What are the initial steps to manage an infant who is not feeding?

Initial Management of an Infant Who Is Not Feeding

Immediately assess for red-flag symptoms requiring urgent intervention, then systematically address organic causes before considering behavioral or developmental feeding issues. 1, 2

Immediate Assessment for Red-Flag Conditions

When an infant presents with feeding difficulty, prioritize identifying life-threatening or serious organic causes through targeted history and physical examination:

Critical Red Flags to Identify

• Acute distress or respiratory compromise during feeding attempts, which may indicate aspiration, airway obstruction, or cardiac disease 1, 2
• Signs of dehydration including decreased urine output, sunken fontanelle, poor skin turgor, or weight loss >12% from birth 3
• Bilious vomiting or abdominal distension, which may suggest gastric volvulus, malrotation, or intestinal obstruction 3, 4
• Cyanosis or apnea during or after feeds, potentially indicating gastroesophageal reflux with laryngospasm or cardiac pathology 3
• Poor weight gain or failure to thrive, requiring immediate nutritional assessment 3, 5

Initial Vital Signs and Monitoring

• Check temperature using axillary thermometer with emollient to reduce friction, or infrared thermometer if available 3
• Assess hydration status through clinical examination and strict input/output monitoring 3
• Document weight, length, and head circumference on growth curves to identify growth failure 3

Systematic Evaluation of Organic Causes

Most serious feeding problems occur in infants with underlying medical conditions, and organic causes should be excluded systematically 5, 2:

Gastrointestinal Evaluation

• Assess for gastroesophageal reflux disease (GERD) if infant has gross emesis, "awake apnea" (episodes while awake and supine), or obstructive apnea pattern with respiratory efforts but no air movement 3
• Consider swallowing dysfunction requiring evaluation with swallowing studies, pH studies, or upper GI series if feeding difficulties persist 3
• Rule out anatomical abnormalities including cleft palate, gastric volvulus, or intestinal malrotation through appropriate imaging if vomiting is prominent 3, 4

Neurological and Developmental Assessment

• Evaluate for hypotonia or gross motor delay that may impair oral-motor coordination, requiring physical and occupational therapy referral 3
• Screen for developmental delay as 80% of developmentally delayed children have feeding disorders 5
• Assess for infantile spasms or seizure activity that may interfere with feeding 3

Metabolic and Endocrine Screening

• Obtain thyroid function studies (TSH, free T4) as thyroid abnormalities can cause feeding difficulties 3
• Consider growth hormone deficiency if growth failure is present, particularly between ages 2-3 years 3
• Rule out inborn errors of metabolism if clinically indicated, though routine lactic acid or bicarbonate screening is not recommended for lower-risk presentations 3

Immediate Nutritional Support Strategies

Non-Pharmacologic Interventions for GERD-Related Feeding Difficulty

If gastroesophageal reflux is suspected as contributing to feeding refusal 3:

• Avoid overfeeding and provide frequent burping during feeds
• Hold infant upright on caregiver's shoulders for 10-20 minutes after feeding before placing supine
• Avoid car seats or semi-supine positions immediately after feeding, as these exacerbate reflux
• Consider thickened formula (if not breastfed and no milk-protein intolerance), which decreases regurgitation frequency though not acid exposure
• Encourage exclusive breastfeeding when possible, as breastfed infants have less frequent GER than formula-fed infants

Pain Management for Oral Lesions

If oral pain is limiting intake (e.g., hand-foot-mouth disease or other oral pathology) 6:

• Administer acetaminophen or ibuprofen 30-45 minutes before feeding attempts
• Offer cold, soft foods including ice cream, yogurt, smoothies, pudding, and popsicles
• Avoid acidic foods (citrus, tomatoes), salty/spicy foods, and rough-textured foods that irritate lesions
• Encourage small, frequent sips of cold beverages throughout the day

Feeding Technique Modifications

• Use small, frequent feeds rather than large-volume feeds, as infants with feeding difficulties tolerate smaller volumes better 6, 1
• Ensure proper positioning with infant held securely but gently, avoiding pressure on skin if conditions like epidermolysis bullosa are present 3
• Consider continuous enteral feeding via nasogastric tube if oral intake is inadequate and infant requires nutritional support 3

When to Escalate to Tube Feeding

If oral intake remains inadequate despite interventions, initiate enteral tube feeding to prevent malnutrition while addressing underlying causes 3, 5:

Indications for Nasogastric or Gastrostomy Tube

• Failure to thrive with weight loss >12% from birth or crossing growth percentiles downward 3
• Persistent feeding difficulties requiring assisted feeding, found necessary in 40-50% of certain conditions like cardio-facio-cutaneous syndrome 3
• Severe oropharyngeal dysphagia confirmed by swallowing studies 4
• Inadequate oral intake despite maximal medical and behavioral interventions 5

Tube Feeding Implementation

• Start with nasogastric tube for short-term support, transitioning to gastrostomy if prolonged feeding support (>4-6 weeks) is anticipated 3
• Initiate enteral nutrition at normal concentrations (not diluted) and increase gradually based on tolerance 3
• Reduce parenteral nutrition proportionally as enteral feeds increase, if PN was initiated 3
• Continue oral feeding attempts even with tube feeding to prevent oral aversion and maintain oral-motor skills 3

Medication Considerations

Acid Suppression Therapy

Do not routinely prescribe proton pump inhibitors or H2-blockers for feeding difficulties unless GERD is clearly diagnosed 3:

• Acid suppression is indicated only when reflux causes troublesome symptoms or complications meeting GERD diagnostic criteria
• Inappropriate acid suppression exposes infants to increased risk of pneumonia and gastroenteritis
• Simple spitting up or throat-clearing without troublesome symptoms does not warrant treatment

When GERD Treatment Is Appropriate

• Consider proton pump inhibitors only after confirming GERD diagnosis through pH/impedance studies or endoscopy showing esophagitis 3
• Implement non-pharmacologic measures first before initiating medication 3

Interdisciplinary Referral Strategy

Most feeding disorders require interprofessional team evaluation for comprehensive assessment and treatment 5, 2:

Essential Team Members

• Gastroenterologist for evaluation of GERD, swallowing dysfunction, and anatomical abnormalities 3, 5
• Feeding therapist (occupational or speech therapist) for oral-motor assessment and intervention 3, 5
• Nutritionist for growth monitoring and nutritional planning 3, 5
• Behavioral psychologist if behavioral feeding patterns or parent-child interaction issues are identified 5, 2

Timing of Referrals

• Immediate gastroenterology referral for infants with persistent feeding difficulties, poor growth, or suspected GERD in early infancy 3
• Early intervention services referral at diagnosis if developmental delay or hypotonia is present 3
• Feeding therapy evaluation as soon as feeding difficulties are identified to prevent progression 3

Common Pitfalls to Avoid

• Do not delay nutritional support while pursuing extensive diagnostic workup—initial attempts should prioritize oral route, but tube feeding should not be delayed if growth is compromised 5
• Do not assume all feeding problems are behavioral—overwhelming evidence indicates most have underlying organic causes requiring medical treatment 5, 2
• Do not use benzydamine hydrochloride or betamethasone mouthwash in young children, as these are adult recommendations 6
• Do not place infants in car seats or semi-supine positions after feeding if reflux is suspected, as this worsens symptoms 3
• Do not restrict fluids based on misapplied concepts from chronic disease management—acute feeding difficulties require adequate hydration 6

Monitoring and Follow-Up

• Monitor weight gain closely at each visit, with more frequent monitoring (every 1-2 weeks) if growth concerns exist 3
• Reassess feeding strategy if chosen approach fails, trying again more slowly with modified techniques 3
• Continue oral feeding attempts even with tube feeding to prevent long-term oral aversion 3, 5
• Measure TSB levels if jaundice is present, as hyperbilirubinemia can contribute to poor feeding 3