Infant Feeding Problems: A guide for parents
Written By Kate Annat, APD
In the first year of life your baby is receiving their nutrition predominantly from breast milk or formula. It might seem relatively simple, but I know this is not always the case. There are a multitude of reasons why your child might struggle with feeding and I want to help you break down some of those reasons to help you best.
Together we will get to the root cause and in the process ensure your baby is getting the right level of nutrition they need, at this critical developmental stage.
What are the common feeding issues a baby can experience, beyond general fussiness?
Babies experience feeding difficulties on a regular basis. I’m here to help you when the issue is beyond the common 4pm witching hour. Some of these include:
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A potential allergic reaction to breastmilk or formula
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Refluxing on formula feeds
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Lack of growth after NICU
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Feeding after tube insertion
If the problem is more related to a physical breastfeeding issue, it’s best to discuss this with a Lactation Consultant. I’d be happy to make recommendations to Lactation Consultants I have worked with.
Is my baby allergic to breastmilk or formula?
If reflux is the ONLY symptom, it's likely your baby is suffering from reflux. But if other symptoms are present, it could signal a non-IgE allergy. Looking at all the symptoms helps us determine if an allergy exists. The typical symptoms are:
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Reflux
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Vomiting (delayed 24 - 72 hours)
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Diarrhoea (delayed - 24 - 72 hours)
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Blood in stool
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Mucous in stool
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Eczema
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Congestion
Individually each of these symptoms don't mean an allergy. But if there is a history of 3 or more symptoms, I think ‘bingo’ let's focus on allergy. Don't worry. Regardless of whether you're breastfeeding or bottle feeding, we can resolve an allergy with a tailored nutrition plan for mum and bub. Check out my non-IgE allergy page for more information.
What if my baby has reflux?
Helping your baby with reflux is all about understanding why your child has reflux. I like to think of reflux more like a symptom of something else versus a diagnosable issue. When we see things from this perspective, as a symptom, then we can get to the root of the issue.
In simple terms, reflux typically occurs because baby is small and doesn’t have the strength and core muscle tone to hold the feeds down. Adults have a strong sphincter between our stomach and oesophagus. It acts as a valve, closing once food or liquid lands in the tummy. In small babies, this valve may not close all the way, allowing the feed to come right back up again.
What you can do to help your baby with reflux
After the feed, breastfed or bottle fed, keep baby upright for 15 - 20 minutes. If your baby is bottle fed, find a slower flow teat or a bottle with a anticolic valve (burps cause reflux too!). Every infant is unique so I don’t normally recommend specific teats or bottles until after I’ve met your baby, but to name a few, I like:
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Dr Brown’s (anticolic valve)
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Pigeon teat and bottles
I’ve found tommy tipee teats can be quite a fast rate. For your refluxing baby, a slower rate teat or a new bottle could be the solution.
Feeding issues for NICU premies
Parents face many hurdles on the NICU such as,
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infection
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oxygen support
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congenital defects
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cardiac defects
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reflux
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NEC
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ileostomies
All of these impact your child’s ability to grow and tolerate their feeds. With higher energy needs than a full term baby, these little ones require ongoing support.
Premie babies may not have enough muscle or have weaker core muscles making it easier to reflux. A baby who refluxes frequently doesn't grow as well. By reducing the overall volume baby is consuming at each feed and supplementing with a formula could be the solution, whether that is adding to breast milk or concentrating formula only. Think of it this way, reflux is a volume problem and a strength problem. If we reduce the volume but increase the calories we help baby grow.
Infants with cardiac defects are expending high amounts of energy on maintaining their heart rate. Likewise oxygen support infants, for their lungs. And gut resection babies are suffering malabsorption in their intestine. All these babies need energy dense feeds.
As a paediatric dietitian I have the knowledge to work with all these conditions and find solutions you can manage.
How a Paediatric dietitian can help infants with Cardiac defects
Cardiac defects are vast and varied but ultimately the goal is to balance all the symptoms your child might be experiencing with good growth. For example a cardiac baby can have a faster heart rate which causes increased energy expenditure. The heart rate can have an impact of oxygenation and thus work of breathing during feeding. The lungs may start to work harder to improve oxygenation. This then presses more on the diaphragm which can result in reflux.
You will often need a Speech pathologist in your corner to monitor that feeding is going safely, whether this is breast or bottle. In some instances both oral and tube feeding maybe warranted depending on how hard baby is working to feed and grow.
What I can do is provide you with a low volume and high calorie feeding plan
How to support feeding your tube fed baby
Tube feeding a baby is about finding that sweet spot between making your baby comfortable whilst also supporting them to grow. Some children will be safe to swallow and might have a combination of oral and tube feeding whilst others might need to be fully tube fed. I have experience with both and can help your family navigate this tricky time.
In a tube feeding consult I do the following:
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Check medical history
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Understand reason for tube insertion
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Assess growth trends
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Review feeding plan
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Compare plan with requirements
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Discuss symptom management - vomiting, reflux, diarrhoea
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Identify an exit plan for your child’s nasogastric tube (NGT)
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Develop plan based on assessment
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Implement strategies to develop and maintain oral feeding skills
The question I regularly ask is - Why? Why is the tube in? What is stopping us from taking it out? I wouldn't do this without your doctor's consultation but I do want to get to the root of the issue. It could be many things such as a poorly managed allergy, extreme reflux, laryngomalacia or a congenital abnormality. I will also guide you to professionals able to diagnose these conditions so we can make an end date for that tube!
How can a Paediatric Dietitian help my baby grow?
To create the perfect feeding plan for you and bub, I look at the whole picture:
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Whether your feeding plan is to include breast or formula
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The feeding equipment
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Your feeding styles, bottles and teats
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Review your routine and feeding times
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Supporting you to keep breastfeeding in your feeding plan
I calorie count the feeding plan and compare this with their catch up growth requirements. I tailor it to your feeding preferences and your babies feeding style.
So if you have a little IUGR baby, an ex prem, a baby who is refluxing, a baby with an NGT tube or a breastfed baby with allergy who is breastfed, I will come up with the feeding solution to make your child comfortable again.
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Book an appointment: in-person or online video call
I’ll meet with you and your child via telehealth or face to face. We’ll discuss your child’s full history from birth until today and answer all your questions.
Get a customised nutrition plan
You’ll receive a nutrition plan that meets your child’s specific needs.
See your child thrive and their confidence grow
As your child’s digestion improves happiness will return to your mealtimes.
FAQ’s: Your questions answered.
Can I keep breastfeeding when my child has allergies?
Yes of course! A lot of professionals will tell you to start expressing and place your child on formula in the meantime while you change your diet around. But this is the worst thing you can hear. Honestly, you express, which takes up all your time and your supply can diminish whilst doing so. You just need an experienced paediatric dietitian to work out what your child's allergies are and then you are on your way.
It is almost always dairy, soy, egg or wheat. Now when you read that do not just go and remove those four allergens. It is very very very rarely all four. So speak with me and we can make a plan. Now keep this in mind that your child may respond immediately but some children may take a few weeks for symptoms to improve. So do not take anything else out from your diet during this time. Let me help you take the struggle out of this stressful period.
How to help my baby with IUGR grow?
There are a lot of factors to consider when helping a baby, especially one who is IUGR grow. I want to give you a run through of exactly what I do to assess and help. Here are the steps
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I work out your feeding routine and timings of feeds
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Assess growth against expected targets
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Calculate calorie intake from feeding plan
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Compare intake against requirements
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Assess symptoms affecting growth - reflux, stools or allergic symptoms
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Observe and make recommendations on feeding style
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Create tailored feeding plan based on family preferences and growth needs of the baby
I have helped many babies to grow once they are home and out of the NICU. I love working with little babies and would have so much joy supporting your baby.
When can the tube come out for my baby?
I can definitely help you make an assessment of this. What we can do is assess how much your baby is taking in calorie wise orally and compare this against the calories they are receiving from their tube. What typically helps is creating a concentrated feeding plan for your baby to consume. What this means is increasing the formula/100mL or adding formula into your expressed breast milk. The reason this works is that your baby can get more calories from less volume.
Also depending on how the actually feeding is going I might get you assessed from a Speech Therapist (Carly Betts - Brisbane Feeding Clinic) who I work with. She will be able to support you with progress with feeding. Otherwise I will aim to find a local service for you to support with this.
This is a very individual outcome for every baby and I will ensure I give you a very clear and concise feeding plan, a tube exit strategy and volume targets so you can see your babies progress.
How can a Paediatric Dietitian help with an ileostomy?
I used to be both a surgical and a neonatal dietitian when I was working at the John Radcliffe Hospital in Oxford, UK. This meant I regularly worked with the neonatologists and surgeons to come up with the most appropriate feeding plan for your child. What I do is make an assessment on your child's surgical history. Knowing what parts of your child's intestine has been resected is crucial to create a tailored feeding plan for your child.
For example your ileum is where most of your fat is digested. If you child has most of their ileum intact then we can do a feeding plan with normal fats. However if they have a majority of the ileum resected then we may need to consider a feed containing medium chained triglyceride fats. These absorb earlier in the intestine and do not require your ileum for absorption. This is just one example to factor in when dealing with ileostomies. Other things include rate and timing of feeds, medications and feed type.
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