Immediate Questions

A. How long have symptoms been present? Has patient been acutely ill with fever, vomiting or diarrhea, or symptoms of upper respiratory infection? Or have symptoms existed chronically with recent flare-up? Children commonly decrease food intake prior to and immediately following acute, self-limited illness. The situation is urgent only if symptoms of dehydration (dry mucous membranes, decreased urine output, poorly perfused skin) or change in mental status (lethargy, excessive irritability, inconsolable crying) are noted.

B. Does patient have underlying medical conditions that are associated with poor oral intake? Conditions that predispose to disordered passage of food from the mouth to the stomach -(dysphagia) include central and peripheral nervous system disorders, diseases of muscle, and structural abnormalities of the oral cavity, pharynx, and esophagus. Decreased food intake having a behavioral basis or resulting from developmental delay is more likely to be associated with disruptive mealtime behavior and food selectivity than acute cessation of liquids and solids. Development of or exacerbation of known reflux esophagitis can lead to refusal to feed, especially if retching during or post-feeding is present.

C. Is choking, gagging, or respiratory distress present? Choking, gagging, and ultimate respiratory distress with feeding should prompt assessment for aspiration and pulmonary sequelae (see IV, C, later). Food refusal having a behavioral basis is less likely to present with acute choking and is never associated with increased work of breathing or true respiratory distress.

D. Is patient taking any new medication(s) or herbal supplements)? Has there been any exposure to toxins? Food refusal can be secondary to acute ingestion of poisons that ulcerate or scar the mucosal lining of the mouth. Some decrease in appetite may be seen with medications or herbal supplements that directly cause disordered taste sensations or exacerbation of GI upset.

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