Poor feeding in infants and children — branching viva

Stem

You are covering acute and clinic paediatrics. The examiner will challenge threat triage, mechanism classification and long-term feeding plans. [5] [1]

Branch 1 — Acute neonate

Examiner: A day-5 baby “is not feeding.” Where do you start? [26]

Strong answer: Appearance and ABCDE first. Glucose early. Sepsis risk assessment. Hydration and temperature. Only then a detailed feeding history. Poor feeding is a serious-illness symptom in this age. [26] [25] [5]

Examiner: Glucose is low. Next? [25]

Strong answer: Treat hypoglycaemia with age-appropriate glucose delivery, reassess neurology and feeding readiness, investigate drivers of low intake, and follow neonatal monitoring guidance rather than discharging on a single corrected number. [25]

Branch 2 — Mechanism and observation

Examiner: The infant stabilises. How do you classify the feeding problem? [1] [5]

Strong answer: Acuity plus mechanism: offer, latch/oromotor efficiency, dysphagia, pain, cardiorespiratory work, losses, behavioural/dyad factors. Write a one-sentence problem representation. [1] [5]

Examiner: Demonstrate what you look for in a feed. [5]

Strong answer: Position, latch or teat flow, suck–swallow–breathe rhythm, work of breathing, colour, fatigue, milk transfer cues, caregiver handling. LATCH can structure breastfeeding documentation. Stop the trial if the infant becomes unsafe. [5]

Branch 3 — Cardiac and aspiration forks

Examiner: The baby sweats and desaturates halfway through feeds. [19]

Strong answer: Consider cardiorespiratory load, including congenital heart disease. Limit endurance demands, support breathing, examine carefully, escalate to cardiology when indicated. Do not label as behavioural. [19]

Examiner: Instead the infant coughs and has a wet voice with thin milk. [2]

Strong answer: Swallow safety concern. Protect airway, involve SLP/feeding specialist, consider instrumental assessment if stable and it will change management. No cough does not exclude silent aspiration. [2]

Branch 4 — Clinic preschooler

Examiner: A 4-year-old with autism accepts three foods and is falling across centiles. [1] [14]

Strong answer: Frame with PFD domains and possible ARFID-pattern restriction without body-image goals. Multidisciplinary plan: medical screen, dietetics, feeding therapy, behavioural support. Avoid force-feeding. [1] [14]

Examiner: When would you use a tube? [35]

Strong answer: When oral route cannot meet safety or energy needs despite optimised therapy, with explicit goals, monitoring and exit or reassessment plan. Tubes are tools, not identities. [35] [1]

Branch 5 — Pitfalls

Examiner: Parents ask for immediate tongue-tie release and a PPI. [7]

Strong answer: Assess function and alternative causes first. Frenotomy may help selected breastfeeding dyads after skilled lactation review; evidence has limits. Uncomplicated regurgitation does not equal automatic long-term PPI. Never let either request close a sepsis or cardiac differential. [7] [5]

Examiner extras

• Infant botulism script: constipation, weak cry, poor suck, descending weakness. [20]
• Safety-net content before discharge: volumes, wet nappies, breathing, colour, lethargy, return path. [5]
• Four PFD domains in the plan: medical, nutritional, feeding skill, psychosocial. [1]