History and exam
Key diagnostic factors
common
time taken to feed >30 minutes
stressful mealtimes
Caregivers may report stressful mealtimes due to the length of time taken to feed, behavior of the child during feeding, or difficulty in giving adequate amounts or variety of food.[8][41] This should be addressed, because an early feeding disorder can be compounded by abnormal learned behavioral responses to these stresses.[7]
Length of meals, strategies used to encourage feeding, and behavior at mealtimes should be ascertained.
Many of the strategies employed by caregivers hoping to improve feeding may actually reinforce negative behavior.[52] For example, distracting the infant at feeding time can teach the infant that refusal to eat gains attention.[52]
Feeding disorders in infants have been associated with depression in adult caregivers.[49]
uncommon
faltering growth (crossing downward 2 centiles)
Simple feeding disorders do not cause faltering growth initially. It is important to review growth from birth and relate this to any changes in feeding (e.g., in celiac disease there may be failure to gain weight after weaning) or environment (including family stressors, major life events).
Faltering growth despite adequate caloric intake requires an alternative approach. See Faltering growth.
food refusal
Strongly indicates a behavioral component to the feeding disorder, such as abnormal behavioral interactions between the caregiver and child.[5]
Correlates to family feeding problems, difficult mealtime behavior, and health problems.[53]
It may also result from any feeding disorder where eating becomes associated with an unpleasant sensation such as vomiting or acid reflux.[54]
May also be the result of sensory aversion and anatomic abnormalities (e.g., dysphagia with solid foods due to esophageal stricture).[3]
craniofacial abnormalities
Symmetry of the infant's face and jaw, lips and palate, and the rhythm and strength of non-nutritive and feeding suck should be assessed.[8]
An open-mouthed posture may reflect nasal or pharyngeal obstruction.[8] Tonsillar hypertrophy is possible if an older child is predominantly mouth breathing or stertorous (snoring) breathing is heard.[8]
abnormal neurodevelopmental assessment
Feeding disorders are seen in up to 80% of children with neurodevelopmental delay.[3]
Failure to achieve feeding milestones may be the presenting sign of more global developmental delay.
Attention should be paid to the infant's posture, position during feeds, truncal tone, and movement. The infant's response to sensory stimuli may also give more clues about developmental issues.[8]
Other diagnostic factors
common
inappropriate volume of feed
A detailed dietary history is crucial to assess whether the diet being offered is adequate, and should ideally be performed by a pediatric dietitian.[40] The type and amount of feed should be ascertained, looking for evidence of overfeeding or inadequate intake, errors in the preparation of formula feeds, changes in formula, and introduction of solids.[35]
vomiting
Recurrent vomiting with additional symptoms (e.g., abdominal pain, colic, or constipation), but without failure to thrive and with a normal physical exam, is common in uncomplicated GERD.[35] Similar symptoms may also be seen in cows' milk protein allergy.
Bilious vomiting in a term infant indicates an upper gastrointestinal obstruction usually requiring surgical intervention. However, it is a common finding during the establishment of enteral feeding in premature infants, and is normally managed medically in this population.
Projectile, nonbilious vomiting is characteristic of gastric outflow obstruction (e.g., pyloric stenosis).
A sudden onset of vomiting in a previously well child may be a symptom of other conditions, notably infections such as meningitis and urinary tract infection, which should be considered and ruled out first.
Simple regurgitation without any other symptoms is physiologic and does not require either investigation or treatment.[36][37]
abdominal pain, distension, or colic
Colic is defined as paroxysms of irritability or crying lasting >3 hours per day and occurring >3 days per week for at least 1 week.[38]
Colic can occur in isolation, or concomitantly with GERD or cows' milk protein allergy (CMPA).[39] Infants who are reported to have symptoms of colic have more disorganized feeding behaviors, less rhythmic sucking, and lower responsiveness during feeds.[39]
Abdominal distension can occur in lactose intolerance.
Abdominal pain can occur in GERD and CMPA.
apnea, desaturations, and bradycardias in premature infants
GERD in premature infants is often characterized by these signs, which are not always associated with times of feeds. These signs may also reflect difficulty coordinating breathing, suckling, and swallowing, particularly if there is concomitant cardiac or respiratory disease.
irritability or lethargy at mealtimes
Overall responsiveness and temperament of the infant should be assessed.[8]
Normal infants can cry up to an average of 2 hours per day, and a symptom diary may be helpful to determine the length of irritability and any temporal association with feeds.
abnormal feeding pattern on observation
Feeding should be observed for a full 20 minutes to gain an accurate impression of the infant's feeding pattern.[8] The infant should be observed to assess response to cues, level of infant alertness, breathe-suck-swallow coordination, and quality of feed (length, quantity, associated symptoms). The interactions between the caregiver and the infant should be observed, looking for positive interactions (maintaining eye contact, offering praise for good behaviors, reciprocal vocalization, responding to satiety cues) and negative interactions (forced feeding, bribing, distracting).[40]
uncommon
underlying illnesses and previous hospitalizations
Medical conditions such as cystic fibrosis, bronchopulmonary dysplasia, and congenital heart disease can lead to poor respiratory reserve and difficulties feeding due to tachypnea.[40]
previous gastrointestinal or cardiac surgery
Complications following surgical repair of structural anomalies are well recognized. For example, following esophageal atresia or tracheoesophageal fistula repair, complications include GERD and esophageal stricture leading to dysphagia.[10] Pharyngeal and esophageal dysmotility, and delayed feeding milestones, are common in infants with gastroschisis following surgical repair of the abdominal wall defect.[12] In a retrospective study of infants who underwent cardiac surgery in the neonatal period, 22% experienced feeding disorders.[23]
Short bowel syndrome after bowel resection for necrotizing enterocolitis was found in 1.1% of a cohort of extremely low birth weight infants.[33]
family history of atopy
family history of feeding problems
Parental infant feeding problems are associated with an increased likelihood of feeding problems in their offspring.[46]
recurrent pulmonary infections and wheeze
coughing or retching at meal times
posture changes during feeds
Posture changes during feeds may indicate discomfort.[2] Arching the neck and turning the head to one side may be seen in Sandifer syndrome, an uncommon manifestation of severe GERD.
atopic features
Rashes (especially eczema) and rhinitis may be symptoms of cows' milk protein allergy.[42]
apparent life-threatening event (ALTEs)
ALTEs may be associated with recurrent regurgitation. ALTEs may have multiple causes, so are not diagnostic of a feeding disorder.
Many infants who have had an ALTE also have a history of regurgitation and vomiting suggestive of GERD, but it can be difficult to prove a causal relationship.[58] Moreover, in infants followed for 2 months after an ALTE, the coexistence of GERD did not predict the risk for having recurrent ALTEs, prolonged apnea, or bradycardia.[59]
drooling
May be a sign of difficulty in swallowing, such as anatomic and neurologic problems.
ankyloglossia (tongue-tie)
Tongue-tie has been associated with difficult suckling in breastfed infants.[28]
features of genetic conditions
Many genetic conditions are associated with feeding disorders. For example, infants with Down syndrome may be slower to feed due to hypotonia, and are at an increased risk of duodenal atresia. Characteristic physical features of Down’s syndrome include brachycephaly with a flat occiput; epicanthal folds and upslanting palpebral fissures; Brushfield spots in the iris; low nasal bridge; low-set ears; broad neck; and small hands with transverse crease.
Infants with Pierre Robin sequence have micrognathia (small lower jaw) and glossoptosis (tongue displaced posteriorly in oral cavity).[30] These anatomic abnormalities cause positional airway obstruction.[31] Some infants with Pierre Robin sequence also have a cleft palate. Affected infants struggle to coordinate breathing and swallowing, and are at higher risk of GERD.[31][32]
Risk factors
strong
prematurity
Premature infants are more likely than term infants to present with symptoms of feeding disorders.[3][4] One third of patients referred with feeding disorders are born at <37 weeks' gestation.[3] The more premature the infant, the more likely there are to be feeding problems. In one feeding disorders program, the prevalence of neonates born at <34 weeks' gestation was 20 times greater than in the local population.[3]
Preterm infants have impaired coordination of suckling, swallowing, and breathing; slow gut transit times; decreased lactase activity; increased risk of GERD; and increased risk of surgery (e.g., stoma formation or bowel resection for necrotizing enterocolitis). Prematurity increases the likelihood of medical manipulation of the oropharynx (ventilation with endotracheal tube placement, tube feeds, oropharyngeal suctioning), which is postulated to increase sensory aversion, and lead to behavioral feeding difficulties.[3]
intrauterine growth restriction
Intrauterine growth restriction refers to birth weight at less than the 10th percentile for gestational age.
Infants referred to tertiary centers for management of feeding disorders have a significantly lower birth weight for their gestational age, implying that feeding problems are associated with intrauterine growth restriction.[3]
developmental delay
Up to 80% of patients with complex feeding disorders are found to have developmental delay.[4]
In children with cerebral palsy, a wide range of feeding problems have been described, including needing help with feeding, choking on food, and feeding time greater than 3 hours per day.[26] The prevalence of feeding disorders in children with hemi- or diplegic cerebral palsy is 25%, rising to 50% in children with quadriplegic cerebral palsy.[8]
Delay in acquiring feeding skills (e.g., transition to some solid foods at 6 months) may be the presenting symptom of a more global developmental delay.[8]
anatomic abnormalities of the oropharynx or gastrointestinal tract
Normal sucking, swallowing, and oral motor development are dependent on normal anatomy.[27] Structural anomalies accounted for 60% of referrals to one large US pediatric feeding team.[4]
Cleft lip and palate prevent an infant from making an adequate seal, leading to a decreased ability to suck.
Tongue-tie (ankyloglossia) has been associated with difficulty suckling in breastfed infants.[28]
Up to 75% of patients with esophageal atresia, with or without associated tracheoesophageal fistula, have feeding difficulties. The anatomic abnormalities increase an infant’s risk of aspiration, and are often accompanied by dysmotility, esophageal outlet obstruction, and esophagitis.[29]
Infants with Pierre Robin sequence have micrognathia (small lower jaw) and glossoptosis (tongue displaced posteriorly in oral cavity).[30] These anatomic abnormalities cause positional airway obstruction.[31] Some infants with Pierre Robin sequence also have a cleft palate. Affected infants struggle to coordinate breathing and swallowing, and are at higher risk of GERD.[31][32]
[Figure caption and citation for the preceding image starts]: An infant with Pierre Robin sequenceReproduced from https://pubmed.ncbi.nlm.nih.gov/22300418/ under a CC BY 2.0 license; no changes have been made to the image [Citation ends].
gastrointestinal surgery
Complications following surgical repair of structural anomalies are well recognized. For example, following esophageal atresia or tracheoesophageal fistula repair, complications include GERD, or esophageal stricture leading to dysphagia.[10] Pharyngeal and esophageal dysmotility, and delayed feeding milestones, are common in infants with gastroschisis following surgical repair of the abdominal wall defect.[12]
Short bowel syndrome after bowel resection for necrotizing enterocolitis was found in 1.1% of a cohort of extremely low birth weight infants.[33]
neonatal cardiac surgery
In one retrospective study of infants who underwent cardiac surgery in the neonatal period, 22% experienced feeding disorders defined as inadequate intake for appropriate age, failure to thrive, and need for nasogastric feeding.[23] Infants with congenital heart disease experience prolonged hospitalization with intubation, delayed onset of enteral feeding, and higher incidence of GERD, which can collectively impair the acquisition and development of feeding skills.[1]
Down syndrome
Over 50% of infants with Down syndrome have some degree of dysphagia. The risk of dysphagia is increased in infants with Down syndrome who are premature, are underweight, desaturate with feeds, or have respiratory or airway anomalies.[34] Infants may be slower to feed due to hypotonia, and are more likely to have orofacial abnormalities or congenital cardiac disease.
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