Why does my child not want to eat?
This problem is more common than most think. About 25% of all children have some issue(s) with eating. The degree to which the issue impedes a child’s health helps to determine if there is a feeding disorder.
Populations of Children with Feeding Issues
Some children with feeding disorders were born prematurely or are on the autism spectrum, while other have MR, cystic fibrosis, cerebral palsy (CP), or Down syndrome.
Many have had or still have severe medical conditions, while in other cases, no medical causes can be found. Some children have had medical issues resolved, but still have feeding problems.
There is a large population of children born prematurely who also suffer from feeding-related issues. Prematurity and related complications can cause feeding problems in children for a number of reasons.
Some premature babies must be intubated when they are born. Often, babies who are intubated refuse formula or breast milk after the period of intubation. Intubation may cause discomfort, resulting in a negative association with swallowing. Even when the pain of intubation has stopped, the child may not want to eat, or may still exhibit vomiting or other behaviors that occurred during intubation.
There are many other complications of prematurity (such as heart conditions, poor suck reflex, and other physical abnormalities that require further medical intervention), which are related to feeding problems.
Some children with medical issues have a gastric tube (G-Tube) or nasogastric tube (NG-Tube) placement. This may be necessary because the child is not safe to eat by mouth or is weak due to a heart condition, prematurity, surgery, or due to other medical issues. Some of these issues are unavoidable, and feeding issues can begin or become more problematic after feeding tube placement. Once medical issues are resolved and a physician has cleared your child to eat by mouth, feeding therapy can usually begin.
In many instances, feeding issues are attributed to reflux. Reflux occurs when food or drink passes into the stomach, and then some of the stomach contents travel back up the esophagus. This can be painful for the infant or child, and eventually may cause the child to refuse to eat. Sometimes, even when the reflux and accompanying pain are eliminated, food refusal will continue.
In most cases of reflux, feeding therapy can begin with medical clearance.
Swallowing Problems / Dysphagia
Issues with swallowing can also cause feeding issues. Swallowing problems can include difficulty with chewing or sucking, or problems with either starting to swallow, or with food or liquids entering the lungs while swallowing (aspiration).
Some effects of swallowing problems include long meal times, children not eating enough food, poor nutrition, weight loss, or decreased weight gain; and, in the case of aspiration, repeated bouts of pneumonia and infections in the lungs.
Feeding Issues with Unknown Cause
There are also a great many children and toddlers who have both an unremarkable medical history and feeding problems. These children have been through necessary medical testing to rule out anatomical abnormalities, as well as other medical conditions that would contribute to a child refusing to eat.
These tests include, but aren’t limited to: allergy testing, barium swallow study, endoscopy, gastric emptying study, or upper GI series.
Barium Swallow Study (Upper GI)
In the upper GI series, the child drinks a chalky liquid with barium, which shows up on an X-ray. X-rays or video fluoroscopy / barium swallow study (video X-ray of the liquid as it passes through the upper GI tract) are taken as the child drinks. An X-ray can show places in which damage to the esophagus becomes scar tissue, making a narrow passage for food to pass. The X-ray can also show deformities of the upper digestive tract, including the esophagus, stomach, and duodenum.
The video fluoroscopy shows the child drinking liquids with barium and may show refluxed liquid traveling into the esophagus, or aspirating into the lungs. The child can then be fed liquids of different thicknesses to find a safe level of thickness to reduce or eliminate aspiration during meals. To establish whether aspiration is still occurring, the swallow study may be repeated as the child grows.
Upper GI Endoscopy
A lighted, flexible endoscope with a camera is threaded down the esophagus and into the stomach and duodenum. Video images are transmitted to a video screen, so the doctor can examine the intestinal lining and may be able to identify damage from reflux or gastritis as well as physical abnormalities. Biopsies of the esophagus, stomach, and upper small intestines can also be taken through the endoscope and may be used to rule out food allergies, Celiac, and esonophilic disorders.
Lower GI series / Colonoscopy
For the lower GI series, or barium enema, the patient must not eat solid foods for 1–3 days before the procedure, and a laxative is given to remove all solid material from the colon. On the day of the procedure, a lubricated tube is inserted into the anus and the large intestine is filled with a barium liquid, which will show up on an X-ray. X-ray pictures and/or video are taken to determine if there are any structural abnormalities, signs of gastroenteritis or diseases such as Crohn’s disease, or intestinal obstructions in the lower intestine.
24-Hour pH Probe
This is a reliable test for reflux. A thin tube is fed through the nose and placed in the esophagus where the stomach and esophagus meet. The tube measures acid levels over the course of 24 hours. If acid levels are consistently high, reflux is occurring. Also, this test can show if high acid levels occur when the child cries, coughs, or shows other symptoms of reflux.
Gastric Emptying Study (Milk Scan)
A gastric emptying study, such as a milk scan or gastroesophageal scintigraphy, measures how quickly the stomach empties. The child swallows milk or another food or drink mixed with a radium-labeled powder, which can be followed through the digestive tract. The test focuses on the esophagus (to test for reflux), lungs (to check for aspiration), and stomach (to check for slow gastric emptying).
Because this test measures how long food or drink stays in the stomach, it is an effective test for gastrointestinal motility issues. The test may be more accurate in detecting reflux than a pH probe, because it more closely resembles normal feeding, and follows digestion through the entire digestive tract. It is less effective in detecting structural abnormality than an endoscopy or barium swallow study.
Esophageal Manometry / Antroduodenal Motility Studies
With esophageal manometry, a thin tube is fed through the nose and into the esophagus. The tube measures pressure in the lower part of the esophagus, to test if the esophagus is contracting and relaxing correctly when swallowing.
As with esophageal manometry, in an antroduodenal motility study, a thin tube is fed through the nose and esophagus and into the stomach and duodenum (beginning of the small intestine). The tube measures pressure in the stomach and duodenum to test the strength of the muscles to ensure that they are moving food through the stomach and into the duodenum correctly. This test may be used to find the cause of motility in children.
A small amount of the suspected allergen, or a battery of allergens in specifically labeled locations, is inserted under the skin. A hive, or redness and swelling, will form where there is a reaction to the specific allergen, and so one can generally obtain a quick positive or negative result for Immunoglobulin G (IgG).
The suspected irritant is applied to the skin topically and held in place with an adhesive patch. A sterile control patch is also applied to another location. If hives appear under the suspect patch, but not under the control patch, then the test is positive.
A skin test cannot predict what kind of reaction might occur upon ingestion of a food containing the allergen, but it can confirm an allergy suggested by the patient’s history of reactions to particular foods.
Blood tests, most commonly radioallergosorbent test (RAST), can measure the actual amount of IgG antibodies in the bloodstream, which is then compared to predictive values for certain foods. Blood tests allow for hundreds of allergens to be screened from a single sample, and cover inhalants as well as food allergens. However, non-IgG mediated allergies cannot be detected by this method. There is some dispute about the significance of blood tests for IgG antibodies, which may be implicated in delayed-onset food allergies (associated with viruses, bacteria, and fungi), in contrast to the more common rapid onset of IgG allergies.
Skin tests may be quicker and more sensitive than blood tests, depending on technique, but blood tests are less likely than skin tests to be affected by certain medications or a pre-existing rash. Blood tests are preferred when the subject may have such a high sensitivity level that administration of a suspected allergen could have serious side effects.
Food Challenge Tests
Food challenge tests are administered under strict supervision in closely monitored environments, ideally as double-blind, placebo-controlled tests, in order to eliminate other factors such as food preparation techniques or psychological reactions to food recognition.
An elimination diet is the deliberate removal of specific suspect foods or ingredients from a child’s diet. If the symptoms clear up after a period of time, the pediatrician or allergist will direct a gradual reintroduction of the avoided foods or ingredients, one at a time. If symptoms return, a specific diagnosis can usually be confirmed. This can be repeated to narrow the range of culprit ingredients, one at a time. If symptoms return, a specific diagnosis can usually be confirmed. This can be repeated to narrow the range of culprit ingredients. A dietitian can assist in planning menus to compensate for the absence of nutrients normally found in potential allergenic food(s).
Elimination diets and food challenge tests cannot be used if anaphylactic or other severe reactions are involved.