Feeding a baby should be an enjoyable experience for all involved, however when baby repeatedly refuses to feed despite being hungry this makes feeding a frustrating and stressful experience for all involved. Identifying the cause is essential if the problem is to be resolved. This article describes reasons why hungry babies refuse to eat.
What is a feeding aversion?
An aversion is the avoidance of a thing or situation because it is associated with an unpleasant, stressful or painful stimulus. A feeding aversion refers to a situation where a baby - who is physically capable of feeding or eating - exhibits partial or full food refusal. Babies can develop an aversion to breastfeeding, bottle-feeding and/or solid foods.
An aversion involves a conditioned response. Initially, baby's fussy or distressed behavior occurs in direct response to the stimulus (the thing or situation causing the feeding experience to be unpleasant, stressful or painful). However, following repeated exposure baby learns to associate the act of feeding or eating with the stimulus and may then start to fuss or refuse to feed or eat prior to the stimulus occurring. This can make it challenging for parents and health professionals to accurately identify the stimulus.
Failure to identify and eliminate the stimulus means baby’s conditioned response (aversive behavior in regards to feeding or eating) may continue to be reinforced, and thus her fussy feeding behavior or food refusal can continue for weeks, months or years.
A baby might exhibit one or more of the following behavior:
- Skip feedings or meals without distress; or appear hungry but refuse to eat.
- Fuss or cry when a bib is placed around her neck; when placed into a feeding position; or when the bottle is presented.
- Clamp her mouth shut and turn her head away from the breast, bottle, spoon or food.
- Take a few sips or a small portion of the milk or food offered, and pull away or arch back and begin to cry. (Please note: Babies back arch to distance themselves. Back arching does not provide evidence of acid reflux.)
- Feed only while drowsy or asleep.
- Consume less milk or food than expected.
- Display poor growth; may be diagnosed as 'failure to thrive'.
The type and intensity of behavior varies between babies. At one end of the spectrum, a baby might simply refuse to eat a particular food owing to a bad experience while eating that food. At the other end, baby might display complete food refusal and require a feeding tube to ensure she receives sufficient nutrients for healthy growth.
The stimulus responsible for individual babies to develop aversive feeding behavior can vary. The following list includes common causes.
Some parents will attempt to pressure or force their baby to feed out of loving concern for their baby’s physical wellbeing. They hate doing this but do so because they worry that their baby will fail to gain sufficient weight or become unwell if they don’t make sure their baby consumes what they believe to be an acceptable amount of milk or food. Being pressured or forced to feed makes the feeding experience unpleasant or stressful for babies. When repeated, a baby can develop an aversion to feeding. A vicious cycle can develop. As a result of developing a feeding aversion the baby will fuss or refuse to feed and the parents then feel compelled to force their baby to feed; by doing so they may be unknowingly reinforcing their baby’s feeding aversion.
Obviously a mother cannot force her breastfed baby to feed. A breastfed baby may develop an aversion to breastfeeding in situations where the mother repeatedly attempts to force her baby to the breast (owing to concerns that her baby has not fed for long enough).
A baby may develop an aversion owing to fright as a result of a choking episode.
Conditions affecting a baby's mouth, throat, esophagus or gastrointestinal tract, such as mouth ulcers, acid reflux, milk allery or intolerance, chronic constipation, could cause a baby to associate eating with discomfort.
Unpleasant or invasive medical interventions such nasal or oral suctioning, feeding tube insertion, intubation, being forced to take foul-tasting medicines could cause the baby to develop aversive behavior in relation to feeding.
Sensory processing disorder
Children with a sensory processing disorder perceive sensation differently to other children. They can display aversive behavior to lumps in food or the smell, taste or feel of certain foods.
There are many other possible reasons for a baby to display aversive behavior in regards to breastfeeding, bottle-feeding or eating solid foods. Any feeding situation that results in a baby becoming frightened or stressed has the potential to trigger partial or complete food refusal.
The cause of an infant feeding problem could be due to one or a combination of different causes. A feeding aversion can become even more complex when other feeding problems are involved. (See bottle-feeding problems.)
Is the cause pain?
The distress displayed by babies who have developed an aversion to feeding can be so intense that it appears like they are suffering from pain. Therefore pain is typically the first thing blamed by parents, and by health professionals during brief consultations, when other causes for a baby's aversive feeding behavior are not obvious. However, pain is not the only reason for babies to become distressed during feeds.
So how can you tell if pain is the cause of a baby’s troubled feeding behavior? A process of elimination can help you decide if pain is likely. Here are a few clues.
- If your baby is happy once you stop trying to feed her, pain is unlikely. Pain fades away. It doesn't suddenly cease because the feed has ended.
- If your baby is content between feeds, pain is unlikely. Discomfort associated with acid reflux or milk protein allergy or intolerance, chronic constipation is not restricted to feed times. Your baby would display signs of discomfort or distress at other times in addition to feed times.
- If your baby predictably feeds well in certain situations, for example during the night or while drowsy or asleep, pain is unlikely to be the cause of her aversive feeding behavior at other feed times. If it is painful for her to feed during the day or while awake, its reasonable to expect it would also be painful for her to feed at night or when ‘sleep-feeding’.
- If your baby displays any unusual signs that might indicate illness or a physical problem, or if you are worried that your baby is suffering from pain, have her examined by a doctor.
Conflicted feeding behavior where baby takes a few sucks, sharply turns away or arches back, cries, quickly returns and wants to suck again, takes a few sucks, turns away or arches back, cries, returns to feeding and so on, is often interpreted by parents and others as pain, but its not necessarily due to pain. Babies who have become averse to feeding will behave in this way regardless of the cause. If your baby is quickly soothed once the feed has ended, its probably not pain.
The following are a few examples of problems that have the potential to develop when an infant feeding aversion continues over the long term.
Infant and parental distress
When a baby has developed a feeding aversion, feeding becomes stressful for the baby and for parents. Repeated stressful feeding experiences can cause parents to dread feeding times. Many parents develop anticipatory anxiety triggered by the thought of feeding their baby. Parents also have the additional worry about their baby’s health and growth.
Parental lack of confidence
In my opinion, no baby care problem is more soul destroying for a parent than an infant’s feeding aversion. An infant feeding aversion can adversely impact on a parent’s sense of competency and self-esteem.
Many parents feel they are unable to leave the house with their baby because they do not want to feed their baby in public owing to the distress their baby displays during feeds.
Impaired parent/infant bonding
Babies who have developed a feeding aversion will often refuse to be fed while lying in a parent’s arms. The baby fusses, kicks and screams during the feed. Parents often feel like their baby is rejecting them (which is not the case). Stress triggers a flight or fight response. Even the most loving parent may find they have fleeting thoughts of anger towards their baby, and then suffer feelings of shame and guilt over having such thoughts.
Many babies (but not all) experience poor growth as a result of feeding aversion.
If growth is compromised it may become necessary for the baby to have a feeding tube inserted to deliver nutrients directly into her stomach, bypassing the need for her to feed. This not only causes more work and more worry for parents, it can cause additional problems for the baby over the long term. As a result of being tube feed the baby is prevented from self-regulating her dietary intake (deciding for herself when she is full) and she may become desensitized to her own internal cues that indicate hunger and satiety (satisfaction). She may also miss out on the developmental skills gained from feeding from a breast or bottle and from eating solid foods.
An older baby or young child might miss out on important vitamins, minerals or nutrients as a result of food refusal.
The treatment of a feeding aversion differs depending on the cause or stimulus. Failure to accurately identify the stimulus is likely to result in a treatment plan that is ineffective.
The following treatments are often recommended by medical practitioners to remedy a baby's troubled feeding behavior suspected of being caused by pain.
- Medications: Acid suppressing medications such as H2 antagonists e.g. Ranitidine and proton pump inhibitors e.g. Omeprazole may be prescribed to treat acid reflux.
- Dietary changes: Specialized hypoallergenic infant formulas are recommended to treat cows milk and soy protein allergy or intolerance.
Once the condition causing the baby's discomfort is effectively treated, her troubled feeding behavior will fade and disappear. Please note: H2 antagonists and proton pump inhibitors used in the treatment of acid reflux are extremely effective in reducing the production of stomach acid. If your baby is still fussing or fighting feeds two weeks after commencing medications, there's a good chance that acid reflux is not responsible her troubled feeding behavior. Similarly, if your baby's troubled behavior continues two weeks after switching to a specialized hypoallergenic formula, the reason may be that milk protein allergy or intolerance is not the cause. This does not imply that your baby is not affected by these problems, rather that these problems are unlikely to be the cause of her current problematic feeding behavior.
If the above strategies fail to resolve a baby's aversive feeding behavior some healthcare professionals recommend one or more of the following strategies to address growth concerns.
- Thickened feeds: AR anti-regurgitation formula or adding rice cereal or food thickeners to infant formula.
- High-energy feeds: Increasing the caloric content of feeds by adding extra scoops of formula in relation to water content when preparing infant formula or by adding oils or carbohydrates e.g. Polyjoule to infant formula. The theory behind this strategy is that the baby will receive more calories compared to what she would receive if she consumed regular strength formula. But what can often be the case is that the baby consumes even less milk as a result of the additional calories.
- Starting solids early: A baby with a breastfeeding or bottle-feeding aversion might accept solid foods. Some babies with an unresolved breast or bottle feeding aversion will go on to develop an aversion to solid foods as well, particularly if the underlying cause of breast or bottle feeding aversion was not identified and thus resolved.
- Feeding tube: Insertion of a feeding tube in cases where the above strategies fail to resolve growth issues.
While the above strategies can be effective in minimizing growth delay associated with a feeding aversion in some cases, they generally do nothing to address the underlying cause of a baby's fussy feeding behavior or food refusal.
Please note: DO NOT use any of the above strategies unless advised to do so by your baby's doctor. When used incorrectly these strategies could cause fluid andor nutritional imbalances that have the potential to compromise a baby's health.
If medical treatments fail to resolve your baby's feeding problem, extend your search to cover other potential causes, in particular behavioral reasons such as being pressured to eat.
Your doctor might refer your baby to a speech therapist to assess her ability to suck and swallow effectively. If your baby feeds well at some feeds for example in a sleepy state, or has fed well in the past prior to developing a feeding aversion, its unlikely that the source of her fussy feeding behavior or food refusal is due a sucking or swallowing problem.
Your doctor might refer your baby to an occupational therapist for assessment of oral aversion due to a sensory processing disorder. To encourage a child with oral aversion occurring due to a sensory processing disorder to feed as normal as possible requires a very long process lasting months or years. So you need to be sure the diagnosis is correct. If your baby's aversion presents primarily as food avoidance, consider the possibility of behavioral causes.
Because the baby's aversive feeding behavior is a conditioned response, the resolution of a feeding aversion is not simply a matter of removing the stimulus and suddenly the baby willingly feeds in a relaxed state. The resolution of a feeding aversion involves a process of desensitization to undo the negative feelings the baby has in relation to feeding. [Desensitization is defined as the diminished emotional responsiveness to a negative or aversive stimulus after repeated exposure to it.
Accurate identification of the stimulus - which can vary for individual babies - is essential to the successful resolution of a feeding aversion due to any cause. This requires a comprehensive understanding of infant development, infant behavior, and age-appropriate infant feeding practices. Without pinpointing the stimulus its possible that the baby may continue to be exposed to the stimulus and as a consequence her aversion to feeding will continue to be reinforced.
Identifying the cause of a feeding aversion, explaining this from a baby's perspective and providing parents with information on effective strategies to resolve this problem is not something that can be achieved during a brief consultation. And it definitely cannot be achieved without asking parents about their infant feeding practices. Few health professionals are familiar with age-appropriate infant feeding practices and/or the desensitization process involved in resolving feeding aversions experienced by babies and young children. Therefore, they are ill equipped to guide and support parents to resolve this complex and highly stressful situation.
Written by Rowena Bennett