Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

anatomical abnormalities

1st line – feeding advice + nutritional support

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ACUTE
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anatomical abnormalities
1st line – 

feeding advice + nutritional support

Symptoms usually improve once the anatomical abnormality has been corrected, providing that the neurological function is normal. These patients may require ongoing nutritional support and monitoring for postoperative complications, including new feeding disorders.

Plus – surgical repair

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ACUTE
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anatomical abnormalities
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cleft lip/palate
Plus – 

surgical repair

Treatment recommended for ALL patients in selected patient group

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]

Plus – breastfeeding support ± surgical division

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ACUTE
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anatomical abnormalities
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ankyloglossia (tongue-tie)
Plus – 

breastfeeding support ± surgical division

Treatment recommended for ALL patients in selected patient group

Difficulties with breastfeeding such as latching on and painful feeding are associated with the presence of ankyloglossia (tongue-tie).[28]

Early referral for breastfeeding support is important. When symptoms are persistent, referral for frenotomy is indicated.

When the diagnosis of ankyloglossia (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]

gastrointestinal disorders

1st line – parental education and reassurance + feeding assessment

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ACUTE
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gastrointestinal disorders
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GORD
1st line – 

parental education and reassurance + feeding assessment

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.[36]

Referral for breastfeeding assessment should be considered in breastfed infants with frequent regurgitation associated with marked distress. Feed volumes should be reduced in formula-fed infants if they are excessive for the infant’s weight; a trial of smaller, more frequent feeds should be considered.[36]

Consider – feed thickener or anti-reflux formula

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ACUTE
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gastrointestinal disorders
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GORD
Consider – 

feed thickener or anti-reflux formula

Additional treatment recommended for SOME patients in selected patient group

Feed thickeners or anti-reflux (AR) formulas can be used in addition to advice about upright positioning after feeds.[35][36]

No significant difference in efficacy has been found between different types of feed thickener (carob-bean gum, carob-seed flour, carmellose sodium [sodium carboxymethylcellulose]).[68] 

Feed thickeners can be added to formula or expressed breast milk either as a first-line treatment or in combination with other treatments.

Thickened feed may require use of a large-bore teat and, when used long term, can result in excessive weight gain.[67][68]

AR formulas reduce frequency and volume of vomiting and have the benefit of providing an energy intake more suited to an infant's needs, compared with feed thickener. AR formulas also require less sucking effort, therefore removing the need for a large-bore teat.[35]

Consider – compound alginate

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ACUTE
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gastrointestinal disorders
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GORD
Consider – 

compound alginate

Additional treatment recommended for SOME patients in selected patient group

A compound alginate preparation (e.g., sodium alginate/magnesium alginate) is available for infants, which both thickens feed and acts as a 'raft' to float on the surface of the stomach contents to reduce reflux and protect the oesophageal mucosa.

A 1- to 2-week trial should be offered in breast- or bottle-fed infants who continue to show symptoms despite previous interventions. Feed thickeners should be stopped before introducing alginates, to avoid over-thickening of stomach contents.[36]

Consult product literature for guidance on dose.

Consider – prone + lateral positioning while awake

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ACUTE
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gastrointestinal disorders
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GORD
Consider – 

prone + lateral positioning while awake

Additional treatment recommended for SOME patients in selected patient group

Prone and left-lateral positioning decreases 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][69]

Maintaining a more upright position after feeds may be helpful in some cases, although a strong evidence base is lacking.

Consider – trial of extensively hydrolysed formula

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ACUTE
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gastrointestinal disorders
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GORD
Consider – 

trial of extensively hydrolysed formula

Additional treatment recommended for SOME patients in selected patient group

In infants who have persistent regurgitation and poor weight gain it is important to investigate for other causes of faltering growth. Symptoms of cow’s milk protein allergy may be indistinguishable from gastro-oesophageal reflux. It is reasonable to give a 2- to 4-week trial of an extensively hydrolysed formula, which should alleviate symptoms (usually within 2 weeks).[42] 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] Recurrence of symptoms following reintroduction of cows’ milk confirms the diagnosis.

Consider – proton-pump inhibitor

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ACUTE
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gastrointestinal disorders
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GORD
Consider – 

proton-pump inhibitor

Additional treatment recommended for SOME patients in selected patient group

If overt regurgitation is associated with either faltering growth, distress, or feeding difficulties, a 2- to 4-week trial of a proton-pump inhibitor can be considered for breastfed and formula-fed infants. These drugs should not be used for regurgitation occurring as an isolated symptom. 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 proton-pump inhibitor may be useful.[35][36]

Primary options

omeprazole: 1 mg/kg/day orally given as a single dose or in 2 divided doses

2nd line – enteral tube feeding

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ACUTE
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gastrointestinal disorders
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GORD
2nd line – 

enteral tube feeding

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]

3rd line – Nissen fundoplication

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ACUTE
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gastrointestinal disorders
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GORD
3rd line – 

Nissen fundoplication

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]

1st line – dietary modification

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ACUTE
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gastrointestinal disorders
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cows' milk protein allergy
1st line – 

dietary modification

A 2- to 4-week trial of hypoallergenic (extensively hydrolysed) formula, followed by reintroduction of cows’ milk protein, establishes the diagnosis in formula-fed infants. Breastfeeding mothers should temporarily exclude all milk and milk products from their diet for 2 to 4 weeks. This usually requires support from a dietitian to identify hidden sources of cows’ milk protein.[42] If no improvement is seen in symptoms, the trial should be discontinued and alternative diagnoses (such as GORD) should be considered.[42]

Soya protein-based formulas should not be used where cows' milk protein allergy is suspected, as up to 10% of children with cows' milk protein allergy will be equally sensitive to soya.[72]

2nd line – GORD treatment

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ACUTE
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gastrointestinal disorders
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cows' milk protein allergy
2nd line – 

GORD treatment

If cows' milk protein allergy is suspected but symptoms do not improve on the modified diet, GORD treatment should be considered.

1st line – dietary modification

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ACUTE
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gastrointestinal disorders
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coeliac disease
1st line – 

dietary modification

A lifelong avoidance of gluten (e.g., wheat, rye, barley) is advised.

Patients should be advised that some medications may contain gluten.

1st line – dietary modification

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ACUTE
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gastrointestinal disorders
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lactose intolerance
1st line – 

dietary modification

Lactose intolerance can be primary (requiring lifelong dietary modification) or secondary (often following viral gastroenteritis, requiring temporary dietary modification, until symptoms resolve).

The short-term use of a low lactose or lactose-free soya-based or hypoallergenic formula for 6 to 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.

1st line – specialist referral

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ACUTE
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gastrointestinal disorders
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eosinophilic oesophagitis
1st line – 

specialist referral

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

short bowel syndrome

1st line – total parenteral nutrition followed by enteral feeding

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ACUTE
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short bowel syndrome
1st line – 

total parenteral nutrition followed by enteral feeding

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]

neurological impairment

1st line – feeding advice + nutritional support

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ACUTE
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neurological impairment
1st line – 

feeding advice + nutritional support

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]

Consider – nasogastric feeding or gastrostomy

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ACUTE
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neurological impairment
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with impaired swallow or very prolonged feeding time
Consider – 

nasogastric feeding or gastrostomy

Additional treatment recommended for SOME patients in selected patient group

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.

Consider – feed thickener or anti-regurgitant formula

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ACUTE
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neurological impairment
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with GORD
Consider – 

feed thickener or anti-regurgitant formula

Additional treatment recommended for SOME patients in selected patient group

GORD is a common problem among children with neurodevelopmental disorders and should be managed by changing feed volume and frequency and optimising calorific content initially, then adding feed thickeners or anti-regurgitant formulas.

No significant difference in efficacy has been found between different types of feed thickener (carob-bean gum, carob-seed flour, carmellose sodium [sodium carboxymethylcellulose]).[68]

Feed thickeners can be added to formula or expressed breast milk either as a first-line treatment or in combination with other treatments.

Consider – compound alginate

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ACUTE
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neurological impairment
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with GORD
Consider – 

compound alginate

Additional treatment recommended for SOME patients in selected patient group

A compound alginate preparation (e.g., sodium alginate/magnesium alginate) is available for infants, which both thickens feed and acts as a 'raft' to float on the surface of the stomach contents to reduce reflux and protect the oesophageal mucosa. Consult product literature for guidance on dose.

Consider – proton-pump inhibitor

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ACUTE
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neurological impairment
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with GORD
Consider – 

proton-pump inhibitor

Additional treatment recommended for SOME patients in selected patient group

Evidence for effectiveness of proton-pump inhibitors in children with neurodisabilities is limited.[70]

However, infants with neurological impairment are likely to have GORD symptoms that persist beyond infancy and therefore it is reasonable to try acid suppressants, especially where reflux oesophagitis is demonstrated.[35][36]

Primary options

omeprazole: neonates: consult specialist for guidance on dose; infants and children <2 years of age: 0.7 mg/kg orally once daily, maximum 3 mg/kg/day or 20 mg/day

OR

lansoprazole: neonates: consult specialist for guidance on dose; infants and children: 0.5 to 1 mg/kg orally once daily, maximum 15 mg/day (children ≤30 kg)

OR

pantoprazole: neonates, infants, and children: consult specialist for guidance on dose

Consider – Nissen fundoplication

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ACUTE
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neurological impairment
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with GORD
Consider – 

Nissen fundoplication

Additional treatment recommended for SOME patients in selected patient group

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

1st line – gradual introduction of enteral feeds

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ACUTE
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prematurity
1st line – 

gradual introduction of enteral feeds

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.

Consider – dextrose 10%

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ACUTE
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prematurity
Consider – 

dextrose 10%

Additional treatment recommended for SOME patients in selected patient group

Avoidance of hypoglycaemia (blood glucose <3.33 mmol/L [<60 mg/dL]) is critical. Administer intravenous fluid early (10% dextrose without additional electrolytes at 80 mL/kg/day).

See Premature newborn care.

respiratory disorders

1st line – nutritional advice + feeding support

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ACUTE
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respiratory disorders
1st line – 

nutritional advice + feeding support

Patients require evaluation by a multidisciplinary team and a personalised management plan. 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]

cardiac disorders

1st line – nutritional advice + feeding support

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ACUTE
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cardiac disorders
1st line – 

nutritional advice + feeding support

Patients require evaluation by a multidisciplinary team and a personalised management plan. Infants with congenital cardiac disease may require tube feeding after discharge from hospital, and enrichment of breast and formula milk.[77][78]

behavioural problems

1st line – nutritional advice + parental support

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ACUTE
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behavioural problems
1st line – 

nutritional advice + parental support

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

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.[64]

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]

2nd line – hospital admission

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ACUTE
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behavioural problems
2nd line – 

hospital admission

Hospitalisation may be required in severe cases to observe infant-carer interactions while optimising any medical treatment.

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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