Differential Diagnosis

A. Acute Viral or Bacterial Illness. Infectious processes can directly affect the GI tract, with resultant vomiting or diarrhea that decreases oral intake. Likewise, symptoms of upper respiratory tract infection, streptococcal pharyngitis, or pneumonia can affect child's oral intake.

B. Reflux Esophagitis. Acute presentation of reflux esophagitis, especially in infants, can diminish oral intake. Pain associated with feeding efforts (secondary to acid reflux) may initially present post-prandially or generalize to food refusal and selectivity. Children taking antireflux medications can experience flare-up of dysphagia if the medication dose is subtherapeutic or intercurrent illness exacerbates acid production in the stomach.

C. Developmental or Behavioral Food Refusal. Children with developmental disabilities (including mental retardation and autistic spectrum disorder) may "shut down" feeding efforts as a behavioral response to their environment. Typically, developing children (especially around age 2 years and in summer) can also go on "hunger strikes," but rarely will they cease all oral intake for more than a day if mealtime structure is maintained.

D. Airway or Foodway Anomalies. Children with congenital defects of the nasopharynx, oral cavity, and laryngeal region are predisposed to disordered passage of food from mouth to stomach.With growth and introduction of more highly textured food, decompensation of feeding may occur, with possible aspiration risk. Acquired anatomic defects secondary to tumor, trauma, or post-surgical manipulations can also disorganize feeding.

E. Neurologic Deficits. CNS disease affecting the signals to swallow safely may underlie decreased feeding efforts. In peripheral nerve disorders and neuromuscular diseases, acute decline of oral intake may be associated with decompensation in neurologic status.

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