No matter what your credentials, caring for a family dealing with infant feeding difficulties requires a team-based approach. Determining how to best support and where and when to refer is important to ensuring feeding success for these infants and their families. This article breaks down the alphabet soup of infant feeding credentials and highlights the scope and specialty of each professional who can support the infant feeding journey. 

What is the role of the pediatrician?

The pediatrician or family medicine provider plays an integral role in the identification of infant feeding difficulties. They serve as the first call for families and are relied on to provide support and make appropriate referrals to other members of the care team. Their time, however, is in high demand. Pediatricians are able to spend about 15 minutes with a patient during well-child visits and have an enormous scope of practice¹. These health care providers self-report their training on infant feeding in their medical education is limited and review of the current medical school and training curriculum consistently demonstrate that limited time is spent on lactation, infant feeding, and nutrition related education²,³,⁴. 

When might a baby need to be referred to a specialist for infant feeding?

The American Academy of Pediatrics encourages all feeding concerns be taken seriously, fully addressed, and referrals made if warranted, as soon as a difficulty is identified⁵. The first year of life is viewed as a critical period for the development of feeding skills and any disruption to feeding during this time can lead to longer term feeding difficulties⁶. Feeding difficulties present in many different ways: prolonged feeding times, difficulty latching, slow weight gain, coughing when feeding, frequent spits ups, feeding refusal, only feeding when sleepy, and atypical stool color or consistency to name a few⁷. Exploring the quality of an infant’s feeding, family concerns, and other reported difficulties are just as important as looking at an infant's growth. In doing so, providers can best support infants and their families and help minimize the likelihood of long term feeding difficulties. 

The infant feeding care team: 

The infant care team is made up of a multitude of providers with complementary skill sets and scopes of practice. Perhaps the most important member of the infant feeding care team is the family. They are the expert in the infant they are caring for and play a central role in the care team. Other members of the team include:

Gastroenterologist (GI)

GIs specialize in the management of the gastrointestinal tract and assessment of growth and nutrition. They are experts in the management of dietary needs of infants and determining the cause and management of GI related disorders. 

Ear, Nose, and Throat Doctor or Otolaryngologist (ENT)

ENTs specialize in management of the airway. They are experts in the management of disordered breathing and swallowing that may impact feeding. 

Dietitian (RD)

RDs specialize in optimization of nutrition to support adequate growth. These providers can support both infants and parents if dietary modifications are recommended.

Pediatric Dentist

Pediatric dentists specialize in oral health and can provide interventions that support dental hygiene during infancy. Pediatric dentists with specialized training in infant feeding collaborate with other providers regarding the contribution of infant oral anatomy to feeding difficulties.

Occupational Therapist (OT) 

OTs who are members of the infant feeding team will have received specialized training in infant feeding. These OTs specialize in fine motor, gross motor, and sensory assessment and utilize these skills to support infant development and safe, comfortable feeding. 

Speech-Language Pathologist (SLP)

SLPs who are members of the infant feeding team will have received specialized training in infant feeding. These SLPs specialize in the feeding and swallowing mechanism and diagnose and manage dysphagia or disordered swallowing. They use these skills to help improve feeding quality and safety. 

Physical Therapist (PT)

PTs who are members of the infant feeding team will have received specialized training in infant feeding. These PTs specialize in the management of motor development and organization and utilizes these skills to support optimization of development or intervention where there may be developmental delay or atypical posturing. 

Lactation professional (International Board Certified Lactation Consultant (IBCLC) or Certified Lactation Counselor (CLC))

Lactation professionals specialize in the knowledge and management of lactation and use these skills to support infant-caregiver feeding dyads by providing assessment and intervention related to breastfeeding. Depending on their training an experience, a CLC can usually provide basic education and support, while an IBCLC should be utilized for more complex lactation concerns.

Case Examples:

A few example cases may be helpful to illustrate how these professionals may work together on an infant feeding team. 

Case 1: A breastfeeding infant with continuous green frothy stool and slow weight gain

Who to consult:

• GI: Assess for food sensitivity or possible allergy
• RD: Assess caloric needs, support infant and family with dietary modification if deemed medically necessary by GI
• Lactation professional: Assess latch and ability to transfer milk, support breastfeeding 

Case 2: A formula feeding infant with frequent coughing and loud, squeaky breathing while feeding

Who to consult:

• ENT: Assess laryngeal anatomy and determine whether any additional intervention may be needed
• SLP: Assess feeding safety and recommend feeding strategies or additional studies to assess swallowing safety

Case 3: A combo-fed infant with torticollis who is struggling to latch

Who to consult:

• Lactation professional: Assess latch and ability to transfer milk and determine necessity of additional referrals if function of latch is impacted by anatomy
• OT: Provide skilled intervention to support behavioral state regulation and optimization or feeding safety and comfort
• PT: Provide skilled intervention for management of torticollis

How to work collaboratively?

Multi-disciplinary, team-based care results in improved outcomes for infants with feeding difficulties. Here are a few tips for working collaboratively:

• Include families in the care of their infant and empower them to share their feeding journey with each individual provider. Listen to their concerns as they may change over time as their infant grows and matures. 
• Maintain regular contact with members of the care team, this includes allied health professionals and the infant’s pediatrician. This keeps providers on the same page and working toward a common goal.
• Remember that each member of the infant feeding care team has specialized training to support optimal feeding outcomes for infants. Knowing how other providers can support infants with feeding difficulties and asking if you are unsure helps build a stronger team. 
• Make referrals in a timely manner and provide additional detail regarding what the reported feeding difficulty is in referrals where possible. This helps prepare other members of the infant feeding team to best support infants and families. 

Conclusion

Taking a multidisciplinary approach to caring for infants with feeding difficulties has been shown to result in the best outcomes. Early referral to the appropriate professionals and ensuring that infants and their families have access to timely support is consistently noted to be one of the most important determiners of short and long term feeding success⁶. It truly takes a village and when we all work together, with knowledge of each other’s areas of expertise and when to consult one another, our village becomes that much stronger.

‍

References:

¹LeBaron, C. W., Rodewald, L., & Humiston, S. (1999). How much time is spent on well-child care and vaccinations?. Archives of pediatrics & adolescent medicine, 153(11), 1154–1159. https://doi.org/10.1001/archpedi.153.11.1154

²Toomey, E., Flannery, C., Matvienko-Sikar, K., Olander, E. K., Hayes, C., Heffernan, T., Hennessy, M., McHugh, S., Queally, M., Kearney, P. M., Byrne, M., & Heary, C. (2021). Exploring healthcare professionals' views of the acceptability of delivering interventions to promote healthy infant feeding practices within primary care: a qualitative interview study. Public health nutrition, 24(10), 2889–2899. https://doi.org/10.1017/S1368980020004954

³Feldman-Winter, L., Barone, L., Milcarek, B., Hunter, K., Meek, J., Morton, J., Williams, T., Naylor, A., & Lawrence, R. A. (2010). Residency curriculum improves breastfeeding care. Pediatrics, 126(2), 289–297. https://doi:10.1542/peds.2009-3250

⁴Crowley, J., Ball, L., & Hiddink, G. J. (2019). Nutrition in medical education: a systematic review. The Lancet. Planetary health, 3(9), e379–e389. https://doi.org/10.1016/S2542-5196(19)30171-8

⁵Kerzner, B., Milano, K., MacLean, W. C., Jr, Berall, G., Stuart, S., & Chatoor, I. (2015). A practical approach to classifying and managing feeding difficulties. Pediatrics, 135(2), 344–353. https://doi.org/10.1542/peds.2014-1630

⁶Gosa, M. M., Dodrill, P., Lefton-Greif, M. A., & Silverman, A. (2020). A Multidisciplinary Approach to Pediatric Feeding Disorders: Roles of the Speech-Language Pathologist and Behavioral Psychologist. American journal of speech-language pathology, 29(2S), 956–966. https://doi.org/10.1044/2020_AJSLP-19-00069

⁷Bernard-Bonnin A. C. (2006). Feeding problems of infants and toddlers. Canadian family physician Medecin de famille canadien, 52(10), 1247–1251.