What to do if a 9.5-month-old infant refuses to drink milk?

Management of a 9.5-Month-Old Infant Refusing Milk

Continue breastfeeding if currently nursing, or if formula-fed, focus on ensuring adequate nutrition through complementary foods including meat, poultry, fish, eggs, and dairy products (yogurt, cheese) while persistently offering milk without forcing it. 1

Understanding Normal Feeding Patterns at This Age

At 9.5 months, infants are in a transitional feeding period where:

• Breastfeeding should continue alongside complementary foods introduced around 6 months, with the goal of continuing as long as mutually desired by mother and child through at least 12 months and ideally 2 years or beyond 2, 3
• Complementary foods become increasingly important as breast milk or formula alone no longer meets all nutritional requirements after 6 months 4, 5
• Milk refusal at this age does not constitute a nutritional emergency if the infant is consuming adequate complementary foods 1

Immediate Nutritional Strategy

If Currently Breastfeeding:

• Continue offering the breast frequently throughout the day and night, as breastfeeding is associated with reduced odds of wasting (malnutrition) and underweight 4
• Do not discontinue breastfeeding even if intake seems reduced, as any amount of breast milk provides immunological protection and nutritional benefits 2
• Introduce small oral bolus feeds of complementary foods to avoid development of oral hypersensitivity and feed aversion 1

If Formula-Fed:

• Offer formula at regular intervals without forcing, as infants can self-regulate total caloric intake 3
• Ensure dairy products (yogurt, cheese) are offered daily as alternatives to liquid milk, since dairy foods can be introduced before 12 months 1
• Do not switch formulas frequently based on refusal alone without medical indication 2

Essential Complementary Foods to Emphasize

Prioritize animal-source foods daily or as often as possible:

• Meat, poultry, fish, or eggs should be eaten daily to meet protein and micronutrient needs 1
• Vitamin A-rich fruits and vegetables should be offered regularly 1
• Legumes provide protein and dietary fiber as complementary protein sources 1
• Sources of long-chain polyunsaturated fatty acids (fish, eggs) promote cognitive and motor development 1

Dietary diversity is critical: Low dietary diversity scores are significant predictors of stunting (chronic malnutrition) in this age group 4

Feeding Technique Modifications

• Make only one change at a time when modifying feeding approaches to properly assess what works 6, 3
• Respond to infant satiety cues and avoid forcing the infant to finish bottles or meals, as forced feeding can worsen refusal 3
• Introduce foods repeatedly even if initially refused, as early flavor exposure influences later acceptance 3
• Offer milk from a cup rather than bottle if bottle-feeding is associated with refusal, as bottle feeding is associated with increased odds of stunting 4

Common Pitfalls to Avoid

• Do not maintain complete milk starvation if the infant refuses; instead ensure adequate nutrition through complementary foods while continuing to offer milk 6
• Avoid introducing foods without nutritional value (juices, sweets) simply to provide calories 3
• Do not delay introduction of nutrient-dense complementary foods due to milk refusal, as inadequate micronutrient intakes are common when animal-source food intake is low 5
• Avoid overheating or overbundling during feeding times, as overheating can reduce appetite 1

When to Escalate Care

Seek immediate medical evaluation if:

• Weight gain drops below 9 g/kg/day, which requires immediate intervention to prevent impaired neurodevelopment 6
• Signs of dehydration appear (decreased urine output, dry mucous membranes, lethargy) 6
• The infant shows signs of failure to thrive or weight loss 2
• Diarrheal disease develops, as this is associated with increased odds of wasting and underweight 4

Monitoring Requirements

• Track growth parameters regularly (weight, length) to ensure adequate nutrition despite milk refusal 2
• Assess dietary diversity to ensure at least 4 different food groups daily, as this is associated with reduced odds of stunting 4
• Monitor for signs of micronutrient deficiencies (iron deficiency anemia, vitamin deficiencies) that can occur with inadequate animal-source food intake 5

Reassurance and Perspective

Milk refusal at 9.5 months is manageable as long as the infant receives adequate nutrition from complementary foods, particularly animal-source foods and dairy products in other forms (yogurt, cheese). The key is ensuring dietary diversity and continued offering of milk without pressure, while maintaining breastfeeding if applicable. 1, 4