Feeding difficulties in infants
Feeding difficulties in infants present a common problem for all health care professionals. They result in significant anxiety for parents, who feel pressure for their child to eat a balanced diet, and demonstrate appropriate weight gain. This comes from many sources, health care workers, relatives, and society as a whole from the media. Many studies have shown that as many as 30% of children will develop some difficulty with eating. These problems are varied and range from a child who is thought to be fussy or picky, to the child who refuses food and is unable to take enough calories to thrive.
In clinical practice there are three broad groups of problems, although there is a lot of overlap. These include an aversion for texture, where lumpy foods are rejected, or taste where certain food types are refused, if severe this can lead to neophobia, where there is an inability to introduce any new foods into the diet. In newborns these difficulties present with refusal of milk, either difficulty with sucking or swallowing, or discomfort during a feed. The peak age for feeding difficulties is at the age of six months when solid foods are introduced, although there have often been subtle indicators before. This time is an important milestone in development. It represents the start of chewing. As with other developmental milestones it is well recognised that the stimulus, i.e. solid food, has to be introduced at the correct time. If this is delayed the skill has to be learned which will result in delay. (1,2,3)
There is no satisfactory definition of feeding difficulties, and this causes confusion as to which children need intervention, and what services are required. There is no doubt that children who have faltering growth, should be assessed. A multidisciplinary team best achieves this. The parental anxiety, and regular monitoring of weight gain in record books, means that usually the first port of call is the health visitor. Currently there is very little consensus as to the correct management for these children. This results in confusion among health care professionals, heightening parental anxiety, and therefore aggravating the difficulties.
Working in our multidisciplinary feeding clinic at the Royal London, we have become aware that many feeding difficulties have an original insult, often medical, which has resulted in a maladaptation in feeding behaviour. The significance of this is that in severe feeding problems, the rigid separation between organic and non-organic approaches is doomed to failure. Feeding clinics are increasing in many health districts to provide support for this group. The key members of such a team are dieticians, speech and language therapy (SALT), and nursing. It is also helpful to include an interested paediatrician, at least in the initial assessment.
Infants At Risk
Some groups of infants can be identified early. This enables intervention, particularly with dieticians and speech and language therapists, to provide support and practical advice to parents. Studies of preterm babies have shown an increase in the development of feeding difficulties, such as discoordinated sucking and swallowing. This appears to be separate from neurological problems. Many of these babies are tube fed for a varying period. If no stimulus is provided to encourage sucking, a change to oral feeding may be difficult and longstanding. Neonatal intensive care units are now aware of this potential problem and are increasingly involving SALT early.(4)
Children with neurological handicap often present with slow, and difficult feeding which is often an early clue to the diagnosis. An early SALT review is essential to ensure that swallowing is safe, with no risk of aspiration. This group requires specific intervention, by specialist teams and is not discussed further in this paper.
As we have already noted a delay of providing a stimulus of chewing at the milestone of six months makes the later development of managing solids difficult. This was highlighted in 1987 in East London where it was observed that it was a common practice to delay weaning foods, and provide convenience sweet foods such as egg custard. These children had difficulty in establishing lumpy foods, even as toddlers.
Any child with a medical problem may have difficulty in sucking. An example is those children with congenital heart disease, who cannot provide the energy required in sucking. Children with congenital gastro-intestinal problems such as tracheo-oesophageal fistula, will inevitably have difficulty due to the dysmotility of the oesophagus, which persists even after surgical correction.
Presentation of feeding difficulties
The most common presentation in babies is a refusal to suck, or screaming and pulling away during feeds. This is commonly associated with arching of the back and stiffening. These symptoms are often related to gastro-oesophageal reflux, or milk allergy.
At the time of weaning a common presentation is gagging, on lumps. In many children this is normal and will improve, but if it persists, it may continue to a refusal of any food other than almost a puree. This can often be misconstrued as vomiting. A specific preference for food types then can develop, as these are considered safe for the baby. This results in inadequate calories and progress to faltering growth.
Drooling is an important observation, and again indicates an urgent SALT opinion, particularly if it is associated with recurrent chest infections. It is associated with neurological problems or involvement of the larynx such as a cleft.
A frequent sign, which often ignored, is a delay in duration of mealtimes. Most children will take adequate calories over thirty minutes. Longer than this results in frustration in parent and child and leaves to force-feeding. (6)
The first step in assessment is an accurate measurement of both height and weight, with a review of the health record to identify faltering growth. A detailed medical history is taken to identify potential risk factors, and developmental progress. Physical examination will exclude associated medical problems. It should be noted that it is important to examine the mouth, which is often neglected. A sub mucosal cleft of the palate is often missed. The jaw shape needs to be examined, as malformations such as Pierre Robin will interfere with effective feeding.
A dietary history should be taken to demonstrate calorie intake. In babies the type of milk should be noted. In children on a weaning diet, it is important to explore the potential of micronutrient deficiencies such as iron.
A SALT review is needed to look for episodes of choking, respiratory infections. An observation of feeding will reveal disco-ordinate swallow, and potential for aspiration.
A psychosocial review is important to review the family dynamics around feeding, parental anxieties, and expectations. The settings of a normal mealtime are helpful, particularly looking at issues such as force-feeding. A review of the child's behaviour in general is helpful, although rare it should be remembered that autistic spectrum could present with feeding issues.
Gastro-oesophageal reflux disease
In our experience, and that of others, gastro-oesophageal reflux disease is probably the most common medical association with feeding difficulties. This often involves problems of both texture, and taste. Reflux is almost universal in babies in the first six months of age. If there are problems such as pain, chest infections or discomfort, it is termed reflux disease or GORD. There may not be associated vomiting and in this situation it is referred to as silent reflux. The discomfort the patient experiences is related to food and an aversive pattern is established. It is important to consider this in children with feeding difficulties, as if this is not corrected, psychology alone will be unsuccessful.
Food allergy is often an association, an needs to be considered. There may not be a rash, but here is often a history of atopy in the family. (6)
It must be stressed that a multidisciplinary approach is best. The association with antecedent organic problems need to be identified and managed alongside the psychological approach to succeed. It should be recognised that babies very quickly learn to modify behaviour in response to aversive episodes such as chocking, pain, and vomiting, particularly if it occurs at the same time as feeding.
Routine medical screening tests are difficult to establish, due to the varied conditions involved. Currently tests for GORD are invasive, such as endoscopy, and impedance, and are reserved only for those children with severe problems or failure to thrive.
Dietary management is aimed to provide adequate calories for growth, and correction of vitamin or trace element deficiency. Supplemental feeds, and advice about calorie dense foods, may be helpful to re-establish weight gain. The child with reflux and delayed emptying, may be helped by small, frequent volumes. Fluid intake is important, as many of these children may have associated constipation.
Children at risk of aspiration require an assessment of eating with video-fluoroscopy. An experience speech and language therapist must perform this. This can also be an adjunct to therapy, as the handling of both solids and liquids can be reviewed, and if liquids are aspirated they may be tolerated if thickened. Children, such as those with oesophageal dysmotility, are helped considerably by drinking fluid during a meal, as it seems to help food bolus to be cleared.
Children who have an aversion to lumpy foods may be helped by the introduction of bite and dissolved foods, which are easier to clear the mouth, and may give the child some confidence to handle them.
The introduction of new foods is difficult and often very slow, to the frustration of the careers. It must be remembered that it takes over twenty times of exposure for a normal individual to decide they like it. Therefore parents need to have realistic expectations. To the child there is a real fear associated with the new foods; the introduction with minuscule portions such as a pinhead may help.
General Behavioural Approaches
The first step to any practical management is to address the anxiety around the parents. It must be remembered that feeding is a dyad and their attitudes and fears may have an additional aversive effect. The most common worry is inadequate weight gain. The children has been regularly weight and monitored. There is therefore extreme pressure on the parents to achieve the desired weight. If this seems to be failing they resort to force-feeding. This creates increasing fear for the child around mealtimes and worsens the situation. Our policy is to explain to the parents that we will take responsibility for weight gain, during the program. It is often difficult to change entrenched behaviour and it's essential that all members of the family are consistent in their approach.
Realistic volumes of intake must be set for the child, taking note of problems such as delayed gastric emptying. The duration of eating is also important, and a limit set. Meal times have often become a protracted battlefield, for the whole family, which is counterproductive. If new foods are being tried it is often helpful to only set aside one meal for this.
Young children who are food aversive, will often benefit from messy play with food, to try a get used to food on their fingers. It is important that the child has some involvement and control over their feeding and the use of finger foods may help the child to get used to control of lumps, which in the face of oral aversion is less threatening than being spoon fed. Many groups such as sure start now have regular groups for this, and often watching others is beneficial. In older children it should be borne in mind that the pressure for change is from the parent. If the child is putting on weight they often have no drive to change, their eating pattern. Any interventions are almost impossible until the older child wants to change, this often comes from peer pressure not parents.
Very rarely, in severe cases of failure to thrive tube feeding, may be needed. This is for as short a period as possible. During this period oral feeding is still important. The advantage is that meal times are less pressurised and one mealtime can be set aside for this. (7)
Feeding difficulties are an important, but poorly recognised problem in childhood. Management is often difficult because of the need for a multidisciplinary approach. Parents need a lot of support during a difficult time. Meals should be enjoyable, and its hard for families when it is a constant battle.
Any management of this problem should take into account both the organic and non-organic aspects of the etiology.
In most health areas it is encouraging that there are teams emerging with the required expertise to provide help.
- Rommel N, De Meyer A et al. The complexity of feeding problems in 700 infants and young children presenting to a tertiary care institution. JPGN; 37:75-84.2003
- Miller-Lonner C, Bigsby R, Waalace M, Lester B. Infant colic and feeding difficulties. Arch Dis Child. 2004;89:905-912
- Illingsworth RS, Lister J.The critical period with special reference to certain feeding problems in infants and children. J Peddiatr. 1964;65:839-48
- Jonsoon M, VanDoom J, Van de Berg J. Parents. Parents perceptions of eating skills of preterm vs full term infants from birth -3years. Int J Speech Lang Pathol. 2013;6:604-12
- Northstone k, Emmett P, Nethersole F, and the ALSPAC Team Study(2001). The effect of age of introduction to lumpy foods eaten and reported feeding difficulties at 6 and 15 months. Journal of Human Nutrition and Dietetics. 2001;14:43-54
- Falconer J. Gastro-oesophageal reflux and gastro-oesophageal disease in infants and children. J Fam Health Care. 2010;20:175-7
- Lukens CT, Silverman AH. Systematic review of psychological interventions for pediatric feeding problems. J Pediatr Psycol. 2014;16