Poor feeding and refusal to feed

Poor feeding is reduced intake of milk or food that is insufficient for the child's age and growth. Refusal to feed is a persistent unwillingness to take feeds.

In a neonate or young infant it is a nonspecific sign of serious illness and must be treated as an emergency until a cause is found. Causes include sepsis, meningitis, urinary infection, congenital heart disease, metabolic disease, hypoglycaemia, necrotising enterocolitis, and intestinal obstruction.

In older infants and children it more often reflects local oral pain, acute infection, feeding technique, developmental or behavioural factors, food allergy, chronic disease, or an eating disorder such as avoidant restrictive food intake disorder.

Definitions.

• Feeding refusal is rejection of feeds despite hunger cues, often with crying, arching or turning away.
• Poor feeding is intake under what is needed for expected weight gain. Neonates need 150 mL/kg/day of milk by day 5 to 7; infants 120 to 150 mL/kg/day, with 100 to 120 kcal/kg/day.
• Feeding difficulty includes poor latch, poor suck coordination, prolonged feeds, fatigue, choking, coughing, or gagging.
• Faltering growth is weight gain that falls across one or more centile spaces, under the 2nd centile, or weight loss exceeding 10% of birth weight after day 3.
• Avoidant restrictive food intake disorder is restriction of intake due to sensory aversion, lack of interest, or fear of aversive consequences, causing weight loss or nutritional deficiency.

Classification by cause

• Infection: neonatal sepsis, meningitis, urinary tract infection, pneumonia, bronchiolitis, otitis media, gastroenteritis, omphalitis, oral candidiasis, herpetic gingivostomatitis, hand foot and mouth disease, malaria, and tonsillitis.
• Cardiac and respiratory: congenital heart disease with heart failure, cyanotic disease, bronchiolitis, laryngomalacia, and chronic lung disease.
• Gastrointestinal: gastro-oesophageal reflux disease, oesophagitis, cow's milk protein allergy, eosinophilic oesophagitis, pyloric stenosis, intestinal obstruction (atresia, malrotation, volvulus), Hirschsprung disease, necrotising enterocolitis, intussusception, constipation, coeliac disease, and inflammatory bowel disease.
• Neurological: prematurity with immature suck, hypoxic ischaemic encephalopathy, cerebral palsy, hypotonia, neuromuscular disease, bulbar palsy, seizures, raised intracranial pressure, and bilirubin encephalopathy.
• Metabolic and endocrine: hypoglycaemia, inborn errors of metabolism, congenital adrenal hyperplasia, hypothyroidism, hypocalcaemia, renal tubular acidosis, and electrolyte disorders.
• Oral and anatomical: cleft lip or palate, tongue tie, micrognathia, choanal atresia, teething, dental caries, and oral ulcers.
• Renal: urinary infection, obstructive uropathy, renal failure.
• Haematological and malignant: anaemia, iron deficiency, leukaemia, neuroblastoma.
• Feeding technique and psychosocial: incorrect positioning or latch, low milk supply, infrequent feeds, flow rate problems, bottle or teat problems, excess juice or milk, forced feeding, parental depression, neglect, and abuse.
• Behavioural and developmental: food refusal in toddlers, selective eating, autism spectrum disorder, sensory feeding disorders, and avoidant restrictive food intake disorder.
• Drugs and toxins: maternal drugs in breast milk (sedatives, opioids), infant medicines, lead poisoning, and constipating or appetite suppressing medicines.

Epidemiology. Feeding problems affect 25% to 40% of healthy infants and up to 80% of those with developmental disability or prematurity. About 5% to 10% of young children have significant feeding refusal. Poor feeding is among the commonest presenting signs of neonatal sepsis and appears in most cases. Faltering growth affects 5% to 10% of children and is mostly due to inadequate intake.

Mechanisms. Feeding is a coordinated act of suck, swallow and breathing. It requires neurological maturity, adequate energy, and absence of pain, breathlessness and nausea. Systemic illness reduces appetite through cytokines. Increased work of breathing or cardiac failure causes fatigue during feeds. Aversive experiences (reflux pain, choking, force feeding) produce learned refusal.

Key distinctions.

• Poor feeding with lethargy, temperature instability, jaundice, tachypnoea or apnoea suggests sepsis.
• Poor feeding with sweating and breathlessness during feeds and poor weight gain suggests heart failure.
• Projectile non bilious vomiting at 2 to 8 weeks with a hungry infant suggests pyloric stenosis.
• Bile stained vomiting suggests obstruction or malrotation.
• Colicky pain with currant jelly stool suggests intussusception.
• Refusal with drooling and mouth ulcers suggests herpetic gingivostomatitis or hand foot and mouth disease.
• Arching, crying during feeds and irritability suggests reflux or oesophagitis.
• Refusal of solids with gagging and normal growth in a toddler suggests behavioural feeding difficulty.

History

• Feeding: milk type (breast, formula, mixed), frequency, duration of each feed, volume taken, position, latch, suck, sweating or breathlessness with feeds, cough, choking or gagging, arching, vomiting (non bilious, bilious, bloody), regurgitation, wet nappies, stool frequency and colour, and change from usual pattern.
• Onset and course: abrupt or gradual, intermittent or persistent, in relation to illness, new foods or formula, weaning, teething, or family events.
• Associated symptoms: fever, lethargy, irritability, rapid breathing, cyanosis, sweating, pallor, jaundice, rash, cough, diarrhoea, constipation, abdominal distension, mouth lesions, drooling, ear pulling, seizure, and reduced urine output.
• Birth and neonatal history: gestation, birth weight, resuscitation, jaundice, feeding difficulty in the neonatal period, nasogastric feeding, antenatal scans, maternal infection or drug use, and family history of metabolic or genetic disease.
• Growth: weights over time (centile chart), developmental milestones, and head size.
• Medical history and medicines: heart disease, reflux, allergy, previous infections, vitamin and supplement use, and recent antibiotics.
• Family and social: breastfeeding support, maternal health and mental health (postnatal depression), mother's medications, parental concerns, feeding environment and mealtime routines, forced feeding, food insecurity, and safeguarding concerns.
• Weaning history and diet: age of solids, texture, variety, juice or milk volume, and food refusal or selectivity.

Examination

• General appearance and alertness: assess using a structured risk scheme (colour, activity, response to stimuli, cry, breathing, hydration). Measure temperature, heart rate, respiratory rate, oxygen saturation, blood pressure (and in four limbs if cardiac disease is suspected), capillary refill, and blood glucose.
• Anthropometry: weight (compared with birth weight and earlier readings), length, and head circumference on growth charts; calculate weight for length.
• Hydration: fontanelle, mucous membranes, skin turgor, eyes, capillary refill, and urine output.
• Mouth: lips, palate (inspect and palpate for submucous cleft), tongue (tongue tie), gums, oral thrush, ulcers, vesicles, and tonsils.
• Ears, nose (patency) and neck.
• Respiratory: grunting, recession, nasal flaring, wheeze, crackles, stridor.
• Cardiac: murmurs, gallop, hepatomegaly, femoral pulses, and cyanosis.
• Abdomen: distension, tenderness, masses (olive mass in pyloric stenosis), hernias, and genitalia.
• Neurological: tone, alertness, primitive reflexes, suck, gag, fontanelle tension, fisting, and seizures.
• Skin: pallor, jaundice, rash, eczema (food allergy), petechiae, bruising (abuse), and umbilicus.
• Observe a feed: positioning, latch, rhythm of suck and swallow, coughing, choking, desaturations, fatigue, and parent child interaction.

Red flags

• Age under 3 months with poor feeding (high risk of sepsis).
• Lethargy, floppiness, high pitched cry, bulging fontanelle, seizure, or apnoea.
• Temperature over 38.0 degrees Celsius or under 36.0 degrees Celsius.
• Grunting, recession, respiratory rate over 60 breaths/min, cyanosis, or oxygen saturation under 92%.
• Tachycardia, prolonged capillary refill, mottling, or hypotension.
• Hypoglycaemia (glucose under 2.6 mmol/L in neonates, under 3.0 mmol/L in older infants).
• Dehydration of more than 5% (sunken fontanelle, dry mucosa, reduced skin turgor, oliguria), or weight loss of over 10% of birth weight.
• Bile stained vomiting, abdominal distension, blood in stool, or tender abdomen.
• Persistent projectile vomiting.
• Jaundice beyond 14 days or severe early jaundice.
• Murmur, cyanosis, hepatomegaly, or poor femoral pulses.
• Dysmorphic features, hypotonia, or abnormal movements (neurological or metabolic disease).
• Poor weight gain across centiles or head growth abnormality.
• Unexplained bruising or injuries (non accidental injury).
• Foul smelling urine, or rash with fever.
• Parental depression, exhaustion, or inability to cope.

Special groups

• Neonates: first week poor feeding with weight loss, jaundice and dehydration. Think sepsis, hypoglycaemia, and ductal dependent heart disease.
• Preterm infants: immature suck swallow coordination before 34 to 36 weeks, gastro-oesophageal reflux, apnoea, and chronic lung disease.
• Infants with congenital anomalies: cleft palate, Down syndrome, congenital heart disease, and syndromes needing feeding support.
• Toddlers: food refusal is common between 1 and 3 years and mostly benign if growth is normal.
• Children with developmental delay or autism: sensory aversion and oral motor problems.
• Children with severe malnutrition: lack of appetite is the sign that guides admission.
• Region specific: malaria, neonatal tetanus (inability to suck, trismus), HIV exposure and infant feeding choices, oral thrush, severe acute malnutrition, rotavirus, and tuberculosis.

Infection

• Neonatal and infant sepsis, meningitis, and bacteraemia.
• Urinary tract infection and pyelonephritis.
• Pneumonia, bronchiolitis, pertussis, and upper respiratory infection.
• Oral candidiasis, herpetic gingivostomatitis, hand foot and mouth disease, herpangina, and pharyngitis.
• Otitis media, omphalitis, and cellulitis.
• Gastroenteritis, necrotising enterocolitis, malaria, tuberculosis, and HIV.
• Neonatal tetanus.

Cardiorespiratory

• Congenital heart disease with heart failure (left to right shunts, left heart obstruction, coarctation, ductal dependent lesions).
• Cardiomyopathy and myocarditis, supraventricular tachycardia.
• Bronchiolitis, chronic lung disease, laryngomalacia, and vascular rings.

Gastrointestinal and surgical

• Gastro-oesophageal reflux disease and oesophagitis.
• Pyloric stenosis, malrotation with volvulus, intestinal atresia, Hirschsprung disease, intussusception, and strangulated hernia.
• Cow's milk protein allergy, lactose intolerance, eosinophilic oesophagitis, and food protein induced enterocolitis.
• Constipation, coeliac disease, and inflammatory bowel disease.
• Biliary atresia and liver disease.

Neurological and developmental

• Hypoxic ischaemic encephalopathy, intracranial haemorrhage, hydrocephalus, subdural haematoma (non accidental injury).
• Hypotonia (spinal muscular atrophy, Prader-Willi syndrome, congenital myopathy), cerebral palsy, bulbar palsy.
• Seizures, infant botulism, and kernicterus.
• Autism spectrum disorder and sensory processing differences.

Metabolic and endocrine

• Hypoglycaemia (congenital hyperinsulinism, inborn errors), inborn errors of metabolism (urea cycle defects, organic acidaemias, galactosaemia), congenital adrenal hyperplasia, hypothyroidism, hypocalcaemia, hypernatraemic dehydration, and renal tubular acidosis.

Oral and anatomical

• Tongue tie, cleft palate, micrognathia (Pierre Robin sequence), choanal atresia, teething, dental disease.

Feeding and psychosocial

• Breastfeeding difficulty: poor attachment, low supply, infrequent feeding, flat or inverted nipples, mastitis, and maternal medication.
• Formula related: incorrect preparation, wrong teat flow, overdilution or over concentration.
• Behavioural feeding disorder, toddler food refusal, and avoidant restrictive food intake disorder.
• Parental anxiety or depression, neglect, and abuse.
• Poisoning: lead, drugs, and sedatives in breast milk.

Step 1. Identify the sick infant. Assess airway, breathing, circulation and consciousness. Check glucose, temperature, and oxygen saturation immediately. In any infant under 3 months with poor feeding and any red feature, begin sepsis evaluation and treatment.

Step 2. Assess hydration and growth. Weigh the infant (naked), plot on a centile chart, calculate percentage change from birth weight, and estimate fluid deficit. Compare feeding volumes with requirements.

Step 3. First line tests

• Capillary glucose, and blood gas with lactate in ill infants.
• Urinalysis and culture (catheter or suprapubic specimen in infants).
• Full blood count, C-reactive protein, blood culture, urea, creatinine, electrolytes (sodium, potassium, chloride, bicarbonate), calcium, magnesium, and liver tests, with bilirubin (total and conjugated).
• Chest radiograph for respiratory signs, and cerebrospinal fluid analysis (and herpes simplex virus polymerase chain reaction) in ill infants under 3 months.
• Malaria test in endemic areas or after travel.
• ECG and pre and post ductal oxygen saturation (a difference of 3% or more, or saturation under 95%, suggests cardiac disease); four limb blood pressure.

Step 4. Targeted tests

• Echocardiography and chest radiograph for suspected heart disease; hyperoxia test if cyanotic.
• Abdominal ultrasound for pyloric stenosis (pyloric muscle thickness of 3 mm or more and channel length of 15 mm or more), intussusception (target sign), and renal tract.
• Abdominal radiograph and upper gastrointestinal contrast study for obstruction or malrotation. Surgical review without delay for bile stained vomiting.
• Metabolic screen for suspected inborn errors (lethargy, acidosis, hypoglycaemia, hyperammonaemia): ammonia, lactate, ketones, plasma amino acids, urine organic acids, acylcarnitine profile, and reducing substances in urine (galactosaemia).
• Take a critical sample during hypoglycaemia (insulin, cortisol, growth hormone, beta-hydroxybutyrate, free fatty acids).
• Thyroid function, 17-hydroxyprogesterone, cortisol, and electrolytes for adrenal and endocrine disease.
• Videofluoroscopic or fibreoptic endoscopic swallow study, and speech and language therapy or occupational therapy assessment for suspected aspiration or oral motor dysfunction.
• pH impedance monitoring or upper endoscopy with biopsy for suspected refractory reflux, eosinophilic oesophagitis, or oesophagitis.
• Allergy testing (specific IgE, skin prick tests) and supervised elimination and challenge for suspected food allergy.
• Coeliac serology (tissue transglutaminase IgA with total IgA) after introduction of gluten, and faecal calprotectin.
• Cranial ultrasound or magnetic resonance imaging for neurological signs; electroencephalogram if seizures.
• Skeletal survey and retinal examination if non accidental injury is suspected.
• Lead level, HIV test, sweat chloride (cystic fibrosis), and genetic testing as indicated.

Step 5. Interpretation. In a neonate or young infant, assume infection until proven otherwise. Hypoglycaemia is both a cause and a consequence of poor feeding. Non bilious projectile vomiting with metabolic hypochloraemic hypokalaemic alkalosis suggests pyloric stenosis. A weight loss of over 10% of birth weight in the first week suggests insufficient intake or illness. Normal growth with isolated refusal in a toddler suggests behavioural feeding difficulty, and reassurance with a feeding plan is appropriate.

Limits. Early sepsis can show only subtle feeding change. Weight is affected by hydration and scale accuracy. Test results may be normal in early inborn errors, so repeat when clinical suspicion persists.

Immediate (sick infant)

• Give oxygen to keep saturation 94% or over. Secure intravenous or intraosseous access and keep warm (36.5 to 37.5 degrees Celsius). Stop oral feeds if breathing is distressed or obstruction is possible.
• Hypoglycaemia (glucose under 2.6 mmol/L, or any with symptoms): 10% dextrose 2 mL/kg intravenously over 5 to 10 minutes.
• Follow with an infusion of 10% dextrose at glucose infusion rate 6 to 8 mg/kg/minute (about 80 to 100 mL/kg/day). Recheck glucose after 30 minutes and then hourly until stable.
• If there is no intravenous access, give glucagon 0.03 mg/kg (maximum 1 mg) intramuscularly while access is obtained. Add hydrocortisone 2.5 mg/kg intravenously for hypoglycaemia that persists. Feed as soon as safe.
• Persistent hypoglycaemia requiring over 10 mg/kg/minute suggests hyperinsulinism and needs endocrine care.
• Shock: isotonic crystalloid 10 mL/kg bolus (up to 20 mL/kg), repeated up to 40 to 60 mL/kg with reassessment. Add adrenaline infusion 0.05 to 0.3 micrograms/kg/minute if shock persists.
• In suspected duct dependent heart disease (cyanosis, shock, absent femoral pulses in the first 2 weeks), give prostaglandin E1 (alprostadil) 0.01 to 0.05 micrograms/kg/minute intravenously and arrange urgent cardiology review (watch for apnoea).
• Suspected sepsis: blood, urine and cerebrospinal fluid cultures and antibiotics within 1 hour.
• Neonates under 28 days: ampicillin 50 mg/kg intravenously every 6 to 8 hours (100 mg/kg every 6 hours if meningitis is suspected) with gentamicin 5 mg/kg intravenously every 24 hours (measure levels), or cefotaxime 50 mg/kg every 6 to 8 hours (every 12 hours in the first week).
• Infants over 28 days: ceftriaxone 80 mg/kg intravenously once daily (maximum 4 g; avoid ceftriaxone in jaundiced neonates and with calcium containing infusions).
• Add aciclovir 20 mg/kg intravenously every 8 hours for suspected herpes simplex virus infection.
• Duration 7 to 10 days for sepsis, 14 to 21 days for meningitis (21 days for Gram negative and group B Streptococcus meningitis).
• Dehydration, mild to moderate (5% to 10%): oral rehydration solution 50 to 100 mL/kg over 4 hours by cup, spoon or syringe, or by nasogastric tube.
• Dehydration, severe (over 10%) or shock: intravenous isotonic fluid bolus 10 to 20 mL/kg, then rehydrate with 0.9% sodium chloride with 5% dextrose over 24 hours.
• Calculate maintenance by weight: 100 mL/kg/day for the first 10 kg, 50 mL/kg/day for the next 10 kg, and 20 mL/kg/day thereafter (neonates day 1: 60 mL/kg/day rising to 150 mL/kg/day by day 5 to 7).
• Replace deficit over 24 to 48 hours. Go slower, over 48 hours, in hypernatraemia, lowering sodium by no more than 0.5 mmol/L/hour and 12 mmol/L in 24 hours.
• Pyloric stenosis: resuscitate and correct metabolic alkalosis and hypokalaemia with 0.9% sodium chloride with 5% dextrose and potassium chloride 10 mmol in each 500 mL once urine flows (chloride over 100 mmol/L and bicarbonate under 28 mmol/L before anaesthesia). Use a nasogastric tube on free drainage, then Ramstedt pyloromyotomy.
• Bile stained vomiting, malrotation with volvulus, intussusception, necrotising enterocolitis: nil by mouth, nasogastric decompression, intravenous fluids, broad spectrum antibiotics (ampicillin with gentamicin and metronidazole 7.5 mg/kg every 8 hours), and urgent surgical review. Intussusception is reduced by air or contrast enema under radiological supervision.
• Heart failure: oxygen if hypoxic, furosemide 1 mg/kg intravenously or orally two to three times daily, high calorie feeds by nasogastric tube, and cardiology care.
• Seizures: lorazepam 0.1 mg/kg intravenously (maximum 4 mg), phenobarbital 20 mg/kg loading dose in neonates. Look for hypoglycaemia, electrolyte disturbance, infection, and metabolic disease.
• Suspected inborn error (lethargy, acidosis, hyperammonaemia): stop protein feeds, give 10% dextrose with electrolytes at 1.5 times maintenance, and discuss with a metabolic specialist early. Treat hyperammonaemia (sodium benzoate and sodium phenylacetate, arginine) as directed by the metabolic specialist.
• Neonatal tetanus (trismus, inability to suck): benzodiazepines (diazepam 0.1 to 0.3 mg/kg every 4 to 6 hours), human tetanus immunoglobulin 500 units intramuscularly, metronidazole 7.5 mg/kg every 8 hours, and intensive care.

Treatment by cause (stable infants and children)

• Breastfeeding difficulty: skilled lactation support, with assessment of latch, position and milk transfer. Increase feeding frequency to 8 to 12 times in 24 hours.
• Express milk and supplement with expressed milk or formula by cup, syringe or supplemental nursing system when needed. Treat nipple pain.
• Mastitis: flucloxacillin 500 mg four times daily for 10 to 14 days for the mother.
• Thrush: miconazole 2% cream applied after feeds for 7 to 14 days to nipples, and miconazole oral gel 1.25 mL to the infant's mouth four times daily after feeds, continued 2 days after healing. Alternatively nystatin 100,000 units/mL, 1 mL to each side of the mouth four times daily for 7 to 14 days.
• Tongue tie causing feeding difficulty: frenotomy after assessment by trained staff.
• Gastro-oesophageal reflux disease with feeding refusal: positioning, smaller more frequent feeds, thickened feeds for formula fed infants, and time limited exclusion of cow's milk protein for 2 to 4 weeks.
• For this exclusion use extensively hydrolysed formula; for breastfed infants, maternal elimination of dairy with calcium 1000 mg daily.
• Acid suppression only for proven oesophagitis (omeprazole 0.7 to 1 mg/kg once daily for 4 to 8 weeks).
• Cow's milk protein allergy: extensively hydrolysed formula (or amino acid formula for severe disease) for 6 to 12 months, or until 9 to 12 months of age with reintroduction supervised.
• Oral lesions: paracetamol 15 mg/kg every 4 to 6 hours before feeds, ibuprofen 5 to 10 mg/kg every 6 to 8 hours, chlorhexidine or benzydamine mouthwash in older children, and fluids (cold drinks, small frequent sips).
• Severe herpetic gingivostomatitis in the first 72 hours: aciclovir 15 mg/kg orally five times daily (maximum 200 mg for each dose) for 5 to 7 days.
• Constipation: macrogol 0.5 to 1 g/kg daily, and diet.
• Tube feeding: nasogastric tube feeding with expressed breast milk or formula when oral intake is insufficient for safety or growth. Start 10 to 20 mL/kg/day and increase by 10 to 20 mL/kg each day to 150 mL/kg/day for neonates.
• Use supplementary energy dense feeds of 1 kcal/mL to achieve 120 to 150 kcal/kg/day for catch up, with speech and language therapy for oral stimulation and safe swallowing. Gastrostomy for prolonged need (over 3 months).
• Faltering growth: dietitian review, energy dense feeds (fortify formula by concentration under supervision, breast milk fortifiers), small frequent meals, and treatment of cause.
• Iron deficiency anaemia: ferrous sulphate 3 to 6 mg/kg of elemental iron daily in 2 to 3 divided doses for 3 months, and dietary advice.
• Vitamin supplementation: vitamin D 400 units daily for breastfed infants, vitamin K prophylaxis at birth (1 mg intramuscularly; if refused, oral doses), and zinc 10 to 20 mg daily for 10 to 14 days in diarrhoea.
• Severe acute malnutrition: therapeutic feeding (F-75 then F-100, ready to use therapeutic food), routine antibiotics (amoxicillin 50 to 100 mg/kg daily in two doses for 5 to 7 days), vitamin A, folic acid, and treat hypoglycaemia and hypothermia.
• Toddler food refusal and behavioural feeding difficulty: regular meal and snack times (3 meals and 2 to 3 snacks), limit milk to 500 mL daily and juice, no distractions or forcing.
• Use repeated neutral exposure to new foods (10 to 15 times), parental modelling, small portions, and praise. Avoid pressure; expect fluctuation.
• Avoidant restrictive food intake disorder: multidisciplinary care with psychology, dietetics, and paediatrics; graded exposure; family based approach; nutritional supplements or tube feeding if needed. Medication is not first line.
• Developmental and neurological feeding problems: speech and language therapist or occupational therapist, modified textures and thickened fluids, positioning, adaptive utensils, and treatment of reflux and constipation.
• Postnatal depression or parental distress: screen and support the parent (Edinburgh Postnatal Depression Scale), and arrange mental health care.
• Safeguarding concern: follow child protection procedures, with documentation and referral.

Special populations

• Preterm infants: fortified breast milk, cue based feeding, and developmental feeding support.
• Infants of mothers with HIV: individual counselling on feeding with antiretroviral therapy and prophylaxis for the infant.
• Children with chronic disease: tailored nutrition support.
• Kidney and liver impairment: adjust drug doses (gentamicin, ceftriaxone) and fluids.

Monitoring. Weight at each visit (daily in sick or newborn infants, then every 1 to 2 weeks until growth is regained). Length and head circumference monthly. Feeding volumes and diaries, urine output, glucose (before feeds in at risk infants), electrolytes in dehydration and during refeeding, temperature, oxygen saturation, vomiting, and development.

Referral and escalation. Neonatal or paediatric admission for sick infants. Paediatric surgery for obstruction and pyloric stenosis. Cardiology for heart disease. Gastroenterology for refractory reflux, allergy, and malabsorption. Dietitian, speech and language therapy and occupational therapy for feeding assessment. Lactation consultant for breastfeeding problems. Child psychology and psychiatry for avoidant restrictive food intake disorder. Metabolic and endocrine specialists for suspected metabolic disease. Social services if neglect or abuse.

Admission criteria. Age under 3 months with poor feeding and fever or other red features, any red feature, dehydration over 5%, hypoglycaemia, weight loss over 10% of birth weight, bile stained vomiting, respiratory distress, suspected heart disease or metabolic disease, failure of oral intake for 12 to 24 hours in infants, severe malnutrition, and unsafe home or inability to feed adequately.

Discharge and follow up. Discharge only when feeding well (taking at least 80% of the required volume), hydration is adequate, glucose is stable, weight is stable or rising, and the family has a feeding plan and support. Review within 24 to 48 hours for infants. Take weekly weights until regain of birth weight and steady gain (20 to 30 g daily after the first week).

Safety net advice: return for fewer than 4 wet nappies in 24 hours, fever, lethargy or difficulty waking, vomiting that is green or bloody, a swollen abdomen, fast or laboured breathing, blue lips, yellow skin, floppiness, seizure, or refusal of all feeds for 6 hours or more.