Baby feeding aversion treatment

How to Help Your Baby Overcome a Bottle Aversion — Malina Malkani

Parents respond with nourishment when their babies cry and fuss because of an empty belly. Once their tiny tummies are nice and full, they turn their head away from the bottle or purse their lips closed. At least, that's the feeding experience parents hope for and expect to have!

What does it mean when a baby refuses a bottle even though they're hungry?

A bottle aversion can be confusing and upsetting to parents, but if you’re one of them, you're not alone.

Approximately 20% - 30% of infants and toddlers have feeding-related problems.

A baby or young child's feeding problem can lead to nutrient deficiencies and malnourishment, ultimately affecting their growth and development.

Some babies can resolve it on their own with time. Still, many need support from parents and/or a team of professionals that includes pediatricians, pediatric dietitians, and speech-language pathologists.

Keep reading to find out what a bottle feeding aversion is, what to do about it and when to call the pediatrician.

What is a Feeding Aversion?

Childhood feeding problems range from picky eating to a refusal to eat.

Can a baby really be a picky eater?

Picky eating and bottle aversions both fall under the umbrella of childhood feeding disorders. A feeding disorder is an inability or refusal to eat and drink enough food to meet nutritional needs.

Feeding difficulties tend to fit within three general categories that may be very familiar to some parents: limited intake, selective intake, and the fear of feeding. However, most children have mild feeding problems that don't affect their weight and health, despite being very challenging for parents.

What Causes a Bottle-Feeding Aversion?

As an experienced parent, you probably expect some degree of pickiness with your child. But a baby’s refusal to eat might be unexpected and confusing.

Here are some of the most common reasons a young child refuses to eat even though they might be hungry.

Sensory aversions and developmental disorders
Feeding problems affect 70%-89% of children with developmental disabilities. For example, children with Autism Spectrum Disorders commonly have sensory food aversions and refuse to eat because of a food's texture, color, appearance, or smell.
Premature infants
Premature babies have a high risk of aspiration while feeding. It's common for preterm infants to have oral feeding difficulties. As a matter of fact, difficulty eating is a huge factor in what delays a baby's discharge from the neonatal intensive care unit (NICU).
Swallowing difficulties

The first step in digestion is the physical processing of food by the mouth, throat, and tongue. Underdeveloped muscles or tongue-tie affect the baby's ability to move food around their mouth, swallow and suck. A frustrated and uncomfortable baby will reject a bottle if they have difficulty sucking.

Pain and discomfort
Babies may develop a learned feeding aversion if they associate pain with eating. A milk protein allergy, choking, or acid reflux are common reasons a bottle-fed baby might experience pain during eating. And, don't forget about ear infections. This common childhood illness makes swallowing very painful.

What About Bottle Aversion in Breastfed Babies?

Pumping keeps a mom's milk supply up and allows a baby to continue breastfeeding even when life gets busy. Using a bottle for breast milk can also give moms a much-needed break during overnight feedings and a chance for others to bond with the baby during feedings.

But, bottle feeding is a different sensory experience than breastfeeding, and babies may prefer one over the other.

Breastfed babies can develop a bottle aversion. Breastfed babies may not like the change in feeding position, the temperature of milk, lack of skin-to-skin contact, and fast flow rate even though the milk tastes the same.

The opposite can also happen.

Bottles allow babies to drink faster and more steadily than breastfeeding. And the difference in the rate and flow of milk can cause nipple confusion. In addition, some babies may take to the faster pace of bottle drinking and reject the breast.

The tips below work for formula-fed or breastfed babies who use a bottle.

What to Do if Your Baby Refuses to Eat From a Bottle

It’s important to individualize treatment for a baby's bottle aversion. Every baby is different, and what works for one child may not be the answer for another. The most effective strategies depend on what is causing the feeding aversion, how old your infant is, and your baby's preferences.

As a result, the best way to use these tips is to apply them one at a time. Then, reassess after a few days before applying a new strategy. (You don't want to overwhelm your baby with too many changes at the same time, and if you try too many strategies at once, you won't know which one worked!)

Keep in mind also that some babies end up showing improvement on their own.

And let your pediatrician know immediately if there are any changes in your baby's weight, growth, or energy level.

1. Don’t force your baby to eat

Nudging a bottle into a baby’s mouth isn’t recommended. As a parent, I understand the temptation to get a child to eat, especially a very young infant that you’re concerned about. But forcing a baby to eat can make a childhood feeding disorder worse. It’s also dangerous. A baby trying to refuse a bottle can choke if they’re forced to drink.

2. Find out why your baby is refusing the bottle

A pediatrician can determine whether there's a medical reason for your baby's bottle aversion. If so, a speech-language pathologist can assess your baby's ability to swallow and suck. Then they'll recommend treatments such as swallow exercises. If your baby has a tongue or lip tie that affects their eating ability, a pediatrician may recommend surgery to correct it.

3. Use paced bottle-feeding techniques

Paced bottle-feeding techniques mimic breastfeeding and allow your baby to drink at a slower rate than traditional bottle feeding.

Responsive feeding can teach you how to recognize and respond to your baby's hunger and fullness signals. Then, when you pick up on your baby's cues, you can respond warmly and promptly with food.

Common signs a baby is hungry include:

Making sucking sounds
Chewing and sucking on fingers
Crying - the key is to learn to differentiate hungry crying from the crying of a sleepy or uncomfortable baby
Fussing

If your baby shows signs they've had enough, parents should let the baby stop eating. Signs a baby is full include:

Turning their head away
Gagging
Spitting up
Slowing down or stopping
Falling asleep
Starting and stopping

4. Change up the bottle

The type of bottle and/or size of the nipple hole can affect the flow rate. If you practice responsive feeding, you'll recognize when the pace and flow of the milk are working well for the baby.

Every baby eats at a different pace and may need a faster or slower bottle nipple. Babies that are both breast and bottle-fed would do better with a slower pace nipple since that's closer to the pace of breastfeeding.

Generally, babies born around their due date can use a newborn flow rate. In addition, there are special nipples for babies with colic. And there are even bottles designed to give your baby the ability to drink at their own pace. For example, the Infant Self-Pacing (ISP) Feeding Bottle allows your baby to control the flow of formula.

5. Change the feeding position or routine

Change the routine with fun and relaxing activities before it's time for a bottle. For example, a few minutes of playtime together on the mat or a walk can diffuse the anxiety around feeding time for you and your baby! Even changing the order of your baby's daily routine might help break up a pattern of feeding difficulties.

Or your baby's usual position might be uncomfortable. Adjust the feeding position or highchair until your baby is comfortable and content. Babies should be held in a semi-upright position with their heads supported.

6. Change the formula

Not all formulas taste the same, and your baby may enjoy another brand better. Also, some babies prefer different formula temperatures, so you can experience warming the bottle vs. not warming the bottle.

If your baby shows signs of a milk protein allergy or dairy intolerance, try another type of formula.

7. Be patient

Understandably, you might be stressed and frustrated when your baby refuses to eat from a bottle. I get it. But, babies can pick up on the tension and stress, which only worsens feeding fears and anxiety. Try to engage in positive food parenting practices that provide structure and encourage autonomy. Patience and a positive feeding experience are important for you and your baby!

Last Thoughts on Bottle Aversion

Aversions to food textures and certain foods' appearances are common in children.

A temporary aversion to certain foods isn't usually a medical concern as long as your child is growing and doesn't fall off their percentile on the growth chart.

But a bottle-feeding aversion isn't picky eating, and your baby may need the help of a team to move through it.

Talk to your pediatrician if there's a change in your baby's weight. A few ounces of body weight is a lot for a tiny baby to lose. Speech-language pathologists and pediatric dietitians are other specialists that can help guide you through your baby's bottle aversion.

If you’re getting ready to start your baby on solids, download my FREE Baby-Led Feeding Essential Checklist to make sure you have everything you need to get started. You might also want to check out my new online course for parents, based on my best-selling book which will walk you through the whole process of starting solids using a baby-led approach.

Alternatively, if your baby is almost ready to start solids and you’re looking for someone you trust to map out the entire first 12 weeks of your baby’s solid food feeding journey, check out my new Safe & Simple 12 Week Meal Plan! Over 30 recipes, weekly shopping lists, tons of balanced baby meals, a complete plan for top allergen introduction, & lots of guidance (with photos) on how to safely serve each food.

And if you're looking for personalized nutrition support for yourself, your babies and/or your kids, I am currently accepting new clients in my virtual private practice. Looking forward to meeting you online…

Feeding Aversion - Why your baby is refusing bottles, breast or solids – Baby Care Advice

When we imagine what it should look like to feed a baby, we picture a scene of a hungry baby, gently cradled in our arms, who serenely gazes towards us as he contently feeds, peacefully stopping when satisfied. This is in stark contrast to the way in which babies who develop an aversion to feeding or eating behave. The scene is one of a screaming, hungry baby who acts like you're trying to poison him when you offer him a bottle of milk, breastfeed, or solid foods.

What is a feeding aversion?

An aversion is the avoidance of a thing or situation because it is psychologically linked with an unpleasant, stressful, frightening, or painful experience. Basically, it’s fear that is displayed in anticipation of something bad happening again. A ‘feeding phobia’ and ‘feeding strike’ are other terms that may be used to describe a feeding aversion.

A feeding aversion refers to a situation where a physically well baby, repeatedly exhibits partial or full feeding refusal despite obvious hunger. A feeding-averse baby has a history that demonstrates he’s capable of feeding but for reasons yet to be identified and corrected, he refuses to feed or eats very little.

Babies as young as 7 weeks of age can develop an aversion to breastfeeding or bottle-feeding. Older babies can become averse to eating solids. Not just certain foods but the experience of eating solids. A baby could become averse to one, two, or all three feeding methods.

Feeding aversion signs and symptoms:

A baby might exhibit one or more of the following behaviors:

Skips feedings or meals without distress.
Appears hungry but refuses to eat.
Fusses or cries when a bib is placed around his neck, or when placed into a feeding position, or when the bottle is offered or shown.
Clamps his mouth shut or cries and turns his head away from the breast, bottle, spoon, or food.
Takes a few sips or a small portion of the milk or food offered but then pulls away or arches back in a tense manner or cries. (NOTE: Babies back arch to distance themselves. Back arching does not provide evidence of acid reflux.)
Feeds only while drowsy or asleep.
Consumes less milk or food than expected.
Refuses milk but eats solids.
Displays poor or slow growth. May be diagnosed as 'failure to thrive'.

The type and intensity of behavior vary 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, a baby might display almost complete food refusal, eating very little, and require a feeding tube to ensure that he receives sufficient nourishment for healthy growth.

Feeding is not something that a baby can avoid entirely. A feeding-averse baby will reluctantly eat enough to survive but not voluntarily eat enough to thrive. Once averse to feeding a baby will try to ignore his hunger cues for as long as possible. Only willingly, but cautiously, eating when ravenous. Then eating quickly in fear of a repeat occurrence of whatever it is causing his fears. Eating just enough to soothe pangs of hunger, but not enough to feel completely satisfied.

A few behaviors displayed by some, but not all, feeding-averse babies require special mention due to the confusion they cause. These include:

- Conflicted feeding behavior.

- Sleep-feeding.

- Accepts water from a bottle.

Conflicted feeding behavior

Many feeding-averse babies display conflicted feeding behavior - where the baby takes a few sucks, sharply turns away or arches back in a tense manner, possibly cries, quickly returns and wants to suck again, takes a few sucks, turns away or arches back, cries, and returns to feeding and so on. This disjointed feeding behavior is often interpreted by parents and others as an indication that the baby is experiencing pain, especially if he is intermittently crying, but it’s not necessarily due to pain. Babies who have become averse to feeding will behave in this tense or distressed manner regardless of the cause.

Sleep-feeding

Feeding-averse babies often feed better or well when drowsy or during light sleep. When drowsy or asleep, a baby is not fully aware that he is being fed, and therefore he’s not on edge in anticipation of whatever it is that is causing him to fear feeding. In a drowsy or sleepy state, a hungry baby’s guard is down, instincts kick in, and he feeds well. A feeding-averse baby may refuse and fight feedings while awake but could complete a full feed without resistance when drowsy or asleep. (See other reasons for sleep-feeding.)

Accepting water from a bottle

A small percentage of feeding-averse babies willingly accept water from a bottle but not milk. This causes parents to believe it’s the taste of the milk that baby objects to, which could be the case, but not necessarily so. It can be because the baby associates the taste of the milk with an unpleasant or stressful experience, for example, being pressured to feed.

Parents often pressure their baby to drink milk from a bottle but seldom pressure their baby to take water from the bottle. Babies are smarter than we give them credit for. They learn to link the taste of the milk with being pressured and therefore react as soon as they taste the milk.

Why babies become averse to feeding

A baby could develop an aversion to feeding if an event occurring directly before, after, or while he is feeding triggers negative emotional responses, such as stress, pain, fear, or disgust. Several scenarios could potentially trigger such emotions. For example:

Stress

If a baby is pressured or forced to feed against his will, this makes for an annoying, frustrating, or stressful experience depending on the feeding strategies parents employ, and how long they persist.

Being repeatedly pressured to feed against their will is without exception THE most common reason for babies to develop an aversion to feeding and then not want to eat. In most cases, it's the original and only cause of a baby's feeding aversion. However, in around 10 percent of cases, it's a secondary cause that develops after the baby's initial feeding refusal due to one or more of the reasons that follow.

Pain

Sucking could be painful if a baby has mouth ulcers, and swallowing could be painful if a baby is suffering from esophagitis caused by acid reflux, or milk protein allergy. Chronic constipation or gastroparesis (delayed emptying of the stomach) could also cause a baby to associate eating with discomfort.

When a baby refuses to feed due to discomfort or pain, the parent might then pressure their baby by employing subtle or obvious forms of pressure to make him eat. This adds to the baby’s distress. The baby now has two reasons to want to avoid feeding – pain and the stress associated with being pressured to eat. It’s often the stress associated with being repeatedly pressured to feed that continues to reinforce the baby’s avoidant feeding behavior long after medications or dietary changes have removed pain from the feeding experience.

Fright

Medical procedures involving the baby's face or mouth, like nasal or oral suctioning, insertion of an NG (nasogastric) feeding tube, or intubation can be frightening, painful, and stressful.

Aspirating fluids or choking on solids would make for a frightening experience. A baby could aspirate owing to dysphagia (an uncoordinated sucking-swallowing pattern) or due to moderate or severe laryngomalacia (floppy vocal cords), or because the flow rate from the nipple of a bottle or breast is too fast, or due to poor head or bottle positioning negatively impacting on the baby’s latch, suction, and sucking and swallowing coordination, or when the parent persists in trying to make their baby eat while he is crying in distress.

Disgust at taste of milk or medicines

Being forced to take foul-tasting medicines or milk (which can be the case for hypoallergenic formula or if a mother produces high levels of lipase in her breastmilk) could cause the baby to develop an aversion to feeding. If medications are added into a baby’s milk bottle, which then changes the flavor of the milk, or if given via a nipple-like device this could cause a baby to reject bottle-feeds. Parents often resort to pressure or force to get their baby to swallow something that tastes unpleasant, adding another reason for the baby to want to avoid feeding, or anything else the parent might try to place into his mouth.

Babies affected by a sensory processing disorder may find the sensation of the nipple, or anything else in their mouth, to be abhorrent. They can display aversive behavior to lumps in food or the smell, taste, or feel of certain foods.

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.)

Other reasons for why your baby won't take a bottle, breast or solids

There are several other possible reasons for individual babies to display aversive behavior towards breastfeeding, bottle-feeding, or eating solid foods. Any situation that results in a baby becoming frightened, stressed or experience pain while feeding has the potential to trigger partial or complete food refusal.

A single occurrence of one of these events doesn't usually trigger an aversion, but it is possible, especially if the experience is traumatic for the baby. It would generally take repeated occurrences while feeding to cause a baby to become averse to feeding. When such episodes are repeated, the baby learns to link the sequence of events and expect a similar occurrence each time he feeds. And so, he tries to avoid feeding to avoid the situation that has caused him fright, stress, or pain in the past. It's at this stage he will react before the event because he knows what's going to happen. And so, he may become distressed as soon as he recognizes he is about to be offered a feed. Or even if he thinks he is about to be fed because of the position he is held.

Is pain the cause for your baby's feeding refusal?

The distress displayed by many feeding-averse babies 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 feeding refusal 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 your baby’s troubled feeding behavior?Check how he behaves at times outside of feeding as this will provide clues. For example:

If your baby is happy once you stop trying to feed him, 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, constipation or gastroparesis is not restricted to feeding times only. Your baby would display signs of discomfort or distress at other times in addition to feeding 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 his oppositional feeding behavior. Sleep does not numb a baby to the sensation of pain. If it is painful for him to feed during the day or while awake, it’s reasonable to expect it would also be painful for him to feed at night or when sleep-feeding.

NOTE: 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 him 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, it's probably not pain.

Is pressure the cause?

Some parents will 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 he consumes what they believe, or have been told, is an acceptable amount of milk or food.

Many of the feeding strategies that we believe are ‘encouraging’ or ‘supporting’ a baby to eat involve subtle forms of pressure. For example:

Pushing the nipple into a baby’s mouth against his wishes.
Preventing him from pushing the nipple out of his mouth with his tongue.
Following his head with the bottle when he turns or arches back in tense manner.
Restraining his head to prevent him from turning away.
Restraining his arms to prevent him from pushing the bottle away.
Offering repeatedly at a time when he's rejecting or upset.
Upwards pressure under his chin in a bid to trigger his sucking reflex.
Gently compressing his cheeks to apply pressure on his buccal pads (cheek pads).
Jiggling or twisting the bottle to try and make him continue sucking.
Squeezing milk into his mouth.
Trying to trick him into accepting the nipple by switching his pacifier for the nipple.

If these things don’t upset your baby - which generally appears to be the case for babies under the age of eight weeks who due to immaturity have limited ability to complain during the feed but can after the feed – such strategies might be causing no harm. However, doing these things in a bid to control how much a baby eats has the potential to make the experience of feeding unpleasant or stressful for the baby. When repeated, a baby can develop an aversion to feeding.

As a result of developing a feeding aversion the baby will fuss or refuse to feed and the parents, not knowing any better, may then feel compelled to force their baby to eat, and by doing so they may be unknowingly reinforcing their baby’s feeding aversion.

Behavior that is reinforced will continue. Once averse to feeding, the situation spirals downwards as a result of the ‘fear-avoidance-cycle’.

The more the parent pressures their baby, the less their baby is willing to eat. The less their baby eats, the more the parent pressures. And around and around it goes. The 'fear-avoidance-cycle' can spiral downwards to complete feeding refusal while awake, poor growth, and possible hospitalization where a feeding tube might be inserted.

Direct and indirect reinforcements

Any pressure, even subtle forms, has the potential to directly reinforce a feeding aversion. However, there are other strategies, for example feeding a baby while sleeping, giving solids to compensate for the loss of calories from milk, providing milk in other ways such as spoon, syringe, or feeding tube, can indirectly reinforce a behavioral feeding aversion by enabling the baby to avoid feeding while awake during the day. All reinforcements – direct and indirect – need to be removed.

Solutions for baby's bottle feeding aversion

Medical treatments

A feeding-averse baby is often distressed at feeding times (an exception being those who mostly sleep-feed during naps and at night). Pain is typically the first thing blamed, but the least likely cause of aversive feeding behavior displayed by physically well, thriving babies.

If you go to the doctor with a fussy baby who cries and refuses to eat, he or she may tend to explore physical causes before all others. The following treatments are often recommended by medical practitioners in a bid to remedy a baby's fussy or distressed feeding behavior.

Medications: Acid suppressing medications may be prescribed to treat suspected esophagitis - inflammation of the baby’s feeding tube caused by repeated exposure to refluxed stomach acid. And perhaps prokinetic medication (also called propulsive agents) to treat gastroparesis - delayed emptying of the stomach.

Dietary changes: A hypoallergenic infant formula may be recommended to treat suspected eosinophilic esophagitis - inflammation caused by an allergic reaction to cow’s milk based infant formula or soy infant formula.

Once the condition causing the baby's discomfort is effectively treated, his troubled feeding behavior will fade and disappear.

NOTE: A doctor cannot see into a baby’s esophagus and therefore cannot confirm if he is suffering from esophagitis during a routine medical examination. h3 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 for his troubled feeding behavior. Similarly, if your baby's avoidant feeding behavior continues two weeks after switching to a specialized hypoallergenic formula, the reason may be that milk protein allergy is not the cause. This does not imply that your baby is not affected by these conditions, rather that these conditions are unlikely to be the cause of his avoidant feeding behavior.

Band-Aid solutions: If medications and dietary change fail to resolve a baby's aversive feeding behavior, band-aid solutions such as high-calorie feeds, food thickeners, starting solids, sleep-feeding, might be recommended in an attempt to minimize the risk of poor growth caused by an unresolved feeding aversion. However, band-aid solutions are often ineffective in the case of a feeding aversion because they do not address the cause, which is the stimulus that is causing the baby to fear feeding.

If medical treatments fail to resolve your baby's feeding issues, consider the possibility of a misdiagnosis or that there is more than one cause involved. And extend your search to cover other potential causes, in particular behavioral reasons such as being pressured to eat.

Speech therapy

If your baby often chokes or experiences problems with aspiration while feeding, his doctor might refer him to a speech therapist to assess his ability to suck and swallow effectively. This can be helpful if choking episodes are reinforcing the baby's aversive behavior.

However, if your baby feeds well at some feeds for example in a sleepy state or has fed well in the past before developing a feeding aversion, it's unlikely that the source of his fussy feeding behavior or food refusal is due to a sucking or swallowing problem.

Occupational therapy

If an oral aversion due to a sensory processing disorder is suspected, your doctor might refer your baby to an occupational therapist for an assessment. Encouraging a child with oral aversion occurring due to a sensory processing disorder to feed as normally as possible requires a very long process that may last months or years.

An oral aversion is wide ranging with the baby not wanting anything near his mouth. A feeding aversion is specific, related to feeding, and requires very different treatment to resolve the problem compared to an oral aversion

NOTE: Some of the feeding strategies recommended to resolve an oral aversion, such as placing rubbery implements into the baby’s mouth to ‘desensitize’ him to the feel of things in his mouth, are counterproductive in the case of a behavioral feeding aversion that developed or is currently reinforced as a result of being pressured to feed. Placing things into a baby’s mouth without his permission will not regain his trust. Hence, the diagnosis must be correct. If your baby is happy to have anything other than the nipple of a bottle or food in his mouth, it’s probably a feeding aversion rather than an oral aversion.

Behavior approach

A behavioral approach views challenging infant behaviors such as incessant crying, fussy feeding behavior, feeding refusal, and sleeping problems in the context of the care the baby receives. In the case of physically well babies, it’s not assumed that the baby has a physical problem, rather the parent’s childcare practices are examined.

Infant behavior, whether this is desirable or undesirable behavior, is reinforced by the actions parents take or don’t take. To resolve a behavioral problem, and thus change a healthy baby’s behavior from fussy, distressed feeding refusal to enjoying feeding to satisfaction, it’s necessary for the parent to first make appropriate changes to their childcare practices.

The parent’s infant feeding practices are the last suspected cause of a healthy baby's aversive feeding behavior when it should be one of the first. You will know how thoroughly your baby’s healthcare professionals have assessed the possibility of behavioral reasons for his feeding issues by the number of questions asked of you regarding his feeding history. For example, feeding equipment, feeding frequency and duration, milk type, and concentration, feeding pattern, total daily milk intake, his sleeping patterns (sleep has a profound effect on feeding behavior and milk intake) and most important of all, your infant feeding and sleep settling practices. Our Baby Care Advice questionnaire includes 80+ questions to pinpoint the cause.

No questions asked = minimal to no consideration given to behavioral causes.

Misdiagnosis

Accurate identification of the cause is essential to finding an effective solution. This is not something that can be achieved during a brief consultation with a health professional. And it definitely cannot be achieved without asking the parents multiple questions about their infant feeding practices. An accurate, and thorough diagnosis of the cause, or causes as is often the case, requires a comprehensive understanding of infant development and behavior, and age-appropriate infant feeding practices, as well as an understanding of the reasons and solutions to infant feeding aversion. At Baby Care Advice we allocate 2 hours for feeding problems.

Misdiagnosis occurs when assumptions are made about the cause in the absence of a comprehensive feeding assessment. Failure to accurately identify the stimulus causing and reinforcing the baby's feeding aversion - which can vary for individual babies - is likely to result in an ineffective treatment plan.

Not only will a misdiagnosis fail to address the cause, but many of the strategies recommended based on a misdiagnosis, such as those described as indirect reinforcements, have the potential to reinforce a baby’s aversive feeding behavior. A baby’s feeding aversion will continue while it’s reinforced. An unresolved breast- or bottle-feeding aversion increases the risk of the baby developing an aversion to eating solids for the same reasons. Feeding issues can persist for weeks, months or years.

How we can solve your baby's bottle feeding refusal and get your baby to happily take a bottle

Few health professionals are familiar with age-appropriate infant feeding practices and/or the process involved in resolving behavioral feeding aversions experienced by normal developing babies and young children. Therefore, they are ill-equipped to guide and support parents to resolve this complex and highly stressful situation.

A baby's avoidant feeding behavior, poor milk intake, and poor growth could be due to one or a combination of the causes already mentioned. However, a feeding aversion can become even more complex if other feeding issues are involved. For example, unsuitable or faulty equipment, poor feeding position, or the parent’s providing an inappropriate response to their baby’s feeding cues. (See bottle-feeding problems for more.)

If you suspect that your baby has developed a feeding aversion, there are a couple of ways we can help.

You might choose to see if you can figure things out on your own as a result of being guided by my book 'Your Baby’s Bottle-feeding Aversion’.

You might prefer to have one of our experienced consultants undertake a comprehensive assessment of all causes and provide individualized feeding advice. You also have the option to receive daily email guidance and support as you work towards resolving your baby’s feeding aversion.

You can purchase Rowena's Online Bottle-Feeding Aversion Program - six modules with clear step by step instructions on how to overcome your baby's bottle-feeding aversion. With a 95% success rate using Rowena's Bennett's method.

‘Your Baby's Bottle-Feeding Aversion’ book

In my book, ‘Your baby’s Bottle-feeding Aversion’, I have described physical and behavioral reasons for babies to develop an aversion to bottle-feeding. How to identify the cause and the solutions to match. Included are step-by-step instructions on how to regain your baby’s trust and resolve a feeding aversion caused or reinforced by repeated pressure to feed.

While the book was written for bottle-fed babies, many nursing mothers have found that applying the same strategies has also helped them to successfully resolve a breastfeeding aversion.

You might find that reading this book is all you need to do to understand the steps you need to take to resolve your baby’s feeding aversion and get him back to the point of enjoying eating until satisfied.

Baby Care Advice Consultations

If you would like an individualized assessment of all reasons for infant feeding problems, not just feeding aversion, we also provide a consultation service. Baby Care Advice consultants have extensive experience in pinpointing the cause of feeding aversion and other behavioral feeding problems such as those related to equipment and the parent’s feeding practices. (For more on what’s included in a consultation).

Rowena's Online Bottle-Feeding Aversion Program

Six time-saving modules to help your family enjoy feeding again with Rowena's step-by-step plan. Enjoy additional tools to manage anxiety, troubleshoot any issues, introduce new carers, how to manage illness/teething and much more.

Join Our Facebook Support Community

Baby Care Advice has facebook support groups in various languages, for those who have purchased either Rowena's 'Your Baby's Bottle-Feeding Aversion' book/ Online program/ consultation. They are made possible by a volunteer group of parents, who offer empathetic, compassionate support and guidance as you work your way through resolving your baby's feeding aversion.

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By Rowena Bennett, RN, RM, CHN, MHN, IBCLC.

Written Sept 2013. Revised July 2021.

diagnosis of symptoms and treatment of anorexia in a child

Signs of anorexia in a child can be observed long before adolescence. Medical practice knows cases when treatment was required for babies at the age of only two years. The development of the disease in children has its own characteristics, so parents often do not notice the problem and attribute the symptoms to pampering or a desire to attract attention.
Anorexia does not go away on its own, so if you suspect a disease, you must definitely consult a doctor for an examination. With weight loss to critical values, problems appear in the development of bones and internal organs. For a growing organism, this is especially dangerous. The Eating Disorders Research Center can help you cope with the first signs of an eating disorder.

Article content:

Anorexia in children
Disease classification
Causes of anorexia in children
Symptoms of anorexia in children
Disease diagnosis
Treatment of childhood anorexia
Alternative methods

Anorexia in children

Anorexia nervosa can develop in a child of any age. Eating disorders of varying severity are found in every third preschooler. Parents often complain about the child's appetite, but do not always pay due attention to this problem. But the baby may refuse to eat due to physiological or psychological problems.

Classification of the disease

Children's anorexia is divided into several types according to clinical manifestations:

dystmic - the child cries, is dissatisfied with the very process of eating food, is capricious while eating;
regurgitation - manifested by regurgitation without the presence of other diseases or problems with the gastrointestinal tract during meals or after a heavy meal;
active refusal of food - the child can close his mouth, turn away, not swallow, in every possible way demonstrate his unwillingness to eat;
passive refusal to eat - the symptoms are aversion to foods familiar to age.

But it should be remembered that the cause of poor appetite can be not only serious health problems, but also a temporary refusal to eat during stress, severe overexcitation, illness, taking certain medications.

Causes of anorexia in children

The causes of the disease are not the fault of the parents, and the fault of the child himself is also absolutely excluded.
An eating disorder develops under the influence of several factors - genetic predisposition, increased emotional sensitivity, crisis in life, fixation on certain goals.
To date, psychiatry even knows genes, the presence of which significantly increases the risk of developing anorexia.

Symptoms of anorexia in children

Newborns

The symptoms of anorexia in infants are hard to miss. The baby may protest against meals. At this age, this is manifested by a refusal to take the pacifier in the mouth, suck or swallow. He turns his head away, spits out food, or simply does not swallow.

Another worrying factor is frequent vomiting. Especially after eating a lot of food. It usually occurs almost immediately after feeding. In addition, children often cry, whimper when it comes to eating.

With such manifestations, it is important to exclude the presence of intestinal infections and other health problems. If pathologies are excluded, then without treatment, such behavior can become fixed and lead to severe weight loss and other consequences of the disease.

Toddlers (1-3 years old)

At this age, a child may experience temporary problems with appetite when new foods are added to the diet. Food aversion manifests itself in passive and active ways. In the first case, the symptoms will be the inability to feed adult food - meat, vegetables, cereals and other familiar dishes usually do not get into the child's diet, regardless of the method of preparation.

Active resistance is fighting, tight lips, spitting out food. Also, the child can arrange games with food, turn over plates, throw away spoons and forks. If no health problems are found, then the eating disorder will be treated.

Preschool age

In children aged 4-7 years, parents may notice the following symptoms:

direct refusal to eat without complaints of well-being;
worsening of sleep - trouble falling asleep, insomnia;
too much excitability or lethargy;
isolation in communication with peers - often takes on signs of autism;
frequent constipation;
pruritus;
incontinence.

Communicating with sick children, you should not count on a frank discussion about problems. Despite their young age, babies can hide the problem.

It is important to monitor the weight of the child, if it is rapidly decreasing, then this is one hundred percent factor for consultation with a specialist.

It is much more difficult to deal with severe anorexia, because in addition to psychological problems, you need to literally save a life, as well as minimize the negative consequences for health.

School age

Diagnosis and treatment of anorexia at the age of 7-10 years is much more difficult because children begin to hide their feelings better. During this period, it is unlikely that the child decides to throw the plate off the table or starts crying loudly.

Symptoms begin with frequent avoidance of meals for various reasons. It can be sports, lessons or talking with friends. Joint lunches and dinners will become rare, because in the presence of parents it is difficult to throw food in the trash can or flush it down the toilet. Girls may become interested in fashion and become interested in famous actresses, ask or search the web for information about diets.

It should be known that in the presence of all the above symptoms, even in the absence of serious weight loss, full treatment is necessary.

To begin treatment, it is necessary to involve a child psychiatrist and other specialists who are familiar with the course of the disease in babies. To complicate matters, parents rarely realize the extent of the problem in time. Therefore, the first visit to a specialist usually occurs two to three years after the onset of symptoms.

Diagnosis of disease in childhood

Diagnosis of childhood nervous diseases is complicated by the denial and silence of the reasons for refusing food. Therefore, if the baby can communicate, then treatment begins with a conversation. Parents are also interviewed to detect behavioral disturbances, changes in weight and appearance.

The process uses special questionnaires to detect eating disorders. With the child, you can conduct tests to determine self-esteem, emotional state. Popular methods of SMIL, Dembo-Rubinstein and others.

To treat a disorder, other causes of the problem must be ruled out. Especially if the symptoms appear in young children. It is almost impossible to establish full-fledged contact with them, so the survey is conducted only with parents, the analysis data and the overall clinical picture are taken into account.

Treatment of childhood anorexia also includes general laboratory tests, including blood and urine tests, hormone samples, kidney and liver tests. To understand the causes of poor appetite, the gastrointestinal tract is examined by instrumental methods.

The child psychiatrist should rule out early onset schizophrenia or other serious mental disorders that could lead to anorexia as a symptom. To do this, the specialist checks the functions of thinking and other features.

Treatment of anorexia in children

Outpatient and inpatient treatment of anorexia in children is available at the CIRC, depending on the patient's health condition at the time of contacting the clinic. We offer:

individual approach to solving problems with childhood eating disorders;
application of methods of treatment and identification of the causes of the disease, which are recognized as effective and safe in the world community;
best approach thanks to collaboration with the Linechen Institute, an international eating disorder academy where our physicians receive additional training and supervision;
advanced treatment methods involving relatives;
compilation of an individual menu, taking into account food preferences for each patient;
treatment services in the intensive care unit if the child is in serious condition;
participation in family intensives, communication with a psychotherapist via Skype to prevent recurrence of childhood anorexia.

Anorexia in adolescents and toddlers is often associated with weight loss, so the primary goal of treatment is to eliminate the symptoms of malnutrition. At this stage, such methods of treatment as frequent fractional and parenteral nutrition, maximum rest in bed are used.

When weight gain is noted, the issue of food perception for children can be addressed. With the help of a psychologist, psychotherapist or psychiatrist, the fight against the psychological manifestations of anorexia begins. For this, up to six months, cognitive-behavioral therapy is carried out, which allows you to change children's distorted ideas about food, get rid of anger and anxiety.

Family therapy plays an important role in treatment. It is important to find problems in the relationship between parents and the child that could provoke the disease.

Alternative methods

Anorexia often cannot be treated without medication. At the first stage, anti-vomiting, constipation and dehydration agents are used. Appetite stimulants may also be prescribed. For pediatric therapy, tranquilizers and antidepressants are less commonly recommended. But in some cases, without the use of these tools, therapy does not work well.

A very important and difficult part of the work is the correction of lifestyle. The child can consult with a nutritionist to get the necessary information about proper nutrition, the importance of eating a variety of foods. You can also learn how to make your own menu. It is useful to accustom the baby to an interesting sport for him.

Physical activity allows you to form the right habits and improve your health. In addition, with the help of sports, an adequate self-esteem, a normal perception of one's body is formed. Accordingly, childhood anorexia is less likely to lead to eating disorders during adolescence or later.

Recovery from childhood anorexia can take up to 5-7 years, depending on the timeliness of contacting a specialist. About 70% of patients return to a full lifestyle. Increases the likelihood of a favorable outcome active work with a psychologist.
Get complete therapy and emergency help at the Center for the Study of Eating Disorders. Make an appointment in Moscow by calling +7(499) 703-20-51 or using the online form.

Author: Sineutskaya Ekaterina Olegovna

Head of the inpatient department of the TsIRPP

Psychiatrist, psychotherapist, narcologist

child not eating Maybe an eating disorder? - Miloserdiye.ru

Sergey Butriy, a pediatrician and chief physician of the Rassvet children's clinic, tells about the causes of eating disorders in babies and what to do about it.

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Cut flowers out of carrots

«My son is five years old, he doesn't eat anything except milk porridge with cottage cheese and chocolate, - says Nadezhda S. - He doesn't even try. He never ate a single fruit or vegetable in his entire life. Even pizza, chips and nuggets, beloved by all the children of the world, do not arouse his interest. He does not know the tastes of food, does not distinguish between sour and salty.

Pediatricians, neuropathologists, gastroenterologists, nutritionists shrug their shoulders. But not because they don’t know how to help, but because the solution, in their opinion, is elementary: “Cut out flowers from carrots, fry eggs in the form of a funny face, come up with something. You are his mother, you cannot feed your own child?“

Can't. Every day I fry, cut, involve in cooking, buy beautiful appliances and pasta in the form of cars, play food, take to cafes, to kindergarten and to visit where other children gather and eat. All this does not work. I can’t feed my child and I don’t even know where to go for help with this.”

Nadezhda breathed a sigh of relief when she learned that this problem has a name - Restrictive / Selective Eating Disorder (OR-ED) or in English Avoidant / Restrictive Food Intake Disorder (ARFID), which means that she is not alone in her trouble, does not go crazy, and the solution is somewhere.

“Eating disorders in children older than 3 years are called ARFID,” says pediatrician Sergei Butriy, one of the first to start a discussion about this problem in Russia. - Such a child cannot eat because the taste of food seems disgusting to him, he does not like the smell, texture, temperature, color. He is afraid to eat.

Most children are picky about food at some point in time, catching onions from soup, choking on lumps, an unpleasant taste can make any child vomit - this is a common story. To understand how this differs from an eating disorder (ARFID), here is an example.

Imagine that you come to an aboriginal tribe and they eat live worms there. Juicy, fatty, that move in the mouth. And they offer them to you. This is roughly how a child with ARFID feels when they are asked to try something new.

Such children are very afraid to try new or even old, but with unpredictable taste. Let's say a child is afraid to eat an apple, because the taste of an apple is a lottery, it is always different. In the morning the apple is sour, in the afternoon it lay in the sun and became loose and sweet, fell - the barrel became cloying. And Danissimo vanilla curd is predictable, always the same, the child does not want to take risks, and gradually his choice narrows down to a very limited list of products.

Such neophobia (fear of the new) once helped cubs to survive. And in our safe time, when there is nothing for children in the apartment to poison themselves, except for household chemicals or uncleaned medicines, this useful skill has turned into a functional disorder.

Functional disorders are a difficult thing to accept, says Butriy. The quality of life decreases enormously, but it is impossible to find a physical or mental cause of this condition, which torments both parents and doctors.

In order to somehow feed the baby, the family spends colossal resources. “The main thing that distinguishes eating disorder from childhood whims is that it is incredibly draining of parents’ resources,” explains the pediatrician. - The whole life revolves around eating behavior and the question “how to feed him?” If they go on vacation, they bring with them suitcases of food that the child is used to. Exhaustion of the nerves of the family and depletion of the fat of the child are two criteria after which we speak of an eating disorder, and not just a child with special nutritional needs or difficult to feed.

“A new diagnosis does not mean a new illness,” the doctor emphasizes. “There have always been babies who refuse to eat, in the absence of help they get sick and die. But against the background of general infant mortality from poverty, starvation, infections and injuries, rare babies with eating disorders were not a problem worthy of attention. Times have changed, now children are growing up in much more safety, it's time to notice more "small" and rare problems.

EDD in children lies at the intersection of pediatrics, gastroenterology and psychiatry. But above all, self-education of the family is necessary. The more the family knows about eating disorders and ARFID, the less guilt and fear, the more likely it is to find a good specialist, or at least develop the best feeding and upbringing strategy on their own.” If you have a trusted pediatrician who does not judge, saves, constantly learns and is ready for new challenges, Sergey Butriy recommends you to him. But if this is not the case, unfortunately, you will have to make a circle on gastroenterologists, other pediatricians, breastfeeding consultants, complementary feeding consultants, psychologists, etc. You need to find among this list a person who is familiar with the problem and is ready to help, his specialization, in the context of a general shortage of such personnel, is secondary.

Eating disorders in babies: are parents doing something wrong?

Eating disorders can occur even in infants, but it is not the family's fault. “In infants, the cause of eating disorders is usually fear, perhaps some memory of the risk of suffocation due to food,” Sergey Butriy explains. - They brought me a seven-month-old child with RPP. At two and a half months, he was admitted to the hospital with covid pneumonia. It was very bad and scary there, he was given oxygen, injections, and amid stress, he stopped eating. In order to somehow feed him, his mother, in a panic, on the advice of medical workers, in the same place, in the hospital, tightly swaddled him, poured food into his mouth, holding his nose, until he swallowed. Of course, she only fixed the negative to food, and since then the child has had RPP, although they have been at home for a long time and there are no painful procedures and violence in food. If not fed, he will not eat and will not show signs of hunger. It will just emaciate and die."

The doctor says that the causes of these diseases, their groups/risk factors are still poorly understood, but it is almost never the fault of the parents.

Eating disorder occurs on its own, but then sometimes parents (including on the advice of doctors) can use violent and non-pedagogical methods, thus reinforcing the infant's aversion to feeding at the level of conditioned reflexes.

“But I am very afraid to talk about the fault of parents even in this context: when your child completely refuses to eat at the age of three months, such animal fear covers that people are ready for the most desperate deeds,” says Sergei Butriy. – These parents are already drowning in guilt, and one of the goals of treatment is to remove this feeling, give working strategies for feeding and helping, and also show “red flags” - dangerous symptoms, the appearance of which will indicate that it is no longer possible to cope at home Time to go to the hospital."

“Due to a very limited diet, these children can develop anemia (deficiency of iron or vitamin B12), beriberi (scurvy) and many other secondary problems,” continues the doctor. – I usually say watch for blood in the stool, signs of dehydration, excessive lethargy, halving the volume of wet diapers, etc. But, firstly, this leads to dozens of new questions, and they are different for everyone, and secondly, anyway, everything depends on regular examinations by a competent pediatrician, and ideally, also a direct connection of the family with him.

Adolescents with eating disorders often die. Are babies in the same danger?

Adolescent eating disorders are psychiatric diseases arising from disgust for one's own body (dysmorphophobia) - a dangerous condition with a colossal lethality. But children's ED (pediatric food disorders) do not arise at all due to dysmorphophobia, their mortality is lower and the prognosis is better, the doctor says.

Even without special treatment and assistance to the family, children's eating disorders in most cases go away on their own, if the family adjusts and learns to live with it, even if it spends enormous resources on the feeding process. As a result, the child survives, grows, develops healthy, and with age, the RPP disappears.

Some children with childhood eating disorders, however, end up in hospitals, need tube feeding or a gastrostomy for 3-12 months to survive the crisis and the child does not die of malnutrition. But even such children have a very low mortality in the end, they are nursed, and then they almost always grow up healthy.

“Consequences and prognosis of RPP depend on a lot of factors,” says Sergey Butriy. – Physical health (is it an isolated eating disorder or, say, is it part of a genetic syndrome). Comorbid psychiatric disorders (whether or not the child also has autism, ADHD, or oppositional defiant disorder). It also depends on the quality of medical care, involvement, level of education and financial well-being of the family, etc.”

Treatment of childhood eating disorders starts with parental support

Parents who cannot feed their own child experience fear, frustration, shame, and guilt at the same time. “Firstly, when they just find out that there are still such children, it becomes much easier for them,” the pediatrician shares his observations. - Secondly, if a parent does not make super-mistakes (gross violence, for example), he, as a rule, empirically gropes for a suitable way to feed the child.

So the core of ARFID and EDD treatment is: do what you do and don't feel guilty. I allow a lot of things - to distract, entertain, feed half asleep, feed monotonously and give vitamins, puree food even before school. Eat - and good! Gradually, he will begin to try.

Give up unrealizable ideals, they only spoil your nerves. Find a supportive doctor or psychologist, talk periodically, get feedback that you are still on the right track, listen to his advice. Check out the RPP and ARFID materials on my blog. Avoid authoritarian and harsh doctors and relatives who give careless advice - they can undermine the rest of your strength.

The treatment of eating disorders is cognitive behavioral therapy. Imagine that you are afraid to fly. The psychotherapist brings you to the airport, but you will not fly anywhere today, he promises this. He brought you just to look at the planes, get used to it, so that the heart would stop jumping out of fear. Then he will offer to walk around the cabin, sit, listen, fasten your seat belt. All this is wildly scary, but you know for sure that you will not fly today. And little by little you get used to it. Man is an adaptive being. In the same treatment of children's eating disorders and ARFID. True, according to Sergey Butriy, there are almost no CBT therapists specializing in eating disorders in children in Russia. But parents themselves can move in this direction.

“Infant eating disorder starts at 2-3 months, peaks at 3-7 months, then it gets better from month to month, and by the age of one and a half, most children no longer exhaust the family with their demands for food, although they remain picky eaters. ARFID can start about 2.5-5 years, intensify in the first years, the peak passes in 3-4 years; most likely, these children will have nutritional problems in adulthood: they are usually slender, do not want to eat many foods, but at the same time they are quite satisfied with the quality of their lives. But I have not seen cases where ARFID turns into dysmorphophobia (teenage or adult eating disorders, where a person is not satisfied with his body). ”

The first months (for infantile eating disorder) and the first years (for ARFID) from the onset of symptoms are the most difficult, and then the family adapts, and the symptoms gradually subside, and in general, the strength that is required to cope with this, going less and less.

“Be patient and save your energy,” Sergei Butriy advises. “This is not your fault. The problem is real, you didn't make it up, you don't go crazy. Many mothers have gone this way and then remember this period with a shudder, but already as a passed stage. Only these people will be able to understand how hard it is for you right now, do not attach too much importance to the words of people who have no idea what an eating disorder is.

Sources:

Lecture by pediatrician Sergei Butriy "Eds in children" https://youtu.be/hXPVMnkplHw

Pediatric Feeding Disorder. Consensus Definition and Conceptual Framework https://journals.lww.