At UNC Hospitals, I do about 7 new feeding evals each week. 5 of these are with our pediatric feeding team which includes speech, GI and nutrition and 2 are scheduled as a speech pathology/feeding evaluation. The evals are scheduled based on the doctor’s referral so they come in earmarked for feeding team or written for a speech path feeding eval.
I’ve been making a mental note of the fact that each week when I do my “solo” evals, the kids almost always need GI management in addition to my recommendations.
Here are some examples:
- 4 month old healthy infant with coughing and choking with bottle feeds.
- Assessment revealed that most of the coughing and choking was occurring after feeds and the infant had color changes as well. This baby was also extremely constipated with 1 hard stool per week. Parents reported that stool was stuck sometimes and baby crying with stooling. Suck/swallow/breathe coordination was good except for a small amount of oral spill. Some pacing easily corrected that. The infant was referred to GI who placed the infant on medication for reflux and constipation, symptoms resolved in about 4 weeks.
- 10 month old healthy male infant who breast feeds and bottle feeds breast milk but refuses purees and expels soft solids.
- Assessment revealed many soft signs of GER which included gagging and grimacing on solids, frequent grunting, congestion and wet sounds after feeding, nasal congestion, and reswallowing. This infant also had some constipation with stooling every 3 days with straining. No oral motor or swallowing deficits. Recommendations were for PCP to consider starting GER and constipation management and refer to peds GI as part of feeding team.
3. 8 year old female with history of prematurity, ADD, and feeding difficulty
- feeding issues included patient being a very slow eater ( meals take 1 hour), pocketing of food and needing verbal cues to chew. Assessment revealed history of constipation ( hard BM 1x, daily or may skip days), reported blood with stooling in the past. Soft signs of GER (bad breath, c/o stomach pain, frequent nasal congestion and nasal tics) and recent weight loss of of 1/2 lb.
- Recommendations include asking for referral to peds GI for constipation, GER and feeding difficulty. Speech recs were to use high calorie drinks and purees for 1/2 meal and 1/2 meal solids to decrease time needed to chew solids until pt sees GI, then feeding therapy.
4. 2 1/2 year old male feeding difficulty and poor chewing .
- Assessment revealed limited diet consisting of mostly carbs, food refusal,mouth stuffing, oral motor delay with poor chewing and some sucking and expelling of solids. History was positive for vomiting triggered by crying, laughing, running, gagging on foods. Vomiting was occurring daily, outside of meals and even during nap time. Patient was also constipated with1 stool per day that was soft but occurred with straining. Recommendations included referral to peds GI, diet changes to reduce chewables in meal, and oral motor therapy for chewing skills.
- 2 months later patient is not longer vomiting, eating more volume and variety and is showing improved chewing with therapy techniques.
Thoughts and Tips for therapists:
Recognize the GI issues that interfere with feeding progress and treat these first, this will improve your patients response to your oral motor /sensory and feeding therapy. Some kids will improve greatly after GER and constipation management because they feel better. I’ll go out on a limb here (big sturdy limb) and say pediatricians don’t get much training in feeding and swallowing issues so educate them on how GI discomfort negatively affects feeding. We actually have to “over treat” in some cases to help the child feel well enough to begin making progress. Our goals are individual to each child but often include decreasing reflux symptoms and achieving daily soft stooling.
Therapists often tell me they feel uncomfortable making these recommendations to the referring doctor. I have a few thoughts on this one- think of your self as part of medical team! Feeding difficulty is often related to a medical problem that can develop into sensory and behavioral issues. We need to communicate with the referring medical team so they begin to recognize these issues earlier.
We do a lot of different types of GI management on our feeding team. This includes GER and constipation management but also GI sensitivity and pain issues, motility problems, allergy and intolerance issues etc. But if you are working in a non-hospital setting such as private practice or early intervention, start with looking at gastroesophageal reflux symptoms, constipation, and food intolerance. That is the place to start. I’ll blog more about the signs and symptoms as well as diagnostic and therapeutic strategies used to address these problems but for now I hope this gives you some ideas!
Allison Crumpler says
Great post, Krisi! The case study examples make it so easy to think about patients on your own caseload who have GI issues that gone undiagnosed for a while, thus their feeding is negatively impacted. From my experience, 99.9% of the time, there are underlying GI issues that must be addressed in order for progress to be made in feeding therapy. Please keep sharing real-life examples. It really helps to link the research with the clinical aspect. I would love to see more in depth case study examples posted and what was recommended with therapy, GI, and nutrition.
Marcia Kirby says
Great post. Reflects much of my frustration as home based speech therapist with a majority of case load infants with feeding difficulties. A problem we have is getting the Peds GI on board with our concerns. They seem to take a wait and see approach much of the time which is quite frustrating to parents as well as therapists. Any suggestions?
Krisi Brackett says
Marcia, this is a great comment and might spark an entire blog post! I’ll share some of my thoughts here first.
I often tell therapists to develop a team of professionals that you can refer your clients too, specifically a doctor, dietician and physical therapist. That might mean doing some research to find out which GI doctor or GI nurse practitioner in your area works with feeding kids. If you are in a smaller town you may need to reach out to the nearest children’s hospital. Call the therapists working there and ask who do you refer your feeding clients too for medical support? Just like therapists have different skill levels with feeding intervention, GI docs do as well. You could also reach out to a feeding team- a hospital based feeding team may be a good way to get medical management for your kids. This is something we routinely offer to our kids here at UNC. Kids can come see us for medical and nutritional management and then go back to local therapists for feeding therapy. Or if a feeding therapist feels they are stuck they can refer their kids to us for another opinion.
In terms of the “wait and see” or “she will grow out it” attitude – I think physicians and nurses in general need more education on feeding problems and need to understand the benefits of early identification and treatment. At the grass roots level, we can educate our referral sources but short in-services for pediatricians and GI’s are needed citing research! I’ll attack that one in a future post.
If you want to email me and tell me where you live , I will see if I have any resources for you! Thanks for the comment.
Marcia Kirby, MA CCC SLP says
Excellent comments! I completely agree. I am in home health with referrals from a large pediatric hospital. I would have to say that at least 75% of my caseload has a swallowing and usually a GI component. It is very important to be able to refer these kiddos to appropriate resource. It is equally as important to be able to recognize when to refer.
Sherry Gajos says
I liked what you said about recognizing the GI issues that interfere with feeding progress and treat these first. My son is having a lot of trouble with his bowels and we’ve been taking him to specialists, so I want to learn more about how I can help him not be in so much pain. Thank you for the information about looking into GER and constipation management to help my kid.