Children with developmental disorders, traumatic brain injury or throat deformities may have difficulties communicating or problems swallowing and eating.
Learn about the treatment options available for children dealing with these conditions from a UVA specialist in speech language pathology.
Selected Podcast
Helping Children Address Issues with Communicating and Eating
Featured Speaker:
UVA Speech Language Therapy
Polly Bickley
Polly Bickley is a speech language pathologist and director of the Encouragement Feeding Program at UVA Children's Hospital.UVA Speech Language Therapy
Transcription:
Helping Children Address Issues with Communicating and Eating
Melanie Cole (Host): Children with development disorders, traumatic brain injury, or throat deformities may have difficulties communicating or problems swallowing and eating. My guest is Polly Bickley. She’s a speech language pathologist and director of the Encouragement Feeding Program at UVA Children’s Hospital. Welcome to the show, Polly. What are some of the most common communication and eating disorders? What are the conditions that would cause children to have these issues?
Polly Bickley (Guest): Well, in this day and age, we’ve had such advances in medical technology that we’re having children survive as early as 24 weeks. So one of the biggest things we see is premature birth, children born at 24th to 26th to 28th weeks. We know that those children’s systems are still immature. The lungs, the heart, the GI system aren’t really ready to be working perfectly coordinated together. And so, a lot of times, we’ll see children who are not able to eat safely, efficiently, effectively; who are not able to breathe very well—so the very complicated kiddos who stay in the hospital for quite a while. That environment, as good as we try to make it, isn’t really the best place for children to start learning and developing their eating skills and their communication skills.
We’re also pretty darn amazing at being able to fix some cardiac anomalies that we were not able to fix even 5 or 10 years ago. So we see a lot of children with very complex heart deformities that are now reparable, being fixed. And so they’re also in the hospital for a very long time, very, very medically fragile, and they’re not able to do the things that most babies do right away—which is eat and start to babble and start to learn language from listening to their parents talk to them. Those things kind of put them behind the eight ball.
We’re also seeing a much greater incidence of autism, where children don’t really understand the point of communication—that if I point at something, you’ll give it to me, or if I say a word, that’s identifying what I’m wanting. So those are all things that are keeping us busy in the world of speech pathology.
Melanie: So then, what about the eating disorders that go along with these conditions that you’re talking about? What kinds of treatments are available and what are some of the signs and symptoms that parents should be looking out for, red flags, Polly?
Bickley: Right. Well, eating should be effortless at birth. For the first several months, it’s a reflexive behavior that children do. If that is not going smoothly, if your child is not taking a bottle or breastfeeding in an easy manner, if it’s effortful, if it takes a long time, if they’re choking or coughing or changing colors, or if they’re not growing well, that is definitely a red flag that we need to help them. We need to look at them and figure out what is not working, why is this child not enjoying this activity, why it’s not happening smoothly?
The other thing is we want to look at children as they advance through going from bottle to breast, from breast to baby food, and then to table food. That usually happens between four to five to six and nine to twelve months. That should really be smooth and effortless, and children should enjoy eating and they should give you good cues that they’re enjoying eating. And some of our children don’t enjoy eating because perhaps it hurts when they swallow. They might have reflux. They might have something else that interferes with them eating in a safe and efficient manner. So we’re going to want to get some help for those things pretty quickly. We have a saying in the speech pathology world, at least at UVA, that we want quality over quantity. We know that parents really want to see their child eat a good quantity of food, but we want children to eat happily and efficiently and effectively, even if it’s smaller amounts. Those are the things that we would like to look at. So if you’re worried that your child is not eating the volume that they should and the manner that they should because they’re not enjoying it, definitely, touching base with your pediatrician, who then could make a referral to one of us, would be helpful.
Melanie: How are these conditions diagnosed, Polly? Do you do some tests to see what’s going on in there?
Bickley: Mm-hmm. It kind of depends on what we’re seeing from a clinical standpoint. The speech pathologist is going to want to watch the child eat, whether it be an infant taking a bottle or an older child eating some sort of pureed or table foods and we’re looking for signs that they’re having difficulty swallowing, or maybe this food is actually going into their lungs instead of their stomach. That’s called aspiration. We see signs of wet, gurgly vocal quality. We see their eyes tear up, they do some coughing. Or they’ve had respiratory illnesses in the past that are not explained by other lung issues. And so we’re going to want to look at that first. And then we may recommend a video fluoroscopic swallow study, where we actually have a child take food with barium in it and the radiologist takes a picture of the child swallowing so we can see if there’s any physical reason for them not to be swallowing safely. A lot of times, however, it’s more than just a physical issue. It becomes more of a, “This doesn’t feel good. When I eat, it hurts later. Therefore, I don’t want to eat.” And so, we do have some behavioral avoidance of eating or seeing children now that are extremely picky. So it’s not just, “I don’t know how to eat because I was so medically fragile I didn’t get to practice eating,” but, “I can eat fine, but I only want to eat blue food when the moon is full and my mom is singing ‘Happy Birthday’ because I’m very picky and rigid about what I’ll eat because I’m a little overwhelmed by this activity. It’s not as easy as I’d like it to be.” So, with those kiddos, we’re looking at what the diet is, what textures, what flavors, what types of foods they’d like to eat efficiently, and which ones they have a trouble and then reject.
Melanie: Then what treatment options are available? What interventions do you use to get those children to be able to eat and to enjoy it, more importantly, as you say, because then, the behavioral issues start coming in because they’re remembering these things? What treatment options are available?
Bickley: Right, right. Well, from the very get go, my coworkers that are working over in the NICU, again, have that mantra of good quality over quantity. And so they’re looking at babies very young and saying, “How can I make this baby eat efficiently and effectively in a manner that’s comfortable to them?” So they’re going to be looking at what type of nipple to use, how to position the baby, how not to overwhelm the baby, and what type of viscosity of the formula. Should we be thickening it? Should we just use a very slow-flow nipple so that the child can coordinate that suck-swallow-breathe pattern that they feel comfortable eating? When they get a little bit older, my co-workers and I who work in the outpatient setting are looking at what is it about this food that is hard for you. Is it too sharp? Are the crumbs too sharp—because your mouth is a lot more hypersensitive than my mouth would be? Or is the weight of this pureed food, does that end up making you gag, and why is that? And then, how can we gently, consistently, in a playful manner, teach you that this isn’t going to hurt you? We’re going to practice it so many times in a fun, playful manner that it’s not going to hurt you anymore. And again, that’s hard, because a lot of times, we have to get the calories in to get the child to grow and thrive, but we have to do it in a manner that’s not painful, so that they don’t start to avoid more things.
Many times, this particular picky, rigid eating are what we call selective eating disorder, goes along with a bigger picture; goes a long with significant rigidity; sometimes goes along with the diagnosis of autism; goes along with the diagnosis of anxiety, hyper vigilance about the world. And so, we really need to back up and look at those things because the mouth is a symptom. The eating is necessarily a symptom of the bigger picture. So it really takes a whole team. We’re referring back to their physicians. We’re referring to the GI doctors. We’re referring to some psychologists. We’re referring to developmental pediatricians, occupational therapists so that we can look at the whole kit and caboodle to figure out what’s broken and fix the whole child, not just the symptom of feeding.
Melanie: Well, it’s a real multidisciplinary approach, Polly. So why should families come to UVA for treatment of these conditions?
Bickley: Well, I think there’s numerous reasons, I think the first reason being that the clinicians that are currently at UVA have probably pretty much an average of at least 15 to 20 years’ experience among all of us. So there’s many us that have been here for an extremely long time, therefore we’ve been around the block and we’ve seen this quite a bit. The other issue is that UVA is really committed to research and continuing ed, so I feel like we really have some cutting edge opportunities in working in the NICU and seeing the children and the surgeries that they’re doing and some of the research that’s coming out of there. And then, I think that the other big thing is that we really do work well together as a team. And so, when I am puzzled about a child, I have so many resources to go to very close at hand that we can problem-solve together.
Melanie: That is great information. Thank you so much for all you do, Polly. You’re listening to UVA Health Systems Radio. And for more information, you can go to uvahealth.com. This is Melanie Cole. Thanks so much for listening, and have a great day./AT/rj/es
Helping Children Address Issues with Communicating and Eating
Melanie Cole (Host): Children with development disorders, traumatic brain injury, or throat deformities may have difficulties communicating or problems swallowing and eating. My guest is Polly Bickley. She’s a speech language pathologist and director of the Encouragement Feeding Program at UVA Children’s Hospital. Welcome to the show, Polly. What are some of the most common communication and eating disorders? What are the conditions that would cause children to have these issues?
Polly Bickley (Guest): Well, in this day and age, we’ve had such advances in medical technology that we’re having children survive as early as 24 weeks. So one of the biggest things we see is premature birth, children born at 24th to 26th to 28th weeks. We know that those children’s systems are still immature. The lungs, the heart, the GI system aren’t really ready to be working perfectly coordinated together. And so, a lot of times, we’ll see children who are not able to eat safely, efficiently, effectively; who are not able to breathe very well—so the very complicated kiddos who stay in the hospital for quite a while. That environment, as good as we try to make it, isn’t really the best place for children to start learning and developing their eating skills and their communication skills.
We’re also pretty darn amazing at being able to fix some cardiac anomalies that we were not able to fix even 5 or 10 years ago. So we see a lot of children with very complex heart deformities that are now reparable, being fixed. And so they’re also in the hospital for a very long time, very, very medically fragile, and they’re not able to do the things that most babies do right away—which is eat and start to babble and start to learn language from listening to their parents talk to them. Those things kind of put them behind the eight ball.
We’re also seeing a much greater incidence of autism, where children don’t really understand the point of communication—that if I point at something, you’ll give it to me, or if I say a word, that’s identifying what I’m wanting. So those are all things that are keeping us busy in the world of speech pathology.
Melanie: So then, what about the eating disorders that go along with these conditions that you’re talking about? What kinds of treatments are available and what are some of the signs and symptoms that parents should be looking out for, red flags, Polly?
Bickley: Right. Well, eating should be effortless at birth. For the first several months, it’s a reflexive behavior that children do. If that is not going smoothly, if your child is not taking a bottle or breastfeeding in an easy manner, if it’s effortful, if it takes a long time, if they’re choking or coughing or changing colors, or if they’re not growing well, that is definitely a red flag that we need to help them. We need to look at them and figure out what is not working, why is this child not enjoying this activity, why it’s not happening smoothly?
The other thing is we want to look at children as they advance through going from bottle to breast, from breast to baby food, and then to table food. That usually happens between four to five to six and nine to twelve months. That should really be smooth and effortless, and children should enjoy eating and they should give you good cues that they’re enjoying eating. And some of our children don’t enjoy eating because perhaps it hurts when they swallow. They might have reflux. They might have something else that interferes with them eating in a safe and efficient manner. So we’re going to want to get some help for those things pretty quickly. We have a saying in the speech pathology world, at least at UVA, that we want quality over quantity. We know that parents really want to see their child eat a good quantity of food, but we want children to eat happily and efficiently and effectively, even if it’s smaller amounts. Those are the things that we would like to look at. So if you’re worried that your child is not eating the volume that they should and the manner that they should because they’re not enjoying it, definitely, touching base with your pediatrician, who then could make a referral to one of us, would be helpful.
Melanie: How are these conditions diagnosed, Polly? Do you do some tests to see what’s going on in there?
Bickley: Mm-hmm. It kind of depends on what we’re seeing from a clinical standpoint. The speech pathologist is going to want to watch the child eat, whether it be an infant taking a bottle or an older child eating some sort of pureed or table foods and we’re looking for signs that they’re having difficulty swallowing, or maybe this food is actually going into their lungs instead of their stomach. That’s called aspiration. We see signs of wet, gurgly vocal quality. We see their eyes tear up, they do some coughing. Or they’ve had respiratory illnesses in the past that are not explained by other lung issues. And so we’re going to want to look at that first. And then we may recommend a video fluoroscopic swallow study, where we actually have a child take food with barium in it and the radiologist takes a picture of the child swallowing so we can see if there’s any physical reason for them not to be swallowing safely. A lot of times, however, it’s more than just a physical issue. It becomes more of a, “This doesn’t feel good. When I eat, it hurts later. Therefore, I don’t want to eat.” And so, we do have some behavioral avoidance of eating or seeing children now that are extremely picky. So it’s not just, “I don’t know how to eat because I was so medically fragile I didn’t get to practice eating,” but, “I can eat fine, but I only want to eat blue food when the moon is full and my mom is singing ‘Happy Birthday’ because I’m very picky and rigid about what I’ll eat because I’m a little overwhelmed by this activity. It’s not as easy as I’d like it to be.” So, with those kiddos, we’re looking at what the diet is, what textures, what flavors, what types of foods they’d like to eat efficiently, and which ones they have a trouble and then reject.
Melanie: Then what treatment options are available? What interventions do you use to get those children to be able to eat and to enjoy it, more importantly, as you say, because then, the behavioral issues start coming in because they’re remembering these things? What treatment options are available?
Bickley: Right, right. Well, from the very get go, my coworkers that are working over in the NICU, again, have that mantra of good quality over quantity. And so they’re looking at babies very young and saying, “How can I make this baby eat efficiently and effectively in a manner that’s comfortable to them?” So they’re going to be looking at what type of nipple to use, how to position the baby, how not to overwhelm the baby, and what type of viscosity of the formula. Should we be thickening it? Should we just use a very slow-flow nipple so that the child can coordinate that suck-swallow-breathe pattern that they feel comfortable eating? When they get a little bit older, my co-workers and I who work in the outpatient setting are looking at what is it about this food that is hard for you. Is it too sharp? Are the crumbs too sharp—because your mouth is a lot more hypersensitive than my mouth would be? Or is the weight of this pureed food, does that end up making you gag, and why is that? And then, how can we gently, consistently, in a playful manner, teach you that this isn’t going to hurt you? We’re going to practice it so many times in a fun, playful manner that it’s not going to hurt you anymore. And again, that’s hard, because a lot of times, we have to get the calories in to get the child to grow and thrive, but we have to do it in a manner that’s not painful, so that they don’t start to avoid more things.
Many times, this particular picky, rigid eating are what we call selective eating disorder, goes along with a bigger picture; goes a long with significant rigidity; sometimes goes along with the diagnosis of autism; goes along with the diagnosis of anxiety, hyper vigilance about the world. And so, we really need to back up and look at those things because the mouth is a symptom. The eating is necessarily a symptom of the bigger picture. So it really takes a whole team. We’re referring back to their physicians. We’re referring to the GI doctors. We’re referring to some psychologists. We’re referring to developmental pediatricians, occupational therapists so that we can look at the whole kit and caboodle to figure out what’s broken and fix the whole child, not just the symptom of feeding.
Melanie: Well, it’s a real multidisciplinary approach, Polly. So why should families come to UVA for treatment of these conditions?
Bickley: Well, I think there’s numerous reasons, I think the first reason being that the clinicians that are currently at UVA have probably pretty much an average of at least 15 to 20 years’ experience among all of us. So there’s many us that have been here for an extremely long time, therefore we’ve been around the block and we’ve seen this quite a bit. The other issue is that UVA is really committed to research and continuing ed, so I feel like we really have some cutting edge opportunities in working in the NICU and seeing the children and the surgeries that they’re doing and some of the research that’s coming out of there. And then, I think that the other big thing is that we really do work well together as a team. And so, when I am puzzled about a child, I have so many resources to go to very close at hand that we can problem-solve together.
Melanie: That is great information. Thank you so much for all you do, Polly. You’re listening to UVA Health Systems Radio. And for more information, you can go to uvahealth.com. This is Melanie Cole. Thanks so much for listening, and have a great day./AT/rj/es