To whom should an infant with feeding difficulties be referred for evaluation and management?

Referral for Infants with Feeding Difficulties

An infant with feeding difficulties should be referred to a pediatric gastroenterologist as the primary specialist, with additional referrals to a multidisciplinary feeding team that includes feeding therapists (speech/occupational therapists), nutritionists, and behavioral specialists. 1

Primary Referral: Pediatric Gastroenterologist

A pediatric gastroenterologist should be the first specialist consulted for several important reasons:

• They can evaluate and manage underlying medical causes of feeding difficulties, including:

  • Gastroesophageal reflux disease (GERD)
  • Swallowing dysfunction
  • Oral aversion
  • Intestinal dysmotility
  • Failure to thrive 1

• Early evaluation by a gastroenterology specialist is specifically recommended in infancy to guide:

  • Appropriate diagnostic testing
  • Decisions regarding supplemental feeding needs
  • Management of reflux with medications like proton pump inhibitors
  • Potential surgical interventions if needed 1

Multidisciplinary Team Approach

In addition to gastroenterology referral, the following specialists should be involved:

Feeding Therapists

• Speech-Language Pathologist and/or Occupational Therapist
  • Should be consulted at the first sign of oral aversion 1
  • Evaluate oral-motor functioning, articulation, and swallowing safety 1
  • Provide feeding therapy for suck/swallow dysfunction and transitioning to solid foods 1
  • Assess aspiration risk and dysphagia 1

Nutritionist/Dietitian

• Essential for:
  • Nutritional assessment and growth measurements 1
  • Developing appropriate feeding plans 1
  • Monitoring growth according to appropriate growth curves 1
  • Yearly clinical follow-ups to monitor nutritional status 1

Behavioral Specialist/Psychologist

• Important because:
  • Feeding disorders exist on a continuum between psychosocial and organic factors 2
  • Behavioral modification can alter inappropriate learned feeding patterns 2
  • Parental anxiety about feeding can lead to moderate to severely disturbed eating habits 1
  • Behavioral feeding strategies have been successful even in organically mediated feeding disorders 2

Special Considerations

When to Consider More Intensive Support

• If there is failure to thrive or poor growth despite initial interventions
• If there are signs of aspiration or respiratory complications
• When supplemental feeding may be necessary (nasogastric or gastrostomy tubes) 1

Common Pitfalls to Avoid

1. Delayed referral: Early intervention is critical to prevent worsening of feeding problems and nutritional deficits
2. Focusing only on medical aspects: Feeding difficulties are rarely limited to the child alone and often involve family dynamics 2
3. Overlooking parental anxiety: Parents who are anxious about feeding are more likely to have children who develop moderate to severely disturbed eating habits 1
4. Exclusive tube feeding too early: Initial attempts to achieve nutritional goals should be via the oral route when possible to avoid iatrogenic feeding problems 2

Timing of Referrals

• Immediate referral is warranted for:

  • Significant weight loss or failure to thrive
  • Signs of aspiration or respiratory complications
  • Severe oral aversion

• Early referral (even if problems seem mild) is important because:

  • 25% of all children present with some form of feeding disorder
  • This increases to 80% in developmentally delayed children 2
  • Even mild feeding difficulties can have long-term consequences if inappropriate feeding practices are adopted 3

By ensuring prompt referral to a pediatric gastroenterologist and appropriate feeding specialists, infants with feeding difficulties can receive comprehensive care that addresses both the medical and behavioral aspects of their condition, improving long-term outcomes related to growth, development, and quality of life.