911: From Triage to Treatment© Cheri Fraker, CCC/SLP ......Use the guide below to assess your evaluation and treatment plan. Start by making sure you have covered every area in treatment.

_____________________________________________________________________________________________©Copyright 2015 Fraker, Walbert and Cox -Preemietalk

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911: From Triage to Treatment© Cheri Fraker, CCC/SLP, Laura Walbert, CCC/SLP and Sibyl Cox, RD, LD, CLC The Anatomical and Physiological Factors that Create Roadblocks to Successful Oral Eating:

The medically complex, challenging patient with feeding disorder needs careful evaluation and management.

Assess the SCOPE of the problem carefully. Start with questions about feeding from infancy to the current date. Look for

patterns; this can be very tricky due to the similarities between so many disorders.

Take time to gather information from the family and use this information as you develop your treatment program.

Look for patterns-good and bad. Patterns in GI function, appetite, eating, drinking, behavior. Is the child experiencing complicated reflux or uncomplicated reflux?

Weight loss, blue spells, feeding refusals or difficulties are signs of complicated reflux. Patterned vomiting can be a sign of a problem requiring intervention. DO NOT skip this step.

Assess the growth charts What patterns do you see in the foods the child accepts? Are there similar

tastes or textures? Are the textures uniform (don’t change excessively during mastication)

Educate the family about feeding aversion, help them understand where this came from. What type of disorder does the child have? Is it more of a sensory-based problem or an oral motor chewing problem? Base your treatment on what type of disorder you are treating.

Does the child have the skills to eat/drink ENOUGH to meet his needs orally? Look at the parent-child dynamic at the table. Is the parent over-controlling

or under-attentive? Help the parent/feeder see what may be contributing to the feeding problem. Is the child attention seeking or fearful/anxious?

A safe table is key to trust. Trust leads to acceptance of new food. Do not push the child. Observe and stay in the moment. Follow the sensory hierarchy and treat appropriately.

Triage: The Warning Signs

Colic as an infant Feeding problems in infancy, poor latch, difficulty finding a bottle that

worked Difficulty transitioning from breast to bottle feeding Difficulty with transitions to higher level feeding skills Frequent cough that does not go away Stridor Hoarseness


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Persistent dark circles under the eyes Snoring, restless sleep/frequent waking Pallor Rash Lack of appetite Eczema and Hives Wheezing Constipation Withholding Diarrhea Gagging while eating Persistent pattern of mouth breathing Open mouth chewing Self limited liquid intake History of frequent respiratory illnesses or pneumonia Choking Complaint of food sticking in throat or chest Grimacing or effortful swallow Retching while eating Vomiting while eating or patterns of vomiting Vomiting at night Complaint of belly pain

More on Triage: Differential Diagnosis What problem are you REALLY dealing with?

GER: Spitting up, vomiting, colicky behavior, persistent sore throat, feeding aversion

GERD: Frequent or recurrent vomiting, persistent cough, choking or gagging while eating, heartburn, history of colicky behavior, regurgitation and reswallowing, feeding aversion

EoE: Cough, gagging, choking while feeding, vomiting, poor weight gain, food caught in esophagus, eczema, asthma, hives

Acute Painful Swallowing (Odynophagia): Sudden food refusal, child may have no GER or GERD history. Can be caused by a viral infection of the esophagus or swelling of the esophagus. If the child has a deficient or suppressed immune system, the child may need specific antiviral or antifungal therapy.

Milk Protein Allergy: Vomiting, red rash or bumpy skin, congestion, constipation, blood in stool, feeding aversion in infancy

Food Allergies: hives, rash, eczema, itching, sneezing, runny nose, nasal congestion, wheezing, abdominal pain, diarrhea, vomiting, anaphylaxis

Motility Disorder: Vomiting, severe aversion, constipation, abdominal pain


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Adenoiditis: Dark circles under the eyes, poor nasal breathing, persistent mouth breathing, runny nose, restless sleep, snoring, bed wetting, poor attention, signs of hyperactivity, fatigue, dizziness, low energy, feeding aversion

Malnutrition: fatigue, low energy, dizziness, irritability, poor growth, leg pain, dry skin, weight loss, painful joints, poor immune function, hair loss, brittle nails, loss of appetite, short stature compared to peers

Caregiver Interview RD Questions:

Child’s birth weight and length (head circumference if available) Gestational age? Child ever hospitalized? Why? Medical diagnoses? Feeding tube-when placed, who manages it and current feeding regimen?

Bolus, continuous, intermittent? How long do feedings take? Rate? Vomiting, retching, gagging, constipation?

Current medications? How long was child on meds? Spitting up or vomiting? Improved with medication? Diagnosed with reflux? When? Symptoms? Treatment? Constipation or diarrhea or both? Concerns about weight gain? When first started to see problems? How does

this coincide with illnesses, developmental milestones, changes in what/when/how child was fed?

Breast or bottle-feeding difficulties? Ask even if patient is no longer an infant.

Nursing-how often? Difficulty with transition to sip cup or open cup? If taking formula, how is it prepared? Did you need to change formulas? What formulas have been trialed and for

how long? What age transitioned to baby foods? table foods? Problems? What foods work for your child? What foods does your child reject? Typical breakfast, lunch, snack and dinner foods

o Any fruits or vegetables? Does the child eat cheese, yogurt or dairy? o Any meats, fish, eggs, beans or peanut butter? o Bread, cereal, pasta or rice? o How do you know your child is hungry? Is your child ever hungry? o Food jags?

What does the child drink? How much of each liquid each day? Schedule for meals and snacks? Grazing? Self-feeding? Positioning for meals Length of meals


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Eating environments (any where child eats better or worse?) Any nutritional supplements or vitamins?

Malnutrition/under-nutrition and Failure to Thrive

Failure to thrive or growth failure describe children whose weight or length/height is not increasing at a rate consistent with growth standards. Multiple definitions including weight for age below the 3rd percentile or weight for length more than 2 standard deviations from the mean; decreased growth velocity resulting in weight or height curve decreasing and crossing two major growth percentiles.

Single point is not helpful; need serial measurements over time Use of WHO growth charts until age 2 and CDC growth charts from age 2-20.

Not recommended to use specialized growth charts at this time. Some shifting of growth percentiles occurs in healthy children is expected with 39% of children between birth and 6 months.

Children who have constitutional growth delay or delays in velocity that eventually become normal growth should have bone age that matches chronological age.

Undernutrition is typically when weight velocity decreases followed by linear growth

Causes: inadequate intake (feeding problems, improper mixing of formula or offering low energy foods/juice too often, grazing), malabsorption, increased energy needs (hypertonia, pulmonary and heart disease, prematurity)

Nutritional assessment includes growth history, calculating severity of malnutrition, obtaining detailed feeding history, estimating energy needs for catch up growth, use of nutritional supplements, high calorie diets, formula concentrating may be used to improve growth

Obesity and feeding aversion

Adequate weight gain or excessive weight gain does not always demonstrate that patient is well nourished

Not getting adequate nutrients means our organs and body processes might not work as well and will increase risk of disease

People who are overweight can be undernourished due to eating excessive calories but their calories are coming from foods that are low in nutrients

Diets usually consist of highly processed foods heavy in starches and sugar, and little to no fruits, vegetables, proteins


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Food Allergy: An adverse health effect arising from a specific immune response that occurs reproducibly on exposure to a given food. Food Allergens: Specific components of food or ingredients within food (typically proteins, but sometimes also chemical haptens) that are recognized by allergen-specific immune cells and elicit specific immunologic reactions, resulting in characteristic symptoms. Food Intolerance: Nonimmune reactions that include metabolic, toxic, pharmacologic, and undefined mechanisms.

• Examples of Food Intolerances include: • Lactose • Other disaccharides • MSG • Preservatives • Artificial colors

Adverse Food Reactions • Non-immunologic

(primarily food intolerance) • Metabolic (lactose intolerance • Pharmacologic (caffeine) • Toxic (fish toxin)

Common Food Allergens Milk, egg, soy, wheat, peanut, tree nuts, shellfish, fish

IgE Mediated: Anaphylaxis, oral allergy syndrome, asthma, urticarial, food associated exercise induced anaphylaxis Mixed IgE Mediated & Non-IgE Mediated: Atopic dermatitis, Eosinophilic Esophagitis & gastroenteropathies

Non-IgE Mediated (Cell Mediated): Food Protein-Induced Enterocolitis (FPIES), Food protein induced proctocolitis, Celiac Disease

• Food Protein Induced Enterocolitis Syndrome (FPIES) (infancy) • Emesis, diarrhea, lethargy, poor growth; re-exposure can result in

diarrhea, emesis and hypotension in some cases • Common triggers are cow’s milk, soy, rice, oat, other grains, poultry • Tests are almost always negative; resolves with removal of protein

Diagnostic Tools (IgE mediated): Clinical history is critical in the diagnosis, skin testing, RAST testing, elimination diets, oral food challenge

• Atopy patch testing: Topical application of a food-containing solution to the skin for 48 hours, no standardization, NOT recommended outside of research setting


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• Patients at risk for developing food allergy do not need to limit exposure to foods that may be cross-reactive with the 8 major food allergens.

• Evidence is insufficient to determine whether eating foods that cross react with the major allergenic foods will cause symptoms.

• Unnecessary food avoidance can result in inadequate nutrient intake and growth deficits.

• Testing of allergenic foods in patients at high risk prior to introduction • Insufficient evidence to recommend routine food allergy testing prior to

introduction of highly allergenic foods such as milk, egg and peanut. • Timing of introduction of allergenic foods to infants

• Introduction of solid foods should not be delayed beyond 4-6 months including potentially allergenic foods

Which of your patient’s may have food allergies? • Feeding difficulties and food refusals, delayed growth, dysphagia with solid

foods

How do you know when to refer? • Diagnosed allergy to one or more foods, pick or selective eater, delayed

introduction of solid foods, poor variety or volume of foods accepted/provided

Impact of food allergies on your patients? • Poor growth, negative infant experience with foods, reinforcing poor intake,

delayed introduction of foods, poor feeding acquisition and nutrient intake

Why to Refer? • Children with multiple food allergies or cow’s milk allergy are at

increased risk of… • Macronutrient/Micronutrient deficiencies or imbalances, short stature,

FTT, nutritional rickets, marasmus/kwashiorkor • Prolonged elimination diets that omit multiple foods have been

reported to induce severe malnutrition

Troubleshooting: Getting Back on Track

Use the guide below to assess your evaluation and treatment plan. Start by making sure you have covered every area in treatment. Following the therapy checklist, you have been provided with tips for multidisciplinary management of problems such as GERD, EoE, chronic nasal congestion, etc. Use this guide to discuss concerns with the primary care physician and other team members. Therapist Self Check: Am I Doing the Right Thing?

o Do I have the child’s full medical, feeding and developmental history? o Do I communicate with the child’s doctor? o Do I have the right team members?


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o Have I assessed the swallow carefully? Do I continue to reassess the swallow throughout treatment?

o Am I using cervical auscultation of the swallow for every patient? Every session?

o Do I know enough about feeding products and flow rate? Print and use in therapy: http://www.neonataltherapists.com/pdf/Go-With-The-Flow-Handout.pdf

o Have I completed a swallow study using Varibar barium? Have TWO therapists or therapist/radiologist reviewed the study frame by frame?

o Did I mimic a real meal during the study? o Did I flavor the barium to make the experience as positive as possible? o Did the parent feed the child with my assistance? o Do I understand that barium is different from food and liquids the child

actually consumes? o Am I carefully assessing the pulmonary history in ADDITION to the swallow

study results (just a moment in time)? o Did I discuss the results with the MD or just send a report? o Did my report effectively describe the swallow study? What products were

used? Did the study appear to be a good representation of the child’s skills? o Did I use the child’s feeding products from home AND assess with products

that may improve swallow safety? o Do I understand muscle strengthening can be achieved for future feeding

skills by using the correct feeding products? Bolus formulation and control can be improved dramatically with the right feeding product.

o Do I understand the impact of GROWTH of the oral structures and the possible negative impact on swallow safety?

o Do I understand that adenoiditis can significantly impact the efficiency of the suck/swallow/breathe sequence and ORAL MOTOR skill development?

o Do I understand the ASPIRATION can occur due to adenoiditis, a laryngeal cleft, a submucous cleft, vocal cord dysfunction, etc. Do I know how to determine if oral stage is the cause of aspiration or if symptoms suggest a pharyngeal stage disorder?

o Do I understand that 80% of taste perception is dependent on good nasal breathing?

o Do I understand the negative effect of laryngopharyngeal reflux (LPR) on the swallow and feeding skill development?

o Do I understand salivary and gastric aspiration risks? o Does the child need a feeding tube? Can I say why with confidence? o Where do I go from there? Once a tube is in, do I have a plan? o Am I exposing the non-oral child to SAFE tastes from all flavor families? o Do I know how to set up a PreChaining program and mimic the experiences

of an oral feeder to keep the child on track as much as possible until I have successfully treated the swallow?

o Do I understand the complexity of the oral motor sequences needed to consume a diet of foods of different textures/consistencies and that I am


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trying to develop FLEXIBLE oral motor skills? Help the child develop effective shifts in those sequences based on the food presented?

o Does the child only munch or am I developing chewing skills? Do I know how to do this with the non-oral child using flexible utensils and tiny tastes?

o Do I know how to use the Food Chaining Intake correctly? Can I organize foods from easy to eat to more challenging to write dysphagia chains?

o Do I understand that high liquid intake can significantly decrease oral intake of food?

o Am I training the parent to be the feeder in all my sessions or keeping the parent in the waiting room?

o Am I co-treating or working closely with OT? PT? RD? All team members? o Do I understand sensory processing disorder? o Do I have a strong behavior management plan that I can use when needed? o Do I have a strong knowledge base (re: CP, autistic spectrum disorder, cleft

lip/palate, developmental disorders, sensory processing disorder?) to customize a program to meet the child’s needs.

o Do I regularly review the literature? o Evidence based practice? o Do I communicate well with families and share information in a manner that

is respectful and informative? o Do I come off as judgmental? Arrogant? Or can the family comfortably share

information with me? o Do I look at the stress level experienced by the child and family at the table? o Am I communicating where my program for the child/parent is going and

what I hope to see happening next? (PreChaining and Food Chaining) o Am I an encourager? o Do I know when I need help, advice and can I ask for it easily?

Check the child. Is treatment program on track? Quick checklist: Treatment for GERD

Prevacid or other proton pump inhibitor (Omeprazole, Lansoprazole, Prilosec)

Zantac, Axid or Pepcid at night may be an option for some children Elevated head of bed may ease distress and reduce risks of LPR at night Constipation management (Plums or prunes, MiraLAX in clear liquids,

Lactulose in milk (prescription), fiber, increase fluids, decrease milk, assess for allergies)

Rule out allergies or Eosinophilic disorder Modify diet Use medications with Caution Medications in the PPI drug therapy class have been proven safe and

effective in children and adolescents for the short-term treatment of GERD


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and EoE. However, PPIs are often used to treat conditions that have not been formally diagnosed.

PPIs are used for the prevention and treatment of gastric acid related conditions. These FDA-approved indications and age ranges apply to the prescribing of PPIs:

The FDA-approved indications for use in pediatric patients are the short-

term treatment of symptomatic GERD and healing of EoE; Only rabeprazole is FDA approved for the treatment of GERD in pediatric

patients ages 1 to 11; No PPI is FDA approved for use in patients younger than one year old; and Five of the six currently available PPIs have an FDA-approved indication for

patients younger than 18 years old The North American Society for Pediatric Gastroenterology, Hepatology and

Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) developed guidelines for the treatment of GERD in pediatric patients. The guidelines are available from the Agency for Healthcare Research and Quality (AHRQ) National Guideline Clearinghouse database http://www.guideline.gov/content.

PPIs are generally well tolerated. The most common adverse reactions seen in pediatric patients are headache, diarrhea, constipation, and nausea.

Clinical trials in infants have not demonstrated evidence for use of PPI medications in infants

Treatment for Eosinophilic Esophagitis

Referral to peds GI and RD for management Remove milk, soy, eggs, peanuts, tree nuts and wheat from the diet Elemental diet for 8 weeks, rescope to see if clear Introduce one of the 6 foods Repeat scope, if clear, introduce another of the 6 foods Food trials and scopes continue What foods should I be avoiding? Is the diet protecting the child? Are foods restricted? Many varying approaches, who is managing? I need to know more! Website http://www.apfed.org

Treatment for Poor Nasal Breathing

Assessment completed for hypertrophic adenoids and enlarged tonsils, allergies, sleep apnea AND dysphagia?

If tonsils are stage III or IV, removal needed? Sleep apnea risks? Sleep apnea can look very sensory or like ADHD. Bet wetting? Cough at night? Gagging issues when eating? Chronically ill? This could all be adenoiditis. Adenoiditis

http://www.apfed.org/


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impacts the suck/swallow/breathe sequence. Child will keep mouth open for air intake while feeding. This can create weakness in the oral facial musculature. Treat the NOSE to treat the oral stage to treat the SWALLOW!

Trial of Zyrtec, Nasonex and reflux medication Elevated head of bed for sleep Ocean Saline Spray may help Monitor status, adenoidectomy may be needed Is the feeding product flooding the oral cavity? Does the child only want meltable solids? Avoids dense foods?

Treatment for Poor Respiratory Function

Improve nasal breathing (see above) Allergy assessment and management Physical therapy Chest PT program Prone or modified prone program Ribcage treatment (Mary Massery) Movement Aqua therapy Rule out salivary, gastric aspiration and aspiration of food-pulmonology and

otolaryngology referrals? Assessment and Treatment for Allergies

RD and GI to manage food allergies Work closely with allergist and otolaryngology What is the treatment plan Children with grass allergies, need treatment in January to be ready for

March (many of these children become ill in late winter-early spring) Patterns? Note: Some types of allergies cannot be diagnosed by blood or skin testing.

What do I SEE?

Allergy Symptoms in Children

Skin rashes or hives (atopic dermatitis or eczema) Difficulty breathing (asthma) Sneezing, coughing, a runny nose or itchy eyes Stomach upset

Common Allergy triggers in Children

Outdoors: tree pollen, plant pollen, insect bites or stings Indoors: pet or animal hair or fur, dust mites, mold Irritants: cigarette smoke, perfume, car exhaust Foods: peanuts, eggs, milk and milk products

http://acaai.org/asthma/about


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Website: http://acaai.org/allergies My Toolbox: Do I have the right Feeding Products ? Feeding products build the skills for oral intake. This is key to treatment. 1) Standard Dr. Brown preemie or level I bottle nipple (we do not recommend the wide mouth Dr. Brown) 2) Bionix bottle 3) Medela Calma bottle 4) ThinkBaby sip cup –do not rush the transition to cup drinking 5) Nuby or NUK sip cup 6) ThinkBaby straw cup 7) Munchkin or Playtex straw cup 8) Sip Tip 9) Soothie brand pacifier is only pacifier we recommend, can be used as first spoon 10) DuoSpoon –as utensil 11) TriChew teether –as utensil 12) PQ chew tube –as utensil 13) NUK brush-as utensil 14) Kidsme Food Feeder *Issue products in treatment as much as possible. Can the parents afford products? Can social worker help? Quick Check: Treatment For Dysphagia (Infants) Implement these three techniques to improve safety of intake: 1) Side tilt positioning- Upright, side tilt, NOT side lying 2) Slow flow products-(determine best product via VFSS) 3) External pacing of the feeding *No thickened feedings, unless you have tried other options first. Gelmix and rice cereal can be used for thickening. Right recommendations and Referrals (Infants): 1) Swallow study or FEES study? 2) ENT consult (nasal breathing, assessment of the upper airway)? 3) Peds GI consult may also be needed 4) RD consult (RD can concentrate feedings to decrease intake demands or manage tube feedings if necessary)? Quick Check: Treatment for Dysphagia (Kids) 1) Small bolus size-small diameter straw, soft spout sip cup, small diameter straw cup, SipTip straw 2) Sensory loaded liquids (sour, cold, carbonated) and free water trials (small single boluses of water-cold, sparkling water, flavored water) 3) Thickening can be an option-but it is only an intervention not treatment


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Thickening with progressive weaning techniques for children post laryngeal cleft repair 4) RD consult 5) ENT consult 6) Peds GI consult Do I Understand and Communicate the Aspiration Risks to Medical Team and Family?

Remember aspiration may be the first indication of neurologic or neuromuscular dysfunction. A feeding disorder that starts in the first weeks of life is an indication of neurologic or neuromuscular dysfunction.

Cranial nerve injury or dysfunction such as Mobius syndrome or injury to the recurrent laryngeal nerve following a difficult vaginal delivery often leads to defective swallowing and aspiration

Perinatal asphyxia, congenital hydrocephalus or neonatal IVH may lead to swallowing dysfunction

Congenital neuromuscular diseases with aspiration Werdnig-Hoffman disease (spinal muscular atrophy) and myotonic dystrophy. Cornelia deLange syndrome and familial dysautonomia have swallowing dysfunction

Causes of aspiration can be divided into three categories: anatomic, functional or pica

Anatomic: ET tubes for long periods can experience remodeling of the palate because of pressure of the tube on the hard and soft palate. Following extubation, infants may suffer from palatophayrngeal incompetence characterized by the inability to form a seal around a nipple during sucking and the formation of a gap in the closure of the soft palate with the posterior pharynx during swallowing. This may lead to aspiration caused by nasal reflux of feedings and defective integration of the suck/swallow mechanism

Submucosal clefts, occult muscular deficiencies, congenital palatal fistula, abnormalities of the faucial pillars, or palatopharyngeal disproportion may have defective swallowing mechanisms characterized by extrapharyngeal spillage, leaking of feedings, swallowing muscular dysfunction, or palatopharygeal insufficiency

Exposure of the pharynx or larynx to solids or liquids triggers a series of protective reflexes that prevent aspiration. These include the cessation of breathing, closure of the vocal cords, and swallowing. If refluxed material enters the larynx, cough expels the material from the airway, and bronchoconstriction prevents aspiration from reaching the alveolar surface. The refluxed gastric contents are expelled from the mouth or swallowed before breathing is reinitiated. Failure of these laryngeal and airway protective reflexes allows aspiration into the airway.

If the child has concerns for aspiration of gastric content and aspiration during the swallow it may be necessary to sort out which is occurring

Eliminate oral feedings and feed by tube for a prescriptive time period Feeding into the jejunum to bypass the stomach (continuous)


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Case Analysis: Food Chaining Therapy Programs-Start with the 6 steps: 1) Determine if the child has an underlying medical condition contributing to

the feeding disorder. 2) Nutritional assessment, allergy screening and observation. Not all allergies

can be evaluated by testing. Observation and reactions need to be monitored. Determine if the child has nutritional deficiencies. RD will also evaluate current methods of oral and/or tube feedings. Hydration will also be evaluated. Growth charts will be evaluated.

3) Oral motor skill level. Does the diet being offered match the child’s current skills? Many times families offer foods that are way beyond the child’s skill


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level. If there are significant oral motor deficiencies, this MUST be treated. Use carefully selected foods and flexible chewy utensils (ex. DuoSpoon, TriChew teether, PQ chew tube, NUK brush, Kidsme Food Feeder) as your oral motor tools.

4) Sensory evaluation-determine if the child has signs of sensory processing disorder.

5) Behavior-if the child has any of the above issues; you will definitely see negative behaviors at the table. Behavior is actually very often the child’s way of communicating what is wrong. Behavior problems can develop around a feeding disorder, but behavior is rarely the main reason behind selective eating.

6) Food Chaining or PreChaining therapy to expand the food repertoire by introducing the child to new foods that have the same features (textures, tastes) as the currently accepted foods in the diet. Write out the SCOPE of the problem in the boxes below:

Medical Issues

Nutritional Concerns

Oral

Motor/Swallowing Skill Level


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Sensory Challenges

Behavior (Age of onset, behavior at meals and non-meal times)

Food Acceptance (# of food groups, food loss, choking risks, patterns?)

Liquid Intake


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Impressions__________________________________________________________________________________

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Plan:

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Frequency and Duration:

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Chaining Example: How Can the diet be expanded using Food Chaining Therapy? The Food Chaining Program Initial Changes: The purpose of these modifications is solely to help the child become comfortable with change in his diet and to add variety in the types of food he accepts. Goal is for the child to develop a feeling of trust and calm at the table. We want to expand his diet and give him high sensory input and enjoyable food choices. Start with one or two foods you feel do not produce a highly negative response.


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Accepted Foods Modifications Goldfish Whales Cookies Brownies Pop Tarts

Crackers can be modified in a variety of ways.

□ Goldfish whales can be modified to Cheese-It’s or White Cheddar Cheese-It’s.

□ Try a variety of crackers and jelly (Club crackers, etc.). Cheese flavor can also be explored via Cheese puff balls, crunchy Cheetos or other brands of cheese puffs may be offered.

□ Later a variety of cheese flavored crackers can be offered. Cheese Ritz Bits may be accepted.

□ Cheese can be offered in dips or sauces.

□ Cheese quesadilla, toasted cheese or thin crust cheese pizza may be accepted later in the treatment program.

□ Garlic toast, crackers, rolls, and breadsticks, cheesy garlic bread may be compared to pizza and can be targeted over the course of treatment.

Novel Foods:

□ Pirate’s Booty, Veggie Stix (snacks made from vegetables), potato chips, sweet potato chips, shoestring potato sticks, sweet potato French fries can be placed in the looking place.

French Fries

□ Try all types of French fries. □ Tator rounds are basically the

same as Tator Crowns, Tator Tots and Hash Browns. They also come in a variety of flavors.

□ You may be able to expand to baked French fries, Steak fries, waffle fries or other potato


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products. Cut open a tator tot and a tator crown. Teach him that they are the same.

□ Dips may be offered with these foods (ketchup, BBQ, Honey mustard, ranch dressing).

□ The dip can later be used to mask the flavor of other novel foods.

Cookies:

□ A variety of flavors and types of cookies can be explored in treatment. Let him shop with you and pick out a cookie he wants to try.

□ Try shortbread cookies or move to pie crusts with cinnamon and brown sugar, etc.

□ Roll out cookie dough or pie crust and let him cut out shapes.

Learning activity:

□ Make cookies/pastries at home. Slice and bake cookies can be decorated with different types of frosting.

□ Crush graham crackers, shortbread cookies, chocolate cookies in a Ziploc bag and make a dessert or pour them over the top of a pudding, ice cream or yogurt for a parent or sibling to eat.

Brownies

□ Try other brands of brownies; add chocolate chips, nuts or frosting.

□ Try chocolate Texas sheet cake or cupcakes. Just accepting a different texture or appearance of the food may add variety to the diet and lead to other foods like fruit muffins, breads or rolls.


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Other Modifications

□ Cinnamon Roll Pop Tarts or Strawberry Pop Tarts may be offered. In time, a variety of Pop Tarts can be offered to expose the child to the fruit flavors in Pop Tarts.

□ Fresh strawberries can be pureed and added to frosting or compared to the filling in the Pop Tart. Preserves can also be used for this activity.

□ If you want to try cinnamon rolls again (previously accepted) or for the first time, I would suggest starting with cinnamon on toast, pie crust, and cookies or in Pop Tarts. When he is ready he may also like Cinnamon Rolls, a variety of doughnuts or Hawaiian bread. This is a more gummy consistency and it may take him a while to feel comfortable with this texture.

□ If your child accepts Fruit Snacks.

He may also like Fruit Rolls Ups. Fruit Roll Ups or Streamers, gummy bears can also be offered to introduce fruit flavor in a texture he can feel comfortable eating. Talk about these foods and the fruit flavors.

□ Cut dried fruit into tiny pieces and compare to Fruit Snacks.

□ Later he may accept jellies or preserves on toast or pie crust with fruit from the Pop Tart chain.

Later in treatment New food ideas: Fruit breads, muffins


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or rolls may be accepted. You may want to puree the fruit and then add to bread batter. Learning activities: Cheese

□ Shred cheese, melt cheese, slice cheese, and look at string cheese at the store and shredded cheese.

□ Talk about the colors, make toasted cheese or quesadilla in different shapes or paint a face on the tortilla with salsa.

□ Talk about cheese flavor on popcorn, in chips and crackers. Compare to real cheese products. In time, cheesy salsas or other dips may be accepted on crackers or chips.

Peanut Butter

Peanut butter □ Try peanut butter on other types

of breads (other brands of white, wheat, crackers, breadsticks, rolls, toast). Vary the brands of jelly (other brands of grape or strawberry jelly, try preserves or other flavors of jelly)

Learning activities: Peanut Butter-

□ Learn about peanut butter and how it is made. Show your child pictures of different types of nuts.

□ Put nuts on new foods, roll a banana in chocolate and coat with crushed peanuts, make a sundae and top with nuts, make peanut butter cookies.

□ Open Nutter Butters, Ritz bits and peanut butter cups. Scoop out the peanut butter and compare to regular peanut butter. Make peanut butter cookies.

□ Work toward a variety of nuts; maybe introduce granola, raisins, Craisins, dried cherries or


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pretzels to the mix. Chocolate-Learn about chocolate in chocolate syrups, a variety of candies, Quik powder, as a sauce, pudding, mousse, in sprinkles, dips or as a fondue. Learn about how candy bars or M-n-M’s are made. Melt M-n-M’s in a pan. Compare it to Hershey’s chocolate syrup. Paint with brush on a plate using your chocolate paint. Later in treatment you can do a Fun with Food Activity: You can dip pretzels, pound cake, banana, marshmallows or fruits in fondue. Learn about white chocolate and dark chocolate. Learn about bakeries and special cakes.

Learning About Food Websites: “Milk Matters program” on-line at www.nichd.nih.gov/milk/ may be very helpful.

www.dole5aday.com/ Dole 5 a Day program on line may help teach Steven about fruits and vegetables. You can look up individual foods and learn about them.

www.cosmeo.com has helpful information about a wide variety of information on for education and other topics including food, health and nutrition. Books, songs, indoor or outdoor gardening, visiting a Farmer’s Market, farm, etc. may also be helpful.

http://www.nichd.nih.gov/milk/

http://www.dole5aday.com/

http://www.cosmeo.com/


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Pasta-Pizza, Spaghettios, Hamburger Helper

□ Teach about what pasta is, how it feels before you cook it, how it softens in hot water and what types of meals people eat that are made from pasta.

□ Make Kraft Macaroni and Cheese and let him smell the cheese powder (compare it to the cheese powder on Cheetos, etc.) and help pour it in the noodles.

□ Make macaroni and cheese with different shapes of pasta or put one noodle in that is in a different shape.

□ Raviolios may be accepted or Spaghettios may be offered or mixed with a little homemade spaghetti sauce.

Learning Ideas:

□ Talk about Italy and Italian foods. Study flags from different countries and the types of foods from other cultures.

□ Make your own spaghetti sauce or salsa together

□ Talk about the vegetables you use and why they are good for you. If a child will accept a sauce or salsa or cheese soup, many vegetables can be pureed and added to the mix.

□ Vegetables (pick one or two to try) that mix in well to these foods include pureed squash, zucchini, tomato, onion, green pepper, green beans or carrots.

□ Start with a tiny amount at first and work your way up.

Course Post Test:

1. T/F When implementing a Food Chaining program you should change flavor

before you change texture.


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2. T/F There are five important steps that must be considered before

considering what foods to change in a Food Chaining Program. Making

changes to the foods is the sixth step.

3. T/F A referral to ENT would be indicated if there are concerns such as

chronic congestion, snoring, and despite therapeutic intervention, ongoing

pharyngeal stage dysphagia.

4. T/F Speech and occupational therapists should change an infant’s formula or

place children on a supplement to improve their nutritional status. There is

no need to consult a dietitian or physician and it is best practice for a

therapist to do this.

5. T/F Physical therapists assist in feeding programs by intervening for

patients whose breathing patterns does not support feeding.

6. T/F It is NOT important that infants and children use therapeutic utensils

(bite arcs, chew tubes, DuoSpoons) independently. The therapist should

ALWAYS be in control of putting these items in the child’s mouth.

7. T/F Lip seal is the first place in the valving system for a strong swallow.

8. T/F It is NOT important to consider the flow rate of the nipple or cup.

9. T/F Signs of milk protein allergy in infants can include symptoms such as

eczema, constipation, feeding difficulties and red rash.

10. T/F Eosinophilic esophagitis can remodel the esophagus and cause

permanent esophageal dysphagia.

11. T/F You should consider thickening liquids only after therapy to decrease

bolus size, trialing to increase the sensory properties of the liquid or if a

swallow study/FEES study necessitates it. Thickening should is an

intervention and not a place where treatment ends.

12. What are the signs of complicated reflux? (Circle all that apply) a) weight

loss/feeding aversion b) color change (blue or pale) c) sleep problems d) all

of the above

13. Failure to thrive is diagnosed when a child presents with growth parameters

below the 5th percentile for: a) height b) weight c)head circumference

d)nutritional intake

14. If a patient has adequate oral preparatory and oral stage of the swallow but

has pharyngeal stage dysphagia there is suspicion for a) eosinophilic

esophagitis b)laryngeal cleft c) food allergy d) nutritional deficits

15. To help an infant master the suck swallow breath sequence therapists can a)

change to a slow flow nipple b)use side tilt positioning c) use external pacing

d) all of the above


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911: From Triage to Treatment© Cheri Fraker, CCC/SLP ......Use the guide below to assess your evaluation and treatment plan. Start by making sure you have covered every area in treatment.

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