Simcoe Feeding Assessment Simcoe Feeding Assessment and Consultation Servicesand Consultation Services

(FACS)(FACS)

Liz Day, OT; Bronwen Jones, SLP;

Jane Anne Sullivan, RD; Allison Brooker, SLP

Royal Victoria Hospital

SYMPOSIUM 2008Working Together for Kids & Teens with Disabilities

Simcoe Feeding Simcoe Feeding Assessment and Assessment and

Consultation ServicesConsultation Services(FACS)(FACS)

Enhancing Local Diagnostic and Enhancing Local Diagnostic and Treatment CapacityTreatment Capacity

WHO are we?WHO are we?

TheThe Simcoe Feeding Assessment and Simcoe Feeding Assessment and Consultation Service Consultation Service consists of consists of

Feeding ClinicFeeding Clinic (Speech/Language (Speech/Language Pathologist, an Occupational Therapist Pathologist, an Occupational Therapist and a Dietitian) with consultation from and a Dietitian) with consultation from pediatrician, Dr. G. Vomieropediatrician, Dr. G. Vomiero

Community PartnersCommunity Partners – CTG, CCAC, – CTG, CCAC, RVH, CTS, Simcoe Preschool Speech and RVH, CTS, Simcoe Preschool Speech and Language Program, SCS, Speech Clinic, Language Program, SCS, Speech Clinic, physicians, New Path, Kerry’s Placephysicians, New Path, Kerry’s Place

WHAT do we do?WHAT do we do?

The FACS team sees children with The FACS team sees children with complex complex feeding problemsfeeding problems with regard to with regard to chewing chewing

and swallowingand swallowing; ; nutrition and physical nutrition and physical health health ; ; sensory processingsensory processing and and functional functional

feeding skillsfeeding skills. .

WHAT do we do?WHAT do we do?

Feeding ClinicFeeding Clinic multi-D assessment and problem analysismulti-D assessment and problem analysis trial of intervention strategies trial of intervention strategies home programming home programming recommendations/referrals to Local Team recommendations/referrals to Local Team

PartnersPartners Videflouroscopic Swallow StudiesVideflouroscopic Swallow Studies

completed as needed at RVHcompleted as needed at RVH approximately 4 spots/month availableapproximately 4 spots/month available

WHAT do we do?WHAT do we do?

Local Team PartnersLocal Team Partners provide the bulk of community feeding provide the bulk of community feeding

services and refer to feeding clinic when services and refer to feeding clinic when necessary necessary

attend clinic with clientsattend clinic with clients follow-up with programming and follow-up with programming and

recommendationsrecommendations

WHO do we see?WHO do we see?

Children from birth to 19 years of age with:Children from birth to 19 years of age with: Oral – Motor or Sucking difficultiesOral – Motor or Sucking difficulties such as such as

decreased co-ordination of suck swallow decreased co-ordination of suck swallow breathe; weak suck; decreased chewing; tonic breathe; weak suck; decreased chewing; tonic bite; fatiguebite; fatigue

Sensory Difficulties Sensory Difficulties such as oral aversion such as oral aversion Severe irritabilitySevere irritability or or behaviour problemsbehaviour problems during during

feedsfeeds Extremely Picky EatersExtremely Picky Eaters

WHO do we see?WHO do we see?

Risk ofRisk of aspiration aspiration History of recurrent pneumonia/chest History of recurrent pneumonia/chest

infectionsinfections Lethargy or decreased arousal during feedingLethargy or decreased arousal during feeding Breathing disruptions or apnea during feedingBreathing disruptions or apnea during feeding Excessive gagging or recurrent coughing Excessive gagging or recurrent coughing

during feedsduring feeds

WHO do we see?WHO do we see?

Unexplained Unexplained food refusalfood refusal Failure to thriveFailure to thrive TransitionTransition from tube feeding to oral feeding from tube feeding to oral feeding Feeding difficulty related to Feeding difficulty related to structural structural

anomaliesanomalies (cleft palate, high palate, etc.) (cleft palate, high palate, etc.) DeteriorationDeterioration of feeding and swallowing of feeding and swallowing

ability related to disease process (e.g. ability related to disease process (e.g. seizures, MD)seizures, MD)

Two Major Areas of Focus in Two Major Areas of Focus in bringing Services Closer to bringing Services Closer to

Home…Home…

Providing Videoflouroscopy at RVHProviding Videoflouroscopy at RVH Increasing Feeding Expertise at the Local Increasing Feeding Expertise at the Local

LevelLevel

Videoflouroscopy Videoflouroscopy (VFFS)(VFFS)

Videofluroscopy (VFSS)Videofluroscopy (VFSS)

Now available at RVH for children in Now available at RVH for children in SimcoeSimcoe

Start up of this service has resulted in Start up of this service has resulted in shorter wait times and less traveling for shorter wait times and less traveling for familiesfamilies

Children previously seen at BKR & HSC Children previously seen at BKR & HSC can now be seen closer to home for VFSScan now be seen closer to home for VFSS

What is VFFS?What is VFFS?

X-ray study of the X-ray study of the

child’s swallow to child’s swallow to

determine safetydetermine safety

of oral feedingof oral feeding

with regards to with regards to

choking and choking and

aspirationaspiration

VFSSVFSS

GI Motility online (May 2006) | doi:10.1038/gimo95

Figure 1

To Videoflo or not to To Videoflo or not to Videoflo?Videoflo?

Medical History Medical History Highly Suggestive of Aspiration:Highly Suggestive of Aspiration:

Recurrent chest infectionsRecurrent chest infections History of aspiration pneumoniaHistory of aspiration pneumonia History of increased upper airway History of increased upper airway

sounds or wheezing with oral feedssounds or wheezing with oral feeds Findings on chest x-rayFindings on chest x-ray Positive aspiration on upper GIPositive aspiration on upper GI

To Videoflo or not to To Videoflo or not to Videoflo?Videoflo?Medical History Medical History

Possibly Suggestive of AspirationPossibly Suggestive of Aspiration History of bronchiolitisHistory of bronchiolitis Frequent undiagnosed feversFrequent undiagnosed fevers Recurrent URT infectionsRecurrent URT infections Perioral cyanosis with feedsPerioral cyanosis with feeds Poor secretion controlPoor secretion control Persistent apnea, bradys, desatsPersistent apnea, bradys, desats Absent gag reflexAbsent gag reflex Poor weight gainPoor weight gain

To Videoflo or not to To Videoflo or not to Videoflo?Videoflo?

Clinical EvaluationClinical Evaluation AlwaysAlways do a clinical evaluation before do a clinical evaluation before

proceeding to videoflo… proceeding to videoflo… VFFS radiation is equal to ~ 30 x-raysVFFS radiation is equal to ~ 30 x-rays A simple intervention often solves the A simple intervention often solves the

problem without the need for a videoflo problem without the need for a videoflo ( e.g. coughing when bottle feeding – often ( e.g. coughing when bottle feeding – often solved by decreasing the flow)solved by decreasing the flow)

To Videoflo or not to VideofloTo Videoflo or not to Videoflo

ClinicallyClinically - - highly suggestive of highly suggestive of aspiration:aspiration:

Consistent coughing with oral feedsConsistent coughing with oral feeds Increased upper airway sounds and congestions Increased upper airway sounds and congestions

with oral feedswith oral feeds Sudden, significant drop in O2 sats, heart rate Sudden, significant drop in O2 sats, heart rate

with oral feedswith oral feeds Increased chest soundsIncreased chest sounds Change in voice qualityChange in voice quality

To Videoflo or not to VideofloTo Videoflo or not to Videoflo

ClinicallyClinically - - Possibly suggestive of Possibly suggestive of aspiration:aspiration:

Distress signs – grimacing, irritability, Distress signs – grimacing, irritability, change in respiration, change of state, etc.change in respiration, change of state, etc.

To Videoflo or not to To Videoflo or not to Videoflo…Videoflo…

Provide clinical feeding Provide clinical feeding interventionsinterventions

thickeningthickening positioning positioning pacing pacing addressing GI symptomsaddressing GI symptoms

If problems persist, If problems persist, proceed with proceed with videoflovideoflo

Building CapacityBuilding Capacity

Capacity at the Local Level:Capacity at the Local Level:MentoringMentoring

FACS team members are available to FACS team members are available to provide mentoring when appropriateprovide mentoring when appropriate

CCAC- CCAC- Closing The GapClosing The Gap has identified has identified mentors (OT Susan Scott & RD Melanie mentors (OT Susan Scott & RD Melanie Larkin) to help build expertise in therapistsLarkin) to help build expertise in therapists Organize & provide in-service education & Organize & provide in-service education &

workshops e.g. transitioning from oral to tube workshops e.g. transitioning from oral to tube feedsfeeds

Consultation to therapists with less expertiseConsultation to therapists with less expertise

Capacity at the Local Level:Capacity at the Local Level:Extremely Picky Eaters Extremely Picky Eaters

WorkshopWorkshop

Provided by FACS team to community Provided by FACS team to community partners partners

Handouts from the workshop for Handouts from the workshop for therapists to give to parents available on therapists to give to parents available on SharePointSharePoint

Capacity at the Local Level: Capacity at the Local Level: ResourcesResources

Local HubsLocal Hubs – e.g. The Common Roof – e.g. The Common Roof Dieticians from Simcoe and York FACS teams Dieticians from Simcoe and York FACS teams

have made available Parent Handoutshave made available Parent Handouts Feeding equipment and assessment kits at Feeding equipment and assessment kits at

hubshubs Educational Materials for therapists and Educational Materials for therapists and

families e.g. Tube Feeding with Love DVD’sfamilies e.g. Tube Feeding with Love DVD’s

Capacity at the Local Level:Capacity at the Local Level:Guided Assessment ToolGuided Assessment Tool

Created by York and Simcoe FACS team Created by York and Simcoe FACS team leadersleaders

Resource for therapists - meant to guide Resource for therapists - meant to guide their assessment and interventionstheir assessment and interventions

Available on SharePointAvailable on SharePoint

Case ExampleCase Example

9 year old girl with history of meningitis in 9 year old girl with history of meningitis in infancy with global developmental delay, infancy with global developmental delay, currently a resident of a group homecurrently a resident of a group home

Presented to Feeding Clinic with Presented to Feeding Clinic with swallowing difficulties and inability to self-swallowing difficulties and inability to self-feed. feed.

Recent history of pneumoniaRecent history of pneumonia Taking only purees and thickened liquidsTaking only purees and thickened liquids

Case ExampleCase Example

Local Team players include CTG OT, RD Local Team players include CTG OT, RD and PT, paediatrician, group home staff, and PT, paediatrician, group home staff, CAS, school EA’s,CAS, school EA’s,

Local team: Local team: seating and positioning seating and positioning variety of foods/nutrients/caloriesvariety of foods/nutrients/calories thickened liquidsthickened liquids

Case ExampleCase Example

Feeding Clinic – clinical assessment Feeding Clinic – clinical assessment suggests risk of aspirationsuggests risk of aspiration

VFFS - Recommendations VFFS - Recommendations No liquidsNo liquids thin and thick purees onlythin and thick purees only Meeting fluid requirements on puree dietMeeting fluid requirements on puree diet

Local team implements and educates Local team implements and educates caregivers and school EA’scaregivers and school EA’s

Simcoe FACSSimcoe FACSLocal Team

Feeding Clinic Assessment and VFSS (if nec)

Local Team