Approach to poor feeding (newborn and infant): Clinical sciences

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Introduction0:00–0:32

Any impairment in a newborn or infants, latch suck and swallow, breathe, mechanics can result in poor feeding. Although self-limited difficulties with latching and breastfeeding are common in otherwise healthy newborns and infants, persistent feeding problems might indicate a functional issue or an anatomic abnormality that impairs the ability to latch suck or swallow.
Breathe. When a newborn infant presents with poor feeding, your first step is to perform a focused history and physical examination.

Focused H&P0:32–1:51

Caregivers typically report that their infant is unable to effectively latch suck or swallow, breathe during feedings as part of your workup, you'll need to make sure your patient has no history of systemic conditions that might impact feeding such as neurologic, cardiovascular pulmonary or gastrointestinal disorders or infections and no history of preterm delivery.
Here's a high yield fact, the ability to suck and swallow develops in utero and is usually established by 34 weeks gestation.
Therefore, premature infants born before this age are often not able to effectively coordinate their latch suck and swallow, breathe mechanics.
As for the physical exam, most patients will demonstrate normal muscle tone and reflexes, but you might notice atypical facial features or you may even hear stertor or stridor with feedings.
At this point, you should assess for any craniofacial abnormalities that might impact feeding mechanics. Let's start with cleft lip or palate.

Cleft lip or palate1:51–2:55

Affected infants often have difficulty latching and sucking and many experience nasal regurgitation or gasping with feedings.
The exam might reveal a cleft lip which can range in severity from a notch in the vermilion border to complete separation involving the skin muscle teeth and bone.
Patients with cleft palate can have a defect in the soft or hard palate. While a soft palate defect can occur in isolation.
Separation of the hard palate is always associated with cleft lip. Any one of these findings confirms a diagnosis of cleft lip or palate.
Here's a high yield fact, potential causes of cleft lip and palate include genetic conditions and prenatal medication, tobacco or alcohol exposure.
But in some cases, they occur idiopathically as an isolated finding. Now let's move on to micrognathia.

Micrognathia2:55–3:41

These infants typically present with difficulty swallowing and breathing and some also have Pierre Robin sequence which refers to the triad of micro or retrognathia airway obstruction and glossoptosis or a posteriorly displaced tongue.
If the examination demonstrates an undersized mandible and an overbite, possibly with audible stridor diagnose micrognathia.
While micrognathia is associated with some genetic conditions such as degeorge syndrome, it can also occur as an isolated finding and can present with a wide range of symptom severity.

Ankyloglossia3:41–4:40

All right, if you don't identify any obvious craniofacial abnormalities, your next step is to assess the infant's ability to latch suck and swallow.
If the primary problem is a decreased ability to latch. Consider ankyloglossia also known as tongue tie.
Breastfeeding. Parents will often report nipple pain during latching and the infant may become fatigued with feeding.
The presence of a tight lingual or upper lip frenulum confirms ankyloglossia. Here's another high yield fact.
Although breastfeeding difficulties are extremely common, most are not related to any underlying pathology. Many transient issues such as breast pain and difficulty latching can be remedied with lactation support.
This includes education about breastfeeding techniques like positioning and feeding schedules, as well as emotional support and encouragement.

Esophageal atresia4:40–6:18

Moving on. Let's discuss conditions associated with a decreased ability to swallow, start by looking for frothing or bubbling at the nose or mouth.
And if present, consider esophageal atresia history frequently reveals prenatal polyhydramnios and the newborn often demonstrates coughing, cyanosis and respiratory distress with feedings.
Physical exam classically demonstrates patent nares with an inability to pass a nasogastric or orogastric tube into the esophagus to evaluate further order a chest x-ray, bronchoscopy and endoscopy.
The x-ray might demonstrate a coiled feeding tube in the esophageal pouch and an air distended stomach or an airless scaphoid abdomen.
Endoscopy will confirm a blind oesophageal pouch which is diagnostic of esophageal atresia and bronchoscopy may reveal a tracheoesophageal fistula which is commonly associated with esophageal atresia time for a clinical pearl, esophageal stenosis, impaired vocal fold motion and laryngotracheal esophageal clefts are less common conditions that can also impact feeding and swallowing.
Laryngotracheal, oesophageal clefts occur when the septum between the esophagus and trachea does not fully develop, allowing communication between the esophagus and the larynx or trachea.

Choanal atresia6:18–7:22

Now, if you don't notice throbbing or bubbling at the nose or mouth, your next step is to assess for abnormal breathing sounds during feeding.
The presence of stern should make you consider choanal atresia affected newborns typically present with cyanosis that resolves with crying.
In addition to rhinorrhea or drainage from one nostril. If the atresia is unilateral, the physical exam classically reveals the inability to pass a catheter through one or both nostrils into the nasopharynx.
To confirm the diagnosis, obtain a CT scan of the head if it demonstrates unilateral or bilateral bony atresia with retained fluid in the nasal cavity, your patient has choanal atresia.
Here is another clinical pearl. Remember that any mass or obstruction involving the nose, mouth or neck can impact the ability to swallow and breathe.
Now, let's talk about infants with stridor during feedings. Here consider laryngomalacia.

Laryngomalacia7:22–8:16

This condition classically presents with inspiratory stridor during feeding, crying and agitation as well as regurgitation, emesis, choking and slow feeding.
The growth chart might reveal evidence of weight loss or sub optimal weight gain to confirm the diagnosis. Obtain a flexible laryngoscopy.
If you see dynamic collapse of the supraglottic structures, redundant mucosa and a tubular epiglottis, your patient has laryngomalacia, this common and self-limited cause of newborn stridor usually resolves spontaneously by 12 to 24 months of age.
Finally, if your patient demonstrates poor feeding, despite a normal ability to latch suck and swallow, consider gastroesophageal reflux.

Gastroesophageal reflux disease8:16–9:30

This common condition is caused by reduced lower oesophageal sphincter tone history usually reveals frequent regurgitation, possibly in combination with arching during feedings refusal to feed and irritability.
Exam. Findings are often unremarkable but the growth chart might show weight loss or suboptimal weight gain.
While this diagnosis is usually made clinically, you can assess your patient's response to thickened feedings, upright positioning, and possibly a trial of proton pump inhibitors.
If symptoms improve with treatment, diagnose gastroesophageal reflux. Here's one more clinical pearl before the recap.
Some of these conditions like cleft lip or palate micrognathia, tracheoesophageal fistula and choanal atresia might be detected on the prenatal ultrasound.
So the diagnosis can be made even before birth. All right, as a quick recap.

Review9:30–10:20

Effective newborn in infant feeding requires coordinated latch suck and swallow. Breathe mechanics.
In otherwise healthy infants, feeding mechanics might be impaired by craniofacial abnormalities like cleft lip or palate and micrognathia.
On the flip side. Latching might be impaired by other anatomic abnormalities like ankyloglossia or tongue tie while the ability to swallow and breathe is impacted by esophageal atresia, choanal atresia and laryngomalacia.
Finally, if an infant can latch suck and swallow, breathe effectively. But experiences regurgitation and discomfort with feeding, consider gastroesophageal reflux