Feeding disorders are common in infants and, if the underlying cause is not addressed, may persist into childhood.
Etiologies are usually multifactorial, and are best managed by a multidisciplinary team. Causes include prematurity; anatomic abnormalities; neuromuscular/neurodevelopmental conditions; gastrointestinal, genetic, cardiac, or respiratory conditions; and behavioral factors.
Diagnosis is usually clinical, with a consistent history supported by dietetic assessment. Complementary diagnostic tests and subsequent management are guided by physical findings and severity of symptoms.
Feeding disorders are usually subacute to chronic in nature. A sudden change in feeding habit may be associated with other conditions, notably infections, which need to be excluded.
Feeding plays an important role in the life of infants. Early motor milestones are related to feeding, and feeding is an important time for infant-caregiver interaction. During the first year of life, infants' weights may be more closely monitored than at other times, and feeding and growth become an important component of medical review.
The focus of this topic is infants <1 year of age. One European study reported that, of 700 children referred for tertiary assessment of a severe feeding disorder, 50% presented at less than 1 year of age. Another study conducted in the US showed that 67% of patients were under 3 years of age at presentation, and many had symptoms beginning in the first year of life.
History and exam
Key diagnostic factors
- time taken to feed >30 minutes
- stressful mealtimes
- faltering growth (crossing downward 2 centiles)
- food refusal
- craniofacial abnormalities
- abnormal neurodevelopmental assessment
Other diagnostic factors
- inappropriate volume of feed
- 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 gastrointestinal or cardiac surgery
- family history of atopy
- family history of feeding problems
- recurrent pulmonary infections and wheeze
- coughing or retching at meal times
- posture changes during feeds
- atopic features
- apparent life-threatening event (ALTEs)
- ankyloglossia (tongue-tie)
- features of genetic conditions
- intrauterine growth restriction
- developmental delay
- anatomic abnormalities of the oropharynx or gastrointestinal tract
- gastrointestinal surgery
- neonatal cardiac surgery
- Down syndrome
Investigations to consider
- temporary exclusion of cows’ milk protein
- esophageal 24-hour pH study
- upper gastrointestinal contrast study
- esophageal impedance study
- videofluoroscopic swallow
- fiberoptic endoscopic evaluation of swallowing with sensory testing
- upper gastrointestinal endoscopy with biopsy
- radioallergosorbent testing (RAST) to cows' milk protein
- trial of lactose-free diet
- fecal-reducing substances
- tissue transglutaminase (TTG) antibodies and total IgA
short bowel syndrome
Helen McElroy, MBChB, MSc, FRCPCH
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 topic.
SG and US declare that they have no competing interests.
Alexander K.C. Leung, MBBS
Alberta Children's Hospital
University of Calgary
AKCL declares that he has no competing interests.
Sarah N. Taylor, MD
Division of Neonatology
Medical University of South Carolina
SNT declares that she has no competing interests.
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