If your baby was previously a 'good breast-feeder’ but now gets upset and refuses to latch except when drowsy or asleep, it may be that he has developed a breastfeeding aversion. This common but often overlooked or misdiagnosed problem is as distressing for nursing mothers as it is for their babies.
Your baby's sudden refusal to breastfeed doesn't need to signal an end to your breastfeeding goals. A breastfeeding aversion can be resolved! The key to an effective solution is accurately identifying cause.
This article explains what a breastfeeding aversion is, common causes, how an aversion differs from a nursing strike, and other reasons for feeding refusal.
What is an aversion?
An aversion is the avoidance of a thing or situation because it is psychologically linked with an unpleasant, stressful, frightening, or painful experience.
Babies as young as seven weeks of age can develop an aversion to breast- or bottle-feeding. Older babies can develop an aversion to the process of eating solid foods.
The incidence of infant breastfeeding aversion is unknown, largely because it's a poorly recognized and thus poorly managed problem. The distress and frustration associated with an unresolved breastfeeding aversion often results in nursing mothers giving up on their breastfeeding goals and switching their babies to bottle-feeds.
Behaviors that may point to a feeding aversion
Baby has a history of breastfeeding well, indicating that he knows how to successfully breastfeed. He might exhibit a number of the following behaviors:
- He becomes agitated as soon as he recognizes he is about to be offered a breastfeed.
- Turns his head away from the breast.
- He may appear hungry but refuses to latch.
- He latches but then pulls away once a letdown has occurred.
- Only willingly nurses when ravenous or directly before naps when drowsy.
- Nurse sessions a very brief, possibly only lasting for the first let-down before pulling or pushing away in a tense manner or crying.
- More willing to nurse during the night compared to the day.
- Might display poor or slow growth or be diagnosed as 'failure to thrive'.
- A feeding aversion often begins with fussing and rejecting one feed and then progresses to all feeds offered while awake. However, depending on the cause, a baby could suddenly refuse all feeds while awake.
Feeding is not a situation that a baby can avoid entirely. Once averse to feeding, a baby will try to ignore his hunger cues for as long as possible. Only willingly, but very cautiously, eating when ravenous. Then eating quickly in fear of a repeat occurrence of whatever it is that is causing his fears. Eating just enough to soothe pangs of hunger, but not enough to feel completely satisfied.
The type and intensity of behaviors vary between babies according to their stage of development and how hungry or tired they are at the time. Of course, some of these behaviors could have other causes besides a feeding aversion. All babies have times when they don't want to eat. It's a combination of the listed behaviors that point to a feeding aversion.
Two behaviors displayed by many, but not all, feeding-averse babies require further explanation. These include:
- Conflicted feeding behavior.
- Sleep-feeding.
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, fusses or cries, quickly returns, latches again, takes a few sucks, turns away or arches back, fusses or cries, and returns to feeding and repeats.
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. However, it's not necessarily due to pain. Many feeding-averse babies will behave in this tense or distressed manner regardless of the cause. They are conflicted between their need to eat and their fear that something bad is going to happen when feeding.
In some cases, conflicted feeding behavior may also be misinterpreted as the baby having a problem coordinating sucking-swallowing and breathing.
If your baby nurses well in a drowsy state, this rules out pain and an uncoordinated sucking pattern as all feeds would be affected if either of these causes is responsible.
Baby that only breastfeeds asleep or drowsy
A feeding-averse baby may refuse and appear to 'fight' feedings while awake but feed better or well when drowsy or during light sleep. In a drowsy or sleepy state, a hungry baby is not aware that he is feeding. Hence, he's not on edge in anticipation of whatever it is that is causing him to fear feeding. He feeds instinctively without resistance until satisfied. (See other reasons for sleep-feeding.)
Why babies develop a breastfeeding aversion/ refusal
A baby could develop an aversion to feeding if something occurs while feeding that triggers a negative emotional response, such as fear, stress, or pain. Several scenarios could potentially trigger such emotions. The most likely reasons for a physically well baby to develop a breastfeeding aversion include:
- Stress associated with being pressured to latch or continue feeding when unwilling to do so.
- Fright linked to a forceful letdown.
Less likely causes…
- Pain due to a medical condition.
- Traumatic experiences.
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 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 pressure the cause of baby's breast refusal?
You can't make a baby breastfeed if he chooses not to. However, some mothers try to make their baby feed by repeatedly pushing their baby's head to the breast. As the baby cries and pulls away, the mother pushes him back toward the breast and this repeats over and over. Mothers often do this when they believe their baby has "not fed for long enough" or has "not had enough hindmilk" or because "he should be hungry by now" or when worried about their baby's growth.
Imagine what it might feel like for a defenseless baby to experience the suffocating sensation of having your mouth and nose covered as your head is repeatedly pushed to the breast. Stress associated with being repeatedly pushed to the breast is the most common reason for breastfed babies to develop an aversion to breastfeeding.
Other ways in which a baby might be pressured to breastfeed include:
- Restraining his head to prevent him from turning away.
- Restraining his arms to prevent him from pushing away from the breast.
- Offering repeatedly at a time when he's rejecting or upset.
Doing these things in a bid to make a baby feed for longer than he is willing to feed has the potential to make the experience of feeding unpleasant or stressful for the baby. Babies younger than 8 weeks of age may not be mature enough to complain when feeling pressured, but older babies will.
Fear-avoidance-cycle
Once averse to feeding, the situation spirals downwards as a result of the 'fear-avoidance-cycle'.
Fearing repeated unpleasant or stressful experiences, the baby now tries to avoid feeding for as long as possible. He might fuss and cry due to hunger and yet refuse to latch. Not knowing how to manage this situation, the mother may feel compelled to pressure her baby to latch, and by doing so, replicates the experience her baby is trying to avoid, thereby reinforcing her baby's feeding aversion.
The more the mother pressures her baby, the less her baby is willing to eat. The less her baby eats, the more the mother pressures. And around and around it goes. The 'fear-avoidance-cycle' can spiral downwards to complete feeding refusal while awake, poor growth, switching baby to bottle-feeds, or possible hospitalization where a feeding tube might be inserted.
Is an overactive let-down responsible?
The fuller the mother’s breasts, the more forceful her letdown. When a large volume of milk is forcefully ejected from the breast, this can be frightening for a baby. The volume and speed at which milk sprays into his mouth may make it difficult for him to coordinate his suck-swallow-breathe pattern. The rapid flow rate could cause him to cough and splutter as his airways are threatened. Fright due to a choking sensation can trigger a feeding aversion.
Is my baby refusing because of pain?
A baby could become fearful of feeding, and hence develop a breastfeeding aversion, if feeding causes pain. Sucking could be painful if a baby has mouth ulcers, and swallowing could be painful if he has developed esophagitis caused by acid reflux or milk protein allergy.
The distress displayed by 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 unknown or not considered.
How to tell if pain is responsible for your baby's breast refusal
A baby experiencing pain will not solely be distressed at feeding times. Consider how your baby behaves at times outside of feeding as this will help you to recognize if pain is likely. For example:
- If your baby calms quickly once you stop trying to feed him, pain is unlikely. Pain fades. It doesn't suddenly disappear because the feed has ended.
- If your baby is generally content between feeds, pain is unlikely. Pain associated with teething, acid reflux, or milk protein allergy or intolerance is not limited to feeding times. Your baby would display signs of distress at random times both during the day and night. He would be difficult to soothe. (NOTE: If your baby is often upset between feeds, check out our article on lactose overload and sleep-association problems, which are common reasons for babies' distress, before assuming the cause is a medical condition.)
- 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 avoidant feeding behavior when awake. 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 feeding while drowsy or asleep.
NOTE: If your baby displays any unusual signs that might indicate illness or a physical problem, or if you are worried that he is suffering due to pain, have him examined by a doctor.
Could it be due to traumatic experiences?
Medical procedures involving a 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 for a baby.
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).
If these episodes have long since passed, and your baby no longer faces painful medical procedures, aspirates, or has choking episodes, he then gets to enjoy pleasant feeding experiences and his avoidant feeding behavior will fade and disappear.
Direct and indirect reinforcements
Behavior, whether it be desirable or undesirable, continues because it's reinforced. A breastfeeding aversion can be directly or indirectly reinforced.
Direct reinforcements
A baby's avoidant feeding behavior will be directly reinforced if the trigger - which is the thing or situation that is causing the breastfeeding experience to be stressful, painful, or frightening – is present at feeding times.
Stress associated with being repeatedly pressured to latch or continue nursing is a trigger in virtually all cases. If not the original cause, it's typically a secondary trigger. For example, a baby might refuse to eat because it's painful to swallow. Unaware, the mother pressures him to latch or continue to nurse for "long enough". This adds to his distress. He now has two reasons to avoid feeding – pain plus the stress associated with being pressured to feed. While he continues to be pressured, this will reinforce his avoidant feeding behavior long after medications or dietary changes have removed pain from the feeding experience.
Indirect reinforcements
A breastfeeding aversion has the potential to be indirectly reinforced in other ways. Circumstances that remind the baby of the trigger, or which enable him to avoid breastfeeding while awake during the day, can unintentionally encourage his avoidant feeding behavior to continue even after the trigger is no longer present. The following are examples of ways in which a breastfeeding aversion could be indirectly reinforced.
- If you were to use pressure or force to make your baby take bitter-tasting medications or to bottle-feed, or to drink unpleasant-tasting formula.
- Giving your baby milk from a bottle, syringe or cup may enable him to avoid breastfeeding.
- Breastfeeding your baby in a drowsy state or while asleep enables him to avoid nursing while awake.
- Breastfeeding more often at night in an attempt to increase your baby's daily milk intake means he does not need to feed as often the following day; hence this can encourage a reverse-cycle feeding pattern where a baby eats more in the night than he does in the day.
- Filling your baby up with solid foods will curb his appetite and make him less inclined to want to breastfeed.
- Trying to trick your baby using a 'bait and switch' approach by getting him to suck on something like a pacifier or bottle and then switching to the breast will not earn his trust.
Feeding aversion or nursing strike?
Are these the same? Both present in the same way, i.e., a physically well baby who has been nursing well now refusing to breastfeed despite obvious signs of hunger. Babies display the same avoidant feeding behavior in both cases. However, the outcome differs depending on whether the behavior is reinforced or not.
The main point of difference is that a nursing strike is short-lived, generally lasting for two to four days before the baby returns to nursing well. While it would be helpful to identify the trigger to prevent a reoccurrence, it's not essential to do so because a nursing strike is a self-limiting problem that resolves spontaneously in a few days. The reason the baby returns to willingly nursing is that the trigger is no longer present. Over a few days, the baby slowly regains confidence that the 'bad thing' that caused stress, pain, or fright is not going to happen again.
If your baby's avoidant breastfeeding behavior continues for longer than four days, you might be dealing with a breastfeeding aversion rather than a nursing strike.
A breastfeeding aversion is a more serious problem because it does not resolve spontaneously. The baby's avoidant feeding behavior can persist for weeks or months because:
1) The trigger remains present; hence the baby's feeding aversion is directly reinforced as a result of being repeatedly reminded that the experience of breastfeeding is stressful, painful, or frightening.
OR
2) Because the baby's avoidance of breastfeeding while awake during the day is indirectly reinforced in the ways mentioned. (NOTE: Strategies that have the potential to indirectly reinforce a feeding aversion are commonly recommended to keep a baby well-fed during a nursing strike.)
The successful resolution of a breastfeeding aversion is dependent on accurately identifying and removing direct reinforcements, i.e., the trigger (there can be more than one), and also anything that might be indirectly reinforcing the baby's avoidance of nursing while awake during the day. While feeding a baby when drowsy or asleep might initially appear like a solution to a short-term nursing strike, it is not an effective solution to a breastfeeding aversion due to the restrictiveness this has on family life.
A nursing strike can evolve into a more serious case of feeding aversion if not well managed. Alternatively, a baby's avoidant feeding behavior could be a feeding aversion from the onset but mistakenly assumed to be a nursing strike.
Other reasons for the appearance of feeding refusal
There can be other reasons for babies to fuss or refuse feeds that are not related to a breastfeeding aversion or nursing strike. For example:
- Reduced appetite due to teething, illness, or vaccinations
- Bottle-feeding preference
- Breastfeeding-sleep association
- Reverse-cycle feeding pattern
- Poor latch
- Distraction
- Low milk supply
- Delayed letdown
- Sucking and swallowing problems
- Self-weaning
Each of these problems can result in partial or full feeding refusal. All need to be considered when assessing possible reasons for fussy feeding behavior or feeding refusal.
Potential solutions to a breastfeeding aversion
The solution to a breastfeeding aversion varies according to the cause. Potential solutions can be divided into two groups - medical and behavioral.
- Behavioral solutions include educating the mother on where and how to make appropriate adjustments to her infant feeding practices and therapies to improve the baby's sucking coordination.
- Medical solutions include medications, dietary changes, feeding tubes, and surgery.
Behavioral solutions
In the case of normal healthy babies, the solution is often as simple as the mother receiving reliable advice on how to adjust her infant feeding practices in ways that enable her baby to easily access the milk and feed in a comfortable state. Feeding advice might include strategies to manage under- or oversupply and/or forceful or delayed letdown, improve latch technique, interpret and respond to baby's feeding cues, resolve a sleeping problem (poor sleep is a common reason for poor feeding), or how to remedy a reverse-cycle feeding pattern.
If your baby is physically well, the first step is to consult with an International Board-Certified Lactation Consultant (IBCLC) for a breastfeeding assessment and advice on feeding management.
Behavioral solutions also include assessment by a speech and language therapist regarding possible suck training for a baby who has a physical problem that negative affects his suck-swallow-breathe coordination.
If a baby has a structural or functional problem affecting his sucking abilities this will be evident from the time he first starts to feed orally. Plus, it will affect all feeds, even sleep feeding. Whereas the appearance of a sucking problem linked to a feeding aversion will occur after weeks of feeding well and might only be evident when the baby is feeding while awake.
Medical solutions
If you suspect your baby is suffering from pain – as most parents of feeding-averse babies do - it's wise to have your baby physically examined by a medical practitioner.
Acid reflux and milk protein allergy are the 'go to' diagnoses made by doctors concerning any problem that troubles a physical well-baby, including crying for unknown reasons, sleeping, and feeding problems.
NOTE: A doctor cannot see into a baby's esophagus or intestinal tract during a routine medical examination. Therefore, he/she cannot confirm if your baby is suffering from esophagitis due to acid reflux or milk protein allergy without the aid of diagnostic tests.
The following treatments are often recommended by medical practitioners in a bid to remedy a baby's fussy, distressed, or avoidant feeding behavior.
- Maternal dietary restrictions: It is estimated that 1:200 (0.5 percent) of breastfed babies react to foods eaten by the mother.[1] [The vast majority of feeding problems that affect breastfed babies are completely unrelated to their mother’s diet. If your baby displays gastrointestinal symptoms such as vomiting or frequent loose watery stools, I recommend you rule out the possibility of lactose overload before assuming the cause is related to maternal diet.]
- Acid-suppressing 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. (See our article on reflux for more information on how to tell the difference between spitting up and acid reflux).
- Hypoallergenic formula: A hypoallergenic infant formula may be recommended to treat suspected eosinophilic esophagitis - inflammation caused by an allergic reaction to food proteins eaten by a nursing mother or infant formula or foods consumed by the baby.
Once the condition causing the baby's pain is effectively treated, his troubled feeding behavior will fade and disappear. If the problem is not resolved within two weeks of the commencement of treatment, you need to question if the diagnosis was correct or whether there are other causes involved that are not yet addressed.
Get the diagnosis for your baby's nursing refusal right!
An effective solution to an infant feeding problem addresses the cause. Hence, getting the diagnosis right is the key to getting your baby back to loving breastfeeding.
While it's wise to have your baby physically examined, don't overlook the possibility of behavioral causes. Medications, and switching to hypoallergenic formula should NOT be a first-line approach, as such strategies can complicate a breastfeeding aversion as a result of the baby being forced to take unpleasant-tasting medications or infant formula.
In general, doctors are not trained to provide breastfeeding advice, an exception being the tiny percentage who undergo specific training in breastfeeding. Typically, a diagnosis of medical causes for infant feeding problems is made during a brief consultation without asking the mother relevant questions related to her infant feeding and sleep/settling practices necessary to assess potential behavioral causes such as those previously mentioned. The tendency of doctors to consider medical conditions first can result in breastfeeding management problems being overlooked.
An assessment of all possible reasons, such as those listed for feeding aversion and the appearance of feeding refusal, requires knowledge and time.
An accurate, and thorough diagnosis of the cause, or causes as is often the case, requires an understanding of infant development and behavior, and age-appropriate infant feeding practices, as well as knowledge of the various reasons and solutions to breastfeeding aversion. Few health professionals undergo formal breastfeeding education and even less have experience in advising nursing mothers on how to resolve a breastfeeding aversion. Hence, the health professionals you have consulted with thus far may not recognize a breastfeeding aversion or be able to differentiate this from other reasons for a baby's feeding refusal.
A comprehensive feeding assessment requires time. It's not something that can be achieved during a brief consultation and not without asking the mother multiple questions about her infant feeding practices.
You can tell how thoroughly a healthcare professional has assessed the possibility of behavioral reasons for your baby's feeding issues by the number of questions asked of you regarding his feeding history. For example, feeding frequency and duration, complementary feeds, feeding pattern, feeding behavior during awake and drowsy feeds, his sleeping patterns and most important of all, your infant feeding, and sleep-settling practices.
No questions asked = minimal to no consideration given to behavioral causes.
Misdiagnosis is common
Assumptions about the cause of a baby's feeding refusal are made in the absence of a comprehensive feeding assessment. A baby's feeding aversion will continue while it's reinforced. Failure to accurately identify direct and indirect reinforcements for a baby's feeding aversion - which can vary for individual babies - is likely to result in an ineffective treatment plan.
If the treatments and strategies you have employed thus far are not working, it's highly likely that you and your advisors are missing something, for example, the trigger or indirect reinforcements or latch or supply problems, breastfeeding-sleep association, or reverse-cycle feeding pattern.
How we can help your baby enjoy breastfeeding again!
An infant feeding aversion is one of the most complex and confusing of all feeding problems. While I would love to be able to advise you to do X and Y so that you can solve this very distressing problem, the solution varies depending on the cause. The various direct and indirect reinforcements vary between individual babies. There are two ways in which we may be able to assist you.
-
Baby Care Advice Consultation
A breastfeeding problem is not a problem you would normally consider solvable through an online consultation. Correcting a baby's latch is something that is better achieved during a hands-on consultation, but all other reasons for breastfeeding problems, not just breastfeeding aversions, can be assessed remotely and an effective solution explained.
Baby Care Advice consultants have extensive experience in pinpointing the cause of infant feeding aversions (breast, bottle and solids) and other behavioral feeding problems such as those related to equipment and the parent's feeding practices.
Our Baby Care Advice expandable questionnaire includes 80+ questions to pinpoint the cause. At Baby Care Advice we allocate 2 hours for an assessment consultation. This includes carefully reading your answers to the questionnaire before we speak; a 1 to 1.5-hour discussion where we explain how to resolve the problem, and another 20 to 30 minutes to complete a written plan to emailed to you, which might include links to further readings, or something to refer back to and to share with other caregivers. You also have the option to receive daily email guidance and support as you work towards resolving your baby's feeding aversion.
While my book ‘Your Baby's Bottle-feeding Aversion' was written for bottle-fed babies, the basic principles are the same for a breastfeeding aversion. Many nursing mothers have used this book to successfully resolve a breastfeeding aversion.
By Rowena Bennett, RN, RM, CHN, MHN, IBCLC.
Written August 2021
Copyright www.babycareadvice.com 2021. All rights reserved. Permission from the author must be obtained to reproduce all or any part of this article.
[1] Host A and Halken S, Cow's milk allergy: Where have we come from and where are we going?, Endocrine, Metabolic Immune Disorders – Drug Targets. 2014;14(1):2–8.