10/5/2018 What’s the Big Deal about Feeding? An Interdisciplinary Approach Towards Improvement DATE: October 13th, 2018 PRESENTED BY: Kristin Mangan, MA, CCC‐SLP Erin Cochran, MS, OTR/L Sarah Sahl, BS, RD Darren Janzen, PsyD Kevin Senn, MD Financial Disclosures • We are all employees of the Institute for Development & Disability at OHSU. We have no further financial disclosures. 2 Goals of this presentation: • Examine collaborative roles within an interdisciplinary clinic • Understand the interdisciplinary model of treatment for pediatric feeding difficulties • Explore how to assess feeding problems • Discuss why some children have difficulties with feeding through case studies • Review behavior-based interventions 3 3 1
10/5/2018 Why the team approach? Whole Child Approach • Complicated Sensory Needs: Feeding is one of the only actions that requires all 8 sensory systems • Whole Body Effort: Feeding requires at least 7 functions of the body • Frequency: Individuals feed and eat 4-11x/day, depending on age and stage • Feeding is of utmost importance for overall growth and development • Feeding is a complex system that is most often BOTH organic and non-organic in nature • Therefore, a comprehensive approach for assessment and treatment is optimal for these families 5 CDRC Pediatric Feeding & Swallowing Disorders Clinic: Who We Are • Medical Provider (MD, PNP) • Speech-Language Pathologist • Occupational Therapist • Dietitian • Lactation Consultant • Behavioral Psychologist 6 2
10/5/2018 Medical Provider • Developmental Pediatrician or Nurse Practitioner • Overall medical assessment with a focus on respiratory health, GI health, sleep, musculoskeletal status • Developmental screening • Referrals and communication with needed specialists (and PCP) • Manage medications impacting feeding • Team resource on less common medical conditions, including evaluation and interpretation of growth in special populations 7 The Role of the Oral Motor Specialist (OT or SLP): • Chart review and team staffing • Caregiver interview and case history • Oral motor examination • Clinical observation of feeding • Recommendation and completion of instrumental assessments if warranted • Diagnosis of dysphagia types • Collaborative development of recommendations and follow up • OT also providing individual and group feeding treatment at OHSU 8 An Additional Role of the SLP • SLP training includes coursework detailing the anatomy and physiology of oral, pharyngeal, and laryngeal function, as well as the aerodigestive tract. • State licensures and SLP national accreditation both detail the SLP’s scope of practice to include performance, interpretation, and diagnosis of feeding difficulties and various dysphagias through clinical and instrumental evaluations – MBSS /VFSS/Oropharyngeal Swallow Studies – FEES : Fiberoptic Endoscopic Evaluation of Swallowing 9 3
10/5/2018 The Role of the Dietitian and Lactation Specialist • Assess recent growth and growth trends • Anthropometrics • Clinical, medical history and biochemical data • Assess provision of key micronutrients and macronutrients through nutritional assessment • Nutrition focused physical exam • Review labs with MD • Support lactating moms with strategies to improve latch, positioning, and milk supply • Family dynamic and stress level in feeding 10 The Role of the Psychologist • Assessing the child’s development and how the family is functioning (e.g. stress, structure, and coordination) • Understanding what behavioral issues may be present: Behavior is often Avoidance-, Access-, and/or Attention-maintained • Teaching techniques to manage and modify behavior using Shaping and Fading techniques • Helping with targeted goal setting to overcome barriers and lessen stress • Providing support and encouragement for adherence to goals and any achieved success 11 Management Clinic • Initial Evaluation – Generally MD/NP, RD, Oral motor • Psychology participates in initial evaluation if clear need based on referral • Based on clinical assessment, have patient return for follow up visit with appropriate team members in as soon as a month (ex. NG tube management) and as long as a year (ex. Medically stable with minimal changes) • Manage formulas, dietary textures, feeding/swallowing techniques, weight and nutrition monitoring, ensure appropriate feeding-related referrals (ex. MBSS, FEES, ENT, GI, etc) • Refer for specific treatment to outside local clinics (or CDRC) when appropriate 12 4
10/5/2018 CDRC Pediatric Feeding & Swallowing Disorders Clinic: Who We Serve • Ages: birth through transition to adult services • Post-NICU feeding challenges/Prematurity • Sensory based feeding difficulties • Behavioral based feeding difficulties • Medical based feeding difficulties including neurological (ex. CP), gastrointestinal (ex. Reflux, EoE), structural etiologies (ex. Cleft lip & palate), and congenital syndromes (ex. Down Syndrome) • Difficulties with chewing/swallowing • Difficulties transitioning between textures of liquids/foods • Limited Food Repertoire (Need to assess why this is happening) • Poor Weight Gain with developmental concerns • G-tube/NG tube feedings and weaning 13 Family Centered Approach • Meet the family where they are (culturally, emotionally, education level/style, etc) • Recognize the challenges they have faced before getting to our clinic and what strategies they have already tried • Use family-friendly language • Understand what changes a family can realistically make in a given timeframe • Recognize their family system (One household? Two parent household? Many siblings? Many generations?) 14 Why feeding? 5
10/5/2018 Why is this an important area? • Feeding difficulties are commonly faced : – Only about half of Americans regularly sit down to family meals. – Forty percent of parents in one study prepared separate meals for their grade school-aged children (Fulkerson et al. 2008). • Sense of taste is genetic – Carried on chromosome 4 = some are more taste sensitive. • Multiple births, prematurity, and other birth complications increase the risk for feeding problems. • Misconception: “All children eat when they are hungry.” – This leads to hospitalization for dehydration and malnutrition in select children. 16 16 What do caregivers want to fix? My child doesn’t eat enough . My child is dependent on formula and/or tube feedings . My child coughs and chokes when eating/drinking. My child only eats certain foods or certain textures. My child doesn’t self-feed . My child doesn’t indicate hunger. Understand: Parent perception of “normal” vs. “abnormal” 1 2 Decide: What to prioritize with parents 3 Target: Balance short-term vs. long term goals 17 17 Is this picky eating or problem feeding? Picky Eaters: • Eat around 30 foods. • Eat one or more foods from each type of texture or food group. • Have a favorite food that they eat consistently then burn out and will not eat that food, but after 2 weeks may resume eating it again. • Accept new foods on their plate and willingly touch or try new foods. • Will eat a new food after being exposed to it ~ 10 times. • Generally, consume enough calories per day. 18 Kay Toomey http://sosapproach-conferences.com/wp-content/uploads/2016/06/PickyEaters-VS-Problem-Feeders.pdf 6
10/5/2018 Is this picky eating or problem feeding? Problem Feeders: • <20 foods. Drop items over time until limited to 5-10 foods. • Refuse certain textures and food groups altogether. • Jag on foods then drop them permanently from repertoire. • Dysregulated when offered a new food, even if told they don’t have to eat it. • Difficulty touching or tasting a new food. • Almost always eats a different meal than the family. • Are unwilling to try a new food even after 10 exposures. • Have rigidity and need for routine/sameness during meals, inflexible about certain foods. 19 Kay Toomey http://sosapproach-conferences.com/wp-content/uploads/2016/06/PickyEaters-VS-Problem-Feeders.pdf Why some children won’t eat: That’s • Deficits in abilities What if I Gross! -Oral motor delays choke… -Fine motor delays • Deficits in motivation -Conditioned aversion I’ll only eat -Lack of appetite if you make • Deficits in the environment I’m not me what I hungry. -Behavioral mismanagement want… -Faulty caregiver knowledge 20 Treating issues sequentially: Get food to the mouth – increase acceptance Keep food in the mouth – decrease expels Swallow the food – increase mouth clean Increase volume – increase bites, grams Increase variety – number of foods eaten Increase texture – texture eaten, gagging Increase self-feeding – level of prompting Goa Goal: : Independent Eater 21 7
10/5/2018 Kay Toomey’s sequential approach? 22 Kay Toomey, Ph.D http://www.qicreative.com/wp-content/uploads/Steps-To-Eating.pdf Speech Language Pathologist Five Key Questions to Ask Parents: 1- How long does it take to feed your child? 2- Are meal/feeding times stressful to you or your child? 3- Is your child adequately gaining weight? 4- Are there signs of respiratory problems? 5- Is your child progressing with feeding as you would expect him/her to? 24 8
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