Feeding Clinic Development

Question: I am developing an outpatient feeding clinic to become more interdisciplinary. When you do a feeding evaluation on a child for the first time, what professionals are usually involved?

 

I received this question and thought it would make a good blog post on how to do an interdisciplinary feeding evaluation as well as develop a feeding team. I haven’t posted many blogs from a personal perspective. I have been concentrating on informational type posts so please let me know if you find these interesting or helpful.

 

My background and the development of the feeding team            

I work on a pediatric feeding team in the NC Children’s Hospital which is part of UNC Healthcare in Chapel Hill, NC. I have been at UNC off and on for 20 years so I actually started at the hospital before there was a feeding program. Many of you “seasoned clinicians” will understand what I am saying. 20 years ago this was still a new area of speciality. It’s been amazing to see how intervention in pediatric feeding has grown and developed. To clarify “off and on”, I have left UNC twice. Once in the early 1990’s to work at the Children’s Hospital of Philadelphia (CHOP) where I received special training from their intensive feeding program which was directed at the time by Dr. Peggy Eicher (who nows runs the Pediatric Feeding and Dysphagia Program, St. Joseph’s Hospital, Paterson, NJ, www.feedingcenter.org). I left a second time for 5 years to move to Salt Lake City, UT for my husband’s job where I contracted myself to 2 hospitals (LDS Hospital, Primary Children’s Hospital) as well as early intervention feeding and private practice.

 

Clinicians in pediatric feeding come from different disciplines and training. Many of us learn on the job although there are many continuing education opportunities available now. My background in pediatric feeding is in a medical, motor, and behavioral approach which I learned at CHOP from the team that was there ( Dr. Peggy Eicher, Cathy Fox, OT, Cis Manno, SLP, and Dr. Mary Lou Kerwin, psychology). I consider these professionals my mentors and still reach out to them when I have hard case or need ideas.

 

The interdisciplinary feeding program at UNC developed slowly over many years out of a need for collaborative care. Because I was trained to look at the medical side of feeding problems, I developed a close relationship with my colleagues in pediatric GI (gastroenterology). In the beginning, we (in speech) often asked peds GI to see our feeding patients because of gastroesophageal reflux, constipation, or food intolerance issues that were interfering with progression of skills. In turn, they also were seeing children with failure to thrive, poor growth, vomiting, or tube dependence and needed a feeding therapist to help evaluate and set up feeding programs to help the child progress from a feeding or eating standpoint. Thrown into the mix was a necessity to have a pediatric dietician there to help assess caloric and nutrient needs, recommend appropriate formulas for GI issues as well as intolerance, and to trouble shoot creative ways to meet caloric needs in children who have a difficult time eating.

 

The development of a coordinated clinic where we actually see children together took about 10 years altogether. I was lucky to have a colleague (thank you Jenn Rayburn Paulson, SLP!) who continued to develop the program in my absence.

So to answer the original question, our feeding clinic consists of 3 primary disciplines:

• Pediatric GI (mainly peds GI Nurse Practitioners)

• Pediatric Speech Pathology

• Pediatric Dieticians

 

We see the child in clinic together at the first visit and develop a plan based on our evaluations. The feeding plan consists of:

• medical management (medicines, lab work, clean outs to improve stooling, further testing, referrals to specialists)

• nutritional management (formulas, caloric goals, oral and tube feeding volume and rate recommendations, calorie additives)

• therapeutic management (diet texture recommendations, objective swallowing studies, utensil recommendations (spoons, nipples, cups), positioning, feeding techniques, feeding therapy)

 

*we send the kids home with formula samples or samples of calorie additives as well as nipples, bottles, cups, spoons, and chewy tubes to use at home.

 

* From the GI standpoint, we are able to access a peds GI attending when needed. Our NP’s have training in feeding/GI management. Feeding patients often take a lot of time due to the complex nature of these problems as well as the fact that theses issues effect the entire family. In my experience, peds GI NP’s trained in feeding management have the time and interest to work successfully with these patients.

 

Follow up for the team is monthly:

Typically, we bring the kids back monthly to see the entire team for a period of time until the GI issues are improved enough that the child can be seen less frequently. I see the child one extra time during the month for an individual therapy visit so typically I see kids two times per month. Nutrition sees the child monthly with the team and may also see the child at the extra visit with speech. We provide families with contact information to reach us with questions or concerns between visits.

 

So our core team consists of Peds GI, Speech, and Nutrition. However, we frequently refer to other specialty services that the child might require whether it is for further evaluation or therapy. These include:

• physical and occupational therapy

• psychology, behavioral feeding

• otolaryngology

• pulmonary

• lab work

• radiology

• craniofacial or oral maxillary facial

• home feeding therapy to supplement the hospital visits

• lactation

• neurology

• genetics

• developmental pediatrician

• Intensive feeding program

• peds surgery

 

Growth and Outcomes:

Our clinic has grown solely on word of mouth. We now offer 8 new evaluations per week in 2 locations. Our feeding team provides inservices locally and nationally on using a team approach to provide intervention in feeding. Our next goal is to begin tracking our outcomes and publishing data. We work with the UNC Feeding Research Committee, The Feeding Flock to assist with research in the area of pediatric feeding.

 

One of the surprise benefits I have seen from our feeding clinic is that we provide a tremendous resource for local clinicians. We often see children with feeding problems served by outside clinicians who need assistance with medical and nutritional management or who need help getting started. We often hear that clinicians are having difficulty getting local medical support and turn to us for help. We are now seeing children from all over the state of NC as well as neighboring states. This makes it imperative for us to work with local clinicians for many of our patients can only see us once per month due to distance.

 

Training

Our feeding team provides inservices and workshops on using a team approach. We have provided inservices for our state association meetings in speech pathology and for nurse practitioners as well as nationally at the ASHA yearly meeting. Because UNC is a teaching hospital, we provide specialized training for residents as well as therapists interested in learning more about this complicated but rewarding specialty area.

 

Conclusion

Our feeding team is a work in progress. It continues to grow and develop with the mission of providing interdisciplinary care for successful outcomes for children with feeding and swallowing problems and their families.