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Aetna Aetna
Clinical Policy Bulletin:
Pediatric Intensive Feeding Programs
Number: 0809


Policy

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:

  1. Behavior problems are interfering with feeding; and
  2. Diagnosis-specific treatment plan with child-specific interventions and estimated length of treatment are proposed and documented; and
  3. Medical causes of failure to thrive have been treated (e.g., acidosis, renal insufficiency, malabsorption) without resolution of the feeding problem; and
  4. Neurological or oral-motor problems exist; and
  5. Normal feeding milestones have not been met; and
  6. Physician will coordinate and oversee the treatment program; and
  7. Suboptimal score on nutritional assessment has been documented as indicated by any of the following:
     
    1. Weight below the 3rd or 5th 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
    2. Weight less than 80 % of ideal weight for age, using the standard growth charts of the National Center for Health Statistics (NCHS); or
    3. Depressed weight for length (i.e., weight age less than length age, weight for length less than10th percentile); or
    4. 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
    5. A rate of daily weight gain less than that expected for age over the previous 2 months, and
       
  8. 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. 

Notes:

  1. Interventions for behavioral therapy are covered under the member's behavioral health benefits.  Please check benefit plan descriptions.
  2. 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. 
  3. Aetna considers electrical stimulation for the treatment of swallowing/feeding disorders experimental and investigational because its effectiveness for these indications has not been established.
  4. Aetna'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. 
  5. 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: http://www.cdc.gov/growthcharts/.

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.

See also CPB 0049 - Nutritional CounselingCPB 0061 - Nutritional SupportCPB 0116 - Frenectomy or Frenotomy for AnkyloglossiaCPB 0226 - Hospitalization for the Initiation of Ketogenic Diet for the Treatment of Intractable SeizuresCPB 0243 - Speech TherapyCPB 0248 - Fiberoptic Endoscopic Evaluation of Swallowing (FEES)/Fiberoptic Endoscopic Evaluation of Swallowing with Sensory Testing (FEESST)CPB 0250 Occupational Therapy Services, CPB 0625 - Dysphagia Therapy, and CPB 0648 - Pervasive Developmental Disorders.



Background

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 5th 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 3rd or 5th 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 5th) 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: (i) the child is fed directly by the therapist to establish a new set of feeding responses, (ii) parents are introduced into the feeding environment, and (iii) 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: (i) structural abnormalities, (ii) neurological conditions, (iii) behavioral issues, (iv) cardio-respiratory problems, and (v) 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: (i) structural-neurological-behavioral (30 %), (ii) neurological-behavioral (27 %), (iii) behavioral (12 %), (iv) structural-behavioral (9 %), and (v) 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 (i) the case studies were not randomly selected, (ii) there was no comparison control population, and (iii) 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 (i) feeding disorders cannot be easily classified as organic or non-organic, (ii) their treatment requires a multidisciplinary approach, and (iii) 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 (i) feeding problems in early childhood often have multi-factorial causes and a substantial behavioral component, (ii) family physicians have a key role in detecting problems, offering advice, managing mildly to moderately severe cases, and (iii) 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: (i) possible inconsistency in documentation, (ii) potential variability in weight and height data collection techniques, (iii) ambiguous parental perception(s) about reporting progress, (iv) a possible lack of professionals’ goal standardization, (v) normal developmental outcomes during growth and development, and (vi) 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 3rd 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: (i) tube dependent, (ii) liquid dependent, or (iii) 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)

 
CPT Codes / HCPCS Codes / ICD-9 Codes
There are no specific codes for pediatric intensive feeding programs:
CPT codes covered if selection criteria are met:
90785 Interactive complexity (List separately in addition to the code for primary procedure)
90832 - 90840 Psychotherapy
92526 Treatment of swallowing dysfunction and/or oral function for feeding
92610 Evaluation of oral and pharyngeal swallowing function
96150 - 96151 Health and behavior assessment
96152 - 96155 Health and behavior intervention
97001 - 97004 Physical and Occupational therapy evaluations and re-evaluations
97530 Visual evoked potential (VEP) testing central nervous system, checkerboard or flash
97535 Self-care/home management training (eg, activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact, each 15 minutes
97802 Medical nutrition therapy; initial assessment and intervention, individual, face-to-face with the patient, each 15 minutes
97803     re-assessment and intervention, individual, face-to-face with the patient, each 15 minutes
97804     group (2 or more individual(s)), each 30 minutes
99509 Home visit for assistance with activities of daily living and personal care
HCPCS codes covered if selection criteria are met:
G0129 Occupational therapy requiring the skills of a qualified occupational therapist, furnished as a component of a partial hospitalization treatment program, per session (45 minutes or more)
G0151 Services performed by a qualified physical therapist in the home health or hospice setting, each 15 minutes
G0152 Services performed by a qualified occupational therapist in the home health or hospice setting, each 15 minutes
G0153 Services performed by a qualified speech-language pathologist in the home health or hospice setting, each 15 minutes
G0155 Services of a clinical social worker in home health or hospice setting, each 15 minutes
G0270 Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regime (including additional hours needed for renal disease), individual, face-to-face with patient, each 15 minutes
G0271 Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regime (including additional hours needed for renal disease), group (2 or more individuals), each 30 minutes
S9127 Social work visit, in the home, per diem
S9128 Speech therapy, in the home, per diem
S9129 Occupational therapy, in the home, per diem
S9131 Physical therapy, in the home, per diem
S9152 Speech therapy, re-evaluation
S9470 Nutritional counseling, dietitian visit
ICD-9 codes covered if selection criteria are met:
261 Nutritional marasmus
263.0 - 263.9 Malnutrition
269.0 - 269.9 Other nutritional deficiencies
270.0 - 270.9 Disorders of amino-acid transport and metabolism
271.0 - 271.9 Disorders of carbohydrate transport and metabolism
272.0 - 272.9 Disorders of lipoid metabolism
275.0 - 275.9 Disorders of mineral metabolism
276.0 - 276.9 Disorders of fluid, electrolyte, and acid-base balance
281.0 - 281.9 Iron and other deficiency anemias
579.0 - 579.9 Intestinal malabsorption
585.1 - 585.9 Chronic kidney disease (CKD)
749.00 - 749.25 Cleft palate and cleft lip
775.5 Other transitory neonatal electrolyte disturbances
775.7 Late metabolic acidosis of newborn
775.81 Other acidosis of newborn
779.31 Feeding problems in newborn
779.34 Failure to thrive in newborn
783.21 Loss of weight
783.22 Underweight
783.3 Feeding difficulties and mismanagement
783.41 Failure to thrive
783.9 Other symptoms concerning nutrition, metabolism, and development
787.20 - 787.29 Dysphagia
ICD-9 codes not covered for indications listed in the CPB (not all-inclusive):
278.00 - 278.02 Overweight and Obesity
307.1 Anorexia nervosa
307.51 Bulimia nervosa
759.81 Prader-Willi syndrome
Other ICD-9 codes related to the CPB:
307.50 Eating disorder, unspecified
307.52 Pica
307.53 Rumination disorder
307.54 Psychogenic vomiting
307.59 Other disorders of eating (feeding disorder of infancy or early childhood of nonorganic origin)
309.3 Adjustment disorder with disturbance of conduct
312.0 - 312.9 Disturbance of conduct, not elsewhere classified
314.2 Hyperkinetic conduct disorder
343.0 - 343.9 Infantile cerebral palsy
758.0 Down's syndrome
758.6 Gonadal dysgenesis [Turner's syndrome]
783.0 Loss of appetite
V40.3 Other behavioral problems
V40.9 Unspecified mental or behavioral problem
V41.5 Problems with smell and tast
V41.6 Problems with swallowing and mastication
V48.0 - V48.9 Problems with head, neck, and trunk
V49.1 Mechanical problems with limbs
V49.2 Motor problems with limbs
V57.1 Encounter for other physical therapy [additional code required for underlying condition]
V57.21 Encounter for other occupational therapy [additional code required for underlying condition]
V57.3 Care involving use of rehabilitation procedures, speech therapy-language therapy [additional code required for underlying condition]
V57.89 Other care involving use of rehabilitation procedures [multiple training or therapy] [additional code required for underlying condition]
V65.3 Dietary surveillance and counseling
V69.1 Inappropriate diet and eating habits
ICD-9 codes not covered for plans that exclude developmental delay:
315.00 - 315.9 Specific delays in development
317 - 319 Mental retardation
783.40 Lack of normal physiological development, unspecified
783.42 Delayed milestones
784.61 Alexia and dyslexia
V40.0 Problems with learning
V40.1 Problems with communication (including speech)
Electrical stimulation for the treatment of swallowing/feeding disorders:
CPT codes not covered for indications listed in the CPB:
64550 Application of surface (transcutaneous) neurostimulator
97014 Application of a modality to 1 or more areas; electrical stimulation (unattended)
97032 Application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes
HCPCS codes not covered for indications listed in the CPB:
G0283 Electrical stimulation (unattended), to one or more areas for indication(s) Procedures & Professional Services other than wound care, as part of a therapy plan of care
ICD-9 codes not covered for indications listed in the CPB (not all-inclusive):
307.59 Other disorders of eating
779.31 Feeding problems in newborn
783.3 Feeding difficulties and mismanagement
787.20 - 787.29 Dysphagia


The above policy is based on the following references:
  1. Fryer GE Jr. The efficacy of hospitalization of nonorganic failure-to-thrive children: A meta-analysis. Child Abuse Negl. 1988;12(3):375-381.
  2. 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.
  3. Black MM, Dubowitz H, Hutcheson J, et al. A randomized clinical trial of home intervention for children with failure to thrive. Pediatrics. 1995;95(6):807-814.
  4. Burklow K, Phelps AN, Schultz JR, et al. Classifying complex pediatric feeding disorders. J Pediatr Gastroenterol Nutr. 1998;27(2):143-147.
  5. Washington State Department of Health, Office of Children with Special Health Care Needs, Division of Community and Family Health. Cost Considerations: The benefits of nutrition services for a case series of children with special health care needs in Washington State. Olympia, WA: Washington Department of Health; May 1998. Available at: http://www.doh.wa.gov/cfh/mch/documents/CostConsiderations.pdf. Accessed August 11, 2010.
  6. Kerwin ME. Empirically supported treatments in pediatric psychology: Severe feeding problems. J Pediatr Psychol. 1999;24(3):193-214.
  7. Manikam R, Perman JA. Pediatric feeding disorders. J Clin Gastroenterol. 2000;30(1):34-46.
  8. Schwarz SM, Corredor J, Fisher-Medina J, et al. Diagnosis and treatment of feeding disorders in children with developmental disabilities. Pediatrics. 2001;108(3):671-676.
  9. Rudolph CD, Mazur LJ, Liptak GS, et al; North American Society for Pediatric Gastroenterology and Nutrition. Guidelines for evaluation and treatment of gastroesophageal reflux in infants and children: Recommendations of the North American Society for Pediatric Gastroenterology and Nutrition. J Pediatr Gastroenterol Nutr. 2001;32 Suppl 2:S1-31.
  10. Rudolph CD, Link DT. Feeding disorders in infants and children. Pediatr Clin North Am. 2002;49(1):97-112.
  11. Perrin E, Frank D, Cole C, et al. Criteria for determining disability in infants and children: Failure to thrive. Evidence Report/Technology Assessment No. 72. Prepared by Tufts-New England Medical Center Evidence-based Practice Center under Contract No. 290-97-0019. AHRQ Publication No. 03-E020. Rockville, MD: Agency for Healthcare Research and Quality (AHRQ); March 2003. Available at: http://www.ahrq.gov/downloads/pub/evidence/pdf/failthrive/failthrive.pdf. Accessed August 11, 2010.
  12. Rommel N, De Meyer AM, Feenstra L, et al. 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.
  13. Gerarduzzi T, Biasotto E, Faleschini E, et al. Comment on: The complexity of feeding problems in 700 infants and young children presenting to a tertiary care institution. J Pediatr Gastroenterol Nutr. 2004;38(3):360-361.
  14. Bernard-Bonnin AC. Feeding problems of infants and toddlers. Can Fam Physician. 2006;52(10):1247-1251.
  15. Marchand V, Motil KJ; NASPGHAN Committee on Nutrition. Nutrition support for neurologically impaired children: A clinical report of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition. J Pediatr Gastroenterol Nutr. 2006;43(1):123-135.
  16. Williams S, Witherspoon K, Kavsak P, et al. Pediatric feeding and swallowing problems: An interdisciplinary team approach. Can J Diet Pract Res. 2006;67(4):185-190.
  17. Ayoob KT, Barresi I. Feeding disorders in children: Taking an interdisciplinary approach. Pediatr Ann. 2007;36(8):478-483.
  18. 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.
  19. Bell HR, Alper BS. Assessment and intervention for dysphagia in infants and children: Beyond the neonatal intensive care unit. Semin Speech Lang. 2007;28(3):213-222.
  20. Gisel E. Interventions and outcomes for children with dysphagia. Dev Disabil Res Rev. 2008;14(2):165-173.
  21. Greer AJ, Gulotta CS, Masler EA, et al. Caregiver stress and outcomes of children with pediatric feeding disorders treated in an intensive interdisciplinary program. J Pediatr Psychol. 2008;33(6):612-620.
  22. Twachtmann-Reilly J, Amaral S, Zebrowski PP. Addressing feeding disorders in children on the autism spectrum in school-based settings: Physiological and behavioral issues. Language, Speech, and Hearing Services in Schools. 2008;39:261-272. Available at: http://lshss.asha.org/cgi/content/full/39/2/261. Accessed August 11, 2010.
  23. Arvedson JC. Assessment of pediatric dysphagia and feeding disorders: Clinical and instrumental approaches. Dev Disabil Res Rev. 2008;14(2):118-127.
  24. Miller CK. Updates on pediatric feeding and swallowing problems. Curr Opin Otolaryngol Head Neck Surg. 2009;17(3):194-199.
  25. American Academy of Pediatrics (AAP). Recommendations for preventive pediatric health care (periodicity schedule). Elk Grove Village, IL: AAP; 2010. Available at: http://practice.aap.org/content.aspx?aid=1599. Accessed August 11, 2010.
  26. American Speech-Language-Hearing Association (ASHA). Feeding and swallowing disorders (dyspagia) in children. Rockville, MD: ASHA; 2010. Available at: http://www.asha.org/public/speech/swallowing/feedswallowchildren.htm. Accessed August 11, 2010.
  27. Kirkland RT and Motil KJ. Management of failure to thrive (undernutrition) in children younger than two years. UpToDate [online serial]. Waltham, MA: UpToDate; 2010.
  28. Washington State Department of Health. Nutrition for children with special health care needs (CSHCN). Seattle, WA: CSHCN; August 11, 2010. Available at: http://depts.washington.edu/cshcnnut/feeding/index.html. Accessed August 11, 2010.
  29. Latif LA, Brizee LS, Casey S, et al.; Washington State Department of Health. Nutrition interventions for children with special health care needs. 3rd ed. Olympia, WA: Washington State Department of Health; 2010. Available at: http://here.doh.wa.gov/materials/nutrition-interventions/15_CSHCN-NI_E10L.pdf. Accessed August 11, 2010.
  30. Haas AM. Feeding disorders in food allergic children. Curr Allergy Asthma Rep. 2010;10(4):258-264.
  31. Silverman AH. Interdisciplinary care for feeding problems in children. Nutr Clin Pract. 2010;25(2):160-165.
  32. Carnaby-Mann GD, Crary MA. Examining the evidence on neuromuscular electrical stimulation for swallowing: A meta-analysis. Arch Otolaryngol Head Neck Surg. 2007;133(6):564-571.
  33. Clark H, Lazarus C, Arvedson J, et al. Evidence-based systematic review: Effects of neuromuscular electrical stimulation on swallowing and neural activation. Am J Speech Lang Pathol. 2009;18(4):361-375.
  34. Christiaanse ME, Mabe B, Russell G, et al. Neuromuscular electrical stimulation is no more effective than usual care for the treatment of primary dysphagia in children. Pediatr Pulmonol. 2011;46(6):559-565.
  35. Humbert IA, Michou E, MacRae PR, Crujido L. Electrical stimulation and swallowing: How much do we know? Semin Speech Lang. 2012;33(3):203-216.
  36. Doeltgen SH, Huckabee ML. Swallowing neurorehabilitation: From the research laboratory to routine clinical application. Arch Phys Med Rehabil. 2012;93(2):207-213.
  37. Cincinnati Children's Hospital Medical Center. Best evidence statement (BESt). Behavioral and oral motor interventions for feeding problems in children. Cincinnati (OH): Cincinnati Children's Hospital Medical Center; July 15, 2013. Available at: http://www.guideline.gov/content.aspx?id=47062&search=Intensive+Feeding+Programs+. Accessed September 4, 2104.


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Copyright Aetna Inc. All rights reserved. Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.
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