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• Specialist Feeding Clinics
  Dr Moira Stewart
  Published on: 22 March 2016
• Feeding difficulties in infants: how much a iatrogenic condition?
  Alessandro Ventura
  Published on: 22 March 2016

• Published on: 22 March 2016

  Specialist Feeding Clinics

  • Dr Moira Stewart, Consultant Paediatrician
  • Other Contributors:
    • Ms Vicky O'Sullivan, Ms Lorraine McErlean and Ms Sonya Jain

  The recent paper on Specialist Feeding clinics highlighted the lack of dedicated services for children with feeding difficulties, irrespective of comorbidities, and those which address other issues in addition to physical growth and well being (1).

  Over the past 40 years, Northern Ireland and Belfast in particular has attracted media attention for many unfortunate reasons. For health professionals, who have wo...

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  The recent paper on Specialist Feeding clinics highlighted the lack of dedicated services for children with feeding difficulties, irrespective of comorbidities, and those which address other issues in addition to physical growth and well being (1).

  Over the past 40 years, Northern Ireland and Belfast in particular has attracted media attention for many unfortunate reasons. For health professionals, who have worked through “The Troubles” there are also developments within delivery of health care to children which have been innovative and progressive. Ten years ago, in response to identified need, we set up a specialised multidisciplinary community based feeding clinic in North and West Belfast. We have designated input from speech and language therapy, dietetics, access to videofluoroscopy and other investigations, and in recent times, child psychology and community children’s nursing teams. All these services are now perceived as essential components in assessment and management.

  A recent audit confirms the range and scope of feeding problems among children referred to the clinic. The age of children ranges from birth to 16 years, referrals come from health visitors (52%), family doctors (36%) and other consultants (12%). Diagnoses are almost equally divided between feeding behaviours, physical problems including oral motor dysfunction/delay and concerns about weight. There are now additional, similar feeding clinics across Belfast and in other parts of Northern Ireland and we are in the process of setting up a complimentary hospital based service for children with more complex medical conditions.

  Experience highlights the need for a comprehensive, multiprofessional assessment if aetiological factors are to be identified. Regardless of whether there is a single cause, or multiple contributors, the implications of feeding problems for the child, the family and the community mean that decisions on management are made by the team even if input from all members is not required. It is important that we continue to treat many referrals as “urgent”, despite pressures of waiting list targets, as we recognise the stresses on families of children with feeding problems and also the potential for escalation within short periods of time.

  We know that we need to develop additional expertise within the clinic, particularly in relation to children within the autistic spectrum, as well as earlier identification of risk factors for feeding problems in infants and children and setting of standards for clinical outcomes. However, we also believe that within the team we have the skills and expertise to address these issues and provide a quality service for children and their families.

  1. Puntis JW Specialist Feeding Clinics. Arch Dis Child 2008;93:164-7

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  Conflict of Interest:
  None declared.

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• Published on: 22 March 2016

  Feeding difficulties in infants: how much a iatrogenic condition?

  • Alessandro Ventura, University Hospital Pediatrician
  • Other Contributors:
    • Federico Marchetti, Zemira Cannioto, Egidio Barbi,Stefano Martelossi

  We read with interest the review by Puntis (1) regarding the feeding difficulties in childhood and the possible therapeutic approaches. As the Author underlines, food refusal in infants may be related to an unpleasant early oral experience, to an abnormal mother-child relationship due to psychological problems among the family, or due to some organic conditions especially when related to neurological diseases._ We would li...

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  We read with interest the review by Puntis (1) regarding the feeding difficulties in childhood and the possible therapeutic approaches. As the Author underlines, food refusal in infants may be related to an unpleasant early oral experience, to an abnormal mother-child relationship due to psychological problems among the family, or due to some organic conditions especially when related to neurological diseases._ We would like to stress that in several cases food refusal may be considered, at least in part, a iatrogenic condition ensuing in particular an improper diagnosis of food allergy (FA) and gastro-oesophageal reflux disease (GORD) in the first months of life. Trivial gastrointestinal complaints such as easy vomiting and crying after meal, are in fact frequently approached by paediatricians as related to GORD or food allergy without any substantial evidence (2,3,4). Between January 2003 and July 2007, forty-eight children admitted in our department had a final diagnosis that included the term “food refusal”. Among them, twenty- five(52%) cases (9 mts-11 yrs, 12 males) were affected by cerebral palsy or other neurological disorders with severe GORD disease, nine cases (19%, 7-66 mts, 5 females) had been artificially fed since birth (3 TPN, 6 nasogastric tube) and 14 (29%) cases had a clinical history characterized by trivial G.I. complaints (such as easy vomiting and colics, difficult feeding with “arching”, irritability) since the first weeks of life. They had all had a clinical diagnosis of GOR and had been treated with PPIs (13) or Ranitidine (3)(which was still being given when accepted in our ward) without any improvement of the symptoms. Eleven had undergone one or more EGDS and contrast Rx with inconclusive results. They had all undergone also several changes in their diet for a presumptive diagnosis of cow’s milk allergy and were assuming an elemental formula or were still not allowed to assume several foods (egg, beef, wheat) when seen in our department. However, no one had undergone a food challenge test to confirm the diagnosis nor had had clear benefit from the exclusion-diet. All cases developed a severe food refusal with failure to thrive. The interpersonal relationships among the familiy did appear impressively disturbed. GORD was excluded in all cases by endoscopic and radiological examinations and by pH-metry. All cases well tolerated a normal diet (with catch-up growth) without any pharmacological treatment, after a personalized multidisciplinary approach was started. This approach consisted mainly in offering a normal-for-age free diet avoiding any insistence and, initially, prolonging the time in between meals. A psychological support was necessary in most cases in order to make parents accept that the child was not affected by any allergy or GORD. We suggest that, in cases in which the mother-child relationship is already fragile and instable, an “easy”, improper diagnosis of food allergy and GORD may negatively interfere with the natural ability of the mother in facing common, physiological infants’ symptoms such as irritability and vomiting. This troubled mothering may cause or significantly worsen food refusal, finally leading to failure to thrive. This condition should be considered a true iatrogenic syndrome which can be precisely defined and named as IGARIS: Iatrogenic Ghost Allergy and Reflux Infant Syndrome.

  1.Puntis JW Specialist feeding Clinics. Arch Dis Child 2008;93:164-7

  2.Heine RG, Jaquiers A.,Lubitz L. et al Role of gastro-oesophageal reflux in infant irritability Arch Dis Child 1995; 73: 122-5

  3.Diaz DM,inter HS, Coletti RB et al Knowledge, attitude and practice styles of North American Pediatricians regarding gastroesophageal reflux disease. J.Pediatr Gastroenterol Nutr 2007; 45:56-64

  4.Vandenplas Y, Brueton M, Dupont C et al Guidelines for the diagnosis and management of cow’s milk protein allergy in children. Arch Dis Child;92:902-8

  Alessandro Ventura, Federico Marchetti, Zemira Cannioto,Egidio Barbi,Stefano Martelossi Department of Reproductive and Developmental Sciences, IRCCS Burlo Garofolo-University of Trieste-Italy

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  Conflict of Interest:
  None declared.

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