The first clinical sign of familial dysautonomia (FD) is usually poor feeding with choking or coughing. Most infants have problems coordinating sucking and swallowing and suffer from aspiration pneumonias (lung infections caused by the misdirection of fluid or food when swallowing). Poor muscle tone and impaired temperature regulation are also common in infants with FD. Feeding difficulties usually continue throughout the first year into childhood and in some cases, adulthood. As children with FD age, milestones such as walking and speech are often delayed because of poor motor coordination. Indifference to pain and temperature increase the risk of injuries, which often go unnoticed by the child. Corneal insensitivity and inadequate eye moisture often result in corneal abrasions impairing vision. Breath-holding episodes occur in a number of children. Vomiting crises accompanied by hypertension, tachycardia, profuse sweating and skin blotching that occur in response to emotional stress or infection are a red flag sign of FD and a frequently associated with changes in mood. Anxiety and learning difficulties are common. Short stature, abnormal spinal curvature, problems with bone health and physical coordination can occur in adolescents. Orthostatic hypotension is also common. Renal failure, respiratory failure, sleep apnea, optic atrophy and worsening gait can develop in adult years. The lifelong Lack of overflow tears with emotional crying is another distinctive clinical feature of FD.