Message: I have a client who has a baby boy who is 14 months old.  He is exclusively breastfed, but he refuses all kind of solid food.  The mother has tried almost everything.  He appears a little overweight. She asks if she has to wean him?

Ameera Hassan, IBCLC
Cairo, Egypt

Barbara & Kay Respond:

Dear Ameera,

Normally, between 4 to 6 months, babies become curious about foods and begin to reach for food from their mother’s plate. Eating with the family becomes an enjoyable social experience. When a child refuses all attempts to get them to eat solids, we would not describe this a breastfeeding problem.  Millions of babies enthusiastically consume solids while continuing to breastfeed.

Sometimes mothers misunderstand how much food the toddler should eat.  They may describe a child who eats only small portions or merely tastes things as “not eating”.  However, small portions are normal for toddlers.  In addition, some toddlers are very resistant to certain foods or even to being fed. Many families tell funny stories about toddlers who would eat only one food for weeks, or who would only eat if allowed to feed themselves.

Once babies are 6 months old, parents should try putting small amounts of mashed food from the table in front of babies and allowing the baby to taste things without any pressure to consume more than they want. Flexibility and a relaxed attitude are necessary when feeding toddlers.

There are some reasons for outright refusal of solid foods:

1. Vitamin and mineral deficiencies can result in  food refusal.  Sometimes the child has a medical problem that results in inability to metabolize micronutrients; sometimes the mother has a deficiency and the breastfed infant becomes deficient because the mother’s milk is lacking in a specific vitamin or mineral. There are case reports (see references below) of Vitamin B(12) deficiency resulting in solid food refusal.

2. There could be a mechanical problem in the child’s throat or intestinal track (a blockage or stricture) that may affect his willingness to swallow solids or ability to digest anything but a liquid diet.

3. Sometimes feeding aversions develop as the result of early unpleasant oral experiences (such as long periods of intubabtion.)  Feeding aversion can also result if something about the solid food feeding experience feels unpleasant to the child.

You mention that the boy appears slightly overweight.  Could an undiagnosed illness of some sort be causing him to retain fluids and appear swollen when perhaps he is actually malnourished?

Once again, we think this should not be labeled a “breastfeeding problem” but as a feeding problem.

The baby should have a medical evaluation, and the mother tested for Vitamin B(12) deficiency. Perhaps the mother could receive counseling to insure that she has realistic expectations of toddler feeding behavior.  Breastfeeding should continue while they figure out why the baby refuses solids.

Please let us know what the result of your investigation finds.  We are curious about this case.

Update

Ameera contacted us with the following additional information:

They did the blood work on the baby and everything looks fine.  The pediatrician is not convinced that it is necessary to do invasive investigations like endoscopy.  His diagnosis is that the  baby is taking too much milk through breast feeding so he is too full to try any new food.  He advised the mother to let the baby get hungry as much as possible.  According to the mother this did not work, so she decided to  wean him completely and abruptly despite anything I said to her.  Today will be the third day without any breastfeeding.  I am waiting to hear from her about the outcome of her decision.

Barbara & Kay respond:

It is good news that the baby’s blood work showed no problems, but how frustrating to still not have an answer.  Perhaps more will become clear over time.  Just to be re-emphasize one point, the Vitamin B(12) deficiency that is referred to in the reference below was a maternal vitamin deficiency that affects the baby, so the mother’s Vitamin B(12) levels should be checked.

References:

Eur J Pediatr. 2011 Jul 7. [Epub ahead of print]

Solid food refusal as the presenting sign of vitamin B(12) deficiency in a breastfed infant.

Ide E, Van Biervliet S, Thijs J, Vande Velde S, De Bruyne R, Van Winckel M.

Source

Paediatric Gastroenterology and Nutrition, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium.

Abstract

Dietary vitamin B(12) (vitB(12)) deficiency, although common in the elderly, is rare in childhood. We report on an exclusively breastfed 8-month-old infant, presenting with persistent refusal of solid foods. Three months later, developmental regression and failure to thrive led to the diagnosis of vitB(12) deficiency, as a consequence of a subclinical pernicious anaemia with vit B(12) deficiency in the mother. Treating the infant with parenteral vit B(12) induced prompt recovery including acceptance of weaning food. Conclusion: This case illustrates refusal of complementary foods as a presenting symptom of vitB(12) deficiency in a breastfed infant. Symptoms, diagnostic tests and treatment of vitamin B(12) deficiency are reviewed. Early diagnosis and treatment are important to prevent irreversible neurological damage.

Eur J Pediatr. 2010 Mar;169(3):373-4. Epub 2009 Oct 28.

Food refusal in 1-year-old child.

Ravikumara M.

Source

Paediatric Gastroenterologist, Princess Margaret Hospital for Children, Roberts Road, Subiaco 6008, Australia. Madhur.Ravikumara@health.wa.gov.au

Abstract

This is a case report of a 1-year-old, otherwise healthy, girl who presented with the history of refusal of solid foods and vomiting of 1-month duration. She underwent upper gastrointestinal endoscopy, which revealed an eye-catching endoscopic finding and the cause of her symptoms.