Feeding development and difficulties


  • Feeding difficulties in an infant who only feeds when asleep

    Successful feeding is based on a reciprocal relationship between mother (or carer) and baby.  The baby’s tasks in the relationship are to give cues to hunger and satiety and to set the pace of feeding.  The mother’s tasks are to feed in response to baby’s cues.  The relationship is based on mutual trust with mother trusting that baby knows when and how much to feed and baby trusting that the mother will recognise and respond to feeding cues.

    Concerns regarding a baby’s growth and how much they feed even when unwarranted can disrupt the feeding relationship.  Strategies used to increase intake and promote weight gain that override baby’s cues to feeding may inadvertently contribute to the development and maintenance of feeding problems.

    Case scenario

    Nina is 4 months of age and has been referred for management of feeding difficulties.  Over the last 2 months she has become increasingly difficult to feed.  She will only feed when asleep but in the last few weeks has not been sleeping well and now wakes when the feed is started.  When the bottle is presented she will cry or just play with the teat.

    Remember to consider your own response before viewing suggested answers.

    Question 1

    What are the key elements of your assessment of Nina’s feeding difficulty?

    Answer Question 1

    Key elements of your assessment include:

    • Parent’s perception of the problem.
    • Medical, developmental, growth and social history.
    • Dietary assessment.
    • Observation of feeding.

    Your assessment reveals the following details:

    Parent’s perception of the problem.

    • Mum is worried that Nina doesn’t feed enough.  “She is tiny.  I am worried that her brain is not growing.”
    • Nina was breast fed for about 3 weeks before being weaned to a standard infant formula.  Mum reports that she attached well to the breast and had good suck and swallow but then she would fuss coming on and off the breast. Feeds would sometimes go for an hour.  “I don’t think she was getting enough breast milk.  I thought if I give her a bottle I will know exactly how much she is drinking. I can be sure she gets the right amount to grow properly.
    • To try and get Nina to take a bit more mum tried a ‘dream feed’ which worked really well.  She then started doing this with each sleep.
    • However mum is now concerned as she is not sleeping as often.  When she does sleep and the bottle is given she wakes and only drinks a small amount.  At other times when the bottle is offered she cries for just plays with the teat. She never drinks the amount that the label on the can of formula recommends for her age.
    • Mum feels she is spending most of her time getting Nina to feed.  There is little time for playing or enjoying Nina.

    Medical, Developmental, Growth and Social History.

    • Nina was born at 38 weeks gestation after a long labour.  She was small for dates weighing 2.4 kg. 
    • There are no concerns regarding Nina’s development.  She is alert and interactive and meeting developmental milestones.  
    • She was slow to regain birth weight but since then her weight has generally tracked albeit below the 5th percentile. Weight gains have slowed in the last couple of weeks to around 100g/week compared to 150g previously.   Length has tracked along the 5th percentile.
    • Nina’s parents are in Australia on a Student Visa.  She is their first child.  They have no family support and dad is about to sit his final exams.  Maternal and Child Health Nurse has been on leave and mum has seen 3 different nurses.  She has not had the opportunity to establish rapport for support.   Mum is described as anxious but not depressed.
    Nina - Length Nina - Weight
    Nina - Length Nina - Weight

    Dietary assessment

    • Formula is being made correctly according to directions on the can.
    • Despite ongoing concerns regarding inadequate volumes:
    • Nina is having 4-5 wet nappies per day suggesting fluid intake is adequate. 
    • Growth has been adequate. (refer to growth charts)

    Feeding Observation

    • At the time of the observation Nina has not been fed for a few hours. She is giving cues that she is hungry
    • She is held in a comfortable stable position with support to head and trunk.
    • She accepts the teat readily and sucks well for a few minutes. As the pace slows mum becomes anxious that she is not going to drink enough.
    • When Nina pauses mum starts to jiggle and turn the bottle attempting to encourage Nina to start drinking again.
    • Nina responds by refusing to take any more.
    • Nina appears content but mum is clearly anxious believing that Nina has not had enough.  Mum reports that she would normally keep trying for up to an hour to get Nina to drink more.

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