ICD-10 Diagnosis Codes

• R63.3, Feeding Difficulties
• R13.10, Dysphagia, unspecified
• R62.51, Failure to thrive (child)
• F50.82, Avoidant/restrictive food intake disorder
• F98.21, Rumination disorder of infancy
• F98.22, Other feeding disorders of infancy and early childhood
• F98.3, Pica of infancy and childhood
• P92x, Feeding problems of newborn (add specifier)

ICD-10-CM Codes

• Z13.21, Encounter for screening for nutritional disorder
• Z13.39, Encounter for screening examination for other mental health and behavioral disorders

There are currently no published guidelines for screening for feeding and swallowing problems in low-risk pediatric populations. However, a screening tool may help clinicians detect children at risk for a feeding problem and can also be considered when there are red flags (see above). A feeding screen can also be used as a proxy assessment tool to monitor the child’s feeding problems over time, such as for a child weaning off dependence on a feeding tube. Finally, responses on screens can serve as a discussion point for clinicians and parents. However, a screen should replace an instrumental evaluation, typically a modified barium swallow study, when there is concern for dysphagia.

Numerous pediatric feeding problem screeners are available, but they vary in quality, age ranges, focus on organic vs. behavioral concerns, length, and psychometric properties. Some require background knowledge or training in pediatric feeding and swallowing disorders and are not applicable in most primary care settings.

Below are examples of screens that could be used in the medical home. Non-standardized instruments, such as questionnaires, which can help guide clinicians taking a feeding history for both orally and tube-fed children, are not included. The first 2 screens are freely accessible and were provided by their authors.

Montreal Children's Hospital Feeding Scale (MCH-FS)

A 14-item parent-report using a 7-pt Likert scale examining 4 types of feeding problems: lack of motivation, oral-motor deficits, food selectivity according to texture, and food selectivity according to taste. Includes questions about parental concerns, mealtime behaviors, family strategies, and family reactions to their child’s feeding. (

• Ages: 6 months to 6 years
• Languages: English, Dutch, French, Portuguese, Thai
• Sensitivity = 87% and specificity = 82% using a total score of 45 as the cut-off.
• Scoring: Normal range = raw score 0-45 [T-score 35-60], mild difficulties = 46-52 [T-score 61-65], moderate 53-58 [T-score 66-70], severe >=59 [T-score >70]. The questions correspond with specific types of problem: oral motor (items 8 and 11), oral sensory (items 7 and 8), appetite (items 3 and 4), maternal concerns about feeding (items 1, 2, and 12), mealtime behaviors (items 6 and 8), parental strategies used (items 5, 9, and 10), and family reactions to their child’s feeding (items 13 and 14).

Free to access at Montreal Children's Hospital Feeding Scale (MCH-FS) ( 307 KB), Montreal Children's Hospital Feeding Scale (MCH-FS) [in French] ( 458 KB), and Montreal Children's Hospital Feeding Scale (MCH-FS) Scoring Instructions ( 289 KB).

Screening Tool of Feeding Problems Applied to Children (STEP-CHILD)

A 15-item parent-report using a 3-pt Likert scale, including chewing problems, rapid eating, food refusal, food selectivity, vomiting, and stealing food. Studied in children with feeding problems, autism spectrum disorder, and special needs.

• Ages: 24 months to 18 years
• Languages: English
• Sensitivity/specificity: N/A. Reliability and validity are addressed in the study.

Free to access at Screening Tool of Feeding Problems Applied to Children (STEP-CHILD) ( 13 KB) and Screening of Feeding Problems for children (STEP-CHILD): Child and Parent ( 190 KB).

The following screens may be relevant in specific populations:

Behavioral Pediatric Feeding Assessment Scale (BPFAS)

A widely used parent-report with 35 items on a Likert scale that addresses child behaviors, such as feeding refusals, stalling, and refusal of textures, and parents’ perceptions and strategies. Since it takes approximately 15 minutes, it is not optimal for routine screening in primary care. [Allen: 2015] [Jaafar: 2019]

• Ages: 9 months to 18 years, although original study validated for ages 9 months to 7 years [Jaafar: 2019]
• Languages: English and a not-yet-published Greek version [Jaafar: 2019]
• Scoring: Higher scores are more concerning. Contact the authors for more information.
• Sensitivity/specificity: >75%/>85% in all domains. [Jaafar: 2019] First published in 2001, the BPFAS has been repeatedly shown to have adequate reliability and validity as a measure of mealtime behavior problems in typically developing children, children presenting to a clinic with feeding difficulties, and children with autism spectrum disorder, cystic fibrosis, CHARGE syndrome, children with diabetes, eosinophilic gastrointestinal disorder, and overweight/obesity.

Contact the study authors [Jaafar: 2019] for more information about accessing the BPFAS.

Brief Autism Mealtime Behavior Inventory (BAMBI)

An 18-item parent report using a 5-pt Likert scale focused on mealtime behaviors in children with autism spectrum disorder. [Lukens: 2008]

• Ages: 3-11 years
• Languages: English, Brazilian Portuguese
• Sensitivity/specificity: N/A. Reliability and validity are addressed in the study. [Lukens: 2008]
• Scoring: No clinically validated cutoff scores, although studies are underway

See Brief Autism Mealtime Behavior Inventory (BAMBI) ( 27 KB) or contact the study authors [Lukens: 2008] for more information.

Pediatric Assessment Scale for Severe Feeding Problems (PASSFP)

A 15-item parent-report using Likert scales, including quality of life, nutrition, behaviors, oral sensory, and oral motor concerns. Designed to assess progression in oral skills for young children requiring prolonged tube feeding. [Crist: 2004]

• Ages: At least 4 months
• Languages: English
• Sensitivity/specificity: N/A. Reliability and validity are addressed in the study. The scale is shown in the study article. Contact the authors for scoring information.

The scale is shown in the study article. Contact the authors [Crist: 2004] for scoring information.

When concerns are low based on objective data like growth patterns, lack of red flags from the history, and lack of suspicion for underlying medical problems, reassurance and routine growth monitoring and follow-up may suffice. The clinician can also provide basic pediatric feeding guidance: [Kerzner: 2015]

• Avoid distractions during mealtimes (television, cell phones, etc.)
• Maintain a pleasant neutral attitude throughout meal
• Feed to encourage appetite
  • Limit meal duration (20–30 min)
  • 4–6 meals/snacks a day with only water in between
• Serve age-appropriate foods
• Systematically introduce new foods (up to 8–15 times)
• Encourage self-feeding
• Tolerate age-appropriate mess

If yes, obtain labs, such as a complete blood count (CBC), complete metabolic panel (CMP), erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP), and urine analysis, plus or minus a celiac disease screening panel (see Celiac Disease, Clinical Assessment). Consider inpatient admission for severe derangements and stabilization.

If yes, obtain a modified barium swallow study (MBSS). If dysphagia is present on the study, thicken liquids or feeds as recommended. Consider tube feedings if unable to safely swallow.

If yes, consider acid reflux treatment trial or dedicated imaging studies. See Gastroesophageal Reflux Disease for more information.

While both feeding and eating disorders can share some common ground, such as food avoidance and restriction, the psychology behind feeding and eating disorders is different. Feeding disorders may be behavioral or organic in nature, whereas body dysmorphia, inappropriate coping skills, or need for control underlies many eating disorders. See Screening for Eating Disorders for more information.