Module 2: Oral Aversion

Definition: Feeding aversion occurs when a competent baby (one with adequate oral function who was previously feeding well) refuses to feed.
Can start as early as seven weeks of age.
Aversion can be to breast, bottle, or solids, or to the entire process of eating.

Cries or screams when bib is placed around neck, put into feeding position, or shown the bottle.
Appears hungry but refuses to eat.
Eats only when ravenous.
On-off feeding pattern (unsustained feeding).
Eats only when distracted.
Feeds only while asleep or drowsy.
Consuming less milk or food than expected for age.
Displays poor growth.
Avoids eye contact with caregiver while feeding.
Rejects feeding while held in arms.
Accepts milk from another source.
Accepts water but not milk from the bottle.
Clamps mouth shut and turns head away from breast or bottle.
Fussing or crying when preparations are made for feeding time.
Taking a small amount of breast or bottled milk and then pulling away.
Not all babies present all signs and symptoms.
Babies with oral aversion show reluctance, avoidance, or fear of eating, drinking, or accepting sensation in or around the mouth.

A three-month-old that is distracted while feeding, and the mom needs to be in a very quiet place to feed this baby, that's not feeding aversion.
A baby that is fussy with the flow, but feet's okay if the flow is present, that's not feeling aversion.
Feeding aversion is a competent baby who was feeding fine, now it's not, even if hungry, refuses to eat.

Refusal:
- Baby primarily breastfed, may have fed from bottle occasionally.
- May have fussed a little with the bottle when younger.
- May play with the bottle but not eat from it.
- There might be an anatomical issue or not.
Aversion:
- Usually seen in a baby that is fully bottle fed.
- Low intake and very small volumes at each feed.
- Cries or screams at sight of bottle.
- Only feeds when asleep or distracted.
- No anatomical issues or sucking problems.
- Behavioral issues are acquired.

Reacts for no obvious reason (distress appears unprovoked).
Baby is not coughing or choking while feeding or physically uncomfortable while feeding.
Feeding only when distracted (walking, rocking, bouncing, using screens, etc.).
Conflicted behavior: accepts the teat, sucks a few times, then cries, arches, fusses, latches on again, repeating the cycle.
Appears hungry but doesn't feed consistently; misinterpreted as sucking issues or pain.
Sometimes seen after procedures like tongue releases.

Suck issues: history of sucking issues before seven weeks of age.
Aversion: past experiences, such as procedures (e.g., tongue-tie release) or pressure feeding.

Mistaking aversion for sucking problems or pain can lead to incorrect and potentially harmful interventions (e.g., unnecessary oral work).

Two-thirds of babies with feeding aversion present this symptom.
Parents discover baby feeds better while asleep, so they eventually don't even try to feed the baby while awake.
One-third of babies end up exclusively feeding while asleep.

Rule out high lipase by scalding the milk.
If not high lipase, consider past experiences related to stressful or frightening feeding episodes.
The trigger might not be the bottle but the milk itself, often related to pressure feeding.

Common in preemies due to unpleasant NICU experiences or limited oral stimulation.
Can start from birth, especially in babies fed with a feeding tube.
Consistent characteristic: defensive and fearful behavior regarding food, drinks, or objects related to feeding.
Motor issue: difficulty moving food/milk through the mouth due to muscle weakness, anatomical issues, or poor coordination.
Sensory issues: hypersensitivity to the feeling of food/milk in or near the mouth.
Fear: of negative consequences like choking, triggered by traumatic events (bitter taste, choking, oral trauma/surgery) or repeated events (frequent gagging, pressure feeding).

Frustration for parents, caregivers, and babies.
Psychosocial and medical complications, including compromised development and impaired parent-infant bonding.
Infant and parental distress.
Parental lack of confidence.
Poor growth.
Social isolation due to feeding rituals.

Team of specialists working together.
Gentle feeding techniques.
Responsive feeding techniques.
Lactation care and a plan to maintain supply if applicable.
Pain control and pleasant touch on the face.
Feeding tube as an option if necessary.
Interdisciplinary team: pediatrician, gastroenterologist, SLP, nutritionist, occupational therapist, physiotherapist, psychologist, and social worker.
Strategies:
- Stop pressure feeding.
- Teach responsive feeding.
- Create a positive atmosphere around feedings.
- Use oral motor toys.
- Practice with pretend foods and toys outside of mealtimes.
- Consistency and patience (progress may not be linear).
- Extended support.

It is not within a lactation consultant's scope of practice to "treat" oral aversion, per se.
Understand causes, prevention, and identification of oral aversion vs. refusal.
Know how oral aversion is managed and when to refer out. Focus on bottle refusal and breast refusal.