Pediatric feeding disorders are a complex set of feeding and swallowing problems that disrupt the acquisition of age-appropriate feeding habits. Feeding problems may include but are not limited to food refusal, disruptive meal-time behavior, rigid food preferences, suboptimal growth, and failure to master self-feeding skills commensurate with the child’s developmental abilities. Feeding is a critical self help skill that develops during infancy and toddlerhood. Inability to self- feed in toddlers or inability to be cooperative with caretaker feeding during infancy may result in severe functional limitation, thus contributing to or establishing disability.

Children present for the evaluation and treatment of feeding and swallowing problems for a variety of reasons. Feeding problems are estimated to occur in as many as 25 to 45 % of children with normal development, in 33 % of children with developmental disabilities, and in up to 80 % in children with severe or profound mental retardation (Silverman, 2010). Approximately 50 to 67 % of children with feeding disorders present with mixed causes that include behavioral, physiological, and developmental factors. The consequences of feeding problems can be severe and include: growth failure, susceptibility to chronic illness, and even death. For a child to be diagnosed with feeding disorder of infancy or early childhood, the disorder must be severe enough to affect growth for a significant period of time.

Failure to thrive (FTT) is a term used to describe children, generally up to 3 years of age, who demonstrate a downward deviation in growth when compared to expectations from the standard growth charts of the National Center for Health Statistics (NCHS) Centers for Disease Control (CDC) growth charts. It refers to infants whose weight is less than the norm for their gestation-corrected age, sex, genetic potential, and medical condition. It does not include infants and young children with genetic short stature, constitutional growth delay, prematurity, or intrauterine growth restriction and who have appropriate weight for length and normal growth velocity. The underlying cause of FTT is insufficient usable nutrition (i.e., inadequate intake or absorption, excess metabolic demand, or defective utilization). Generally, growth failure is considered to be below the fifth percentile of weight and height for gestation-corrected age and sex when plotted on an appropriate growth curve (e.g., NCHS for children without genetic abnormalities, Down syndrome growth curve for children with Down syndrome, etc.) and who have decreased velocity of weight gain that is disproportionate to growth in length, taking into account appropriateness of size at birth. Failure to thrive is not used to describe children growing along a curve with a normal interval growth rate, even if their weight is less than the fifth percentile.

There is no consensus regarding the definition of FTT, or how long a growth concern should exist before a child meets criteria for FTT. However, the term may be attributed to a child who, with observation of growth over time, has

any

of the following:

Weight below the third or fifth percentile for gestation-corrected age and sex on more than one occasion. Special growth charts for selected genetic syndromes should be used when indicated (e.g., for children with Down syndrome, Turner syndrome, etc);

or

Weight less than 80 % of ideal weight for age, using the standard growth charts of the NCHS;

or

Depressed weight for length (i.e., weight age less than length age, weight for length less than10th percentile);

or

A rate of weight gain that causes a decrease in 2 or more major percentile lines (90th, 75th, 50th, 25th, 10th, and fifth) over time (e.g., from 75th to 25th);

or

A rate of daily weight gain less than that expected for age.

Pediatric feeding problems are typically treated in outpatient settings by individual practitioners. Some hospitals have developed comprehensive outpatient clinics with interdisciplinary care models called "pediatric intensive feeding programs" or "feeding clinics" that are designed to evaluate, diagnose, and treat children with severe or complex feeding and swallowing difficulties. These interdisciplinary clinics are intended to provide greater environmental control, greater frequency of treatment, accelerated learning by increased contact with caregivers, and frequent medical and nutrition monitoring to provide clinicians with additional treatment options (e.g., appetite manipulation, swallow induction). An interdisciplinary team of specialists work with the child and family to address the multiple factors involved with eating. Programs vary across locations but generally focus on the feeding problems of infants and children up to 16 years of age. The Kennedy Krieger Institute (Baltimore, MD) is an example of a facility that offers services ranging from outpatient assessment, intensive day treatment, and inpatient feeding programs that typically last about 8 weeks. Key aspects of the program include direct observation behavior assessment, approaches for increasing and decreasing feeding behavior, skill acquisition, transfer of treatment gains, and parent training.

According to the recommendations of the American Academy of Pediatrics (AAP, 2010), screening for nutrition risks and problems is an expected part of routine preventive health services. When the feeding problem is severe or complex, medical causes of FTT have been treated, and initial treatment efforts by a single discipline (e.g., occupational therapist, speech language pathologist) have failed, intensive treatment is considered. A referral is made to an interdisciplinary team for assessment and intervention in order to evaluate and treat all factors influencing growth. Services can include a comprehensive clinic evaluation, videofluoroscopic swallow study, feeding therapy, and family and caregiver education. A nutrition assessment completed by a registered dietitian obtains information needed to rule out or confirm a nutrition related problem. Nutrition assessment consists of an in-depth and detailed collection and evaluation of data in the following areas: anthropometrics, clinical/medical history, diet, developmental feeding skills, behavior related to feeding, and biochemical laboratory data. During the assessment, risk factors identified during nutrition screening are further evaluated and a nutrition diagnosis is made. The assessment may also reveal areas of concern such as oral-motor development or behavioral issues that require referral for evaluation by the appropriate therapist or specialist. Other members of the interdisciplinary team may include behaviorists, occupational therapist, physical therapist, speech language pathologist/therapist, social worker, and home health care providers.

Interventions are comprehensive and include behavioral modification to alter the child's inappropriate learned feeding patterns and parent education and training in appropriate parenting and feeding skills. A majority of feeding problems can be resolved or greatly improved through medical, oral motor, and behavioral therapy. Behavioral feeding strategies have been applied successfully even in organically mediated feeding disorders. To avoid iatrogenic feeding problems, initial attempts to achieve nutritional goals in malnourished children should be via the oral route. The need for exclusive tube feedings should be minimized. (Manikam and Perman, 2000).

In many intensive treatment programs, the intervention involves 3 phases :

the child is fed directly by the therapist to establish a new set of feeding responses,

parents are introduced into the feeding environment, and

parents feed their child with clinicians coaching remotely.

Common treatment objectives of the feeding team may include the following:

Pediatric psychologist:

Provides a behavioral perspective on feeding disorders, assesses for co-morbid behavioral or psychiatric conditions within the child or family system, and provides interventions or facilitates referrals as appropriate. Behavioral treatment strategies include implementation of meal-time structure and feeding schedule, appetite manipulation, behavior management, and parent training.

Physician:

Monitors overall medical well-being of the child and provides oversight and support as needed while the child is in treatment. Completes medical studies to identify and treat various physiological causes (e.g., endoscopy), manages various conditions through medication (e.g., medication for appetite stimulation, acid reflux therapy), and coordinates the broader treatment team.

Registered dietitian:

Provides targeted nutrition interventions to improve growth (weight at or above 90 % of ideal body weight for length), improve growth velocity, increase nutrient intake, improve nutrient balance, redistribute calories from protein, carbohydrate, and fat, and help families avoid harmful foods/supplements.

Speech and language pathologist:

Includes therapies to improve chewing and swallowing coordination, strengthen oral musculature, and improve oral tolerance to a broad range of flavors, textures, and temperatures of foods.

Most nutrition and feeding problems of children can be improved or controlled, but may not be totally resolved in complex cases. Some children may require ongoing and periodic nutrition assessment and intervention. Hospitalization may be neither helpful nor necessary unless the child is severely malnourished, seriously ill, or at risk of harm. Separation of the child from the family by hospitalization may promote anxiety and anorexia in the child and cause a delay in feeding and supporting the child within his or her established environment (Kirkland and Motil, 2010).

Indications for hospitalization include:

Extremely problematic parent-child interaction

Failure to respond to several months of out-patient management

Precise documentation of energy intake

Psychosocial circumstances that put the child at risk for harm

Serious inter-current illness or significant medical problems

Severe malnutrition (less than or equal to 75 % of ideal body weight)

Significant dehydration.

A review of the literature on pediatric feeding disorders reveals the complexity involved in classifying feeding problems in infants and children. The most frequently cited is the organic-nonorganic dichotomy. Most feeding disorders have underlying organic causes; however, evidence indicates that abnormal feeding patterns are not solely due to organic impairment and that disordered feeding in a child is seldom limited to the child alone but is also a family problem. Organic feeding disorders include problems related to structural abnormalities involved with feeding (e.g., anatomical defects of the palate, tongue, and esophagus), neuromuscular problems (e.g., cerebral palsy, paralysis), or other know physiologic reasons (e.g., esophagitis, gastroesophageal reflux (GER)) in which feeding can be disrupted. In contrast, feeding disorders which are classified as having nonorganic origins include disruptive social and environmental circumstances. Rarely can one reason or cause for feeding disorders be isolated or identified. The most prominent medical diagnoses that can lead to feeding disorders include:

Apraxia

Autism/Pervasive developmental disorders

Brain injury

Cardiac problems

Cerebral palsy

Children with tube feeding

Cleft palate

Constipation

Failure to thrive

Feeding difficulties

Food allergies

Malabsorption

Muscular dystrophy

Neurological problems

Oral dysphagia

Prematurity

Reflux

Respiratory complications (e.g., pneumonia)

Short gut/bowel syndrome.

Burklow et al (1998) reported multiple characteristics associated with complex pediatric feeding problems and determined the relative frequency of each classification in a population referred to an interdisciplinary feeding team. Written reports from team evaluations on 103 children (64 males, 39 females; age range of 4 months to 17 years) were reviewed. Prematurity and/or presence of developmental delay were coded. Identified factors related to current feeding problems were coded according to 5 categories :

structural abnormalities,

neurological conditions,

behavioral issues,

cardio-respiratory problems, and

metabolic dysfunction.

Inter-rater reliability for the classification coding was 88 %. Thirty-eight percent of the children had a history of prematurity and 74 % were reported to have evidence of developmental delay. The following 5 categories or combinations were coded most frequently :

structural-neurological-behavioral (30 %),

neurological-behavioral (27 %),

behavioral (12 %),

structural-behavioral (9 %), and

structural-neurological (8 %). Overall, behavioral issues were coded more often (85 %) than neurological conditions (73 %), structural abnormalities (57 %), cardio-respiratory problems (7 %), or metabolic dysfunction (5 %).

The authors concluded that complex pediatric feeding problems are bio-behavioral conditions in which biological and behavioral aspects mutually interact and that both need to be addressed to achieve normal feeding. In addition, the authors stated, "[e]mpirically validated treatment protocols specific to the constellation of problems present are needed to both increase effectiveness and reduce costs." The Washington State Department of Health (1998) examined the costs and benefits of nutrition and feeding team services for children with special health care needs in a case series of 30 children. The children received services in the community, outpatient or home settings, and reflected a variety of medical conditions and congenital or genetic disorders. Costs for the interventions provided and the interventions avoided were based on actual reported costs of providing these services in the community, or the costs were assigned uniformly, based on common practice in Washington State. The children ranged in age from 11 days to 17 years, and had multiple visits over variable time periods within a variety of settings. The estimated medical costs avoided exceeded the intervention costs for nutrition and feeding team services for 28 of the 30 children. The ratio of intervention costs to medical costs avoided ranged from 1:0.8 to 1:20. Positive outcomes for these children following nutrition or feeding team interventions included appropriate growth, improved dietary intake and adequacy, decreased illness and hospitalization, improved feeding skills and feeding behavior, and progress in feeding development. The greatest improvements were in growth and dietary intake, which addressed the frequent initial problems of poor growth and inadequate diet. The authors concluded that an investment in professional time with multiple family/child contacts can achieve improvements in nutrition and feeding problems and result in savings in overall health care expenditures. Limitations of the study included

the case studies were not randomly selected,

there was no comparison control population, and

the specific cases did not necessarily represent all children with similar diagnoses.

Schwarz et al (2001) reported the results of diagnostic evaluation and the effects of nutritional intervention on energy consumption, weight gain, growth, and clinical status in children (n = 79) with moderate to severe motor or cognitive dysfunction (male: female, 38:41; age, 5.8 +/- 3.7 years) who were referred for diagnosis and treatment of feeding or nutritional problems. Initial assessments included a 3-day calorie intake record, videofluoroscopic swallowing study, 24-hour intra-esophageal pH monitoring, milk scintigraphy, and esophagogastroduodenoscopy. These studies demonstrated GER with or without aspiration in 44 of 79 patients (56 %), oropharyngeal dysphagia in 21 (27 %), and aversive feeding behaviors in 14 (18 %). Diagnosis specific approaches included GER therapy in 20 patients (25 %), fundoplication plus gastrostomy tube (GT) in 18 (23 %), oral supplements in 17 (22 %), feeding therapy only in 14 (18 %), and GT only in 10 (13 %). After 25 months, relative calorie intake improved significantly. The z scores increased significantly for both weight and height. Improved subcutaneous tissue stores were demonstrated by increased thickness of both sub-scapular skin folds and triceps skin folds. After nutritional intervention, the acute care hospitalization rate, compared with the 2-year period before intervention, decreased from 0.4 +/- 0.18 to 0.15 +/- 0.06 admissions per patient-year and included only 3 admissions (0.02 per patient-year) related to feeding problems. The authors concluded that in children with developmental disabilities, diagnosis-specific treatment of feeding disorders resulted in significantly improved energy consumption and nutritional status and decreased morbidity (reflected by a lower acute care hospitalization rate) may be related, at least in part, to successful management of feeding problems.

Rommel and De Meyer (2003) examined the complexity of feeding problems in infants and young children less than 10 years of age (n = 700) presenting to a tertiary care institution for severe feeding problems. The first aim of the study was to characterize the etiology of feeding difficulties as medical, oral, or behavioral. The second aim was to assess the prevalence of prematurity and dysmaturity in the patients and their relationship to the type of feeding problem. Approximately 50 % of the children had a combined medical and oral condition underlying their feeding difficulties. More than half of the children were examined for gastrointestinal conditions, particularly GER. Behavioral problems were more frequently seen in children greater than age 2 years. A significant relationship was found between the type of feeding problem and age: infants born preterm and/or with a birth weight below the 10th percentile for gestational age were at greater risk for developing feeding disorders. Oral sensory-based feeding problems were found to be related to past medical interventions. The authors concluded that a multidisciplinary team approach is essential for assessment and management of complex feeding problems in infants and young children because combined medical and oral problems are the most frequent cause of pediatric feeding problems. In a review of the study by Rommel and co-workers, Gerarduzzi et al (2004) stated that

feeding disorders cannot be easily classified as organic or non-organic,

their treatment requires a multidisciplinary approach, and

careful attention should be given to early detection of causes that may be prevented.

Tufts-New England Medical Center conducted a systematic evidence review for the Agency for Healthcare Research and Quality (AHRQ, 2003) on the relationship between FTT and disability in children aged 18 years or younger. The report concluded that evidence clearly suggests a relationship between FTT and concurrent disability, disability within 6 months, and disability beyond 6 months. The report stated, "[t]here is substantial evidence that long term growth in all parameters (weight, height, and head circumference) of children with FTT compares unfavorably with thriving children and that this disparity persists even with appropriate attempts at intervention. This pattern of a persistent growth deficit is seen in both developed and developing countries and across a wide spectrum of severity of FTT. The effect on head growth is especially concerning, since increasing head circumference reflects brain growth, and therefore any impairment in head growth impacts neuro-developmental outcomes. There is also evidence that the longer the growth failure continues, the less likely it becomes that treatment will be effective in reversing the negative long-term outcomes. These findings highlight the importance of early identification and intensive nutritional intervention for children with FTT syndrome to improve efficacy of the therapy and to minimize long-term damage." In addition, the report stated, "[a] consistent finding among these studies reviewed was the ineffectiveness of existing intervention programs."

In a review of the literature on feeding problems of infants and toddlers, Bernard-Bonnin (2006) concluded that

feeding problems in early childhood often have multi-factorial causes and a substantial behavioral component,

family physicians have a key role in detecting problems, offering advice, managing mildly to moderately severe cases, and

more complicated cases should be referred to multidisciplinary teams.

A report by the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition on the nutrition support for neurologically impaired children (Marchand and Motil, 2006) stated, "[e]arly involvement by a multidisciplinary team of physicians, nurses, dieticians, occupational and speech therapists, psychologists, and social workers is essential to prevent the adverse outcomes associated with feeding difficulties and poor nutritional status. Careful evaluation and monitoring of severely disabled children for nutritional problems are warranted because of the increased risk of nutrition-related morbidity and mortality."

Lakeridge Health Corporation (Oshawa, ON, Canada), formerly Oshawa General Hospital, developed an interdisciplinary pediatric feeding and swallowing clinic in 1995. Children ranged in age from birth to 16 years and have developmental delay, sensory integration difficulties, oral motor control problems, oral sensory problems, and/or poor weight gain and growth. The interdisciplinary team consists of a pediatrician, a speech-language pathologist, an occupational therapist, and a registered dietitian. A retrospective review to assess the performance of the clinic was performed on 104 subjects. Goals were related to improvements in growth and/or feeding abilities and were individualized to each subject. Initial goals were attained by the first follow-up visit in 75.9 % (95 % confidence interval: 70 to 81) of the subjects. Progress in the clinic, as measured by the number of goals achieved by the first follow-up visit, was further analyzed according to the patient age group/category (i.e., infant, toddler, and child) and by the health care professional to ascertain and compare success rates in these groups and professionals. The overall success rates in the patient age groups (p = 0.07) and among the different professionals (p = 0.92) were not significantly different. The authors concluded that the interdisciplinary team approach proved successful in treating feeding problems in patients referred to the clinic. Study limitations include :

possible inconsistency in documentation,

potential variability in weight and height data collection techniques,

ambiguous parental perception(s) about reporting progress,

a possible lack of professionals’ goal standardization,

normal developmental outcomes during growth and development, and

sample size and large variance limit the statistical analysis.

The authors stated that the results should be interpreted with caution and confirmed by further research with a larger sample size (Williams et al, 2006).

Schadler et al (2007) examined the long term outcome to therapy in a case series of 86 ex-premature infants with severe feeding disorders. Children with a gestational age of less than 37 weeks referred for hospital rehabilitation because of severe feeding disorders, defined as tube feeding or average feeding times of more than 30 minutes were included. Ex-premature infants accounted for 86/266 patients admitted for treatment of feeding disorders between 1995 and 2004. The patients had the following diagnoses: cerebral palsy (41 %), mental retardation (51 %) and interaction problems (87 %). The main element of treatment was behavioral therapy. The authors reported a 62 % response rate at discharge. Univariat analyses showed that tube feeding at admission and swallowing difficulties were the best predictors of failure to respond to the intervention. Long-term follow-up data that were collected for 53 of the 86 children with similar initial response to therapy (64 %) compared to children with no follow-up data (58 %). Success of therapy after discharge was maintained in 94 %; however, 25 % of the children with normal body mass indexes at discharge and sustained success of therapy fell below the third body mass index percentile. Cerebral palsy, mental retardation and interaction problems were found to be important risk factors for severe feeding disorders in ex-premature infants. The authors reported that therapeutic intervention based on behavioral therapy achieved sustained success in almost two thirds of the children.

Greer et al (2008) investigated the impact of an intensive interdisciplinary feeding program on caregiver stress and child outcomes of children with feeding disorders across 3 categories :

tube dependent,

liquid dependent, or

food selective.

Outcomes for caregiver stress levels, child meal-time behaviors, weight, and calories were examined at admission and discharge for 121 children. Repeated measures of analysis of variance were used to examine differences pre- and post-treatment and across feeding categories. Caregiver stress, child meal-time behaviors, weight, and caloric intake improved significantly following treatment in the intensive feeding program, regardless of category placement. The authors concluded that regardless of a child's medical and feeding history, an intensive interdisciplinary approach significantly improved caregiver stress and child outcomes.

In a report for the Washington State Department of Health on nutrition interventions for children with special health care needs, Latif et al (2010) stated, "[o]ften pediatric undernutrition and growth failure originate from multiple physical and psychosocial factors that change over time and are most effectively treated by an interdisciplinary team."

There is some preliminary evidence of the effectiveness of selected clinical interventions to treat complex feeding and swallowing difficulties in infants and children (Miller, 2009). While randomized controlled studies on the impact of pediatric intensive feeding programs on outcomes are needed, case studies indicate that an inter-disciplinary treatment approach to feeding disorders in complex cases offers the most comprehensive care for the treatment of these disorders and will likely promote the safest and most effective treatment plans (Silverman, 2010).

In a meta-analysis, Carnaby-Mann et al (2007) evaluated the effect of transcutaneous neuromuscular electrical stimulation (NMES) on swallowing rehabilitation. Medline, PubMed, CINAHL, NML, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, doc online, Google, and EMBASE were searched for studies using NMES to treat dysphagia between January 1966 and August 2006. Included were published or unpublished, English-language, clinical trials with a quantifiable dependent variable. Two researchers independently performed data extraction. A random-effects model was used to pool study results. The Cochran Q test was used to evaluate heterogeneity, and a funnel plot and Egger test were used to evaluate publication bias. A best-research synthesis using a methodological quality analysis was conducted. A total of 81 studies were reviewed; 7 were accepted for analysis. A significant summary effect size was identified for the application of NMES for swallowing (Hedges g, 0.66; p < 0.001). Heterogeneity was significant for the combined trials (p < 0.10). When 2 outlier trials were removed, heterogeneity was no longer significant (p < 0.08). Publication bias was not identified on the funnel plot or Egger test (p = 0.25). Best-evidence synthesis showed indicative findings in favor of NMES for swallowing. The authors concluded that this preliminary meta-analysis revealed a small but significant summary effect size for transcutaneous NMES for swallowing. However, because of the small number of studies and low methodological grading for these studies, caution should be taken in interpreting this finding. They stated that these results support the need for more rigorous research in this area.

Clark et al (2009) reviewed the literature examining the effects of NMES on swallowing and neural activation. The review was conducted as part of a series examining the effects of oral motor exercises (OMEs) on speech, swallowing, and neural activation. A systematic search was conducted to identify relevant studies published in peer-reviewed journals from 1960 to 2007. All studies meeting the exclusion/inclusion criteria were appraised for quality and categorized as efficacy or exploratory research based on pre-determined criteria. Out of 899 citations initially identified for the broad review of OMEs, 14 articles relating to NMES qualified for inclusion. Most of the studies (10/14) were considered exploratory research, and many had significant methodological limitations. The authors concluded that this systematic review revealed that surface NMES to the neck has been most extensively studied with promising findings, yet high-quality controlled trials are needed to provide evidence of efficacy. Surface NMES to the palate, faucial pillars, and pharynx has been explored in phase I clinical trials, but no evidence of efficacy is currently available. Intra-muscular NMES has been investigated in a single phase I exploratory study. The authors stated that additional research is needed to document the effects of such protocols on swallowing performance.

Christiaanse et al (2011) compared change in swallowing function in pediatric patients with dysphagia who received NMES to a control group who received usual oral motor training and dietary manipulations without NMES. These investigators carried out retrospective analysis of change in Functional Oral Intake Scale (FOIS) level derived from video-fluoroscopic swallowing studies performed before and after NMES (treatment group: n = 46) compared to control group (control group: n = 47). Children were classified into 2 groups based on the etiology of their dysphagia (primary versus acquired). Neuromuscular electrical stimulation took place in a tertiary medical center for an average of 22 treatment sessions over 10 weeks. An independent t-test was used to test for differences in the change in FOIS level between groups. An analysis of co-variance was run within groups to assess the relationship between diagnosis and change in FOIS level. Both groups improved in their FOIS level (p < 0.01) but the amount of change was not different (p = 0.11). Only the treatment group who had acquired dysphagia improved more than the similar subgroup of control children (p = 0.007). The authors concluded that NMES treatment of anterior neck muscles in a heterogeneous group of pediatric patients with dysphagia did not improve the swallow function more than that seen in patients who did not receive NMES treatment. However, there may be subgroups of children that will improve with NMES treatment.

Humbert et al (2012) noted that consequences of dysphagia substantially reduce quality of life, increase the risk of medical complications and mortality, and pose a substantial cost to healthcare systems. As a result, it is of no wonder that the clinical and scientific communities are showing interest in new avenues for dysphagia rehabilitation. Electrical stimulation for the treatment of swallowing impairments is among the most studied swallowing interventions in the published literature, yet many unanswered questions about its effectiveness remain.

Doeltgen and Huckabee (2012) stated that the recent application of neurostimulation techniques to enhance the understanding of swallowing neural plasticity has expanded the focus of rehabilitation research from manipulation of swallowing biomechanics to manipulation of underlying neural systems. Neuromodulatory strategies that promote the brain's ability to re-organize its neural connections have been shown to hold promising potential to aid the recovery of impaired swallowing function. These techniques include those applied to the brain through the intact skull, such as transcranial magnetic stimulation or transcranial direct current stimulation, or those applied to the sensorimotor system in the periphery, such as NMES. Recent research has demonstrated that each of these techniques, either by themselves or in combination with these and other treatments, can, under certain circumstances, modify the excitability of motor representations of muscles involved in swallowing. In some studies, experimentally induced plastic changes have been shown to have functional relevance for swallowing biomechanics. However, the transition of novel, neuromodulatory brain stimulation techniques from the research laboratory to routine clinical practice is accompanied by a number of ethical, organizational, and clinical implications that impact professions concerned with the treatment of swallowing rehabilitation. The authors provided a brief overview of the neuromodulatory strategies that may hold potential to aid the recovery of swallowing function, and raise a number of issues that they believe the clinical professions involved in the rehabilitation of swallowing disorders must confront as these novel brain stimulation techniques emerge into clinical practice.

Currently, there is insufficient evidence to support the use of electrical stimulation in the treatment of feeding/swallowing disorders. Well-designed studies are needed to ascertain the effectiveness of electrical stimulation for these disorders.

Cincinnati Children's Hospital Medical Center’s best evidence statement (BESt) on "Behavioral and oral motor interventions for feeding problems in children" (2013) recommended that an intensive feeding program model that combines oral motor and behavioral interventions may be used with children with severe feeding problems to increase intake. (

Note

: Programs ranged from 2 weeks to 8 weeks duration; treatments 4 to 11 times per day).

In a prospective, single-center study, Lagatta and colleagues (2021) compared healthcare use and parent health-related quality of life (HRQL) in 3 groups of infants whose neonatal intensive care unit (NICU) discharge was delayed by oral feedings. This trial included infants in the NICU from September 2018 to March 2020. After enrollment, weekly chart review determined eligibility for home nasogastric (NG) feeds based on pre-determined criteria. Actual discharge feeding decisions were at clinical discretion . At 3 months' post-discharge, these investigators compared acute healthcare use and parental HRQL, measured by the PedsQL Family Impact Module, among infants who were NG eligible but discharged with all oral feeds, discharged with NG feeds, and discharged with gastrostomy (G) tubes. They calculated NICU days saved by home NG discharges. Among 180 infants, 80 were orally fed, 35 used NG, and 65 used G tubes. Compared with infants who had NG-tube feedings, infants who had G-tube feedings had more gastro-intestinal (GI) or tube-related re-admissions and emergency encounters (unadjusted odds ratio [OR] 3.97, 95 % confidence interval [CI]: 1.3 to 12.7, p = 0.02), and orally-fed infants showed no difference in use (unadjusted OR 0.41, 95 % CI: 0.1 to 1.7, p = 0.225). Multi-variable adjustment did not change these comparisons. Parent HRQL at 3 months did not differ between groups. Infants discharged home with NG tubes saved 1,574 NICU days. The authors concluded that NICU discharge with NG feeds was associated with reduced NICU stay without increased post-discharge healthcare use or decreased parent HRQL, whereas G-tube feeding was associated with increased post-discharge healthcare use.

Ostadi and associates (2021) noted that preterm infants showed problems with pharyngeal swallowing in addition to sucking problems. Oral motor intervention and non-nutritive sucking (NNS) were introduced for promoting oral feeding skills in preterm infants. NNS cannot cover all the components of oral feeding. On the other hand, the swallowing exercise (SE) can accelerate the attainment of independent oral feeding in the preterm infants. In a randomized controlled trial (RCT), these researchers examined if a combined program of NNS and SE compared with a program that only involved NNS would be more effective on oral feeding readiness of premature infants. This study was carried out in a NICU); 45 preterm infants were recruited in 3 groups. In group I, infants were provided with NNS twice-daily; group II received a program that involved 15 mins of NNS and 15 mins of SE daily. Both interventions were provided 10 days during 2 consecutive weeks; group III (control group) received the routine NICU care. All infants were evaluated by functional oral feeding outcome measures including post-menstrual age (PMA) at the start of oral feeding, PMA at full oral feeding, transition time (days from start to full oral feeding), PMA at discharge time and also the infant's dependency on tube-feeding at discharge time after interventions. Furthermore, all infants were evaluated via Preterm Oral Feeding Readiness Scale (POFRAS) before and after intervention. No significant differences were observed in the PMA mean at start of oral-feeding (p = 0.29), full oral-feeding (p = 0.13), discharge time (p = 0.45) and the mean of transition time (p = 0.14). Compared to the control group, more infants in group II were discharged without tube-feeding (p = 0.01). The mean of POFRAS was significantly higher in both groups I and II compared to the group III (p = 0.02 and p = 0.01, respectively). This score was, however, not statistically different between the groups I and II (p = 0.98). The authors concluded that both studied interventions were superior to routine NICU care in enhancing the oral feeding readiness of preterm infants based on the POFRAS score. The studied combined program of NNS and SE, and not NNS program, could significantly increase the number of discharged infants without tube-feeding compared to control group.

Some children with food refusal are completely reliant on a feeding tube or oral formula supplementation for their nutritional needs. These patients may not present as underweight/malnourished/failure to thrive (FTT) because the medical intervention (i.e., feeding tube; formula dependence) maintains their weight status, but the use of a feeding tube does not resolve the pediatric feeding disorder. Sharp, et al. (2020) reported a electronic chart review assessing the characteristics and outcomes of young children receiving intensive multidisciplinary intervention for chronic food refusal and feeding tube dependence. The investigators conducted a retrospective study of consecutive patients (birth to age 21 years) admitted to an intensive multidisciplinary intervention program over a 5-year period (June 2014-June 2019). Inclusion criteria required dependence on enteral feeding, inadequate oral intake, and medical stability to permit tube weaning. Treatment combined behavioral intervention and parent training with nutrition therapy, oral-motor therapy, and medical oversight. Data extraction followed a systematic protocol; outcomes included anthropometric measures, changes in oral intake, and percentage of patients fully weaned from tube feeding. Of 229 patients admitted during the 5-year period, 83 met the entry criteria; 81 completed intervention (98%) and provided outcome data (46 males, 35 females; age range, 10-230 months). All patients had complex medical, behavioral, and/or developmental histories with longstanding feeding problems (median duration, 33 months). At discharge, oral intake improved by 70.5%, and 27 patients (33%) completely weaned from tube feeding. Weight gain (mean, 0.39 ± 1 kg) was observed. Treatment gains continued following discharge, with 58 patients (72%) weaned from tube feeding at follow-up. The investigators concluded that their findings support the effectiveness of an intensive multidisciplinary intervention model in promoting oral intake and reducing dependence on tube feeding in young children with chronic food refusal. The investigators stated that further research on the generalizability of this intensive multidisciplinary intervention approach to other specialized treatment settings and/or feeding/eating disorder subtypes is warranted.

Sharp, et al. (2017) conducted a systematic evidence review assess models of care and conducted a meta-analysis of program outcomes for children receiving intensive, multidisciplinary intervention for pediatric feeding disorders. The investigators searched Medline, PsycINFO, and PubMed databases (2000-2015) in peer-reviewed journals for studies that examined the treatment of children with chronic food refusal receiving intervention at day treatment or inpatient hospital programs. Inclusion criteria required the presentation of quantitative data on food consumption, feeding behavior, and/or growth status before and after intervention. Effect size estimates were calculated based on a meta-analysis of proportions. The systematic search yielded 11 studies involving 593 patients. Nine articles presented outcomes based on retrospective (nonrandomized) chart reviews; 2 studies involved randomized controlled trials. All samples involved children with complex medical and/or developmental histories who displayed persistent feeding concerns requiring formula supplementation. Behavioral intervention and tube weaning represented the most common treatment approaches. Core disciplines overseeing care included psychology, nutrition, medicine, and speech-language pathology/occupational therapy. The overall effect size for percentage of patients successfully weaned from tube feeding was 71% (95% CI 54%-83%). Treatment gains endured following discharge, with 80% of patients (95% CI 66%-89%) weaned from tube feeding at last follow-up. Treatment also was associated with increased oral intake, improved mealtime behaviors, and reduced parenting stress. The investigators stated that these results indicate intensive, multidisciplinary treatment holds benefits for children with severe feeding difficulties. The investigators stated that future research must address key methodological limitations to the extant literature, including improved measurement, more comprehensive case definitions, and standardization/examination of treatment approach.

Children with severely restricted diets, such severe food selectivity, may consume enough calories to maintain growth, but present with multiple areas of nutrient insufficiency that place then at risk for diet related diseases (e.g., rickets, scurvy). Sharp et al. (2018) explained that food selectivity is common in children with autism spectrum disorder (ASD). The clinical characteristics, however, of severe food selectivity in children with ASD is not well documented.

The investigators examined the demographic characteristics, anthropometric parameters, risk of nutritional inadequacy, dietary variety, and problematic mealtime behaviors in a sample of children with ASD with severe food selectivity. The study involved a cross-sectional electronic medical record review. Data extraction followed a systematic protocol for data extraction. Children (age 2 to 17 years) with ASD, severe food selectivity, and complete nutritional data who received a multidisciplinary evaluation at a specialty feeding clinic in the southeastern United States between January 2014 and January 2016. Criteria for severe food selectivity used in this clinical practice required complete omission of one or more food groups (eg, fruit, vegetable, protein, grain, dairy) or consuming a narrow range of items on a weekly basis (eg, five or fewer total food items). Analyses examined demographic characteristics, dietary preferences, risk for nutritional inadequacies, anthropometric parameters, and problematic mealtime behaviors. Of the 279 patients evaluated during the 24-month period, 70 children with ASD and severe food selectivity met inclusion criteria. Caregivers reported 67% of the sample (n=47) omitted vegetables and 27% omitted fruits (n=19). Seventy-eight percent consumed a diet at risk for five or more inadequacies. Risk for specific inadequacies included vitamin D (97% of the sample), fiber (91%) vitamin E (83%), and calcium (71%). Children with five or more nutritional inadequacies (n=55) were more likely to make negative statements during meals (P<0.05). Severe food selectivity was not associated with compromised growth or obesity. The authors concluded that children with ASD and severe food selectivity may be at increased risk for nutritional inadequacies. They stated that future research should examine causes, consequences, and remediation of severe food selectivity in this population.

Volkert, et al. (2021) stated that expert consensus increasingly recognizes intensive multidisciplinary intervention (IMI) as the standard of care to address chronic and severe feeding problems in pediatric populations. The investigators examined the clinical presentation, intervention characteristics, and treatment outcomes for young children receiving IMI for avoidant restrictive rood intake disorder (ARFID) involving nutritional insufficiencies associated with severe food selectivity. The investigators followed the Strengthening the Reporting of Observational Studies in Epidemiology statement to conduct this retrospective chart review. The review focused on consecutive patients (birth to age 21 years) admitted to the IMI program over a 5-year period (June 2014 to June 2019). Inclusion criteria required micronutrient insufficiencies (vitamins A, B12, C, D, E; folic acid; calcium; iron; and zinc) and chronic mealtime refusal behavior (e.g., turning head away from food/spoon, pushing or throwing spoon, crying, screaming, and leaving the table) associated with severe food selectivity. Over the 5-year period, 63 of the patients met study entry requirements. Of these, 60 patients (50 boys and 10 girls; mean age = 72 ± 39 months; range = 23-181) completed intervention (95% treatment completion rate). At discharge, dietary diversity improved by 16 new therapeutic foods (range: 8-22), rapid acceptance and swallowing of new foods exceeded clinical benchmarks (80% or > bites), and risk for nutritional inadequacies declined for this patient cohort. Results of the current study support the benefits of IMI to increase dietary variety, improve mealtime behaviors, and enhance nutritional intake for children with ARFID presenting with severe food selectivity.

Severe psychosocial impairment with or without malnutrition/failure to thrive is also part of all new diagnostic frameworks for pediatric feeding disorders. This includes cases where the level of food avoidance/restriction significantly interfere with daily functioning; impairment that may not be detected by an examination of growth parameters. Goday, et al. (2019) noted that pediatric feeding disorders (PFDs) lack a universally accepted definition. The authors stated that feeding disorders require comprehensive assessment and treatment of 4 closely related, complementary domains (medical, psychosocial, and feeding skill-based systems and associated nutritional complications). Previous diagnostic paradigms have, however, typically defined feeding disorders using the lens of a single professional discipline and fail to characterize associated functional limitations that are critical to plan appropriate interventions and improve quality of life. Using the framework of the World Health Organization International Classification of Functioning, Disability, and Health, a unifying diagnostic term is proposed: "Pediatric Feeding Disorder" (PFD), defined as impaired oral intake that is not age-appropriate, and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction. By incorporating associated functional limitations, the proposed diagnostic criteria for PFD should enable practitioners and researchers to better characterize the needs of heterogeneous patient populations, facilitate inclusion of all relevant disciplines in treatment planning, and promote the use of common, precise, terminology necessary to advance clinical practice, research, and health-care policy.

Scope of Policy

This Clinical Policy Bulletin addresses pediatric intensive feeding programs.

Medical Necessity

Aetna considers professional services for pediatric intensive feeding programs consisting of an inter-disciplinary team (e.g., behavioral therapist, occupational therapist, physician, registered dietitian, and speech language pathologist/therapist) to treat complex feeding and swallowing disorders in infants and children medically necessary when

all

of the following conditions are met:

Behavior problems are interfering with feeding;

and

Diagnosis-specific treatment plan with child-specific interventions and estimated length of treatment are proposed and documented;

and

Medical causes of failure to thrive have been treated (e.g., acidosis, renal insufficiency, malabsorption) without resolution of the feeding problem;

and

Physician will coordinate and oversee the treatment program;

and

Member has one or more of the following feeding problems:

Significant nutritional deficiencies from severely restricted diets (e.g., severe food selectivity) that place them at risk for diet related diseases (e.g., rickets, scurvy);

or

Feeding problems, such as food refusal, that result in dependence on enteral feeding or nutritional supplementation;

or

Severe psychosocial impairment where the level of food avoidance/restriction significantly interferes with daily functioning;

or

Malnutrition, as demonstrated by a suboptimal score on nutritional assessment as indicated by

any

of the following:

Weight below the third or fifth percentile for gestation-corrected age and sex on more than one occasion. Special growth charts for selected genetic syndromes should be used when indicated (e.g., for children with Down syndrome, Turner syndrome, etc);

or

Weight less than 80 % of ideal weight for age, using the standard growth charts of the National Center for Health Statistics (NCHS);

or

Depressed weight for length (i.e., weight age less than length age, weight for length less than 10th percentile);

or

A rate of weight gain that causes a decrease in 2 or more major percentile lines (90th, 75th, 50th, 25th, 10th, and 5th) over time (e.g., from 75th to 25th);

or

A rate of daily weight gain less than that expected for age over the previous 2 months,

and

Unresponsive to initial treatment efforts by a single discipline (e.g., occupational therapist, speech language pathologist/therapist) over a 2-month period.

Aetna considers pediatric intensive feeding programs experimental and investigational for all other indications (e.g., childhood obesity, Prader-Willi syndrome) because their effectiveness for indications other than the ones listed above have not been established.

Outpatient care is appropriate for the majority of children with complex feeding problems. Inpatient admission may be appropriate for management of acute problems in children who are severely malnourished (less than or equal to 75 % of ideal body weight), seriously ill, or at risk of harm.

Experimental and Investigational

Aetna considers electrical stimulation for the treatment of swallowing/feeding disorders experimental and investigational because its effectiveness for these indications has not been established.

Policy Limitations and Exclusions

Notes:

Interventions for behavioral therapy are covered under the member's behavioral health benefits. Please check benefit plan descriptions.

Some plans limit coverage of medically necessary speech therapy and occupational therapy. Speech therapy of the developmentally delayed child has included training to improve the functioning of oral and pharyngeal muscles. This oral-motor training is usually introduced before the emergence of speech. Most Aetna plans exclude treatment of developmental delay. Please check benefit plan descriptions for details.

A

etna's policies typically exclude coverage for services, treatment, education testing, or training related to learning disabilities or developmental delays. When the policy has such an exclusion, speech therapy and occupational therapy are not covered when the primary or the only diagnosis for a member is mental retardation or a learning disability such as a perceptual handicap, brain damage not caused by accidental injury or illness, minimal brain dysfunction, dyslexia, or developmental delay.

Members should check their benefit plan descriptions for any applicable benefit plan limitations and exclusions on coverage for speech therapy services.

Standard growth charts of the National Center for Health Statistics (NCHS) are available at:

Standard growth charts of the National Center for Health Statistics (NCHS)

.

Pediatric feeding disorders should not be confused with anorexia or bulimia, which are characterized by marked disturbances in eating behavior more common in adolescence and adulthood. For anorexia and bulimia, see

CPB 0511 - Eating Disorders

.