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Feeding and eating difficulties

Scope

Infants, children and young people in Eastern Devon with or without medical diagnoses who present with a feeding or eating problem.

Out of Scope

  • Excludes children with a cleft palate under the Bristol Cleft Team. The cleft team will support http://www.uhbristol.nhs.uk/cleft
  • Excludes overweight and obese children
  • Excludes adults over 18 years
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Signs and Symptoms

Common feeding issues that can usually be managed in primary care by universal services.

Common feeding problems in infants

Breastfeeding/bottle feeding difficulties:

  • Discomfort during feeding e.g. posseting, colic
  • Latching difficulties with breast feeders under 6 weeks of age
  • Tongue tie
  • Minor growth disturbances

Weaning difficulties:

  • Difficulties achieving progression with textures
  • Coughing/gagging on oral solids
  • Difficulties transitioning from bottle to cup for oral liquids
  • Difficulties accepting different types of food (e.g. only eating smooth purees)
  • Avoidance of a variety of different foods
Common feeding problems in older children

Toddlers and younger children

  • Continued reliance on milk or other liquids for nutrition at an inappropriate age
  • Picky eating (children who consume an inadequate variety of foods through rejection of a substantial amount of foods that are familiar as well as unfamiliar to them)
  • Food neophobia (avoidance of new foods)
  • Prolonged mealtimes
  • Disruptive mealtime behaviour
  • Reduced appetite
  • Where any of these are occurring, but the child is otherwise healthy and happy, growth is good and developmental milestones are being reached, these feeding problems can be managed in primary care by universal services

Older children and young people

  • Picky eating and other food issues in younger children become less common as children age, though difficulties with accepting new foods, or some food groups may remain throughout the teenage years and beyond. In older children, it is important to be alert to the signs and symptoms of eating disorders, and refer promptly if you are concerned.
When do feeding issues become a worrying problem?

Many feeding behaviours in infants and younger children are part of typical feeding development and are usually transient. Children displaying a significant number of these behaviours or displaying behaviour to a greater extent for a prolonged period may be considered to have a 'Feeding Difficulty'. In other words, it is not merely the presence of behaviour but the severity and duration of behaviours that signifies a problem.

Significant feeding difficulties which are likely to require onward referral:

Significant feeding problems in infants

Breast/bottle feeding difficulties:

  • Atypical suck
  • Interruption of the feed by abnormal movements e.g. jaw clenching, tongue thrusting
  • Abnormal oro-facial tone
  • Aversion/Hypersensitivity to teat or nipple e.g. gagging and vomiting, head turning, crying
  • Back arching/vomiting/distress during or after feeds
  • Reduced or absent feeding cues e.g. lack of interest in feeding
  • Aversion e.g. head turning/grimacing/crying when presented with nipple or teat
  • Excessively long feeding times over 30 minutes
  • Coughing or spluttering during feeds, becoming short of breath

Weaning difficulties :

  • Difficulties with the child accepting any solids into the mouth (e.g. oral aversion)
  • Immediate reactions to new weaning foods (e.g. facial swelling, breathing difficulties, hives, vomiting)
Significant feeding problems in older children

Toddlers and younger children

  • Traumatic event associated with food leading to refusal or dependence on a particular type or texture of food
  • Sensory food difficulties resulting in highly restricted diet (e.g. where entire food groups are avoided)

Older children and young people

  • Anorexia nervosa
  • Bulimia Nervosa
  • ARFID (Avoidant Restrictive Food Intake Disorder – restricts/avoids foods to extent that weight loss or poor growth occurs, reliance on nutritional supplementation to meet needs and marked interference with physical and mental wellbeing but no issues with body image)
  • Obsessive compulsive rituals with food or fluids which prevent appropriate intake of nutrition for growth and wellbeing

History and Examination

Where to start

1. Asses growth
 Always measure weight and length/height, plot on a RCPCH growth chart to identify whether growth faltering is a problem

2. Consider the cause

Is the problem…

Consider

Potential reasons

Giving appropriate nutrition?

  • When/where/how are feeds or meals given?
  • Do care-givers have appropriate food preparation facilities and skills?
  • Is there enough money or storage for food?
  • Are appropriate amounts and types of food offered?
  • Is the carer responding to the child's hunger cues?
  • Poor care-giver knowledge
  • Poverty
  • Attachment difficulties
  • Neglect (this is rare)

Taking appropriate nutrition?

  • Is there a structural/postural issue which affects feeding?
  • Are there behavioural problems with eating or drinking?
  • Is poor appetite a feature?
  • Cleft palate
  • Tongue Tie
  • High or low muscle tone e.g. Down's syndrome/Cerebral Palsy
  • Sensory difficulties e.g. Autistic Spectrum Condition
  • Chronic illness
  • Anaemia
  • Constipation
  • Eating disorders

Using appropriate nutrition?

  • Is there a suspected problem with absorbing nutrition e.g. diarrhoea/vomiting
  • Could there be a reason for increased requirements?
  • Reflux
  • Pyloric Stenosis
  • Cow's milk protein allergy
  • Coeliac disease
  • Cardiac defects
  • Pulmonary disease e.g. Cystic Fibrosis
  • Hormone imbalance e.g. thyroid disease
  • Diabetes Mellitus

3. Decide whether investigations are needed

Growth assessment, examination and history-taking are the most important tools in determining cause. Any medical investigations should be directed by symptoms.

The following blood tests may be helpful where there is growth faltering or chronic gastrointestinal symptoms but other investigations may be appropriate depending on symptoms and signs:

  • Full blood count
  • Urea and electrolytes
  • Liver function tests
  • Coeliac screen
  • IgA
  • CRP

4. Is it urgent?

Organic:

  • Dysphagia – mechanical difficulties with eating, drinking or swallowing
  • Aspiration (including frequent chest infections)
  • Apparent pain with eating, drinking or swallowing
  • Vomiting and diarrhoea (consider allergy or gastrointestinal pathology)
  • Developmental delay
  • Chronic cardio-respiratory symptoms
  • Significant growth failure (faltering growth) - see https://www.rcpch.ac.uk/resources/growth-charts for growth charts and information on assessing growth
  • Acute reduction in intake leading to dehydration

Behavioural:

  • Selective and extreme dietary limitations resulting in a significantly inadequate diet
  • Total food and fluid refusal leading to rapid weight loss and/or dehydration
  • Force feeding from parent/carer
  • Abrupt cessation of feeding after a trigger event
  • Anticipatory gagging
  • Multiple sensory processing difficulties including but not exclusive to feeding
  • Significant disruption to the parent/child relationship e.g. looked after or adoptive children, resulting in attachment difficulties
  • In older children, suspicion of a restrictive eating disorder e.g. Anorexia Nervosa

Rapid identification and treatment in cases of Anorexia Nervosa is essential for good long term outcomes. If you suspect a child or young person of having Anorexia Nervosa, please refer to CAMHS at an early opportunity. Guidance for whether joint referral to paediatrics is appropriate can be accessed here

5. Can the problem be managed in primary care?

In cases of transient feeding or eating difficulties, particularly in younger children, reassurance about growth and a discussion about normal development will help reduce anxiety and support parents to move forward.

Universal Services

The Health Visiting team (under 5s) or School Nursing team (school age children) have a wide knowledge of normal childhood feeding, and can trouble shoot difficulties, particularly in

  • Breast or bottle feeding issues
  • 'Fussy eaters'
  • Toddlers/children who refuse to eat lumpy/chewy foods
  • Difficulties transitioning from a bottle to a cup for liquids

Common medical causes for feeding difficulties should be identified and managed in primary care e.g. constipation, anaemia, reflux or non IgE food allergies

6. Who can you refer onto?

Referral to a paediatrician

Feeding or eating difficulties can occasionally be the first symptom of a significant medical condition. A referral to paediatrics for feeding difficulties is warranted for:

  • Exclusion or detection of more serious or rare diagnoses causing feeding difficulties
  • the child has a chronic condition that is affecting feeding, such as cerebral palsy
  • Where behavioural feeding difficulties are associated with growth faltering or abnormal neuro-development.

Single agency services supporting children with feeding difficulties

Where feeding difficulties are causing a significant risk to quality of life or physical health, and impacting on growth and development, children may meet the threshold for specialist single agency services:

ASC Assessment Service (Virgin Care, Integrated Children's services)

Service remit – assessment or advice for: Diagnosis of autistic spectrum condition

Service Exclusions: A request for the service will not be accepted if there is not clear evidence that the child or young person has signs or symptoms that are expected for ASC or when a Paediatrician or Psychiatrist does not support the request

How to refer: Autism Spectrum Assessment Service

Bladder and Bowel Nurses

Service remit – assessment or advice for: Idiopathic constipation affecting feeding in children and young people who have not responded to initial treatment within 3 months.

Service Exclusions: Children where constipation is not affecting feeding, or who have not undergone treatment in primary care for at least 3 months

How to refer: Bladder & Bowel Service

CAMHS (Virgin Care, Integrated Children's services)

Service remit – assessment or advice for:

  • Behavioural eating disorders. Diagnosis and management of eating disorders (anorexia, bulimia, ARFID)
  • Behavioural support for children with traumatic experiences/anxiety/ phobias related to food
  • 0-18

Service Exclusions: Children with behavioural feeding problems which are not significantly impacting on the child's mental or physical health

How to refer: Child and Adolescent Mental Health Services (CAMHS)

Dietetics (Based at RDE Hospital)

Service remit – assessment or advice for: Growth nutritional adequacy

  • Faltering growth
  • Nutritional adequacy of self-limited or medically restricted diets e.g. cow's milk protein allergy
  • Enteral tube feeding
  • 0-18

Service Exclusions: Children with difficulties managing or refusing textures , amounts or types of food where there are no growth concerns and some foods from each food group are consumed

How to refer: e-Referrals

  • Specialty: Child & Adolescent Services
  • Clinic Type: Other Medical
  • Service: DRSS-Eastern-Child & Adolescent Services-Devon ICB - 15N
Occupational Therapy (Virgin Care, Integrated Children's services)

Service remit – assessment or advice for: Sensory postural fine motor skills

  • Sensory processing difficulties related to feeding and at least one other function and where this is causing significant risk or impact on daily living
  • Postural feeding issues/fine motor dysfunction in children with complex additional needs
  • 0-18

Service Exclusions: For general OT exclusion criteria see toileting request criteria

How to refer: Occupational Therapy

Paediatric Psychology (Based at RDE Hospital)

Service remit – assessment or advice for: Feeding behaviour secondary to a medical diagnosis

  • Children with behavioural feeding issues under the care of a paediatrician and where such issues are secondary to a medical condition
  • 0-18

Service Exclusions: Children not under the care of paediatrics, and those without a medical condition causing behavioural feeding concerns

How to refer: Referrals must come from a paediatrician

Paediatric Psychology (Virgin Care, Integrated Children's services)

Service remit – assessment or advice for: Behaviour under 5s neurodevelopmental

  • Behavioural support for parents and children under 5 with feeding difficulties as part of neurodevelopmental problems in children with additional complex needs
  • 0-5

Service Exclusions:

  • Children without additional needs who do not qualify for support from Specialist Children's Assessment Centres (SCAC)
  • Children over 5

How to refer: Specialist Children's Assessment Centres

Speech & Language Therapists (Dysphagia) (Virgin Care)

Service remit – assessment or advice for: Children presenting with mechanical eating, drinking and swallowing problems who are under the care of a paediatrician

  • Aspiration risk
  • Repeated chest infections
  • History of serious coughing, choking, respiratory changes when eating/drinking resulting in hospitalisation
  • Preterm baby or a baby/child with a neurological problem/medical condition associated with feeding difficulties
  • Difficulties managing food or drink when it is in the mouth or throat
  • Long mealtimes (more than 30-40 mins = increased aspiration risk)
  • Difficulties progressing from tube feeding
  • 0-18

Service Exclusions:

  • Children with sensory feeding difficulties with no mechanical component e.g. ASD
  • Children with behavioural feeding difficulties with no mechanical component
  • Fussy eaters
  • Drooling only
  • Vomiting only
  • Children not under the care of a paediatrician

How to refer: Dysphagia request criteria page

  • Patients must be under the care of a paediatrician
Specialist Infant Feeding Clinics (Virgin Care)

Service remit – assessment or advice for: Breastfeeding

  • Any breast or bottle feeding mother and infant dyad with challenging feeding behaviour
  • 0-1

Service Exclusions: Older children (over 1)

How to refer: Devon Infant Feeding Clinic

Multidisciplinary services

There are no multidisciplinary clinics to assess feeding difficulties in Eastern Devon, apart from the Virgin Care Eating Disorder service (CAMHS + medical and dietetic support from RDE Paediatrics).

The following groups are more likely to receive support from multiple agencies, which will include some MDT working, though this is not necessarily formalised:

  • Children who require tube feeding
  • Children with complex neurodevelopmental conditions under the care of Honeylands SCAC or who attend Special Schools
  • Children with feeding difficulties who are inpatients at the RD&E Hospital

Assessing growth (access to growth charts and training)

Royal College of Paediatrics and Child Health

GP training on faltering growth

BMJ Review on faltering growth

Useful reading:

Eating Disorders

Junior Marsipan Guidelines for Assessing Physical Risk

MindEd has mental health orientated e-learning applicable across the health, social care, education, criminal justice and community settings. It is aimed at anyone from beginner through to specialist.

Sensory Difficulties

Pharmacological and dietary interventions in Autism under 19 years NICE

Pathway Group

This guideline has been signed off on behalf of NHS Devon.

Publication date: February 2017

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