Common Problems Encountered by Breastfeeding Women

Low milk supply; flat and inverted nipples Engorgement Delayed nursing; milk failure; sore nipples Treating sore nipples; blood in milk

Yeast infection; bacterial infection; sensitive skin

Breastfeeding is the way women have fed their babies from the beginning of time, so you should expect the process to proceed uneventfully, right? After all, it seems only fair that a woman who makes the positive choice to breastfeed her baby would be able to nurse as long as she desires. The surprising and disappointing truth is that lactation problems do occur, even among women with the best of intentions and the highest motivation to succeed at breastfeeding. Sometimes problems involve the mother's breasts and nipples or relate to her overall health. At other times, breastfeeding problems involve the baby or impact the baby's well-being. Some problems are due to circumstances beyond our control, while others are the direct result of lack of knowledge or lack of confidence, improper technique, or bad advice. Most problems that cause women to discontinue breastfeeding before they had wanted arise within the first few weeks, but a breastfeeding complaint can present at any point in the course of lactation. Whether breastfeeding problems begin in the hospital or surface months later, they can be the source of great stress and threaten long-term breastfeeding. The Importance of Getting Help Early The early recognition and treatment of a breastfeeding problem offers the best chance that the difficulty can be resolved successfully. The chief message is: Get help as quickly as possible so you can resolve your problem before it becomes complicated by insufficient milk. Unfortunately, many health professionals practice a wait-and-see approach to breastfeeding complaints, hoping that any difficulties automatically will self-correct between office visits. This nonintervention approach is understandable considering how little training most health professionals receive about the management of breastfeeding problems. Without corrective measures, however, many problems are compounded by low milk or an underweight baby, making a bad situation worse. Why Breastfeeding Problems Are Readily Complicated by Low Milk Supply Breastfeeding difficulties can cause physical discomfort, exhaustion and frustration, as well as infant fussiness and poor infant growth. Furthermore, many breastfeeding problems readily become complicated by low milk supply. Often, complaints in breastfeeding women are linked to ineffective or infrequent emptying of milk. If milk is not removed from the breasts regularly, a chemical inhibitor in residual milk accumulates and decreases further milk production. In addition, excessive pressure from unemptied milk can cause damage to the milk-producing glands. Thus, milk left in the breast acts to decrease further milk production. Problems that impair milk removal-infrequent or short feedings, inverted nipples, breast infections, sore nipples, breast engorgement-can quickly result in diminished milk production. Flat and Inverted Nipples A flat nipple is one that cannot be made to protrude with stimulation. An inverted nipple retracts inward instead of becoming erect when the areola is compressed. Both flat and inverted nipples can make it difficult for an infant to grasp the breast correctly. They also are more prone to trauma from early breastfeeding efforts, which can result in painful cracks and damaged skin. When flat or inverted nipples are discovered prenatally, several treatment options are available to draw the nipples out. The most popular of these is the wearing of breast shells, also known as milk cups, over the nipples inside the maternity bra. These dome-shaped devices have an inner ring that is worn over the nipple. When a breast shell is situated over a flat or inverted nipple, it applies steady pressure at the base of the nipple which causes it to protrude through the central opening. When prenatal treatment isn't possible or when the problem isn't detected until after delivery, mothers may need extra help with getting started breastfeeding. Whether or not your flat or inverted nipple(s) was treated prenatally, the most important thing you can do when your baby is born is to get skilled help with proper breastfeeding technique and expert guidance in helping your baby attach to your breast correctly. Flat nipples can range from those that are only slightly less protuberant than normal, to nipples that are almost indistinguishable from the surrounding areola. Inverted nipples range from those with a slight central crease or dimple to deep central inversions that interfere with infant latch-on and prevent milk from flowing normally. Depending on the characteristics of your particular nipples, your baby may be able to latch on and draw your nipples out without any special treatment. If your baby is having trouble grasping your flat or inverted nipples, you can try the following strategies:

Gently compress and roll your nipple between your thumb and index finger for a minute to try to make it more erect before attempting to feed your baby. With patience and persistence, your baby can probably attach to your breast and nurse effectively even if you have flat or inverted nipples. Use a breast pump to draw your nipple(s) out immediately before breastfeeding your baby. A hospital-grade electric pump may be available on the postpartum floor for your convenient use. If an electric pump is not available, a hand pump can be used to create steady, gentle suction for about thirty seconds. If one nipple is more protuberant than the other, begin your breastfeeding attempts using that nipple. Once your baby learns to nurse from one breast, he may be better able to draw the nipple out on the other side. You can build on this initial success as you offer the more difficult side. Wear breast shells for about thirty minutes before each feeding to help pull your nipples out. Obviously, the devices must be removed prior to breastfeeding. Some women can tolerate longer periods of wear, but overuse of breast shells can make nipples sore by trapping moisture. They can also cause plugged ducts by pressing against swollen breast tissues once milk comes in. (Any leaking milk that collects in the shells should be discarded.) If your baby has not learned to latch on well to both breasts and nurse effectively within twenty-four hours of birth, I recommend that you begin regular milk expression. Use the most effective pump you can obtain, preferably a hospital-grade electric breast pump with a dual collection system. Pump your breasts for approximately ten minutes after each feeding attempt. Pumping serves several purposes. It draws

your nipples out with each pump cycle, and it provides effective draining of your breasts to assure you continue to produce a plentiful milk supply. Pumping also obtains expressed breast milk to use to supplement your baby until she learns to nurse effectively.

While your baby is learning to breastfeed correctly, some experts believe it is preferable not to use a bottle to give the required supplemental milk. They argue that a preference for bottle-feeding can easily develop in babies who haven't learned to nurse effectively. These advocates recommend cup feeding or another alternative method of giving the extra milk. Other breastfeeding proponents insist that using bottles doesn't necessarily interfere with learning to nurse, so long as the mother's milk supply is kept plentiful by frequent pumping, and the baby is guided in correct breastfeeding technique. When a baby is having trouble learning to nurse due to flat or inverted nipples, I suggest temporarily avoiding bottle-feeding, if possible, and choosing an alternative method of feeding supplemental milk, at least during the period you are in the hospital.

Most importantly, keep first things first. Your top priorities are assuring your baby receives sufficient milk and preserving a generous breast-milk supply. With regular pumping and persistent attempts at the breast, your baby will probably be able to eventually breastfeed well. Rarely, a woman might have to pump several weeks until her nipples have been drawn out sufficiently for her baby to learn to nurse effectively. But such extra effort is well worth the benefits gained by breastfeeding.

Common Breastfeeding difficulties

Difficulty or Condition Prevention Solutions

Engorgement

Correct positioning and attachment Breastfeed immediately after birth Breastfeed on demand (as often and as long as baby wants) day and night: 10 - 12 times per 24 hours Allow baby to finish first breast before switching to the second breast

1. Apply cold compresses to breasts to reduce swelling; apply warm compresses to "get milk flowing." 2. Breastfeed more frequently or longer 3. Improve infant positioning and attachment 4. Massage breasts 5. Express some milk 6. Apply a warm bottle (demonstrate use of warm bottle)

Sore or Cracked Nipples

Correct positioning of baby Correct latch-on Do not use bottles, dummies or pacifiers Do not use soap on nipples

1. Make sure baby is positioned well at the breast 2. Make sure baby latches on to the breast correctly 3. Apply drops of breast milk to nipples and allow to air dry 4. Remove the baby from the breast by breaking suction first 5. Begin to breastfeed on the side that hurts less 6. Do not stop breastfeeding 7. Do not use bottles, dummies or pacifiers 8. Do not use soap or cream on nipples 9. Do not wait until the breast is full to breastfeed. If full, express some milk first.

Plugged Ducts and Mastitis

Get support from the family to perform non-infant care chores Ensure correct attachment Breastfeed on demand

1. Apply heat before the start of breastfeeding 2. Massage the breasts before breastfeeding 3. Increase maternal fluid intake

Avoid holding the breast in scissors hold Avoid sleeping on stomach

4. Rest (mother) 5. Breastfeed more frequently

Difficulty or Condition (mother)

Prevention

Solutions

Avoid tight clothing Use a variety of positions to rotate pressure points on breasts

6. Seek medical treatment; if mastitis antibiotics may be necessary 7. If mother is HIV-positive: express milk and heat treat or discard 8. Position baby properly

Insufficient Breast milk Mother "thinks" she doesn't have enough milk

Breastfeed more frequently Exclusively breastfeed day and night Breastfeed on demand

1. Withdraw any supplement, water, formulas, tea, or liquids 2. Feed baby on demand, day and night 3. Increase frequency of feeds

Correct positioning of baby Breastfeed on demand at least every 3 hours Encourage support from the family to perform non-infant care chores Avoid bottles and pacifiers 4. Wake the baby up if baby sleeps throughout the night or longer than 3 hours during the day 5. Make sure baby latches-on to the breast correctly 6. Reassure mother that she is able to produce sufficient milk 7. Explain growth spurts 8. Baby takes fore and hind milk

Insufficient Breast milk Insufficient weight gain Fewer than 6 wet diapers per day Dissatisfied (frustrated and crying) baby

Same as above

Same as above Refer mother and baby to nearest health centre

Special Situations
Special Situation Solutions

Sick Baby

Baby under 6 months: If the baby has diarrhoea or fever the mother should breastfeed exclusively and frequently to avoid dehydration or malnutrition. Breast milk contains water, sugar and salts in adequate quantities, which will help the baby recover quickly from diarrhoea. If the baby has severe diarrhoea and shows any signs of dehydration, the mother should continue to breastfeed and provide ORS either with a spoon or cup. Baby older than 6 months: If the baby has diarrhoea or fever, the mother should breastfeed frequently to avoid dehydration or malnutrition. She should also offer the baby bland food (even if the baby is not hungry). If the baby has severe diarrhoea and shows any signs of dehydration, the mother should continue to breastfeed and add ORS.

Sick Mother

When the mother is suffering from headaches, backaches, colds, diarrhoea, or any other common illness, she should continue to breastfeed her baby. The mother needs to rest and drink a large amount of fluids to help her recover.

Special Situation

Solutions

If mother does not get better, she should consult a doctor stating that she is breastfeeding.

Premature Baby

Mother needs support for correct latch-on. Breastfeeding is advantageous for pre-term infants; supportive holds may be required. Direct breastfeeding may not be possible for several weeks, but expressed breast milk can be stored for use by infant. If the baby sleeps for long periods he/she should be unwrapped to encourage waking and held vertically to awaken. Mother should watch baby's sleep and wake cycle and feed during quietalert states. Note: Crying is the last sign of hunger. Cues of hunger detection include rooting, licking movements, flexing arms, clenching fists, tensing body, and kicking legs.

Malnourished Mothers

Mothers need to eat extra food - "Feed the mothers, nurse the baby" Mothers need to take micronutrients

Mother who is separated daily from her infant

Mother should express or pump milk and store it for use while separated from the baby; the baby should be fed this milk at the same times he/she would normally feed. Mother should frequently feed her baby when she is at home. Mother who is able to keep her infant with her at the work site should feed her infant frequently.

Twins

The mother can exclusively breastfeed both babies. The more the baby nurses, the more milk is produced.

Inverted Nipples

Detect during pregnancy Try to pull nipple out and rotate (like turning the knob on a radio) Make a hole in the nipple area of a bra. When a pregnant woman wears this bra, the nipple protrudes through the opening If acceptable, ask someone to suckle the nipple

Baby who refuses the breast

Position the baby properly Treat engorgement (if present) Avoid giving the baby teats, bottles, pacifiers Wait for the baby to be wide awake and hungry (but not crying) before offering the breast Gently tease the baby's bottom lip with the nipple until he/she opens his/her mouth wide Do not limit duration of feeds Do not insist more than a few minutes if baby refuses to suckle Avoid pressure to potential sensitive spots (pain due to forceps, vacuum extractor, clavicle fracture) Express breast milk, and give by cup

Medications

There are three important things known about drugs and human milk: 1. Most drugs pass into breast milk 2. Almost all medication only appears in small amounts in human milk, usually less than 1% of the maternal dosage

Special Situation

Solutions

3. Very few drugs are contraindicated for breastfeeding women

Cleft Lip and/or Palate

Let mother know how important breast milk is for her baby Try to fill the space made by the cleft lip with the mother's finger or breast Breastfeed infant in a sitting position Express milk and give to the infant using a cup or a teaspoon

Mother who is away from her infant for an extended period Mother expresses breast milk. Caregiver feeds expressed breast milk from a cup.

Mother expresses breast milk by following these steps: 1. Wash hands 2. Prepare a clean container 3. Gently massage breasts in a circular motion 4. Position thumb on the upper edge of the areola and the first two fingers on the underside of the breast behind the areola 5. Push straight into the chest wall 6. For large breasts, first lift and then push into the chest wall 7. Press the areola behind the nipple between the finger & thumb 8. Press from the sides to express milk from the other segments of the breast 9. Repeat rhythmically: position, push, press; position, push, press 10. Rotate the thumb and finger positions Mother stores breast milk in a clean, covered container. Milk can be stored 810 hours at room temperature in a cool place and 72 hours in the refrigerator Mother or caregiver gives infant expressed breast milk from a cup. Bottles are unsafe to use because they are difficult to wash and can be easily contaminated

Mother who is HIV-Positive chooses to breastfeed

Mother should practice exclusive breastfeeding for 6 months. At 6 months mother should introduce appropriate complementary foods Mother who experiences breast difficulties such as mastitis, cracked nipples, or breast abscess should breastfeed with the unaffected breast and express and discard milk from the affected breast Mother should seek immediate care for a baby with thrush or oral lesions Mother who presents with AIDS-related conditions (prolonged fever, severe cough or diarrhoea, or pneumonia) should visit a health centre immediately Note: A lactating woman should use condoms when having sex to protect herself from exposure to infected semen

Mother who is HIV-Positive chooses to replacement feed

Mother should practice safe and appropriate use of infant formula or animal's milk (with additional sugar) exclusively for the first 6 months Mother should use a cup, not a bottle Mother should not mix-feed - "Give only breast milk substitutes, do not breastfeed"

How to cope with toddler feeding problems

How do I know when my toddler is full?

What is the best way to cope with my faddy eater? What shouldn't I do? What should I do if I am still worried?

By Judy More

When you are feeling at the end of your tether with a fussy eater, take a deep breath, relax and remember this is a normal phase in your toddler's development which will resolve with time.

By being anxious you can often make the problem worse, particularly if you are expecting your toddler to eat more than she needs. If allowed to do so, toddlers will eat just enough calories for their own requirements, so you should always respect your toddler's decision that she has had enough to eat. You need to resist trying to persuade her to eat more. All this is of course, easier said than done. Remember that it is your responsibility to offer your toddler nutritious food but always allow her to choose how much she will eat.

How do I know when my toddler is full?

It may seem obvious but your toddler is telling you that she has had enough to eat of a particular food, course or meal, if she is:

keeping her mouth shut when offered food

saying no

turning her head away from the food being offered

pushing away a spoon, bowl or plate containing food

holding food in her mouth and refusing to swallow it

spitting food out repeatedly

leaning out of her highchair or trying to climb out

 crying, shouting or screaming

gagging or retching

What is the best way to cope with my faddy eater?

Most toddlers go through a phase of only eating a very narrow range of foods. This is a normal part of toddler development called food neophobia - being frightened of new foods. Your toddler needs time to learn that these foods are safe to eat and enjoyable. She will learn this by watching you and others eating those foods. Eventually she will widen the variety of foods she eats but some take much longer than others to do this. To help her on her way, and to keep your sanity, follow these tips:

Eat with your child as often as possible. Toddlers learn to eat foods they are unfamiliar with by watching and copying their parents and other children eating them.

Make positive comments about the food you are eating. Parents are strong role models and if you make positive comments about foods, your toddler will be more willing to try them.

Arrange for your toddler to eat with other toddlers as often as possible. Invite a friend from playgroup over for tea. Your toddler may eat better when she is with her own age group.

Develop a daily routine of three meals and two to three snacks around your toddler's daytime sleep pattern and try to stick to it. Toddlers thrive on routine and knowing what to expect. She won't eat well if she becomes over-hungry, and toddlers who are tired will be too miserable to eat. Don't expect her to eat a large meal just before going to bed. Give her a small snack or drink and save her proper meal until later, after she has woken up.

Offer two courses at mealtimes: a savoury course followed by a sweet course. Toddlers often get bored with too much of one taste and will be ready to try something new. Two courses also give your toddler two opportunities to take in the calories and nutrients needed and means there is a wider variety of foods at each meal.

Limit mealtimes to about 20 - 30 minutes and accept that after this your toddler is unlikely to eat much more. It is better to wait for the next snack or meal and offer some nutritious foods then, rather than extending a meal trying to persuade your toddler to eat more. Most toddlers eat whatever they are going to in the first 20 minutes.

Praise your toddler when she eats well because toddlers respond positively topraise. If you only give her attention when she is not eating, she may refuse food just to get some attention from you. Toddlers like attention, even if it is negative. If she doesn't eat well, take the uneaten food away without commenting and accept that she has had enough.

Give small portions. Toddlers can be overwhelmed by large portions and lose their appetite. If the small portion is finished, praise your toddler and offer her some more.

Offer finger foods as often as possible and allow your toddler to make a mess at mealtimes. Toddlers enjoy having the control of feeding themselves with finger foods.

Eat in a calm relaxed environment away from distractions such as the TV, games and toys. Toddlers can concentrate on one thing at a time so distractions make it more difficult for them to concentrate on eating.

Be aware that if you are eating out, your toddler may not be prepared to try any of the food on offer, as it may all be unfamiliar to her. Take something that she will eat with you to tide her over until her next meal or snack.

Involve older toddlers in food shopping and preparing for the meal such as putting things on the table. This will encourage a positive attitude to food and mealtimes.

Involve your toddler in simple cooking and food preparation (if you have the time and patience). By handling and touching new foods without pressure to eat them, your toddler will become familiar with new foods and may be more likely to try them.

Change the venue of your toddler's meals. For example, have a picnic outside. This will make eating a fun experience for your toddler and will allow them to see others enjoying food.

What shouldn't I do?

Don't rush a meal. Some toddlers eat slowly and rushing your toddler to eat can reduce her appetite.

Don't pressure a toddler to eat more when she has indicated to you that she has had enough. Never insist she finishes everything on her plate.

Don't take away a refused meal and offer a completely different one in its place. A toddler will soon take advantage if you do. In the long run it is always better to offer family meals and accept that your child will prefer some foods to others. Always try to offer one food at each meal that you know she will eat.

Don't offer the sweet course as a reward for eating the first course. You will make the sweet course seem more desirable than the savoury one.

Don't offer large drinks of milk, squash or fruit juice within an hour of the meal.Large drinks will reduce your toddler's appetite. If she is thirsty, give her a drink of water instead. Try to phase out bottles so that all your toddler's drinks, including milk, are given in cups or beakers.

Don't offer snacks just before or just after a meal. Don't give a snack soon after a meal if your toddler hasn't eaten well at her main meal. It is tempting to do this just to ensure that your toddler has eaten something. However, it is best to have a set meal pattern and wait until the next snack or meal before offering food again.

Don't assume that because your toddler has refused a food she will never eat it again. Tastes change with time. Some toddlers need to be offered a new food more than 10 times before they feel confident to try it.

Finally, don't feel guilty if one meal turns into a disaster. Put it behind you and approach the next meal positively. Parents also learn by making mistakes.

What should I do if I am still worried?

If you are still doubtful, make a list of all the food and drinks your toddler consumes over a week and then review it. If your toddler's diet includes foods from all the food groups (read our article on how to feed your toddler for more information) and some variety within each group then you can reassure yourself that the problem is not as bad as you thought.

If you continue to worry about how much your toddler eats or if you think she might beunderweight, talk to your GP or health visitor who may be able to reassure you that there is no problem. Occasionally there are medical reasons why your toddler may not eat and a GP can assess this.

Written by Judy More

Judy More is a registered dietician and a member of the British Dietetic Association and the Nutrition Society. She specialises in children's nutrition. She studied nutrition at Sydney University and graduated with a B.Sc. in Biochemistry and Pharmacology and a Postgraduate Diploma in Dietetics & Nutrition. Judy writes for several publications and is on the editorial board of the Journal of Family Health Care.

Created October 2006

Feeding and Swallowing Disorders (Dysphagia) in Children

What are feeding and swallowing disorders? What are some signs or symptoms of feeding and swallowing disorders in children? How are feeding and swallowing disorders diagnosed? What treatments are available for children with feeding and swallowing disorders? What other organizations have information about feeding and swallowing disorders?

What are feeding and swallowing disorders?

Feeding disorders include problems gathering food and getting ready to suck, chew, or swallow it. For example, a child who cannot pick up food and get it to her mouth or cannot completely close her lips to keep food from falling out of her mouth may have a feeding disorder. Swallowing disorders , also called dysphagia (dis-FAY-juh), can occur at different stages in the swallowing process:

Oral phase- sucking, chewing, and moving food or liquid into the throat Pharyngeal phase- starting the swallow, squeezing food down the throat, and closing off the airway to prevent food or liquid Esophageal phase- relaxing and tightening the openings at the top and bottom of the feeding tube in the throat ( esophagus ) Return to Top

from entering the airway ( aspiration ) or to prevent choking and squeezing food through the esophagus into the stomach

What are some signs or symptoms of feeding and swallowing disorders in children?
Children with feeding and swallowing problems have a wide variety of symptoms. Not all signs and symptoms are present in every child. The following are signs and symptoms of feeding and swallowing problems in very young children:

arching or stiffening of the body during feeding irritability or lack of alertness during feeding refusing food or liquid failure to accept different textures of food (e.g., only pureed foods or crunchy cereals) long feeding times (e.g., more than 30 minutes) difficulty chewing difficulty breast feeding coughing or gagging during meals excessive drooling or food/liquid coming out of the mouth or nose difficulty coordinating breathing with eating and drinking increased stuffiness during meals gurgly, hoarse, or breathy voice quality frequent spitting up or vomiting recurring pneumonia or respiratory infections less than normal weight gain or growth

As a result, children may be at risk for: dehydration or poor nutrition aspiration (food or liquid entering the airway) or penetration pneumonia or repeated upper respiratory infections that can lead to chronic lung disease

embarrassment or isolation in social situations involving eating Return to Top

How are feeding and swallowing disorders diagnosed?

If you suspect that your child is having difficulty eating, contact your pediatrician right away. Your pediatrician will examine your child and address any medical reasons for the feeding difficulties, including the presence of reflux or metabolic disorders. A speech-language pathologist (SLP) who specializes in treating children with feeding and swallowing disorders can evaluate your child and will:

ask questions about your child's medical history, development, and symptoms look at the strength and movement of the muscles involved in swallowing observe feeding to see your child' s posture, behavior, and oral movements during eating and drinking perform special tests, if necessary, to evaluate swallowing, such as:
modified barium swallow -child eats or drinks food or liquid with barium in it, and then the swallowing process is viewed on an endoscopic assessment -a lighted scope is inserted through the nose, and the child's swallow can be observed on a screen. X-ray.

The SLP may work as part of a feeding team. Other team members may include: an occupational therapist a physical therapist a physician or nurse a dietitian or nutritionist a developmental specialist

Your child's posture, self-feeding abilities, medical status, and nutritional intake will be examined by the team. The team will then make recommendations on how to improve your child's feeding and swallowing. To contact a speech-language pathologist, visit ASHA's Find a Professional. Return to Top

What treatments are available for children with feeding and swallowing disorders?
Treatment varies greatly depending on the cause and symptoms of the swallowing problem. Based on the results of the feeding and swallowing evaluation, the SLP or feeding team may recommend any of the following:

medical intervention (e.g., medicine for reflux) direct feeding therapy designed to meet individual needs nutritional changes (e.g., different foods, adding calories to food) increasing acceptance of new foods or textures food temperature and texture changes postural or positioning changes (e.g., different seating) behavior management techniques referral to other professionals, such as a psychologist or dentist

If feeding therapy with an SLP is recommended, the focus on intervention may include the following: making the muscles of the mouth stronger increasing tongue movement improving chewing increasing acceptance of different foods and liquids

improving sucking and/or drinking ability coordinating the suck-swallow-breath pattern (for infants) altering food textures and liquid thickness to ensure safe swallowing

After the evaluation, family members or caregivers can ask questions to understand problems in feeding and swallowing make sure they understand the treatment plan go to treatment plans follow recommended techniques at home and school talk with everyone who works with the child about the feeding and swallowing issues and treatment plan provide feedback to the SLP or feeding team about what is or is not working at home

To contact a speech-language pathologist, visit ASHA's Find a Professional. Return to Top

SYMPTOMS

DIAGNOSIS

SELF-CARE

Begin Here

1. Does your baby always seem hungry? Yes

Go to Question 7.* No

2. Is your baby breast-fed?

Yes

If your baby still seems hungry despite frequent feedings, he or she may not be attaching to the breast correctly. When a baby does not latch on properly, he or she may not get enough milk during each feeding. Sometimes, the mother's milk supply may be insufficient for the baby or the baby's mouth may be sore.

Get tips on how to position your baby forbreast-feeding. If your baby is still having problems latching on, talk to your doctor or to a lactation consultant. Frequent feedings or pumping may help increase your milk supply. Drinking plenty of fluids may also help. Talk with your doctor about your concerns and keep a close watch on your baby's weight. If there are sores or white patches in or around the baby's mouth, see your baby's doctor.

No

3. Is your baby bottlefed, or does the baby have a sore mouth?

Yes

The bottle's nipple may be CLOGGED or TOO SMALL, or the baby's mouth may be SORE.

A proper bottle nipple should drip 1 drop per second when the bottle is turned upside down. If you think the nipple is clogged, unscrew the cap to release pressure. If your baby's mouth is

sore, see your baby's doctor. No

4. Does your baby fall asleep soon after starting to feed from the breast or bottle?

Yes

It's not unusual for younger babies to fall asleep while nursing. This should occur less often as your baby grows. Sometimes, babies who don't latch on correctly also fall alseep while nursing.

Talk with your baby's doctor to make sure there are no other contributing causes. Your baby's doctor will probably check your baby for growth and weight gain. If your baby is not latching on properly, carefully break the suction and try repositioning your baby.

No

5. Does your child cry after feeding? Yes

Go to Question 9.** No

6. Is your baby throwing up large amounts of milk with forceful vomiting? Yes

Your baby may have PYLORIC STENOSIS, a condition in which the lower part of the stomach becomes enlarged and prevents food from passing to the intestines. This makes the baby throw up.

Contact your baby's doctor right away.

No

*7. Does your child seem to have a lot of gas and stomach discomfort?

Yes

These symptoms may be a sign of LACTOSE INTOLERANCE, the inability to digest lactose. Lactose is a sugar found in milk and other dairy products.

Ask your baby's doctor if you should switch to a soy formula. Toddlers may also have soy or rice milk.

No

8. Does your baby cry intensely after meals, sometimes for hours at a time?

This may be COLIC.

Yes

See your baby's doctor. Rubbing your baby's stomach gently, or rocking your baby in a rocking chair or cradle may help relieve the pain.

No

**9. Does your child seem to have little interest in food or have a slow weight gain? No

Yes

This may be from a DEVELOPMENTAL PROBLEM.

See your baby's doctor.

10. Does your child have diarrhea after the feedings?

Yes

If you are feeding the child formula or cereal, these symptoms may represent an allergy or more severe intolerance to cow's milk (LACTOSE INTOLERANCE) or wheat (CELIAC DISEASE).

See your baby's doctor. Infants who are lactose intolerant may benefit from switching to a soy formula. Toddlers may also have soy or rice milk. Children who have celiac disease should avoid cereals that contain gluten.

No

For more information, please talk ot your doctor. If you think the problem is serious, call your doctor right away.

Introduction

Possible feeding problems with toddlers

You will naturally find that your toddler is becoming more assertive in all aspects of her life, and food is no exception. It is also during this period that the first signs of weight imbalances may appear.

Food fads by toddlers Dislike of foods by toddlers Weight problems

Food fads by toddlers

Jupiter

Between the age of one and two your child will begin to show pronounced preferences for certain foods. It is common for children to have these food fads, eating one food and refusing everything else. He may, for example, go right off meat and want to eat only yogurt. A week of this may be followed by a dislike of yogurt and desire to eat cheese and fruit. Being a good parent means not making a fuss about any of this. There is nothing magical about any one food and there is always a nutritious alternative to the one that your child rejects. Don't spend time cooking food that you know your toddler will refuse and then feel resentful when he does. Take the easy way out and cook food that you know he really wants, even if it's something of which you disapprove. Research has shown that as long as you offer your child a wide variety of foods, the diet that he chooses will be a balanced one. There is, after all, no reason on earth why your toddler should eat the food that you choose. His tastes are not necessarily yours and, if it is your child's happiness and well-being that you are concerned about, you will soon realize that it is more important that he eats something that he likes than that he doesn't eat at all. Be flexible about what you give your toddler.

Dislike of foods by toddlers

I really don't believe in camouflaging a disliked food, mixing it with a food that is well-liked, or bribing a child to have a spoonful of a disliked food with a spoonful of one that is liked. If your child dislikes something, give him an alternative food that provides the same nutrients and that you know he likes. If your baby shows a profound dislike for one food, trying to trick or bribe him into eating it may well result in the child refusing other foods as well. When you introduce a new food do it when you know your baby is hungry and he's more likely to take it. The only thing that you must be on your guard against is your child excluding all of one food group. If this happens then his diet will become unbalanced. Other than that there is absolutely nothing wrong with odd fads, and don't forget, the more worked up you get about them the more your toddler will display them because he'll very quickly learn that it is a way of manipulating you. So play them down.

Weight problems
If your baby is offered the right kind of food he can be neither underweight nor overweight. Your baby will always regulate his food and will take in just enough to supply his needs at any particular time. An underweight or overweight baby is, therefore, the fault of the parent in offering the wrong kind of food.

Overweight
Excess weight in a baby is nearly always due to too much fatty meat, too many sweetened drinks and refined carbohydrates (cakes, biscuits, jams and sweet foods) in the diet. It may also be because you curb your toddler's activity by keeping him in a pram or playpen and not allowing him to use up energy by crawling and walking. Always encourage your child to be active by playing games with him yourself - the livelier the better.

Underweight
Unless purposely deprived of food, very few toddlers are actually underweight, even if they weigh less than another baby of the same age and sex. Many parents worry unnecessarily about having a small, thin toddler; some children, like some adults, are naturally (and healthily) small and thin. If you are giving your baby a balanced diet and he is happy, contented and developing normally (see General Development) then you probably have nothing to worry about. However, if you are concerned, check with your doctor or health visitor. Dr Miriam Stoppard

Feeding problems of infants and toddlers

Anne-Claude Bernard-Bonnin, MD, FRCPC
Correspondence to: Dr Bernard-Bonnin, 3173 Cte Ste-Catherine, Montreal, QC H3T 1C5; telephone 514 345-4675; fax 514 345-4822; email ab.acbb@videotron.ca

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Abstract
OBJECTIVE To propose a diagnostic and therapeutic approach to feeding problems in early childhood. QUALITY OF EVIDENCE Articles were retrieved through a MEDLINE search from January 1990 to December 2005 using the MeSH terms eating disorders, infant, and child. Recommended practice is based mainly on levels II and III evidence. MAIN MESSAGE Feeding problems are classified under structural abnormalities, neurodevelopmental disabilities, and behavioural disorders, with overlap between categories. A medical approach also needs an evaluation of diet and an assessment of the interaction between parent and child. Treating medical or surgical conditions, increasing caloric intake, and counseling about general nutrition can alleviate mild to moderate problems. More complicated cases should be referred to multidisciplinary teams. Behavioural therapy aims to foster appropriate behaviour and discourage maladaptive behaviour. CONCLUSION

Feeding problems in early childhood often have multifactorial causes and a substantial behavioural component. Family physicians have a key role in detecting problems, offering advice, managing mildly to moderately severe cases, and referring more complicated cases to multidisciplinary teams.

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Rsum OBJECTIF
Proposer une faon de diagnostiquer et traiter les problmes alimentaires des jeunes enfants.

QUALIT DES PREUVES

On a fait un relev darticles dans MEDLINE entre janvier 1990 et dcembre 2005 laide des termes MeSH eating disorders, infant et child. Les pratiques recommandes reposent sur des preuves de niveaux II et III.

PRINCIPAL MESSAGE
Les problmes alimentaires peuvent relever danomalies structurelles, de dsordres neurodveloppementaux et de troubles du comportement, ces catgories se chevauchant. Lapproche mdicale doit aussi valuer le rgime ainsi que linteraction parentenfant. Se peut tre efficace de traiter les conditions mdicales ou chirurgicales, daugmenter lapport calorique et de donner des conseils gnraux sur la nutrition dans les cas lgers modrs. Les cas plus compliqus devraient tre adresss des quipes multidisciplinaires. La thrapie comportementale vise favoriser un comportement appropri et dcourager un comportement inadapt.

CONCLUSION
Les problmes alimentaires de la petite enfance ont souvent des causes multiples ainsi quune importante composante comportementale. Le mdecin de famille joue un rle cl pour dtecter ces problmes, donner des conseils, traiter les cas lgers modrs et diriger les cas plus compliqus des quipes multidisciplinaires.

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EDITORS KEY POINTS

Some 25% to 40% of infants and toddlers are reported by their caregivers to have feeding problems, mainly colic, vomiting, slow feeding, and refusal to eat. This article reviews the classification and clinical features of such problems, proposes an approach to diagnosis, and describes some practical therapeutic strategies. Five key elements should be considered in evaluating feeding disorders. How does the problem manifest? Is the child suffering from disease? Have the childs weight and development been affected? What is the atmosphere during meals? Is the family under stress? When infants are growing and developing normally, physicians should reassure parents and explain that no investigations are indicated at that point. Family physicians are in a key position to detect problems early on, to make a differential diagnosis, to give practical ad

Feeding is an important part of the everyday life of infants and young children, and much parent-child interaction occurs at feeding times. About 25% to 40% of infants and toddlers are reported by their caregivers to have feeding problems, mainly colic, vomiting, slow feeding, and refusal to eat.1 Although some of these difficulties are transient, some problems, such as refusal to eat, are found in 3% to 10% of children and tend to persist.2-6 Parents soon become concerned and turn to their family physicians for advice. This article reviews the classification and clinical features of early childhood feeding problems, proposes a diagnostic approach, and describes some practical therapeutic strategies.

Quality of evidence
MEDLINE was searched for all articles published in English or French between January 1990 and December 2005 using the MeSH terms eating disorders, infant, and child. The references of articles retrieved were searched for further articles not found in the MEDLINE search. There were few randomized controlled trials, and those that were identified had few patients enrolled. Recommended practice is based mainly on levels II and III evidence.

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Classification of feeding disorders

Feeding disorders can be classified under 3 categories (Table 1), although there is often overlap among categories. Structural abnormalities affect 3 areas: the naso-oropharynx, the larynx and trachea, and the esophagus. Neurodevelopmental disabilities disrupt the process of learning to eat and can result in oral hypersensitivity and oral-motor dysfunction. The third category is behavioural feeding disorders, as defined by Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSMIV-TR)7 criteria, which have been refined by Chatoor.8Describing these disorders, however, is beyond the scope of this review. It should be emphasized that, at present, these disorders have been described mainly from a single site and that their face validity is overly dependent on case reports (level II evidence).

Evaluating feeding problems

Five key elements should be considered in evaluating feeding disorders.

How is the problem manifested? Is the child suffering from any disease? Have the childs weight and development been affected? What is the emotional climate like during the childs meals? Are there any great stress factors in the family?

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History
Medical history should include antenatal and perinatal history; family history of atopy or feeding problems; previous illnesses and hospitalizations; and manipulation around the oropharynx, such as tube feeding. The chronology of feeding problems, diet since birth, changes of formulas, introduction of solids, current diet, textures, route and time of administration, and feeding position should be recorded. Food aversions, quantities eaten, length of meals and associated routines, strategies already used, and environment and behaviour around mealtimes need to be documented. Anatomic abnormalities should be suspected when children have problems swallowing. A history of recurrent pneumonia should alert physicians to chronic aspiration because about 70% to 94% of episodes of aspiration are silent.9 Stridor in relation to feeding could be due to glottic or subglottic abnormalities. Suck-swallow-breathing coordination can be affected by choanal atresia. Vomiting, diarrhea, or constipation; colic; and abdominal pain should alert physicians to the possibility of gastroesophageal reflux (GER) or allergy to cows milk, because some symptoms are similar for both diseases.10 Finally, physicians should explore social stress, family dynamics, and emotional problems. Examples of questions that might elicit information on maternal depression11 are shown in Table 2.
Table 2 Questions that elicit information about maternal depression

Physical examination
Physical examination should start with anthropometric measurements, including head circumference. A growth curve should have been documented since birth. Craniofacial abnormalities, signs of systemic disease, and atopy should be sought. A complete neurologic examination is mandatory, as is an evaluation of psychomotor development.

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Investigations
No laboratory investigations are indicated for infants with normal results of physical examinations, normal growth curves, and normal results of developmental assessments. For children with colic and occasional vomiting, an immunoglobulin Emediated cows milk allergy can be suspected. Confirmation of this diagnosis with skin testing and radioallergosorbent testing is not readily available, however, and these tests are not completely reliable either12 (level I evidence). Gastroesophageal reflux should be considered. Although upper gastrointestinal contrast studies are neither sensitive nor specific for GER, they allow observation of the coordination as a bolus is moved through the oropharynx and esophagus and for detection of anatomic abnormalities, such as malrotation.13 Esophageal pH monitoring is not readily available and should be reserved for patients who do not respond to empiric treatment with acid suppressants13 (level II evidence). Feeding problems that appear to stunt growth need thorough investigation. First-line laboratory investigations should include a complete blood count and assessment of sedimentation rate, serum albumin and protein, serum iron, iron-binding capacity, and serum ferritin to detect specific nutrient deficits and to assess hepatic and renal function, as well as a sweat test to screen for systemic diseases. Antitransglutaminase antibodies for celiac disease are becoming more widely available. If diagnosis of GER is unclear, esophagogastroduodenoscopy and biopsy can determine the presence and severity of esophagitis, strictures, and webs13 (level II evidence). A detailed dietary history must be taken with the help of a nutritionist, if possible. Quality and quantity of food ingested must be assessed to document deficits in calories, vitamins, and trace elements and food aversions. Physicians should inquire about excessive consumption of milk or fruit juices. Parent-child interactions during feeding should be assessed. Positive interactions, such as eye contact, reciprocal vocalizations, praise, and touch, and negative interactions, such as forced feeding, coaxing, threatening, and childrens disruptive behaviour (turning the head away from food, throwing food) should be noted. An assessment should also document behaviour occurring before food is presented, such as prompting and positive reinforcement for accepting food and use of neutral or ineffective consequences for other behaviour.14

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Management of feeding disorders

When infants are growing and developing normally, physicians should reassure parents and explain that no investigations are indicated at this point. In cases of colic and occasional vomiting, dietary intervention is worth a trial. Excluding allergenic foods, such as dairy products, eggs, nuts, fish, soy, and wheat, from the breastfeeding mothers diet or giving bottle-fed infants hypoallergenic formulas might reduce symptoms of colic, mainly in infants with a positive family history of atopy15(level I evidence). If physicians suspect cows milk allergy, mainly in atopic families, excluding allergenic foods can be empirically suggested to breastfeeding mothers and hypoallergenic formulas can be suggested for infants not breastfed12 (level III evidence). If vomiting and irritability persist despite use of hypoallergenic formulas, a trial of acid suppression is worth initiating under the assumption of a possible overlap between cows milk allergy and GER. Histamine-2 receptors can be used, followed by proton pump inhibitors (levels II and III evidence). Cisapride, a drug restricted because of the risk of arrythmias, should not be used before confirmation of GER by esophageal pH monitoring13 (level I evidence). If a childs growth appears to be stunted, caloric intake should be increased. Human milk can be fortified with formula powder, carbohydrate, or fat. Infant formula can be concentrated up to 3.4 to 4.2 kJ/mL, by either lessening dilution or adding glucose

polymers or vegetable oil. Solid foods can be fortified with butter, vegetable oil, cream, sauces, glucose polymers, and powdered milk (level III evidence). Children with normal neurologic function generally do well after surgical correction of anatomic abnormalities. Neurologically disabled children, however, need nasogastric or gastrostomy feedings when they are unable to ingest adequate calories safely and when the time required to provide adequate nutrition by mouth consumes parents and childrens lives, leaving little time for nurturing activities9 (level III evidence). Coexisting medical problems should be addressed. Good medical management does not always alleviate feeding problems adequately. For instance, young children with cystic fibrosis often have a pattern of eating slowly, having difficulty chewing, preferring liquids, refusing to eat solids, and having an aversion to new food.5Retrospective and case-control studies have shown that, despite medical and surgical therapy, infants with GER have lower intake of energy-generating food, have fewer adaptive skills and less readiness for solids, are more likely to refuse food, and are more demanding and difficult at feeding time6,16 (level II evidence). Under these conditions, behavioural interventions should be considered.

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Behavioural interventions
Parents should first know the basic food rules that apply to all young children17 (Table 3). Parents should control what, when, and where children are being fed. Children should control how much they eat in order to learn internal regulation of eating in accordance with physiologic signals of hunger and fullness. In the feeding disorder termed state regulation, mothers should be helped to modulate the amount of stimulation during feeding (level III evidence). Infants should be fed promptly before prolonged crying (not more than 30 minutes) and should not be unnecessarily aroused, burped, or wiped. Mothers anxiety, fatigue, or depression should be addressed.18 In the feeding disorder termed reciprocity, the focus should be on training parents in sensitivity and responsiveness to infants feeding cues18 (level III evidence). Complicated cases need a multidisciplinary approach where family physicians can play a key role in coordinating services. In cases of infantile anorexia, the mother-child dyad becomes involved in conflicting interactions, with a struggle for control and food being the battleground. Therapy consists of helping parents understand their childrens special temperaments, set limits, and structure mealtimes to facilitate the internal regulation of eating and to counteract the external regulation produced by emotional interactions within the caregiving environment.19 Food rules are strongly encouraged, and time out should be used in response to childrens inappropriate behaviour (level II evidence). Prevention of sensory food aversions starts with introducing various foods at 4 to 6 months of age. New foods should be introduced singly and not during illnesses, such as colds and diarrhea, and parents should persevere and present the new food day after day until children get used to it. Toddlers more easily accept a new food if they see their parents eating it. Withholding favourite food to get toddlers to eat healthy food seems to have a negative effect.20 Treatment of food aversions is based on increasing appropriate behaviour through positive reinforcement and decreasing maladaptive behaviour by extinction (removing what reinforces a response) and time out14 (level II evidence). Feeding problems associated with concurrent medical conditions might result from an interaction between intrinsic oral motor dysfunction, oral hypersensitivity, odynophagia, and learned aversive behaviour. Parents should be taught management skills, such as setting clear time limits for meals, ignoring non-eating behaviour, and using contingencies (active praising, positive reinforcement) to motivate children to meet the food-intake goals that have been set21 (level I evidence). Infants with posttraumatic feeding disorder are generally receiving enteral tube feeding that interferes with their experience of hunger and development of oropharyngeal coordination. Treatment is aimed at eliminating tube feeding and overcoming the resistance to oral feeding, either through the behavioural technique of extinction, which was shown to be successful in 1 controlled study22 (level I evidence), or by gradual desensitization (level II evidence).8

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Conclusion
Infants and toddlers feeding problems often have multifactorial causes and a substantial behavioural component. During well-child visits, family physicians are in a key position to detect problems early on; to make differential diagnoses; to give practical advice to parents on food rules and increase of caloric intake, if needed; and to initiate therapeutic approaches to colic, cows milk allergy, and GER. More complicated cases are generally managed by multidisciplinary teams; primary care physicians can have a key role in coordinating services.

Levels of evidence
Level I: At least one properly conducted randomized controlled trial, systematic review, or meta-analysis Level II: Other comparison trials, non-randomized, cohort, case-control, or epidemiologic studies, and preferably more than one study Level III: Expert opinion or consensus statements

Biography

Dr Bernard-Bonnin is an Associate Professor of Pediatrics at CHU Ste-Justine at the University of Montreal in Quebec. Her main interest is in ambulatory pediatrics, and she is a member of the Nutrition Clinic at the Ste-Justine Outpatient Department.
Footnotes

Competing interests: None declared

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References
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