Five Things to Know if Your Client Has Food Allergies

shutterstock_263393825

For pediatric feeding therapists, whether working in the home, school/community or hospital/clinic setting, understanding safety precautions for kids with food allergies is essential. Here are five things every SLP should know when treating a child with food allergies:

  1. Know the symptoms of the reaction. They often occur suddenly, but a slight delay after exposure is also possible. They might vary from client to client, so ask parents to describe their child’s unique symptoms. According to physician Kirstin Carel of Children’s Hospital Colorado, symptoms may include:
  • Respiratory: wheezing, coughing, shortness of breath, hoarseness, throat swelling.
  • Skin: hives, redness, itching, swelling, eczema.
  • Gastrointestinal: mouth or throat itching, lip or tongue swelling, vomiting, diarrhea, cramping.
  • Cardiovascular: low blood pressure, abnormal heart rhythm, pale or blue skin, fainting.
  • Neurological: fainting.
  • Behavioral: sudden irritability (in combination with other symptoms).
  1. Know how your client communicates his or her symptoms. A child might perceive bodily changes before any of the signs noted above become apparent to you. According to Food Allergy Research & Education (FARE), children can communicate their symptoms by saying:
  • “This food is too spicy.”
  • “My tongue is hot [or burning].”
  • “It feels like something’s poking my tongue.”
  • “My tongue [or mouth] is tingling [or burning].”
  • “My tongue [or mouth] itches.”
  • “It [my tongue] feels like there is hair on it.”
  • “My mouth feels funny.”
  • “There’s a frog in my throat.”
  • “There’s something stuck in my throat.”
  • “My tongue feels full [or heavy].”
  • “My lips feel tight.”
  • “It feels like there are bugs in there” (to describe itchy ears).
  • “It [my throat] feels thick.”
  • “It feels like a bump is on the back of my tongue [throat].”

Ask parents if their children describe their feelings or symptoms with specific language or how they respond to the body changes after being exposed to the allergen. Learn more about various symptoms here.

  1. The epinephrine auto-injector stays with the child. Severe allergic reactions can happen suddenly. A caregiver sitting in a waiting room or away from the treatment setting might run out of time to locate this life-saving device. Know your agency’s policies on using an auto-injector when the parent is not nearby. Ask the parent to walk you through the steps on how to use it, should it be needed.
  2. Avoid cross-contact. Whether treating a child individually or in a group setting, everyone in the room should wash hands thoroughly with soap and water before beginning the session and dry with their own paper towel. Hand sanitizers are not adequate for getting rid of food proteins. Equipment used in food preparation is another factor, including knives, cutting boards, blenders and more. One common mistake is using a community toaster when toasting gluten-free bread for a child with celiac disease. Crumbs in the toaster contaminate the gluten-free food. Likewise, scrub tables, countertops or other surfaces where another child many have played with or eaten the allergen. Toys or equipment that you take from home to home, or even your clothes, may spread an allergen. Being cautious about cross-contact is essential, especially in the realm of feeding treatments where each client is exploring new foods throughout your work day.
  1. Know how to read a label. According to FARE’s website, food manufacturers must note major allergens in ingredients on conventional foods, dietary supplements, infant formula and medical foods containing milk, eggs, fish, crustacean shellfish, peanuts, tree nuts, wheat and soy. Manufacturers might add the phrase “contains _____” or list it in parenthesis. For example: “albumin (egg).” Read the label every time before serving the food. Ingredients and manufacturing processes can change without warning. Advisory labeling such as “Processed in a facility that also processes ____” and “Processed on equipment shared with ___” is voluntary on the part of the product’s manufacturer. Be cautious after reading both statements, especially the second, because the risk of exposure is much greater for products processed on shared equipment,.

What strategies do you use to keep your clients safe when they have food allergies? Or do you have allergies yourself that require special precautions? Share your ideas in the comments below.

 

Melanie Potock, MA, CCC-SLP, treats children, birth to teens, who have difficulty eating. She is the co-author of “Raising a Healthy, Happy Eater: A Parent’s Handbook—A Stage by Stage Guide to Setting Your Child on the Path to Adventurous Eating” (Oct. 2015), the author of “Happy Mealtimes with Happy Kids,” and the producer of the award-winning kids’ CD “Dancing in the Kitchen: Songs That Celebrate the Joy of Food!

Tip Back That Tongue! The Posterior Tongue Tie and Feeding Challenges

shutterstock_2457179

In a March 2015 post titled Just Flip the Lip, we explored how the band of tissue or “frenum” that attaches the upper lip to gum tissue can affect feeding development if the frenum is too restrictive. Today, we’ll focus on the lingual frenal attachment that is the easiest to miss: The posterior tongue tie (sometimes referred to as a submucosal tongue tie), a form of ankyloglossia.

Consider that the normal lingual frenum inserts at about midline, just under the tongue and down to the floor of the mouth allowing free range of movement and oral motor skill development. While many pediatric professionals are familiar with a tongue-tie when the frenum attaches closer to the tongue tip (where it’s visible when the tip is gently lifted), the posterior tongue tie requires a specific technique to view. According to Bobby Ghaheri, an ENT surgeon who specializes in treating ankyloglossia, whether anterior or posterior terminology is used, the focus should be on function. As he describes in this article, many anterior ties also include a posterior restriction and releasing just the thin membrane is not always adequate for full tongue function necessary for feeding. The frenum, if visible at all, may appear short and thick, but is often buried in the in the mucosal covering of the tongue.

As a pediatric feeding therapist, I gently lift up the tip of every child’s tongue during the oral examination. But, if I suspect a posterior tongue tie, my next step is to follow the procedure noted in this video by Dr. Ghaheri. This gives me enough information to ask the family to consult further with their pediatrician or primary care provider and a then a pediatric ENT, pediatric dentist or oral surgeon, who may also use specific instruments to better view the attachment. I feel my role as an SLP is to screen, not diagnose.

There are clues that indicate that a posterior tongue tie may be present before following the procedure noted above. The following are just some of the more common indicators of possible restriction of the lingual frenum impacting feeding development:

Appearance

  • Square, heart shaped or indented tip of tongue at rest and/or upon attempted protrusion—this is often indicative of anterior tongue ties, but as noted by Dr. Ghareri, the posterior restriction my still be present.
  • Dimpled tongue on dorsal surface, especially during movement.

Breast and Bottle Feeding

  • Difficulty latching and/or slow feeding.
  • Mother experiences pain while baby nurses.
  • In addition, as seen with upper lip ties, an inadequate latch and/or a poor lip seal may contribute to the following partial list of symptoms:

Spoon and Finger Feeding

  • Retraction of tongue upon presentation of the spoon.
  • Inadequate caloric intake due to inefficiency and fatigue.
  • Tactile oral sensitivity secondary to limited stimulation/mobility of tongue.
  • Over-use of lips, especially lower lip.
  • Difficulty progressing from “munching” to a more lateral, mature chewing pattern.
  • Tongue restriction may influence swallowing patterns and cause compensatory motor movements, which may lead to additional complications, such as “sucking back” the bolus in order to propel it to be swallowed.
  • Possible development of picky, hesitant or selective eating because eating certain foods are challenging.
  • Gagging and subsequent vomiting when food gets “stuck” on tongue.
  • Secondary behaviors to avoid discomfort that are thus protective in nature, such as refusing to sit at the table or being able to eat only when distracted.

Oral Hygiene, Dental and Other Issues Related to Feeding

  • Dental decay in childhood and adulthood because the tongue cannot clean the teeth and spread saliva.
  • Possible changes in dentition with certain compensatory methods to propel bolus posteriorly for swallowing, such as finger sucking.
  • Open bite.
  • Snoring.
  • Drooling.
  • Messy eating.
  • Requiring frequent sips of liquid to wash down bolus.

On sharing my findings with a child’s caregivers and primary care physician, a pediatric dentist, oral surgeon or ENT will determine next steps for the frenectomy. Linda Murzyn-Dantzer at Children’s Hospital Colorado shared her insight on the use of laser treatment for frenectomies. She noted that the laser can be used safely in a clinic setting, eliminating the need for treatment under sedation or general anesthesia. The laser itself provides some analgesia and often there is minimal need for other anesthetics, which may not be well-tolerated and may compete for other cell receptors and influence oxygen levels.

The laser can help to control bleeding and stitches may not be required. The laser offers precision when cutting tissue, and if the patient moves even slightly, the controls allow the beam to be stopped almost instantly. Traditional surgical techniques are also an option and used in a variety of situations, but Dr. Murzyn-Dantzer chooses the use of a laser over electrocautery techniques that may overheat or burn tissue, affecting cell layers beneath the targeted tissue and causing post-operative discomfort and increased healing time.

 

Melanie Potock, MA, CCC-SLP, treats children, birth to teens, who have difficulty eating. She is the co-author of “Raising a Healthy, Happy Eater: A Parent’s Handbook—A Stage by Stage Guide to Setting Your Child on the Path to Adventurous Eating” (Oct. 2015), the author of “Happy Mealtimes with Happy Kids,” and the producer of the award-winning kids’ CD “Dancing in the Kitchen: Songs that Celebrate the Joy of Food!

Melanie@mymunchbug.com

Top 10 Lessons I Learned from Loving Kids with Autism

Lessons Learned from Loving Kids with Autism

Editor’s Note: Today is World Autism Awareness Day, so we have a special post to celebrate the wonders that people with this unique perspective bring to the world. Read more about autism in this month’s April ASHA Leader issue devoted to the topic, which includes articles on the importance of helping people with ASD predict what happens next and how to measure clients’ progress in social skills groups.

 

If you’ve had the good fortune of loving kids with autism, you’ve probably encountered a few unexpected lessons in life.  In honor of National Autism Awareness Month and to express my gratitude for what my friends with autism spectrum disorder have taught me, I’d like to share my Top 10:

#10. In a world of too many gadgets and gizmos, a spinning top is pretty cool.

#9. Echolalia keeps my “over 40” brain sharp. I’ve learned to repeat, repeat, repeat.

#8. Parents with patience are the best teachers.

#7. Consistency is so comforting.

#6. Random objects can bring one kid a lot of joy. I’ve learned to appreciate road maps, bathroom signs and every single state’s license plates, to name just a few.

#5. Sometimes, carrying a favorite toy all day long just makes everything go better.

#4. Flapping really does feel good.

#3. The world needs more quirky.

#2. The first spontaneous “hug” is the best one of all.

And the #1 lesson I learned from my clients with autism?

#1. Love is when you take the time to know someone who sees the world differently than you.

 

What lessons have you learned from loving kids with autism? I’d love to know. Let’s start a list here to celebrate and raise awareness of all that the world can learn from these extraordinary, beautiful people.

 

Melanie Potock, MA, CCC-SLPtreats children, birth to teens, who have difficulty eating. She is the co-author of Raising a Healthy, Happy Eater: A Parent’s Handbook – A Stage by Stage Guide to Setting Your Child on the Path to Adventurous Eating (Oct. 2015), the author of Happy Mealtimes with Happy Kids, and the producer of the award-winning kids’ CD Dancing in the Kitchen: Songs that Celebrate the Joy of Food!  Potock’s two-day course on pediatric feeding is offered for ASHA CEUs.  Melanie@mymunchbug.com  

 

 

Just Flip the Lip! The Upper Lip-tie and Feeding Challenges

shutterstock_121795222

While many pediatric professionals are familiar with a tongue-tie, the illusive lip-tie hides in plain sight beneath the upper lip. Because I focus on feeding difficulties in children and an upper lip-tie can be a contributing factor if a child has trouble feeding, then I probably encounter more lip-ties than some of my colleagues. Still, I’d like to encourage my fellow SLPs to just flip the lip of every single kiddo whenever assessing the oral cavity. And document what you observe. Help increase general knowledge among professionals on different types of upper lip-ties by raising awareness of how they may impact the developmental process of feeding.

Upper lip-ties refer to the band of tissue or “frenum” that attaches the upper lip to the maxillary gingival tissue (upper gums) at midline. Although most babies should have a frenum that attaches to some degree to the maxillary arch, the degree of restriction varies. So it’s important to flip the lip of every child we evaluate in order to gain a better understanding of the spectrum of restriction – especially if you are an SLP who treats pediatric feeding.

During the feeding evaluation process, consider four things: 1) The mobility of the upper lip for breast, bottle, spoon and finger feeding; 2) How well it functions in the process of latching and maintaining the latch; 3) If the lip provides the necessary stability for efficient and effective suck-swallow-breath coordination; and 4) If the lip is an effective tool for cleaning a spoon, manipulating foods in the mouth and contributing to a mature swallow pattern.

Dentist Lawrence A. Kotlow has created an upper lip-tie classification system to better identify, describe and consider the need for treatment. The tie is classified according to where the frenum connects the lip to the gums, known as “insertion points.” Envision a child with a very big “gummy” smile and the upper gum line exposed. Divide the gums into three zones, as described in this article by Kotlow:

“The soft tissue covering the maxillary bone is divided into 3 zones. The tissue just under the nasal area (zone 1) is called the free gingival area; this tissue is movable. Zone 2 tissue is attached to the bone and has little freedom of movement… Zone 3 extends into the area between the teeth and is known as the interdental papilla. This is where the erupting central incisors will position themselves at around 6 months of age.”

Now, consider the insertion points. A Class I lip-tie inserts in Zone I and (unless extremely short and tight) does not inhibit movement of the upper lip and should not interfere with breast or bottle feeding. However, if the lip itself is retracted to the degree that a child cannot flange his upper lip for adequate latching and for maintaining suction, further consideration of this type of lip tie may be necessary. Class II lip-ties have an insertion point in Zone 2, where the tissue is attached to the bone. Kotlow describes the Class III tie as inserting in Zone 3, where “the frenum inserts between the areas where the maxillary central incisors will erupt, just short of attaching into the anterior incisor.”  A Class IV lip-tie “involves the lip-tie wrapping into the hard palate and into the anterior papilla (a small bump located just behind where the central incisor will erupt).”

How might an upper lip-tie impact the developmental process of feeding?

The impact of the upper lip-tie can vary according to its classification and, in my professional experience, the fullness of the upper lip also comes into play. But, in general, consider these key points:

Breastfeeding and Bottle Feeding

  • Breast – Inadequate latch: An infant must flange the lips to create enough suction and adequate seal around the tissue that includes the areola and not just the nipple. It is essential that babies take in enough breast tissue to activate the suckling reflex, stimulating both the touch receptors in the lips and in the posterior oral cavity in order to extract enough milk without fatiguing. When the baby suckles less tissue, painful nursing is also a result. One sign (not always present) is a callus on baby’s upper lip, directly at midline. While not always an indicator of a problem, it’s typically associated with an upper lip-tie. It’s simply a reminder to flip the lip!
  • Bottle – Inadequate Seal: Because bottles and nipple shapes are interchangeable and adaptations can be made, it’s possible to compensate for poor lip seal. However, these compensatory strategies are often introduced because all attempts at breastfeeding became too painful, too frustrating or result in poor weight gain…and the culprit all along was the upper lip-tie. It is then assumed that the baby can only bottle feed. I’ve assessed too many children held by teary-eyed mothers who reported difficulty with breast feeding – and no indication in the chart notes that the child had an upper lip-tie. But, upon oral examination, the lip-tie was indeed present and when observing the child’s feeding skills, the tie was at the very least a contributing factor. Releasing the tie resulted in improved ability to breast feed and progress with solids.
  • In addition, an inadequate latch and/or a poor lip seal may contribute to the following partial list of symptoms:
    • Gassiness; fussiness; “colicky baby”
    • Treatment for gastroesophogeal reflux disease, yet to be confirmed via testing
    • Fatigue resulting in falling asleep at the breast
    • Discomfort for both baby and mother, resulting in shorter feedings
    • Need for more frequent feedings round the clock
    • Poor coordination of suck, swallow, breathe patterns
    • Inability to take a pacifier, as recommended by the American Academy of Pediatrics and noted here.

Spoon Feeding

  1. Inability to clean the spoon with the top lip
  2. Inadequate caloric intake due to inefficiency and fatigue
  3. Tactile oral sensitivity secondary to limited stimulation of gum tissue hidden beneath the tie
  4. Lip restriction may influence swallowing patterns and cause compensatory motor movements which may lead to additional complications

Finger Feeding

  1. Inability to manipulate food with top lip for biting, chewing and swallowing
  2. Possible development of picky, hesitant or selective eating because eating certain foods are challenging
  3. Lip restriction may influence swallowing patterns and using compensatory strategies (e.g. sucking in the cheeks to propel food posteriorly to be swallowed) which may lead to additional complications

Oral Hygiene & Dental Issues

  1. Early dental decay on upper teeth where milk residue and food is often trapped
  2. Significant gap between front teeth
  3. Periodontal disease in adulthood
  4. Possible changes in dentition with certain compensatory methods to propel bolus posteriorly for swallowing, such as finger sucking.

After documenting what we observe during the evaluation, clear communication with parents and other professionals will help to determine next steps. In feeding therapy, our role is to provide information for involved parents and professionals (this may include pediatricians, lactation consultants, otolaryngologists, gastroenterologists, oral surgeons and/or pediatric dentists). Our primary role is to determine, document and communicate to what degree the restricted top lip is influencing a child’s difficulty feeding.

For detailed information and additional photos, please read Kotlow’s article, Diagnosing and Understanding the Maxillary Lip-tie as it Relates to Breastfeeding, published in the Journal of Human Lactation in May 2013.

In a future post for ASHA, we’ll discuss tongue-ties (ankyloglossia) and the impact on feeding. Upper-lip ties are frequently associated with tongue-ties, so please remember to look for both during oral examinations.

Have you had an experience with an upper lip-tie impacting the feeding progress of one of your clients? If so, please tell us in the comments below.

 

Melanie Potock, MA, CCC-SLPtreats children birth to teens who have difficulty eating.  She is the co-author of Raising a Healthy, Happy Eater: A Parent’s Handbook – A Stage by Stage Guide to Setting Your Child on the Path to Adventurous Eating (Oct. 2015), the author of Happy Mealtimes with Happy Kids and the producer of the award-winning kids’ CD Dancing in the Kitchen: Songs that Celebrate the Joy of Food!  Melanie’s two-day course on pediatric feeding is offered for ASHA CEUs.  She can be reached at Melanie@mymunchbug.com

 

Picky Eaters in the Preschool Classroom: 7 Tips for Teachers

Two scoop sizes allow children to select a smaller portion for unfamiliar foods.
Two scoop sizes allow children to select a smaller portion of unfamiliar foods.

As a pediatric feeding therapist, part of working in the child’s natural environment is making regular preschool visits to offer teachers and staff guidance when a child is not eagerly participating in mealtimes. Whether a child is a selective eater or the more common picky-eater, here are seven tips for teachers that focus on the seven senses involved in food exploration and eating:

  1. Sight: New foods are better accepted when the sight of them is underwhelming. When serving foods family style, include TWO utensils for scooping from the main bowl or platter [see above]. Present each food with one larger scoop and a standard spoon. The kids at the table can choose which scoop/spoon they would like to use, which allows the more hesitant eater to choose a small sample instead of what might feel like an overwhelming shovel-full. If meals are served pre-plated, offer smaller portions (1 tablespoon) of new foods and allow the kids to request more after their first taste.
  2. Smell: Warm foods often have a stronger aroma and for some kids, this can be a quick turn-off before the food ventures toward their lips. In regards to the hesitant eater, begin passing the bowl of warm foods so that it ends up at his seat last, when it will be less aromatic. For meals that are pre-plated, simply dish up his first but place it in front of him last, so that the food has time to cool a bit. Straws are an excellent option for soups, because they allow the child to sample by sipping. The longer the straw, the farther away they are from the smell. The shorter the straw, the less distance the soup needs to travel to reach the tongue, but the closer the nose is to the aroma. Consider what suits each child best and adjust accordingly. Thinner straws allow for a smaller amount of soup to land on the tongue, but if the soup is thick, you may need a slightly wider straw. Keeping the portion as small as possible also keeps the aroma to a “just right” amount for little noses. Try tiny espresso cups, often under $2, for serving any new beverage, soup or sauce.
    espresso cups
  3. Taste: Experiencing food doesn’t always mean we taste it every time. If the best a hesitant eater can do that day is help dish up the plates or lick a new food, that’s a good start! But when it comes to chewing, encourage kids to taste a new food with their “dinosaur teeth.” A fun option are these inexpensive tasting spoons commonly found in ice cream shops. Keep a small container in the center of the table for kids to take tiny sample tastes direct from their plates.
    tasting spoons
  4. Touch: Like any new tactile sensation, few of us place our entire hand into a new substance with gusto. It’s more likely that we’ll interact with a new tactile sensation by first using the tip of one finger or the side of our thumb. Take it slow – and remember that touch doesn’t just involve fingers and hands. The inside of the mouth has more nerve endings than many parts of our bodies, so it may be the last place that the hesitant eater wants to experience a new texture, temperature or other type of sensation. Start with where he can interact and build from there.
  5. Sound: The preschool classroom is abuzz with activity and thus, noise. Beginning each snack or mealtime with a song or a ritual, such as gently ringing some wind chimes to signal “it’s time to be together with our food” is a routine that centers both teachers and children. Whatever the ritual, involve the most hesitant eaters in the process and encourage their parents to follow the same routine at home if possible. Kids do best with when routines are consistent across environments.
  6. Proprioceptive Input: The sense of proprioception has a lot to do with adventurous eating. One fun routine that provides the proprioceptive input to help us focus is marching! In one preschool classroom, we implemented a daily routine where the kids picked a food and marched around the table with it as a way to mark the beginning of a meal and provide that much-needed stomping that is calming and organizing for our bodies. Download the song “The Food Goes Marching” here (free till February 1, 2015) as the perfect accompaniment!
  7. Vestibular Sense: While we all know the importance of a balanced diet, you may not be aware that a child’s sense of balance has a lot to do with trying new foods! Our sense of balance and movement, originating in the inner ear and known as the vestibular system, is the foundation for allfine motor skills. In order to feel grounded and stable, kids need a solid foundation under the “feet and seat.” Many classroom chairs leave preschoolers with little support and feet dangling. Create a footrest by duct taping old text or phone books together or if you’re extra handy, create a step stool that allows the chair legs to sit inside the stool itself.
    footrest
    An inexpensive version can be made with a box of canned baked beans from COSTCO, like this one. Carefully open the box because you’ll be using it again to create the footrest. Simply remove the cans, empty just two, then rinse thoroughly and discard the lids. Now place the cans back in the box with the two empty cans facing up, so that the legs of the chair will poke through the box and into those two cans. Reinforce with duct tape. Instant footrest!

Melanie Potock, MA, CCC-SLPtreats children birth to teens who have difficulty eating.  She is the co-author of Raising a Healthy, Happy Eater: A Parent’s Handbook – A Stage by Stage Guide to Setting Your Child on the Path to Adventurous Eating (Oct. 2015), the author of Happy Mealtimes with Happy Kids and the producer of the award-winning kids’ CD Dancing in the Kitchen: Songs that Celebrate the Joy of Food!  Melanie’s two-day course on pediatric feeding is offered for ASHA CEUs.  She can be reached at Melanie@mymunchbug.com