Last reviewed: July 2020
Last updated: March  2018



History and exam

Key diagnostic factors

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

Other diagnostic factors

  • inappropriate volume of feed
  • regurgitation
  • vomiting
  • abdominal pain, distension, or colic
  • apnea, desaturations, and bradycardias in premature infants
  • irritability or lethargy at mealtimes
  • abnormal feeding pattern on observation
  • underlying illnesses and previous hospitalizations
  • 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
  • anatomic abnormalities of the oropharynx
  • postsurgical correction of oropharyngeal or GI abnormalities

Diagnostic investigations

Investigations to consider

  • trial of hypoallergenic feed
  • esophageal 24-hour pH study
  • upper GI contrast study
  • esophageal impedance study
  • CXR
  • abdominal x-ray
  • abdominal ultrasound
  • videofluoroscopic swallow
  • fiberoptic 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
  • fecal-reducing substances
  • tissue transglutaminase (TTG) antibodies
More investigations to consider

Treatment algorithm


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 reviewersVIEW ALL

Pediatric Consultant

Alberta Children's Hospital

University of Calgary




AKCL declares that he has no competing interests.

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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