Feeding Problems, Pediatric, Emergency Medicine

Basics

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
Acute feeding problems may be a component of acute systemic disease:
- Infection, bowel obstruction
Chronic feeding problems may result from underlying neuromuscular, cardiovascular, or behavioral issues:
- Cerebral palsy, prematurity, congenital heart disease, chronic neglect
Minor feeding difficulties reported in 25-50% of normal children:
- Mainly colic, vomiting, slow feeding, and refusal to eat
More severe problems observed in 40-70% of infants born prematurely or children with chronic medical conditions.

Etiology

Several distinct areas of pathology-but overlap is common
Structural abnormalities:
- Naso-oropharynx:
  - Cleft lip/palate
  - Choanal atresia
  - Micrognathia and/or Pierre Robin sequence
  - Macroglossia
  - Tonsillar hypertrophy
  - Retropharyngeal mass or abscess
- Larynx and trachea:
  - Laryngeal cleft or cyst
  - Subglottic stenosis
  - Laryngo- or tracheomalacia
  - Tracheoesophageal fistula
- Esophagus:
  - Esophageal strictures, stenosis, or web
  - Tracheoesophageal compression from vascular ring/sling
  - Esophageal mass or tumor
  - Foreign body
Neurologic conditions:
- Cerebral palsy
- Muscular dystrophies
- Mitochondrial disorders
- Arnold-Chiari malformation
- Myasthenia gravis
- Brainstem injury
- Pervasive developmental disorder (autism spectrum disorders)
- Infant botulism
- Brainstem glioma
- Polymyositis/dermatomyositis
Prematurity
Immune disorders:
- Allergy
- Eosinophilic esophagitis
- Celiac disease
Congenital heart disease:
- Precorrection: Fatigue, respiratory compromise, increased metabolic needs
- Postcorrection: Any/all of the above, recurrent laryngeal nerve injury
Chronic aspiration
Conditioned dysphagia:
- Gastroesophageal reflux (GER)
- Prolonged tube or parenteral feeding early in life
Metabolic disorders:
- Hypothyroidism
- Inborn errors of metabolism
Acute illness or event:
- Sepsis
- Pharyngitis
- Intussusception
- Malrotation
- Shaken baby syndrome
Behavioral issues:
- Poor environmental stimulation
- Dysfunctional feeder-child interaction
- Selective food refusal
- Rumination
- Phobias
- Conditioned emotional reactions
- Depression
- Poverty (inadequate food available)

Diagnosis

Signs and Symptoms

Common presentations:

Caregiver concerns regarding feeding or postfeeding behavior
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
Failure to thrive/poor weight gain
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
Recurrent vomiting or gagging:
- If yes, when
Diarrhea, rectal bleeding
Onset of irritability or lethargy during feeding, colic
Duration of feeding highly variable, especially in breast-fed infants-for all ages, feeding times >30 min on a regular basis is cause for concern:
- Full-term healthy infant usually has 2-3 oz of formula every 2-3 hr.
- Breast-fed baby eats 10-20 min on each breast every 2-3 hr.
- As child gets older, duration and frequency may decrease.
- 1 mo old normally eats 4 oz every 4 hr.

Physical Exam

Vital signs, including oximetry
Weight, length, head circumference:
- Comparison with prior measurements; plotting growth curve
- Slow velocity of growth
- Impaired nutritional status. Severe cases may show emaciation, weakness, apathy.
General physical exam-especially note:
- Affect and social responsiveness
- Dysmorphism (facial asymmetry, tongue and jaw size, etc.)
- ENT-oropharyngeal inflammation, infection, or anatomic abnormality
- Cardiovascular status (murmur, tachycardia, tachypnea, retractions)
- Pulmonary-tachypnea, color change, evidence of aspiration
- Abdominal exam-bowel sounds, distension, tenderness, masses
- Neurologic-tone, coordination, alertness
- 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: Neuromuscular tone, posture, position; patient motivation; oral structure and function; efficiency of oral intake:
- Ability to handle 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

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.

Diagnosis 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 organic acids, and blood for inborn errors or metabolism if concern for metabolic disorders

Imaging

CXR if suspected cardiopulmonary concerns
EKG if cardiac disease suspected
Referral or admission for ultrasound and other imaging studies as indicated. Fiberoptic or videofluoroscopic evaluation of swallowing may be needed.
MRI if concerns for brainstem, skull base, or spinal problems

Diagnostic Procedures/Surgery

May need a multidisciplinary evaluation involving speech pathologist, pediatrician, and potentially an otolaryngologist.
Surgical correction of specific pathology

Differential Diagnosis

Feeding disorder encompasses symptoms observed as a final pathway for many disorders.
Specific clues to the etiology may include:

Prolonged feeding, fatigue:
- Consider cardiac disease.
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:
- Consider allergy or GER.

Treatment

Pre-Hospital

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.

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
Ondansetron for acute vomiting
Treat respiratory distress if present:
- Nasal suction to clear secretions prior to feeding may be very helpful in young infants with URI/bronchiolitis symptoms
- Oxygen and other interventions as needed
Treat infection if suspected.

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 PRN nausea or vomiting-min. oral dose 2 mg, max. dose 4 mg:

Monitor if patient at risk of QT prolongation
For short-term use (2-3 doses) in patients >6 mo.
Review FDA black box warning re QT prolongation

Follow-Up

Disposition

Admission Criteria

Suspected systemic infection
Inability to maintain hydration
Sustained hypoxia during feeding
Significant failure to thrive:
- Particularly in infants <3 mo
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.
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.

Pearls and Pitfalls

Successful feeding in infants requires coordinated, effective interaction of complex physiologic, developmental, and environmental factors.
The factors are interdependent-disruption of 1 often leads to disruption of others:
- Premature infant gavage fed for immature suck-swallow coordination, misses critical period for developing this reflex-develops aversion to oral stimulus because of recurrent noxious stimuli.
Feeding problems of recent, acute onset are likely to have a single identifiable cause:
- Gastroenteritis, pyloric stenosis, pharyngitis, sepsis
In an infant with upper respiratory symptoms the answer may be as simple as vigorously suctioning the nose to effectively clear it immediately before feeding
More chronic, long-term problems are more likely to have multifactorial and/or subtle causes:
- Feeding is an essential part of the parent-child interaction:
  - Dysfunctional interaction may be the cause of or a response to a feeding problem.
Chronic feeding issues of medical origin may result in continued behavioral feeding difficulties even after the medical problem is corrected.
Swallowing disorders and aspiration are frequently occult.

Additional Reading

Arvedson JC. Assessment of pediatric dysphagia and feeding disorders: Clinical and instrumental approaches. Dev Disabil Res Rev. 2008;14(2):118-127.
Bernard-Bonnin AC. Feeding problems of infants and toddlers. Can Fam Physician. 2006;52(10):1247-1251.
McDevitt, Barbara E. Vomiting, spitting up, and feeding disorders. In: Baren JM, Rothrock SG, Brennan JA, et al, eds. Pediatric Emergency Medicine. Philadelphia, PA: Saunders-Elsevier; 2008:319-327.

Codes

ICD9

779.31 Feeding problems in newborn
783.0 Anorexia
783.3 Feeding difficulties and mismanagement
787.20 Dysphagia, unspecified
307.59 Other disorders of eating

ICD10

P92.9 Feeding problem of newborn, unspecified
R63.0 Anorexia
R63.3 Feeding difficulties
R13.10 Dysphagia, unspecified
F50.8 Other eating disorders

SNOMED

102609007 Feeding problem in child (finding)
161838002 Infant feeding problem (finding)
79890006 Loss of appetite (finding)
40739000 Dysphagia (disorder)
105481005 refusing food (finding)

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