Feeding problems of infants and toddlers
Anne-Claude Bernard-Bonnin, MD, FRCPC
Dr Bernard-Bonnin is an Associate Professor of Pediatrics at CHU Ste-Justine at the University of Montreal in Quebec. Her main interest is in ambulatory pediatrics, and she is a member of the Nutrition Clinic at the Ste-Justine Outpatient Department.
Feeding is an important part of the everyday life of infants and young children, and much parent-child interaction occurs at feeding times. About 25% to 40% of infants and toddlers are reported by their caregivers to have feeding problems, mainly colic, vomiting, slow feeding, and refusal to eat.1
Although some of these difficulties are transient, some problems, such as refusal to eat, are found in 3% to 10% of children and tend to persist.2-6 Parents soon become concerned and turn to their family physicians for advice. This article reviews the classification and clinical features of early childhood feeding problems, proposes a diagnostic approach, and describes some practical therapeutic strategies.
Quality of evidence
MEDLINE was searched for all articles published in English or French between January 1990 and December 2005 using the MeSH terms eating disorders, infant, and child. The references of articles retrieved were searched for further articles not found in the MEDLINE search. There were few randomized controlled trials, and those that were identified had few patients enrolled. Recommended practice is based mainly on levels II and III evidence.Levels of evidence
Level I: At least one properly conducted randomized controlled trial, systematic review, or meta-analysis
Level II: Other comparison trials, non-randomized, cohort, case-control, or epidemiologic studies, and preferably more than one study
Level III: Expert opinion or consensus statements
Classification of feeding disorders
Feeding disorders can be classified under 3 categories (Table 1), although there is often overlap among categories. Structural abnormalities affect 3 areas: the naso-oropharynx, the larynx and trachea, and the esophagus. Neurodevelopmental disabilities disrupt the process of “learning to eat” and can result in oral hypersensitivity and oral-motor dysfunction. The third category is behavioural feeding disorders, as defined by Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR)7 criteria, which have been refined by Chatoor.8 Describing these disorders, however, is beyond the scope of this review. It should be emphasized that, at present, these disorders have been described mainly from a single site and that their face validity is overly dependent on case reports (level II evidence).
Evaluating feeding problems
Five key elements should be considered in evaluating feeding disorders.
Medical history should include antenatal and perinatal history; family history of atopy or feeding problems; previous illnesses and hospitalizations; and manipulation around the oropharynx, such as tube feeding. The chronology of feeding problems, diet since birth, changes of formulas, introduction of solids, current diet, textures, route and time of administration, and feeding position should be recorded. Food aversions, quantities eaten, length of meals and associated routines, strategies already used, and environment and behaviour around mealtimes need to be documented.
Anatomic abnormalities should be suspected when children have problems swallowing. A history of recurrent pneumonia should alert physicians to chronic aspiration because about 70% to 94% of episodes of aspiration are “silent.”9 Stridor in relation to feeding could be due to glottic or subglottic abnormalities. Suck-swallow-breathing coordination can be affected by choanal atresia. Vomiting, diarrhea, or constipation; colic; and abdominal pain should alert physicians to the possibility of gastroesophageal reflux (GER) or allergy to cow’s milk, because some symptoms are similar for both diseases.10 Finally, physicians should explore social stress, family dynamics, and emotional problems. Examples of questions that might elicit information on maternal depression11 are shown in Table 2.
Physical examination should start with anthropometric measurements, including head circumference. A growth curve should have been documented since birth. Craniofacial abnormalities, signs of systemic disease, and atopy should be sought. A complete neurologic examination is mandatory, as is an evaluation of psychomotor development.
No laboratory investigations are indicated for infants with normal results of physical examinations, normal growth curves, and normal results of developmental assessments. For children with colic and occasional vomiting, an immunoglobulin E–mediated cow’s milk allergy can be suspected. Confirmation of this diagnosis with skin testing and radioallergosorbent testing is not readily available, however, and these tests are not completely reliable either12 (level I evidence). Gastroesophageal reflux should be considered. Although upper gastrointestinal contrast studies are neither sensitive nor specific for GER, they allow observation of the coordination as a bolus is moved through the oropharynx and esophagus and for detection of anatomic abnormalities, such as malrotation.13 Esophageal pH monitoring is not readily available and should be reserved for patients who do not respond to empiric treatment with acid suppressants13 (level II evidence).
Feeding problems that appear to stunt growth need thorough investigation. First-line laboratory investigations should include a complete blood count and assessment of sedimentation rate, serum albumin and protein, serum iron, iron-binding capacity, and serum ferritin to detect specific nutrient deficits and to assess hepatic and renal function, as well as a sweat test to screen for systemic diseases. Antitransglutaminase antibodies for celiac disease are becoming more widely available. If diagnosis of GER is unclear, esophagogastroduodenoscopy and biopsy can determine the presence and severity of esophagitis, strictures, and webs13 (level II evidence).
A detailed dietary history must be taken with the help of a nutritionist, if possible. Quality and quantity of food ingested must be assessed to document deficits in calories, vitamins, and trace elements and food aversions. Physicians should inquire about excessive consumption of milk or fruit juices.
Parent-child interactions during feeding should be assessed. Positive interactions, such as eye contact, reciprocal vocalizations, praise, and touch, and negative interactions, such as forced feeding, coaxing, threatening, and children’s disruptive behaviour (turning the head away from food, throwing food) should be noted. An assessment should also document behaviour occurring before food is presented, such as prompting and positive reinforcement for accepting food and use of neutral or ineffective consequences for other behaviour.14
Management of feeding disorders
When infants are growing and developing normally, physicians should reassure parents and explain that no investigations are indicated at this point. In cases of colic and occasional vomiting, dietary intervention is worth a trial. Excluding allergenic foods, such as dairy products, eggs, nuts, fish, soy, and wheat, from the breastfeeding mother’s diet or giving bottle-fed infants hypoallergenic formulas might reduce symptoms of colic, mainly in infants with a positive family history of atopy15 (level I evidence). If physicians suspect cow’s milk allergy, mainly in atopic families, excluding allergenic foods can be empirically suggested to breastfeeding mothers and hypoallergenic formulas can be suggested for infants not breastfed12 (level III evidence).
If vomiting and irritability persist despite use of hypoallergenic formulas, a trial of acid suppression is worth initiating under the assumption of a possible overlap between cow’s milk allergy and GER. Histamine-2 receptors can be used, followed by proton pump inhibitors (levels II and III evidence). Cisapride, a drug restricted because of the risk of arrythmias, should not be used before confirmation of GER by esophageal pH monitoring13 (level I evidence).
If a child’s growth appears to be stunted, caloric intake should be increased. Human milk can be fortified with formula powder, carbohydrate, or fat. Infant formula can be concentrated up to 3.4 to 4.2 kJ/mL, by either lessening dilution or adding glucose polymers or vegetable oil. Solid foods can be fortified with butter, vegetable oil, cream, sauces, glucose polymers, and powdered milk (level III evidence).
Children with normal neurologic function generally do well after surgical correction of anatomic abnormalities. Neurologically disabled children, however, need nasogastric or gastrostomy feedings when they are unable to ingest adequate calories safely and when the time required to provide adequate nutrition by mouth consumes parents’ and children’s lives, leaving little time for nurturing activities9 (level III evidence).
Coexisting medical problems should be addressed. Good medical management does not always alleviate feeding problems adequately. For instance, young children with cystic fibrosis often have a pattern of eating slowly, having difficulty chewing, preferring liquids, refusing to eat solids, and having an aversion to new food.5 Retrospective and case-control studies have shown that, despite medical and surgical therapy, infants with GER have lower intake of energy-generating food, have fewer adaptive skills and less readiness for solids, are more likely to refuse food, and are more demanding and difficult at feeding time6,16 (level II evidence). Under these conditions, behavioural interventions should be considered.
Parents should first know the basic food rules that apply to all young children17 (Table 3). Parents should control what, when, and where children are being fed. Children should control how much they eat in order to learn internal regulation of eating in accordance with physiologic signals of hunger and fullness.
In the feeding disorder termed “state regulation,” mothers should be helped to modulate the amount of stimulation during feeding (level III evidence). Infants should be fed promptly before prolonged crying (not more than 30 minutes) and should not be unnecessarily aroused, burped, or wiped. Mothers’ anxiety, fatigue, or depression should be addressed.18
In the feeding disorder termed “reciprocity,” the focus should be on training parents in sensitivity and responsiveness to infants’ feeding cues18 (level III evidence). Complicated cases need a multidisciplinary approach where family physicians can play a key role in coordinating services.
In cases of infantile anorexia, the mother-child dyad becomes involved in conflicting interactions, with a struggle for control and food being the battleground. Therapy consists of helping parents understand their children’s special temperaments, set limits, and structure mealtimes to facilitate the internal regulation of eating and to counteract the external regulation produced by emotional interactions within the caregiving environment.19 Food rules are strongly encouraged, and “time out” should be used in response to children’s inappropriate behaviour (level II evidence).
Prevention of sensory food aversions starts with introducing various foods at 4 to 6 months of age. New foods should be introduced singly and not during illnesses, such as colds and diarrhea, and parents should persevere and present the new food day after day until children get used to it. Toddlers more easily accept a new food if they see their parents eating it. Withholding favourite food to get toddlers to eat “healthy” food seems to have a negative effect.20 Treatment of food aversions is based on increasing appropriate behaviour through positive reinforcement and decreasing maladaptive behaviour by extinction (removing what reinforces a response) and time out14 (level II evidence).
Feeding problems associated with concurrent medical conditions might result from an interaction between intrinsic oral motor dysfunction, oral hypersensitivity, odynophagia, and learned aversive behaviour. Parents should be taught management skills, such as setting clear time limits for meals, ignoring non-eating behaviour, and using contingencies (active praising, positive reinforcement) to motivate children to meet the food-intake goals that have been set21 (level I evidence).
Infants with posttraumatic feeding disorder are generally receiving enteral tube feeding that interferes with their experience of hunger and development of oropharyngeal coordination. Treatment is aimed at eliminating tube feeding and overcoming the resistance to oral feeding, either through the behavioural technique of extinction, which was shown to be successful in 1 controlled study22 (level I evidence), or by gradual desensitization (level II evidence).8
Infants’ and toddlers’ feeding problems often have multifactorial causes and a substantial behavioural component. During well-child visits, family physicians are in a key position to detect problems early on; to make differential diagnoses; to give practical advice to parents on food rules and increase of caloric intake, if needed; and to initiate therapeutic approaches to colic, cow’s milk allergy, and GER. More complicated cases are generally managed by multidisciplinary teams; primary care physicians can have a key role in coordinating services.
Correspondence to: Dr Bernard-Bonnin, 3173 Côte Ste-Catherine, Montreal, QC H3T 1C5; telephone 514 345-4675; fax 514 345-4822; e-mail firstname.lastname@example.org
1. Reau NR, Senturia YD, Lebailly SA, Christoffel KK; the Pediatric Practice Research Group. Infant and toddler feeding patterns and problems: normative data and a new direction. J Dev Behav Pediatr 1996;17:149-53.
2. Dahl M. Early feeding problems in an affluent society. III. Follow-up at two years: natural course, health, behaviour and development. Acta Paediatr Scand 1987;76:872-80.
3. Dahl M, Sundelin C. Feeding problems in an affluent society. Follow-up at four years of age in children with early refusal to eat. Acta Paediatr 1992;81:575-9.
4. Dahl M, Rydell AM, Sundelin C. Children with early refusal to eat: follow-up during primary school. Acta Paediatr 1994;83:54-8.
5. Mitchell MJ, Powers SW, Byars KC, Dickstein S, Stark LJ. Family functioning in young children with cystic fibrosis: observations on interactions at mealtime. J Dev Behav Pediatr 2004;25:335-46.
6. Nelson SP, Chen EH, Syniar GM, Christoffel KK. One-year follow-up of symptoms of gastroesophageal reflux during infancy. Pediatrics 1998;102:e67. Available from: http:// pediatrics.aappublications.org/cgi/content/full/102/6/e67. Accessed 1998 December 1.
7. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Text revision. Washington, DC: American Psychiatric Association; 2000.
8. Chatoor I. Feeding and eating disorders of infancy and early childhood. In: Weiner JM, Dulcan MK, editors. Textbook of child and adolescent psychiatry. Arlington, Va: American Psychiatric Publishing Inc; 2004. p. 639-52.
9. Arvedson JC. Management of pediatric dysphagia. Otolaryngol Clin North Am 1998;31:453-75.
10. Salvatore S, Vandenplas Y. Gastroesophageal reflux and cow milk allergy: is there a link? Pediatrics 2002;110:972-84.
11. Green M. Diagnosis, management, and implications of maternal depression for children and pediatricians. Curr Opin Pediatr 1994;6:525-9.
12. Bahna SL. Cow’s milk allergy versus cow milk intolerance. Ann Allergy Asthma Immunol 2002;89(6 Suppl 1):56-60.
13. Rudolf CD, Mazur LJ, Liptak GS, Baker RD, Boyle JT, Colletti RB, et al. North American Society for Pediatric Gastroenterology and Nutrition. Pediatric Gastroesophageal Reflux Clinical Practice Guidelines. J Pediatr Gastroenterol Nutr 2001;32(Suppl 2):S1-31.
14. Babbitt RA, Hoch TA, Coe DA, Cataldo MF, Kelly KJ, Stackhouse C, et al. Behavioral assessment and treatment of pediatric feeding disorders. J Dev Behav Pediatr 1994;15:278-91.
15. Garrison MM, Christakis DA. A systematic review of treatments for infant colic. Pediatrics 2000;106:184-90.
16. Mathisen B, Worrall L, Masel J, Wall C, Shepherd RW. Feeding problems in infants with gastro-oesophageal reflux disease: a controlled study. J Paediatr Child Health 1999;35:163-9.
17. Chatoor I, Dickson L, Schaefer S, Egan J. A developmental classification of feeding disorders associated with failure to thrive: diagnosis and treatment. In: Drotar D, editor. New directions in failure to thrive: research and clinical practice. New York, NY: Plenum Press; 1985. p. 235-58.
18. Satter EM. The feeding relationship: problems and interventions. J Pediatr 1990;117:181-9.
19. Chatoor I, Hirsch R, Persinger M. Facilitating internal regulation of eating: a treatment model of infantile anorexia. Inf Young Children 1997;9(4):12-22.
20. Birch LL. Development of food preferences. Ann Rev Nutr 1999;19:41-62.
21. Powers SW, Jones JS, Ferguson KS, Piazza-Waggoner CP, Daines C, Acton JD. Randomized clinical trial of behavioral and nutrition treatment to improve energy intake and growth in toddlers and preschoolers with cystic fibrosis. Pediatrics 2005;116:1442-50.
22. Benoit D, Wang EE, Zlotkin S. Discontinuation of enterostomy tube feeding by behavioural treatment in early childhood: a randomized controlled trial. J Pediatr 2000;137:498-503.
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