Paediatric feeding disorder: nutritional and gastrointestinal management — formative SAQs

SAQ 1 — The child with food refusal, faltering growth and reflux (20 marks, ~15 minutes)

A three-year-old with cerebral palsy has refused most foods for six months, accepting only smooth yoghurt and milk. Her weight has fallen from the tenth to below the third centile. Her reflux has been poorly controlled and she is constipated. The family has been told her refusal is behavioural. ^[4]

Questions

1. Give the unifying diagnosis using the consensus definition and explain why labelling the refusal purely behavioural is incomplete. (5 marks) ^[1]
2. Outline the four-domain assessment that should precede a management plan. (5 marks) ^[1]
3. Explain why treating the reflux and constipation is the first management lever, and why treating the gut alone may not resolve the refusal. (5 marks) ^[4]
4. Describe the stepped nutritional and feeding management, including the role of enteral feeding and the tube-weaning principle. (5 marks) ^[12]

Model answer (must-hit)

1. The unifying diagnosis is a paediatric feeding disorder, defined by the 2019 Goday consensus as impaired oral intake that is not age-appropriate and is associated with medical, nutritional, feeding skill and/or psychosocial dysfunction. Labelling the refusal purely behavioural is incomplete because this child has clear medical drivers (reflux, constipation), nutritional dysfunction (faltering growth), and likely feeding-skill and psychosocial components; the consensus framework requires assessment across all four domains. ^[1]
2. The four-domain assessment characterises the medical domain (reflux, constipation, eosinophilic oesophagitis, allergy, oromotor and swallow status), the nutritional domain (intake, growth trajectory, micronutrient screen such as ferritin), the feeding-skill domain (oromotor examination and instrumental swallow study if aspiration is suspected), and the psychosocial domain (mealtime interaction, conditioned aversion, carer burden). The case report form from the consensus framework structures this. ^[1]
3. Treating reflux and constipation is the first lever because uncontrolled reflux conditions the child to associate feeding with pain and constipation suppresses appetite through early satiety, so feeding will not improve while the gut is uncomfortable. However, treating the gut alone may not resolve the refusal because the child has developed a conditioned taste aversion and sensory narrowing that persist after the medical driver is removed, so the behavioural layer needs its own structured intervention. ^[4]
4. The stepped plan treats the medical driver first, then builds feeding skill and applies structured behavioural intervention, then supports nutrition with dietary fortification and oral nutritional supplements. Enteral feeding by nasogastric tube or gastrostomy, guided by the ESPGHAN position paper, is used when intake is unsafe or insufficient, with an active tube-weaning plan in place from the outset so that feeding tube dependency is prevented rather than created. ^[12]