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

Any impairment in a newborn or infant's 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 or infant presents with poor feeding, your first step is to perform a focused history and physical examination. 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. 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 vermillion 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. 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 DiGeorge syndrome, it can also occur as an isolated finding and can present with a wide range of symptom severity.

Alright, 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.

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.