ASHA Convention 2019 Highlights

Thoughts from the ASHA Convention…

I know this is late- ASHA was weeks ago but due to a busy semester I am just now getting to my post.  

Thank you!

To all of the presenters/authors for pediatric feeding and dysphagia. I was only able to attend some of the sessions but the ones I attended were excellent and I heard good feedback about the topics, speakers, and overall variety of topics this year. To be honest there were many speakers I missed due to overlapping sessions or preparing for my own talk; Polly Tarbell, Heidi Moreland, Michele Cole-Clark , Jennifer Morris-Meyer, Catherine Shaker , Sue Thoyre, Maureen Leifton-Greif, Catherine Genna Watson, to name a few.

I am going to post some snippets from sessions I attended, Please know these are based on my notes and not directly from the presenter. These were some of my take-aways that I want to share. 

Understanding Pediatric Anxiety & Feeding Disorders : Melanie Potock  SLP-CCC and Jennifer Kazmerski  Ph.D, BCBA-D

My take: I loved this talk because  we are seeing many children with anxiety and feeding difficulty. I am not a psychologist and currently do not work with psych on our feeding team so it reinforced for me some of the techniques we currently use . It also opened my eyes to parent  behavior being a result of parental anxiety. I have toyed with the idea for years now of doing an experiment of just treating the parents. If we just worked with parents , would kid behavior change? 

• Function of eating has been disrupted because of anxiety
• Anxiety  is how a child manages his fear, not about the food. 
• Anxiety is paired with aversive response   (examples: refusing, over chewing, wiping tongue, doing just enough to g et approval)

Parents:

• Parents fear hinders progress. Focus on the parent, change parent behavior to change kid behavior . 
• Parents anxiety – can  show up  as arguing, nagging patient, avoid follow through, excuses, negotiating, begging child, cancellations.  
• Remember where the parents are coming from. Intervention must fit the family.
• It’s okay to  have family rules about  food. For example,  “we don’t throw food.” Consequences for breaking the family rules.  Negative punishment is called parenting.

Therapists

• End sessions on success!
• Progress goals in sequence working toward sitting and eating. 
• Meal time scheduling can help with hunger and understanding of task.
• Meal time strategies: offer preferred and non preferred foods, focus on family, meals end in 20-30 minutes, reinforce desired behaviors, ignore non desired behaviors 
• Exposure is everything- progressive, small steps,  repeated positive practice over time.

A Sensory-Motor Approach to Supporting Modified Baby-Led Weaning in Babies with Down Syndrome (DS)  Jill Rabin, SLP-CCC/IBCLC and Lori Overland , SLP-CCC, C/NDT, CLC

My take: I absolutely loved this talk . This completely  opened my eyes to BLW in a different way. We see  babies in our clinic who are trying to do BLW and honestly, we have seen choking and poor weight gain.  This session opened my eyes to the idea that we could modify this approach for babies with not only DS but low tone and with feeding difficulty. What I particularly loved was the idea of loading spoons for babies as a way to begin the self feeding and hand to mouth skills. 

Lori started the talk by saying that as soon as we feel we know everything in the field, it’s  time to get out . (I am paraphrasing but love the point.) This is a dynamic field and we are always learning and evolving our practice.

• Structural issues 
• Look for tongue tie and labial tie
• •Palate – shaped  by tongue, many  babies  with DS are born with normal palate
• Myth that  children with DS’s tongue do not fit in their mouths.

Baby  Led  Weaning – babies feed themselves from the time they start  solids. 

• Baby self feeds, food in easy form to grab and munch, no spoon feeding, no pressure
• easy for typical developing babies
• modified for DS

Benefits of Breast Feeding for babies with DS.

• •Can change the shape of the palate
• •Help with room for dentition and breathing
• •Working on closed mouth posture early on

Modified BLW with therapeutic feeding- improves fine motor

• •preloaded spoons
• •chewy spoons
• •silicone feeder – work with easy texture and  start with  thin puree,  thicker puree and
• •preloaded spoons handed to baby
• •soft solids that can pick up
• •chew on hard texture

Finally got to meet Jennifer Morris Meyer!!!!

Oral  Dysfunction as a Cause Malocclusion & Suboptimal Facial Development  –  Linda D’ Onofrio  SLP-CCC

My take: This is an area that I am working to improve my understanding of how we can better serve our kids with malocclusion, structural issues, and breathing problems.  I loved this talk and wish I could hear it again. This talk was entirely research based. My head was swimming with anatomy and thoughts on oral structures. To my surprise, Linda was on one of my bus rides back to the hotel and I was able to pick her brain even more! 

Structure impacts function

• Oral motor impacts skeletal shape, facial development
• OMD – clinical marker for OSA (obstructive sleep apnea), often preventative, takes more than one profession to fix
• OMD- dysfunctional lips, jaw, tongue, oropharynx cause disorder
• Oral rest postures – “your  lips are your faces  braces. your  tongue  is your palate expander”

Breast feeding is important – it recruits different muscles and helps to shape the  palate. 

• BF widens your palate, the longer you  nurse the better  your  face looks
• •BF rotates your jaw  forward and  sets  up  alignment 
• •BF sets  up  facial structure for development  of jaw, reduced malocclusion
• •Oral  dysfunction/malocclusion/OSA- wrapped up together. 6 months of BF had less OSA.

Tongue Tie (TT)

• Look at teeth, your tongue is your tooth brush, if you can’t clean your teeth due to restriction, may see cavities
• Impact of TT on hard palate- the more restricted the TT, the more narrow the  palate, the  more sharp the jaw  angle
• TT narrows the  palate and  inhibits jaw growth  forward, flattening our faces, and driving oral structures into the airway.
• A  high palate: palate is bottom of your nose and can deviate the nasal septum. 
• Oral habits –  anything that keeps mouth open and tongue low , set ups  cascade
• Intubation- anything  that makes  the tongue  go  low changes  the  swallow

Symptoms of Problematic Eating in Children with Autism Spectrum Disorder  (ASD) – Cara McComish, SLP, Ph.D

My take: this was technical session and based on research using the Pedi-EAT tool. This was interesting  because results showed higher sub scores (indicating problems) in all areas  across ages which implies feeding issues are not getting better with age without intervention. A common myth I hear from  parents  is that their doctor  said their child will grow out of the  problem. This is more evidence for  early referral and intervention! We are working with the Feeding Flock now in our clinic and giving the Pedi-Eat and Neo-EAT to all of our kids to identify presenting problems and to track  progress.

-50% of children with ASD present with feeding difficulty

• High subscores in all 4 areas then typical peers (seen in across ages)- implied, symptoms  not improving without intervention

Master Class Panel from the International Pediatric Feeding Consortium- https://iapfs.org with  Sherry Cohen, MD, Colleen Leukens, Ph.D, Sally Asquith, SLP , Nanette Martin, PNP, Jessica Brown, RD. 

My take: I loved this because it was all complex cases. The presenters analyzed the cases from the perspective of 4 frames (medical,  behavioral, skill, and nutrition).  This talk reinforced what our team is doing and gave us ideas. It also drove home that feeding is complex and often requires multiple professionals to assist with management. 

4 domains and influence on feeding were discussed withe each case.

• What we ask parents to do is harder than the maladaptive behaviors
• Nutritional – malnourished brain, approaches food, hunger differently
• Dependence on formula is feeding problem
• Feeding therapy- is about asking a child to do something they don’t want to do. 
• Parents – want independent feeding, often is a long road to get there.
• https://iapfs.org – Join the International association for pediatric feeding and swallowing

Collaborative Decision-Making in the Care of Complex Pediatric Aerodigestive Patients Dr. Paul Willging, MD, Claire Mille, SLP-CCC, Therese O’Flaherty RD

My Take: I enjoyed hearing about how this team provides intervention. Highlight/confirmation for me was that  wet vocal quality does not always mean aspiration , especially the context of an airway disorder .

• Dr. Willing talked about being an ENT and  the need at times to push patients to find to find new way to swallow (head and neck cancer example) vs making someone NPO. 
• Wet vocal quality- not necessarily swallowing problems, could be related to anatomy/airway protection and phonation

Tracheo-esophageal fistula (TEF):

• Always have malacia   down to the carina
• Always have motility  problems
• Often have long term feeding issues
• lots of GERD, inflammation, aspiration, increased LTC

Neuro related feeding issues

• -Keep orally feeding as long as possible , may not  get better

Respiratory issues

• Not always lung issues, may be  cardiac 
• You can’t breathe well if you don’t circulate your blood

Testing:

• ENT – rigid/flex scopes- provide different info
• Impedance- can give info on GERD severity
• Lipid  laden macrophage test (may indicate aspiration or lung injury)
• High resolution CT can give info on aspiration
• MBSS- only do when a kid his well, not sick

Nutrition – talked about their Pureed by G-tube diet for retching/gagging. 

FEES coloring book pdf – available through the Cincinnati Airway Team’’s website

Opposites Attract: A Marriage of Sensory & Behavioral Strategies in Feeding Therapy Melanie Potock SLP-CCC and me

My take: Melanie and I had a lot of fun putting this together. Our take home point was that feeding therapy needs to be tailored to the child and family and there is no one size fits all.  In fact, I think the strongest therapists are the ones that pull from a variety of techniques to individualize the treatment plan. From a speaker standpoint, I think it went well. The audience was lovely, asked great questions and seemed engaged. Thanks for everyone who came out and those sitting in the overflow room! We appreciate it! 

• We reviewed the research (10 articles total) that looked at either comparison of sensory vs  behavioral feeding or looked at out comes using different approaches.
• Behavioral therapy was stronger in all studies for improving food acceptance and reducing inappropriate meal time behavior. 
• However, many authors alluded to better carry over and generalization when incorporating  both types of therapy. 
• message: pull from both sides and don’t limit yourself or the child!

Exhibits

My favorite new gadget is by far the throat scope. Honestly, I use it everyday and think it is amazing. You get a great view into the oral cavity, can see all the way back to the tonsils and then you can have a light saber battle with your kiddo. (I get nothing from endorsing this product, unless you buy through the blog and then I get a teeny tiny but of change. I think may 10 cents for every dollar spent. I say this with full disclosure because this is how I fund this blog and keep it ad free.)

Throat scope

And we ended this wonderful convention with a trip to one of my favorite places with my peeps! Finally got to ride the Seven Dwarfs mine ride. Thank you Kristen for waiting in line for 75 minutes.