Sleep Feeding: Observations and Insights
By Jan Gambino, M.Ed.
I became interested in sleep feeding when parents started leaving messages on The HealthCentral Network (www.healthcentral.com/acid-reflux) message boards, where I moderate discussions and write a weekly blog on all aspects of parenting an infant, child or teen with Gastroesophageal Reflux (GER) or Gastroesophageal Reflux Disease (GERD). Sleep feeding is the term used to describe a baby who needs to be drowsy or asleep to feed. Soon other parents were joining the discussion and in a short period of time, HealthCentral became SleepFeedingCentral with new parents typing in detailed descriptions of feeding their sleepy babies with reflux on a regular basis. As far as I can tell, the HealthCentral site has the largest repository of anecdotal information on sleep feeding that is available with approximately two dozen different, detailed sleep feeding stories, offering rich data. It is not clear if sleep feeding is on the rise or if the internet just provided the means for the information to be shared.
I need to disclose that I am neither a speech language pathologist nor a physician. I am a mom with extensive “on the job” training in caring for a child with GERD. I have provided support and information to hundreds of parents as a former associate director of a GERD patient support organization and lately as a freelance writer and author of a parents guide to coping with GER and GERD. In addition, I am an educator with extensive experience in early intervention/preschool special education. The purpose of this article is to define sleep feeding, identify characteristics and offer some possible treatment/management strategies. As an advocate for parents and children, I will also present the parents point of view of sleep feeding and its impact on the family.
What is Sleep Feeding?
Sleep feeding is the term used to describe feeding a drowsy or sleeping baby. Sleep feeding may be a normal process in the newborn period as many newborns begin a feeding in an alert state and gradually become drowsy and end the feeding in a light sleep. Suzanne Evan Morris, Ph.D., founder and director of New Visions (www.new-vis.com) stated, “When we begin to fall asleep, brain waves slow down and alert brain function decreases. The area of the brain that supports automatic, rhythmical sucking and swallowing remains active and strong at first, and then decreases as the baby moves to a deeper sleep.” (1) In addition, research has shown that swallowing decreases during sleep compared to when awake.
As an infant matures, “a parent may use sleep feeding to encourage a young infant to sleep through the night or decrease the number of night feedings. This is a parent driven process with the parent offering the bottle or breast to her sleeping infant just before going to bed. It is hoped that this late night feeding, sometimes referred to as a ‘top off feeding’ will decrease night time hunger. A baby who is moving from a 24 hour feeding schedule to a daytime only schedule may adjust with short term sleep feeding during the transition “(2).
A review of the literature found no research on sleep feeding however; there is extensive research on infant feeding and sleep patterns, feeding disorders and GER/GERD symptoms and treatments. In general, feeding disorders are thought to have multiple origins including medical, developmental and behavioral factors. It is not clear if sleep feeding is a feeding disorder, a symptom of reflux or something else.
Sleep Feeding and Reflux
An infant with GERD may experience difficulty with bottle feeding or nursing with typical symptoms including: pulling away, crying out and arching. It is thought that reflux pain and digestive discomfort may lead to feeding difficulties and the goal of treatment is to reduce pain and lessen other symptoms such as spit up and vomiting. However, it appears that some babies need to be drowsy or sleepy to accept the bottle or breast and exhibit the sleep feeding pattern as a reaction to pain. Sleep feeding probably stems from many causes, most notably the pain from GERD and also from a combination of sensory issues, food allergies/intolerances, dysphagia and behavior/ learned patterns.
In an attempt to define sleep feeding, I would like to suggest the following definition:
“Sleep feeding is the term used to describe feeding a drowsy or sleeping infant due to digestive pain/discomfort caused by Gastroesophageal Reflux Disease (GERD) and related conditions.” Sleep feeding is not harmful and may provide a short term feeding strategy while the underlying cause of sleep feeding is determined.
Further, I propose a continuum of feeding problems associated with GER and GERD:
Level 1: Happy Spitter: The happy spitter is a baby with GER. She nurses or drinks easily, then regurgitates a small amount or the entire meal without pain or discomfort.
Level 2: Poor eating- As characterized by fussing, pulling on and off the breast or bottle and arching during a feeding. This is by far the most common pattern associated with GERD.
Level 3: Feeding Aversion-A pattern of poor eating that persists, leading to weight loss or poor weight gain. The baby may experience sensory/swallowing symptoms such as: choking, gagging and painful swallowing.
Level 4: Feeding Refusal/Feeding Strike-Is characterized by a baby who demonstrates poor eating and feeding aversion. In addition, he/she decides that feeding is just too painful and attempts to “fix” the problem by refusing all nourishment by mouth.
When a baby gets to the point of feeding refusal, there is a desperate attempt to offer nourishment. Parents have reportedly tried spoons, syringes, cups and even droppers to get a bit of liquid in. When all else fails, a parent will report these worrisome symptoms to the doctor or go to the emergency department. The doctor will evaluate the infant and rule out other causes for feeding refusal (illness, allergy, intolerance, and dysphagia). If a baby is dehydrated from prolonged feeding refusal, the infant may be hospitalized for observation, evaluation/testing or IV fluids. Often a parent is send home with GER/GERD home care instructions such as holding upright after feeding, small, frequent meals, dietary changes and perhaps medication. Some infants are referred to a lactation specialist, speech language pathologist or occupational therapist for intervention. In most cases, the baby improves and begins taking nourishment again. Unfortunately, a small subset of babies continues to struggle with feeding and their desperate parents stumble upon sleep feeding.
As each and every meal results in digestive discomfort, the baby will resist and the parents will struggle to adapt the feedings and manipulate the environment to successfully nourish the baby.
Parents on the HealthCentral website often describe similar feeding experiences:
<!--[if !supportLists]-->· <!--[endif]-->“I have to wait until he is asleep to feed him.”
<!--[if !supportLists]-->· <!--[endif]-->“When I lean her back in my arm to give her the bottle she cries.”
<!--[if !supportLists]-->· <!--[endif]-->“If I show him the bottle, he turns away and arches his back.”
<!--[if !supportLists]-->· <!--[endif]-->“When he is almost asleep, I can slip the bottle in his mouth for the feeding. “
<!--[if !supportLists]-->· <!--[endif]-->“It is getting harder and harder to feed him now that he naps less during the day. “
Parents experience a great deal of stress and anxiety about their inability to provide nourishment for their children. When they stumble upon sleep feeding, there is often a sense of relief. Within a short period of time, relief is replaced by new worries as sleep feeding becomes the only way their baby will eat. Parents often encounter questions and concerns from family members and friends who offer little understanding or support for the baby’s feeding difficulties and need to eat while drowsy or asleep. Further, physicians may not understand the feeding pattern. If the baby is well nourished and growing from the vigilant efforts of a sensitive caretaker, the doctor may assume that there is not a medical or feeding problem. In addition, the doctor may conclude that the parent is having difficulty regulating the baby’s sleep and feeding schedule and may instruct the parent to “teach” or “train” the baby to behave differently. This message conveys feeling of confusion and inadequacy as well as stress and anxiety. Unfortunately, some parents have felt compelled to “teach” the baby to eat and may withhold nourishment for hours at a time to induce hunger or force the baby to take a bottle, further strengthening the behavioral resistance to feeding.
I believe that sleep feeding emerges as a result of a sensitive, observant caretaker who carefully reads the baby’s cues, observes subtle changes in behavior and instinctively helps the baby by swaddling, rocking, feeding in a quiet, dark place and even waiting until the baby is drowsy but not asleep to initiate feeding. Caretakers often report feeling of isolation as they must adjust their schedules around getting the baby to sleep or feeding the baby in a specific area so the baby will sleep feed. One mother reported that she needed to sit in a closet with the door closed to get her baby to eat. Other parents take turns staying up at night to feed their baby or set the alarm to wake up at intervals to initiate feedings so the baby can make up for missed feedings while awake during the day.
Parents and specifically mothers may experience feelings of sadness or inadequacy due to the struggles with sleep feeding. By day, the baby is in no distress and will smile, play and cuddle. Friends and family see a healthy, happy, well nourished baby. That is unless she is presented with a bottle whereupon the baby will turn away, cry, arch and become upset. One mother reported that her baby didn’t want to be held because the baby thought the mother was going to initiate a feeding. Other babies cry out even when placed in a semi reclined position on the caretakers lap. Many mothers have attempted nursing and quit with the belief that the baby “did not like my milk” or “my milk was causing so much pain”.
The caregiver burden is significant when a baby will only eat when drowsy or asleep. Several parents have hired a nanny or asked a relative to live with the family to assist with running the household and offering support. The entire schedule is planned around naps, getting the baby to fall asleep or arranging the environment for optimal feeding (decreasing noise and distractions, darkening the room, turning off the TV and phone) to initiate feeding and then slowly getting the baby to suck on the bottle by rotating the bottle in the baby’s mouth. The sleep feeding sessions are often long and only result in a small overall intake.
The connection and feelings of relief are enormous when a parent stumbles upon an online discussion such as the HealthCentral Network discussion board and discovers that he/she is not alone and he/she isn’t the only person in the world with a baby who needs to sleep feed.
What we know
One member of the HealthCentral Network community, Archana Sudame took it upon herself to talk with as many caretakers of sleep feeding babies as possible and compiled information on the condition.
Based on her careful inquiries and from speaking to physicians and feeding therapists (speech language pathologists, occupational therapist), it seems that babies who sleep feed have the following characteristics:
<!--[if !supportLists]-->· <!--[endif]-->Sleep feeding occurs in otherwise healthy infants.
<!--[if !supportLists]-->· <!--[endif]-->Sleep feeding is an accepted short term feeding intervention for a baby with GERD as the medical team and feeding team explore treatment options and address the underlying pain/discomfort.
<!--[if !supportLists]-->· <!--[endif]-->Sleep feeding begins before 4 months of age.
<!--[if !supportLists]-->· <!--[endif]-->Prompt/effective medical treatment and reintroduction of awake feeding before 4-6 months may lead to resolution of sleep feeding.
<!--[if !supportLists]-->· <!--[endif]-->Untreated or unresolved sleep feeding that persists beyond 6 months of age may lead to a pattern of pain response/behavior that requires feeding therapy/intervention in addition to medical treatment.
<!--[if !supportLists]-->· <!--[endif]-->Sleep feeding usually resolves when an infant or toddler transitions to solids and learns to drink from a cup, usually between 9-15 months.
The medical team needs to identify medical/sensory/behavioral conditions that have lead to or perpetuated sleep feeding.
<!--[if !supportLists]-->· <!--[endif]-->GER/GERD
<!--[if !supportLists]-->· <!--[endif]-->Milk Soy Protein Intolerance
<!--[if !supportLists]-->· <!--[endif]-->Food allergies/intolerances
<!--[if !supportLists]-->· <!--[endif]-->Dysphagia
<!--[if !supportLists]-->· <!--[endif]-->Sensory Processing
<!--[if !supportLists]-->· <!--[endif]-->Oral Motor/feeding disorders/delayed feeding skills
<!--[if !supportLists]-->· <!--[endif]-->Illness
<!--[if !supportLists]-->· <!--[endif]-->Constipation
<!--[if !supportLists]-->· <!--[endif]-->Behavior: learned behavior, reaction to pain.
<!--[if !supportLists]-->· <!--[endif]-->Family: maternal depression, support, parenting skills.
The medical team needs to work with the family to diagnose and treat the underlying medical causes of sleep feeding. It appears that prompt evaluation and treatment of the underlying cause of the sleep feeding may turn off the pain/discomfort and allow a young baby (under 4 months of age) to rapidly resolve sleep feeding. A lactation specialist or a feeding specialist may offer vital assistance to caregivers and help to reverse the sleep feeding. A speech language pathologist may assist the doctor in assessing the feeding pattern to rule out an oral motor problem. A few babies need nasogastric or gastrostomy tube feedings to supplement sleep feeding and maintain weight gain. If the sleep feeding does not resolve despite aggressive medical treatment, referral to a feeding therapist or feeding clinic may be necessary. During the treatment, parents need ongoing, intensive support and reassurance from the medical team and referral to a patient support network.
Sleep feeding seems to run its course during the first year as the baby moves from bottle or breast to eating solids from a spoon and drinking from a cup. Early intervention to promote early acceptance of the spoon and cup may help a baby resolve sleep feeding before one year of age. Parents may need assistance to develop strategies to gradually help the baby move away from sleep feeding. Strategies may include: offering an empty bottle, spoon or cup for play and exploration, offering the bottle or breast at intervals while awake and gradually lessening the environmental modifications (from a darkened room to a dimly lit room). Some babies benefit from music, white nose, movement (rocking chair) and singing. Most babies gradually move toward cup and bottle drinking by day and require supplemental sleep feeding at night to ensure the proper intake of nutrients and fluids. Parents, doctors and feeding therapists all agree that sleep feeding babies present many challenges for intervention. The goal of intervention is often supportive as the infant gradually moves toward eating while awake.
There is a great need for research on sleep feeding to identify the causes, natural course and treatment /intervention. It is likely sleep feeding has several causes and may be multi factorial in nature. Food allergies, intolerances and infant GERD appear to be on the rise and may be a factor in causing/perpetuating sleep feeding. A recent study found that babies with symptoms of GERD often have dysphagia (3). Perhaps fear of choking or dysphagia causes some babies to literally shut down so they can manage to slowly and carefully suck and swallow.
As an early childhood special education teacher, I often deal with feeding issues since there is such a strong correlation between feeding disorders and developmental disorders. With the increase in Autism Spectrum Disorders (ASD) and the associated feeding and sensory issues, it is possible that some of the infants who sleep feed may be presenting with early sensory/processing problems that will later result in a diagnosis of ASD.
In the meantime, parents and doctors need to communicate effectively to describe and quantify feeding patterns that warrant further investigation and treatment. I spend a great deal of time helping parents to take a snapshot of a typical day by keeping a journal. A well organized list will help a sleepy, stressed parent with a fussy baby effectively communicate symptoms and concerns during the short time parents and doctors are together and may lead to a serious discussion about the feeding pattern. At the same time, physicians, lactation specialist and others who interact with new parents and newborns need to be aware of the signs and symptoms of GER; GERD and feeding patterns such as sleep feeding that are worrisome. If a parent report that the baby doesn’t like to eat, turns away from the bottle or refuses the bottle, the medical team needs to make further inquiries and follow up to ensure the underlying problem is identified and addressed. It is discouraging that pediatricians still have limited knowledge of the NASPGHAN guidelines for evaluation and treatment of GER in infants and children despite efforts to increase awareness of the treatment guidelines(4).
The pendulum is swinging as it always does in medicine. In the past, infant GERD was believed to be under-treated and diagnosed. With the increased availability of new medications (specifically PPI’s) for infants and children, there is a great deal of concern that all babies who present with GER symptoms are being administered strong medication for a non medical problem. A multi center, double blind placebo controlled trial of PPI’s for the treatment of infant reflux demonstrated that half the babies treated with PPI’s showed improvement. Surprisingly, half the babies in the control group also improved (5). While the new research greatly increases the medical team’s ability to offer safe and effective treatment, it appears that physicians need access to this important information. There is a trend toward diagnosing and treating food allergies and intolerances in infants and the careful, short term use of GERD medications for some infants.
I have found that parents and doctors have limited awareness of the role of the feeding specialist in caring for an infant with GERD, sleep feeding and associated feeding issues. At the same time, not every community has a feeding clinic or SLP or OT who specializes in working with infant feeding disorders.
I recently published a book on parenting an infant or child with reflux. Reflux 101: A Parent’s Guide to Gastroesophageal Reflux (Lulu, 2008) helps parents communicate with the medical/feeding team and gives parents the tools they need to implement the home care program that is vital to successful GER and GERD treatment. Often a busy doctor or a health clinic does not provide the time or follow up to ensure that the caregivers understand the home care plan and have the resources to carry out the plan. Parents need information, support and hope to take care of a baby in distress and help their baby grow and thrive. This is especially true for a baby with reflux who must be drowsy or asleep to take in nourishment.
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