Feeding difficulties


These guidelines have been produced to guide clinical decision making for general practitioners (GPs). They are not strict protocols. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.


Feeding difficulties is a broad term to describe a variety of feeding behaviours perceived as problematic.1

Problems with feeding may lead to significant negative nutritional, growth and developmental & psychological sequelae.1,2,3,4,5 

What is a feeding difficulty?

  • Picky eating
  • Food refusal
  • Highly selective food behaviour
  • Poor appetite
  • Delay in self feeding
  • Prolonged subsistence on inappropriate textures
  • Problem mealtime behaviours.1,2,3,4,5

What is a tertiary level feeding difficulty?

Children who are at risk of hospitalisation or critical incident due to:
  • Malnutrition or Failure to thrive
  • Clinical signs of dysphagia e.g. aspirating or poor chest health
  • Respiratory difficulty during mealtimes
  • Coexisting morbidity affecting feeding (e.g. respiratory difficulties during feeding, cardiac, etc)
  • Significant food aversion and/or distress during feeding 1,2,3,4,5

The PCH Feeding Service provides diagnostic assessment and management for children with tertiary level feeding difficulties.

Important features on history

  • Developmental history- when did issues begin and possible contributing factors, eg developmental delay.1,4,5
  • Weight, length and head circumference monitoring. 1,2,4
  • Child/parent interaction. 3,4
  • Parental perception, including family beliefs and cultural practices in relation to food. 1,4

Other things to consider (i.e. red flags)

Conditions affecting feeding  eg organic causes which include; cerebral palsy, reflux, prematurity, low birth weight, heart disease, history of cleft lip and/or palate, conditions affecting the airway, autism, muscle weakness, respiratory difficulties and medications that cause lethargy or decreased appetite, dysphagia. 5

Pre referral investigations

  • Weight and length monitored and charted 1,4
  • Three day food diary including type, texture and volume of food.1,4
  • Video of behaviour
  • Oral/motor skills and position for feeding 1,4
  • Presence of distractions. 4
  • Establish parameters around meals, no grazing, only water to drink, 3 meals a day plus pm snack and meal times limited to 30 minutes. 3

When to refer

Children referred will be assessed by a General Paediatrician initially. Ongoing management may include referral to occupational therapy, dietitian, speech pathologist and /or clinical psychologist.1,2,5

Children with tertiary level, complex feeding difficulties can also be referred directly to the PCH Feeding Service. Poor outcomes associated with feeding problems include detrimental effects on family life, behaviour problems and eating disorders. 2,3,4 5


  1. http://www.rch.org.au/feeding difficulties/What_is_a_feeding_difficulty/
  2. http://www.healthline.com/health/feeding-disorder-of-infancy-and-early-childhood. 2012
  3. http://www.mednet.ca/en/report/feeding-difficulties-in-infants-and-young-childr.html
  4. Arts-Rodas D, Benoit D. Feeding problems in infancy and early childhood: Identification and management. Paediatric Child Health; 1998 Jan-Feb; 3(1):21-27
  5. http://www.asha.org/public/speech/swallowing/Feeding-and-Swallowing-Disorders (Dysphagia) in Children

Reviewer/team: Department of General Paediatrics Review date: Jan 2021
    Next review date: Jan 2024
Endorsed by: Medical Advisory Committee (MAC) Date:  Jan 2021

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Referring service

Department of General Paediatrics

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