Want to Work in Acute Care Pediatrics? 5 Traits for Success

preemie

It’s hard to believe I’ve been an SLP for 38 years! For most of that time, I’ve worked in an acute-care pediatric setting. I’m employed at the Florida Hospital for Children in Orlando, where I provide pediatric/neonatal swallowing and feeding services for multiple acute-care services, including neonatal intensive care, pediatric intensive care, newborn nursery, general pediatrics, oncology, epilepsy, ears, nose and throat, gastrointestinal, congenital heart surgery, plastics, and extracorporeal membrane oxygenation. Thinking on my feet, but carefully considering both the evidence base and interdisciplinary perspectives, is a must every day.

Sometimes people ask me: What are you passionate about? What drives you?

I am passionate about the neonatal intensive care unit and our tiny patients. Being a part of this wonderful team and fostering the parent-infant relationship through supporting safe and successful feeding continues to fill my heart with joy after all these years. I am a lifelong learner and am passionate about creating opportunities to learn from physicians, nurses, respiratory therapists, my rehab colleagues and the families I serve.

Are you interested in working with these tiny and fragile patients? If so, here are some questions to ask yourself:

  1. Do you like to solve a puzzle? Problem-solving is essential in acute care! Critically thinking about a patient’s medical history and co-morbidities, then looking at the data and making sense of the information is key. Is the infant/child safe to feed? If so, what is the best approach? How can the child best communicate? What is interfering?
  2. Are you passionate about evidence-based practice? Physicians want to know why you are recommending what you are and what evidence there is to back it up. Sometimes the highest level of evidence is our clinical experience and wisdom. But we need to be aware of what hard evidence exists and bring it to the physicians.
  3. Do you work best in a team setting? Looking at the critically ill child works best in the context of multiple perspectives. Physician specialists, bedside nursing, respiratory therapists, dieticians and our rehab colleagues bring information that helps us make better clinical decisions. Through team interactions, we jointly problem-solve.
  4. Do change and unpredictability give you a buzz? Some days we need rollerskates! The day can change quickly with new consults, children being discharged, and changes in the patients we are treating. Being ready for change and staying focused are key to riding the wave.
  5. Are you well-grounded in normal and atypical development? This knowledge allows us to problem-solve and recognize what symptoms deserve our focus. Experience in birth-to-3 is invaluable for preparing to become a pediatric acute-care SLP.

Do the traits above sound like you? If you are thinking about moving into acute-care pediatrics, stay tuned for more to guide you on your journey!

 

Catherine S. Shaker, MS, CCC-SLP, BCS-S, works in acute care/inpatient pediatrics at Florida Hospital for Children in Orlando. She offers seminars on a variety of neonatal/pediatric swallowing/feeding topics across the country. Follow her at www.Shaker4SwallowingandFeeding.com or email her at pediatricseminars@gmail.com.

 

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

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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

 

Smart PHONeNATION: How My Device Revolutionized My Voice Rehabilitation Practice

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My smartphone has literally revolutionized the way I give sessions. And I don’t mean literally Rachel Zoe style. I use my phone practically every session! Now I hear those of you who are seasoned professionals. You are unfamiliar, maybe apprehensive about technology like this. “It’s too difficult,” you say, “I’m not generation text message-thumb.” I hope this piece encourages you to give it a try.

Age knows no bounds when you apply technology, because most everyone can benefit from these innovations. I’ll echo a recent ASHA post on SLP hats and inquire the same about the many jobs of your smartphone:

  • Stop-watch. I have one less item to worry about if I use my phone for timing maximum vowel prolongations, S/Z ratios and structured session tasks. Your phone timer also tracks session length. We all have those clients who love (I mean REALLY love) to talk, which is good when you advance to structured conversational tasks, but sometimes they carry on too long. Use your phone timer if you feel it’s appropriate for signaling a wrap-up.
  • Recording device. I record my acoustic measures when I analyze cepstral peak prominence and fundamental frequency, but during therapy—where the hard work begins—I employ my voice memo app. I also teach patients how to use their own voice memo programs, which is important for home practice. Follow-through is such a different game now, because most patients have recording options on their phones. You can record session highlights for easy patient access on his or her own device, versus cassette-taping the session.
  • Biofeedback. It’s great if you have a state-of-the-art Computerized Speech Lab setup. If you don’t, your smartphone has an app for that. (Ha! You were waiting for that phrase, weren’t you?) Bla | Bla | Bla works as a visual sound meter. As you get louder, the faces change. It doesn’t replace the software that helps you stay within a target pitch range, but can provide biofeedback for intensity tasks. I use smartphone video recorders to improve self-awareness for laryngeal and upper body tension. Instant review of these videos may help your patient meet goals sooner.
  • Piano. For Joseph Stemple’s Vocal Function Exercises, I use my MiniPiano app for pitch matching on Warm-up and Power. For the small group of clients with NO musical inclination, just do you best to find a mid-range pitch for VFE’s, but for your type-A’s (you know who they are), the option to have perfect pitch right at your fingertips wastes no time.
  • Anatomy. I used to lug around literally (Ha, Rachel again!) thousands of copies of anatomy drawings for patients. The copies usually ended up in the trash. The Dysphagia app has been my most effective tool for explaining the anatomy of a swallow, vocal folds as well as reflux. It has nice color videos demonstrating disordered and normal swallows and dramatically enhances patient education. Plus, the video action makes a more lasting impression.
  • Alarm. Ever get a patient who doesn’t practice? (You can always tell.) With a smartphone, you can name each alarm and set them to go off at certain times. The patient can deliberately practice diaphragmatic breathing and single syllable target words every hour on the hour! We’re going for making new muscle memory here, so it’s key to entice the patient to practice mindfully and not just be on autopilot. It’s beneficial for whole body exercise to take place for short periods throughout the day, so why not phonation training? And it keeps patients accountable.

Embracing the technology out there doesn’t mean you need to de-humanize sessions. The relationships you build with your clients are special. Their progress depends on how comfortable they feel in the room. Don’t spend the entire session glued to your phone, but strive to find a good balance where you use it when you think it will make a difference.

We SLP’s and AuD’s are in the people business and let’s not forget we’re professional voice users ourselves. Voice therapy techniques used to be difficult to maintain out of the treatment room. Now our clients have a fighting chance to recreate that buzzy forward-focused sound every time they glance at their smartphone between Facebook updates and Yahoo news articles.

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She provides voice, swallowing and speech therapy in her own private practice, a tempo Voice Center, LLC. She also lectures on the singing voice to area choirs and students. She belongs to ASHA’s Special Interest Group 3-Voice and Voice Disorders. She keeps a blog on her website at www.atempovoicecenter.com. Follow her on Twitter @atempovoice or like her on Facebook at www.facebook.com/atempovoicecenter.

Snow Day Recap

AugustSnowman

It’s a snow day here at ASHA and for many of our members on the East Coast. So whether (pun intended!) you’re snowed in or not, curl up with some of our most popular posts from 2014 in this compilation published earlier this year.

 

From stuttering to aphasia, hearing loss to hearing aids, early intervention to telepractice and more, ASHA’s blog posts are written by you—our members—sharing knowledge with peers on a variety of subjects. But there’s no doubt about it, pediatric feeding has been the topic on ASHAsphere in 2014!

Check out your five favorite posts from last year:

Step Away From the Sippy Cup!

SLP Melanie Potock specializes in pediatric feeding and explains that sippy cups were created to keep floors clean, not as a tool to be used for developing oral motor skills.

“Sippy cups were invented for parents, not for kids. The next transition from breast and/or bottle is to learn to drink from an open cup held by an adult in order to limit spills or to learn to drink from a straw cup. Once a child transitions to a cup with a straw, I suggest cutting down the straw so that the child can just get his lips around it, but can’t anchor his tongue underneath it.” – Potock

Baby Led Weaning: A Developmental Perspective

For parents interested in following the Baby Led Weaning (BLW) philosophy of pediatric feeding, which states that babies are developmentally capable of reaching for food and putting it in their mouths at about 6 months of age, SLP Melanie Potock shares some thoughts to consider.

“For children in feeding therapy, incorporating some aspects of BLW is dependent on that child’s individual delays or challenges and where they are in the developmental process, regardless of chronological age. My primary concern for any child is safety—be aware and be informed, while respecting each family’s mealtime culture.” – Potock

Collaboration Corner: 10 Easy Tips for Parents to Support Language

Paying attention to body language, reading every day and using pictures are just a few tips SLP Kerry Davis shares with parents to support their child’s language development.

“Take pictures of your child’s day and talk about what is coming up next, or make a photo album of fun activities (vacation, going out for ice cream) to talk about.” – Davis

What SLPs Need to Know About the Medical Side of Pediatric Feeding

To overcome pediatric feeding problems, SLP Krisi Brackett explains the importance of first figuring out why the child’s in a food rut.

“Whether the child is dependent on tube feedings, not moving to textured foods, grazing on snack foods throughout the day, failing to thrive, pocketing foods or spitting foods out, using medical management strategies can greatly improve a child’s success in feeding therapy.” – Brackett

Preventing Food Jags: What’s a Parent to Do?

For kids who only eat a limited number of foods, it can be difficult for parents to provide the right nutrition for their kids. SLP Melanie Potock shares her top 10 suggestions for preventing food jag.

“Food Left on the Plate is NOT Wasted: Even if it ends up in the compost, the purpose of the food’s presence on a child’s plate is for him to see it, smell it, touch it, hear it crunch under his fork and  perhaps, taste it.  So if the best he can do is pick it up and chat with you about the properties of green beans, then hurray!  That’s never a waste, because he’s learning about a new food.” – Potock

 

ASHA always welcomes new blog contributers. Interested? Apply to here become an ASHAsphere blogger.

Sara Mischo is the web producer at ASHA. She can be reached at smischo@asha.org.

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

More than a Picky Eater: How to Really Know?

boy not eating

The struggles of a parent during mealtime with a picky eater can range from bad to worse. It often begins with the ever-present protest of “No!”  then ends with screaming, tantrums and food flying across the room. The question remains: is the food refusal normal of a picky eater or could the signs be more consistent with a feeding disorder?

A pediatric feeding problem is often accompanied by a developmental delay or medical disorder. These can include, but are not limited to, autism spectrum disorders, Down syndrome, gastrointestinal motility disorders, cerebral palsy, respiratory disorders or cystic fibrosis.

Children who were hospitalized for an extended time at birth or who received a tracheotomy or feeding tube may also have difficulty transitioning to an age appropriate feeding pattern. However, children who are considered typically developing can also develop a fear of food. Research shows that 25 percent of children suffer with some degree of a feeding disorder. In children who suffer from a developmental, neurological or genetic disorders, that number rises to 80 percent (Branan & Ramsey, 2010).

A feeding disorder is characterized by any difficulties eating or drinking including chewing, sucking or swallowing. Children who have not developed age appropriate feeding skills and/or have a genetic, developmental or behavioral disorders can have difficulty during mealtime.

Some signs and symptoms of a problem feeder include:

  • Trouble breathing when eating or drinking
  • Choking, gagging or excessive crying during mealtimes
  • Tantrums when presented with new foods
  • Excessive drooling or spillage of foods/liquids from the mouth
  • Difficulty chewing or swallowing food
  • Restricted variety of foods eaten—usually less than 20
  • Refusal of categories of food based on texture or basic food group
  • Refusal to eat meals with the family

In order to better treat children with feeding problems, it is important to understand those children who do not meet the criteria. Children who are picky eaters present with the following signs and symptoms (Toomey 2010; Arvedson 2008):

  • Eat a limited variety of foods; but have around 30 foods they will eat
  • Intake enough calories a day for growth and nutrition
  • Lose interest in a certain food for a period of time, but accept it again after a few weeks
  • Eat at least one food from all major food groups (protein, grains, fruits, etc.)
  • Tolerate a new food on the plate, even if they don’t eat it

Although mealtimes with either issue can be difficult for parents, distinguishing between the two helps SLPs create the best individualized treatment approach.

Once a professional diagnoses a child with a feeding disorder, there are three key concepts to remember:

  1. Contact a child’s pediatrician, nutritionist and other health care providers in order to create the best treatment plan for that child. A multidisciplinary approach provides various viewpoints that bring the whole child into consideration.
  2. Choose foods that are meaningful to the family. If no one else in the family eats broccoli, it may not be a necessary food to add to the child’s eating repertoire.
  3. Create both short term and long term goals to track progress and keep both the child and family motivated.

Treating a child with a feeding disorder is a challenging but rewarding task. The end goal of treatment should always be a safe, happy and healthy eater.

 

April Anderson, MA, CCC-SLP, is a Speech-Language Pathologist at National Speech/Language Therapy Center in Bethesda, MD.  She works with infants and toddlers, as well as school-aged children with feeding disorders. April can be reached at  april@nationalspeech.com.

 

Pediatric Feeding Tops the Charts in 2014

baby eating

From stuttering to aphasia, hearing loss to hearing aids, early intervention to telepractice and more, ASHA’s blog posts are written by you—our members—sharing knowledge with peers on a variety of subjects. But there’s no doubt about it, pediatric feeding has been the topic on ASHAsphere in 2014!

Check out your five favorite posts from last year:

Step Away From the Sippy Cup!

SLP Melanie Potock specializes in pediatric feeding and explains that sippy cups were created to keep floors clean, not as a tool to be used for developing oral motor skills.

“Sippy cups were invented for parents, not for kids. The next transition from breast and/or bottle is to learn to drink from an open cup held by an adult in order to limit spills or to learn to drink from a straw cup. Once a child transitions to a cup with a straw, I suggest cutting down the straw so that the child can just get his lips around it, but can’t anchor his tongue underneath it.” – Potock

Baby Led Weaning: A Developmental Perspective

For parents interested in following the Baby Led Weaning (BLW) philosophy of pediatric feeding, which states that babies are developmentally capable of reaching for food and putting it in their mouths at about 6 months of age, SLP Melanie Potock shares some thoughts to consider.

“For children in feeding therapy, incorporating some aspects of BLW is dependent on that child’s individual delays or challenges and where they are in the developmental process, regardless of chronological age. My primary concern for any child is safety—be aware and be informed, while respecting each family’s mealtime culture.” – Potock

Collaboration Corner: 10 Easy Tips for Parents to Support Language

Paying attention to body language, reading every day and using pictures are just a few tips SLP Kerry Davis shares with parents to support their child’s language development.

“Take pictures of your child’s day and talk about what is coming up next, or make a photo album of fun activities (vacation, going out for ice cream) to talk about.” – Davis

What SLPs Need to Know About the Medical Side of Pediatric Feeding

To overcome pediatric feeding problems, SLP Krisi Brackett explains the importance of first figuring out why the child’s in a food rut.

“Whether the child is dependent on tube feedings, not moving to textured foods, grazing on snack foods throughout the day, failing to thrive, pocketing foods or spitting foods out, using medical management strategies can greatly improve a child’s success in feeding therapy.” – Brackett

Preventing Food Jags: What’s a Parent to Do?

For kids who only eat a limited number of foods, it can be difficult for parents to provide the right nutrition for their kids. SLP Melanie Potock shares her top 10 suggestions for preventing food jag.

“Food Left on the Plate is NOT Wasted: Even if it ends up in the compost, the purpose of the food’s presence on a child’s plate is for him to see it, smell it, touch it, hear it crunch under his fork and  perhaps, taste it.  So if the best he can do is pick it up and chat with you about the properties of green beans, then hurray!  That’s never a waste, because he’s learning about a new food.” – Potock

 

ASHA always welcomes new blog contributers. Interested? Apply to here become an ASHAsphere blogger.

Sara Mischo is the web producer at ASHA. She can be reached at smischo@asha.org.

Ten Tips for Making Progress in Feeding Therapy

Dad and son at farmer's market

Parents’ Ten Tips for Making Progress in Feeding Therapy

The end of a year is a reflective time for many parents, especially those who have children in any type of therapy.  As a pediatric SLP who focuses on feeding, I asked over forty parents for their number one tip that helped their child progress through feeding therapy.  I found it interesting that typically what popped into their minds wasn’t an oral motor tool or a specific therapy modality or other tips like “practice, practice, practice!”  What struck me was that most parents focused on an emotional component.  When we consider the bond between parent and child, that makes perfect sense.  I learn so much from the parents of the children I treat and I’m grateful for their wisdom.

Here are the Parents’ Ten Tips for Making Progress in Feeding Therapy:

#10: “Meet my child where she is…show interest in what she’s interested in” and build from there.  It builds relationships and that’s the foundation for mealtimes.

#9 “Your child sets the pace.” Expectations and goals are two different things, as described in this article for ASHA.

#8: “Patience.” This was the most popular response.  One…step…at…a…time.

#7:  Pause and “be compassionate.” It’s not easy for many kids to move through the developmental process of eating.  Both physical and emotional pain may come into play.

#6: “Have FUN and PLAY daily in food!”  Join in and get the whole family involved, as noted in this ASHA article.

#5: “Expose kids to the Joy of food” – and not just at mealtimes: Farmer’s Markets were a top pick along with the produce isle at the grocery store.  Focus on sharing time together and the event, not what might or might not happen when the food makes it to the dinner plate.

#4: “Build Trust.”  When a child trusts their mealtime partner, whether it be a therapist, parent or caregiver, that builds confidence in eating skills over time.

#3: Kids get sick and sometimes that stalls progress or causes some regression.  One parent stated that: “It’s just part of being a kid, so it’s also part of the process.”

#2: “Rely on Faith,” and not just the religious kind: Faith in family and faith in your child … but also faith in yourself as a parent.

#1: “Park your own stress in the driveway.”  That’s a tip that I teach to parents – and I am pleased to see it repeated here.  Life is full of stressful moments and it’s easy to bring those into your home.  But family mealtimes are a time to focus on family and if there is one thing I am sure of,  it’s that kids mimic  their parent’s emotions.  Be sure to take care of you too – the  feeding therapy process isn’t always easy, but it’s incredibly rewarding and exciting when you witness even the smallest changes in your child’s ability to enjoy all kinds of food.  Those changes often start with your emotions: Smile when you can, laugh even more and be ready for all the good things to come.

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.

 

If You Give My Picky Eater Some Turkey…

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An open letter to any relative who plans to invite my family to Thanksgiving dinner:

In the spirit of the season, I want to thank you and yours for inviting my family and our little picky eater to your traditional Thanksgiving celebration.  I should warn you that my sweet 3-year-old isn’t always the most adventurous eater and may turn up her nose at the traditional holiday fare, but I have a few helpful tips for you here:

If you give my picky eater some turkey, she’s going to ask for a hot dog.  When you give her the hot dog, she’ll probably ask you for ketchup.  Then, she’ll ask for more ketchup.  And then, she’ll refuse the hot dog, because it’s “cold”.  It’s a cold dog.  So she’ll just eat the ketchup.

If you give my picky eater green bean casserole, she’ll panic.  She only eats foods that are easily identified.  Green bean casserole is not easily identified.  But, if you put ketchup on it, it’s fine.  I’ve brought her favorite brand of ketchup, which you have to serve in the original plastic bottle so she can see you squirting it onto her plate. Don’t ever remove the bottle from your lavishly-set table. She’s needs to see it at all times.

If you give my picky eater cranberry sauce from a can, she’ll ask: “How did it get in the can?” along with 100 gazillion other questions.  “Why does it jiggle? What are those lumps? Cranberries? What are cranberries?  It looks like red vomit.”  Now, no one at the Thanksgiving table will eat the canned cranberry sauce…even with ketchup. I’m very sorry for that. That’s why I brought you this very expensive bottle of wine. I suggest you open it now.

If you give my picky eater the platter of candied yams and suggest she helps sprinkle on the mini-marshmallows, she’ll stick out her tongue, but then join in.  As she places the last tiny marshmallows on the layer of yams, she’ll ask why the marshmallows stick to yams.  You’ll probably tell her “It’s the sticky syrup on the yams.”  She’ll reply “Oh, I thought it was because I licked each one.”  You’ll have another glass of wine.

If you give my picky eater some mashed potatoes, she’ll gag.  “But, they taste just like French fries!” you’ll exclaim. She’ll gag again and run from the table.  While having a complete Thanksgiving meltdown, she’ll scream “I want French fries!!!” and you’ll make an immediate mental search of what fast food drive-thrus are open on Thanksgiving. You’ll send you husband out to find French fries and he’ll happily agree to leave.

If you give my picky eater some stuffing, she’ll stare at it.  You’ll tell her it’s chopped-up chicken nuggets that your husband bought while he bought her French fries at the drive-thru. She’ll pause…she’ll ponder…she’ll ask: “Where’s the toy?”  You’ll grab three mini-marshmallows, smoosh them together and tell her it came with a toy “Olaf” from Frozen.

If you give my picky eater some gravy, she’ll ask: “What is this?”  So you’ll lie and say “It’s brown ketchup.” She’ll stare at the brown ketchup and ask “If I eat it, do I get dessert?”

Upon the suggestion of dessert, you’ll give my picky eater a slice of pumpkin pie.  After all, pumpkin’s a vegetable, right?  She’ll ask for some whipped cream to go with it.  But not the homemade kind: She only eats the kind in the can.  “Not like the can that had cranberry sauce,” she’ll explain.  “Only the ‘squirty’ kind of can.”  She’ll eat all the whipped cream off the top of her pie, completely missing any remnant of “vegetable” you hoped she would consume.  That is, unless she detects any kind of lump…like those lumpy cranberries…which are red.  The red will remind her of her favorite food: ketchup.  So, she’ll ask for some ketchup.  And chances are if she asks for ketchup, she’ll want some turkey to go with it.

(Many thanks to Laura Numeroff, author of If You Give a Mouse a Cookie, which was the inspiration for this piece.)

 

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.

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.