Intolerance of Feeding in Infants

By Meg Brannagan Aug 16, 2013

Feeding intolerance occurs when a baby is unable to eat and digest food without becoming ill. The
condition affects both preterm and full-term infants. Feeding intolerance may be difficult for parents to
manage, as feedings often are a time of bonding with a baby. Instead, parents may be faced with an
infant who screams with each feeding. Diagnosis can help determine the underlying cause of intolerance
and lead to the best method of treatment.

Causes
A baby may have allergies to protein or lactose found in formula, leading to a cow's milk allergy or
lactose intolerance. Breastfeeding infants may have hypersensitivity to foods a mother eats, which are
transmitted to the baby through breast milk. According to Cedars-Sinai Medical Center, feeding
intolerance may also occur due to gastroesophageal reflux -- a condition where food and stomach acid
come back up the esophagus after eating, causing pain and spitting.
Symptoms
Symptoms of feeding intolerance include spitting up or vomiting after feeding, diarrhea and irritability.
Infants may have slow weight gain because of feeding refusal. If feeding causes discomfort, an infant will
naturally avoid eating and may lose weight. Preterm infants may also have temperature instability or
high blood sugar. Infants who are fed with a feeding tube may have increased gastric residuals, indicating
the food is not being digested.

Diagnosis
Feeding intolerance that is due to allergies is diagnosed by trial and error. A physician may recommend a
specific formula, but often the baby must eat for several feedings before seeing results. Breastfed infants
who show feeding sensitivity benefit from a mother's elimination diet. The foods that most commonly
cause problems are eliminated first, but some mothers must strictly limit foods in order to determine
cause. Reflux is diagnosed by a number of tests, including a 24-hour pH probe study, which checks the
level of a baby's stomach acid; or a bronchoscopy, which checks for lung damage associated with acid
reflux.

Treatment
Many types of formula exist for infant hypersensitivities to feeding. For a formula-fed infant who has a
cow's milk allergy or is lactose intolerant, changing formula to a soy-based product may reduce
symptoms. Le Leche League International states that breastfed infants with feeding intolerance often
improve when their mothers begin an elimination diet by discontinuing offending foods.
Gastroesophageal reflux is treated with medications that reduce stomach acid production and by feeding
an infant with a nasogastric tube until he tolerates feedings.

Premature Infants
Infants born prematurely may suffer from feeding intolerance because their gastrointestinal system is
immature. Premature babies often have less energy to eat; do not have the coordination to suck and
swallow; and have lower immune function, placing them at higher risk of intestinal infection. Preterm
infants may need calorie-fortified milk to boost weight gain if they do not tolerate feedings. They may
also need some feedings via a nasogastric tube until they have more capability to eat on their own.
One of the early and more difficult issues that parents face with tube feeding is feed intolerance. Feed
intolerance may present as vomiting, diarrhea, constipation, hives or rashes, retching, frequent burping,
gas bloating, or abdominal pain. In very young children, prolonged crying and difficulty sleeping may be
the only symptoms.

What is feed tolerance and intolerance?

Feed tolerance is how well a child tolerates feeds. A child who is comfortable and happy during and after
tube feeds is tolerating them well. If a child is uncomfortable, agitated, unhappy, retching, gagging,
vomiting, swallowing hard, or experiencing diarrhea or excessive gas may not be tolerating feeds well.
The key to feed intolerance is that it is a recurring pattern. The child pretty consistently will experience
these things with tube feeds.

The initial feeding schedule should be seen as a starting point. It is very common that adjustments and
changes will need to be made to make the child more comfortable with their tube feeds. It is common
for parents to panic when their child isnt tolerating feeds. It is important to remember that changes can
(and should) be made to the tube feeding regimen.

When making changes, only change one thing at a time. Go slowly, and wait a few days before making
another small change. Making too many changes at once will make it challenging to know what is or is
not working.
Why does feed intolerance occur?
The Underlying Medical Condition. Many of us do have a diagnosis and complete understanding of our
childs medical condition when we start tube feeding. The following are just a few examples:
An allergy or sensitivity to the formula or the protein in the formula
Motility problems, which make digestion too slow or too fast
Absorption problems, such as from cystic fibrosis, that make it difficult to break down fats or proteins
A metabolic disorder that requires a special component added or removed from formula
Structural or anatomic problems that may make volumes difficult to handle
Dramatic Increase in Calories, Volume, or Concentration. Many children who are labeled failure to
thrive are not eating or drinking enough when they have their feeding tube placed. They are often put
on a feeding regimen that is a dramatic increase in volume and calories over what they were taking in
orally. This can lead to feed intolerance. Sometimes you need to add calories more slowly, so that
children can adjust to the increase.
Incompatible Feeding Schedule. Sometimes a certain feeding schedule just does not work for a certain
child. Some children are always nauseous at night, but can take large volumes during the day. The
schedule must be designed to suit the child, and not the other way around.
Feed intolerance really does matter.
The perception that many parents have is that no one cares if their child is vomiting, or retching, as long
as the child is gaining weight. However, recurrent retching and vomiting takes a significant toll on both
the child and the parents. It impacts oral aversions, oral eating, and quality of life for both the child and
the rest of the family. So, it is important to bring it up to your medical team.

What can help with feed intolerance?

Make sure that you discuss any changes to your childs diet or feeding schedule with your medical
professionals.
Feeding intolerance (FI), defined as the inability to digest enteral feedings associated to increased gastric
residuals, abdominal distension and/or emesis, is frequently encountered in the very preterm infant and
often leads to a disruption of the feeding plan. In most cases FI represents a benign condition related to
the immaturity of gastrointestinal function, however its presentation may largely overlap with that of an
impending necrotizing enterocolitis. As a consequence, individual interpretation of signs of FI represents
one of the most uncontrollable variables in the early nutritional management of these infants, and may
lead to suboptimal nutrition, delayed attainment of full enteral feeding and prolonged intravenous
nutrition supply. Strategies aimed at preventing and/or treating FI are diverse, although very few have
been validated in large RCT and systematic reviews. The purpose of this paper is to summarize the
existing information on this topic, spanning from patho-physiological and clinical aspects to the
prevention and treatment strategies tested in clinical studies, with specific attention to practical issues.

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