Author:
Dorka M. JimenezAlmonte
RichardGabor
Description
- Problems may present in 1 or several of the components of “feeding”:
- Getting food into oral cavity: Appetite, food-seeking behavior, ingestion
- Swallowing food: Oral and pharyngeal phases
- Ingestion and absorption: Esophageal swallowing, GI phase
- Poor feeding is common in acute pediatric disorders:
- Infectious, inflammatory, obstructive
- Chronic feeding problems may result from underlying structural, neuromuscular, cardiovascular, respiratory, GI, behavioral, or environmental issues:
- Congenital anomalies, cerebral palsy, prematurity, congenital heart disease (CHD), GERD avoidant/restrictive food intake disorder, neglect
- Minor feeding difficulties are reported in 25-50% of normally developing children:
- Mainly colic, vomiting, slow feeding, and picky eating
- Transient. Causes no serious outcomes
- Often present during feeding transitions (breast to bottle, introduction to solids)
- More severe problems observed in 40-80% of infants born prematurely and children with chronic medical conditions and /or developmental disabilities
Etiology
- Several distinct areas of pathology - but overlap is common
- Structural abnormalities:
- Naso-oropharynx:
- Cleft lip/palate, submucosal cleft
- Choanal atresia
- Micrognathia and /or Pierre Robin sequence
- Macroglossia (Down syndrome, Beckwith-Wiedemann syndrome)
- Tongue/sublingual masses
- Tonsillar/adenoidal hypertrophy
- Larynx and trachea:
- Laryngo- or tracheomalacia
- Tracheoesophageal fistula
- Laryngeal cleft or cyst
- Esophagus:
- Esophageal strictures, stenosis, or web
- Tracheoesophageal compression from vascular ring/sling
- Esophageal mass or tumor
- Foreign body
- Neurologic/neuromuscular conditions:
- Cerebral palsy
- Hypoxic injury
- Traumatic brain injury
- Cerebrovascular disease
- Posterior fossa tumors
- Muscular dystrophies
- Mitochondrial disorders
- Myasthenia gravis
- Infant botulism
- Polymyositis/dermatomyositis
- Prematurity (especially those requiring prolonged enteral or parenteral feedings)
- Chronic aspiration
- CHD:
- Precorrection: Fatigue, respiratory compromise, increased metabolic needs
- Postcorrection: Any or all of the above as well as recurrent laryngeal nerve injury
- Immune disorders:
- Allergy
- Eosinophilic esophagitis
- Celiac disease
- GI problems:
- Gastroesophageal reflux disease (GERD)
- Constipation
- Obstruction
- Metabolic disorders:
- Hypothyroidism
- Inborn errors of metabolism
- Acute illness or event:
- Sepsis
- Pharyngitis, tonsillitis, peritonsillar abscess, retropharyngeal abscess, epiglottitis, CNS infection
- Oropharyngeal/esophageal lesions:
- Intussusception, malrotation
- Trauma: Abusive head trauma, oropharyngeal trauma/burn, abdominal trauma
- Foreign body ingestion or aspiration
- Developmental problems:
- Pervasive developmental disorders (includes autism spectrum disorders)
- Developmental delays
- Behavioral problems:
- Avoidant/restrictive food disorder (DSM-5):
- Eating too little
- Eating restrictive number of foods
- Fear of eating, phobia
- Rumination (food is regurgitated then reswallowed)
- Conditioned emotional reactions
- Depression
- Environmental/parental issues:
- Poor environmental stimulation
- Dysfunctional feeder-child interaction
- Poverty (inadequate food available)
Signs and Symptoms
Common presentations:
- Caregiver concerns regarding feeding or postfeeding behavior
- Food refusal, gagging, choking, swallowing resistance, or regurgitation
- Poor weight gain/failure to thrive
- Recurrent or chronic respiratory illness
History
- Onset of problem
- Length of meals (often prolonged)
- Food refusal/oral aversion
- Independent feeding (if >8 mo):
- Neuromuscular problems decrease ability to get food to the mouth
- Diaphoresis or easily tired with feedings (CHD):
- Recurrent pneumonia/respiratory distress:
- Most aspiration episodes are silent in infants
- Recurrent pneumonia or wheezing may be primary symptoms of chronic aspiration
- Chronic lung disease (BPD, CF)
- Recurrent vomiting or gagging:
- Diarrhea, rectal bleeding
- Medications (older children) that could cause decrease in appetite such as stimulants or topiramate
- Failure to thrive/poor weight gain:
- Newborns should regain birth weight by 14 d of age
- Infants typically gain 1 kg per month the first 3 mo of age and 0.5 kg per month from 3-6 mo of age
- Infants double their birth weight by 6 mo and triple birth weight by age of 1
- Fussy spells lasting 2-3 hr (normal and calm rest of the day) suggests colic, ages 2 wk-4 mo
- Duration of feeding highly variable, especially in breastfed infants - for all ages, feeding times >30 min on a regular basis is a cause for concern:
- Full-term healthy infant usually feeds 2-3 oz of formula every 2-3 hr
- Breastfed baby eats 10-20 min on each breast every 2-3 hr (may eat more frequently)
- As child gets older, duration and frequency may decrease
- 1 mo old normally eats 3-4 oz every 4 hr
ALERT |
| Ask how caretaker prepares the infant's formula (usually 2 oz of water per 1 scoop of formula). Regular formula and breastmilk contain 20 kcal per ounce. Diluting formula may result in poor weight gain and hyponatremia. Infants with certain medical conditions (prematurity, CHD, FTT) may require high-calorie (concentrated) formula |
Physical Exam
- Vital signs, including oximetry
- Weight, length, head circumference (infants):
- Comparison with prior measurements, evaluate growth chart
- Growth velocity deceleration (height below the 5th percentile for age and gender, growth <5 cm/yr after the age of 5 yr)
- Impaired nutritional status. Severe cases may show emaciation, weakness, apathy
- General physical exam - especially note:
- Affect and social responsiveness
- General appearance (cleanliness)
- Dysmorphism (craniofacial asymmetry, tongue and jaw size, etc.)
- ENT - oropharyngeal lesions/inflammation, infection, or anatomic abnormality
- Cardiovascular status (murmur, gallop, tachycardia, decreased/absent femoral pulses, capillary refill)
- Pulmonary - tachypnea, respiratory distress, color change, crackles/wheezing/rhonchi evidence of aspiration
- Abdominal exam - bowel sounds, distension, tenderness, peritoneal signs, masses
- Neurologic - alertness, tone, strength, coordination, developmental stage, cranial nerves
- Skin: Allergic rash or atopy:
- Loss of subcutaneous fluid or fat is often most apparent around the eyes, which will appear “sunken” in most dehydrated or malnourished infants
- Edema, however, may occur with protein deficiency (kwashiorkor)
- Observation of feeding (in person or video): Neuromuscular tone, posture, position; patient motivation; oral structure and function; efficiency of oral intake, developmental/motor skills and caretaker's response and interaction with the child:
- Ability to hand le oral secretions
- Pace of feeding
- Noisy airway sounds after swallowing
- Gagging, coughing, or emesis during feeding
- Respiratory distress with feeding
- Oximetry during feeding may be helpful
- Onset of fatigue or irritability
- Duration of feeding
- Self-feeding skills
- Parent's feeding techniques
Essential Workup
- A well-hydrated, comfortable child with a normal physical exam and recent history of good weight gain may not need any ED workup beyond assuring good follow-up
- Children who show evidence of distress, dehydration, discomfort, respiratory distress, or poor weight gain require further evaluation
Diagnostic Tests & Interpretation
Lab
- Initial assessment if child failing to thrive or appears malnourished:
- CBC, urinalysis, electrolytes, BUN, glucose, erythrocyte sedimentation rate (ESR) and /or CRP, thyroid functions, LFTs, total protein, and albumin
- Cultures of blood, urine, if concern of infection - CSF analysis and culture if concern for meningitis
- Serum NH3, urine for amino and organic acids, and blood for inborn errors of metabolism if concern for metabolic disorders
Imaging
- CXR if suspected cardiopulmonary concerns
- ECG if cardiac disease suspected
- Bedside US if CHF suspected
- Referral or admission for US and other imaging studies as indicated (upper GI series to evaluate anatomy). Fiberoptic or videofluoroscopic evaluation of swallowing may be needed
- MRI if concerns for brainstem, skull base, or spinal problems
Diagnostic Procedures/Surgery
- Depending on the cause, may require a multidisciplinary evaluation which may involve: Speech pathologist, pediatrician, pediatric gastroenterologist, pediatric dietician, developmental pediatrician, child psychologist and potentially an otorhinolaryngologist, plastic surgeon, or pediatric surgeon
- Surgical correction of specific pathology
- Observation of feeding process, parent/child interaction, and child's behavior
Differential Diagnosis
Feeding disorder encompasses symptoms observed as a final pathway for many disorders
Specific clues to the etiology may include:
- Prolonged feeding, fatigue:
- Recurrent pneumonias:
- Consider chronic aspiration
- Stridor with feeds:
- Consider glottic or subglottic anomalies
- Suck-swallow-breathing coordination:
- Consider nasal congestion, choanal atresia
- Vomiting, diarrhea, abdominal pain, colic:
Prehospital
- Assess vital signs and hydration; resuscitate as necessary
- Assess for and treat hypoglycemia
Initial Stabilization/Therapy
- Cardiovascular/respiratory/fluid resuscitation as needed
- Assess for and treat hypoglycemia if suspected
ALERT |
- Certain inborn errors of metabolism (glycogen storage diseases) can cause profound hypoglycemia if unable to take PO feeds - if known or suspected, IV dextrose should be started immediately
- Bilious vomiting in a young infant may be a sign of malrotation with volvulus causing intestinal ischemia - this requires emergent surgical consultation
|
ED Treatment/Procedures
- Treat dehydration if present:
- Oral rehydration if practical
- IV if PO contraindicated, not tolerated, or impractical
- Nasogastric rehydration
- Ondansetron for acute nausea and vomiting
- Pain management for oropharyngeal lesions/ulcers
- Treat respiratory distress if present:
- Nasal suction to clear secretions prior to feeding may be very helpful in young infants with URI/bronchiolitis
- Oxygen and other interventions as needed
- Treat infection if suspected
ALERT |
| Patients with severe malnutrition are at risk for sepsis and may have blunted physiologic responses - a high index of suspicion for infection is warranted in severely malnourished patients |
Medication
Ondansetron: 0.1 mg/kg IV or PO q8h p.r.n nausea or vomiting - min oral dose for <15 kg: 2 mg; ≥15 kg: 4 mg:
- Monitor if patient at risk of QT prolongation
- For short-term use (3-5 doses) in patients >6 mo
- Review FDA black box warning re QT prolongation
- Acetaminophen: 10-15 mg/kg PO q4-6h p.r.n pain. Do not exceed 4 g/24 hr
- Ibuprofen: 5-10 mg/kg PO q6h p.r.n pain
Disposition
Admission Criteria
- Inability to maintain hydration
- Suspected systemic infection
- Respiratory distress/sustained hypoxia during feeding
- Significant failure to thrive:
- Particularly in infants <3 mo
- Provides an opportunity for observation of feeding
- Decompensated cardiopulmonary disease
- Symptomatic anemia or endocrine dysfunction
- Negligent or overwhelmed caretaker
Discharge Criteria
- Demonstrated ability to tolerate oral feedings
- Weight gain if failure to thrive
- Reliable caretaker and follow-up
Issues for Referral
- Specific referrals based on source of problem
- For complex or chronic feeding problems, a multidisciplinary approach is often needed
- Behavioral conditions often require prolonged psychological intervention and support
- Chronic disease process may interfere with feeding and increase caloric needs:
- Nonoral nutrition such as percutaneous endoscopic gastrostomy (PEG) tubes are often needed to address these issues
Follow-up Recommendations
- When available, a primary provider is the most important resource for follow-up
- In the case of complex problems, a multidisciplinary approach is often needed - the primary provider is often in the best position to coordinate this
- FleisherGR, LudwigS. Dysphagia. In: Textbook of Pediatric Emergency Medicine. 7th ed.Philadelphia, PA: Lippincott Williams & Wilkins; 2016:351-357.
- KerznerB, MilanoK, MacLeanWC, et al. A practical approach to classifying and managing feeding difficulties . Pediatrics. 2015;135(2):344-353.
- PhalenJ. Managing feeding problems and feeding disorders . Pediatr Rev. 2013;34(12):549-557.
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