Approach to the Neonate With Poor Feeding

Clinical Presentation and Physical Examination

• A term infant does not feed by mouth.
• Examine the infant. Is he or she ill or well appearing?

Diagnosis and Treatment

• In an ill-appearing infant, evaluate for sepsis, respiratory distress, and congestive heart failure. Appropriate evaluation depending on signs and symptoms would be then indicated.
  
  
• In a well-appearing infant, consider whether he or she is (has):
  • Borderline preterm? Telltale signs include thin red skin, poorly developed breast tissue, undescended testes or poorly developed scrotal rugae (prominent labia minora), and few creases on the anterior third of the feet. A detailed Ballard score would also be helpful
  • Not feeding because he or she has never fed so far or may be very young (only a few hours old) and not learned how to feed. Tincture of time is all that may be required.
  • Very sleepy from just being a normal infant or from maternal magnesium sulphate or narcotics? Cold? Hypoglycemic? All these are easily reversible and require observation.
  • Anatomical barriers to feeding (cleft palate, small chin)?
  • Topical infection (oral thrush)? Tongue tie is not a cause of poor feeding.
  • Any dysmorphic features (trisomy 21) or respiratory distress? Is the infant neurologically normal?
  • Floppy? The floppy infant who feeds poorly should raise suspicions of Prader-Willi syndrome. Abnormal neurologic examination in association with poor feeding is commonly seen in hypoxic ischemic encephalopathy; trisomy (dysmorphic features and hypotonia); Prader-Willi syndrome (undescended testes and dysmorphic features); and many muscle disorders, of which myotonic dystrophy is easy to diagnose by examining the mother. 
  • Withdrawing from maternal narcotic drug abuse? In this case, the infant is more likely to suck vigorously and not gain weight rather than not suck at all.
    
    
    
    
• Recall that feeding is a team effort; the “team” consists of the infant and the mother (if breastfed) and the infant and the caregiver (if bottlefed).
  • Maternal reasons for poor feeding include inexperience, anxiety, engorged breasts, or fissure of the nipple.
  • Caregiver (e.g., mother, father, nurse) reasons include inexperience; feeding varies from “good” (finishes a bottle in <20 minutes) to “poor”!