Baby won’t eat! – Could it be a feeding aversion?

Baby won’t eat! – Could it be a feeding aversion?

It is estimated that 25 to 45 percent of normal developing babies experience feeding problems. The percentage of babies who display avoidant feeding behavior as a result of an aversion to breastfeeding, bottle-feeding or solids is unknown. Possibly because aversive feeding behavior displayed by babies is in general poorly recognized, often misdiagnosed and mismanaged. Consequently, countless families needlessly suffer emotional and financial stress associated with their child’s unresolved feeding aversion, for weeks, months or years.

Having specialized in the area of infant feeding aversions for over 10 years, the biggest mistake made by parents and health professionals that I see, is that they often make an assumption (without consideration of all possible causes of aversive feeding behavior) that the reason for baby’s distress at feeding times is because he’s experiencing pain. An assumption of pain can blind them to other possible causes, and limit their search for a solution to medical treatments. While a feeding-averse baby’s distress at feed times or meal times can appear like pain, in the vast majority of cases the cause is not related to pain. If pain is not responsible, medical solutions will be ineffective in improving a baby’s willingness to feed.

What is an aversion?

An aversion is the avoidance of a thing or situation because it’s associated with something that is unpleasant, stressful or painful.

A feeding aversion refers to a situation where a baby – who is fully capable of feeding or eating – exhibits partial or full feeding refusal. Baby tries to avoid feeding because he fears similar unpleasant, stressful or painful experiences as has occurred in the past.

Behavior associated with feeding aversion

A feeding-averse baby may display a number of the following behaviors.

Becomes tense, cries or screams when a bib is placed around his neck, when placed into a feeding position, when shown the bottle, or after stopping to burp.
Reluctantly eats only when ravenous and then takes only a small amount.
Takes a few sips or a small volume of milk and pulls away or arches back and starts to cry.
Avoids eye contact while feeding.
Rejects feeding while held in arms for feeds, and fusses when held in a position he associates with feeding even when not being offered a feed.
Clamps his mouth shut and turns or arches away from the bottle.
Moves the nipple around his mouth with his tongue and refuses to drink.
Fights being fed with every ounce of his strength until he’s too tired to fight any longer.
Feeds only while in a drowsy state or asleep.
Consumes less milk than expected.
Accepts milk from a dropper, syringe, spoon or sippy cup or enthusiastically eats solid foods after refusing to drink from the bottle or breast.
Displays poor growth or has been diagnosed as ‘failure to thrive’.

The type and intensity of avoidant behavior displayed by babies who have become averse to feeding varies depending on their age and how parents or caregivers respond to their behavioral cues, in particular those that indicate rejection.

In general, babies don’t display clearly identifiable aversive feeding behavior before the age of six to eight weeks. (But could experience feeding difficulties for other reasons.) As a baby matures his memory, awareness and physical ability to feed or refuse to feed is enhanced. And so, it becomes increasingly more obvious that he’s choosing when he will and won’t eat.

If the parent or caregiver responds quickly to baby’s subtle signs of rejection (eg pushing nipple out with his tongue, turning his head) by stopping the feed, he learns that subtle behavioral cues get the desired response. Whereas, if the parent where to overlook or ignore his subtle signs of rejection, and persist in trying to feed him, he will understandably become upset. And the intensity of his behavior will escalate, possibly to the point of forcefully pushing the bottle or breast away, arching back to distance himself, kicking his legs, crying or screaming as he fights against his parent’s efforts to make him continue eating. When repeated, he learns that only an intense, aggressive or vigorous display of rejection will eventually get his parent (or caregiver) to provide the desired response and end the feed. In time, he automatically kicks his legs, screams, thrashes and arches away – behaving in a distressed manner – a his sole way of expressing rejection.

Another behavior commonly displayed by around 80 percent of feeding-averse babies is what I call ‘conflicted’ feeding behavior. Conflicted behavior occurs when a baby has learned that feeding will soothe pangs of hunger, and so he wants to eat. But past feeding experiences have also taught him to expect something bad will happen while feeding, and so he wants to get away before it happens again. And so he swings between wanting to eat and not wanting to eat.

It’s obvious he’s hungry and has the desire to eat, but at the same time he acts as if something is preventing him from eating. He willingly latches, takes a few sucks and suddenly turns away or arches back in tense or upset manner, perhaps crying, but then almost immediately returns and willingly latches, sucks a few more times before pulling away again. Repeating this disjointed feeding behavior over and over.

A baby’s feeding aversion can be resolved but an effective solution relies on accurate identification and removal of the trigger that is causing some or all feeding experiences to be unpleasant, stressful or painful, and thereby continue to reinforce baby’s determination to avoid feeding. The first step is to figure out what’s causing baby to feel so anxious or fearful of feeding that he would rather go hungry or eat only a minimum for survival.

Why babies may become anxious or fearful at feeding times

The following are the most common reasons for babies to develop feeding aversions.

Stress caused by being repeatedly pressured or forced to feed against their will.
Stress associated with frequent gagging or choking episodes while feeding.
Stress and/or pain associated medical procedures involving baby’s face,mouth or nose.
Pain upon swallowing due to an inflamed esophagus caused by acid reflux or milk allergy.
Pain while sucking due to mouth ulcers.
A sensory processing disorder.

If like most parents of feeding-averse babies, you feel convinced that your baby’s distressed behavior is due to pain, you might find that consideration of other possible causes to be beneficial. Choking episodes are obvious. As are mouth ulcers. It’s rare for babies to have a sensory processing disorder. So this narrows the field to the two most likely causes – stress associated with being pressured or forced to feed, and pain occurring when baby swallows.

Stress or pain?

When a hungry, feeding-averse baby displays distressed or conflicted feeding behavior parents understandably suspect pain. However, pain is seldom the cause.Being repeatedly pressured to feed against their will is THE most common of all reasons for babies to display aversive feeding behavior. And yet, parents and health professionals seldom consider ‘pressure’ as a potential cause.

Some health professionals believe babies are too young to display avoidant feeding behavior in response to being repeatedly pressured or forced to feed. And many encourage parents to ‘do whatever you have to do’ to make sure their baby drinks a ‘should have’ volume per feed or per day.

Parents might overlook ‘pressure’ as the cause because they may have always pressured their baby to feed but he may have only started to display resistance to feeding around two months of age. (Before this age babies are limited in their ability to control the feed and demonstrate when they wish to stop.) Also, once averse to feeding babies often display avoidant/distressed behavior in anticipation of being pressured. This causes confusion because at the time baby demonstrates distressed behavior the parent may not have pressured baby. But baby remembers being pressured in the past and is expecting to be pressure again, and so he’s feeling anxious in expectation of what will come.

It is possible for a baby to experience pain while feeding due to an untreated physical problem AND become stressed as a result of being pressured to feed. Thereby, doubling the reasons for him to want to avoid feeding. Alternatively, a baby may have experienced pain in the past, which has since been effectively treated with medications or dietary change, but while he continues to be pressured to eat his feeding aversion is reinforced.

Behavior that is reinforced will continue. Repeatedly pressuring a baby to feed can create a ‘fear-avoidance cycle’.

How to tell if the cause is ‘pressure’ or ‘pain’

Your answers to the following questions may help you to hone in on the cause of your baby’s aversive feeding behavior.

1. Do you pressure baby to feed?

YES: Many parents pressure their baby to feed out of loving concern. I know I did! If a battle of wills occurs over when or how much baby eats – with baby wanting less and parents wanting more – it’s likely that ‘pressure’ is partially or completely responsible for his aversive feeding behavior, and hence why he may now be eating less than he needs for healthy growth.

A ‘yes’ answer does not rule out a pain or other feeding problems. A baby could refuse to feed because it’s painful to suck or swallow and be pressured to feed. Or he may have difficulty feeding due to inappropriate or faulty equipment, or because he was previously an exclusively breastfed baby and has not yet learned how to bottle-feed, and be pressured to feed.

NO: Be aware that ‘pressure’ occurs in varying degrees from subtle to obvious. Subtle forms of pressure could include feeding practices like repeated offers, restraining baby’s head or arms, following his head with the bottle, jiggling the bottle, and touching his face, if these things are done as a means to try to make him continue eating when he wants to stop.

You might be unaware that some of your infant feeding practices involve pressure. You might be feeding your baby in a way that you were taught, and have always done (which might not have appeared to object to prior to two months of age). Or you might think you’re encouraging him to eat. It’s what your baby thinks that counts. If he becomes tense or upset during feeds, it could be because he’s feeling pressured, (but of course there are also other reasons for a baby to be upset during feeds). Whatever the reason, when your baby becomes upset while feeding, you need to stop and figure out what’s bothering him rather than try to make him continue eating. To do so makes for an unpleasant or stressful feeding experience.

2. Does baby feed better while drowsy or asleep?

YES: When a baby predictably fusses or refuses to eat while awake, but then feeds better or well while in a drowsy state or asleep, this is a strong indication that stress rather than pain is responsible for his avoidant feeding behavior while awake. When awake a feeding-averse baby’s guard is up in anticipation of being pressured, and so he fusses and rejects, or reluctantly accepts and eats very little, or displays conflicted feeding behavior. However, when drowsy or asleep, he’s not fully aware he is feeding. His guard is down and so he’s less inclined to resist (depending on his level of hunger and sleep state). And so a feeding-averse baby is more relaxed and may be more inclined to feed while in a drowsy state or when already asleep.

Sleep does not numb a baby to the sensation of pain. If pain is due acid reflux, milk allergy or any other physical problem prevents him from feeding while awake, it will also prevent him from feeding during sleep. Pain upon swallowing will cause him to wake. Similarly, if baby had a physical problem that prevented him from sucking effectively while awake, like tongue-tie, he would experience the same sucking difficulties feeding while drowsy or asleep.

NO: Not all babies will feed during sleep, especially as they get older. So refusing feeds in a sleepy state is not evidence of a physical cause. Alternatively, if a feeding-averse baby arouses and becomes aware he’s being fed, he may wake and fuss or cry due to rejection rather than pain.

3. Does baby calm quickly once the feed has ended?

YES: The stress displayed by a baby in anticipation of being pressured, or while being pressured, will quickly dissipate once he realizes the feed is over. It might take a couple of minutes for him to realize that the feed has ended, but he calms quickly once he does.

Pain fades. It does not suddenly disappear simply because baby stops sucking. If pain upon swallowing, due to acid reflux or milk allergy, is responsible for baby’s feeding refusal, he would continue to be upset for quite a while after the feed has ended.

NO: This might indicate pain. But is not evidence of pain. A feeding-averse baby could continue to fuss due to unsatisfied hunger (and yet reject offers to feed out of fear of being pressured) or fuss due to tiredness or other reasons unrelated to pain.

4. Is baby generally content between feeds?

YES: Many parents of feeding-averse babies claim their baby is happy between feeds, and that the only time baby fusses or cries is at feeding times.

Pain caused by physical problems, such as acid reflux and milk allergy, is not restricted to feeding. When effectively treated these problems will cause a baby no further distress. When untreated or ineffectively treated these conditions will cause baby to become distressed at random times both day and night, in addition to feeding. Baby will have a hard time sleeping, will wake during the night screaming in pain, and will not be readily soothed or quickly helped back to sleep in some way.

NO: Pain is not the only reason a baby might be irritable between feeds. Hunger and sleep deprivation are two major causes of infant irritability, and as such need to be considered before assuming that any fussy or distressed behavior outside of feeding is due to pain.

If you have answered ‘yes’ to most of these questions, it’s likely that your baby’s feeding refusal is at least in part due to being pressured to eat. This does not imply that he does not have a physical problem or condition that causes pain (when untreated). However, it does mean that pinning all your hopes on finding a medical solution to his feeding issues may prove futile if his distress at feeding times is no longer due, or was never due, to pain. No amount of medications or dietary change will break the ‘fear-avoidance’ cycle or resolve a feeding aversion that was caused by and/or continues to be reinforced as a result of being pressured to eat.

I appreciate that it would be very upsetting for loving parents to come to the realization that their infant feeding practices may have contributed to a situation where their baby acts as if he would rather go hungry than eat. It’s not my intention to upset any parent. But it’s essential to identify and remove the cause so that you can remedy the situation. The power to resolve a pressure-related feeding aversion, and make feeding something your baby enjoys, is in your hands.

By enhancing your knowledge about the causes and solutions to infant feeding aversion, you may finally find the solution to your baby’s feeding issues that you so desperately seek. You can read more about feeding aversions and how to resolve them in my book ‘Your Baby’s Bottle-feeding Aversion’. (Note: The same principles apply to resolving a breastfeeding aversion.) Printed and eBook copies are available through leading online booksellers.

Written by Rowena Bennett, RN, RM, MHN, CHN, IBCLC, and author of ‘Your Baby’s Bottle-feeding Aversion’ and ‘Your Sleepless Baby’.