Understanding Breast Refusal (Part 1)
Breast refusal can start suddenly. All of a sudden your baby stops feeding from your breast or chest. It can have a gradual approach, where your baby progressively gets fussier and fussier with feeding until they finally begin to refuse outright. Both of these scenarios may feel like you have approached the end of your feeding relationship, and if your baby is not taking a bottle well, it can also feel very scary.
It doesn’t have to stay that way.
If your baby is refusing feeding from you, they are simply communicating to you that something isn’t working as well as it should. Your baby’s brain is wired for breastfeeding or chestfeeding to be their default choice. If your baby is refusing feeding from you, they are simply communicating to you that something isn’t working as well as it should. Once you identify and remove the roadblock, they will be able to get back to their regularly scheduled programming, and you will be able to continue to meet your feeding goals.
If you suspect that your baby is beginning to refuse the breast/chest, get help from an experienced IBCLC early. The earlier you can identify what the roadblocks are, the less time it takes to remove them from your path. If your baby has been refusing your breast/chest for some time, then that doesn’t mean there isn’t a way for you to salvage your feeding relationship. It just may take a bit longer.
In this 2-part series on feeding refusal, I’m going to talk about what causes feeding refusals, what to keep an eye out for, and what you can do to help make sure your feeding relationship lasts as long as you want it to. But before we get there, I want to offer this: If you are dealing with a breast/chestfeeding aversion, and you missed the earlier signs, give yourself lots of grace and understanding. If your brain wants to run right to a place of blame, that’s a common response. It's also not fair to yourself. Professionals miss early signs all the time. The fact that you recognize them now is amazing, and it’s enough.
3 Main reasons for Chestfeeding/Breastfeeding Aversion
To understand feeding aversions, we have to understand your infant's brain. When your infant is born, they are entirely driven by reflexive behavior. That means that none of their movement patterns are generated by choice. They are all generated because of a response to a specific stimulus. This is how a baby stays alive in the beginning. When you put a bottle or your breast/chest in their mouth, they have a reflex that causes them to suck. When they suck, milk enters their mouth. A different reflex causes them to swallow. Over time, though, as your baby’s brain matures, they begin to develop a choice in moving their body - beginning around 8-10 weeks.
Early signs of feeding aversion can be subtle - they may just cry more with or after feedings or turn their head away when they didn't before. They may begin to cry with feeding or they may start to turn their head away or slide shallow when feeding. As a baby gets older, and we haven’t resolved the underlying reasons why the refusal was occurring, the baby gets more choices. This means they can move their head with more range of motion, they may arch their back, and protest more. They may cut feeds short and refuse to feed after a short period of time. They may feed better at night and when they are asleep than they do during the day. I’ll explain why that happens in the section below.
1. Introduction of a Bottle
Keep an Eye Out For A mismatch between your flow rate and your bottle size.
Symptoms: A sudden onset, often shortly after an increase in the number of bottles given each day.
Solution: Reduce the volume of the bottle and slow the flow rate, if possible.
Sometimes a mismatch between the bottle and breast/chestfeeding can cause a preference for the bottle, and frustration with the breast/chest. The two main areas of a mismatch between the bottle and the chest/breast are the flow rate and the volume.
Sometimes, we can control these things, and sometimes these factors are out of our control, particularly if our child is in a daycare setting that isn’t familiar with chest/breastfeeding babies. Most formula-fed babies are fed according to the instruction on the can, which calls for fewer, increasingly larger bottles. This is designed for ease, and not because of a biological need to have bigger, fewer bottles. On the contrary, babies who are feeding from the breast/chest don’t take in significantly more milk from 6 weeks to 6 months.
So, if they are in a daycare setting that is feeding bigger and bigger bottles to keep up with their peers, a baby may be unsatisfied with feeding from the breast/chest alone because its volume is smaller. This creates a volume mismatch.
A nipple flow mismatch can occur if the flow rate of the nipple is faster than the flow rate of the breast/chest. Just like the volume of the milk from the feeding parent doesn’t change with time, neither does the flow. If your baby has suddenly developed a feeding aversion after being given bottles, make sure you are using a slow-flow bottle.
2. Aversion Because Feeding Doesn’t Feel Good.
Keep an Eye Out For: Symptoms of discomfort after feeding
Symptoms: Feeding progressively gets worse, starting at around 2 months, often uncomfortable feeding with pumped milk from the bottle AND from the chest/breast, may feed better while sleeping than when awake.
Solution: Work with an IBCLC to identify and solve the underlying reasons for the discomfort. This usually takes more than just eliminating dairy.
The design of feeding is to help a baby connect the pleasure center of their brain to feeding. That means by design, feeding is supposed to feel good. It's supposed to be like having the perfect meal - delicious, with good company, and just the right amount - with most feeds. Feeding is supposed to teach what satisfaction and connection feel like.
What happens when a feeding does the opposite? When feeding makes our belly hurt, instead of feeling good, our brain starts to associate feeding with discomfort.
This is often the pattern of the baby who feeds well at night but not during the day. When a baby is asleep, their behaviors revert to being 100% reflexive again. Their choice - and conditioning - are overwritten by instinct. When these babies wake up, the part of the brain that is conditioned to choice takes over, and they may limit feeds again.
A baby may only feed when they are really hungry, and then feed for just long enough until they are no longer hungry. They sometimes have signs of reflux, like spitting up after eating, but not always, because reflux can also be silent. Silent reflux can show up like frequent coughing after feeding, tongue thrusts, chewing, or swallowing after a meal is done.
These babies may start to slowly slide down their growth curve because they limit feeds. This can catch you by surprise when your baby gains well initially and then slows down suddenly at their 4-month visit.
These babies are often fussy during or after feeding, they may arch their back as soon as you offer to get them into position, and have relatively brief periods of time when they are happy. They may need to be held often, and you may just think that they are a ‘fussy baby’, when what is actually happening is that feeding for them just doesn’t feel good.
The good news is that there are lots of things that can be done to help make feeding feel better, and when that happens, you can go right back to building the positive aspects of the feeding relationship.
3. Aversion Because Feeding is Hard.
Keep an Eye Out For: Signs that feeding is hard, like choking, clicking or leaking milk while feeding.
Symptoms : Slow progression to outright refusal often closer to 4+ months, weight gain may be robust (or high), fussy with the breast/chest but not fussy with pumped milk from the bottle.
Solution: Get an oral feeding assessment to work on supporting the muscles used during feeding.
Infant feeding is designed to be easy. When all of the muscles of the tongue and mouth work in the way they are supposed to, and we are allowing our babies to latch in a way that initiates movement, then the process of sucking and swallowing is easy and safe.
When the tongue isn’t able to move in the mouth as easily as it is supposed to, this can make feeding unsafe, or hard. A baby that is given a bottle and the breast/chest, can develop a preference for the ease or the safety of the bottle over the breast/chest, once they recognize the difference, often around 3-4 months.
If feeding is hard, a feeding assessment can help you understand how to help support your baby’s oral motor skills to get feeding and your feeding relationship back on track.
Sometimes, it can take a little while to address the underlying cause or causes of the feeding refusal, so in the second part of this series, I’ll cover some strategies to help you get to the other side. While it's easy (and understandable) to feel worry, a feeding aversion doesn’t mean the potential to have the feeding relationship you wanted it over, it just means you may need to make a detour to get there. The sooner you get help, the sooner you will be on your way.