Feeding Difficulty (Case 11)

Chapter 40 Feeding Difficulty (Case 11)



Deborah M. Consolini, MD




Case


An otherwise healthy 12-month-old boy with frequent emesis and feeding difficulties since birth has poor weight gain and food refusal.




Differential Diagnosis









Behavioral/environmental/etiologies Gastrointestinal disorders Chronic illness or disability


Speaking Intelligently


Feeding problems occur in healthy children, those with gastrointestinal disorders, and in those with chronic illness or disability. The etiology is usually multifactorial, involving medical, behavioral, and environmental factors. Even with a clear organic etiology, maladaptive feeding behaviors can develop and persist after resolution of the organic problem. Feeding difficulty in a child is seldom limited to the child alone; it is a family problem. Parental child-rearing skills, nutritional knowledge, emotional stability, and feeding competency can both precipitate and maintain feeding difficulties. Given the multifactorial nature, assessment and treatment are done best by an interdisciplinary team that may include the pediatrician, a nutritionist, an occupational and/or speech therapist, and often a gastroenterologist and a developmental/behavioral specialist. Intervention should be comprehensive and include treatment of underlying medical conditions, behavioral modification to alter learned maladaptive feeding behaviors, and education and training in appropriate parenting and feeding skills. Most feeding problems can be resolved or greatly improved with medical, oromotor, and behavioral therapy.



Patient Care



Clinical Thinking



• Take parental concerns about their child’s feeding difficulty seriously.

• Is there failure to thrive or weight loss requiring urgent intervention?

• Feeding difficulties are often the first clue of a gastrointestinal disorder causing pain, discomfort, appetite suppression, and/or reduced motivation to feed.


History



• Information about feeding environment, consistency of caregivers, feeding practices, availability of food, child temperament, and food preferences may identify inappropriate mealtime behavior or environment, food selectivity, or food refusal.

• Choking, gagging, and/or coughing with feeds, frequent respiratory infections or a history of aspiration pneumonia, multiple swallows, or noisy breathing, especially during eating, may signal swallowing dysfunction.

• Irritability with feeds, frequent emesis, arching, epigastric pain, or heartburn is suggestive of gastroesophageal reflux (GER)/esophagitis.

• Abdominal pain, early satiety, nausea, vomiting, abdominal distention, excessive belching or flatulence, or abnormal stool pattern may indicate constipation, food allergy or intolerance, malabsorption, or motility disorder.

• Underlying conditions such as central nervous system (CNS) disorders (cerebral palsy), genetic syndromes (Prader-Willi and Down syndromes), and developmental disabilities (autism and prematurity) predispose children to feeding difficulties.


Physical Examination



• Review growth parameters (weight, height, head circumference [<3 years], weight for height, and/or body mass index [BMI]) to assess nutritional status and severity of feeding disorder.

• Noisy breathing, stridor, respiratory distress, increased work of breathing, and/or wheezing suggest swallowing dysfunction or GER with recurrent aspiration.

• Abdominal tenderness or distention or palpable stool suggest a gastrointestinal disorder.

• Abnormal tone, focal neurologic deficits, or dysmorphic features may suggest an underlying CNS disorder or genetic syndrome.


Tests for Consideration


If concerned about nutritional status, vitamin/mineral deficiency, consider:


• Complete blood count (CBC) $116

• Comprehensive metabolic panel $237

• Prealbumin $117

• Ferritin $177

• Zinc level $135

• Lead level $34

• Specific vitamin levels $150-250

If concerned for gastrointestinal disorder, consider:


• pH or impedance probe $5585

• Endoscopy $1313

• Stool for occult blood $170

• Sweat test $25

• Celiac panel $225

• Fecal fat studies $210

If concerned about underlying genetic syndrome, consider:


• High-resolution chromosomes $500

• Fragile X testing $250

• DNA methylation test for Prader-Willi syndrome $250
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Jul 18, 2016 | Posted by in PEDIATRICS | Comments Off on Feeding Difficulty (Case 11)

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