Poor feeding in an infant is a non-specific but serious complaint. Differential spans cardiac (CHF, ductal lesion), neurologic (hypotonia, encephalopathy), GI (reflux, anatomic), infectious (sepsis, UTI), and oromotor (cleft, ankyloglossia).
🚩 Red-flag clues (must not miss)
- •Diaphoresis with feeds + tachypnea = CHF / cardiac
- •Choking, coughing with feeds = aspiration / TEF / cleft
- •Lethargy + poor feeding + temperature instability = sepsis (esp. < 28 d)
- •Bilious vomiting with feeds = malrotation
History
- Volume, duration, frequency, fatigue with feeds
- Choking, color change, sweating
- Stool / weight pattern; growth chart
- Maternal mental health, feeding technique
Exam
- Weight, length, HC plotted
- Cardiac (murmur, hepatomegaly), pulses (4 ext)
- Tone, suck, gag
- Oral exam — palate, frenulum
Differential & next step
| Diagnosis | Clue | Next step |
|---|---|---|
| GERD | Effortless regurg, well infant | Reassure; thicken; PPI only if pathologic |
| Cow milk protein allergy | Blood-streaked stool, eczema | Hydrolyzed formula trial × 2 wk |
| Cardiac (CHF / ductal) | Sweating, tachypnea, hepatomegaly | Echo, PGE1 if duct-dependent suspected |
| Sepsis / UTI | Fever or hypothermia, lethargy | Sepsis w/u, empiric abx |
| Pyloric stenosis | 3–8 wk, projectile non-bilious | US pylorus |
| Ankyloglossia / cleft | Visible on exam | Lactation, ENT/plastics |
| Hypothyroidism | Newborn screen positive, jaundice | TSH, free T4 |
| IEM (urea cycle, organic acidemia) | Vomiting + AMS + acidosis | Ammonia, AA/OA panel, metabolic team |
Management / next steps
- Vital signs, weight vs birth weight (loss > 10% concerning)
- Targeted workup based on findings
- Lactation consult; consider nasogastric feeds if dehydrated
- Admit if FTT, dehydration, or unclear etiology