Food refusal and bottle aversion in children

What is a food refusal (feeding or bottle aversion)?

Food refusal or feeding aversion is also known as bottle aversion.
An aversion is the avoidance of something or a situation following an unpleasant, stressful, frightening, or painful experience. Basically, it is a fear, presented when there is an expectation that something bad or unpleasant will happen again. ‘Feeding phobia’ is another term that may be used to describe a feeding aversion.
Eating refusal refers to a situation in which a physically healthy baby repeatedly refuses feeding, either partially or completely, despite being hungry. The baby is physically able to eat, but for reasons that have not yet been identified or corrected, he avoids or refuses to.

How to identify bottle aversion in babies?

A baby may exhibit one or more of the following behaviors:
• Skipping meals without showing any distress or signs of hunger.
• Seems hungry but refuses to eat.
• Will become restless or cry when the bottle is presented or when placed in feeding position.
• Shuts mouth or cries and turns his head away from the bottle (or breast, spoon or food).
• Takes a few sips when offered, but then becomes fussy. Eating becomes not efficient.
• Baby feeds while distracted or asleep.
• Consumes less milk or food than expected.
• Avoids eye contact with caregiver.
• Plays or bites the nipple in mouth.

What causes bottle aversion?

A baby may develop a feeding aversion if an event that occurs directly before, after, or durind eating causes a negative emotional reaction, such as stress, pain, fear, or disgust.
Stress – If a baby is forced to eat, against his will, baby will become frustrated or stressed during feeds. The extent depends on feeding strategies and how long they have been using then on the baby.
Repeated feeding attempts against the baby’s will or when baby did not show signs of hunger. This is one of the most common reasons why babies develop an aversion, along with stress.
Pain – Eating can be painful, for example if your baby has mouth ulcers or inflammation of the esophagus (esophagitis/inflammation of the esophagus sometimes mistakenly called silent reflux, read more at the following link). In these situations, the parent may pressure the baby to eat, not understanding what is bothering him. The baby now has two reasons to avoid feeding – pain and the stress associated with the pressure to eat.
Fear – Medical procedures involving the baby’s face or mouth, such as nasal or mouth suction, insertion of a feeding tube or invasive ventilation can be painful and fear-provoking and therefore cause food refusal.
Disgust – if the baby received a bitter tasting medicine that was given with proximity to feeding or bad tasting food, sometimes the context will be negative, and this will lead to eating refusal.
Other reasons – There are several other possible reasons for babies to exhibit an aversion to breastfeeding, bottle feeding, or solids. Any situation that causes the baby to feel frightened, stressed or experience pain while feeding has the potential to provoke partial or complete eating refusal.

When do babies exhibit bottle refusal?

Starting from a few weeks of age and up to a few months of age, refusal related to breastfeeding/bottle feeding will appear. Later, refusal to solids may also appear.

I know my baby is hungry, so why is he/she not eating?

Babies with a bottle aversion exhibit contradictory behavior –the baby takes a few sips, turns his head, or stretches his back tensely, perhaps cries, quickly returns to the bottle, takes a few more sips, and repeat. It seems like he doesn’t know what he wants or perhaps he is ambivalent, meaning he want to but also doesn’t want to eat.
Such eating is often interpreted by parents and others as an indication that the baby is experiencing pain, especially if he cries intermittently, but this is not necessarily the case. Babies who are reluctant to eat will behave in this tense or distressed manner regardless of the cause.
So maybe it is inflammation of the esophagus after all (GERD or silent reflux)?

Indeed, there are babies who due to heartburn / inflammation of the esophagus (erroneously called silent reflux), have reached a state of refusal, both because of the physical discomfort they experience while eating and because of the lack of communication with the baby’s feeder that led to the unwanted eating behaviors. However, not every baby experiencing reflux will end up refusing, just as not every baby with an eating refusal is due to silent reflux.
That’s why parents who want to understand more and avoid a misdiagnosis (or on the other hand, overdiagnosis), should read the chapter on our website that explains about reasons for restlessness in infants and toddlers, when one of the most important reasons is actually inflammation of the esophagus (link here).
Every healthy baby experiences food traveling up and down their esophagus countless times a day, many babies will spit up throughout the day and this is of course is completely normal.

What came first? The chicken or the egg?

As mentioned, sometimes there is a good reason that caused a decrease in appetite (routine vaccines, common cold or tummy bug, teething, reflux etc). The baby decreases the amount he/she eats and then the parent, who doesn’t always understand why this happened, starts pressuring baby to eat. When that doesn’t work, they sometimes start using methods that work for a while, such as distracting them, feeding while sleepy or drowsy, feeding while walking or bouncing etc.
Sometimes it is simply a lack of communication and inattentive feeding that brings the baby to a state of unpleasant feedings and hence the ambivalence towards eating up to refusing.

What if the baby doesn’t eat at all?

This is super important for a parent who thinks that if he won’t force feed the baby, he will cause irreversible damage.
Eating is not something a baby can completely avoid. An aversive infant will reluctantly eat enough to survive but will not necessarily eat enough voluntarily to thrive. A baby will try to ignore his hunger cues for as long as possible. That is, you eat when you’re hungry, but carefully, and quickly for fear of a reoccurrence of everything that causes the fears in the first place. The amount will be minimal and enough to satisfy hunger, but not enough to feel complete satisfaction or enable proper growth (growth could still be normal at first or if baby is forced to eat proper amount).

How to beat Bottle refusal?

This is complex.
Firstly, physical, and medical conditions that may affect eating must be ruled out, so start by going to your pediatrician and describe the difficulties.
The treatment fort eating refusal is mainly behavioral. and requires a lot of patience. The parents’ patience of course.
Infant behavior, whether it is desired or unwanted behavior, is reinforced by the actions that parents take or do not take. To solve a behavioral problem you aim to change a baby’s behavior (assuming he is healthy) and turn eating from a stressful event to a pleasure. From eating for minimal satisfaction to eating for the purpose of satiety and satisfaction.

What else do I need to know when dealing with bottle aversion?

From my experience, babies who have had an aversion to breastfeeding/bottles may react similarly when transitioning to solids.
Therefore, even though there are cases where transitioning to solids will work, it should be noted that there is already fussiness around the mouth and a negative experience with food, so it is very important that the transition be very attentive and in accordance with the child’s ability and desire.

Who do I turn to if I think my baby has bottle refusal?

Few healthcare professionals are familiar with age-appropriate infant feeding methods and/or the process involved in resolving behavioral feeding refusals experienced by normally developing infants and young children.
That’s why it’s important to contact a pediatric dietician who specializes in Feeding difficulties or a feeding clinic.

What does the future hold? Will there be any medical or psychological damage to the child who refused?

Refusal to eat is often accompanied by frustration, both on the parent’s side and the child’s’. It is known that most parents dealing with a feeding aversion will develop anxiety at some level. Just the thought of feeding their baby raises concerns, thus affecting the confidence and sense of parental competence.
We know that all a parent wants is to overcome the eating issues so that the baby can continue developing, growing and eating normally. That’s why it’s important to seek help and guidance.
A temporary aversion to certain foods is usually not a medical concern, but if it is a persistent issue or if you are dealing with it daily, it is important to seek help.
There is a simple behavioral solution to eating refusal, and you should start sooner rather than later. On the other hand, you must have the guidance of the right professional.
In conclusion, this is a very important problem in pediatrics. If you feel you are dealing with an eating aversion, contact a professional as soon as possible in order to stop this snowball.