Feeding Problems, Pediatric

Basics

Description

  • Definition: Impaired intake not age appropriate + 1 dysfunctional domain (medical, nutritional, feeding skills and/or psychosocial) present for at least 2 wk
    • Absence of cognitive process consistent with eating disorders
    • NOT due to lack of food or congruent w/ cultural needs
    • Acute <3 mo, chronic >3 mo
  • Most common in ages 1–3 yr
  • 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/pharyngeal phases
    • Ingestion and absorption: swallowing, esophageal, or 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), gastroesophageal reflux disease (GERD), avoidant/restrictive food intake disorder, neglect
  • Minor feeding difficulties are reported in 25–50% of normally developing children:
    • Colic, vomiting, slow feeding, picky eating
    • Transient: Causes no serious outcomes
    • Often present during feeding transitions (breast to bottle, introduction of 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
      • Extensive dental disease
      • Subglottic stenosis
    • Larynx and trachea:
      • Laryngo- or tracheomalacia
      • Tracheoesophageal fistula
      • Laryngeal cleft or cyst
      • Vocal cord/vocal fold paralysis
    • Esophagus:
      • Esophageal strictures, stenosis, or web
      • Tracheoesophageal compression from vascular ring/sling
      • Esophageal mass or tumor
  • Pulmonary:
    • Bronchopulmonary dysplasia
    • Chronic lung disease
    • Chronic tachypnea
    • Pulmonary hypertension
  • 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 including milk protein allergy
    • Eosinophilic esophagitis
    • Celiac disease
  • GI problems:
    • GERD
    • Constipation
    • Obstruction, including pyloric stenosis
    • Dysphagia
    • IBD/IBS eosinophilic esophagitis
  • Metabolic disorders:
    • Hypothyroidism/hyperthyroidism
    • Inborn errors of metabolism
    • Lead poisoning
    • Type 1 diabetes mellitus
    • Cystic fibrosis
  • Acute illness or event:
    • Sepsis
    • Pharyngitis, tonsillitis, peritonsillar abscess, retropharyngeal abscess, epiglottitis, CNS infection
    • Oropharyngeal/esophageal lesions:
      • Gingivostomatitis (HSV), herpangina (coxsackievirus), candida, Stevens–Johnson syndrome, esophagitis, caustic ingestion
    • Intussusception, malrotation
    • Superior mesenteric artery syndrome
    • Cyclic vomiting syndrome
    • 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)

There's more to see -- the rest of this topic is available only to subscribers.