Feeding refusal – Is reflux responsible?
As a child health nurse and feeding therapist who specializes in the area of infant feeding aversions, I don’t get to see babies with where reflux was the only cause of their avoidant and distressed feeding behavior. Once these babies are effectively medicated, pain is removed, and any feeding problem caused by pain resolves within a few days to two weeks.
I do however get to see many babies who have been diagnosed with acid reflux because of their avoidant/distressed feeding behavior, and who are given effective dosages of acid-suppressing medications without improvement to their feeding behavior. The most common reasons in such cases are:
1) Misdiagnosis; Baby doesn’t suffer from acid reflux. His aversive feeding behavior is due to another reason or reasons. This applies to the vast majority of feeding-averse babies. There are many reasons why a healthy, hungry baby might fuss or refuse to feed or eat that has nothing to do with pain.
2) An unrelated or coexisting problem: Acid reflux has been effectively treated. However, Baby’s aversive feeding behavior continues due to other reasons. A diagnosis of acid reflux will not exclude a baby from experiencing feeding issues due to other causes.
If acid-suppressing medications have not resolved your baby’s feeding issues, it might be time to consider other possibilities… like a feeding aversion.
What is an aversion?
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’s past feeding experiences may have been unpleasant, stressful or painful. As a result, he learns to expect that future feeding sessions will be the same. But of course, he cannot avoid feeding completely. He needs to eat to survive. He tries to ignore hunger cues for as long as possible, eating only enough to survive, in a bid to avoid the stress or pain he has learned to associate with feeding.
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, or 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.
- Turns away or arches back to distance himself from the bottle
- 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.
- Accepts milk from a dropper, syringe, spoon or sippy cup or enthusiastically eats solid foods after refusing to drink from the bottle or breast.
- Eats less milk than expected.
- Appears to be ‘conflicted’ – pulling off and on repeatedly.
- Displays poor growth or has been diagnosed as ‘failure to thrive’.
Reasons babies become averse to feeding
The most common reasons for infant feeding aversion include:
- being repeatedly pressured to feed or eat;
- gagging, choking, or aspirating while feeding or eating;
- medical procedures involving baby’s face, mouth or nose;
- pain swallowing due to esophagitis due to acid reflux or milk protein allergy;
- pain sucking mouth ulcers;
- a sensory processing disorder.
By using a process of elimination it’s easy to rule out if Baby has recently had medical procedures. Choking episodes are obvious. Mouth ulcers can be seen. A sensory processing disorder is rare. Pain due to acid reflux or milk protein allergy is often suspected, but seldom the cause. Being repeatedly pressured to feed is seldom suspected, but is THE most common of all reasons for babies and children to develop a feeding aversion – breastfeeding, bottle-feeding or eating solids. So deciding if a pressure-related feeding aversion is partially or fully responsible is a good place to start.
Why you might overlook pressure as the cause
Like many parents in your situation, you might not have considered ‘pressure’ as the cause of your baby’s avoidant/distressed feeding behavior. There could be a number of reasons for this, for example:
> You might be feeding your baby the way you were instructed.
> You might not be aware that you are pressuring your baby.
> You might have been feeding baby in the same way for weeks before he first started to show avoidant/distressed feeding behavior.
> Your baby displays avoidant/distressed behavior before being pressured to feed.
It’s possible that you have been unaware that you were pressuring your baby in subtle ways to continue feeding when he wanted to stop. Many of the feeding strategies we employ to “encourage” a baby to feed involve subtle forms of pressure. For example, pushing the nipple into his mouth without his permission, jiggling the bottle, manipulating baby’s chin, touching his cheeks, squeezing milk into his mouth, resisting his efforts to push the nipple out of his mouth, following his head with the bottle when he turns or arches away in an upset manner, and more.
You might have been feeding your baby in the same way for many weeks before he first started to show troubled feeding behavior, and therefore don’t suspect there is a connection. A baby is too immature to complain about being pressured while feeding during the early weeks after birth. In general, babies don’t first start to fuss during feeds as a result of being pressured until around the age of six to eight weeks.
Baby will initially fuss after the parent pressures him to continue eating when he doesn’t want to. However, once averse to feeding, Baby will display avoidant/distressed behavior in anticipation of being pressured. This understandably confuses parents, because, at the time baby displays avoidant/distressed behavior, the parent may not have been pressuring him. But baby remembers being pressured in the past. He has learned to link the act of feeding with the stress he feels as a result of being pressured to eat against his will. Past experiences have taught him to expect to be pressured at feeding times, and so he experiences stress in anticipation of what will come.
Why you might suspect pain
Virtually all parents of feeding-averse babies at some point believed that pain was the reasons for their baby’s avoidant/distressed behavior. Pain is, of course, a possibility, but it’s down the list of common causes of infant feeding aversion. And there are ways to tell, which I will explain later.
Most feeding-averse babies behavior eventually escalates to a level of distress that appears like pain. How soon before Baby reaches the ‘distressed’ stage depends on his age and how parents’ respond to his behavioral cues.
Babies are born with a strong sucking reflex. A reflex is an automatic, involuntary response. Once a baby’s sucking reflex is triggered, he will suck whether he’s hungry or not. While his sucking reflex is triggered, he cannot choose to not suck. He’s not going to complain about being pressured while feeding because he can’t.
By six to eight weeks of age, Baby’s sucking reflex is not as strong. He can now stop sucking if he chooses to. It’s at this age that a baby might begin to complain about being pressured to feed, by fussing, during the feed. If the parent repeatedly ignores his fussing and persists in trying to “encourage” him to continue feeding to the point where he cries, this could cause him to develop an aversion to feeding.
As Baby matures, he becomes bigger, stronger, smarter, and more aware and physically better equipped to resist his parent’s attempts make him continue eating when he chooses not to. And so his response in anticipation of being pressured, and of being pressured, intensifies with age.
In an ideal world, parents would receive information on how to feed their baby using their chosen infant feeding method (breastfeeding or bottle-feeding). They would be taught to trust that their neurologically healthy baby is capable of deciding when to feed and how much he needs to eat; how to recognize infant behavioral cues that indicate hunger and satiety (satisfaction from eating); and physical and behavioral signs that indicate he’s getting enough to eat.
In this world, the parents would be attuned to their baby’s behavioral cues. Feed baby when he indicates he’s hungry. They would demonstrate their trust in baby to decide how much to eat by watching for his satiety cues (eg pushing nipple out with his tongue, turning his head away), and end the feed. Baby would then learn that subtle behavioral cues get the desired response. The feeding experience would be enjoyable for baby (and parents) and he will be willing to eat next time he’s hungry.
In the real world, parents, in general, are given limited instructions on how to breastfeed and even less on how to bottle-feed a baby. They are instructed to feed a bottle-fed baby at predetermined times (e.g. every 3 hours). They’re taught that it’s their responsibility to do whatever they need to do to ensure their baby receives a “should have” volume of milk at each feed or each day. And they’re taught that the scales will determine if Baby is getting enough to eat.
As a consequence of this type of education, Baby is offered a feed at scheduled times irrespective of whether he’s hungry or not. Subtle cues of satiety are overlooked or ignored while the parent persists in trying to “encourage” baby to drink the recommended amount. The feeding experience is unpleasant or stressful for Baby and parents. When repeated, he learns to link feeding with stress and becomes averse to feeding. Once averse, he tries to ignore the feeling of hunger and no longer eats to satisfaction. The drop in his milk intake cause parents anxiety, and not knowing what else to do, they pressure baby all the more. A ‘fear-avoid cycle’ develops. The more parents pressure, the more upset and more baby resists. The more resistant Baby becomes, the more forcefully parents pressure him to feed.
A neurologically healthy baby (who has inbuilt mechanisms programmed into his brain that enable him to decide how much to eat) will understandably become upset if pressured to continue eating when he wants to stop. The longer the parent (or caregiver) persists in trying to feed baby against his will, the more upset he becomes. The intensity of his behavior escalates, 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 feeding battles are repeated, baby learns that subtle cues of rejection get ignored and that ONLY an intense, aggressive display of rejection (eg kicking and screaming) receives the response from the parent that he wants… to end the feed. In time, he automatically kicks his legs, screams, thrashes and arches away – behaving in a distressed manner – as the only way he expresses rejection.
Without understanding these reasons for a baby to avoidant/distressed behavior at feeding times, parents conclude that the only logical explanation is because he’s experiencing pain. They describe Baby’s behavior to others. The word ‘reflux’ pops up again and again. They search for symptoms of reflux on the Internet (which includes multiple vague behaviors, most of which could apply to all babies). Now somewhat convinced that their baby is suffering pain due to acid reflux, they take him to be examined by a doctor.
Why health professionals suspect pain
There is so much misinformation about acid reflux that is widely spread on the Internet, from parent to parent, and by health professionals who are unaware of behavioral reasons for infant crying feeding and sleeping problems. And so, there is a number of very important points I would like to make regarding infant feeding problems and acid reflux:
- Pain is not the only reason for healthy babies to refuse feeds or become distressed at feeding time (or cry inconsolably or have sleeping problems).
- Pain related to acid reflux does not occur exclusively at feeding times.
- Distress at feeding times is not the only sign of acid reflux.
- Regurgitation of milk is not evidence of acid reflux. 100 percent of babies will regurgitate milk, either spitting up or not spitting up (i.e. silent reflux).
- Back arching is not evidence of acid reflux. A feeding-averse baby will arch to distance himself from breast, bottle or spoon.
- A doctor cannot tell if a baby is suffering from esophagitis due to acid reflux (or milk allergy) during a routine medical examination.
Given that none of these signs provide evidence that a baby’s avoidant/distressed feeding behavior is caused by pain due to acid reflux (or pain, full stop), it’s essential that the doctor (or another health professional) explore the situation further by asking the parent a series of questions.
In an ideal world, the parent would be asked questions about their infant feeding practices, in particular, whether they pressure their baby to feed; how baby behaves when the feed has ended; what his mood like between feeds; and how well he sleeps. The parent might also be asked questions to determine if Baby shows physical signs associated with acid reflux like blood tinged spit up or pooping dark tar-colored stools.
In the real world what tends to happen is the doctor examines Baby and determines that he/she cannot visually see anything wrong; weighs baby to determine if he’s gaining as expected; accepts the parent’s perception that baby’s distress is due to pain; confirms that baby is not eating as much as recommended; and asks no further questions. Unaware of other possible reasons for a hungry baby’s to vigorously object to feeding beside pain, the doctor diagnoses acid reflux, writes a prescription, provides a few tips, like “keep baby upright for 15 to 30 minutes after feeds” (which can create or compound an infant sleeping problem), and “thicken baby’s feeds” (which can increase the caloric content of feeds and thus further reduce the amount a feeding-averse baby will drink), and then escorts the parent and baby to the door.
This does not imply that babies don’t experience feeding issues as a result of acid reflux (or other medical conditions), but rather it explains how easy it is for ‘acid reflux’ to be misdiagnosed as a cause of a baby’s aversive feeding behavior.
How to tell if feeding is painful
As already mentioned, avoidant/distressed behavior display by healthy babies due to learned behavior can appear like he’s in pain. So an assessment of pain needs to be based on more than baby’s behavior at feeding times. It’s relatively easy to rule out pain as the cause of a baby’s avoidant, distressed or conflicted feeding behavior by assessing how he responds in other circumstances. Pain is unlikely to be responsible if…
… baby is happy when you stop feeding him
If Baby is happy as soon as you stop trying to feed him pain is probably not the cause of his feeding problems. Pain fades; it doesn’t suddenly disappear just because the feed has ended.
… baby is content between feeds
If Baby is content between feeds, feeding refusal is probably not due to pain. Discomfort associated with acid reflux, milk protein allergy or intolerance, or chronic constipation is notrestricted to feeding times. Your baby would be distressed at random times day and night in addition to feeding times if he’s suffering pain due to a physical problem
… baby feeds well in a drowsy state
If baby predictably feeds well in certain situations, for example during the night or while drowsy or asleep you can probably rule out pain as the cause. If pain was responsible for distress while feeding during the day or while awake, you’d expect him to also experience pain while feeding at night or when sleep-feeding.
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 when resolving a breastfeeding aversion.) Printed and eBook copies are available through leading online booksellers.
Written by Rowena Bennett, RN, RM, MHN, CHN, IBCLC.
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