Cooking up the Perfect ASHA 2014

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What’s the perfect recipe for ASHA 2014? Blend together science, learning and practice. Add a pinch of party and a heaping of gratitude. Watch it grow for generations.

Like many SLP swallowologists, I’m a foodie. Expand that: I’m a bilingual (Spanish-speaking)-Canadian-American-Salsa-dancing-foodie-mama-dysphagia nut, ready for a stimulating convention getaway in Florida. Good thing ASHA has cooked-up a feast for the body and mind.

Coming from Boston, I’ll feel right at home Wednesday night at Minus5º Ice Bar for the ASHA-PAC Party. Drinking a cocktail in a glass made out of ice may make you swallow faster! Watch out! The icy architecture will cool us down as we discuss the latest political action on Capitol Hill.

On Thursday, ASHA promises “hot, hot, hot” at the The ASHFoundation Latin Party at Cuba Libre Restaurant & Rum Bar. After we swallow liquids, we can test solids from the award-winning chef Guillermo Pernot. Salsa lessons anyone?

But of course we won’t just be there to party– relaxing and dancing will help us learn better.

 

Gratitude for opportunities in Science & Learning

I love seeing my heroes at conventions. This year we are deeply saddened to have lost our pioneer in dysphagia, Jerilyn Logemann.

As we remember Logemann, we also need to remember to thank all our mentors. Take time to reflect on how much they have influenced you and your career. Who would I be today without teachers like Jay Rosenbeck, Joanne Robbins, and James Coyle during my master’s studies years ago? Thank you!

And not just mentors who you know directly, but those who are influencing the profession, too. Thank you Catriona Steele, University of Toronto, for pushing us to go global. She suggests an international consensus for diet texture terminology. How many names do we have for that safe-ish dysphagia diet between puree and regular? Here are a few: mechanical soft, ground, moist ground, chopped, mechanically altered…

Thank you Tessa Goldsmith, Partners MGH, for the very important exploration of Human Papilloma Virus (HPV). SLPs are public health advocates. Michael Douglas was misdiagnosed three times, delaying his treatment by too many months. He said it started with a sore throat and sore gums behind his last molar. As rates of laryngeal cancer from smoking decline, HPV has emerged as the most common cause of oropharyngeal cancer. However, there are many differences between HPV-positive and HPV-negative cancers. Additionally, don’t miss a chance to see Katherine Hutcheson, of MD Anderson, who gave a fabulous series at the ASHA Healthcare & Business Institute this past April. Jeri Logemann co-authored a two-part series on Long-Term Dysphagia After Head & Neck Cancer. Thank you to her team for carrying the torch.

I appreciate how Dr James Coyle is like Socrates, probing with critical questions to seek the truth. His courses ask: Which side is up?; What’s wrong with my patient?; What are we doing and why?; and what can bedside swallowing examinations do and what can’t they do? Every SLP practicing in dysphagia has to take at least one of his courses. We will learn a lot of science that directly relates to our practice, while having fun! I try to capture his humor in my blogs.

Another thank you to the twilight session on Thursday, called “Eating is Not Just Swallowing.” Samantha Shune, University of Iowa, integrates “components of the broader mealtime process with our definition of swallowing.” I typically introduce my bedside swallowing evaluations with: “Your doctor wants me to evaluate your eating and swallowing.” However, I was once told at an old job to not say “eating,” because it was deemed unrelated to swallowing and swallowing impairment. I appreciate this session’s holistic perspective.

 

Generations of Discovery

ASHA conventions inspire growth. I have discovered that you can recreate your career at any age. After performing Modified Barium Swallow Studies for 15 years, I am beginning again in an extensive FEES training program.

This past April at the ASHA Healthcare & Business Institute, a group of us were sharing our dreams and goals for our careers. I realized that I love to constantly learn, synthesize, and share with others. One year ago, I never would have believed that I would start a dysphagia resource website and become an SLP blogger.

As us older generations teach the younger generations, we also need to thank the younger SLPs for inspiring us to keep it fresh. For me that meant finally embracing technology. It is technology that is helping ASHA members network and reach all corners of the globe.

Thank you, ASHA, for this feast!

 

Karen Sheffler, MS, CCC-SLP, BCS-S, graduated from the University of Wisconsin-Madison in 1995. Karen has enjoyed medical speech pathology for 20 years. She is a member of the Dysphagia Research Society and the Special Interest Group 13: Swallowing and Swallowing Disorders. Karen obtained her BCS-S (Board Certified Specialist in Swallowing and Swallowing Disorders) in August of 2012. She has lectured on dysphagia in the hospital setting, to dental students at the Tufts University Dental School, and on Lateral Medullary Syndrome at the 2011 ASHA convention. Special interests include neurological conditions, geriatrics, oral hygiene, and patient safety/risk management. Karen continues to work in acute care and is a consultant for SEC Medical. She started the website and blog www.SwallowStudy.com in May 2014. She has blog posts on ASHAsphere and www.DysphagiaCafe.com. Sheffler is one of four invited bloggers for ASHA’s 2014 Convention in Orlando.

Three Reasons Why Kids Get Hooked on “Kids’ Meals”… and How to Change That

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Let me say this up front: I’m not condemning the American Kids’ Meal that is so common in fast food chains and family restaurants, but clearly I’m not keen on eating that type of food when there are other choices.   My own kids have certainly had their fair share of chicken nuggets, mac n’cheese and French fries, just to name a few of the comfort kid foods that predictably reappear on kids’ menus day after day.   This is not a blog about good vs. healthy nutrition, because most parents (including me) know that the traditional fast food fare is not healthy…and that’s exactly why parents want to change the statistics that 15 percent of preschoolers ask to go to McDonald’s  “at least once a day.”    The millions of dollars spent on advertising and toys to market kids meals certainly makes many of us frustrated when much less is spent on marketing a culture of wellness.  By hooked, I don’t mean addicted, although there is research that suggests that food addiction may be a serious component for a subset of the pediatric population Plus, the added sugars in processed foods have been found to be addictive in lab experiments.  But, for the purposes of this short article, let’s keep kids’ meals in this very small box:  Most kids love them.

Why am I writing about this for ASHA? As a pediatric SLP who focuses on feeding, one of the frequent comments I hear from parents is “As long we’ve got chicken nuggets,  then my kid will eat.”   Besides the obvious “just say no” solution, what parents truly are asking is,  “How do I expand my kid’s diet to include more than what’s on a kids’ menu?”  Whether we are considering our pediatric clients in feeding therapy or simply the garden-variety picky eater, that is an excellent question with not a very simple answer.

In feeding therapy, therapists take into account the child’s physiology (which includes the sensory system), the child’s gross motor, fine motor and oral motor skills  and also behaviors that affect feeding practices.  Therapists then create a treatment plan designed to help that specific child progress through the developmental process of eating.  While the nuances of learning to bite, chew and swallow a variety of foods are too complex to cover in a short blog post, here are just three of the reasons why kids get hooked on kids’ meals and some strategies to avoid being locked into the standard kids’ menu and begin to expand a child’s variety of preferred foods:

  1. Kids barely have to chew.  The common fast food chicken nugget is a chopped mixture of …well, if you want to know, click here.  Warning: it will ruin your appetite for chicken nuggets, so if your kids can read,  clicking might be the first solution.  However, in terms of oral motor skills, bites of chicken nuggets are a first food that even an almost toothless toddler can consume with relative ease.  Simply gum, squish and swallow.  Macaroni and cheese?  Oily French fries?  Ditto.  There’s  not a lot of chomping going on!
  • In feeding therapy, SLPs assess a child’s oral motor skills and may begin to address strengthening a child’s ability to use a rotary chew, manage the food easily and swallow safely.  Many of the families we work with eat fast food on a regular basis and we might start with those foods, but slowly over time, more variety is introduced.
  • For general picky eaters or those progressing in feeding therapy, the key is to offer small samplings of foods that DO require chewing, as long as a parent feels confident that their child is safe to do so.  Starting early with a variety of manageable solids, as described in this article for ASHA, is often the first step.   For older kids, the texture (and comfort) of “squish and swallow” foods can contribute to food jags.  Here are ten tips for preventing food jags, including how to build your child’s familiarity around something other than the drive-thru.
  1. At restaurant chains and drive-thrus, kids’ meals are readily available.  Helpful hostesses grab the crayons and the matching kids’ menus as soon as they spot a parent walking in with little children.  Kiddos quickly become conditioned to ordering mac n’ cheese or hot dogs.   Parents want a peaceful, enjoyable experience dining out, so naturally they like the kids’ menu option because it appeases everyone.  But it’s just that–an option.
  • In feeding therapy,  SLPs assess and often treat a child’s ability to be flexible with food at home and in the community.  A hierarchical approach is often utilized, where exposure to new foods occurs as a gradual process over time.
  • As a parent, if your child likes to stick to the same routine at a restaurant, begin with helping your child order from the “adult” menu, knowing that you can request adaptions to certain dishes if needed.  If the prices feel too steep, order a side for the kids, and give them samplings of everything on your plate.  Keep in mind that often the goal is simply experiencing the presence of new foods, so order a side dish that is a favorite food plus present a selection of new options from your plate if you are concerned your child will not eat anything.  Now you and your child have a new routine and the tasting piece occurs once the routine is established.   If you order a salad in the drive-thru, consider skipping the kids’ meal and creating a kid’s sampling of grilled chicken cubes, sunflower seeds, mandarin oranges or other options directly from your salad when you arrive at your destination.   Request an extra packet of dressing if your kids like to dip.
  1. Kids Meals are QUICK! Quick to buy, quick to eat and quick to raise blood sugars and thus, feel satisfied.  I get it – part of today’s hectic lifestyle is shuttling kids to and from activities and often, mealtimes happen while riding in the mini-van.  Fast food chains understand this too – that’s why it’s marketed as “fast food.”
  • In feeding therapy, this reliance on drive-thru food affects progress in therapy.  For example, it’s not uncommon for elementary school kids in feeding therapy to  have trouble eating in the chaotic school cafeteria and be “starving” when a parent picks them up from school.  The quickest, easiest solution: The drive-thru every day after school.
  • In today’s quick-fix society, our children are losing the valuable skill of waiting.  Feeling hungry and then making a snack or meal together to satisfy growling bellies is one way to practice the art of waiting.  Have some pre-cut veggies ready in the refrigerator to nibble on if waiting for the meal is too challenging.  Besides, it’s the perfect time to place them on the counter while your prepping the entrée because you’ve got hunger on your side!  Hint: Blanched veggies, patted dry and then chilled, hold more moisture and taste slightly sweeter to some kids.  The higher moisture content makes them easier to crunch, chew and swallow.  Most blanched fresh vegetables last for several days in the refrigerator.  Remember, keep presenting fresh foods so that the more common option is a healthy one, rather than the oh-so-well marketed processed foods found on many kids’ menus today.

SLPs and parents, what strategies do you use do limit traditional kid food and help kids become more adventurous eaters?  Please comment and share your tips!

Melanie Potock, MA, CCC-SLP, treats children birth to teens who have difficulty eating.  She is 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 and includes both her book and CD for each attendee.  She can be reached at Melanie@mymunchbug.com.

Tiffani Wallace’s 2012 Top CEU Courses, Books and Apps Related to Dysphagia

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(Photo credit)

2012 was full of a lot of new experiences for me.  I was approached at the beginning of the year to begin speaking on dysphagia for PESI.  My first speaking engagements were in North Carolina in December.  I absolutely loved it!  Granted, I still have some kinks to iron out in the professional speaking world, but all in all, I thought it went pretty well.  I can’t wait for my next speaking engagement in January down south again, then in Illinois in June. I continued work on my BRS-S and finally was accepted!  Not only accepted, I passed my test!  I can now officially put BRS-S after my name.  Such long-sought and hard-earned letters!

Soon after I earned my BRS-S, I was promoted to Rehab Director of our department.  I’m still learning the ropes and working on improving our department.  I love the new job duties though.

I went to ASHA and had the opportunity to visit old friends and meet new friends.  As always, I had such a fun time!  I again had the opportunity to present a poster session.  It had a great turnout.  I worked in the SmartyEars booth, which is so much fun.  It’s always great to meet people and show off SmartyEars apps.  I always feel a lot of pride when people want to see a demonstration of Dysphagia2Go.  I would love to say that I attend the ASHA convention for the CEU’s, but I attend for the socialization.  That is one week of the year I feel like I am in “SLP heaven”.

I decided to end this post with a list.  Everyone always wants to know my recommendations.  Here are my top CEU courses, books and apps related to dysphagia.

Top CEU courses:

The VitalStim course by CIAO seminars is invaluable.  It’s absolutely great information, with such a huge emphasis on anatomy and physiology.  It is definitely worth the price whether you use the device or not.

MBSImP course by Bonnie Martin-Harris, provided by Northern Speech Services is another outstanding course.  Again, this course is based on the anatomy and physiology of the swallow and using it in interpretation of Modified Barium Swallow Studies.

Of course, my Dysphagia course.  I like to think that it is full of invaluable information.  :)

Top Books on Dysphagia:

Dysphagia Following Stroke by Stephanie K. Daniels and Maggie Lee Huckabee is absolutely excellent.  I’m in the process of re-reading it.  It is a book I will keep.


Drugs and Dysphagia
.  Great reference.


The Source for Dysphagia
by Nancy Swigert is my bible.  I love that book.


Clinical Anatomy and Physiology of the Swallowing Mechanism
.  Absolutely must-read!!


My Top Apps for Dysphagia

Of course my top vote goes to Dysphagia2Go.  I use this app all the time when I do a clinical evaluation of swallowing.  It lets me input all my data and then allows me to print a report of my findings.  This app is available for $39.99 on iTunes.

Dysphagia by Northern Speech Services costs $9.99 and offers amazing pictures of swallowing and swallowing deficits to share with your patients.

Lab Tests is a $2.99 app that allows you to look up lab values, their meanings and why the tests are performed.  This app does not require wi-fi to run.

Micromedex is a free drug app that is amazing and gives you not only information about the drug, but possible side effects, warnings, etc.  You can look up virtually any drug.

Cranial nerves is a $2.99 app that gives you information on all 12 cranial apps.  Not only does it give you the in-app information, but also allows you to, with the push of a button, access further information on the app on Wikipedia and Google.

 

I hope everyone has an amazing 2013.  I so look forward to all the new and great things to come!

This post is based on a post that originally appeared on Dysphagia Ramblings.

Tiffani Wallace, CCC-SLP, has been an SLP specializing in Dysphagia for over 11 years.  Tiffani has been very active in the social media world, creating 2 Facebook groups, Dysphagia Therapy Group and Dysphagia Therapy Group-Professional Edition.  Tiffani is also the co-author of the app Dysphagia2Go, available on iTunes.  She is preparing to travel nationally and speak on the topic of Dysphagia.  Tiffani writes a blog called Dysphagia Ramblings and is the author of www.dysphagiaramblings.com.  She is a 5 time ACE awardee and recently obtained her BRS-S.

Dear Patient

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Photo by Foxtongue

Dear patient,

When you were admitted to my facility I was literally heading out of the door to go home and relax for the evening. I probably planned to have some dinner, read and maybe if I was lucky I’d have a good beer to round out the night. But on my way out I was flagged down by a nurse saying that you wanted to drink regular, thin water.  Actually, the nurse said that you were demanding and yelling about it. At this point, I had no idea who you were; I had no idea we even had any new admissions.  So, I put down my bag and made my day a little longer to see what the buzz was about. I know this isn’t your fault; you probably had little control over what time your transfer took place, and even if you did, I was probably the last person on your mind, but probably not even that. There’s a good chance it didn’t register with you that you’d be seeing someone like me. I don’t mind, and since I like my job and I care about your well-being I came straight to your room without even looking at your chart, something I almost never do, to have a little chat.

As I came into your room I noticed right away that you had a trach. I introduced myself and explained my role as the person who works with swallowing and diet modifications, among other things. Without an acknowledgement of who I was, you began to curse and yell at me that you wanted water and that your previous speech pathologist at the other facility let you have ice chips and water. Not that I expected anything less; you’ve been through a lot, I’m sure, and you’re just trying to advocate for yourself. I get it. And I actually believe everything you told me, but being diligent with my duties and to ultimately look out for your well-being I needed to look through your medical chart to get a better sense of your history and to see if there was any information to clear up this misunderstanding.

After you made your needs known to me, I checked your chart. Your transfer order stated that you should have honey thickened liquids. I found no notes from your previous speech pathologist and no other indication that you were allowed water and ice chips. I also learned you had a PEG and some other conditions that put you at risk for swallowing difficulties. Not to mention you have a trach which adds another level of potential problems. Believe it or not, I still believed what you said about about drinking water and having ice chips but that doesn’t mean I can just change your diet.

I came back to your room to tell you what I learned, but before I could explain what this information meant, you flipped out at me, continued to curse at me and demanded that you be allowed to have thin liquids. Obviously you knew where I was going with this conversation. Between your outbursts, I did my best to explain that even though you may have had thin liquids at your last hospital, you came here with a honey thick liquid restriction and that I couldn’t find anything in your chart that indicated you were able to drink thin liquids safely, that is, drinking thin liquids without it entering your lungs. I couldn’t even find a single note about thin liquid trials with your previous speech pathologist. I don’t blame you for how you felt, nor did I get upset about it. Even though I work with dysphagic patients every day, I still can not fathom what it would be like to not drink what I like, on top of that, having a stranger tell me what I can and can not drink. That would totally suck. I once even tried to drink the stuff we give you. Its gross, and I couldn’t imagine drinking that stuff with every meal. That would also totally suck. I could see you were upset because you kept swearing at me. You really do have some foul language! I still don’t blame you, because your situation is awful and I can imagine myself acting very much in the same way. So, as a last ditch effort I called your last hospital but could not get a hold of anybody in the speech department or anyone in nursing who could clarify what your diet was. So honey thickened liquid remained your diet for at least that night.

You see, I did everything I could to determine if thin liquids were safe for you. I do care; I empathize with you, because I do not envy what are going through. But I have to make my decisions not based on entirely what you want, but based on the data I have about you. I believe you when you say you had water and ice at the last hospital, but I have no way to verify that. I don’t have the tools at my immediate disposal to determine if you can drink water without it going into your lungs. You came to my building with a honey thick liquid restriction and that will remain until I can verify that you are safe for thin liquids, whether it be a report from your previous speech pathologist or passing a video swallow eval. This isn’t because I’m a jerk, even though you might think I am-its because I actually do care and I don’t want to make a careless decision that could land you back in the hospital with pneumonia. Pneumonia will undoubtably prolong your course of hospitalization and it will add quite a bit of money to your bill. Not to mention that aspiration pneumonia is life-threatening. You could die if I mindlessly changed you to thin liquids. That is simply a risk I won’t make. Not just for you, but for any of my patients.

You seem like a good person and I do look forward to working with you. I look forward to hopefully getting rid of that nasty honey thick restriction and seeing the happiness and relief on your face when you hear the good news. I want you to avoid getting sucked into the blackhole of health care, bouncing between hospitals and skilled nursing facilities for preventable issues. Instead, I want to see you go home healthy and fit so you can live a happy life. I hope that you realize I’m not some dolt, but someone that does genuinely care about your health.

Your Speech Pathologist,
Adam

(This post originally appeared on slowdog)

 

Adam Slota M.A., CCC-SLP is a speech pathologist working in long term care and long term acute care settings, primarily with tracheostomy and ventilator dependent patients. He is also the author of the blog slowdog where he writes about various topics in speech pathology and beer, among other frisky and/or mundane missives.

Swallowing and Feeding Issues with Internationally Adopted Children

Vegetables in Whole Foods Market


Photo by Masahiro Ihara

My children were “picky eaters.” One would only eat peanut butter and jelly, frozen pizza, chicken nuggets or macaroni and cheese. The other one would only eat frozen pizza and hot dogs. Neither of them would eat any vegetables. If it was green, it was considered inedible! Needless to say, cooking for them was a challenge. Somehow they survived and are both healthy adults who eat more variety than I ever thought they would.

Many of our food preferences are based on our food experiences. Children residing in orphanages have feeding experiences that are affected by the number of staff available to feed large groups of infants and toddlers. Parents have reported observing children left in their cribs with bottles propped up to allow self-feeding, given plates of food too hot to eat without utensils to feed themselves, and children fed pureed instead of solid foods. These experiences may not only affect physical growth and nutrition but also adversely affect eating and swallowing development. Some researchers have reported a wide range of eating and swallowing problems from clinical samples including (a) chewing problems, (b) preoccupation with food availability, (c) gorging and (d) sometimes becoming omnivorous (Johnson & Dole, 1999). Others found that 15% (21 of 144 children adopted from Romania) continued to have chewing and swallowing problems at 6 years old, 2 to 5 years following adoption (Beckett, et al., 2002). Beckett and colleagues also found that if solid food was not introduced before the age of 1 year, more of these children had continued eating and swallowing problems. Many of the children seen at the Saint Louis University International Adoption Clinic present with eating and swallowing difficulty or unusual oral motor problems such as facial tics or intermittent velopharyngeal closure during speech and swallow.

Children adopted from abroad are at risk of having eating and swallowing problems. Practitioners are advised to explore the presence of oral motor sensitivity, eating and swallowing problems with the client or client’s family. If problems were observed or continue to occur, a thorough assessment of oral motor structures and function and possibly an assessment of eating and swallowing behaviors may be needed. If children demonstrate eating disorders related to mental health issues such as bulimia or anorexia, it is important to refer them to clinical psychologists or counseling and family therapists.

References

Beckett, C. M., Bredenkamp, D., Castle, J., Groothues, C., O’Connor T. G., Rutter, M., & the
English and Romanian Adoptees (ERA) Study Team. (2002). Behavior patterns associated with institutional deprivation: A study of children adopted from Romania. Journal of Developmental and Behavioral Pediatrics, 23(5), 297-303. http://journals.lww.com/jrnldbp/pages/default.aspx

Johnson, D. E., & Dole, K. (1999). International adoptions: Implications for early
intervention. Infants and Young Children, 11, 34-45. Retrieved from:
http://www.peds.umn.edu/iac/prod/groups/med/@pub/@med/documents/asset/me
d_49295.pdf

Deborah Hwa-Froelich, Ph.D., CCC-SLP, is a Saint Louis University professor and Director of the International Adoption Clinic with interests in social effects on communication such as culture, poverty, parent-child interaction, maternal/child health, and disrupted development.