Ending Your Baby's Food Refusal: An Approach to Understanding and Managing Feeding Struggles in the Under Fives

Ending Your Baby’s Food Refusal

Copyright © 2021 by Michele Meehan

All rights reserved. No part of this publication may be reproduced, distributed, or transmitted in any form or by any means, including photocopying, recording, or other electronic or mechanical methods, without the prior written permission of the author, except in the case of brief quotations embodied in critical reviews and certain other non-commercial uses permitted by copyright law.

Tellwell Talent

www.tellwell.ca

ISBN

978-0-2288-5856-0 (Hardcover)

978-0-2288-5855-3 (Paperback)

978-0-2288-5857-7 (eBook)

Dedication

To all the babies and their families, who have given me years of pleasure, laughter and entertainment, and for whom I am full of admiration for their skills and devious strategies to avoid feeding.

About the Author

Michele Meehan, a paediatric, maternal and child-health nurse has been employed as the clinical nurse consultant at the Royal Children’s Hospital in Melbourne for over 29 years. In working with babies and their parents in the hospital, her work developed from advising mothers about their sick baby’s feeding to an increasing interest in understanding why some babies have more difficulty in establishing normal routines of feeding, eating, sleeping and comforting than others.

Michele’s involvement with the Infant Mental Health Group at Royal Children’s Hospital was from its inception in 1988, and this now reflects in all her work. In 2008 Michele completed her master’s in Health Science (Parent and Infant Mental Health) at Melbourne University, with a minor thesis entitled, He Won’t Eat! Development of a model for treatment of infant feeding refusal.

She has presented at international forums and is frequently called on to be a speaker at national nursing and health care conferences.

In 2014, Michele established a clinical nurse consultation practice called Parenting Matters. (parenting-matters.com.au) Her clinics have direct contact with the families of referred babies, to assess, advise, manage and follow-up feeding and eating concerns.

Table of Contents

Introduction

Purpose of this Book

Chapters

1. Birth to 2 Weeks

Establishing feeding

2. 2 Weeks to 6 Weeks

Building a Confident Feeding Relationship

3. 6 Weeks to 3 Months

Routine and Reading Infant Cues

4. 3 Months to 6 Months

Oral exploration. Changes in feeding

5. 6 Months to 8 Months

The Introduction of Solids.

A word about the group of possible allergenic foods

6. 8 Months to 12 Months

Consolidating self-feeding skills

7. 12 - 18 Months

Weaning and so to family meals

8. 18 Months to 2 Years

The world of toddler’s mealtimes

9. 2 - 3 Years

Preferences, Healthy Eating Habits, Cultural Differences

10. 3 - 5 Years

Normal Meals

11. Special situations

Oral Aversion, Sensory Play, Play Picnic, Naso-Gastric Tube Weaning

Introduction

One day, while working with the mother of a 15-month-old baby who was being fed by a naso-gastric tube¹ because she would not eat or drink anything, the mother said to me in frustration You would think I’m expecting her to make a bungee jump!

This seemingly incomprehensible fear of food is what has driven my interest in the last 15 to 20 years.

Working at the Royal Children’s Hospital as a clinical nurse consultant from 1984-2013 it was serendipitous that I ended up working in the field of food refusal in young children.

A young mother had presented to the hospital with her 3 month old baby refusing to drink her bottle. She had taken as little as 100mls for the day (required 650mls) and became increasingly distressed with any offering of the bottle.

When I came to see her, she had had a nasogastric tube inserted and was having her milk this way but was still distressed when offered the bottle. It was diagnosed that she had severe cows milk protein intolerance² (CMPI) and was in pain with every feed.

The new formula was to make her feel better and she would feed again then mother was reassured.

Two weeks later she rang me to say that while not upset any more, Ella was still refusing the bottle. She had been told by the hospital that she would drink eventually, but she felt she had made no progress and had no plan to get there.

This led to my interest and subsequent research into understanding, not just what mum should do, but what Ella was saying to us.

MY BACKGROUND

As a paediatric (child) trained nurse, midwife and Maternal & Child Health nurse I was employed at Melbourne’s Royal Children’s Hospital as a Clinical Nurse Consultant and in 1988 a member of the Melbourne Royal Children’s Hospital Infancy Group. My contribution, as well as my learning, has increased my understanding of the infant’s emotional life, and thus afforded greater acknowledgment of the potential for nurses to be involved in this exciting new area of infant mental health.

Exploring research and thinking in this area, reminds me not only that the infant has a mind, but also that parents are ready to think about their baby’s contribution to and experience of, any presenting difficulty. By seeking to understand the dynamics of the situation and by discussing this understanding, major shifts in the infant’s behaviour can be affected.

It is not just the actions of you as mum, but your baby’s contribution as well that affects the situation.

THE PROBLEM

The management of severe feeding problems in babies is an area fraught with anxiety, not only for the parents but also for nurses and medical staff caring for them.

An increasing trend in feeding difficulties seems to be one of almost total feeding refusal by the infant.

They are not always irritable or upset, rather appear quite happy as long as you don’t try to feed them.

Despite an apparent total disinterest in feeds, they often continue to gain adequate weight, but do so in an environment of extreme anxiety for them and their parents.

Parents face a seeming lack of concern from some medical services because the baby is apparently well and is gaining weight.

Reassurance alone is not seen as adequate intervention by the parents.

MY APPROACH

Over the years of my work at the Royal Children’s Hospital I learnt that not all mothers were after advice but rather they felt in their mind they must first seek to understand

I was referred a lot of crying babies and those with feeding problems, and I was interested and puzzled about why THIS baby was having such trouble.

Certainly, there were loud, impatient, feisty, alert, engaging babies, but these were not necessarily the puzzling ones struggling with feeding and settling.

So, I started to think about what the baby was contributing to the struggle.

I started then to focus my observation, not just on what the baby was being fed (and whether she ate it) but what seemed to trigger the negative behaviour when faced with the presentation of the food.

Not so much trying to answer, Why is she doing this? but rather WHAT is she doing?

This was the perfect framework to understand the feeding problems I was referred and this has remained my major interest.

Not why did she refuse to open her mouth, but rather what is she doing?

And the answer became obvious after spending time watching the feeding, rather than just listening to the parents’ report.

She was responding appropriately to what she has been experiencing.

The establishment of feeding enjoyment by baby and mum is vital to the mother-infant relationship. The experience of feeding is part of the development of attachment style, and early feeding difficulties, left unaddressed may lead to a struggle that distorts the give-and-take responses of mum and her baby, leading to more fixed problems in later months

In responding to mothers who are worried about their baby’s feeding it is not enough to offer reassurance alone.

Rather, by listening in detail to the mother’s story and linking infant behaviour to identified feeding stressors, mum can see her baby as purposeful and acting with intent. Spending time with them, by watching and participating in the meal, I could closely track and try to understand and thus describe the baby’s reactions. This prevented the common frustration of mum feeling she was not being heard, and that no one understood what she was experiencing or talking about.

I believe my approach of using food-play as a desensitisation to food refusal is acceptable to families. By showing that babies may be exposed to an experience of bombardment of food and milk all day, my approach was relevant to one of the causes of their increasing difficulty, namely too much pressure.

How the baby reacts to the food play, directs my development of a playful exploration of the food, encouraging the baby to play out her anxiety in a supported setting.

The importance of accepting that the baby may demonstrate no hunger signals, helps direct a planned routine of feeding, timing and scheduling.

The loss of enjoyment of mothering is significant in the families I work with, and play proves an effective interaction to bring mum and baby back together, not just an improvement in feeding.

I believe this sharing of enjoyment allows mum to see that her baby as capable of goal-directed actions, not just random, incomprehensible behaviour.

The primary role of a mother is to feed and nurture her baby, so when this does not go well the whole relationship and confidence is undermined

Mentro (2002)³ has shown that not only does the parent’s attitude affect the infant’s eating, but also a child’s aversion to feeding may cause parental anxiety resulting in pressure on the child to eat.

This ongoing cycle of poor growth and eating struggles may lead to a lack of confidence for the parents. Studies show that mothers of children with growth deficiencies are less confident about their parenting abilities than mothers of children who grow well. (Bithoney 1995)⁴

The bond forged between mother and baby is one of considerable strength, but too often the advice we give in child health is solely related to what the mother can do for, or to the baby, with the implication that the baby will follow.

In providing an alternative baby-focused approach we bring in the role played by the power of the baby’s mind.

Force-feeding, while often the last resort for parents who feel they are faced with no other choice, rarely makes things better. Over-riding the baby’s desires and messages may only make the situation more stressful, with the baby becoming more stubborn about refusing, and parents find they are unable to persist with these methods.

Observation of the baby’s response to play is fundamental to my theory that the baby’s behaviour and his interaction with me help him approach food with less anxiety.

Central to this is an understanding of the effect of early experiences on the baby and also the effect of this on mum feeling connected to her baby. While it is important to understand what first triggered concern about feeding, may not always still be what