• Lauren Tandy

Dysphagia Telepractice Intervention

As promised, I am going to walk you through what my dysphagia (difficulty swallowing) intervention looks like via telepractice. I have several different case scenarios I will share since every client is different and has different needs.

  • A baby who is having difficulty with swallowing from a bottle and parents need help.

  • An adolescent child who is tongue thrusting to swallow, open mouth breathing, and having chronic illness.

  • A 14-month-old who is still swallowing foods whole, tongue mashing, or tongue pumping to swallow.

  • A 9-month-old who is tube-fed and learning to eat or drink orally.

DISCLAIMER: It is the individual speech-language pathologist’s responsibility to follow all state, ASHA, licensure, and professional guidelines surrounding their intervention and practice. A clinician should always judge whether a family or client is appropriate for telepractice intervention – especially for dysphagia – to make sure that it is: in the client’s best interest; that no harm is being done; and that services may not be provided by a different format or venue that would better meet the child’s needs. This blog post in no way informs individual therapy and judgment that the clinician is responsible to perform. Lauren Tandy, M.S., CCC-SLP, Tandy Therapy Box LLC, Early Intervention Telepractice, and Tandy Therapy LLC is not liable or responsible for the results of the clinician’s intervention. We also do not promise results from therapy by using this information. Please refer to ASHA guidelines at asha.org for guidance in the practice of dysphagia intervention by a speech-language pathologist.

I will share what a typical telepractice session for each looks like. I have a class releasing soon that addresses dysphagia intervention via telepractice with a demonstration of case scenario two. I will start today with case scenario number one – a baby who is having difficulty with swallowing from a bottle and parents need help. There is a twist to this scenario - the parents are Spanish speaking and have very little English understanding.

In this scenario, I set each session up with an interpreter. I let the interpreter know my potential three therapy times for the family and she schedules the session. When I put the session in my Theraplatform calendar, I create a contact for the interpreter, as well as the family, and invite both to the session. I then provide the interpreter and family with a Family Telepractice Checklist so they may be as ready as possible for the session. I also provide each with a troubleshooting list for my particular platform.

When the appointment time comes, I go through the steps on my Clinician Telepractice Readiness Checklist to make sure I am ready for my session and will have the least amount of interruptions possible. This is especially important in a feeding session so that I can hear all the sounds from the baby. A baby drinking from a bottle will make subtle sounds that I am trained to decipher meaning from. I don’t want to miss any of those sounds!

Here is my super helpful trick: I have the caregiver walk me through what is happening during the feed. Sometimes the baby is crying and ready to feed when I log on because the parent has held off giving the bottle so that I may observe. My approach is to get the caregiver used to and familiar with what I will be looking for during the feed. It is ideal to have about 5-7 minutes at the beginning of the session, prior to the feed, to tell the parents what I will be watching and listening for (how many sucks per swallow on average, how strong or weak the swallow is, how many sucks and swallows prior to the baby taking a breathing break, wet vocal quality, catch-up breathing, eye redness, watery eyes, etc.)

Here is why I do all of that: I will probably miss some of the feeding and swallowing sounds due to environmental noise on my end or the baby’s side of the camera. There may be siblings running around in the background. The mother may be talking while feeding the baby. Dad may ask a question right when the baby swallows. And here’s another fact – this happens when I am at the home, too! This is not unique to telepractice. We, as clinicians, have to do the best that we can with the information that we have. The surroundings might not be ideal: caregivers might not follow all directions exactly, the siblings might have TV on and be running around, parents might want to talk during the feed. You will deal with some of the same barriers or difficulties via telepractice as you do in person.

In order to circumvent some of these hurdles, I try to have the parent step into my shoes and practice listening. They will quickly find the following:

  • They need the TV off to hear the baby.

  • They need to provide other children something to do so they can focus.

  • They need to look at the baby’s face, listen to their swallow, and do some math all at the same time.

  • They are ABLE to do this even when I am not there.

Just like using the coaching model for child-directed play, it works with feeding and swallowing intervention, as well! Coach the parent to recognize the signs and they will be able to do this during the 35-56 feeds between your weekly sessions. Talk about practice! My goal is to enable them to practice all week long and report back to me at the next session how things went. I want them to be able to provide the following information in this situation:

  • Feeding frequency

  • Feeding volumes

  • Feeding positions and baby responses to these positions

  • Signs or symptoms (overt and covert) that they saw throughout the week (I always provide parents with a list of signs to look for in writing so that they may easily keep track and refer back to this list)

  • Any doctor/specialist visits completed with results/recommendations

  • Recent weights (some families are required to weigh baby at home and report to the doctor every week)

Parents essentially learn how to be my assistants in therapy whether it is at home visits or via telepractice. My goal is to empower them to be able to feed their baby successfully, safely, efficiently, and effectively without me guiding them. My goal is to help them recognize a successful feed where their goals are being met or worked on, versus a feed that needs modification.

So here is the structure of my dysphagia intervention with a baby who is having difficulty with swallowing from a bottle (similar to what it is for my other family coaching model sessions):

  • Be ready for the session ahead of time.

  • Log on and ensure the translator and parents have working audio and visual capabilities.

  • Find out when the last feed was and if baby is ready for another bottle.

If I have time and the baby is not screaming for her bottle, I will have parents review the following:

  • Feeding schedule

  • Feeding volumes on average over a 24 period (include the lowest and include the highest)

  • Signs or symptoms of airway invasion they saw this week (overt or covert) - I have a form for this in my dysphagia packet in the online store

  • Any changes from their doctor or specialists (including registered dietician)

  • Most recent weight, percentile, and BMI (body mass index) if available

  • Any concerns from parents or team

I then observe baby appearance (what is resting breathing, vocal quality, demeanor prior to feed) so that I have a baseline to compare to. I will also ask the parent about how the baby is today to make sure I’m not missing something like a low-grade fever.

I then walk through my 10 Steps for Family-Centered Coaching via Telepractice (available for free download here: https://www.tandytherapy.com/downloads)

  • I have parents review what they were working on between sessions.

  • I set up our feed with what we are working on today

  • In this session, it might be finger support for improved lip seal on the bottle and reduced lateral leakage of fluid from the mouth.

  • I will demonstrate how to support using my thumb middle finger, and index finger during bottle feeding by using a baby and bottle as props on my side of the screen. I ALWAYS have a baby available to model with!

I will then have the parents practice recommendations during a feed. They may take a break to burp in the middle of the feed, which I will take the opportunity of time to review how that felt for them. What did they notice? May I share some helpful hints with them? Would they like me to demonstrate again?

During the second half of feed, they will use the feedback given to practice again.

At the end of the feed, we will debrief how they felt it went. I will share insights and things that I notice. But my real goal is for them to notice before I do so that I know they are looking for the same things. If they didn’t notice, that is my opportunity to coach.

REMEMBER: Ask before giving information. There is nothing more annoying as a parent than for someone to tell you how to parent when it’s something you already know. Look for their knowledge and commend them for their capabilities/confidence.

We will then review what they want to work on between sessions:

  • Which fingers will they use for support (based on what felt accomplishable to them during this session). Who will practice this (just mom or mom and dad?).

  • How often will they practice (even if it’s not 100% of the time, I want they to make improvements so that they don’t feel like they failed at the end of the week. I want them to make goals that they can meet, so I help them identify those).

Lastly, we talk about what we want to focus on next session (possibly an easier hold for mother so that her arm isn’t getting tired all the time or so baby can let liquid pool in her cheek for increased safety and efficiency with feed).

As a supporting tool to help you service your dysphagia caseload, I have taken some of the elements of this blog and created easily adaptable forms for your therapy use. Visit https://www.tandytherapy.com/shop to purchase the Dysphagia Telepractice Packet with the following forms:

  • Dysphagia Telepractice Using Family Coaching. This tool is a step-by-step form used to structure your dysphagia telepractice session. It provides guidance for activities using the family coaching model via telepractice.

  • Signs and Symptoms of Airway Invasion log does families and clinicians

  • Household Food Inventory divided into texture, taste, and temperature

  • Oral Stimulation Item Inventory divided into material, toys, and oral tools.

Lauren Tandy, M.S., CCC-SLP is a certified speech-language pathologist licensed in Idaho and Washington. She has a special interest in early intervention, feeding and swallowing issues, oromyofunctional disorders, telepractice, and speech-language development. Lauren is the administrator of Early Intervention Telepractice Facebook group and creator of Tandy Therapy Box LLC materials and classes. You may find more information at tandytherapy.com. Feel free to contact Lauren with any questions at hello@tandytherapy.com.

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