Pediatricians may believe that because a child is growing well, feeding is appropriate. Similarly, they may overlook “picky eating.”
Feeding involves the caregiver-child relationship, multiple body systems and multiple developmental processes. Many variables impact a child’s ability to learn to eat, grow and be nourished. Pediatricians must understand this and ask the right questions to detect pediatric feeding disorder(PFD).
What is PFD?
PFD is defined as “impaired oral intake that is not age-appropriate, and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction” (Goday PS, et al. J Pediatr Gastroenterol Nutr. 2019;68:124-129). (For diagnostic criteria, see https://bit.ly/3iBUu6g.) PFD results in disability such as impairment, activity limitation or participation restriction.
The term PFD promotes the use of common, precise terminology necessary to advance clinical practice, research and health care policy.
Unlike avoidant/restrictive food intake disorder (F50.82), PFD includes older children and those with comorbid medical diagnoses or dysphagia. It differs from eating disorder (e.g., anorexia nervosa, F50.0) in that PFD excludes adults and does not involve fear of gaining weight or disturbance of body image.
PFD affects up to 20% of neurotypical children and 80% of those with developmental disabilities. Thus, it is more prevalent than eating disorders and autism spectrum disorder.
Multiple factors contribute to PFD. Many feeding problems are preventable or easily treated. Treatment of PFD improves nutritional status, growth, feeding safety and quality of life. Untreated PFD may result in complications.
The Infant and Child Feeding Questionnaire (ICFQ, below) accurately identifies and differentiates PFD from picky eating in children ages 0-4 years based on caregiver responses to six questions (Silverman AH, et al. J Pediatr. 2020;223:81-86.e2). Red flag answers are in orange. If two or more answers are orange, pediatricians should suspect PFD.
Coding for PFD
Previously, 15 International Classification of Diseases, 10th Revision, Clinical Modification(ICD-10-CM) codes were used to capture this diagnosis. Effective Oct. 1, two ICD-10-CM codes are available:
- R63.31 Pediatric feeding disorder, acute
- R63.32 Pediatric feeding disorder, chronic
Vignette
An 8-month-old infant comes in for her 6-month well check. She is behind in her visits. Her caretakers report she is not interested in puréed solids and turns her head when solids are offered with a spoon. They are concerned she may stop growing. She eats well when semi-asleep and the house is quiet. She drinks 3-5 ounces of formula every two hours from 10 p.m. to 5 a.m.
She is at 35th percentile for weight vs. height. Developmentally, she sits with assistance, drops objects after a few seconds of play and smiles but does not babble. She has deficits in the feeding skill and psychosocial domains.
Based on results from the ICFQ (4 positive indicators), she meets criteria for PFD. She would benefit from referral to a feeding skills expert (i.e., speech-language pathologist, occupational therapist) for oral-motor and feeding evaluation.
The physician documents an acute form of pediatric feeding disorder. Therefore, code R63.31 is reported secondary to the well-child exam (Z02.121 - Encounter for routine child health examination with abnormal findings).
Vignette
A 24-month-old presents for his 2-year well check. His caretakers note, “He ate everything until six months ago.” Currently, he accepts only chicken nuggets, french fries, apple juice and chocolate toddler formula. He gags and vomits when offered nonpreferred foods. Caretakers allow him to graze throughout the day and to walk around while eating, but he never seems full.
You observe that the patient is nonverbal, has limited eye contact, walks on his toes and does not respond when you call his name. You suspect he has autism spectrum disorder with secondary deficits in nutrition and psychosocial domains and refer him to a developmental pediatrician or child psychologist.
Based on results from the ICFQ (six positive indicators), he meets criteria for PFD.
The physician documents chronic PFD due to the time of symptom onset (more than six months ago) and assigns code R63.32, code Z02.121for the well-child exam and code R62.0, Delayed milestone in childhood.
If the physician does not document acute or chronic, it would be appropriate for the coder to query the physician. If the coder still is unable to discern which code to use, the default code would be R63.31 (acute).
Dr. Phalen is a member of the AAP Section on Developmental and Behavioral Pediatrics and the Section on Uniformed Services.
