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Feeding Difficulties in Infants Under 6 Months

Infant feeding difficulties are some of the most common causes of referrals to general paediatrics. At RHCYP, general paediatricians and dieticians work closely together in the management of infants with feeding difficulties. For dietetic issues, the Paediatric Dietetic page on RefHelp opens a new window has lots of information about referrals to their service, as well as useful resources and advice for specific dietary issues. Information and advice for infants and children with suspected CMPA can be found here: Cow’s Milk Protein Allergy (CMPA) – RefHelp

Assessing feeding difficulties in primary care

Feeding difficulties in Infants under 6 months
NHS Lothian See sections below under Primary Care Management for further information and advice on individual conditions. There is NICE guidance available for colic, GOR(D), CMPA, and faltering growth.

C.W. & C.H. 19-09-23

Assessment prior to referral

  • Thorough history:
    • Onset and length of issues (vomiting, crying)
    • Birth history
    • General health of the infant, including growth
    • Allergy/atopic symptoms 
    • Maternal dietary exclusions
    • Nature of stools
    • Previously trialled interventions including OTC meds
    • Any red flag symptoms/signs
  • Plot weight, length and head circumference and examine trend
  • Full examination including the mouth, heart, abdomen, skin, and male genitalia
  • Apart from a thorough history and examination, no specific tests are required in primary care for feeding difficulties in infants. Most cases are best managed in a test and treat manner – i.e. commencing on treatment to confirm or disprove a diagnosis. Blood tests are rarely indicated.

Who to refer:

  • Red flags that warrant an acute assessment by the GP or RHCYP ED
    • Unwell child
    • Swollen or tender abdomen
    • Vomit that is bilious or bloody
    • High temperature with vomiting
    • Acute onset change in behaviour or new onset vomiting
    • Signs of dehydration
    • Very distressed or drowsy
    • Refusing to feed
    • Bulging fontanelle
    • Significant blood in stool
  • Red flags that warrant urgent referral to specialist care for further investigation and/or management
    • Faltering growth
    • Severe atopic eczema
    • Pale stools
    • Suspected severe CMPA
    • Suspected mild-moderate CMPA but no clear improvement on cow’s milk elimination diet
    • Suspected GOR whose symptoms are not adequately controlled despite appropriate, stepwise primary care interventions
    • Developmental delay

Advice only referrals are also welcomed for feeding difficulties. Please refer as usual via SCI Gateway and include “Advice only” in the title.

Triaging

Infants will be seen either in a general paediatric clinic or in the joint feeding clinic which will include an assessment by both a paediatrician and paediatric dietician at the same appointment. This decision will be made at the point of triage.

Occasionally after triaging we may feel that the referral is best managed by dietetics and an appointment will be made with them instead. For further information about referring directly to paediatric dietetics, please see their RefHelp pages opens a new window.

Who not to refer:

  • Infants with suspected reflux who have not tried a step-wise approach in primary care.
  • Infants with suspected mild-moderate non-IgE CMPA after commencing a cow’s milk free diet: Please continue on a cow’s milk free diet and refer to Paediatric Dietetics.
  • Weaning advice: Please refer to health visitor.

How to refer:

SCI Gateway > RHCYP > General Medicine > LI Basic Sign Referral

Who can refer:

  • GPs / Nurse practitioners can refer to general paediatrics or dietetics.
  • Health visitors can refer to dietetics directly