Feeding and Gastrointestinal Issues of the Preterm Infant

Feeding disorders are very common in the preterm infant. The problems come in many forms - they are often interrelated and can occur together. All of these issues may result in inadequate nutritional intake and, as a result, poor growth and finally poor developmental outcomes.
  • Oral Aversion: food refusal
  • Oromotor Dysfunction: difficulty with the suck and swallow mechanism
  • Gastrointestinal Dysmotility: nutrition is not tolerated in the gastrointestinal tract
  • Gastroesophageal Reflux (GER) and Gastroesophageal Reflux Disease (GERD): regurgitation of stomach contents into the esophagus, with or without pain or vomiting

Oral Aversion

Feeding an infant can be an easy, natural process that gives the parent and child a tremendous amount of satisfaction and pride. However, when infants refuse food, parents can struggle to understand why and can have difficulty coping with the behavior and the reasons for this behavior. They may even falsely believe that it is their fault. Oral aversion in the preterm infant may be a result of a complex interplay of both medical and behavioral factors. Oral aversions may be short-lived but can go on for years. When an oral aversion occurs, it is important to get specialists involved as soon as possible to begin teasing out the reasons for the problems as well as to begin the therapeutic intervention.This can be as important for the parent as for the child. Speech and language pathologists, occupational therapists, and psychologists with experience in infant feeding difficulties can be very helpful and supportive to families. Often Early Intervention specialists also have a special interest in, and experience with, these difficulties.

Oromotor Dysfunction

Preterm infants may miss the staged approach to developing a coordinated suck and swallow when they have had a prolonged period of endotracheal intubation and/or illness. In addition, neurologic impairments may be present as with hydrocephalus or intraventricular hemorrhage, and these may contribute to the development of oromotor dysfunction. Oromotor dysfunction can result in frank aspiration or occult aspiration of fluid into the lungs which may also contribute to oral aversion. A video swallow study performed under fluoroscopy can be quite helpful to the family and to the therapist working with the child to determine what happens with food or liquid boluses and may provide guidance for intervention. When direct aspiration occurs, it is sometimes necessary to avoid oral feedings altogether and use a gastrostomy tube until the aspiration stops. In this setting, continued non-nutritive oral motor stimulation through active therapy is critical to maintain and/or develop coordination of suck and swallow.

Gastroesophageal Reflux

Gastroesophageal reflux (GER) is a common physiologic process in infants and is especially common in preterm infants. GER is the retrograde movement of gastric material into the esophagus and occasionally the oropharynx due to a relatively short esophageal length and intermittent laxity of the lower esophageal sphincter. When an infant refluxes gastric contents into the oropharynx, the baby may present with regurgitation (“spit up”) or vomiting. In most babies, GER is a BENIGN occurrence that does not cause pain or impair feeding or growth. These babies are often referred to as “happy spitters.” In preterm infants, the physiologic reflux may not be highly acidic and improves over time. As a physiologic process, GER may be managed through reassurance and conservative measures. GER typically resolves completely by 18 months of age.
In contrast, in some infants GER can be uncomfortable and even painful, even without overt vomiting. This condition constitutes gastroesophageal reflux disease or GERD. Common presenting symptoms of GERD in infants include feeding refusal, recurrent vomiting, poor weight gain, irritability, sleep disturbances, and respiratory symptoms such as coughing, wheezing, or recurrent pneumonia. Premature infants are considered “high risk” for GERD. Premature infants may also have severe difficulties with reflux due to the immaturity of, and insult to, the gastrointestinal tract. GERD tends to peak around 4 months of age and gradually diminish over the first year.
Typically GERD may be managed with avoidance of overfeeding, positioning, removal of dairy from the diet, thickening of breastmilk or formula, or medications.
  • Lifestyle Changes: These include shorter and more frequent feeds, avoidance of tobacco smoke, upright positioning during and after feeding for at least 20 minutes, and keeping the infant calm after the feeding. Prone positioning while awake and being actively monitored may improve symptoms in some infants. Inclined supine positioning for sleep (head elevated above feet) has not been demonstrated to be beneficial.
  • Thickening: Many thickening agents have been used including rice cereal, commercially available thickeners and “anti-reflux” formulas. Rice cereal has been used up to a maximum amount of 1 tablespoon of rice cereal per 1 oz. of expressed breastmilk or infant formula. The use of cereals or other thickeners pose certain risks to infants including an unnecessary increase in caloric intake. In particular, thickened feeds increase the preterm infant’s risk of necrotizing enterocolitis. Additionally, recent reports have raised concern for the arsenic content in rice thus raising concern for the use of infant rice cereal which has traditionally been the cereal trialed as a thickener. Commercially available thickeners also may pose some risk particularly for preterm infants who were recently in the NICU. [AAP: 2014] Therefore, thickeners of any type should only be used in consultation with a physician.
  • Dairy-free diet: As some infants have difficulty digesting milk (and soy) proteins, a 2-4 week trial of a dairy-free diet may be beneficial. For breastfed infants, the mother eliminates dairy and egg from her diet. For formula-fed infants, a hypoallergenic formula may be trialed. These formulas typically avoid use of milk or soy proteins and may be extensively hydrolyzed casein protein or amino-acid based formulations. Most infants outgrow dietary protein intolerance by 1 year of age.
  • Medications: Proton pump inhibitors such as omeprazole and lansoprazole are considered more effective than other antacids and histamine 2 receptor antagonists such as ranitidine. However they are more costly and may require insurance preauthorization. Use of medications should be done sparingly and in consultation with the primary care clinician, as they pose risks to the infant. Babies using anti-reflux medications should not be continued on these medications indefinitely. Double coverage with an H2 blocker and proton pump inhibitor is typically not needed. There is insufficient evidence that the benefits outweigh the substantial risks associated with the use of prokinetic agents in infants with GERD, including metoclopramide, erythromycin, bethanechol, and baclofen.
Despite these interventions, in some severe cases, infants may continue to experience severe pain, vomiting, dehydration, and poor growth. In these situations, the primary care provider should consider consultation with pediatric gastroenterology and consideration of surgical interventions such as a fundoplication (a wrap procedure, which narrows the gastroesophageal outlet). For more detailed guidelines on diagnosis and management of pediatric GERD, please see [Lightdale: 2013].

Gastrointestinal Dysmotility

Gastrointestinal dysmotility refers to difficulties passing fluid and nutrition along the gastrointestinal tract, most commonly manifesting with distention, vomiting, constipation, or diarrhea. Preterm infants are at risk for functional gastrointestinal dysmotility, possibly related to delayed introduction of enteral nutrition or immaturity of the GI system. Preterm infants are also at risk for gastrointestinal dysmotility due to the higher prevalence of necrotizing enterocolitis (NEC) in the neonatal period. Although the cause of NEC remains unknown despite years of study, around 5% percent of infants born before 33 weeks develop stage 2 or higher NEC, and approximately 20-40% of infants with NEC require surgical intervention with removal of small to large portions of the intestines. [Yee: 2012] A 2011 review indicated that use of high dose erythromycin may be appropriate as a rescue medication for premature infants suffering from functional gastrointestinal dysmotility. [Lam: 2011] Use of probiotics to aid in motility and prevent NEC in the preterm infant is still under study. [Indrio: 2011] Massage therapy to assist premature infants with dysmotility is also under investigation. [Field: 2010] Use of prokinetic agents for preterm infants with dysmotility is undergoing continual reassessment and scrutiny, so guidance from a pediatric gastroenterologist may be warranted.


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Authors & Reviewers

Initial publication: November 2014; last update/revision: July 2014
Current Authors and Reviewers:
Author: Jennifer Goldman-Luthy, MD, MRP, FAAP
Authoring history
2014: update: Jennifer Goldman-Luthy, MD, MRP, FAAPA; Mary Ann Nelin, MDR
2014: update: Sarah Winter, MDA
2014: first version: Sherrily Brown, FNPA
AAuthor; CAContributing Author; SASenior Author; RReviewer

Page Bibliography

AAP News.
Thickening agent caution expanded to term infants.
The American Academy of Pediatrics; (2014) https://www.aappublications.org/content/early/2012/09/19/aapnews.20120.... Accessed on 4/24/2019.
FDA warns that SimplyThick may increase the risk of necrotizing enterocolitis (NEC).

Field T, Diego M, Hernandez-Reif M.
Preterm infant massage therapy research: a review.
Infant Behav Dev. 2010;33(2):115-24. PubMed abstract / Full Text

Indrio F, Neu J.
The intestinal microbiome of infants and the use of probiotics.
Curr Opin Pediatr. 2011;23(2):145-50. PubMed abstract / Full Text

Lam HS, Ng PC.
Use of prokinetics in the preterm infant.
Curr Opin Pediatr. 2011;23(2):156-60. PubMed abstract

Lightdale JR, Gremse DA.
Gastroesophageal reflux: management guidance for the pediatrician.
Pediatrics. 2013;131(5):e1684-95. PubMed abstract

Yee WH, Soraisham AS, Shah VS, Aziz K, Yoon W, Lee SK.
Incidence and timing of presentation of necrotizing enterocolitis in preterm infants.
Pediatrics. 2012;129(2):e298-304. PubMed abstract / Full Text