Approach

Treatment varies according to the cause and severity of the feeding disorder. Most disorders are multifactorial in nature, and their management is best approached by an interdisciplinary team, which may include a paediatrician for general and neurodevelopmental assessment, a paediatric gastroenterologist, a dietician, a behavioural psychologist, a speech and language therapist, and an occupational therapist.[2][8][63]

Management should include treatment of underlying medical conditions and correction of any anatomical problems, where possible. Further management is informed by the clinical examination and interdisciplinary assessment and may include:[2]

  • Behavioural modification

  • Physiotherapy and oral-motor exercises

  • Occupational therapy

  • Carer education

  • Dietary modifications.

Dietary modifications are individualised. Possible modifications include altered postures/positions for feeding; changes to the taste, temperature, or texture of food or liquid; and establishing mealtime schedules and routines.[8]

General advice includes promoting breastfeeding where possible for the first 6 months of life, controlling when food is available (nutrient quality and portion size), introducing healthy foods and persevering when these are refused, responding to satiety cues, avoiding overfeeding, and encouraging positive behaviour at mealtimes.[7][64] Parents/carers should provide positive reinforcement when the infant accepts food, maintain good eye contact, and give praise. They should avoid forcing the infant to feed, coaxing them, or using distraction techniques.[6][48]

Anatomical abnormalities

Symptoms usually improve in these infants once their anatomical abnormality has been corrected, as long as they have normal neurological function. These patients may require ongoing nutritional support and monitoring for postoperative complications, including new feeding disorders.

Cleft lip/palate

  • Cleft lip repair normally occurs at around 3 months of age, with cleft palate repair occurring at around 9 to 12 months of age. Children presenting with cleft lip/palate abnormalities are best managed by a multidisciplinary team that can advise on best feeding practice pre- and post-repair.[51][65]

Ankyloglossia (tongue-tie)

  • Difficulties with breastfeeding, such as latching on and nipple pain, are associated with the presence of ankyloglossia (tongue-tie).[28] Early referral for breastfeeding support is important. When symptoms are persistent, referral for assessment for frenotomy is indicated. When the diagnosis of tongue-tie is confirmed by an experienced healthcare provider, there is evidence that frenotomy results in improvement in symptoms, but the placebo effect is hard to quantify. Guidance on frenotomy varies internationally, with some countries advocating its use and others abandoning or advising against it.[28][66]

Short bowel syndrome

Initial management is the use of total parenteral nutrition, followed by enteral feeds. Supplemental calories may be required to maintain growth, and hydrolysed or elemental feeds may be needed due to poor nutrient absorption.[33]

Gastro-oesophageal reflux disease

In infants with mild to moderate regurgitation and no other symptoms, treatment is not required, and the carers can be reassured that the symptoms will improve with time.[35][36] Parents should be advised to seek medical attention if the vomiting becomes projectile, is bile-stained, or bloody, if there are new concerns such as distress or poor growth, or if the vomiting persists beyond the first year of life.

Initial management of gastro-oesophageal reflux disease (GORD) differs according to the infant’s feeding mechanism. Breastfed infants with frequent regurgitation associated with marked distress should have a breastfeeding assessment. If symptoms continue despite breastfeeding support, a 1- to 2-week trial of alginate therapy can be considered, and continued if successful.[36] Treatment should be paused periodically to assess whether it is still required.

Formula-fed infants require a detailed feeding history. Feed volumes should be reduced if they are excessive for the infant’s weight. A trial of smaller, more frequent feeds should be considered.[36] If this does not help, or if feeds are already small and frequent, feed thickeners or anti-reflux (AR) formula can be used.

Both thickeners and AR formulas reduce frequency and volume of vomiting.[67] Thickened feed may require use of a large-bore teat and, when used long term, can result in excessive weight gain.[67][68] No significant difference in efficacy has been found between different types of feed thickener (carob-bean gum, carob-seed flour, sodium carboxymethylcellulose).[68] Anti-regurgitant formulas have the benefit of providing an energy intake more suited to an infant's needs and require less sucking effort, so remove the need for a large-bore teat. If thickeners/AR formulas are ineffective, they should be stopped. A 1- to 2-week trial of alginate therapy should be considered, and continued if successful.[36]

Cows’ milk protein allergy may be clinically indistinguishable from GORD, so a temporary cows’ milk exclusion diet may be considered. Formula-fed infants should receive a 2- to 4-week trial of extensively hydrolysed protein formula. Cows’ milk is eliminated from the mother’s diet if the infant is breastfed.

Prone and left-lateral positioning decrease reflux episodes, but should be limited to times when the infant is awake and closely watched, to avoid the increased risk of sudden infant death syndrome (SIDS), which is associated with prone positioning.[35][36][69] Maintaining a more upright position after feeds may be helpful in some cases, but is without a strong evidence base.

If overt regurgitation is associated with either faltering growth, distress, or feeding difficulties, a 2- to 4-week trial of a proton-pump inhibitor (PPI) can be considered for breastfed and formula-fed infants. These drugs should not be used for regurgitation occurring as an isolated symptom. Response should be assessed and referral to a specialist for endoscopy should be considered if symptoms do not resolve or recur after stopping treatment. The evidence for effectiveness of these drugs is limited, particularly in preterm infants and infants with neurodisabilities.[70] In infants with endoscopy-proven oesophagitis a PPI may be useful.[35][36]

Enteral tube feeding should be considered to promote weight gain in infants with vomiting and faltering growth when other causes have been excluded and medical management is unsuccessful. Jejunal feeding may be used in those with reflux-related aspiration.[36]

Surgical management of GORD is rarely needed, but can be considered for children whose symptoms have not responded to optimal medical treatment and who have intractable symptoms, life-threatening complications of GORD (e.g., aspiration), or chronic conditions that increase their risk of GORD-related complications.[35][36] The risks and benefits of surgery should be weighed against those of chronic medication and/or jejunal feeding.[35] Laparoscopic Nissen fundoplication is the procedure of choice.[35][36][71]

Cows’ milk protein allergy

There is significant overlap in symptoms between physiological problems such as GORD and immunological problems such as cows' milk protein allergy (CMPA). The diagnosis of either is therefore usually based on a pragmatic approach of treatment and response. If an infant with GORD does not improve on anti-reflux medications, and particularly where there is a family history of atopy or CMPA, a 2- to 4-week trial of dietary modification is warranted as a diagnostic test for CMPA.[35][42] Infants with CMPA will usually respond to a hypoallergenic formula within 2 weeks.[35] Conversely, if CMPA is suspected but symptoms do not improve on the modified diet, GORD treatment should be considered. Breastfeeding mothers should exclude all milk and milk products from their diet. This usually requires support from a dietician to identify hidden sources of cows’ milk protein.[42] Soya protein-based formulas should not be used where CMPA is suspected, as up to 10% of children with CMPA will be equally sensitive to soya.[72] 

Coeliac disease

A lifelong avoidance of gluten (e.g., wheat, rye, barley) is advised in children with coeliac disease. Patients should be advised that some medications may contain gluten.

Lactose intolerance

Lactose intolerance can be primary, requiring lifelong dietary modification, or secondary. Secondary lactose intolerance is usually transient following a viral infection of the GI tract, and the short-term use of a low lactose or lactose-free formula for 6-8 weeks can help to relieve symptoms. Soya formula should not be used for infants under 6 months with secondary lactose intolerance because of the phyto-oestrogen content, but can be used in those over 6 months who do not tolerate lactose-free formula.[73] A return to normal feeds should be tried once the symptoms have resolved fully. Patients should be advised that some medications may contain lactose.

Eosinophilic oesophagitis

Eosinophilic oesophagitis is recognised in infants, though uncommon, with prevalence increasing with age. Treatments include PPIs, topical corticosteroids (e.g., nebulised), and food elimination diets, which should be started under the supervision of paediatric specialists.[60]

Neurodevelopmental, neuromuscular, and neurological disorders

Severely disabled children are at the greatest risk of feeding disorders and malnutrition.[74] Treatment must be appropriate for an individual's developmental level of function, rather than for their chronological age.[8]

Neurologically impaired children may require nasogastric or gastrostomy feeding if they have an impaired swallow, or if they take a very prolonged time to feed.[63] Although tube feeds may increase weight, linear growth may remain suboptimal if nutritional intervention is delayed until mid-childhood.[75] This supports the need for early recognition and treatment of these problems from infancy.

GORD is a common problem among children with neurodevelopmental disorders and should be managed initially with feed thickeners, anti-regurgitant formulas, and compound alginates before using PPIs. Nissen fundoplication may be considered for children whose symptoms have not responded to optimal medical treatment and who have intractable symptoms, life-threatening complications of GORD (e.g., aspiration), or chronic conditions that increase their risk of GORD-related complications.[35][36]

Prematurity

The neonate should be stabilised and transferred to the neonatal intensive care unit before starting feeding. Prematurity is the major risk factor for necrotising enterocolitis, so usual practice is to introduce enteral feeding gradually. Meta-analysis has shown no difference in rates of necrotising enterocolitis between infants receiving early full feeding and infants receiving minimal enteral feeding, although the evidence was of very low certainty.[76] Feeding is usually via a tube initially, because the infant’s suckling/swallowing/breathing coordination is immature. Intravenous dextrose may be administered to prevent hypoglycaemia.

See Premature newborn care.

Children with cardiac or respiratory conditions

These children require an individualised approach. Infants with bronchopulmonary dysplasia may benefit from jaw and chin support, change in teat size to deliver a slower feed, increasing supplemental oxygen concentration during feeds, and allowing frequent breaks and rest periods during feeding.[24] Infants with congenital cardiac disease may require tube feeding after discharge from hospital, and enrichment of breast and formula milk.[77][78]

Behavioural problems

Parental reassurance, education, and training form a vital role in management. However, care providers should be aware of the potential damaging effect a diagnosis of behavioural problems may have on the infant-carer interaction.[3]

Carers should be taught how to respond to an infant's feeding cues, minimise distracting stimuli during feed times, and develop structured routines to feeding.[40] Treatment of food aversions centres on reinforcing desired behaviour by offering positive feedback, and minimising aversive behaviour by ignoring it.[40] Hospitalisation to observe infant-carer interactions while optimising any medical treatment may be required in severe cases.

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