What Is Known
- Pediatric feeding disorders lack a universally accepted definition.
- Previous diagnostic paradigms have defined feeding disorder from the perspective of a single medical discipline.
What Is New
- A unifying diagnostic term, “Pediatric Feeding Disorder”, using the framework of the World Health Organization International Classification of Functioning, Disability, and Health is proposed.
- This term unifies the medical, nutritional, feeding skill, and/or psychosocial concerns associated with feeding disorders.
- The proposed diagnostic criteria should promote the use of common, precise, terminology necessary to advance clinical practice, research, and health care policy.
Feeding is a complex process that requires interaction of the central and peripheral nervous systems, oropharyngeal mechanism, cardiopulmonary system, and gastrointestinal (GI) tract with support from craniofacial structures and the musculoskeletal system. This coordinated interaction requires acquisition and mastery of skills appropriate for a child's physiology and developmental stage. In children, feeding occurs in the context of the caregiver-child dyad. A disruption in any of these systems places a child at risk for a feeding disorder and associated complications (1,2). Often, more than 1 system is disrupted, contributing to the development and persistence of pediatric feeding disorders (PFDs) (3). Hence, effective assessment and treatment of PFDs require the involvement of multiple disciplines. The lack of a universally accepted definition has, however, hindered collaborative care.
Despite inherent multiple underlying mechanisms and need for multidisciplinary care, the diagnosis of feeding disorders has been approached unilaterally, with each discipline suggesting its own approach. These unilateral paradigms typically do not capture the complexity of feeding disorders. The American Speech-Language-Hearing Association defines pediatric dysphagia in terms of impaired oral, pharyngeal, and/or esophageal phases of swallowing (4). The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition diagnosis of Avoidant/Restrictive Food Intake Disorder incorporates nutritional complications and acknowledges that feeding disorders are common in certain medical conditions; however, it requires that severity of the eating disturbance exceeds that associated with the condition and specifically excludes children whose primary challenge is a skill deficit (5,6).
Historically, feeding disorders were defined using an organic/nonorganic dichotomy. The International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10) diagnostic codes for PFDs either requires the absence of organic disease (F98.2: Other feeding disorders of infancy and childhood) or uses the nonspecific, poorly defined R63.3: Feeding difficulties (7). Existing diagnostic codes are clearly inadequate to describe the multiple factors involved in a feeding disorder (8).
In this article, use of the International Classification of Functioning, Disability, and Health (ICF) framework to define a unifying diagnostic term, “pediatric feeding disorder” (PFD) is proposed. The World Health Organization ICF framework defines functioning as an umbrella term referring to all body functions, activities, and participation, and defines disability as an umbrella term covering impairment (a problem in body function or structure), activity limitation (difficulty encountered in executing a task or action), and participation restriction (problem experienced in involvement in life situations). The ICF framework complements the ICD-10 (9), and emphasizes a holistic understanding of the physiologic and functional impact of PFD, including the impaired mechanisms, environmental barriers, and facilitators and, most importantly, the impact on participation in daily family and community life. The proposed diagnostic criteria in this article result from deliberations among a panel of experts well versed in the care of children with feeding disorders. The diagnostic criteria were derived from a combination of evidence, when available, and expert opinion.
Since the publication of the World Health Organization ICF, there is increasing recognition that diagnoses do not necessarily predict function, and that assessment of functional limitations is critical to planning appropriate interventions to improve quality of life (10). PFDs can profoundly impact a child's physical, social, emotional, and/or cognitive function, and increase caregiver stress (3). A classification system describing the effects of a PFD on function would enable practitioners and researchers to better characterize the needs of heterogeneous patient populations, facilitate inclusion of all relevant disciplines in treatment, and allow the health care team to use a common, precise terminology necessary to advance clinical practice and research (10).
PEDIATRIC FEEDING DISORDER: DEFINITION
PFD is defined as impaired oral intake that is not age-appropriate, and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction. The proposed diagnostic criteria are shown in Table 1. PFD can be classified into acute (<3 months’ duration) and chronic (≥3 months’ duration) (11).
The proposed reference standard for oral intake is age-appropriate feeding: the progressive acquisition of feeding skills enabling progression from breast or bottle feeding to self-feeding a variety of age-appropriate table foods. Children with developmental delays may have feeding skills appropriate for their level of development but not their age; hence, these children will have a diagnosis of PFD.
In the proposed definition, impaired oral intake refers to the inability to consume sufficient food and liquids to meet nutritional and hydration requirements. The definition excludes the inability to take medications or atypical, unpalatable foods. To eliminate transient feeding problems resulting from acute illness, impaired oral intake must be present daily for at least 2 weeks.
To distinguish between PFD and eating disorders (eg, anorexia nervosa), PFD should be diagnosed only in the absence of body image disturbances. Although pica and rumination can be associated with PFD, their presence alone does not constitute PFD (12).
According to the ICF framework, disability results when impairments interact with personal and environmental factors to result in activity limitations or participation restriction. PFD results in disability (13). For example, impaired ability to eat leads to participation restrictions or modifications in childcare, school, and other environments that involve mealtime interactions. In later life, PFD can impair attainment of social relationships and employment (9). Because the definition of disability is dependent on environmental factors (the physical, social, and attitudinal environment in which people live and conduct their lives), culturally specific feeding behaviors in the absence of dysfunction do not qualify as PFD.
Four important domains underlie PFD: medical, nutritional, feeding skills, and psychosocial. Because of interplay between these domains, impairment in one can lead to dysfunction in any of the others. The result is PFD. Disability resulting from interactions among health conditions, personal factors, and environmental factors are discussed below.
Impaired structure/function of the GI, cardiorespiratory, and neurological systems are frequently associated with dysphagia that results in dysfunction in 1 or more feeding domains, and PFD. (Supplementary Table 1, Supplemental Digital Content, http://links.lww.com/MPG/B507) The impairments related to medical conditions give rise to dysfunction through several mechanisms.
Upper GI tract dysfunction is associated with PFD, arising primarily from a GI anomaly or disease, or secondarily from respiratory or airway pathology. Oropharyngeal and laryngeal anomalies can impair the mechanics of normal feeding. Inflammatory diseases of the upper GI tract may also impair normal feeding. Although there is insufficient documented evidence to support a strong association between gastroesophageal reflux disease and PFD, the link between PFD and eosinophilic esophagitis is better established (14). Motility and functional GI disease also may impair feeding including children with repaired esophageal atresia (15), post-fundoplication (16), and feeding volume intolerance independent of gastroparesis in medically complex children.
Diseases of the airway and lungs are the other components of “aerodigestive disease” and can also result in PFD, particularly in young children with chronic tachypnea, where the suck-swallow-breathe coordination is particularly challenging. Chronic lung disease of prematurity often causes tachypnea and dyspnea that affect swallowing and feeding skill acquisition (17). Aspiration resulting from PFD can manifest as lower respiratory tract infections (eg, pneumonia), but is more commonly identified via fluoroscopy based on subtle respiratory signs/symptoms and/or other clinical manifestations (eg, feeding refusal in infancy).
Children with congenital heart disease may require prolonged hospitalization with critical care interventions that can delay and subvert the acquisition of feeding skills. Cardiac surgery can result in recurrent laryngeal nerve injury with left vocal fold paralysis and impaired airway protection. Chronic hypoxia and possible vagal injury may play a role in feeding intolerance and vomiting in these children (18).
Children with neurologic impairments are at increased risk for PFD, particularly as they grow and reach points where nutritional needs exceed their feeding skills (19). Generally, children with more severe motor and cognitive delays have greater feeding impairment (20). Neurogenic dysphagia is common during infancy but may present later secondary to cerebral palsy, leading to morbidity and mortality from chronic aspiration (21).
Neurodevelopmental disorders, specifically autism spectrum disorder, are also associated with PFD (22). Finally, some children who consume inadequate calories for normal growth may have a disorder of appetite signaling mechanisms causing PFD.
Many children with PFD have a restricted quality, quantity, and/or variety of beverages and foods consumed, placing them at risk of malnutrition, overnutrition, micronutrient deficiency or toxicity, and dehydration (Supplementary Table 2, Supplemental Digital Content, http://links.lww.com/MPG/B507). Malnutrition is defined as intake of nutrients insufficient to meet nutritional requirements, resulting in “cumulative deficits of energy, protein or micronutrients” that may adversely impact growth, development, and health (23). Malnutrition affects 25% to 50% of children with PFD (24,25) and is most prevalent among those with chronic disease or neurodevelopmental disorders (26).
The restricted dietary diversity common in PFD can have other adverse nutritional consequences. Exclusion of entire food groups, such as fruits and vegetables, can result in micronutrient deficiency despite adequate macronutrient intake (27–30). Children with excessive intake of specific foods, beverages, or dietary supplements can experience micronutrient excess or, rarely, toxicity (22). Excessive energy intake, especially in the setting of lower energy requirements, can result in obesity (31).
FEEDING SKILL FACTORS
Altered feeding experiences due to illness, injury, or developmental delay may lead to impairment of feeding skills. Neurodevelopmental delay inhibiting feeding may become evident any time in the first few years of life, during periods of change in oropharyngeal anatomy and neuromuscular coordination, texture transitions, and transitions in feeding/drinking utensils (32,33). Specific impairments in oral and pharyngeal sensory-motor functioning may also inhibit feeding skills. In addition, altered oral experiences from physical injury, deficits in neurologic functioning (34), abnormal oral structure or function (35), and/or adverse or limited feeding experience (36–39) can cause feeding skills impairment (Supplementary Table 3, Supplemental Digital Content, http://links.lww.com/MPG/B507).
Impairment in oral sensory functioning inhibits/limits acceptance and tolerance of liquids and food textures expected for age; it may be associated with specific characteristics of liquids and food textures such as the flavor, temperature, bolus size, viscosity, texture, or appearance (40,41). Under-response or hyposensitivity is generally characterized by lack of awareness of food within the mouth, limited bolus formation, loss of food from the mouth, increased bolus size, and gagging or refusal of liquids and food textures that provide inadequate sensory input. These children characteristically seek increased bolus size or exaggerated flavors, temperatures, and textures. Over-response or hypersensitivity is generally characterized by gagging with specific textures or bolus size, excessive chewing, and limited variety of intake. These children characteristically seek bland flavors, finely grained textures, small bolus sizes, and room-temperature foods.
Impairment in oral motor functioning limits bolus control, manipulation, and/or transit of liquids and solids; it can be characterized by inefficient intake, messy eating, poor control of liquids and foods, slow or ineffective bolus formation and propulsion, gagging during bolus formation, and postswallowing residue (42).
Although the clinician can evaluate the oral phases visually, evaluation of pharyngeal structures and their function requires instrumental assessment using a modified barium swallow or fiberoptic endoscopic evaluation of swallowing (37,38,43). Impairment in pharyngeal sensation inhibits airway protection and efficient swallowing; it is often associated with poorly timed and coordinated swallowing during pharyngeal transit, poor awareness of bolus location, presence of pharyngeal residue post-swallow, and silent aspiration. Clinical characteristics of sensory impairment can include gulping or audible swallows, too many or too few swallows per bolus, wet vocalization, and no attempts to clear residue after swallowing (44,45).
Impairment in pharyngeal motor functioning inhibits pharyngeal movements. It may be evidenced by reduction in strength and coordination of pharyngeal constrictors, velar and laryngeal elevation, and vocal fold closure. Symptoms can include multiple effortful swallows per bolus, throat clearing, pharyngonasal flow, chronic nasal congestion, inability to clear residue, and poor airway protection.
To be fully functional, a child's feeding skills must be safe, age appropriate, and efficient. Dysfunction in any of these areas constitutes PFD.
Unsafe oral feeding may present as choking, aspiration, adverse cardiorespiratory events (eg, apnea, bradycardia) during oral feeds, or other adverse mealtime events (eg, gagging, vomiting, fatigue, refusal) (46,47).
Delayed feeding skills may present as a child who is unable to consume age-appropriate liquid and food textures. The child may require food/fluid to be modified from its original form (eg, blending solids into a purée) or may rely on a natural variant (eg, a naturally smooth food) that is not age appropriate. These children may have deficits in use of feeding utensils and devices or self-feeding skills. They may require special feeding equipment, positioning, or feeding strategies (32,33).
Inefficient oral feeding may present as prolonged mealtime duration (ie, >30 minutes) or inadequate oral intake. These children may require modified textures, special feeding equipment or strategies, or nutritional supplementation (32,33).
Factors within the child, caregiver, and the feeding environment (psychosocial impairments) can adversely affect feeding development and ultimately contribute to and maintain PFD (48,49). Problem feeding behaviors are the resultant dysfunction and are often among the first concerns that caregivers express regarding feeding their child (50).
Psychosocial factors in the child and/or caregiver can contribute to feeding dysfunction (51) and are characterized as Developmental Factors, Mental and Behavioral Health Problems, Social Factors, or Environmental Factors (Supplementary Table 4, Supplemental Digital Content, http://links.lww.com/MPG/B507) (48,49). Although problems in any of these domains can lead to feeding dysfunction, most commonly PFD results from an interaction among any or all 4 domains (6,52).
Developmental factors resulting in delays of motor skills, language, socialization, and cognition can contribute to the development of PFD. These delays often result in a mismatch between the feeding abilities of the child and the feeding expectations of adult caregivers who are responsible for feeding the child. For example, if a caregiver's expectations of what a child should eat are not congruent with what a child can eat due to delays in skill development, this incongruence can contribute to aversive feeding experiences resulting in a PFD, particularly if the caregiver persists in attempting to feed the child in a chronologically age-typical manner (53).
Mental and behavioral health problems in the child, caregiver, or dyad can adversely influence feeding behavior (54). In a child, dysregulated temperament, mood disorders, anxiety, or disordered thinking can increase rates of disruptive feeding behavior (55). In a caregiver, stress and/or other mental health factors can alter mealtime interactions (56). These factors may impact how the caregiver approaches the feeding situation, resulting in over- or undercontrolling parenting practices. These factors act bidirectionally within the child-caregiver dyad (51).
Social influences including caregiver-child interactions and cultural expectations within a mealtime context can impact a child's behavior at mealtimes. For example, a caregiver's strategies for general management of problem behavior may not be effective in managing mealtime-specific behavior problems. Caregivers may misinterpret a child's hunger and satiety cues, interrupting the development of positive learning about eating. Finally, a caregiver's cultural beliefs about feeding and nutrition may not be consistent with expectations of others (eg, American Academy of Pediatrics guidelines, expectations of teachers and healthcare providers), which may affect how the caregiver feeds the child and how the child responds.
Environmental factors can contribute to the development of PFD. During meals, a distracting feeding environment (eg, use of television or other electronic devices) or resorting to feeding only at times when a child is asleep, may prevent caregivers from providing appropriate responses to mealtime behavior or can lead to the inadvertent reinforcement of problematic mealtime behavior by well-intentioned caregivers (eg, replacing refused foods with highly preferred foods, attending to crying) (57). An inconsistent mealtime schedule can adversely affect appetite and subsequently mealtime behavior (53). Unavailability of food resources can affect how and what a caregiver feeds their child, which can subsequently affect the child's feeding behavior.
PFD can develop as a result of the impairments described above and generally manifests as one of the following (49):
Learned feeding aversions result when a child repeatedly experiences physical or emotional pain or discomfort during feedings. Over time, the child develops strategies to avoid the aversive feeding situations. When these strategies succeed, the behaviors and learned aversion are strengthened (48).
Stress and distress in the child and/or caregiver are expressed as negative emotions or as disengagement from meals (3,56).
Disruptive behavior that is incompatible with eating. These behaviors can be active (eg, pushing food away, elopement, aggression toward the caregiver) or passive (eg, refusal to self-feed).
Food overselectivity (picky eating) is defined as eating a limited variety of foods or unwillingness to try new foods, despite the ability to eat a broader diet (58).
Failure to advance to age-appropriate diet despite adequate skill (54).
Grazing is defined as consuming small amounts of food or fluid throughout the day. It causes a false sense of satiety and often leads to reduced intake (59).
Caregiver use of inappropriate strategies to improve child nutritional status (59). Some compensatory strategies are functional, but maladaptive. Instead of improving nutritional status, maladaptive compensatory strategies can perpetuate or worsen malnutrition and other manifestations of feeding dysfunction. Examples include offering only preferred foods, feeding a child that has the skills to self-feed, forced feeding, or giving fluid via infant bottle outside of the recommended age for bottle feeding.
These proposed diagnostic criteria for PFD use a conceptual framework that goes beyond disease-oriented or unilateral diagnostic paradigms, defining PFD as restricted oral intake that is not age appropriate and leads to dysfunction in at least one of 4 closely related, complementary domains. Adoption of this definition by healthcare professionals from all disciplines will establish a common terminology that could have widespread impact on clinical practice, education, research, and advocacy.
These criteria aim to create a platform for change to ensure infants and children with PFD receive the best care possible and that the families receive the broadest community support available. This framework supports advocacy by family and professional organizations, and promotion of increased training opportunities, to ensure that children with PFD have access to all specialists needed for optimal management. Although not all children have impairment in all 4 domains, initial evaluation of each domain is strongly recommended because the same presenting symptoms and signs can yield distinct, complementary domain-specific recommendations needed for successful treatment to promote optimal function (60). Optimal care of children with PFD requires a team approach (Supplementary Table 5, Supplemental Digital Content, http://links.lww.com/MPG/B507), but many patients are unable to access evaluations in all 4 domains, due to lack of insurance coverage or lack of available specialists in their geographic location.
By promoting usage of a consistent, comprehensive, interdisciplinary terminology that encompasses both physiologic impairment and function, this definition has the potential to facilitate interdisciplinary collaboration; promote educational curricula to train practitioners; promote research investigating best practices; and allow comparison of outcomes between studies and clinical programs. This, in turn, may lead to recognition of specific diagnostic subtypes with treatment or prognostic implications. Additional systems-oriented advantages include the ability to partner with policymakers so that PFD is a qualifying diagnosis for early intervention services under part C of the Individuals with Disabilities Education Act; and stimulate changes to the ICD-10 codes and insurance coverage policies to allow for improved reimbursement and coverage of infants and children for rehabilitative services.
The authors wish to thank the following individuals without whom this article would not have been possible: Joan Arvedson, PhD, Colin Rudolph, MD, PhD, Kay A. Toomey, PhD, and Shannon Goldwater and Chris Linn of Feeding Matters.
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