Feeding Difficulties in Infants

Educational Objectives

The goal of this program is to improve management of feeding difficulties in infants. After hearing and assimilating this program, the clinician will be better able to:

1. Manage reflux in the pediatric population.
2. Use thickened feeds safely in infants with feeding difficulties.

Summary

Feeding problems: 1% to 2% of infants have serious feeding problems resulting in poor weight gain; feeding is graded as normal, perceived feeding problems, mild feeding difficulties, and true feeding disorders; ≈25% of children fall into one of the categories of disorder

Causes: include neurologic impairment (incoordination of suck and swallow), structural abnormalities (mostly anatomic), physiologic instability (child with severe respiratory distress or congenital heart disease), gastroesophageal reflux disease (GERD), and food allergy and intolerance

Definitions: gastroesophageal reflux (GER) — passage of gastric contents into the esophagus with or without regurgitation; silent reflux — reflux without regurgitation in infants; physiologic phenomenon in infants; GERD — occurs when the infant starts to have troublesome symptoms and/or complications, eg, discomfort, excessive vomiting, or respiratory symptoms; ≈25% of infants develop GERD, which improves with age

Symptoms: the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) included discomfort, irritability, feeding refusal, and failure to thrive; stridor, cough, hoarseness, dysphagia, or discomfort with feeding are less common; dental erosions and frequent ear infections (in older children)

Management: suspect GERD; if any alarming signs (eg, severe failure to thrive, respiratory distress, inconsolable) then adjust the approach; follow reflux precautions in absence of alarm signs including avoiding overfeeding and thickening feeds; continue breastfeeding; recommended to keep the child upright for 45 min after a feeding to avoid regurgitations; a 2 to 4 wk trial of protein hydrolysate or amino acid-based formula is recommended if the child has not responded to earlier strategies; many children with reflux are milk protein sensitive or allergic

Addressing reflux: breastfeeding infants — milk and soy elimination is the first step; infants on formula feeding — consider thickened formulas; hydrolyzed or amino acid formulas may be considered; for milder presentation, start hydrolyzed formulas before amino acid formulas; goat formulas (usually corn-free) can be used depending on family preference; NASPGHAN recommends referring to pediatric gastrointestinal (GI) if changing formula is not effective; consider trial of acid suppression; can use proton-pump inhibitors for a limited time in infants and wean them off when symptoms improve; growth issues, feeding refusal, irritability, or reflux symptoms — refer

Thickened feeds: studies have demonstrated efficacy in managing pediatric reflux; avoid using these in infants <42 wk corrected age (higher risk for necrotizing enterocolitis); baby cereal or thickeners can be used

Aspiration: swallowing involves integrating sensory and motor functions and coordinating voluntary and involuntary functions; oral, pharyngeal, and oropharyngeal phases; a disruption can cause an abnormal swallow; penetration — the bolus enters the airway but not below the vocal folds; aspiration — anything enters the airway and into the vocal folds; silent aspiration — aspiration without any signs (cough, splutter)

Etiologies of aspiration: anatomic — choanal atresia, cleft lip and palate, esophageal atresia, tracheoesophageal fistula; neurologic — vocal cord paralysis, nerve palsies; functional and developmental — may improve over time; related to the development of coordination of suck and swallow; iatrogenic — often seen in children hospitalized in the neonatal intensive care unit (eg, vocal cord paralysis from prolonged intubation)

Signs and symptoms: cough, wheeze, recurrent infections, and choking during feeds are common; irritability, discomfort with feeds, and prolonged feeding times may indicate reflux; GERD-like symptoms were found in 50% of patients (especially premature or children with developmental delay); consider aspiration in children with feeding discomfort refractory to acid suppression; an apparent life-threatening event, or brief, resolved, unexplained event was identified in 29% of infants in a study (swallow study was most likely abnormal in these children)

Assessments: clinical feeding assessments conducted by speech and language pathologists or occupational therapists; clinical feeding evaluations help identify oral and motor issues contributing to feeding difficulties but may not rule out the risk for aspiration; video fluoroscopic swallow study — conducted by speech-language pathologists and radiologists; child drinks a barium mixed liquid under X-ray, testing various textures (thin to thick); dependent on a compliant child; not for breastfeeding children; child needs to consume a sufficient volume; not a suitable for child who has been tube fed, oral aversion, or limited feeding experience; assesses oral, pharyngeal, and esophageal phases; fiberoptic endoscopic evaluation of swallowing (FEES) — done in clinic; involve ENT and speech and language pathologists; can assess breastfeeding children; can assess oral and pharyngeal phases of swallow; can assess with minimal volumes; provides anatomic assessments

Management: feeding modifications include pacing, bottles, and positioning; thickeners reduce respiratory symptoms and hospitalizations and performed well vs gastrostomy tube feedings; supplemental tube feedings can be done; usually infants who aspirate thin liquids do not need a feeding tube

Tethered oral tissues: tongue-tie — present in 4% to 11% of newborns; causes poor feeding and maternal nipple pain; easily corrected; lip-tie and cheek-tie — cause feeding difficulties; the Bristol Tongue Assessment Tool is commonly used for tongue-tie (8 being normal function and <5 being tongue impairment); a Cochrane review found no consistent improvement in infants after repairing tethered oral tissue but there was improvement in maternal nipple pain and breastfeeding experiences with no serious complications

Psychosocial factors: psychosocial or behavioral issues in the parent or child coexist with ≤80% of feeding difficulties; maternal anxiety, postpartum depression, inappropriate feeding styles, and inappropriate mealtime environments contribute; parent and infant attachment issues can result in feeding issues; authoritarian feeding style (the child is forced to eat all the food) and permissive feeding style (feeding the child every hour) are problematic

Oral aversion: negative feeding experiences contribute; infant distress upon introducing the bottle, arching or pulling away, latching briefly and pulling off, or feeling hungry and pulling off are some signs; feeds better drowsy; feeding disorders in infancy are associated with cognitive impairment, behavioral issues, anxiety disorders, and eating disorders; children need to reestablish their hunger drives; allow them to feed as much as they want, when they want until they get back in routine; may lose weight in the first week

Eosinophilic esophagitis (EOE): can affect infants; consider endoscopy if the child is resistant to all strategies and still has minimal intake, vomiting, and poor weight gain

Readings

Clarke P, Robinson MJ. Thickening milk feeds may cause necrotising enterocolitis. Archives of Disease in Childhood, Fetal & Neonatal Edition. 2004 May;89(3):pF280. View Article; Duncan DR, Amirault J, Mitchell PD, et al. Oropharyngeal dysphagia is strongly correlated with apparent life-threatening events. Journal of Pediatric Gastroenterology & Nutrition. 2017 August;65(2):p168–172. DOI: 10.1097/MPG.0000000000001439. View Article; Duncan DR, Mitchell PD, Larson K, et al. Presenting signs and symptoms do not predict aspiration risk in children. Journal of Pediatrics. 2018 October;201:p141–146. DOI: 10.1016/J.JPEDS.2018.05.030. View Article; Kondekar S, Shettiwar S, Bhanushali C, et al. Approach to feeding problems in children. Journal of the Pediatrics Association of India. 2020 Oct-Dec;9(4):p127–130. DOI: 10.4103/JPAI.JPAI_15_21. View Article; Rofes L, Arreola V, Mukherjee R, et al. Sensitivity and specificity of the Eating Assessment Tool and the Volume-Viscosity Swallow Test for clinical evaluation of oropharyngeal dysphagia. Neurogastroenterology & Motility. 2014 September;26(9):p1256–1265. DOI: 10.1111/NMO.12382. View Article; Rosen R. Gastroesophageal reflux treatment in infancy through young adulthood. American Journal of Gastroenterology. 2023 March;118(3):p452–458. DOI: 10.14309/AJG.0000000000002160. View Article.

Disclosures

For this program, the following relevant financial relationships were disclosed and mitigated to ensure that no commercial bias has been inserted into this content: Dr. Danialifar is a Consultant for QOL Medical LLC; and is on the Speakers Bureau for QOL Medical LLC. Members of the planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Danialifar was recorded at Pediatrics in the Islands: Clinical Pearls 2023, held June 24-30, 2023 in Lahaina, HI, and presented by the Children’s Hospital of Los Angeles. For information on future CME activities from this presenter, please visit chla.org/chla-medical-group/cme-conferences. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

FP722102

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.