Roughly 1 in 23 children under the age of 5 years have a pediatric feeding disorder1. This prevalence statistic indicates we pediatric providers and caregivers need to be better educated in this area, in order to advocate for early referrals that help children and families with feeding difficulties.
Let’s discuss pediatric feeding disorders, their signs and symptoms that might signal a referral need, and who can help with assessment and interventions.
What is a Pediatric Feeding Disorder?
A pediatric feeding disorder (PFD) is defined as, “impaired oral intake that is not age appropriate, and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction”2.
Children with a PFD typically have more than one of these domains involved, which attributes to their feeding challenges:
- The medical domain includes dysfunction related to structures or function of cardiorespiratory (e.g. heart, lungs), gastrointestinal (e.g. esophagus, stomach, intestines), and/or neurological systems (e.g. brain, spinal cord)
- Nutritional factors of PFDs may be influenced by inadequate quantity or quality of food and liquids (e.g. eating crunchy foods only)
- Feeding skills involved include oral and pharyngeal structures (e.g. lips, tongue, jaw) and sensory and/or motor functioning (e.g. chewing, swallowing)
- Psychosocial factors involve development, mental and behavioral health, social influences, and environmental factors2
Signs and Symptoms that Warrant Referral
First and foremost, as a pediatric feeding specialist, I want to make it very clear that any caregiver’s concern about their infant or child’s feeding can warrant a referral. I always say, “when in doubt, refer out,” which is important not only to get help, but to support early intervention. The earlier a treatment is started, the better the child’s outcomes and progress are likely to be.
The list of signs and symptoms that can warrant referral to a specialist (below) is divided by each domain. It is not exhaustive and should be used as a guide to seek additional support3:
- Slow, or difficulty with, breathing during and after feeds
- Sweating or color change of lips/face when eating or drinking
- Gurgling or squeaking sounds
- Recurrent upper respiratory infections (e.g., pneumonia, bronchiolitis)
- Crying, arching, coughing, or irritability when eating or drinking
- Suspected food allergies or intolerances
- Frequent formula changes
- Vomiting, constipation, or diarrhea
- No signs of hunger or fullness
- Discomfort when eating or drinking
- Low volume or inadequate intake of liquid to grow or stay hydrated
- Insufficient or too-rapid changes in weight or height
- Lack of certain nutrients (e.g., fiber, iron)
- Dependance on supplemental formulas, vitamins, or enteral feeds (e.g., NG tube, G tube)
- Limited food or liquid variety
Feeding Skill Signs/Symptoms
- Gasping, or difficult, noisy breathing
- Coughing, choking, gagging, retching, or vomiting
- “Gurgle-y” or wet breathing
- Frequent hard swallows/gulping
- Inadequate nutritional intake
- Excessively short (<5 minutes) or long (>30 minutes) meals
- Need for food or liquid modifications (e.g. thickening liquids, mashing solids)
- Difficulty transitioning to solid foods
- Require special strategies, equipment, or positions to feed
- Refusal to eat, drink, or swallow certain textures
- Difficulty chewing
- Stress, worry, or fear in child or caregiver at mealtimes
- Refusal to eat
- Unable to attend or participate at mealtimes
- Presence of bribing, distractions, rewards, or threats at mealtimes
- Disconnect and lack of enjoyment between child and caregiver
For more information to determine if a referral is warranted, or for support to advocate, check out the Feeding Matters Infant Child Feeding Questionnaire (ICFQ). It is a quick, 6-question screener to let you know when services should be accessed4.
Who Can Help?
Quality treatment for pediatric feeding disorders utilizes a team approach. As mentioned above, there are often multiple domains that impact feeding, so we need to consider the best professional within each to support progress.
Here (below) are some providers that may be on a child’s feeding team. As with the lists above, this list in not all-inclusive and teams should be tailored to each child’s specific needs.
- Craniofacial Team
- Developmental Pediatrician
- Occupational Therapist
- Otolaryngologist/Ear Nose Throat
- Physical Therapist
- Registered Dietitian Nutritionist
- Speech Language Pathologist
Noticing the symptoms of PFDs is the first step toward a successful feeding journey for a child. Seeking the right team of experts can then guide a family to success. Together, these elements can set up children with PFDs to be happy and healthy.
- Kovacic, K., Rein, L. E., Szabo, A., Kommareddy, S., Bhagavatula, P., & Goday, P. S. (2021). Pediatric Feeding Disorder: A Nationwide Prevalence Study. Journal of Pediatrics. 228:126-131.e3. doi: 10.1016/j.jpeds.2020.07.047. EPMID: 32702429.
- Feeding Matters. (2021). Pediatric feeding disorders fact sheet. Retrieved from https://www.feedingmatters.org/wp-content/uploads/2021/09/Toolkit-PFD-Fact-Sheet-1.pdf
- Goday, P. S., Huh, S. Y., Silverman, A., Lukens, C. T., Dodrill, P., Cohen, S. S., Delaney, A. L., Feuling, M. B., Noel, R. J., Gidel, E., Kenzer, A., Kessler, D. B., Kraus de Camargo, O., Browne, J., & Phalen, J. A. (2019). Pediatric feeding disorder – Consensus definition and conceptual framework. Journal of Pediatric Gastroenterology and Nutrition. 68(1).
- Silverman, A.H., Kristoffer, B.S., Linn, C., et al. (2020). Psychometric properties of the Infant and Child Feeding Questionnaire. Journal of Pediatrics. DOI: 10.1016/j.jpeds.2020.04.040.