Conquering Fear As A Peds Feeding Therapist

Entering the field of pediatric feeding therapy can be daunting. Many therapists are held back by fear, which is understandable given the complex nature of feeding and swallowing disorders. The anxiety of causing harm, such as choking or aspiration, is a common concern. However, with the right knowledge and strategies, these fears can be managed, allowing therapists to provide effective and safe interventions for their young clients. Further, this allows therapists to enter and move forward confidently earlier in their careers!

Understanding the Fear

Fear in new feeding therapists often stems from a lack of experience and the high stakes involved in feeding therapy. For instance, take the case of Shelly, who is transitioning a child from tube feeding to oral feeding. During one session, the child gagged after being presented with a bite of food. Shelly's immediate reaction was to pull back due to the fear of choking, and now she's unsure how to proceed. This is a common scenario where fear hinders progress.

Similarly, Jessica, an occupational therapist working with a boy with Down syndrome and low facial tone, faces her own set of challenges. The boy is willing to eat a variety of foods but does not chew them well, leading to a risk of choking. Jessica's primary concern is how to keep him safe while encouraging his feeding development.

Moving Forward with Knowledge and Confidence

To move past these fears, it's essential to establish clear safety parameters and implement strategies that promote gradual progress while ensuring safety. Knowing what is safe / unsafe will boost your confidence as a feeding therapist!. Here are some key points to consider:

1. Safety First:

   • CPR: Maintain an active healthcare provider CPR for pediatrics certification- this will enable you to know what to do quickly and effectively if and when a child should ever choke in your sessions. Encourage parents who are fearful or have a child who frequently chokes to become CPR certified.

   • Thorough Assessment: Conduct a comprehensive evaluation of the child's feeding and swallowing abilities. This includes understanding their oral motor skills, sensory preferences, and any medical conditions that may affect feeding.

   • Safety Measures: Implement safety measures such as appropriate food textures, proper positioning during meals, and close monitoring for signs of distress.

   • Know the Signs of Dysphagia:

     • Coughs

     • Cries

     • Arches

     • Stiffens

     • Gets tired

     • Gets irritable and can't settle

     • Takes a really long time to eat/swallow (20-30 + minutes)

     • Spits ups or throws up frequently

     • Audible clearing when swallowing or after swallowing

     • Resting breathing sounds gurgled and not quiet

     • Loud swallow

     • Changes in weight gain

     • Changes in interests in foods and food textures

     • Leaking foods/liquids from mouth

     • Unable to maintain seal/latch on breast or bottle

     • Turning head away from foods

     • Refusing foods or liquids

     • Difficulty transitioning from liquids to solid foods

     • Picky eating

   • Know the Signs of Aspiration:

     • Watery eyes

     • Wet cough

     • Low grade fever following eating / drinking

     • Wet breath sounds

     • Flushed red cheeks

     • Choking

     • Facial Grimace

     • Refusal of foods or liquids

     • Crying / fussing during meals

   • Understand the difference between ASPIRATION and DYSPHAGIA

     • Aspiration: foods or liquids go into the lungs or airways when eating, drinking or swallowing. A child with aspiration is not safe and needs to have their method of eating / drinking graded and adapted until they are not aspirating.

     • Dysphagia: the muscles of the face and mouth are poorly coordinated impacting the functional tasks of feeding eating and swallowing. A child with dysphagia has a hard time eating and drinking with good endurance, strength, and coordination.

     • Every child with aspiration has dysphagia, not every child with dysphagia was aspitration.

2. Grading and Adapting:

   • Gradual Progression: Start with less challenging oral motor exercises and gradually increase the complexity. For example, for a child transitioning from tube feeding, begin with small, easily manageable bites of food and slowly progress to larger quantities of more resistive foods that require more oral motor control and strength as their motor coordination improves. Meet the child where they are with their current skills. For the boy with Down syndrome, offering foods that require less coordinated chewing (such as hard or soft dissolvables) initially while focusing on exercises that expand his oral motor abilities and target weak or missing skills and slowly introducing more challenging foods can help build his oral motor skills without overwhelming him.

   • Grading and Adapting Techniques: Modify the food consistency, size, and shape to match the child's current oral motor capabilities. Keep editing and adapting until you reach a point of safety and that’s your starting point for the just right challenge. For the child who gagged with the, can you grade where in the mouth the food was presented? Grade the size of the bolus? Grade the control over the bolus by presenting it in mesh? Grade the bolus adhesion by pairing the bolus with a sticky smooth food?

3. Home Programs and Parental Involvement:

   • Collaborative Approach: Work closely with parents to develop home programs that reinforce the skills being taught in therapy. Provide clear instructions and demonstrations to ensure consistency and effectiveness. Focus on consistency over perfect technique. A confident parent who is working a home plan that the child is enjoying for increasing oral motor skills is more likely to carryover with consistency.

   • Education and Support: Educate parents about the importance of gradual progression and safety measures. Providing reassurance and support can help alleviate their anxieties and foster a positive feeding environment at home. Try techniques on parents in addition to demonstrating on their child. Invite the parent to collaborate in the problem solving for grading and adapting. Support the parent in leading interventions directly with their child by coaching them and setting them up as the expert in their child’s needs. A parent who understands the why behind your reasoning process and interventions is going to be better able to engage in brainstorming when things doing go “just right” and will be more willing to carryover.

Overcoming Specific Challenges

• For Shelly's Case: Shelly can reflect and education the parent that gagging is a natural reflex and part of the learning process for children transitioning from tube to oral feeding as well as a natural process of oral development for oral feeders as well. Understanding the benefits of gaging is important to decreasing fear. She can continue with solids, but adapt the placement of how the food is offered, allow the child more control over the bolus, position the child leaning forward so that gravity is pulling the bolus forward in their mouth or so many other strategies. Using positive reinforcement and maintaining a calm environment can help reduce the child's anxiety around new foods.

• For Jessica's Case: Jessica can focus on improving the boy's oral motor skills through targeted exercises to improve strength and endurance in weak muscles impacting oral motor control when feeding and swallowing. Activities like chewing on resistive foods (e.g., carrot sticks, beef jerky, gum) can help strengthen his jaw muscles and improve chewing coordination. Exercise like applying a sticky food or high flavor food (peanut butter, nutella, powdered candy, etc) on the inside of the cheeks will promote tongue lateralization range, strength and endurance- all vital for bolus control when chewing. Additionally, she can use a mirror to help the boy visually connect to understand the chewing process, which can enhance his body-awareness.

Conclusion

Fear is a natural part of the journey for new pediatric feeding therapists, but it should not be a barrier to providing effective care. Fear makes us plan for sessions, reflect on what went well and what we want to improve in, and creatively problem solve. By understanding the root causes of their fears, having a clear concept of what safe / unsafe feeding looks like, and implementing gradual, adaptive strategies, therapists can confidently support their young clients in achieving their feeding goals. Remember, progress in feeding therapy is a marathon, not a sprint, and each small step forward is a victory. Through patience, persistence, and a focus on safety, therapists can help children develop the skills they need to enjoy safe and nutritious meals.

Happy eating!