An approach to feeding problems in infants and toddlers

Opening Vignette

Mrs. Chong brought her 7-month-old daughter, Chloe, to see you due to issues with weaning her child onto solids and Chloe’s recent refusal of bottle feeds. You learned that the pregnancy was planned, and Chloe had a normal birth history and no problems with latching on during breastfeeding previously. Mrs. Chong revealed that she has experienced a diminishing breast milk supply on returning to work and has been attempting to introduce formula feeds to Chloe. She also mentioned that when given purees, Chloe would make gagging sounds and spit out the food sometimes. Although Chloe has maintained her growth parameters on the 50th centile, Mrs Chong expressed concerns about her child’s growth and stress over having to ‘battle’ with her child during feeds.

WHAT ARE FEEDING PROBLEMS?

Feeding difficulty is a general term that covers all feeding problems regardless of cause, severity or consequences. This can range from mild forms of picky eating to a severe form of food refusal, such as those seen in children with autism spectrum disorder, requiring a multidisciplinary feeding team approach. Feeding disorders are defined as the inability or refusal to eat a sufficient quantity or variety of food to maintain adequate nutritional status, which can lead to malnutrition, impaired growth, emotional consequences and possible neurocognitive dysfunction.[1]

Feeding disorders can be broadly divided into three main categories as follows:[2]

1. Structural abnormalities: affecting the upper airway and the oesophagus

2. Neurodevelopmental disabilities: disrupting the process of ‘learning to eat’

3. Behavioural feeding disorders (as defined by Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision)[3]

HOW RELEVANT IS THIS TO MY PRACTICE?

Feeding is an important part of the everyday life of infants and toddlers, and much parent–child interactions occur at feeding times.[2] About 25%–40% of infants and toddlers are reported by their caregivers to have feeding problems, which can range from purely behavioural issues (picky eating, refusing to eat) to problems manifesting with symptoms such as vomiting and pain. While only 1%–2% of infants aged <1 year have poor weight gain, 70% of these infants, if the problem is unaddressed, will continue to have feeding problems 4–6 years later. Not only does this have a significant impact on their long-term nutrition and cognitive development, but there is also a significant psychoemotional burden on their caregivers and the family unit. These children are also at a higher risk of developing further behavioural problems and eating disorders in their youth.[4]

Locally, according to a questionnaire survey conducted in 2010 among Singaporean parents, about a quarter of the respondents perceived their child to have some form of ‘picky eating’, with the highest number first noticing their child’s picky eating behaviours or feeding difficulties as early as 1 year of age. It was also reported that all ‘picky eating’ and ‘feeding difficulty’ behaviours that occurred ‘all the time’ were significantly associated with caregiver stress during mealtimes and had a negative impact on family relationships.[5]

Family physicians have an essential role in the detection, management and parental education of feeding issues in infants and toddlers. Identification of more complex cases is also crucial, as it allows for referral to a multidisciplinary team.[2] It is also common to see children with delayed developmental milestones in general practice, and up to 80% of infants with developmental delays have feeding problems.[6] In this article, we present a practical approach to children in the infant and toddler age group with feeding issues and attempt to answer some common clinical questions in daily general practice.

WHAT CAN I DO IN MY PRACTICE?

A structured medical approach is needed to address feeding problems in early childhood. A simple open-ended question during a routine review of the child may reveal parental concerns about feeding practices and underlying feeding problems. Any parental or caregiver concerns need to be taken seriously. Although not uncommon in general practice, failure to thrive (FTT) is not the only diagnostic criterion to be used when considering a child with a feeding disorder.[7]

Clinical approach

The clinical approach involves establishing the existence of feeding difficulties and ruling out any organic or behavioural red flag signs and symptoms that would warrant further specialist referral and assessment by a multidisciplinary team. These feeding problems can occur at any developmental stage of a child and in children who appear to be well nourished or even obese. Hence, it is imperative for the family physician to perform a comprehensive assessment. Feeding problem may be suspected when a child shows one or more of the following: (a) refusal of food for >1 month, (b) prolonged mealtimes, (c) stressful mealtimes, (d) distractions to increase intake, (e) lack of appropriate independent feeding, (f) prolonged breast or bottle feeding, (g) nocturnal feeding, and (h) failure to progress to advanced textures.[8]

History

Simple open-ended questions during a routine review may reveal feeding issues and parental concerns. The following are some suggested questions that could be asked:[1,2]

1. Are there any feeding-related problems in your child?

2. How does the feeding problem manifest during mealtime?

3. Does the child have any known underlying illness that affects oral intake?

4. Any concerns about the child’s growth and development?

5. Any significant stress factors in the family?

If any concern is raised, a comprehensive history should then be obtained [Box 1], and it must include dietary details, feeding-related behaviours, red flags’ symptoms and signs [Box 2], and age-appropriate developmental assessment. It is also important to include any significant antenatal and maternal history, the gestational age and any significant events at birth, previous hospitalisations, and the social and family setup at home [Boxes 1 & 2].

Box 1.

Suggested list of detailed questions to ask to obtain a comprehensive history.[1]

Feeding history:
• At what age were solid foods introduced? What was given? How did the child respond?
• How frequently does the child cough, choke or gag during mealtimes?
• What is the positioning of the child during mealtime?
• When does the child eat? With whom? Where?
• Does the child self-feed or need to be fed?
• Are there any distractions such as television, games and toys that disturb mealtime?
• Are there any feeding battles between the child and the caregiver?
• How does the caregiver respond when the child refuses to eat?
• Does the child show any fear of feeding or depressed mood during mealtime?
Dietary history:
• What, how often and how much does the child eat and drink in a day? (24-h meal recall)
• Any excessive beverage consumption of milk, juices, soda, water?
• Are there any specific food or tastes that the child avoids? Is there a tendency for selective eating or food fixation?
• What and how often does the child eat snacks in between meals?
Medical history:
• Is there a history of vomiting, reflux, diarrhoea, abdominal pain, food allergies or constipation?
• Is there any choking or gagging during feed?
• Are there any signs of respiratory distress or noisy breathing?
• What are the child’s growth parameters like?
• Is the child on follow-up for developmental delays, speech issues or autism spectrum disorder?
• Any history of procedures or surgeries and prolonged hospitalisation?
• Has the child been fed via nasogastric tube or gastrostomy?
Maternal history:
• Are there any maternal issues with breastfeeding, pain, breast engorgement, help at home, stress and depressive symptoms?
• Any significant maternal medical, surgical or psychiatric history?

Box 2.

List of red flags.[8]

Organic:
• Dysphagia
• Choking and aspiration, recurrent pneumonia
• Apparent pain or excessive crying with feeding
• Vomiting and diarrhoea
• Developmental delay or features of autism
• Chronic cardiorespiratory symptoms
• Growth failure (failure to thrive)
• Significant personal or family history of atopy
Behavioural:
• Food fixation (selective, extreme dietary restrictions)
• Noxious (forceful and/or persecutory) feeding
• Abrupt cessation of feeding after the trigger event
• Anticipatory gagging
• Failure to thrive

Physical examination

A review of growth parameters (i.e. height, weight and occipitofrontal circumference) is an essential part of any comprehensive assessment of feeding problems, as it can help to identify children with growth failure and alert the physician to a possible underlying organic cause.[9] A quick general examination would reveal the nutritional status and any associated dysmorphism. Physicians should look for any signs that might indicate neglect and child abuse. A complete neurological exam is mandatory, along with other targeted systemic examination, to rule out any organic causes.[2] A brief age-appropriate developmental assessment should also be done.

Although observation of a mealtime interaction between the caregiver and the child may not be possible in the general practice setup, some of the interactive relationships between the child and the caregiver can be observed. For infants who have just started on solids, one should observe if the child is able to hold the neck steady and sit with support. Other things to look out for include drooling, an open mouth posture, abnormal breathing sounds and coughing. The physician should also examine the child for any structural abnormalities like cleft lip, cleft palate, tongue tie, poor dentition and enlarged tonsils, as well as check the tongue for painful ulcers or oral thrush and the nostrils for choanal atresia.

Differential diagnosis

When a child presents with certain signs and symptoms, it may point the clinician towards a particular differential diagnosis. These may be broadly classified into structural abnormalities, neurodevelopmental disabilities and behavioural feeding disorders [Box 3].[2]

Box 3.

Differentials classified into three main groups.

Structural abnormalities:
• Abnormalities of the naso- and oropharynx: choanal atresia, cleft lip or palate, Pierre Robin sequence, macroglossia, ankyloglossia
• Abnormalities of the larynx and trachea: laryngeal cleft, subglottic stenosis, laryngotracheomalacia
• Abnormalities of the oesophagus: tracheo-oesophageal fistula, congenital oesophageal atresia or stenosis, oesophageal stricture, vascular ring
Neurodevelopmental disabilities:
• Cerebral palsy
• Arnold-Chiari malformation
• Familial dysautonomia
• Muscle dystrophies and myopathies
• Moebius syndrome
• Congenital myotonic dystrophy
• Myasthenia gravis
• Oculopharyngeal dystrophy
Behavioural feeding disorders:
• Feeding disorder of state regulation (0–2 months)
• Feeding disorder of reciprocity (2–6 months)
• Infantile anorexia (6 months–3 years)
• Secondary food aversions
• Feeding disorder associated with concurrent medical condition
• Posttraumatic feeding disorder

WHAT INVESTIGATIONS SHOULD BE DONE?

If a thorough assessment shows that the child has a normal physical examination, normal growth centiles and normal developmental assessment, then no further investigations are recommended.[1,2] If feeding problems have resulted in growth issues, then a thorough investigation is recommended.

First-line investigations

1. Full blood count with an iron panel (serum iron, iron-binding capacity, serum ferritin): to detect any iron-deficiency anaemia and thrombocytosis, which would indicate an ongoing chronic inflammatory process

2. Renal panel, glucose: to detect any electrolyte abnormalities or evidence of dehydration as a complication of restricted eating

3. Other electrolytes (e.g. calcium, magnesium and phosphate levels) and vitamin D: to detect any deficiency in electrolytes or vitamin D levels

4. Liver function test: to look at the serum protein and serum albumin levels, which would give an indication of possible malnutrition

5. Erythrocyte sedimentation rate: to detect any ongoing underlying inflammatory process.

Second-line investigations

Second-line investigations should be based on the physician’s clinical suspicion and can be undertaken at the specialist level.[2] They are as follows:

1. Cow’s milk protein allergy: skin prick test to cow’s milk protein, serum immunoglobulin E to cow’s milk protein (level 1 evidence)

2. Structural abnormalities in the gastrointestinal tract: upper gastrointestinal contrast study, oesophago-gastro-duodenoscopy (OGD)

3. Gastro-oesophageal reflux: Oesophageal pH probe monitoring, only if patients do not respond to empirical treatment with acid suppressants. If severe, patients may need OGD to look for oesophagitis, strictures or webs[4] (level 2 evidence).

4. Coeliac disease: anti-transglutaminase antibody, anti-endomysial antibody and total serum IgA followed by confirmatory intestinal biopsy

5. Neurodevelopmental disabilities: brain imaging and further neurological assessment as clinically indicated

WHEN SHOULD I REFER TO A SPECIALIST?

When children are growing and developing at a normal tempo, physicians should reassure parents and explain that no further investigations are indicated at this point and the specific problematic behaviours noted should be addressed instead. If the associated symptoms are colic or occasional vomiting, but growth is not compromised, there is a role for a trial of dietary intervention. However, if there is presence of red flag symptoms or growth failure, it is recommended to refer the child for specialist evaluation and management.[2]

WHAT ARE THE PRINCIPLES OF MANAGEMENT?

Behavioural issues in the absence of growth problems

If the infant is growing and developing normally and red flags have been excluded, it is important to provide reassurance to parents. Many first-time parents may be anxious and have questions regarding normal feeding behaviour, and so it is important to support them and equip them with knowledge on how to feed their child. There can be a range of different behaviours that are acceptable, and it is important for parents to first know the basic food rules that apply to all young infants and children [Boxes 4 & 5].[2,10,11,12,13] While children can decide how much they wish to eat to learn internal regulation or eating in accordance with the physiological signals of hunger and fullness, parents should be the ones to decide what to eat, and when and where mealtimes should take place. Positive parent–child interactions, such as eye contact, reciprocal vocalisations, praise and touch, should be encouraged, while negative interactions, such as forced feeding, coaxing, threatening and child’s disruptive behaviour (turning the head away from food, throwing food), should be strongly discouraged[2] [Boxes 4 & 5].[2,10,11,12,13] In addition to educating the parent on basic proper food rules,[2,10,11,12,13] there are certain strategies that can help to address more specific feeding problems. The strategies can broadly be divided into the categories discussed below.

Box 4.

Tips for breastfeeding/bottle-feeding infant.[10,11,12]

Breastfeeding infant:
• Baby should be fed on demand. In the first few weeks, he/she should be feeding every 2–3 h, sometimes even hourly.
• Signs that a breastfed baby is getting enough milk include the following:
- Gaining sufficient weight
- At least three or four stools per day after the first week of life
- Six or more wet diapers per day
- Satisfied for at least 1–3 h between feedings
- Nurses at least 8–12 times per day
• If the nursing sessions are too short (<10 min persistently), it may mean that the baby is not getting enough milk. If sessions are too long (>50 min persistently), the baby may not be getting enough milk due to insufficient let down or inefficient suckling.
Bottle-feeding infant:
• Ensure the nipple hole is of the right size. If the baby is choking or gulping too fast, the hole may be too large, whereas if the baby seems to be frustrated or sucking hard, the hole may be too small.
• Ensure the bottle is angled to prevent the baby from swallowing air.
• Do not prop the bottle and leave the baby to feed unsupervised to avoid choking.
• During the first few weeks of life, if the baby sleeps longer than 5 h, wake him/her up for feeding. After 2–4 months of age, the baby may skip a night feed.
• Do not let the baby fall asleep while drinking milk, especially when teeth have started to erupt, as this can result in dental caries. After feeding, gently wipe the milk residue from the gums.
• It is important not to overfeed the baby. Pay attention to cues indicative of satiety to avoid overfeeding.
• In the first few weeks of life, the baby should take about 60–90 mL every three or four hourly. Breastfed infants will usually have smaller, more frequent feeds.

Box 5.

Rules applicable to children beyond infancy.[2,13]

Scheduling:
• Regular mealtimes: only add planned snacks that do not compromise on mealtime intake
• Mealtimes no longer than 30 min
• Nothing offered between meals except water
Environment:
• Neutral atmosphere (no forcing of food)
• Sheet under chair to catch mess
• No game playing
• Food never given as a form of reward or present
Procedures:
• Start with small portions and increase as appropriate
• Feed solids first, fluids last
• Self-feeding encouraged as much as possible
• Food removed after 10–15 min if the child plays without eating
• Meal terminated if the child throws food in anger
• Wipe the child’s mouth and clean up only after the meal is completed

Limited appetite

The physician can advise the parent on how to increase the caloric intake from the limited amount of foods consumed by the child. Fortification of milk (with an additional teaspoon of milk powder to 100 mL of breast milk) and fortification of solid food (with addition of butter, vegetable oil, cream or sauces) are simple ways to increase the caloric intake of the same total volume of food consumed by the child.[2] In case of severe behavioural problems and persistent FTT despite increasing the caloric intake, the child may need to be managed by a behavioural therapist, speech therapist and/or psychologist.

Food selectivity

It is normal for infants and toddlers to reject new food initially. Most will go on to accept these new foods after repeated exposure. Typically, foods must be offered at least 15 times to be accepted, as higher frequency of offering the new foods enhances acceptance in selective eaters.[14] For mildly selective children, simple strategies, such as hiding vegetables in other foods, modelling healthy eating, involving children in food preparation and so on, can be useful.[15,16,17,18] Children who are highly selective, particularly those with severe oral aversion or autism, would benefit from seeing a behavioural therapist and an oromotor therapist.[8] When introducing new foods, it should be done singly and not during intercurrent illness, and parents should persevere and present the new food day after day until the child gets used to it. Toddlers will accept new food more easily if they witness their parents eating it.[4]

Fear of feeding

This may be caused by an event such as choking, gagging or vomiting, or due to an organic condition that causes odynophagia. Apart from treating any underlying organic cause, the main principles of treatment are reassurance, systematic appraisal and treatment of the causes of discomfort, and alleviating the feeder’s anxiety.[8] In young infants, starting with a sleep–feeding schedule to help maintain adequate nutrition may be essential in the beginning. Subsequently, the feeding environment and equipment may be altered to improve acceptance of foods. For infants who truly reject the bottle or breast, earlier transition to cup feeding or solids may be necessary. For older children with moderate to severe symptoms, reassurance is key to recovery. If fear is persistent, a psychologist or psychiatrist may need to be involved.[8]

Infantile anorexia

In situations where the parent–child dyad becomes involved in conflicting interactions, with a struggle for control and food being the battleground, the suggested interventions involve helping the parent to understand their child’s special temperament and triggers. It is important to advise the parent to set clear limits and structure to mealtimes to facilitate the internal regulation of eating and counteract the external regulation produced by emotional interactions within the caregiving environment.[2]

Symptomatic children in the absence of growth problems

In cases of colic and occasional vomiting, a trial of dietary intervention can be carried out by the physician.[2] Maternal elimination of allergenic foods, such as dairy products, eggs, nuts, fish, soy and wheat, could be trialled in fully breastfed infants, while hypoallergenic formula can be given to bottle-fed infants to help reduce or relieve the symptoms of colic, particularly in children with a strong personal or family history of atopy. A diagnosis of food allergy should not be made, however, unless the symptoms are reproducible upon reintroduction of the eliminated food.

If vomiting and irritability persist despite the above measures, a trial of acid suppression or prokinetic agents may help relieve or reduce the symptoms, as there is often an overlap between cow’s milk protein allergy and gastro-oesophageal reflux.[19] Acid suppressants, which include antacids, histamine H2 antagonists and proton pump inhibitors, are more commonly used because of growing evidence that they are more effective than prokinetic agents. However, there is concern of overprescription of acid suppressants, especially proton pump inhibitors; hence, chronic antacid therapy is generally not the first-line recommendation to treat gastro-oesophageal reflux in such children. There are also nonpharmacological measures, such as positioning, thickening feeds, and smaller and more frequent feeds, which can help significantly with symptoms of gastro-oesophageal reflux.

Children with feeding and growth problems

It is important to address the underlying organic cause that has resulted in the feeding issue, which is beyond the scope of this article. However, it is important to note that even with optimal medical management of their underlying condition, children with concomitant medical conditions often continue to have feeding problems that persist, such as eating slowly, food refusal and being demanding and difficult at mealtimes. Under these conditions, the basic food rules [Box 5] and behavioural interventions should be considered. Some behavioural interventions that the parents can adopt include setting clear time limits for meals, ignoring noneating behaviour, and using active praise and positive reinforcement to motivate their children to meet the food intake goals set. However, for more severe symptoms, referral to a tertiary centre is warranted, so that a multidisciplinary team consisting of a paediatrician, dietitian, speech and language or oromotor therapist, occupational therapist and psychologist can conduct further investigations and provide treatment.

TAKE-HOME MESSAGES

1. Feeding problems can occur even in infants and toddlers with normal growth and development.

2. Most cases of feeding problems are due to behavioural issues in the infant and toddler.

3. Some feeding problems may be due to an underlying structural abnormality or an undiagnosed neurological disorder; a thorough assessment is important on top of monitoring the growth parameters.

4. When infants and toddlers are assessed to be growing and developing normally, primary care physicians should reassure parents and explain that no further investigations are indicated at this point in time.

5. If growth is a concern, a referral to a specialist is warranted for further evaluation as indicated.

6. It is essential for the primary care physician to understand the basic food rules and tips for a breastfed or bottle-fed infant.

Closing Vignette

Chloe was found to be growing well along her centiles with no evidence of concern in her height, weight or occipitofrontal circumference. She was also assessed to be developmentally meeting the appropriate milestones for her age, displaying good head and truncal control, as well as demonstrating good suck–swallow–breathing coordination when she drank water from her bottle. Her gagging on eating pureed food was found to be an exaggerated gag reflex, which will improve with gradual increased exposure to solid food. As such, you assured Mrs. Chong that there was no indication for any further investigation. You also advised her to continue exposing her daughter to formula feeding via a bottle with an appropriately sized bottle teat, and to do so comfortably in a calm and positive environment. Mrs. Chong was reassured knowing that her daughter’s growth was not compromised and felt more confident addressing her bottle refusal at home with more patience and less stress.

Conflicts of interest

There are no conflicts of interest.

SMC CATEGORY 3B CME PROGRAMME

Online Quiz: https://www.sma.org.sg/cme-programme

Deadline for submission: 6 pm, 10 January 2025

Question: Answer True or False
1. Feeding problems can range from mild forms of picky eating to severe forms of food refusal.
2. Majority of the feeding issues surface typically between 5 and 6 years of age.
3. Children with feeding problems are at a higher risk for behavioural issues and eating disorders in their youth.
4. Majority of children with developmental delays have feeding problems.
5. Failure to thrive is the only diagnostic criterion to be used when considering a child with feeding disorder.
6. Feeding problems can occur in children who appear to be well nourished.
7. The main aim of physical examination in a child with feeding disorder is to rule out signs of abuse.
8. When children have difficulty in swallowing, anatomical abnormalities should be suspected.
9. Posttraumatic feeding disorder should be suspected in a child who abruptly ceases feeding after a trigger event.
10. All children with feeding disorders need to be sent for extensive laboratory investigations.
11. All children with feeding disorders should be sent for specialist care.
12. Infants with gastro-oesophageal reflux disease symptoms can be managed with nonpharmacological measures.
13. Strategies used to manage feeding difficulties should involve behavioural interventions only for the children and not their parents.
14. Babies should be force-fed and not fed on demand.
15. Children must be encouraged to self-feed as much as possible.
16. Parents should set and adhere to a feeding schedule and model healthy eating and appropriate mealtime behaviour.
17. Food selectivity is uncommon for infants and toddlers initially.
18. For children with extreme food selection and dietary restrictions, sensory food aversion and autism spectrum disorder should be considered.
19. Problem of tongue tie should be suspected in infants with latching issues.
20. For bottle-fed infants, the risk of choking is increased if the bottle is propped and feeding is unsupervised.

Funding Statement

Nil