could lead to nutritional problems for children who develop more slowly than others. Wright concluded "that it is more realistic to encourage infants to self-feed with solid finger food during family meals, but also give them spoon fed purees." [17]

A study published in 2011 at the University of Nottingham by Ellen Townsend and Nicola J. Pitchford suggests that baby-led weaning may lead to less obesity in childhood. The authors conclude that the "results suggest that infants weaned through the baby-led approach learn to regulate their food intake in a manner, which leads to a lower BMI and a preference for healthy foods like carbohydrates". [18] Feeding specialist, Kary Rappaport, OTR/L, SWC, CLE also concludes that a BLW infant, who leads their own food exploration and is exposed to a consistent variety of tastes, textures, and smells at an early age is more likely to develop positive interest in food. This may decrease “picky” eating behaviors in toddlers and young children.

Researcher Joel Voss, a neuroscientist at Northwestern University states, "The bottom line is, if you're not the one who's controlling your learning, you're not going to learn as well". [19] When an adult takes control of the activity, the inherent love of exploration and discovery is lost. BLW allows for natural, developmentally appropriate interaction and play with food, which has the potential to develop a lifelong curiosity with food.

As of June 2019, it was suggested that long-term studies need to be done on the effects of BLW on nutrition adequacy and safety in addition to previous evidence that it is useful in self-regulation of feeding with low risk of choking. [20]

See also

Related Research Articles

<span class="mw-page-title-main">Infant formula</span> Manufactured food designed for feeding infants

Infant formula, also called baby formula, simply formula, baby milk or infant milk, is an ultra-processed food designed and marketed for feeding to babies and infants under 12 months of age, usually prepared for bottle-feeding or cup-feeding from powder or liquid. The U.S. Federal Food, Drug, and Cosmetic Act (FFDCA) defines infant formula as "a food which purports to be or is represented for special dietary use solely as a food for infants by reason of its simulation of human milk or its suitability as a complete or partial substitute for human milk".

Swallowing, also called deglutition or inglutition in scientific contexts, is the process in the body of a human or other animal that allows for a substance to pass from the mouth, to the pharynx, and into the esophagus, while shutting the epiglottis. Swallowing is an important part of eating and drinking. If the process fails and the material goes through the trachea, then choking or pulmonary aspiration can occur. In the human body the automatic temporary closing of the epiglottis is controlled by the swallowing reflex.

<span class="mw-page-title-main">Baby bottle</span> Bottle containing liquid (usually milk or formula) to nourish infant

A baby bottle, nursing bottle, or feeding bottle is a bottle with a teat attached to it, which creates the ability to drink via suckling. It is typically used by infants and young children, or if someone cannot drink from a cup, for feeding oneself or being fed. It can also be used to feed non-human mammals.

<span class="mw-page-title-main">Weaning</span> Process of abandoning maternal nourishment in mammals

Weaning is the process of gradually introducing an infant human or another mammal to what will be its adult diet while withdrawing the supply of its mother's milk.

<span class="mw-page-title-main">Chewing</span> Mechanical procedure for crushing the food and its first enzymatic splitting

Chewing or mastication is the process by which food is crushed and ground by teeth. It is the first step of digestion, and it increases the surface area of foods to allow a more efficient break down by enzymes.

<span class="mw-page-title-main">Breast milk</span> Milk produced by the mammary glands in the breast of a human female

Breast milk or mother's milk is milk produced by the mammary glands in the breast of human females. Breast milk is the primary source of nutrition for newborn infants, comprising fats, proteins, carbohydrates, and a varying composition of minerals and vitamins. Breast milk also contains substances that help protect an infant against infection and inflammation, such as symbiotic bacteria and other microorganisms and immunoglobulin A, whilst also contributing to the healthy development of the infant's immune system and gut microbiome.

A boycott was launched in the United States on July 4, 1977, against the Swiss-based multinational food and drink processing corporation Nestlé. The boycott expanded into Europe in the early 1980s and was prompted by concerns about Nestlé's aggressive marketing of infant formulas, particularly in underdeveloped countries. The boycott has been cancelled and renewed because of the business practices of Nestlé and other substitute manufacturers monitored by the International Baby Food Action Network (IBFAN). Organizers of the boycott as well as public health researchers and experts consider breast milk to be the best nutrition source for infants. The World Health Organization (WHO) recommends infants to be exclusively breastfed for the first six months of their lives, nevertheless, sometimes nutritional gaps need to be filled if breastfeeding is not possible.

<span class="mw-page-title-main">Baby food</span> Food made especially for infants

Baby food is any soft, easily consumed food other than breastmilk or infant formula that is made specifically for human babies between six months and two years old. The food comes in many varieties and flavors that are purchased ready-made from producers, or it may be table food eaten by the family that has been mashed or otherwise broken down.

<span class="mw-page-title-main">Oropharyngeal dysphagia</span> Difficulty controlling the mouth or throat for swallowing

Oropharyngeal dysphagia is the inability to empty material from the oropharynx into the esophagus as a result of malfunction near the esophagus. Oropharyngeal dysphagia manifests differently depending on the underlying pathology and the nature of the symptoms. Patients with dysphagia can experience feelings of food sticking to their throats, coughing and choking, weight loss, recurring chest infections, or regurgitation. Depending on the underlying cause, age, and environment, dysphagia prevalence varies. In research including the general population, the estimated frequency of oropharyngeal dysphagia has ranged from 2 to 16 percent.

<span class="mw-page-title-main">Cerelac</span> Cereal brand

Cerelac is a brand of instant cereal made by Nestlé. The cereal is promoted for infants 6 months and older as a supplement to breast milk when it is no longer the sole item in an infant's diet. Cerelac is not a substitute for breast milk and it is advised to continue breast feeding or infant formula along with Cerelac. Cerelac can help babies develop tastes for other food as they are weaned from breast milk. It also contains vitamins and minerals like iron, along with essential fatty acids. Cerelac products also contain probiotics that are found in the digestive tracts of breastfed babies. The brand was first registered in 1949 and it is currently sold in Kenya, Tanzania, Belgium, Denmark, Germany, Spain, Portugal, South America, Central America, North America, India, the Middle East, Nigeria, North Africa, Malawi, Nepal, Pakistan, Philippines, Ghana, Ivory Coast, South Africa, South East Asia, United Kingdom, Australia, Zambia and Zimbabwe.

Overactive let-down (OALD) is the forceful ejection of milk from the breast during breastfeeding. In some women it occurs only with the first let-down in a feeding, occasionally women may have multiple strong letdowns during a feeding. OALD can make breastfeeding difficult and can be the source of some breastfeeding complications. It may also be known as hyper milk-ejection. A woman may have OALD in addition to an oversupply of breastmilk. The physical or medical cause of an overactive let-down is still unknown. Whether mothers with OALD have a higher overall milk volume – or a strong reaction to the hormone oxytocin also remains to be seen.

<span class="mw-page-title-main">History and culture of breastfeeding</span>

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<span class="mw-page-title-main">Breastfeeding difficulties</span> Medical condition

Breastfeeding difficulties refers to problems that arise from breastfeeding, the feeding of an infant or young child with milk from a woman's breasts. Although babies have a sucking reflex that enables them to suck and swallow milk, and human breast milk is usually the best source of nourishment for human infants, there are circumstances under which breastfeeding can be problematic, or even in rare instances, contraindicated.

<span class="mw-page-title-main">Breastfeeding</span> Feeding of babies or young children with milk from a womans breast

Breastfeeding, or nursing, is the process by which human breast milk is fed to a child. Breast milk may be from the breast, or may be pumped and fed to the infant. The World Health Organization (WHO) recommends that breastfeeding begin within the first hour of a baby's life and continue as often and as much as the baby wants. Health organizations, including the WHO, recommend breastfeeding exclusively for six months. This means that no other foods or drinks, other than vitamin D, are typically given. The WHO recommends exclusive breastfeeding for the first 6 months of life, followed by continued breastfeeding with appropriate complementary foods for up to 2 years and beyond. Of the 135 million babies born every year, only 42% are breastfed within the first hour of life, only 38% of mothers practice exclusive breastfeeding during the first six months, and 58% of mothers continue breastfeeding up to the age of two years and beyond.

A feeding disorder, in infancy or early childhood, is a child's refusal to eat certain food groups, textures, solids or liquids for a period of at least one month, which causes the child to not gain enough weight, grow naturally or cause any developmental delays. Feeding disorders resemble failure to thrive, except that at times in feeding disorder there is no medical or physiological condition that can explain the very small amount of food the children consume or their lack of growth. Some of the times, a previous medical condition that has been resolved is causing the issue.

Premastication, pre-chewing, or kiss feeding is the act of chewing food for the purpose of physically breaking it down in order to feed another that is incapable of masticating the food by themselves. This is often done by the mother or relatives of a baby to produce baby food capable of being consumed by the child during the weaning process. The chewed food in the form of a bolus is transferred from the mouth of one individual to another, either directly mouth-to-mouth, via utensils, hands, or is further cooked or processed prior to feeding.

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<span class="mw-page-title-main">Infant food safety</span>

Foodborne illness is any illness resulting from the food spoilage of contaminated food, pathogenic bacteria, viruses, or parasites that contaminate food. Infant food safety is the identification of risky food handling practices and the prevention of illness in infants. Foodborne illness is a serious health issue, especially for babies and children. Infants and young children are particularly vulnerable to foodborne illness because their immune systems are not developed enough to fight off foodborne bacterial infections. In fact, 800,000 illnesses affect children under the age of 10 in the U.S. each year. Therefore, extra care should be taken when handling and preparing their food.

Toddler nutrition is the description of the dietary needs of toddlers aged one to two years old. Food provides the energy and nutrients that toddlers need to be healthy. An adequate intake in nutrient rich food is good nutrition. A diet lacking essential calories, minerals, fluid and vitamins could be considered 'bad' nutrition. Nutrition needs are different for toddlers. For a baby, breast milk is "best" and it has all the necessary vitamins and minerals. Toddlers typically have been weaned from breast milk and infant formula. Though infants usually start eating solid foods between 4 and 6 months of age, more and more solid foods are consumed by a growing toddler. If a food introduced one at a time, a potential allergen can be identified. Food provides the energy and nutrients that young children need to be healthy. Toddlers are learning to feed themselves and to eat new foods. They should eat a variety of foods from all the food groups. Each day, toddlers need enough nutrients, including

<span class="mw-page-title-main">Establishment of breastfeeding</span>

Establishment of breastfeeding refers to the initiation of providing breast milk of mother to baby. According to the World Health Organisation(WHO), breastfeeding is the best way to provide nourishment, including essential nutrients, energy and antibodies, to infants and toddlers. The start of breastfeeding is supported by the milk production which depends on the development of internal and external breast structure and hormonal control on milk secretion. Besides milk supply, adopting the correct approach of breastfeeding helps build up the maternal bond, which in turn promotes breastfeeding. Not only does nursing strengthen the mother-child relationship, but it also improves the intelligence and immunity of breastfed children and diminishes breastfeeding mothers' risks to have ovarian and breast cancer.

References

American Academy of Pediatrics (2013). Ages & Stages: feeding & nutrition. Accessed 10 October 2013. http://www.healthychildren.org/English/ages-stages/baby/feeding-nutrition/Pages/default.aspx.

Case-Smith, J & Humphry, R. (2005). Feeding Intervention. In J.Case-Smith (Ed.), Occupational therapy for children (pp. 481–520). St Louis, MO: Elsevier.

Morris, S.E, & Dunn-Klein, M.(2000).Pre-feeding skills: A comprehensive resource for mealtime development (2nd ed.). Austin, TX: PRO-ED, Inc.

Rapley, G. & Murkett, T. (2005). Baby Led Weaning: the essential guide to introducing solid foods and helping your baby to grow up a happy and confident eater. New York, NY: The experiment, LLC.

Footnotes

  1. ↑ Gomez, Melisa Sofia; Novaes, Ana Paula Toneto; Silva, Janaina Paulino da; Guerra, Luciane Miranda; Possobon, Rosana de Fátima; Gomez, Melisa Sofia; Novaes, Ana Paula Toneto; Silva, Janaina Paulino da; Guerra, Luciane Miranda; Possobon, Rosana de Fátima (13 January 2020). "Baby-Led Weaning, an Overview of the New Approach to Food Introduction: Integrative Literature Review". Revista Paulista de Pediatria. 38: e2018084. doi: 10.1590/1984-0462/2020/38/2018084 . ISSN   0103-0582. PMC   6958549 . PMID   31939505.
  2. ↑ Section on Breastfeeding (March 2012). "Breastfeeding and the use of human milk". Pediatrics. 129 (3): e827–841. doi: 10.1542/peds.2011-3552 . ISSN   1098-4275. PMID   22371471.
  3. 1 2 3 Bently, Amy (2014). Inventing Baby Food: Taste, Health, and the Industrialization of the American Diet. Oakland: University of California Press. p. 256. ISBN   9780520283459.
  4. 1 2 3 4 5 Rapley, Gill (2008). Baby-led Weaning. Helping your Baby to Love Good Food . London: Vermilion. ISBN   978-0-09192380-8.
  5. ↑ Brown, Amy; Jones, Sara Wyn; Rowan, Hannah (2017). "Baby-Led Weaning: The Evidence to Date". Current Nutrition Reports. 6 (2): 148–156. doi:10.1007/s13668-017-0201-2. ISSN   2161-3311. PMC   5438437 . PMID   28596930.
  6. ↑ Mennella JA, Jagnow CP, Beauchamp GK (2001). "Prenatal and postnatal flavor learning by human infants". Pediatrics. 107 (6): E88. doi:10.1542/peds.107.6.e88. PMC   1351272 . PMID   11389286.
  7. ↑ Susan A. Sullivan, Leann L. Birch 1994 http://pediatrics.aappublications.org/content/93/2/271.abstract
  8. 1 2 3 4 Case-Smith, J.; Nastro, M. A. (1993-09-01). "The Effect of Occupational Therapy Intervention on Mothers of Children With Cerebral Palsy". American Journal of Occupational Therapy. 47 (9): 811–817. doi:10.5014/ajot.47.9.811. ISSN   0272-9490. PMID   8116772.
  9. ↑ Powell, F; et al. (2016). "The importance of mealtime structure for reducing child food fussiness". Maternal and Child Nutrition. 13 (2): e12296. doi:10.1111/mcn.12296. PMC   6866051 . PMID   27062194.
  10. ↑ Morris, Suzanne Evans. (2000). Pre-feeding skills : a comprehensive resource for mealtime development. Pro-Ed. ISBN   1416403140. OCLC   183191718.
  11. ↑ Miller, J.L.; et al. (2003). "Emergence of oropharyngeal, laryngeal and swallowing activity in the developing fetal upper aerodigestive tract: an ultrasound evaluation". Early Hum Dev. 71 (1): 61–87. doi:10.1016/S0378-3782(02)00110-X. PMID   12614951.
  12. ↑ Wolf, L.S.; Glass, R.P. (1992). Feeding and swallowing disorders in infancy: Assessment and management. Tucson, AZ: The Psychological Corporation. ISBN   978-0761641902.
  13. ↑ Coulthard, Helen; Harris, Gillian; Emmett, Pauline (January 2009). "Delayed introduction of lumpy foods to children during the complementary feeding period affects child's food acceptance and feeding at 7 years of age". Maternal & Child Nutrition. 5 (1): 75–85. doi:10.1111/j.1740-8709.2008.00153.x. PMC   6860515 . PMID   19161546.
  14. ↑ Davis Clara M (1939). "Results of the self-selection of diets by young children". Can Med Assoc J. 41 (3): 257–61. PMC   537465 . PMID   20321464.
  15. ↑ Strauss Stephen (2006). "Clara M. Davis and the wisdom of letting children choose their own diets". Can Med Assoc J. 175 (10): 1199. doi:10.1503/cmaj.060990. PMC   1626509 . PMID   17098946.
  16. ↑ Anderson, Laura N; van den Heuvel, Meta; Omand, Jessica A; Wong, Peter D (13 March 2020). "Practical tips for paediatricians: Baby-led weaning". Paediatrics & Child Health. 25 (2): 77–78. doi:10.1093/pch/pxz069. PMC   7069838 . PMID   32189974.
  17. ↑ "Baby-Led Weaning Is Feasible but Could Cause Nutritional Problems for Minority of Infants" Science Daily. January 14, 2011. https://www.sciencedaily.com/releases/2011/01/110112081454.htm
  18. ↑ Pitchford, Nicola J.; Townsend, Ellen (6 February 2012). "Baby knows best? The impact of weaning style on food preferences and body mass index in early childhood in a case-controlled sample". BMJ Open . 2 (1): e000298. doi:10.1136/bmjopen-2011-000298. PMC   4400680 . PMID   22315302. Open Access logo PLoS transparent.svg
  19. ↑ Davis, Joshua (2013-10-15). "A Radical Way of Unleashing a Generation of Geniuses". Wired. ISSN   1059-1028 . Retrieved 2019-08-05.
  20. ↑ Utami, Ayu Fitria; Wanda, Dessie (June 2019). "Is the baby-led weaning approach an effective choice for introducing first foods? A literature review". Enfermería Clínica. 29: 87–95. doi:10.1016/j.enfcli.2019.04.014. PMID   31248733. S2CID   195758644.
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