What to do if a 9-month-old infant is refusing milk?

Management of a 9-Month-Old Refusing Milk

A 9-month-old refusing milk requires assessment of overall nutrition and growth rather than forcing milk intake, as this age marks the transition to solid foods as primary nutrition sources, and milk refusal is often a normal developmental phase. 1

Initial Assessment

Evaluate Growth and Development

• Check weight-for-length and developmental milestones to determine if this is affecting the child's health 1
• Document total caloric intake from all sources, not just milk 1
• At 9 months, infants can self-regulate total caloric intake and should not be forced to finish meals if not hungry 1

Rule Out Medical Causes

• Exclude cow's milk protein allergy, which can present with feeding refusal and may overlap with other feeding issues in 42-58% of cases 2
• Consider whether the infant is experiencing discomfort during feeding that could indicate GERD, though irritability has many causes including constipation, infection, and neurological issues 2
• Assess for signs of iron deficiency, as exclusively breastfed infants without adequate iron-rich complementary foods are at risk by 9-12 months 3

Nutritional Management Strategy

Prioritize Solid Food Nutrition

• Focus on iron-rich complementary foods including iron-fortified infant cereal (2+ servings daily can meet iron requirements) and pureed meats when developmentally ready 3
• Offer vitamin C-rich foods with meals to enhance iron absorption 3
• Provide a wide variety of nutrient-dense foods such as fruits and vegetables 1

Address Milk Intake Appropriately

• If breastfeeding, continue offering but do not force; breastfeeding can continue alongside solid foods 1
• If formula-fed, ensure the infant receives at least some dairy or appropriate alternative to meet calcium needs 1
• Transition to low-fat dairy products is not appropriate until after age 2 years 1

Avoid Common Pitfalls

• Do not introduce bottles if breastfeeding, as early bottle introduction can cause ineffective suckling and breast refusal 4
• Do not use frequent breastfeeding as a comfort measure if solid food intake is poor, as this pattern (frequent breastfeeding + food refusal) is associated with failure to thrive in the second 6 months of life 5
• Never substitute health food beverages or non-fortified alternatives for milk, as these lack essential nutrients and can cause severe nutritional deficiencies including kwashiorkor and rickets 6

Behavioral Feeding Approach

Establish Healthy Feeding Patterns

• Parents choose meal times and what foods are offered; the child decides whether and how much to eat 1
• Respond to satiety cues and allow self-regulation of total caloric intake in the presence of normal growth 1
• Continue offering initially refused foods repeatedly (up to 10 times) to establish taste preferences 1

Monitor for Warning Signs

• Forceful vomiting, choking, gagging, or significant irritability with feedings warrant further investigation 2
• Poor weight gain, decreased weight-for-length, or developmental regression require immediate evaluation 5, 6
• If the infant shows signs of failure to thrive with food refusal, consider psychosocial stressors affecting the mother-infant dyad 5

When to Supplement

Iron Supplementation

• If the infant receives insufficient iron from complementary foods, provide 1 mg/kg/day of iron drops starting at 6 months 3
• This is particularly important for exclusively breastfed infants, as 15-25% are at risk for iron deficiency by 9-12 months without adequate dietary iron 3

Calcium Considerations

• Ensure adequate calcium intake through dairy products or fortified alternatives 1
• If using milk alternatives, they must be appropriately fortified with vitamin D and calcium 6