Clinical UM Guideline


Subject:Intensive Programs for Pediatric Feeding Disorders
Guideline #:  CG-MED-37Current Effective Date:  07/09/2013
Status:ReviewedLast Review Date:  05/09/2013

Description

The term "feeding disorder" refers to a condition in which an individual is unable or refuses to eat, or has difficulty eating, resulting in failure to grow normally. Feeding disorders should not be confused with eating disorders, such as anorexia, which are more common in adolescence and adulthood. Some common types of feeding disorders in children include, but are not limited to, adipsia (the absence of thirst or the desire to drink); dysphagia (difficulty in swallowing); food refusal; inability to self-feed; taking too long to eat; choking, gagging, or vomiting when eating; inappropriate mealtime behavior; and picky eating according to food type and texture.

Note: Please see the following documents for more information regarding issues related to topics addressed in this guideline:

Clinical Indications

Medically Necessary: 

An evaluation* to confirm a suspected diagnosis of pediatric feeding disorder is considered medically necessary for children whose difficulties began under five (5) years of age who meet either of the following criteria:

An evaluation* to confirm a suspected diagnosis of pediatric feeding disorder is considered medically necessary for children of any age who meet either of the following criteria:

*This evaluation should include:

Possible situations that could initiate an evaluation for a pediatric feeding disorder include:

A reevaluation is considered medically necessary when there are any of the following:

Note: There are several routine reassessments that are not considered reevaluations. These include ongoing reassessments that are part of each skilled treatment session, progress reports, and discharge summaries. Reevaluation is a more comprehensive assessment that includes all the components of the initial evaluation, such as:

The treatment of a pediatric feeding disorder is considered medically necessary when such a disorder has been diagnosed after appropriate evaluation and all of the following criteria are met:

  1. A thorough medical evaluation, as described above, has been completed; and
  2. Adequate treatment for any contributing underlying medical conditions, if present, has occurred without resolution of the feeding problem; and
  3. A treatment plan, individualized to each child, is developed and includes diagnosis, problem list, proposed treatment plan with specific interventions, and estimated length of treatment.

Note: Other issues that may be addressed include specific dietary interventions or special formulas, positioning during feeding, behavioral interventions and family/caregiver education.  Intensity of treatment may vary from short-term intermittent outpatient visits to more intensive treatment programs.  Inpatient or intensive outpatient treatment programs may be warranted for severe cases, such as malnutrition or failure to thrive, unstable electrolyte disorders, potentially serious allergic reactions to food, significant difficulty transitioning from tube feedings to oral feedings, etc.

Not Medically Necessary:   

Evaluation and treatment for pediatric feeding disorders are considered not medically necessary when the criteria above have not been met.

A feeding disorder treatment program is considered not medically necessary for children who can eat and swallow with normal functioning, but who are "picky eaters" or have selective eating behaviors and yet continue to meet normal growth and developmental milestones, and other medically necessary criteria above have not been met.

Inpatient admission for a pediatric intensive feeding program is considered not medically necessary, except when the individual requires facility-based care related to acute medical complications of the feeding disorder (e.g., malnutrition or failure to thrive, unstable electrolyte disorders, potentially serious allergic reactions to food, significant difficulty transitioning from tube feedings to oral feedings, etc.)

Duplicate therapy is considered not medically necessary.

Note: When individuals receive concurrent physical, occupational, behavioral, or speech therapy, the therapists should provide different treatments that reflect each therapy discipline's unique perspective on the individual's impairments and functional deficits and not duplicate the same treatment.  They must also have separate evaluations, treatment plans, and goals.

Maintenance programs are considered not medically necessary.

Note: A maintenance program consists of treatments or activities that preserve the individual's present level range, strength, coordination, balance, pain, activity, function, etc. and prevent regression of the same parameters.  Maintenance begins when the therapeutic goals of a treatment plan have been achieved, or when no additional functional progress is apparent or expected to occur. In certain circumstances, the specialized knowledge and judgment of a qualified therapist may be required to establish a maintenance program, however, the repetitive therapy services to maintain a level would be considered not medically necessary.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes.  A draft of future ICD-10 Coding (effective 10/01/2014) related to this document, as it might look today, is included below for your reference.  Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy.  Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

CPT 
 No specific codes for multidisciplinary feeding programs
  
ICD-9 Diagnosis 
 All diagnoses
  
ICD-10 DiagnosisICD-10-CM draft codes; effective 10/01/2014:
 All diagnoses
  
Discussion/General Information

Pediatric feeding disorders include a wide range of problems that interfere with normal eating activities and result in inadequate caloric or nutritional intake, resulting in compromise of the child's growth and development, confirmed when the child fails to consume a sufficient volume or variety of food to maintain weight or to sustain a normal growth rate (Crosby, 2007; Piazza, 2008).

Signs and symptoms of a significant feeding disorder may include refusal to eat or drink; difficulty swallowing, inability to self-feed at an appropriate age, requiring an abnormally long time to eat, choking, gagging, or vomiting when eating, or other inappropriate mealtime behaviors.  If such feeding problems occur for a prolonged period of time, they will have a significant effect upon the child's nutritional intake, affecting growth rates and may result in frequent illnesses, or death in severe cases.  Such disorders may also be accompanied by behavioral problems such as hitting, biting, kicking, tantrums, and vomiting at mealtime as an attention-getting strategy.

Feeding disorders are fairly common in infants and toddlers, with approximately 25-35% of these children experiencing some difficulties with feeding (Kodak, 2008).  The incidence of severe feeding problems has been reported to be even greater, as high as 40-70%, in infants born prematurely or in children with chronic medical conditions (Rogers, 2004).  The number of children affected by feeding disorders is increasing, possibly due at least in part to medical advances that have reduced the mortality rate of children born prematurely and those with serious health conditions.

Feeding disorders may result from a wide range of causes, including medical conditions (e.g., food allergies, neurologic or neuromuscular disease, gastroesophageal reflux, and others), structural or functional abnormalities (e.g., defects of the palate), or behavioral issues (e.g., crying or tantrums that prevent successful completion of mealtimes).  In most cases, there is likely a complex interaction among multiple causative factors.  For example, medical problems such as gastroesophageal reflux disease (GERD) may cause eating to be painful.  Early experiences with pain during eating can cause the child to stop eating and develop behavior problems that make it difficult if not impossible for the parent to feed the child.  Compounding the problem, frequent avoidance of eating may contribute to failure to develop appropriate oral sensorimotor skills required for successful eating and swallowing.

Infants and children who are tube fed for extended periods of time (due to some other illness or disability) have an especially high frequency of feeding problems.  In such individuals, it is believed that there are "critical period" for developing proper oral feeding patterns and reflexes has passed without adequate feeding experiences.  This critical period has been described as being between six and seven months of age, during which acquisition of oral food consumption skill is most likely.  Beyond this period oral feeding abilities may not be established or will be established only with great difficulty (Babbitt, 1994).

Premature infants and those that are of very low birth weight are at very high risk for feeding disorders (Rommel, 2002; Schädler, 2007; Vohr, 2006). The underdeveloped sphincter muscle between the stomach and esophagus can cause the infant to spit up frequently during feedings.  Because this is uncomfortable for the child, he or she may not want to eat.  One study by Schädler and colleagues (2007) in 86 premature children describes the successful use of behavioral therapy for severe feeding disorders.  However, they indicate that other conditions such as cerebral palsy, mental retardation and interaction problems, which are frequent in this population, have a significant negative impact on therapy outcomes and may require an even more intensive approach to address feeding disorders.

Disorders of the digestive system can also cause feeding problems.  Examples of these types of conditions include structural or functional abnormalities of the mouth, throat, or esophagus that may result in inability to chew or swallow, or cause pain during swallowing, or result in aspiration (inhaling food or fluid into the lungs).  Celiac disease, necrotizing entercolitis, Hirschprung disease, short bowel syndrome, pyloric stenosis, and GERD may also contribute to disordered feeding behaviors.  A small controlled study by Mathisen et al. (1999) concluded that the presence of GERD had a significant negative impact on the energy intake of affected infants.  Such infants demonstrated fewer adaptive skills and readiness behaviors for solid foods, and significantly more food refusals and food loss at meal times. 

Neurologic and neuromuscular disorders, such as cerebral palsy, are associated with significantly increased difficulty with feeding.  In such children, spasticity or weakness of the oral musculature results in difficulty with oral food preparation prior to swallowing (e.g., sipping, sucking, or chewing), but problems swallowing may also be present.  This may progress from simple frustration to more significant problems such as aspiration and respiratory infections (Arvedson, 2008; Field, 2003; Gisel, 2008; Rogers, 2004).

Developmental disorders, such as Down syndrome and autism spectrum disorders, also contribute to significant feeding problems (Manikam, 2000). While such individuals frequently have co-existing physical disorders as described above, they may also demonstrate unique behavioral issues that impair feeding (Kodak, 2008; Schreck, 2004).  Food aversion and food refusal in these individuals are sometimes linked to difficulties with food texture and type which significantly limit the accepted food options for these individuals.  It is important to note that feeding disorders may be comorbid with developmental disorders without being part of the developmental disorder itself.  There are no developmental disorders whose diagnostic criteria include feeding disorders as defined above.  Just as a congenital heart defect may be comorbid with Down syndrome, and require medically necessary treatment that is not intended to affect the genetic status of the child, a child with an autistic spectrum disorder may have a comorbid feeding disorder that requires medically necessary treatment that is separate from the treatment of any autistic symptomatology.

Evaluation for pediatric feeding disorders is probably best performed by a multidisciplinary team (Arvedson, 2008; Lifschitz, 2001; Rommel, 2003). Members of this team may include, but are not limited to, a pediatrician, family physician, gastroenterologist, dietitian, occupational therapist, speech-language pathologist, pediatric behavioral and developmental specialist, psychologist, and social worker.  These professionals work together to assess the individual and determine the possible underlying causes for the disorder, followed by creating a treatment plan.  The assessment process should evaluate a wide range of issues, including the structure and function of the mouth, upper airway, gastrointestinal tract; as well as behavioral aspects of feeding such as the parental-child interaction.

The rationale for treatment is that children whose feeding problems are treated with nasogastric, gastrostomy, or jejunostomy tubes are more likely to need therapy to become oral feeders.  Placement of a feeding tube has been shown to actually cause or worsen feeding problems for many children (Crosby, 2007).

Treatment for diagnosed pediatric feeding disorders may also require a multidisciplinary team approach (Arvedson, 2008; Lifschitz, 2001; Rommel, 2003).  This team should include the same types of professionals described above for the evaluation process, to treat both the causative and underlying medical conditions, as well as to provide the various interventions deemed appropriate for the treatment of the individual.  Many studies have demonstrated the benefits of such a multidisciplinary approach (Benoit, 2000; Byars, 2003).  Rommel and colleagues (2003) described the multidisciplinary treatment of 700 infants and young children with feeding disorders, reporting that almost 50% of the study subjects presented with a combination of medical (e.g., GERD, neurologic or other problem) and oral (e.g., oral motor issues, sensory problems, etc.) pathology underlying their disorder.  There were also a substantial number of individuals presenting with combined oral-behavioral (e.g., food avoidance, tantrums, etc), and medical-behavioral conditions as well.  These individuals were treated by a team approach, with 73.1 % of the individuals experiencing significant benefits beyond 2 months to 5 years.

References

Peer Reviewed Publications:

  1. Arvedson JC. Assessment of pediatric dysphagia and feeding disorders: clinical and instrumental approaches. Dev Disabil Res Rev. 2008; 14(2):118-127.
  2. Ayoob KT, Barresi I. Feeding disorders in children: taking an interdisciplinary approach. Pediatr Ann. 2007; 36(8):478-483.
  3. Babbitt Rl, Hoch TA, Coe DA, et al. Behavioral assessment and treatment of pediatric feeding disorders. J Dev Behav Pediatr. 1994; 15(4):278-291.
  4. Benoit D, Wang EE, Zlotkin SH. Discontinuation of enterostomy tube feeding by behavioral treatment in early childhood: a randomized controlled trial. J Pediatr. 2000; 137(4):498-503.
  5. Cooper-Brown L, Copeland S, Dailey S, et al. Feeding and swallowing dysfunction in genetic syndromes. Dev Disabil Res Rev. 2008; 14(2):147–157.
  6. Crosby J, Duerksen DR. A prospective study of tube- and feeding-related complications in patients receiving long-term home enteral nutrition. JPEN J Parenter Enteral Nutr. 2007; 31(4):274-277.
  7. Field D, Garland M, Williams K. Correlates of specific childhood feeding problems. J Paediatr Child Health. 2003; 39(4):299-304. 
  8. Gisel E. Interventions and outcomes for children with dysphagia. Dev Disabil Res Rev. 2008; 14(2):165-173.
  9. Greer AJ, Gulotta CS, Masler EA, Laud RB. Caregiver stress and outcomes of children with pediatric feeding disorders treated in an intensive interdisciplinary program. J Pediatr Psychol. 2008; 33(6):612-620.
  10. Kane ML. Pediatric failure to thrive. Clin Fam Pract. 2003; 5(2):293-311.
  11. Kodak T, Piazza CC. Assessment and behavioral treatment of feeding and sleeping disorders in children with autism spectrum disorders. Child Adolesc Psychiatr Clin N Am. 2008; 17(4):887-905.
  12. Krugman SD, Dubowitz H. Failure to thrive. Am Fam Physician. 2003; 68(5):879-884.
  13. Lifschitz CH. Feeding problems in infants and children. Curr Treat Options Gastroenterol. 2001; 4(5):451-457.
  14. Manikin R, Perman JA.  Pediatric feeding disorders. J Clin Gastroenterol. 2002; 30(1):34-46.
  15. Marshall DD. Primary care follow-up of the neonatal intensive care unit graduate. Clin Fam Pract. 2003; 5(2):243-263.
  16. Mathisen B, Worrall L, Masel J, et al. Feeding problems in infants with gastro-oesophageal reflux disease: a controlled study J Paediatr Child Health. 1999; 35(2):163-169.
  17. Piazza CC. Feeding disorders and behavior: what have we learned? Dev Disabil Res Rev. 2008; 14(2):174-181.
  18. Raynor P, Rudolf MC. Anthropometric indices of failure to thrive. Arch Dis Child. 2000; 82(5):364-365. 
  19. Rogers B. Feeding method and health outcomes of children with cerebral palsy.  J Pediatr. 2004; 145(2 Suppl):S28-S32.
  20. Rommel N, De Meyer AM, Feenstra L, Veereman-Wauters G. The complexity of feeding problems in 700 infants and young children presenting to a tertiary care institution. J Pediatr Gastroenterol Nutr. 2003; 37(1):75-84.
  21. Ross ES, Browne JV. Developmental progression of feeding skills: an approach to supporting feeding in preterm infants. Semin Neonatol. 2002; 7(6):469-475.
  22. Rudolph CD, Link DT. Feeding disorders in infants and children. Pediatr Clin North Am. 2002; 49(1):97-112.
  23. Saarilehto S, Lapinleimu H, Keskinen S, et al. Growth, energy intake, and meal pattern in five-year-old children considered as poor eaters. J Pediatr. 2004; 144(3):363-367.
  24. Schädler G, Süss-Burghart H, Toschke AM, et al.  Feeding disorders in ex-prematures: causes--response to therapy--long term outcome. Eur J Pediatr. 2007; 166(8):803-808.
  25. Schreck KA, Williams K, Smith AF. A comparison of eating behaviors between children with and without autism. J Autism Dev Disord. 2004; 34(4):433-438.
  26. Sheppard JJ. Using motor learning approaches for treating swallowing and feeding disorders: a review. Lang Speech Hear Serv Sch. 2008; 39(2):227-236.
  27. Sigman GS. Eating disorders in children and adolescents. Pediatr Clin North Am. 2003; 50(5):1139-1177.
  28. Tack J, Talley NJ, Camilleri M, et al.  Functional gastroduodenal disorders. Gastroenterology. 2006; 130(5):1466-1479.
  29. Vohr BR, Wright LL, Dusick AM, et al. Neurodevelopmental and functional outcomes of extremely low birth weight infants in the National Institute of Child Health and Human Development Neonatal Research Network, 1993-1994. Pediatrics. 2000; 105(6):1216-1226.

Government Agency, Medical Society, and Other Authoritative Publications: 

  1. American Speech-Language-Hearing Association (ASHA) position statement. Roles of speech-language pathologists in swallowing and feeding disorders. 2002. Available at: http://www.asha.org/docs/html/PS2002-00109.html. Accessed on February 08, 2013.
  2. CDC Growth Charts. Available at: http://www.cdc.gov/growthcharts/. Accessed on February 08, 2013.
Web Sites for Additional Information
  1. American Speech-Language-Hearing Association. Feeding and swallowing disorders (dysphagia) in children. Available at: http://www.asha.org/public/speech/swallowing/FeedSwallowChildren.htm. Accessed on February 08, 2013.
Index

Adipsia
Dysphagia
Feeding Disorders
GERD

History

Status

Date

Action

Reviewed05/09/2013Medical Policy & Technology Assessment Committee (MPTAC) Review. No change to clinical indications section. Updated Reference section.
Reviewed05/10/2012MPTAC Review. No change to clinical indications section. Updated Reference section.
Reviewed05/19/2011MPTAC Review. No change to clinical indications section. Updated Reference and Coding sections.
Reviewed05/13/2010MPTAC Review. No change to clinical indications section. Updated Reference section.
New05/21/2009MPTAC initial document development.