Feeding and Swallowing Intervention via Telepractice
Disclaimer: Clinicians are required to use their professional and clinical judgment to determine which clients are or are not appropriate for telepractice intervention. Please also check with your state and licensing/professional organizations, professional and liability insurance coverages, and business licensing laws where you practice.
Telepractice: Providing intervention utilizing audio and visual live and recorded transmission modalities. I use “telepractice” instead of other terms because it is the preferred terminology of the American Speech-Language and Hearing Association (ASHA), which I am a member of.
Dysphagia: Difficulty eating or swallowing.
SLP: Speech Language Pathologist
OME: Oral mechanism examination
Many professions are transitioning to telepractice in response to national and international stay-at-home orders from our government leaders. For speech-language pathologists (SLP) who perform dysphagia (feeding difficulty) intervention, this has created both an opportunity to get creative with our intervention techniques, but it has created hurdles for both evaluations and intervention as well.
As an early intervention and preschool SLP, I also specialize in feeding/swallowing intervention. I have been providing limited dysphagia intervention via telepractice for the last few years as this has been a reliable way to provide services to underserved populations in remote and rural areas. And because I already had telepractice up and running for use in serving school districts, it has also been a ready option when I could not reach my clients’ homes due to snowstorms; or when their premature child had a compromised immune system and I had a cold; or when a family was sick and I did not want to unwittingly pass along an illness to my other fragile feeders. In these cases, I would offer telepractice as an alternative to an in-person visit, and be able to check in with the family and child to make sure things were progressing well.
When I provide dysphagia intervention via telepractice, I ALWAYS used the parent coaching model. Here is why:
I may not be able to hear every subtle difference in sounds the child makes before, during, or after feeding. But I CAN coach the parent and train them to hear those sounds and know what they mean.
I need to help the parent become knowledgeable and confident about identifying the signs or symptoms of feeding difficulties and how to modify and/or change the food, atmosphere, or their own approach in response to these cues.
Even when I am providing services in-person and able to directly demonstrate how to hold the infant to modify the feeding rate or how to present food in a different way, I need the parent to feel confident doing these things themselves so they are consistent and confident using these methods in-between our sessions. Therefore, the coaching model lends itself to building this competency and confidence with the parents being hands-on.
If I were to cancel a session due to illness, weather, etc., the parent may be practicing a recommendation wrong for several days or weeks before I am able to follow-up to reinforce the strategy, posing a huge health risk to the child or reinforce aversiveness we are trying to desensitize. This reason alone supports using telepractice as an alternative delivery method.
For all of these listed reasons, I believe dysphagia intervention via telepractice is needed for specific clients and families as the risk of harm in these situations is minimal. And letting a family or child practice strategies or skills the wrong way could increase aversiveness, increase aspiration, or even cause respiratory infections. These clients/patients/families need our help and telepractice allows us a way to continue with our care.
Each clinician is required by their licensing organizations to provide tailored intervention that meets the needs of their client. First and foremost, a clinician should think through the reasons that therapy should NOT be provided to a client via telepractice. You must make a plan to provide services that would be equal in quality to in-person, onsite services.
I typically provide dysphagia evaluations in person and then provide telepractice services, as needed, for intervention. Recently, I began providing telepractice dysphagia evaluations with success and with an understanding that I am providing services to a family/child who would otherwise be floundering at this time, in desperate need of help for various reasons.
Here is how I structure my evaluations with dysphagia clients:
I start with a SCREENING: I am looking for appropriateness to complete the evaluation over telepractice, the caregiver’s ability to follow directions, and any connectivity or video and sound quality issues.
If I feel I am able to complete a full evaluation, I will move forward. If I do not feel I can adequately evaluate via telepractice, then I may put the evaluation on hold while providing general information on feeding/swallowing development and precautions.
During the scheduling call, I do a preliminary screening to determine what the primary concerns are. I will ask parents to have certain foods, positioning or seating, utensils, cups, and/or bottles ready on evaluation day.
I may also need to walk through what they have available in the home and what a typical feed looks like for them.
Collect the child’s medical history via a file review and parent report, and sure this is detailed and complete.
Have the parent describe the concerns.
Explain to the parent what I will be looking for during feeding and/or exam.
Ask the parent to eliminate any background noise or ask family to be quiet.
I have the caregiver talk through what they are hearing and seeing during feeding, and I am watching and listening as well. My view and ability to hear clearly depend on the size of screen visual, cooperation of child (as always), audio quality, connectivity, other happenings at home, and more.
It is HIGHLY recommended there be adequate connectivity to evaluate feeding/swallowing. Always follow state and professional guidelines regarding the platform and devices used.
I complete an oral myofunctional examination by asking the parent to position the camera and child so I can see inside their mouth.
I instruct the parent to move the baby so that I can view the shape of baby’s head.
I may ask the parents to use their phone light or get a separate flashlight for better lighting. I may also ask if they have a flashlight ahead of time during our scheduling conversations. If I am unable to get the views that I want, I will have the parent take pictures to show me or email me, giving them instructions about what I am looking for.
I watch the baby during oral play to view how the mouth, face, and tongue move.
Once the baby is in the early intervention program with an approved plan of care, I will start dysphagia intervention via telepractice. I use the same guidelines as my Family-Centered Coaching via Telepractice, but I coach on safe feeding and oral motor integration strategies. I incorporate reflection, coaching, practice and observation, recommendations, and repeat coaching. During the session we make a plan for what they want to work on between visits. We also make a plan for our next session – skills we will target, what that will look like, what foods and utensils should they have ready, what toys we may want to integrate into food play, who should be present, etc. Therapy looks so different for each kid I see, but this is the basic outline for most of my sessions and evaluations. I will be writing follow-up blog posts to break things down even further. Stay tuned for more…