Author(s): Elinor A. Graham, MD, MPH Harborview Medical Center

Date Authored: September 1, 2008

Date Last Reviewed: May 29, 2019

Somali Baby with blue clothing
Photo by Mulugeta Ayene (cc license).

EthnoMed note:  This article is now dated, but the information represents a point in time around a newer refugee community. It highlights the shifting scope of engaging refugee communities in health care and how health care practitioners can work with a community to improve health outcomes. We keep this work public and available, and have added new bibliography on the topic.

Around 2000, providers in the Harborview Children and Teen Clinic began to notice an increased frequency of developmentally and physically normal infants and toddlers of immigrant families presenting with a history of refusing to eat. According to their mothers they refused to take the breast or bottle for feeding and would not take solid foods offered by the parent. The majority of these children were in Somali families and all had immigrant parents. In some cases a significant oral aversion developed resulting in poor weight gain and failure to thrive. Some patients had extensive evaluations for intestinal problems without definitive findings and treatment which included management with feeding tubes for an extended period of time. A quality improvement project “Failure to Thrive and Oral Aversion in Immigrant Infants and Toddlers” was carried out to determine if there were common patterns found in the history and presentation of this apparent “epidemic” of non-organic failure to thrive and if underlying cultural factors might be influencing this condition. It was hoped that this information would lead to more effective intervention and prevention strategies.

Results of this investigation revealed that overfeeding was a common antecedent that seemed to cause the oral aversion and failure to thrive. This pattern of overfeeding was associated with maternal anxiety about adequacy of breast milk, desire to have a plump infant or toddler and subsequent use of supplemental formula in between or at the end of breast feeding. It has also been documented through questionnaires and focus groups with Somali mothers conducted by an NIH-supported research grant, “Infant Overfeeding in Immigrant Families”, at our institution from 2005-2007 (Dr. Mark Doescher was PI). A similar pattern of early supplementation of breast fed infants with pre-lacteal or complementary foods has recently been reported in a United Nations study conducted in Somalia: “Somali Knowledge Attitude & Practices Study: Infant and Young Child Feeding and Health Seeking Practices”. Food insecurity is an underlying and often real concern in Somalia.

When overfeeding is occurring, infants with a strong appetite drive tend to become overweight. Infants without such a strong appetite drive, or those who have a more independent temperament, can develop refusal to feed and an oral aversion. This can lead to weight faltering or frank failure to thrive. Careful attention to the history of frequency and timing of feedings and identifying all foods offered, combined with an open-ended and sympathetic exploration of maternal anxiety about her child’s weight, allows providers to identify this problem. Interventions that we have found clinically to be effective include:

  • Promotion and support of exclusive breast feeding for the first 6 months of life including providing education and equipment to pump and store breast milk.
  • Using the analogy of breast milk equals gold while formula is silver – both precious metals but one is more valuable than the other.
  • Helping mothers identify infant cues for real hunger and satiety and feed based on demand rather than on time periods.
  • Role playing with mothers how infants and toddlers react to overfeeding and how it makes feeding time a negative experience for both mother and infant.
  • Discussing and helping mothers cope with peer pressure that they receive to have a “fat” baby.
  • Providing mothers with goals for healthy weight gain between well child or WIC visits.


Wandel, Terragni, Nguyen, Lyngstad, Amundsen, and De Paoli. “Breastfeeding among Somali Mothers Living in Norway: Attitudes, Practices and Challenges.” Women and Birth 29.6 (2016): 487-93. 

Steinman, Lesley, Mark Doescher, Gina A. Keppel, Suzinne Pak‐Gorstein, Elinor Graham, Aliya Haq, Donna B. Johnson, and Paul Spicer. “Understanding Infant Feeding Beliefs, Practices and Preferred Nutrition Education and Health Provider Approaches: An Exploratory Study with Somali Mothers in the USA.” Maternal & Child Nutrition 6.1 (2010): 67-88. 

Grewal, Navnit Kaur, Lene Frost Andersen, Daniel Sellen, Annhild Mosdøl, and Liv Elin Torheim. “Breast-feeding and Complementary Feeding Practices in the First 6 Months of Life among Norwegian-Somali and Norwegian-Iraqi Infants: The InnBaKost Survey.” 19.4 (2016): 703-15.