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What feeding therapists & pediatricians are getting wrong when it comes to "responsive feeding"

Updated: May 15, 2020

We want to tell you a story of a baby that had some struggles with responsive feeding and then explore why and what could have been done differently. We want to talk about what this tells us about responsive feeding in general, and what both feeding specialists and pediatricians are getting wrong when it comes to responsive feeding...But before we get into that, let's quickly start with some foundational stuff- like what is "responsive feeding." As we described in our last post on this topic:

Responsive feeding is the practice of listening to a baby's communication about hunger or being full, then responding warmly and consistently by offering food or stopping the feeding. This includes offering food when baby "tells" you he or she is hungry (even if it's not "feeding time") and also stopping the meal when baby indicates he or she is full (even if the bottle is not empty or baby "usually" eats more).

For the record, we love this concept. As feeding specialists we strongly agree that infants should be listened to and respected (especially when it comes to feeding) and we would guess you do too. Having practiced in a wide variety of settings for over a decade each, we’ve also witnessed hundreds of babies over the years who were fed in a forceful or prescriptive manner early on and we’ve seen the impact on later feeding (picky eating, poor weight gain and really challenging mealtime behaviors to name a few...) We know feeding responsively is ideal and important, right? But we admit that we thought this was a relatively simple and easy idea when we first learned of it.

Yet we have seen many parents and medical professionals get tripped up with implementing responsive feeding. In fact, feeding therapists (old and new) struggle with this...we all seem to be at risk for getting things wrong when it comes to responsive feeding, which is why we wanted to explore it a bit more.

Let's jump into that story we mentioned. It's about a newborn admitted to the hospital a few days after birth and the journey to practicing responsive feeding.

Meet baby Ella

Ella (not her real name) was born at 37 weeks, 5 days via c-section for maternal preeclampsia. She was discharged home on day of life two, learning to breastfeed, but mostly taking formula from a bottle. Her mother was unfortunately readmitted to the hospital for severe postpartum preeclampsia, and all baby-related tasks were turned over to dad as mom was hospitalized—including bottle feeding.

Newborn baby, feeding issues

Anyone who is a parent will immediately feel that heart pang for mom and dad in this situation. And whether you’re a parent or not you can of course empathize and imagine that everyone is probably feeling pretty stressed, tired, anxious...lots of things besides joy, excitement and a calm focus on feeding.

Yet any feeding therapist who has practiced in an acute care pediatric setting for even a little while can recognize that there’s nothing too complex in this medical history so far. Sounds pretty straight forward right?

While historically the father might have been told to feed the baby every 3 hours, 1-2oz or something prescriptive like that, responsive feeding doesn’t give exact numbers. With responsive feeding, dad would ideally be bottle feeding his baby formula (or pumped breastmilk if mom is able to pump) regularly, whenever the baby is "showing feeding cues" and he would feed her until she gave signs she was done. As long as she is pooping and peeing and gaining weight, all would be considered a-ok.

In this situation, the family had lactation support at the hospital and a pediatrician who gave advice on bottle feeding. (Lactation Consultants are definitely trained in responsive feeding and pediatricians who follow the AAP guidelines should be promoting and guiding families on responsive feeding practices.) So why did this baby end up admitted to a tertiary care hospital getting worked up for failure to thrive due to a greater than 15% weight loss in the first ten days of life? One obvious answer is that this poor family was stressed! But let's explore this a little more deeply.

The common mistakes many parents make

Responsive feeding offers many important benefits, so why do so many families struggle to use these ideas and why do pediatricians and even feeding therapists make recommendations to families that go against responsive feeding practices? Well, lots of reasons...

  • It's very common at first to accidentally underfeed your baby because it's almost unbelievable how often newborns need to eat. If you're a first time parent, it's very easy to make mistakes here.

  • Ultimately babies need to be fed enough to grow and some babies will struggle with staying awake right at first and latching well enough to eat and grow-- which means they won't show normal hunger and satiety cues and won't weight gain well right at first if the caregiver feeds the baby according to the baby's cues. (Yes, we're basically saying that responsive feeding won't work for some babes right at first and this is, in part, what happened to our little Ella.)

  • Being a first time parent is hard and can feel really scary, even when it’s all going well. If you suspect the baby isn’t eating well or baby (or mom or dad) is having health issues, these stressors can amplify the parent's anxiety, which can cause parents to grasp at straws, over react or make odd choices.

  • Newborn and early infant feeding cues can be confusing and are identical at times to cues that the baby is just tired or bored.

  • Every baby is different so while responsive feeding will work for the vase majority of infants, it will also look different with the parent needing to respond differently in many cases.

  • Last, as the baby grows the risk shifts from a high possibility of underfeeding the baby, to a high likelihood of overfeeding the baby because babies have a high suck need and tend to calm when being fed AND many parents whose infant struggled even a little early on with feeding may end up pushing the baby to eat past their "I'm all done" cues.

Out of the reasons above at least 3 apply perfectly to Ella's situation. She was born at 37 weeks which is considered “late pre-term.” The question of true age also came to light—she seemed less mature than her gestational age suggested. It's not uncommon for babies born around that time to be a bit neurologically immature for a few weeks, which means they may be very sleepy most of the time and then fussy and disorganized when they wake up. It's a BIG challenge to feed babies like Ella and it can be exhausting for new parents. Add to that the additional stress and anxiety the dad and mom were experiencing around mom's health issues and you've got a perfect storm of risk factors for feeding and eating issues.

One important lightbulb moment from all of this for feeding therapists and pediatricians (or even better- for insurance providers!) should be the idea that all parents need guidance and that guidance should be more than just "feed baby when she is showing feeding cues." Yes, we want to avoid a one-size fits all/old school "feed baby every 3 hours, 1 oz." But parents do need some guidelines and direction, especially right at first. As the baby grows, parents will need to shift their responses and learn some new feeding skills- which may need explicit coaching from pediatricians and ideally from infant feeding specialists.

Lest you think we are blaming the parents in this case (we hope that is not what this sounds like- we absolutely recognize that the system is the issue and us parents are doing the best we can) let's explore what else happened with baby Ella, from the standpoint of the medical professionals who helped the family.

The common mistakes many medical professionals make

When this baby was admitted, the neonatologist didn't understand how the family wasn't practicing cue-based feeding. It seemed so obvious! What a simple problem to solve. Maybe the pediatrician didn't talk to the family about cue based feeding. Easy-peasy. The big fancy hospital can "fix" this baby, and fast!

Yet, we find the common mistake that many medical professionals make is underestimating how complex the topic of responsive feeding is and how much support parents (and other medical professionals who are at the front line- which basically means primary care pediatricians) actually need in order to use this type of a feeding style.

What we have learned through LOTS of trial and error of helping families and working within medical teams, is that this topic is highly nuanced and there are 5 key ideas that can best support parents with developing responsive feeding habits:

  1. The edu behind what responsive feeding is and why it's important

  2. Learning how to identify and respond to feeding cues

  3. Learning breast and bottle feeding logistics such as how to hold and latch a baby, but also how to keep a baby engaged and awake to the best of your ability without forcing

  4. Understanding signs of intake and signs that indicate that the parent is responding appropriately to the infants feeding cues

  5. Reassurance that feeding is a trial and error activity which will most likely have some errors and that's OK, it does not make you a failure, the baby is just fine, and our success as a parent isn't based on whether the baby has gained weight at each Well Child Care visit. This may even include connecting families who are at high risk to available community programs that give support, such as home visiting programs or postpartum support groups (this is assuming that any of those exist in your area, which is sadly often not the case). When you find there are no services available we strongly recommend the next best thing, which is a mix of increasing the number of early well child care visits (having the family come back every week or so) and "prescribing" a peer support for the parents by asking them to identify one person who might be able to check in regularly and give support (ideally in person but over the phone if needed) then asking mom and dad to reach out immediately to ask this person for daily check-ins.

What we find is that many, many doctors stop after giving parents a little bit of info on number one and two. Even feeding therapists often stop after offering a bit more info on number 3- without diving deeply into actually practicing and coaching families on #3 (on the logistics of feeding the baby) and then we may totally forget number 4 and 5.

Baby Ella, supporting parental competence in responsive feeding

Despite feeding "per cues" for 24 hours, the baby continued to lose weight, and an NG tube was placed for supplemental nutrition. The doctors reported she "just gets so tired! She wants to eat, and then falls asleep!" So... in comes the OT. And wow, were there holes in the story to fill.

The job of the feeding therapist is to chase the "why" and in this case, there were MANY "whys" to problem solve through.

  • Why wasn't this dad using responsive feeding practices? (What had the family heard about reading baby's cues? Did the family know what feeding cues were? What advice were they given at the outside hospital? At the pediatrician's office?)

  • Why wasn't "cue based feeding" working for this baby?

  • Why was the baby falling asleep so quickly? (Was the baby actually fatiguing that fast?)

One of the best tools in an OTs pocket is always the classic occupational profile, which includes a comprehensive narrative and history in order to start to uncover some of the "whys" of the situation. In this case the occupational profile combined with a feeding observation and assessment revealed that dad felt he had been told that the baby had a tongue tie by the lactation consultant and was encouraged to do tongue stretches but wasn't actually shown any stretches. Next, dad reported that the pediatrician told dad he had to wake the baby every 2 hours by putting a cold wash cloth on her face, sitting the baby upright and jiggling the bottle continuously during the meal to keep the baby engaged. Dad felt he must take over full control of her feeding—by giving Ella lots of stimulation and not stopping until she had taken the full bottle. He was also told that Ella did not like to be swaddled, and she should always be unwrapped. During the feeding observation portion of the evaluation, however, it became clear that Ella was:

  1. Quite disorganized in general and she struggled to remain in a quiet-alert organized state (feeding or not)

  2. She was not just "falling asleep" but actively "shutting down" to protect herself

If you are a feeding therapist and you are reading this, we're sure you can see some the issues here. Of course we cannot confirm that the lactation consultant or the pediatrician recommended any of those things but we do know that this is what dad understood (we’ve been there, where a parent hears something completely different than what we think we said.) And unfortunately dad was not budging on these practices, because he was highly stressed and highly stressed people often have trouble thinking clearly and being flexible. Dad did not recall being told anything about responsive feeding- in fact felt he had been encouraged to fully control the feeding, he did not know what to look for in terms of feeding cues, and he did not know how to support the logistics of feeding in a way that was supportive to Ella and could help her remain awake and organized vs sending her into a state of active crying or a state of "shut down." Add to that his stress and anxiety over mom's health which kept him distracted and grasping for control, then add again the fact that Ella was a disorganized baby who struggled to wake up regularly and to show consistent feeding cues and it seems completely obvious that dad wasn't using responsive feeding and that responsive feeding was not going to come easily to this situation.

Getting to responsive feeding in a challenging early feeding situation

What would it take to get this family back to responsive feeding and to get this baby to a place where she could be discharged from the hospital, eating well on a regular basis, growing and enjoying eating? We will explore that next because this post is just getting too long! If you've hung with us this far- drop us a comment below with some of your questions and thoughts. We know this post is a bit meandering rather than being directive. This topic is a complex one and we love that you stuck with us!

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