mother feeding her child a cracker

Feeding Difficulties

Children with feeding difficulties often have challenges because of certain conditions or disabilities.

Feeding difficulties can arise at the start of a child’s life or they can develop over time. Whatever the reason, what’s most important is that caregivers know how to deliver care that supports a child’s ability to eat and drink safely and comfortably so they can grow and thrive.  

Conditions Commonly Associated With Feeding Challenges

A child’s feeding skills are directly related to their entire body’s physical and intellectual development. When a condition, illness or disability is present, feeding skills may be impaired. Many children who have been adopted have varying disabilities, special health care needs or feeding difficulties.  

Conditions or disabilities often connected with feeding difficulties include:  

  • Autism spectrum disorders  
  • Cardiac (heart) conditions  
  • Cerebral palsy  
  • Cleft lip and/or cleft palate  
  • Deafness and hard of hearing  
  • Down syndrome
  • Fetal alcohol spectrum disorders and substance (drug) exposed children  
  • Prematurity and low birth weight  
  • Vision impairments 

What Are Feeding Difficulties? 

There are many different types of feeding difficulties that can arise for a child. Some of these occur at birth and persist for several weeks or months. Other challenges can occur later on in a child’s life and might be short or long-term. Below are 12 feeding difficulties babies and young children may experience.

1. The sleepy, hard-to-wake baby.

These babies fall asleep during feedings and they can be difficult to keep awake while feeding. They often do not let caregivers know when or even if they are hungry. Babies with fragile systems, especially those born early or exposed to substances, have extremely sensitive bodies. They will fall asleep as a way to protect themselves when challenged by stressful environments and situations. This can include babies with Down syndrome, heart problems (cardiac conditions), babies who are medically fragile, born early or babies exposed to substances in the womb. 

2. The fussy baby who is hard to calm.

These babies often fuss when they are being fed and when they are not being fed. They might appear hungry but then fuss when offered the bottle. Babies with fragile systems, especially medically complex babies or those born early or exposed to substances such as drugs or alcohol, will fuss as a way to communicate their discomfort and stress. It can be confusing for caregivers and very hard to understand why they are upset. These are the babies who can be incredibly difficult to soothe or babies who don’t stay calm for very long. This can include babies with cardiac problems (heart conditions), babies exposed to substances in the womb, babies who are medically fragile or born early, or babies with vision or hearing impairments or neurodevelopmental delays. 

3. The baby who has difficulty sucking.

These babies cannot suck strongly or efficiently or have a very disorganized sucking pattern. They might have trouble compressing nipples to get milk flowing using their lips and cheeks. Faster-flowing liquids can be very hard or even dangerous for them to drink. They often have messy feedings and can become tired easily since sucking can take so much effort. These babies can also struggle to find a good sucking rhythm, which can lead to even more tiring and stressful feedings.

Babies with low muscle tone or weak hearts and lungs tend to have this particular challenge.

Babies with low muscle tone or weak hearts and lungs tend to have this particular challenge. This can include babies with Down syndrome, babies with cerebral palsy, babies exposed to substances such as drugs or alcohol in the womb, babies born early, or babies who are medically fragile or have neurodevelopmental delays. 

4. The baby who coughs, chokes or gags.

These babies might cough, choke or frequently gag and spit up while taking liquids from a bottle during a feeding, directly after feeding or both. These babies might look like they are struggling to eat and breathe and gasp for breaths while feeding. This can include babies with heart (cardiac) conditions, Down syndrome, muscle tone issues such as cerebral palsy, or cleft lip and/or palate. This may also include babies exposed to substances such as drugs or alcohol in the womb or babies born early or with neurodevelopmental delays. 

5. The baby who frequently spits up.

Gastroesophageal reflux (GER) happens when food from the stomach comes back up into the throat causing pain and discomfort. Gastroesophageal reflux disease (GERD) is a more serious and long-lasting form of GER and may prevent a baby from feeding well and gaining weight. These babies tend to spit up often, sometimes after every feeding. They appear uncomfortable and seem hungry but frustrated when feeding. Often, over time, these babies may refuse to eat because it is such an uncomfortable and stressful experience. This can include babies with low muscle tone (cerebral palsy), babies exposed to substances such as drugs or alcohol in the womb, or babies born early or with neurodevelopmental delays. 

6. The baby who is born early. 

Babies who are born prematurely include those born before 37 weeks gestation. Depending on how early the baby is born and how much the baby weighs, feeding difficulties are common and will vary in their complexity. When babies are born early, their bodies aren’t fully developed. This means that feeding skills are usually not fully developed and that babies will need additional time and support in order to become safe and successful feeders. This can include babies with a variety of additional medical issues such as heart (cardiac) conditions, neurodevelopmental delays, Down syndrome, muscle tone issues such as cerebral palsy, or cleft lip and/or palate, or babies exposed to substances such as drugs or alcohol in the womb.

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7. The baby or child who tires easily. 

These babies will often feed for only a few minutes before getting tired. They frequently fall asleep during feedings and can have trouble finishing them. Feeding is hard work, especially for babies with fragile systems. Babies with heart or lung issues or those born early tend to tire more quickly than expected and have difficulty building endurance for feeding as well as difficulty with many other activities, such as sitting and crawling.

Babies who tire easily can grow into children who tire easily at mealtimes.

Remember: Babies who tire easily can grow into children who tire easily at mealtimes. This can look like a child who eats less at meals, needs frequent breaks, avoids certain food textures or shows increased fatigue with foods that are harder to manage or chew. This might include babies and children with cardiac (heart) or respiratory (lung) conditions or Down syndrome, or babies and children who are medically fragile, born early or exposed to substances such as drugs or alcohol in the womb. 

8. The baby or child who has problems with muscle tone. 

Babies and children can have low hypotonia (floppy) or high hypertonia (tight, rigid). When a child has trouble controlling the tone in their muscles, feeding activities can be challenging, including sitting upright, holding the head in a neutral position and using the tongue and lips for managing foods. These children can also be at higher risk for swallowing problems and aspiration because the muscles that assist with swallowing can be floppy or tight.

Some children move back and forth between high and low tone. This is called “fluctuating tone” and it is most commonly seen in children with specific types of cerebral palsy. Low and high hypertonia can also occur in children with damaged spinal cords or brain injuries, Down syndrome, heart (cardiac) conditions or children who are medically fragile, born early or exposed to substances such as drugs or alcohol in the womb.  

9. The baby or child who has difficulties with structures of the mouth. 

Babies or children may have feeding difficulties due to structural differences in their bodies. Problems with the jaw, tongue, lips, cheeks and palate may lead to problems with feeding, such as difficulty sucking, biting, chewing, swallowing and eating more difficult food textures. Babies and children born with birth defects that affect the lips, nose and/or roof of the mouth (cleft lips and/or palates) might also experience feeding difficulties.

Because of these clefts (slits, openings), babies tend to have problems forming a tight seal around a nipple (cleft lip) and creating the necessary suction needed for efficiently sucking liquid from bottles (cleft palate). This can also include babies and children with a variety of syndromes or conditions such as Down syndrome, cerebral palsy, autism spectrum disorders and neurodevelopmental delays, as well as children who are medically fragile, born early or exposed to substances such as drugs or alcohol in the womb. 

10. The baby or child who has a sensitive sensory system.

Every baby and child has a unique sensory system. A child can have a sensory system that is hyporeactive (understimulated) or hyperreactive (overstimulated). Problems with a baby or child’s sensory system occur when the body does not process and control sensory information well. This can make many daily activities difficult and very stressful, especially at mealtimes. This may include babies and children with cerebral palsy, Down syndrome, autism spectrum disorders or fetal alcohol spectrum disorders, children with visual or hearing impairments, or children who are medically fragile, born early or exposed to substances in the womb.  

11. The child who is born substance exposed.

Substances, such as drugs or alcohol, hurt a child’s developing body when in a mother’s belly. Children who are exposed to drugs (prescription and/or illegal) and/or alcohol often have feeding difficulties. Depending on what the child was exposed to, how much she was exposed to and how often, the feeding difficulties will vary in their complexity. These children tend to have very sensitive systems because of the substance exposure, leading to frequently spitting up, discomfort when feeding, and difficulty staying calm and focused when fed. This can include children with a variety of additional medical issues, such as heart (cardiac) conditions, neurodevelopmental delays, Down syndrome, muscle tone issues such as cerebral palsy, and cleft lip and/or palate.

12. The child who has trouble biting and/or chewing or swallowing. 

These children have trouble biting through solids and developing effective chewing for eating all types of foods. For children who have cavities and other tooth and gum problems, eating harder textured foods can be painful, leading to avoidance of these foods. For some children with lots of medical needs, biting and chewing can be very tiring, which means they tend to eat less during meals. These children may also cough while taking liquids from a cup or straw during a feeding, directly after feeding or during both interactions. They might look like they are struggling to eat and breathe or are gasping for breath while feeding however we can’t always see that they are having problems.

Just as every child is unique, so too are their feeding difficulties and needs around mealtimes.

Other reasons for these challenges may be linked to high or low muscle tone, sensory issues and/or structural abnormalities. This might include children with Down syndrome, muscle tone issues such as cerebral palsy, heart (cardiac) conditions, dental problems, visual impairments, or cleft lip and/or palate. Additionally, it could also include children who were born early, are medically fragile, have neurodevelopmental delays and have been exposed to substances such as drugs or alcohol in the womb.

Just as every child is unique, so too are their feeding difficulties and needs around mealtimes. It is essential that all caregivers understand each individual child’s strengths and areas for growth, and have the knowledge and skills to offer the best possible support. Mealtimes are valuable experiences that happen every day, multiple times a day. Therefore, it is essential to work toward ensuring each child has the opportunity for positive and safe feeding experiences. If you have any questions about your baby or child’s feeding development, seek support from an expert in your community, such as a feeding specialist or occupational therapist.

For more details on feeding best practices, download Holt International’s Feeding & Positioning Manual: Guidelines for Working With Babies and Children. 

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