1. Simcoe Feeding Assessment and Consultation Services (FACS) Liz Day, OT; Bronwen Jones, SLP; Jane Anne Sullivan, RD; Allison Brooker, SLP Royal Victoria Hospital SYMPOSIUM 2008 Working Together for Kids & Teens with Disabilities

2. Simcoe Feeding Assessment and Consultation Services (FACS) Enhancing Local Diagnostic and Treatment Capacity

3. WHO are we? The Simcoe Feeding Assessment and Consultation Service consists of Feeding Clinic (Speech/Language Pathologist, an Occupational Therapist and a Dietitian) with consultation from pediatrician, Dr. G. Vomiero Feeding Clinic (Speech/Language Pathologist, an Occupational Therapist and a Dietitian) with consultation from pediatrician, Dr. G. Vomiero Community Partners – CTG, CCAC, RVH, CTS, Simcoe Preschool Speech and Language Program, SCS, Speech Clinic, physicians, New Path, Kerry’s Place Community Partners – CTG, CCAC, RVH, CTS, Simcoe Preschool Speech and Language Program, SCS, Speech Clinic, physicians, New Path, Kerry’s Place

4. WHAT do we do? The FACS team sees children with complex feeding problems with regard to chewing and swallowing; nutrition and physical health ; sensory processing and functional feeding skills. The FACS team sees children with complex feeding problems with regard to chewing and swallowing; nutrition and physical health ; sensory processing and functional feeding skills.

5. WHAT do we do? Feeding Clinic Feeding Clinic multi-D assessment and problem analysis multi-D assessment and problem analysis trial of intervention strategies trial of intervention strategies home programming home programming recommendations/referrals to Local Team Partners recommendations/referrals to Local Team Partners Videflouroscopic Swallow Studies Videflouroscopic Swallow Studies completed as needed at RVH completed as needed at RVH approximately 4 spots/month available approximately 4 spots/month available

6. WHAT do we do? Local Team Partners Local Team Partners provide the bulk of community feeding services and refer to feeding clinic when necessary provide the bulk of community feeding services and refer to feeding clinic when necessary attend clinic with clients attend clinic with clients follow-up with programming and recommendations follow-up with programming and recommendations

7. WHO do we see? Children from birth to 19 years of age with: Oral – Motor or Sucking difficulties such as decreased co-ordination of suck swallow breathe; weak suck; decreased chewing; tonic bite; fatigue Oral – Motor or Sucking difficulties such as decreased co-ordination of suck swallow breathe; weak suck; decreased chewing; tonic bite; fatigue Sensory Difficulties such as oral aversion Sensory Difficulties such as oral aversion Severe irritability or behaviour problems during feeds Severe irritability or behaviour problems during feeds Extremely Picky Eaters Extremely Picky Eaters

8. WHO do we see? Risk of aspiration Risk of aspiration History of recurrent pneumonia/chest infections History of recurrent pneumonia/chest infections Lethargy or decreased arousal during feeding Lethargy or decreased arousal during feeding Breathing disruptions or apnea during feeding Breathing disruptions or apnea during feeding Excessive gagging or recurrent coughing during feeds Excessive gagging or recurrent coughing during feeds

9. WHO do we see? Unexplained food refusal Unexplained food refusal Failure to thrive Failure to thrive Transition from tube feeding to oral feeding Transition from tube feeding to oral feeding Feeding difficulty related to structural anomalies (cleft palate, high palate, etc.) Feeding difficulty related to structural anomalies (cleft palate, high palate, etc.) Deterioration of feeding and swallowing ability related to disease process (e.g. seizures, MD) Deterioration of feeding and swallowing ability related to disease process (e.g. seizures, MD)

10. Two Major Areas of Focus in bringing Services Closer to Home… Providing Videoflouroscopy at RVH Providing Videoflouroscopy at RVH Increasing Feeding Expertise at the Local Level Increasing Feeding Expertise at the Local Level

11. Videoflouroscopy (VFFS)

12. Videofluroscopy (VFSS) Now available at RVH for children in Simcoe Now available at RVH for children in Simcoe Start up of this service has resulted in shorter wait times and less traveling for families Start up of this service has resulted in shorter wait times and less traveling for families Children previously seen at BKR & HSC can now be seen closer to home for VFSS Children previously seen at BKR & HSC can now be seen closer to home for VFSS

13. What is VFFS? X-ray study of the child’s swallow to determine safety of oral feeding with regards to choking and aspiration

14. VFSS

15. To Videoflo or not to Videoflo? Medical History Highly Suggestive of Aspiration: Recurrent chest infections Recurrent chest infections History of aspiration pneumonia History of aspiration pneumonia History of increased upper airway sounds or wheezing with oral feeds History of increased upper airway sounds or wheezing with oral feeds Findings on chest x-ray Findings on chest x-ray Positive aspiration on upper GI Positive aspiration on upper GI

16. To Videoflo or not to Videoflo? Medical History Possibly Suggestive of Aspiration History of bronchiolitis Frequent undiagnosed fevers Recurrent URT infections Perioral cyanosis with feeds Poor secretion control Persistent apnea, bradys, desats Absent gag reflex Poor weight gain

17. Clinical Evaluation Clinical Evaluation Always do a clinical evaluation before proceeding to videoflo… Always do a clinical evaluation before proceeding to videoflo… VFFS radiation is equal to ~ 30 x-rays VFFS radiation is equal to ~ 30 x-rays A simple intervention often solves the problem without the need for a videoflo ( e.g. coughing when bottle feeding – often solved by decreasing the flow) A simple intervention often solves the problem without the need for a videoflo ( e.g. coughing when bottle feeding – often solved by decreasing the flow)

18. To Videoflo or not to Videoflo Clinically - highly suggestive of aspiration: Consistent coughing with oral feeds Consistent coughing with oral feeds Increased upper airway sounds and congestions with oral feeds Increased upper airway sounds and congestions with oral feeds Sudden, significant drop in O2 sats, heart rate with oral feeds Sudden, significant drop in O2 sats, heart rate with oral feeds Increased chest sounds Increased chest sounds Change in voice quality Change in voice quality

19. To Videoflo or not to Videoflo Clinically - Possibly suggestive of aspiration: Distress signs – grimacing, irritability, change in respiration, change of state, etc. Distress signs – grimacing, irritability, change in respiration, change of state, etc.

20. To Videoflo or not to Videoflo… Provide clinical feeding interventions Provide clinical feeding interventions thickening thickening positioning positioning pacing pacing addressing GI symptoms addressing GI symptoms If problems persist, proceed with videoflo If problems persist, proceed with videoflo

21. Building Capacity

22. Capacity at the Local Level: Mentoring FACS team members are available to provide mentoring when appropriate FACS team members are available to provide mentoring when appropriate CCAC- Closing The Gap has identified mentors (OT Susan Scott & RD Melanie Larkin) to help build expertise in therapists CCAC- Closing The Gap has identified mentors (OT Susan Scott & RD Melanie Larkin) to help build expertise in therapists Organize & provide in-service education & workshops e.g. transitioning from oral to tube feeds Organize & provide in-service education & workshops e.g. transitioning from oral to tube feeds Consultation to therapists with less expertise Consultation to therapists with less expertise

23. Capacity at the Local Level: Extremely Picky Eaters Workshop Provided by FACS team to community partners Provided by FACS team to community partners Handouts from the workshop for therapists to give to parents available on SharePoint Handouts from the workshop for therapists to give to parents available on SharePoint

24. Capacity at the Local Level: Resources Local Hubs – e.g. The Common Roof Local Hubs – e.g. The Common Roof Dieticians from Simcoe and York FACS teams have made available Parent Handouts Dieticians from Simcoe and York FACS teams have made available Parent Handouts Feeding equipment and assessment kits at hubs Feeding equipment and assessment kits at hubs Educational Materials for therapists and families e.g. Tube Feeding with Love DVD’s Educational Materials for therapists and families e.g. Tube Feeding with Love DVD’s

25. Capacity at the Local Level: Guided Assessment Tool Created by York and Simcoe FACS team leaders Created by York and Simcoe FACS team leaders Resource for therapists - meant to guide their assessment and interventions Resource for therapists - meant to guide their assessment and interventions Available on SharePoint Available on SharePoint

26. Case Example 9 year old girl with history of meningitis in infancy with global developmental delay, currently a resident of a group home 9 year old girl with history of meningitis in infancy with global developmental delay, currently a resident of a group home Presented to Feeding Clinic with swallowing difficulties and inability to self- feed. Presented to Feeding Clinic with swallowing difficulties and inability to self- feed. Recent history of pneumonia Recent history of pneumonia Taking only purees and thickened liquids Taking only purees and thickened liquids

27. Case Example Local Team players include CTG OT, RD and PT, paediatrician, group home staff, CAS, school EA’s, Local Team players include CTG OT, RD and PT, paediatrician, group home staff, CAS, school EA’s, Local team: Local team: seating and positioning seating and positioning variety of foods/nutrients/calories variety of foods/nutrients/calories thickened liquids thickened liquids

28. Case Example Feeding Clinic – clinical assessment suggests risk of aspiration Feeding Clinic – clinical assessment suggests risk of aspiration VFFS - Recommendations VFFS - Recommendations No liquids No liquids thin and thick purees only thin and thick purees only Meeting fluid requirements on puree diet Meeting fluid requirements on puree diet Local team implements and educates caregivers and school EA’s Local team implements and educates caregivers and school EA’s

29. Simcoe FACS Local Team Feeding Clinic Assessment and VFSS (if nec) Local Team