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J Pediatr Gastroenterol Nutr. 2009 Mar;48(3):355-62.

Diagnostic clues for identification of nonorganic vs organic causes of food refusal and poor feeding.

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Pediatric Gastroenterology Unit and Feeding Disorder Clinic, Wolfson Medical Center, Sackler School of Medicine, Tel Aviv University, Israel.



Food refusal, poor feeding, and somatic symptoms such as vomiting, gagging, irritability and failure to thrive (FTT) are commonly found in both infantile feeding disorders (IFD) and common treatable medical conditions. Present diagnostic classifications for diagnosing IFD are complex and difficult to apply in daily practice, leading to underdiagnosis and delay in diagnosis of IFD. We attempted to identify parental and infantile behaviour patterns or symptoms that could help distinguish between organic or behavioural causes for these symptoms.


We screened 226 children with poor feeding. After exclusion criteria, we divided the remaining 151 into 2 groups. The nonorganic group (n=83) included patients with onset of symptoms before age 2, persistent food aversion longer than 1 month, and a response to behavioural intervention. The second group consisted of children (n=68) presenting with similar characteristics, who responded to medical or nutritional therapy in which a final diagnosis of gastro-esophageal reflux disease, milk allergy, or idiopathic or nutritional FTT was made.


Poor intake, poor weight gain, or vomiting did not discriminate between organic and nonorganic causes. Factors indicating the presence of a behavioural cause included food refusal, food fixation, abnormal parental feeding practices, onset after a specific trigger, and presence of anticipatory gagging (P<0.0001 for all).


Integration of a few structured questions regarding infant behaviour, parental feeding practices, infant symptoms, and triggers for the onset of symptoms may help clinicians distinguish between organic and nonorganic causes for food refusal or low intake FTT.

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