Challenging case with advice from Rowena Bennett

I presented a case to Rowena Bennett, RN, RM, MHN, CHN, IBCLC, author of Your Baby’s Bottle Feeding Aversion. We have used Rowena’s techniques many times to help our infants who come to us with bottle refusal or sleep feeding issues. She graciously gave me some advice and I am sharing it here so you can learn with me. Thank you Rowena!

Case: 24  month old female who breast feeds every 2  hours, good weight, and total food refusal. She took a bottle briefly at age 4 months but then stopped. She will takes sips of water and sometimes milk. She has tried reflux medication and periactin (appetite medication) without improvement. The periactin increased breast feeding. The child has been in therapy for over 6 months and will now accept food into her mouth but often spits it out. She sometimes gags and vomits with textured foods. She refuses puree. She was referred to us for help with food refusal. Mother is a single mother and would like to stop breast feeding. I recommended longer stretches without nursing to allow her to get hungry but this has been hard for mom. 

Advice from Rowena Bennett, RN, RM, MHN, CHN, IBCLC. Website babycareadvice.com 

I see children like you describe often. If it’s not painful for her to swallow when breastfeeding, GERD is probably not the cause. Admittedly she is on meds and so it would not be painful anyway but likely GERD was never the cause. If she is good weight, periactin probably won’t help. Her body does not need more calories. Even if it were to stimulate appetite it would probably result in her wanting to nurse more often. 

 Given she is good weight for length, means she is getting the calories she needs for growth, if not from solids, then from breastfeeding. It sounds like a behavioral problem to me. Three possible causes come to mind.

1. SLEEP ASSOCIATION PROBLEM: I tend to find that lack of interest in eating solids to be common when a child has a breastfeeding-sleep association. As such, she relies on breastfeeding as a way to fall asleep, feeding often in the night and therefore can afford to graze and breastfeed to sleep for naps in the day. 
2. SOOTHING: I also find a feeding-sleep association will often go hand in hand with the child also relying on nursing as as a way to soothe. 
3. AVERSION TO EATING SOLIDS: It’s possible she has an aversion to solids if she’s been repeatedly pressured to eat solids and appears to be distressed when placed into the high chair or when offered solids. But I think the two mentioned problems above would be more likely.  

Waiting any set period of will not work in these cases because the child will get distressed if prevented from nursing to sleep when tired or if sometimes she’s allowed to sooth at the breast and other times not.  If this child has  a  breastfeeding sleep association and/or using the breast for soothing or comfort, these issues would need to be addressed first before reducing breastfeeds to encourage motivation to eat solids. 

If this child has a breastfeeding-sleep association, I would recommend the mother stops breastfeeding to sleep both day and night. Ideally, do sleep training to encourage independent settling, which will ultimately mean she’s a better sleeper,  but if the mother did not wish to do this (as any 24 month old would definitely cry during the sleep training phase) then cuddle instead of feeding to sleep. She would have to be consistent and expect resistance in the short term.

If the child is using the breast as a means to soothe, then discuss other ways to sooth, in particular using distraction or cuddles rather than nursing her every time she’s upset or is seeking her breasts.

If she is feeding excessively at night (which at this age is any feeding at night) then gradually reduce an eliminate all night feeds (but only after sleep association problem is resolved).

Once feeding-sleep associations problem is resolved and she can be soothed in other ways, the encourage her to limit the number of breastfeeds to 2 to 3 times in a 24-hour period (all in the day). And also to offer solids before breastfeeding. 

I have seen many babies who have a behavioral feeding aversion gag, cough and vomit due to a behavioral feeding aversion. They can learn doing these things causes the parent to stop. I recommend you check whether the mother pressures her to eat solids and if screams, gets upset or fights being placed into the highchair or when offered solids. If so she could be feeding averse and it’s possible the gagging could be behavioral. In which case she would stop once resolving the aversion. But of course if it is due to a sensitive gag reflex would take longer to resolve.