Signs And Symptoms Of A Feeding Aversion

Feeding aversion is a term used to describe a situation where a baby, despite being physically healthy and showing signs of hunger, consistently refuses to eat or only eats very little. This behavior often stems from a psychological association with negative experiences related to feeding, which can manifest as fear or anxiety about the act of eating itself. Other terms that may be used to describe this situation include 'feeding phobia' and 'feeding strike.'

Even infants as young as 7 weeks can develop an aversion to breastfeeding or bottle-feeding, while older babies may resist solid foods altogether—not just specific foods, but the entire experience of eating solids. The reasons behind this aversion can vary widely, and it’s important to recognize that each baby may respond differently.

Signs and symptoms of a feeding aversion:

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 presented.
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.
Displays poor or slow growth. May be diagnosed as 'failure to thrive'.

For some, the aversion may be mild, such as refusing a particular food due to a past unpleasant experience. For others, the aversion can be more severe, leading to significant food refusal and potentially requiring medical intervention, like a feeding tube, to ensure they receive adequate nutrition for healthy development. Understanding and addressing these aversions is crucial for supporting your baby's feeding journey.

Feeding is an essential part of a baby's life that cannot be completely avoided. A baby who is averse to feeding may eat just enough to survive, but they won't willingly consume enough to truly thrive. When a baby develops a feeding aversion, they might try to suppress their hunger signals for as long as they can, only eating when they are extremely hungry. Even then, they may rush through their meals, anxious about whatever has caused their discomfort.

They may only eat enough to ease their hunger pains, but not enough to feel fully satisfied. Certain behaviors exhibited by some feeding-averse babies can be particularly confusing and deserve special mention. These include:

Conflicted behavior
Sleep-feeding
Accepts water from a bottle

Baby that displays conflicted feeding behavior

Many babies who are averse to feeding exhibit a pattern of conflicted behavior during mealtime. They may take a few sucks, then suddenly turn away or arch their backs in a tense way, sometimes crying before they return to suck again. This cycle of briefly feeding, turning away, and crying can be confusing for parents and caregivers, who might interpret it as a sign of pain. However, this behavior isn't always linked to discomfort. Babies who have developed a feeding aversion can show this tense or distressed response for various reasons, not solely because they are in pain.

Baby that only feeds in drowsy or asleep

Babies who are hesitant about feeding often do better when they are drowsy or in a light sleep. In these moments, they are less aware of the feeding process, which can help ease their anxiety about it. When a baby is in a relaxed state, their natural instincts take over, allowing them to feed more effectively. While a feeding-averse baby might resist and struggle during awake times, they may be able to take a full feed without any fuss when they are drowsy or asleep. (See other reasons for sleep-feeding).

Baby that accepts water but not milk from a bottle

Some babies who are hesitant to feed may surprisingly accept water from a bottle, while refusing milk. This can lead parents to think that the baby dislikes the taste of milk, which might be true, but it’s not the only possibility. The baby may have formed a negative association with the taste of milk due to a stressful feeding experience, such as feeling pressured to eat.

Parents often encourage their babies to drink milk from a bottle, but they rarely apply the same pressure when it comes to water. Babies are more perceptive than we often realize. They can connect the taste of milk with the pressure they feel, which may cause them to react negatively as soon as they encounter it.

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 eat 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

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

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 the cause pain?

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.

How we can help!

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.

Purchase Rowena's Online Bottle-Feeding Aversion Program and start today. With six time-saving modules you will be equiped with the tools you need to overcome your baby's bottle-feeding refusal.

LEARN MORE HERE

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.

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

Revised July 2024.