Last reviewed: 28 Dec 2021
Last updated: 13 Mar 2018



History and exam

Key diagnostic factors

  • age <1 year
  • time taken to feed >30 minutes
  • stressful mealtimes
  • abnormal perinatal events
  • poor growth (crossing downwards 2 percentiles)
  • food refusal
  • craniofacial abnormalities
  • abnormal neurodevelopmental assessment

Other diagnostic factors

  • inappropriate volume of feed
  • regurgitation
  • vomiting
  • abdominal pain, distension, or colic
  • apnoea, desaturations, and bradycardias in premature infants
  • irritability or lethargy at mealtimes
  • abnormal feeding pattern on observation
  • underlying illnesses and previous hospitalisations
  • previous oropharyngeal or GI surgery
  • FHx of atopy or feeding problems
  • recurrent pulmonary infections and wheeze
  • coughing or retching at meal times
  • posture changes during feeds
  • atopic features
  • apparent life-threatening event (ALTEs)
  • drooling
  • ankyloglossia (tongue-tie)
  • features of genetic conditions
  • abnormal cardiorespiratory signs

Risk factors

  • age <1 year
  • prematurity
  • intrauterine growth retardation
  • developmental delay
  • anatomical abnormalities of the oropharynx
  • post-surgical correction of oropharyngeal or GI abnormalities

Diagnostic investigations

Investigations to consider

  • trial of hypoallergenic feed
  • oesophageal 24-hour pH study
  • upper GI contrast study
  • oesophageal impedance study
  • CXR
  • abdominal x-ray
  • abdominal ultrasound
  • videofluoroscopic swallow
  • fibreoptic endoscopic evaluation of swallowing with sensory testing
  • upper GI endoscopy with biopsy
  • nuclear scintigraphy
  • bronchoscopy
  • radio-allergosorbent testing (RAST) to cows' milk protein
  • trial of lactose-free diet
  • faecal-reducing substances
  • tissue transglutaminase (TTG) antibodies

Treatment algorithm



Helen McElroy, MBChB, MSc, MRCPI (Pediatrics)

Consultant Neonatologist

Medway NHS Foundation Trust





HM declares that she has no competing interests.


Dr Helen McElroy would like to gratefully acknowledge Dr Stephanie Gill and Dr Uma Sothinathan, previous contributors to this monograph. SG and US declare that they have no competing interests.

Peer reviewers

Alexander K.C. Leung, MBBS

Pediatric Consultant

Alberta Children's Hospital

University of Calgary




AKCL declares that he has no competing interests.

Sarah N. Taylor, MD

Assistant Professor

Division of Neonatology

Medical University of South Carolina

Children's Hospital




SNT declares that she has no competing interests.

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